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HomeMy WebLinkAbout0079 LONGFELLOW DRIVE or t P 4T e. , 4 , 3 s i n S f/ x- r o , t i a nn r „ , , . x - r 7 7 _ R lm t c - s y, Town of Barnstable Buildin 9 ' PoSt:Thls;Card SoTha!I#,is�/isible,;From:the Street ;-Approved•Plans_Must,be Retained on Jbb and this.Card Must be Kept ,� . Aau - Pos ed Unt I Final Ins ecL�onHas Been Made , `� Permit ' Where a.Cert�ficate•iof Occu anc is Re u�red-°such.8u ldm yshall Not be Occu fed until a F,�nal lns ect�on has.been.made� Per mit Permit No. B-18-1486 Applicant Name: ROBERTJ HARRIS Approvals , Date Issued: 06/05/2018 j Current Use: Structure Permit Type: Building-Addition/Alteration-Residential Expiration Date: 12/05/2018 Foundation: Location: 79 LONGFELLOW DRIVE,CENTERVILLE Map/Loot 188 010 Zoning District: RD-1 Sheathing: r Owner on Record: TARNAVSKI,OLEG � Contractor N me-, ROBERT J HARRIS Framing: 1' Contractor License CS 060160 Address: 79 LONGFELLOW DRIVE 2 CENTERVILLE, MA 02632 a � EstProject Cost: $ 15,000.00 Chimney: ) Description: RAISE CEILING 15X16 LIVING ROOM AREA. INSTALLATION,&3 Permit Fee: $126.50 SKYLIGHTS REPLACE 3 WINDOWS - Insulation: FeePaid $ 126.50 Project<Review Req: y � Dat z 6/5/2018 Final �1 Plumbing/Gas f Building Official Rough Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced vriihm six months after issuance. Final Plumbing: All work authorized by this permit shall conform to the approved application and the�approved construction documents f_or which�this permit has been granted. All construction,alterations and changes of use of any building and strVi tures'shall bd in compliance with the local zoning by laws and codes. Rough Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for Ion for the entire duration of the work until the completion of the same. Final Gas: 15 11 ' The Certificate of Occupancy will not be issued until all applicable signatures by-the Building and,F�re Officialsareprovided o�nthis permit. Electrical Minimum of Five Call Inspections Required for All Construction Work. 1.Foundation or Footing s Service: 2.Sheathing Inspection . �� Rough: 3.All Fireplaces must be inspected at the throat level before firest fluelmmgryis installed „ , 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Rough: 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Health "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site Fire Department 1�:_ All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: ApplicationNumb ...... ........................................... O IREIAPermit Fee.......................................Offier Fee........................ I 4k . .. ...... Total Fee Paid................... ........ TOWN OF BARNSTABLLXv Permit Approval by...... ....... .......On.... BUILDING PERMIT MV........ ...........Parcel...................................I.. APPLICATION Section 1 — owner's information and Project.Location ProjectAddress 7 66-KA e_LLB L�� j L v Village owners Name &)A V 5 1-1-11 owners Legal Address— city ��o (e State zip Owners Cell E-mail S 1 L l 7+60 CJ� -'Section 2—Use of Structure Use Group_ik_ � E] Commercial Structure over 35,000 cubic feet ❑ commercial Structure under 35,000 cubic feet R"Single/Two Family Dwelling Section 3 —Type of Permit F] New Construction F-1 Move/Relocate E] Accessory Structure ❑ Change of use M Demo/(entire structure) F] Finish Basement ❑ Family/Amnesty El Fire Alarm Rebuild El Deck Apartment Sprinkler System ❑ Addition ❑ Retaining wall ❑ Solar [91 renovkion 11 Pool El Insulation Other—Specify Section 4 - Work Description 7A t T-qqt undated-2/9/,2018 Application Number.................................................... Section 5—Detail Cost of Proposed Construction Square Footage of Project tl'D SY� Age of Structure. G��y�S./�� Dig Safe Number AJIA ' # Of Bedrooms Existing Total# Of Bedrooms (proposed) GL/U C 