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HomeMy WebLinkAbout0097 HIGHLAND DRIVE 1, n TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel -,"Application 0 0 Health Division Date Issued a 71 Conservation Division .Application Fee ✓" Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board P2 Lye ��2?/�� Historic - OKH — Preservation / Hyannis Project Stree ddres e Village Sz-1 — ---_-f Owner b'� �� f- iddress R a Telephone Z!� Permit Request t 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, � 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) --Z 4 Number of Baths: Full: existing new Half: existing new mber of Bedrooms: F2 existinogwrw Total Room Count (not including baths): existing new First Floor Room Count vHeat 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_ v 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 P A0 o Telephone Number Address License # 0 Cc YLI t7)4_-� Home Improvement Contractor# �� — Worker's Compensation # (10_0f 501 ALL CON UCTIO DEB E TING FROM THIS PROJECT WILL BETAKEN TO � SIGNATUR DATE f ` FOR OFFICIAL USE ONLY t � APPLICATION# h DATE ISSUED ,MAP/PARCEL NO.� f ADDRESS VILLAGE r OWNER DATE OF INSPECTION: FOUNDATION;"'. t FRAME ti r INSULATION.'! a FIREPLACE ELECTRICAL: ROUGH _FINAL- { PLUMBING: ROUGH FINAL ROUGH mot ;_,,; -.'' FINAL " -FINALBUILDINGI 04 o a -.,DATE CLOSED OUT `¢ ASSOCIATION PLAN NO. The Cominonweallh of Massachusetts, Department of Industrial Accidents r' Office of Investigations -600 Washington Street t Boston, MA 02111 .y • .may www.mrrss.goU/dia - Workers' Compensation at% Insurance Affidavit: Builders/contractors/Electricians/Plu tubers Applicant Information Please Print Led Maine (Business/Organization/Individual): \R )V Lf Address: _. Ci /Statdzi : C�", r�, Phone #: ~� h' P - loin r, Are ou an employer?Check he appropriate box: Type ofproject (required): a employer with 4• I am a general contractor-and I 6 New cons(ructiori employees (full and/or part time),* have hired the sub-contractors.. _ 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 working for me in any capacity. employees and have workers' 9 Ej Building addition [No workers' comp. insurance comp. insurance: ' 5. [} We are a corporation and its 10.❑ Electrical repairs or additions required.) officers have exercised their I LE] Plumbing repairs or additions 3.❑ I am a homeowner doing all work 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 vworkers'- 13.❑ Other comp. insurance required.] *Any applicant that checks box N 1 must also fill out the section below showing their workers'compensation policy in formation. t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside cgntractors must submit a new&Mdavil indicating such. tContraetors that check this box must attached an additional sheet showing the name of the sub-contractors and stale whether or not those entities have employees. If the sub-contractors have employers,they must provide their workers'comp.policy number. I am an employer that is providing workers'.compensation insurance for my employees. Below is the policy and jab site information Insurance Company.Name: Policy# or Self-ins. Lic. #: Expiration Date: Job Site Address: �*�° City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing th.e policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c, 152 can lead to the imposition of criminal penalties of a fine upne-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine to S) .00 al:�11�0of up to $ a dy agains e violator. Be advised that a copy of.this statement may be forwarded to the Office of Inve 'gation of the r ins ranee coverage verification. I o hereby ee rr tin r the. ain and petialties'ofperjury that the information provided abo e is trt and correct. SiznaAID r , Phone#J Official use only. Do not write in this area,'lo be completed by city or town o.ficiaC City or Town; Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing In 6, Other Contact Person: Phone#: Massachusetts General Laws chapter 152 requires a)) employers to provide workers' compensation for their employees, Pursuant to this statute,an employee is defined as "...every person in the service of another under any contrac I of hire, express orimplicd, 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 emp)oyer, or the employing empl receiver or trustee of an individual, partnership, associal'ob or other legal entity oyees. However the own el 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 appurienaot thereto shad.not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also slates 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 JYho 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 until acceptable evidence of compliance with the insuUancc any contract for theperforrrrance of public-work requirements of this chapter have been presented to the contracting authority:" Applicants ' Please fill out.thr workers' compensation affidavit complelely, by checking the boxes that apply to your sitzration and, if necessary, supply sub-contractors) name(s), addresses)and phone number(s)along with their certificate(s) of insurance, Limited Liability Companies (LLC)or Limited Li.ability 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 iaJ employees a policy is required. Be advised that this affidavil may be submitted to the Department of lodustr. Accidents for confirmation of insurance coverage. Also be sure to sign and date th-e 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'nstrred 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 al the bottom of the affidavit foryou to fill out in the event the Office oflnvestigations has to contact you regarding the applicant. Please be sure to fill in the permi01)'Dcnse number which will be used as a.reference number, l-n 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)abd under"Job Skc Address" the applicant should write"all 7ncairons in _(city or town),"A copy of the affidavit that has been officially stamped or marked by the city or tnWn may be provided to the applicant as proof that a valid affidavit is on file for fu ture permits or licenses. Anew affidavi tjrrust be filled nut each year, Where a home owner or citizen is obtaining a license or permit not related to any buSJDeS 9Dr commerci a 1 venture (i,e. a dog license of permit to burn leaves etc.) said person is NOT required to complete this a-JfH8vit• Tbc Office of Inv Cos nnrrat;nn and shou➢d ouhave any questions, please do not besitaie to give us a call. The Department's addirss, Iclephonc and fax number: -The Co=onwea}th of Massachusetts Department oflndusbr a] Accidents Office of Investigations 600 Washington Street Boston, MA 02 11 ] Te). # 617-727-4900 exi 406'or 1-877-MASSAFE Fax # 617 727-7749 Revised 4-24-07 www.[nass.gov/dia I _ ACORPM CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY) 11/24/2009 PRODUCER (508)997-6061 FAX (508)990-2731 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Southeastern Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 439 State Rd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 79398 N. Dartmouth, MA 02747 INSURERS AFFORDING COVERAGE NAIC# INSURED Tupper Construction Co LLC - INSURERA: Arbella Protection Insurance INSURER B: AEIC 27 Roberta Drive INSURERC: West Yarmouth, MA 02673 INSURERD: INSURER E: COVERAGES 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 IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR NSR DATE MMIDDIYYYY DATE MMIDD/YYYY - LIMITS GENERAL LIABILITY 8500008743 11/01/2009 11/01/2010 EACH OCCURRENCE $ 19000,00 X COMMERCIAL GENERAL LIABILITY - DAMAGE TO RENTE PREMISES Ea occurrence $ 100,000 CLAIMS MADE a OCCUR MED EXP(Any one person) $ S,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 29000,000 POLICY PRO--JECT F-1 LOC AUTOMOBILE LIABILITY 56662400002 12/01/2009 12/01/2010 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 11000,00 ALL OWNED'AUTOS BODILY INJURY $ A X SCHEDULEDAUTOS (Per person) X HIREDAUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $' PROPERTY DAMAGE $ (Per accident) INC GARAGE LIABILITY - AUTO ONLY-EA ACCIDENT $ - ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WCC5005593012007 10/03/200 10/03/2010 TORYLIMIIJ T AND EMPLOYERS'LIABILITY UER ANY PROPRIETORIPARTNER/EXECUTIVEY,N RICHARD TUPPER IS E.L.EACH ACCIDENT $ 500,QO B OFFICERIMEMBER EXCLUDED? I���"RRR`(Mandatory in NH) LUDED FOR WC COVERAGE E.L.DISEASE-EA EMPLOYE $ 500,000 If yes.describe under SPECIAL PROVISIONS below E.L.DISEASE•POLICY LIMIT $ 500,00 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT;BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. For Informational Purposes Only. AUTHORIZED REPRESENTATIVE , I . 