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist Design Section 6—Project Specifics ❑ Wiring ❑ Oil Tank Storage ❑ Smoke Detectors ❑ Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑Add/relocate bedroom Water Supply ❑ Public ❑ Private Sewage Disposal ❑ Municipal 'U?'On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility:�p yJS I am using a crane ❑ Yes 9 No Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland, coastal bank? Yes ❑ No Section 8—Zoning Information Zoning District :J� T Proposed Use Lot Area Sq. Ft.. z' Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required . . , ,Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No Last undated:2/92018 �.►+� Town of Barnstable °* Building Department Services Brian Florence,CBO NAM a 'Building Commissioner ,.. . 200 Main Street,.Hyannis,MA 02601 www.town.barnstable.ms.us Office: 508-862-4038 Fax 508-790-6230 r P operty Owner Must Complete and Sign This Section. If Using A Builder L—Oleg Ta.rnayski_.,.as Owner of the-subjecf property hereby authorize_Th'Ugly Duckling,House Company_to act on.my behalf, in..all matters relative.to;work authorized by this building permit application for: 72 Longfellow Drive;MA 02632 (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. Signatu a ok-. wnet Signature of Applicant z O W AV S i<f Ct CAI'>pU�GL- Print Name Print Nam v! L(4"-b J Qkt� 4trj(m Date Q:F.ORMS:OWNERPERMISS10NPOOLS Rev:08/16/17 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home ImprovementTContractor Registration Type: Corporation Registration: 169134 THE UGLY DUCKLING HOUSE COMPANY, 1C 194 MAIN ST i'�� � ��`- _— �� Expiration:• 05/18/2019 W.BARNSTALBE,MA 02668 / I Update Address and return card. Mark reason for change. SCA 1 t9 20M-05/11 ------ - -- - -- --....... ..._. _ —n �a� o - ..W ^enw'":a �.C'^ ^'ent ;�a, C�/e�oarrvneryracuea/C�a��llaruccc/uaell% Office of Consumer Affairs&Business Regulation. a HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to:. 4 s Registration Expiration Office of Consumer Affairs and Business Regulation r _ _169-114 05/18/2019 10 Park Plaza-Suite 5170 " B ton MA 02116 THE UGLY DUCKLINGxHOUSE;COMPANY,LLC t ki! CHRISTINE CALDW.••ELL . �,Q Cam——• 194 MAIN ST W.BARNSTALBE,MA 02668 Undersecretary Not valid without signature z: ` f a ' 6 � �t",�r� F ate• �' '�:. � y.; Ak�q �t"�ry�y�� its "' J �,. Ak • of DiviSloe ofeof Suit ng,RequtklEans _ S ROBERT J ; AAMs ' ,. xix S ENTEI c"O M- misSioner Coe& 41 , S �,g e a. r. �Y C PR r c s L(A +�� Y IL U-) E �� From: theuglyducklinghouse@gmail.com Cf Subject: IMG_0276.JPG Date: May 2,2018 at 3:01 PM f ` To: Ug Duck theuglyducklinghouse@gmail.com gmehusefts Dbepartine t of Pq blie ,fBualding �Regu at tins fad ttand rdds. ENTER HARM MA '02632 f 4 I E#y N. y `� - ratty p it3IFl is 4!"er{ v •/+rY'�ii A r The Commonwealth of Massachusetts Department of Industrial Accidents Isr Office of Investigations FL 600 Washington Street - Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information //�� (�Please PdpALegbly ' Name(Business/Organizafion/IndividuaI)� U VL Ll�0 CIZ,U Address: &`'I v� 11nJ s,i . C�Y• /State/Zi ?-v.�S! 1� C t-%/FF4 hone#: P• Are you an employer?Check the appropriate bo - . Type of project(required): 1.❑ I am a employer with 4. am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner-. listed on the attached sheet. 7. ( 'modeling ship and have no employees These sub-contractors have g, ❑Demolition working for mein any capacity. employees and have workers' 9. E Building addition [No workers'comp.insurance comp.ins,,,-race.# required.] 5. El We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 11. 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 4� ] 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. l t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors 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 uumber. . lam an employer that isproviding workers'compensation insurance for my employees. Below is thepoUcy andjob site information. /,� Insurance Company Name: / � ��- `ee7(� Policy#or Self-ins.Lie.