11(rista Hartford ACORD 25(2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ill r • Nhtssachusctt. - Ikli:u'unrnt of Puhlic Natc(� Bn:u'd of Buildim—, Rc-_-ulatl(in? :Intl St:uid:u•(1% Construction Supervisor License License: CS 69058 I Restricted to: 00 RICHARD S TUPPER 79 B MID-TECH DR ;„ WEST YARMOUTH, MA 02673 Expiration: 12/31/2010 V ( nuni...i ucr Tr--: 7545 0fficak.-Cwmff K4rB16 ;�'�4� License or registration valid for individul use only HOME IMPROVEMENT CO RACTOR before the expiration date. If found return to: Registration: 121845 Type: Office.of Consumer Affairs and Business Regulation Expiration: c6/19/2012 ✓✓✓ Individual 10 Par • e 5170 VID TUPPER ,. st ,MA 02116' RICHARD TUPPER 29 Roberta•Drive ' W.YARMOUTH,MA\'0263 ' J Un`dersecretai µ Y N'ot'valid'witho signature M El Q.V L— E CONSTRUCTION CO.LLc 79B Mid-Tech Drive West Yarmouth, MA 02673 Phone 508-778-0111 Fax 508-778-5010 Registration#121845 License#069058 Date: August 26,2010 Attn: Building Department I hereby authorize Tupper Construction Co., LLC to pull the permits necessary to complete the project described on the attached permit application form. Thank you, Owner's Signature Print Owner's Name: Christine Pratt-Gorrill Street Address: 97 Highland Dr.,Centerville, MA 02632 � . - - - --_ I � � ° � j �- --� �� ! ' S i � � i �� �� __ _ _ . , - �, ss l �©0­7 ERMIT T®wffi of Barnstable *Permit# Expires 6 months from issue date APR 18 2007 Regulatory Services Fee MNIN F BAR ST LE Thomas F,Geller,Director a q11't10-7d1*—' building Division Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 u,v��.toum.b armtable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERAM APPLICATION - RESIDENTLA-L ONLY Not Valid without Red X-Press Imprint Alb �- p/parcel Number ��uu ��''�� ( ` . perty Address , b �Ca `' ��e.�l u V: 4 1 �Ak I` (--3 Z Residential Value of Work `7-�e36 '� Minimum fee of S25.00 for work under S6000.00 ersName&Address Cn , ntractor's Name q+t°t`� LM Z+L CA 6c' -7�'` 1 F44& Telephone Number_ i Ime Improvement Contractor License r(if applicable) /49 Cl,be-r- i>;s�cti��-Srvisor`s-�icer��-(�pp':ieablej lWorkman's Compensation Insurance. Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance ;urance Company Name G M'-t 5 . DIkman'S,Comp.Policy tt yN) C_?_'2 414 9 9 C ipy of Insurance Compliance Certificate must be on file. rmit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders. U-Value `s (maximum.44) 'Where iequired: ISSUZnCe of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission, A c y of the Home Improvement Contractors License is required. t GNATURE: Forms:expmtrg :,A e0613,06 �a Froni:Alt To:Steve White Date:4/17/2007 Time:10:42:28 AM Page 3 of 3 A DRA. 'CERTIFICATE OF LIABILITY INSURANCE 04 17/200' PRODUCER (508)94S-0393 FAX 000945-4048 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eldredge & Lumpkin Ins. Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 697 Main Street HOLDER,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Chatham, MA 02633 INSURERS AFFORDING COVERAGE NAIC# INSURED Caliber Building & Remodeling LLC INSURER A: National Grange Mutual Ins Co 14788 147 Ridgewood Ave INSURERS: Commerce Group CIG001 Hyannis, MA 02601 INSURERC: Granite State Ins. Co.-ARWC 13102 INSURER D: INSURER E: COVERAGES 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 IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION - LIMITS GENERAL LIABILITY MP027360 09/15/2006 09/1S/2007 EACH OCCURRENCE $ 500 r 00 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ S00,000 CLAIMS MADE 7OCCUR ME D EXP(Any one person) $ 10,000 A PERSONAL&ADV INJURY $ S00,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 POLICY PRO- JECT M LOC AUTOMOBILE LIABILITY BBNVCS 02/16/2007 02/16/2008 COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ B 250,000 HIRED AUTOS BODILY INJURY $ NON•OWNEOAUTOS (Per accident) S00,000 PROPERTY DAMAGE $ (Per accident) 100,000 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG S EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC2244990 03/02/2007 03/02/2008 X TWO STATU• OrR— TH- EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 100,000 C ANY PROPRIETORIPARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ 100,000 If yes,describe under - SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMB $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Town of Barnstable BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 200 Main St OF ANY D UPON THE INSU R,ITS AGENTS OR REPRESENTATIVES. Hyannis, MA 02601 AUTHOKZFD 12RES ACORD 26(2001108) ©ACORD CORPORATION 1988 • •Yq • \• 1/Yr Vv..w..wv.w..vwwr.w r.aww..r wr.wwwr --- .