#: lP Expiration Date: Job Site Address: y re �' t,?, City/Sta#e/Zip:( �4e� N��e �&x 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 DIA for insurance coverage verification. I do hereb d r a d enalti o p ury that the information provided above is true and correct. Si a Date: l a Phone#: a 1�� Lf �a Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector. 6.Other Contact Person: Phone#: -Aco O® CERTIFICATE OF LIABILITY INSURANCE. F°ATE`MM/°°"YYY' �/ 01/25/2018 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 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 WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Joanna Bednark DOWLING &O'NEIL INSURANCE AGENCY a/c°N o E : (508)775-1620 77777M.No: ADDRESS: jbednark@doins.com 9731YANN000H RD INSURERS AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: UGLY DUCKLING HOUSE COMPANY LLC INSURERC: INSURER D: 194 MAIN STREET. INSURER E: WEST BARNSTABLE MA 02668 INSURER F: COVERAGES CERTIFICATE NUMBER: 233721 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR - TYPEOFINSURANCE ADDLSUER -. POLICYNUMBER MIWDPOLID/EFF IP EXP IMIDD/ LIMITS LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS MADE 0 OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑ PRO ❑ LOG PRODUCTS-COMP/OP AGG $ JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTYDAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION /� SPER TATUTE ERH AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,000 A OFFICERIMEMBEREXCLUDED? WA WA wA 6S62UB7H71178417 10/04/2017. 10/04/2018 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE. DELIVERED IN Felix Shn@Uf ACCORDANCE WITH THE POLICY PROVISIONS. 44 Hood Street AUTHORIZED REPRESENTATIVE Newton MA 02458. Daniel M.CrAjey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD C DATE(MM/DD/YYYY) A CC CERTIFICATE OF LIABILITY INSURANCE 0/126/2018 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 INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT John MCShera Marshall K Lovelette Insurance Agency Inc FAMES FAX 396 Main St c e . (508)775 4559 (A/C,Nei:(508)775.4577 West Yamouth,MA 02673 ADDRESS: John@loveletteinscom INSURERS AFFORDING COVERAGE NAIC# INSURERA: WESTERN WORLD INS CO INC 13196 INSURED R&R Construction Custom Homes Inc INSURER B: AEIC A0086 90 Nye Road INSURER C: Centerville,MA 02632 INSURER D: INSURER E: INSURER F 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1�TRR TYPE OF INSURANCE ���� POLICY NUMBER MMIDDIYYYY MPOLICY /Y YP LIMITS A COMMERCIALGENERALLIABILITY NPP1452535 01/29/2017 01/29/2018 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR DAMAGE TO RENTED' 100,000 PREMISES Ea occurrence $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JPRO- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea axidert ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLANS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WCC50037992017A 11/29/2017 11/29/2018 PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETORPARIAEREXECUrIVE E.L.EACH ACCIDENT $ 500,000 OFRCERMEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ _ 500,000 IF yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Ugly Duciding Building Company ACCORDANCE WITH THE POLICY PROVISIONS. 194 Main Street __-..... ... -:.......- .. ..__.._.._.. .