• . Department of lndustrial Accidents _ Office of Investigations a 600 Washington Street' Boston,Mf102111 www.mass.govtdia ' 'Workers' Compensation Iisnt•auce Affidavit: lBOders/Contractors/FIdctricians/Pltmbers Applicant Information (( ` �J Please Print LepiJbly Name(Business/Organization/Individud): . �O.l [ e.r 1 t(X%!Lr•t (2,eeui/�o(k e_t v!!�• L Address' City/State/Zip: 0'17(cPhone:#: Are you an employer? Check the'appropziate bog: •'Type of project(required):• . 1. I am a employer with Z 4. [] I am a general contractor and I employees (fall and/or part-time).* have hired the sob-contractors 6.. New construction . 2.M I am a'sole proprietor or partner- listed on the'attached sheet. 7. Epemo&ling ship and have no employees These sub-contractors have g• F]Demolition' working for me in any capacity. employees and have workers' •$. . 9.••[]Building addition [No workers' comp,insurance comp,insurance. required.] 5, We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their ` '3.❑ I am a homeowner doing.all work � 11.[]Plumbing repairs or additions myself[No workers'comp. right bf exemption per MGL' 12.0 Roof repairs . insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13:[]Other comp.insurance requited.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy inforrnation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a Dew affidavitindicating such. $Contractors that cheep this box must attached an additional sheet showing the name of the'sub-contractors and state whether ornot those entities have employees If the sub-contractors bane employees,they must provide tbeir workers'comp.polidynumber. ram an employer that is providing workers'compensation insurance for my employees.-Below is-the policy-and jab.site information Insurance Company Name:_ C rR, +e Policy#'or Self-ins.Lie,A 4 If 9 9 b Expiration Date: �J • a Q Job Site Address: 4 i S� C Citylstate/Zip: ( °- +1 sr-y (e •®v� 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 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 1)IA•for insurance coverage verification. I do hereby certify un r the pions and penalties of perjury that the information provided above is true ani.correct.' Signature:. ,/' � • Date: 7_07. _ Phone#: -,;2 46 - V& g q Official use only..-Do not write,to this area, fa be completed by city or town officiaL City or Town: Permit/License# Issuing ALthority(circle one), :1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6, Other Contactgerson: Phone#: Information And. astructi®ns Massachusetts General Laws chapter 152 requires all employirs to profide workers'compensation for their employees. Pursuant to this statute,an employee 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 rPc^PiyPT or tiStee of an individual,partners association or other legal entity, employing•employees• I3owever the owner.of a dwellfn,g 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 onsuchAwelling-house or on the grounds or building appurtmantthereto shall notbecause,of such•employment be deemed to be an employer." e state or local licensing ene y shall or withhold the issuance IvIGL chapter 152, §25C(�also states that"every s gag, ,y • ,reneWal.of a license or permit to'opeiate a business or to construct:buildings in the commonwealth for any applicaut•who bas not produced-ac aptable evidence of compliance with the insurance coverage required.? Additionzny,MGL chapter 152,•§25C(7)states`Neaer the commonwealth nor any of its political subdivisions shall enter into any contractfor,•theyerformmee of public work until-acceptableevidence•afcomplfanee with the insurance requirement of chapter have been presented•to the contracting authority." requir . Applicants Please fill out the workers'compensation affidavit comipletely,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 certifrcate(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, B.e advised that this affidavit may be submitted to the Department of Iudus rial 