--------- West Barnstable,MA 02668 AUTHORIZED REPRESENTATIVE _J ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) - The ACORD name and logo are registered marks of ACORD ACORO® DATE(MM/DD/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE 05/03/2018 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 INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not'confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: Patricia Amaral HUB INTERNATIONAL NEW ENGLAND LLIC P"�"E Ems: (508)235-2283 ;� NO E-MAIL ADDRESS: patricia.amaral@hubinternational.com 222 MILLIKEN BOULEVARD INSURERS AFFORDING COVERAGE NAIC# FALL RIVER MA 02721 INSURER A: ACADIA INS CO 31325 INSURED INSURER B: RICHIES INSULATION INC INSURERC: INSURER D: 111 OLD BEDFORD RD INSURER E: WESTPORT MA 02790 INSURER F: COVERAGES CERTIFICATE NUMBER: 264826 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - IN TYPE OF INSURANCE ADDL SUER luBk AM POLICY NUMBER M°U IC Y EFF POLICY EXP MMIDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR D AGE O RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑ PRO- ❑LOC JECT 4 PRODUCTS-COMP/OP AGG $ 1 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE. $ AUTOS Per accident UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X STATUTE ERH_ AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,000 A OFFICERIMEMBEREXCLUDED? WA WA N/A MAARP301209 02/10/2018 02/10/2019 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT--$ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Ugly Duckling House Company ACCORDANCE WITH THE POLICY PROVISIONS. 194 Main Street AUTHORIZED REPRESENTATIVE West Barnstable MA 02668 ) L Daniel M.Croyey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD r Application Number........................................... Section 9=:Construction Supervisor Name_ -(�j fr` � Telephone Number Address l�N`1� ( City�pM L4 t�� State C," Zip �� Z License Numbek �� �� License Type L Expiration Date 5171eo- Contractors Email_ jZ(2 Cell I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation req ' ed by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signature Date �SS��f`/ Section.10 -Home Improvement Contractor Name U 61 Lf 0-0&4(-1�A t tiW C' , Telephone Number L c 'Lt C e Address c( wi S`I City Uj- IZ-State Registration Number CQ Expiration Date o'5�/ I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentatio a aired C an o f Barnstable.Attach a copy of your H.LC... Signature Date ���� Section 11 —Home Owners License Exemption Home Owners Name: Telephone Number Cell or Work Number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Townof Barnstable. Signature She �? ��( Date APPLICANT SIGNATURE Signature Date Print Name C S &4,t�� Telephone Number E-mail permit to: t° C) e�(l e G 4,"AC T....f....a.sa. inrini 0 Section 12 -Department Sign-Offs Health Department. ❑ Zoning Board(if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ _� Conservation For commercial+work,please take your plans directly to the fire department for approval t i Section 13 —Owner's Authorization I, , as Owner-of the-subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of job) Signature of Owner date Print Name y, i Last updated:2/92018 u TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION,,, Map ��0 Parcel -0/0 A wici"ation #�� �t� pP Health Division Date Issued lo Conservation Division :Application Fee y: Planning`Dept `.Permit Fee' S l Date Definitive Plan Approved by Planning Board C29 �1 Historic - OKH - Preservation/Hyannis -44 Project Street Address 7 -0006 Du) D iz ie 9 , Village GEt,11-r 1,LC _ Owner,1 SIN tfC%J6&1eK, -�k GAk, 0-r- 8Ac_iL Address COAA6&-I&��"_ e/' Telephone W 5-0 9 v 771 v 709•z (-' 00S"9go- 578 79 CW `SDI. 398- 2L; 0 elk Permit Request ReW104C -NSH VdSKt(e C_o 0PTt*A_.. 14 Do W P 9m,6LS v ire- i L 7 Square feet: 1 st floor: existing 000 proposed /0610 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size_' �y+ Ac�W' Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure 1! 'I7_3 /Historic House: ❑Yes INo On Old King's Highway: ❑ Z Yes o Basement Type: ❑ Full ❑ Crawl ®'Walkout ❑ Other Basement Finished Area (sq.ft.), 3®o Basement Unfinished Area (sq.ft) O Number of Baths: Full: existing: new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing l_new First Floor Room Count Heat Type and Fuel: WGas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes UNo Fireplaces: Existing ZNew Existing wood/coal stove: ❑Yes UNo Detached garage: ❑ existing 0 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 01 Telephone Number go ® s7g 7 Address 4-006 f f.D141 License # cloilr C2 II lC- 'A lk 6_0 l0Qi 1- Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE / 0 / .7 ZI 0 ID a t FOR OFFICIAL USE ONLY r APPLICATION# DATE-ISSUED MAP/PARCEL NO. ` ADDRESS� VILLAGE . - p OWNER DATE OF INSPECTION: FOUNDATION t _ FRAM INSULATION FIREPLACE Eq ff& ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL I FINAL BUILDING z�lo DATE CLOSED OUT ASSOCIATION PLAN NO. Y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 w„ 5: www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): J 05eH .4 NIE0 Address: - t O>.)�R- ,L_zuO DL City/State/Zip: t 1, Phone. #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and d 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.. j'�emodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' $ 9. ❑Building addition o workers'comp.insurance comp.insurance. 10.[1 Electrical repairs or additions equired.] 5. ❑ We area corporation and its 3.1 M I am a homeowner doing all work officers have exercised their I L E]Plumbing repairs or additions 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.❑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 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. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.M Expiration Date: Job Site Address: City/State/Zip: 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 crimirial 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 do hereb er ' d r he pains and penalties of perjury that the information provided above is true and correct. Signature: Date: ./a 9 '1 0 1 O Phone#: v Official use only. Do not write in this area,to be completed by city or town official 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 Instructions Massachusetts General Laws chapter 152 requires all 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 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-contractors)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 pen-nit/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 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 (i.e.a dog license or permit to'bum leaves etc.)said persons 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. The Department's address,telephone-and fax number: The Commonwealth of Massachusetts Depa dent of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 61 Z-127-7749 Revised 11-22-06 www.mass.gov/dia �T Town of Barnstable - , ' "o Regulatory Services snxrtsrnar.e Thomas F.Geiler,Director Mass. 9q, 1639. ��� Building Division RFD NAA'I A Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION q Please Print DATE: 6 y / 2_6lio r�� , JOB LOCATION: W os,4f�6() Z)(L Cc ' 1. f LC n mberrstre et village "HOMEOWNER": JQS '508 - pO— It J{o¢ - 3 — 2: 1 name �i home phone# work phone# CURRENT MAILING ADDRESS: �� tpa- �r rL-V ot.J- LV city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER - ' ' Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit.v'(Section 109,1.1) ' The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and re ' e nts + �' Signa re of Homeowner Approval of Building Official 1 Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of constriction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\homeexempt.DOC Town of Barnstable Regulatory Services saxr' sl EMAS& g` Thomas F.Geiler,Director �i01f0Ma+a,� 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 I, �0 4 $A ��%Vi�1/(,✓L , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for. �A) 1,00 0 (Address of Job) 9-0 124 1 10 Si a of URner Date ' Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:OWNERPERMIS S ION 79 Longfellow Drive, Centerville, MA 02632 Y ' UPPER LEVEL (Total Sq.Ft.