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 pemut.or.license is beipg requested,not the Department of Industrial Accidents; Should you have any questions regarding the law•or-if you are required to obtain a workers'•. comperisationpolicy,please call the Department at the number listed below, Self-insured companies shouM:6nter-their self-insurance license number on the appropriate-line. City or Towp Officials. Please be sure that the affidavit is a mplete'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 sane to fill in the permit/license number which will be used as a reference number. Iu addition, an applicant. that must submit multiple permit(license applications in any given year,need only submit onq affidavit indicating current policy-information(if necessary)and ender"Job Site Address"the applicant should write"aIi•locations yin (City*or town),"A•copy'of the affidavit that has been officially stamped or marked by the city or town shay 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 homeowner or citizen is obtaining a license or permit-not related fo any business or commercial ventute (i.e,a dog license or permit to brim 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,,i please do not hesitate to give us a call. The Depa�ment s address,telephone•and fax number t,,Cazr.DaweaJ. of Massacbm 6t€s Dtrpzd==t of TaduWal A.cxi.dwnts' Office ofIn-yeatiga ons $.Ostcm,MA E7111 Tfl 6:17-727-490-Q ext 406.ar 1-°o77-MA.SSAFE Fax 4 617-727-7 f49-. . Revised 11-22-06 ��pfTHF ,yo Town of Barnstable. y d. Regulatory Services ' nk-C& Thomas F.Geiler,Director 1. 9o°plED►AA�A,�� Building Division Tom Ferry, Building Commissioner 200 Main Street Hyannis,MA 02601 wwzv.town.b arnstable.ma.us Office: 5 08-8 62-403 8 Fax: 5 0 8-790-62.3 0 Property Owner Dust Complete and Sign This Section If Using A Builder I as Owner of the subject property herebyauthorize � uL(lt �t t�-� to act on mybehPH, in all matters relative to work authorized by this building permit application for; . (Address of Job) Signature of Owner Date • � �o�V"tlI . Print'-Na_t ae OrORr/S:O-WN RPEP.MIISSION Results Page 1 of 1 Home Improvement Contractor Look Up Enter Search terms separated by spaces. Search terms can be Town/City,Name, or License number Select Search type: r AND r, OR Search n Search Results Reg. F Applicant =1 Street City State Zip NameCALIBER HOME Title Expiration 14971271 49752 IMPROVEMENT1232 ORAI,DANS HARWICH�02645 STEVEN OWNER 2/6/2008 Total of 1 Records matched. Back to Home Page BBRS Privacy Statement http://db.state.ma.usibbrs/hic.pl 4/19/2007 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I A m / � 'G- IL DATA i r �17 .�. ✓5. y Assessor's map and lot number ..................(... ............... THE o Sewage Permit number .. � "' ' � G '� sC SYSTE y� House number ....................:........................................ VAN i 7 \ y TOWN OF BARNSTA � N s BUILDING INSPECTOR APPLICATIONFOR PERMIT TO .............................:.....................................................................................:......:.. TYPE OF CONSTRUCTION .....R X.......Ac, 1.: ........ `X. .. ...:.......................... ..................i q.;?r •, TO THE INSPECTORW0F'18UILDINOi5`.+"'.: „.,,•,,-m ,: x wda•a- r� ,... �� r.<<.,, ;n„.� ms.�i:.;:�. *..�,. _k ,a,._ t The undersigned hereby applies for a permit according to the following information: Location ......�7..............!..//1 .. ............. .�..: .............Lc:C'�. . .. .2 ...... ................... ProposedUse ... . ::Z..:~........................................................................................................................................... ningDistrict : � /� � /...........Fire District .............................................................................. of Owner(.. `:Y..1... .... .� .`. .? .�x:..............Address .X7.... ev, f Builder 7~' %.. .::.r•. Address / p .. Architect ..................................................................Address ............................................ ........................................ ooms ..................................................Foundation ...............: ':..... .............................................................Roofing �e!S'............ '.................. . .. `.,.....f..%.�.