= 1104) 46 9.5 13.5 8.5 13.5 Dining Kitchen 10 Bath 10 Bedroom.1 10 Room 10.5 3.5 . .-17.5 Hall 3 10 24 . Closet 11 Living D o Bedroom 2 Room 7.5 Bedroom 3 13 " R 9.5 Ln Front Foyer 14 7 79 Longfellow Drive, Centerville, MA 02632 LOWER LEVEL (Total Sq. Ft.= 1300) 14.5 8 10 13 Laudry Room Electronics Room 8 Bath 8 Heat/Hot Water 8 Office 11 17 14 Hall 3.5 3.5 4 Ft Folding Fr e Foyer Counter 13.5 oye Home Theater/Playroom 13.5 3.5 Kitchen 9.5 6 Electric .14.5 Gas Dish Sink Stove washer 23 SunRoom 13.5 79 Longfellow Drive, Centerville, MA 02632 PROPOSED �Pl�o 15 LOWER LEVEL (Total Sq. Ft.= 1300) 14.5 8 10 13 Utility Room Electronics Room 8 Bath 8 Heat/Hot Water 8 Storage Office 11 17 14 Hall 3.5 3.5 4 Ft Folding Fridge Foyer Home Theater/Playroom 13.5 3.5 Laundry Room 9.5 6 Electric 14.5 r Gas Washing Sink Dryer Machine - 23 SunRoom 13.5 Barnstable OF THE Tp� NI-Amedca M * BARNSPABLE, * 1 1 Town of Barnstable s63q.ArED N1p'�A Growth Management Department www.town.barnstable.ma.us/$!rowthmanal!ement 2007 Jo Anne Miller Buntich ; r Director June 28, 2010 Joseph M Hevener &Gail Fitzback 79 Longfellow Drive Centerville, MA 02632 Re: Re: ZBA Appeal #2009-052 - Hevener Fitzback Dear Mr. Hevener and Ms. Fitzback. Our.records indicate that you still have not signed the Declaration of Restrictive Covenants guaranteeing your commitment to and understanding of the program and the income and rental guidelines.. :. I must remind you that on Octo6er,7, 2009 each of you signed.an Accessory Affordable Apartment Program Affidavit that commits you, upon the receipt of a Comprehensive Permit, to the recording of a Declaration of Restrictive Covenants at the Barnstable County Registry of Deeds: For your convenience I .have attached a second copy of the Declaration'of Restrictive Covenants. Please sign and return the document as soon.as possible, If you require assistance.in completing this step, please' contact me.at 508-862-4750.or email cindy.dabkowski@town.barnsable.ma,us . Failure to complete this step by July 12, 2010 will result in referral of your Mile to zoning enforcement and restoration of the property to a single family home use in compliance with applicable zonin&must commence. x Thanks in advance for your cooperation; Sincerely,; ,' ; Cindy Dabkowski " Accessory Affordable Apartment Program Coordinator 367 Main Street,Hyannis, MA 02601 (o) 508-862-4678(0 508-8624782: - 200,Main Street,Hyannis, MA 02601 (o)508-862-4786(0 508-862-4784 Amnesty Apartments Last Name HEVENER First Name J EPH M. 2nd Owner BACK .2nd Owner GAIL FITZ � Last Name _._ _ µ First Name Map Parcel 188010 Property No 79 Property Street ILONGFELLOW DRIVE ZipVillage CENTERVILLE State 32 Status _ Action Required Enforcement Assessors Use Group Single Family�� Comp Per Issue Recorded Date Application# _ Permit Issued: C of CTotal � # - Program Total Descripton i Cert of Occupancy Issued: Cert of Compliance Issued y Notes 9/14/09 BLDG/GMD MTG:QUESTION ON NUMBER OF BEDROOMS, HEALTH SAYS 3,OWNER THINKS TP: OFFICE DOWNSTAIRS CAN'T BE COUNTED AS BEDROOM, DOESN'T HAVE EGRESS. AMNESTY APARTMENT ELIGIBILITY VERIFICATION 1/15/10. 6/2/10 MTG:APPROVED AT 2/10 HEARING,DOC.S. NOT RECORDED, CINDY WILL SEND CERTIFIED LETTER.. 10/4/10 MTG,.DEED RESTRICTION NOT , SIGNED,COUPLE SEPARATED, ADD TO ENFORCEMENT LIST. 10/13/10.OWNER CALLED,WILL'APP1 TO RESTORE TO SF o�1"E t Town of Barnstable Regulatory Services BARNSM19 „ASa Thomas F. Geiler, Director �p 039 ♦0 rEn,,,orA Building Division Thomas Perry, CBO Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 AMNESTY APARTMENT ELIGIBILITY VERIFICATION Re: j 0 (6�2 Date o y After reviewing the street file of the above named property, I verify to the best of my, knowledge that the apartment was in existence before January 1, 2000 This property is now eligible to apply for the Amnesty Program Tom Perry Building Commissioner