�:.....:�Z: ..:.Interior ............................... ........................................ d ......... .................Pwmbing .......: .. -- ......... ......... ......... .................... .............. . z).0.........................................................................Approximate Cost ......... ................................. .......... �e Plan Approved by Planning Board ________________________________19________. Area .....................- ram of Lot and Building with Dimensions Fee ^SUBJECT TO APPROVAL OF BOARD OF HEALTH j r . L__j •�J/" I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above `- construction. 51 Name ... .2.............. .! '?�. :............. r Zafe'ris, John A=190®47 `No .217.4�a.... Permit for ..A•dd A r•••to••dwell—ing " c� .................... ....................................................... Location 9.7—Hi. hland••flr 1 .......................Gentervi11&............................... ! Z Owner ........John••Zaf®ri&................................ _ r Type of. Construction ............... ................................................................................ r Plot .:......................... Lot ................................ . ,+! i / d < Permit Granted QCt....,..22..........179 j40 Date of Inspection ....................................19 _ Date Completed Alec ..........z..19 go PERMIT REFUSED ................................................................ 19 ........... ................................................... ..... .............................................. f n > N .......... A .is. ........................................... Approv ! fic.8. .............................. 19 �r ......... . ...A. 4. ..................... ra ............................................................................... r Assessor's map and lot number ................... �oF THE job Sewage Permit number ...ljt/t IV l.t i� � � �%� ��Q ♦� Z EARN TABLE, i House number ........................................................................ s roes. �p 2 63 q. `00 ��rPY a• TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATIONFOR PERMIT TO ............................................................................................................................... TYPE OF CONSTRUCTION ......�.'''�"% °......f -� i(n� (... ""�.�.: .......... I ...:...... ........t...... ......... :..... �:...:.::.... ................ ,. TO THE INSPECTOR OF BUILDINGS: The undersigned Thereby applies fora permit according to the following information: Location ....... .................f. �.. :�-C �r1 1 ............ 1.. .... -e.......� 'C. �? '�i i.?.. ?..�... ProposedUse .<.%: .. r/� 7:7. ............. #.......p ................. ...... .... .... ....................................... ..... Zoning District ..........Fire District Name of Owner ' ! f�' ?...... r � .....` ..� ,<...............Address ..: .. �'1 G u ...'l..,..-..( ..� .?s� ,0 Name of Builder . !.......,1..f..-`' �... � 4e.,- :..................Address ......:.1/ T .............. ..�i� r '.... • IL Name of Architect .....:............................................................Address Numberof Rooms ..................................................................Foundation .............................................................................. Exterior r ! ...Roofing e:t'...... -..................................................... ................................................................ J _ Floors .... ........:I..?.... < ..... A,.-6!lf AA......Interior ....................................................... . . Heating .......} / ..................................................................Plumbing Fireplace ..................................................................................Approximate Cost ........ /„ .. ^'.......... Definitive Plan Approved by Planning Board ________________________ - 19 - --. Area - . Diagram of Lot and Building with Dimensions Fee ` SUBJECT TO APPROVAL OF BOARD OF HEALTH It I I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .....f :........ �CLltiC�-� .................................. .................. ` . - ` � - � � � ' , � . . � ` � . � —^- ^'^^'—^^^--`'^'----^^' ' Approved ................................................ lV ----'-----'~—^----------`' ----'~----------`—~^^^^'—^' - ' ^