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Home My WebLink About0201 MONOMOY CIRCLE L�� 'l` r . , � '� a I G Town of Barnstable *Permit# �( R ti Expires 6 months�om issue date /!*P / SS p egulatory Services Fee �L Thomas F.Geiler,Director rb)3lofD 2006 0 1 OCT � � Building Division TOwN OF 6ARNSTAhI Perry,CBO, Building Commissioner 0 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number &a z,I Property Address Residential Value of Work v Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address L es 240-BO Contractor's Name:Zkul�A 4!;; r,= /l/�'i Telephone Number Home Improvement Contractor License#(if applicable) ��— Construction Supervisor's License#(if applicable) VWorl man's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner RI have Worker's Compensation Insurance Insurance Company Name %(f.(f 2ZA=aM::: Workman's Comp.Policy# &. ,WL-X-;Z�2 f-111 — Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) VRe-roof(stripping old shingles) All construction debris will be taken to Y,��Q d U 7W ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. SIGNATURE: Q:Fonns:expmtrg Revise071405 The Commonwealth ofMassachuseats Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 y www mass gov1dia- Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers Applicant Information r Please Print Legibly Name(Busiaesa/Organization/Individu4.' mil//✓l ��J� „�G �`� Address: City/Statemp:z�L 2�rz ,, V 0V /1z ' Phone M 72,:�=.�WG 9 Are ou an employer? Check the*appropriate boa; Type of projecf(regnired): 1. / I an a employer with 4. ❑ I am a general contractor and I 6, New construction employees (fall and/or part tmze)* havehlred the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.$ 8• ❑ Remodeling ship and have no eniployees These sub-contractors have SS El Demolition worlang forme in any capacity. workers' camp,insurance. f' 9. ❑ Building addition [No workers' comp.insurance' S. ❑We are a corporation and its officers have exercised their 10.❑ Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Phimbing repairs or additions myself:[No workers' comp. e. 152,$1(4),and we have no 12.IZRoof repairs insurance required.]t . employees.(No workers' 13 ❑ Other firm a ce , required.] . *Any applicant that checlra box#1 mast also fill out the section below showing their workers'compensation policyiaformat;on ' t Homeowners who submit this affidavit indicating they an doing ail work andthen hire outside comb ctors must submit anew&Mdavit indicating such �Cantracbors that check this ben must attached an additional sheet ahawiag the acme ofthe aub-contractors end their workers'camp.policy hformati= I am an employer that is providing workers'compensation Insurance for.my employees. Below Is the policy and job siti information. ' Insm'ancd Company Name: Policy r-or S634m lac.i7 ' 466 9fDX?�12.Z Datc: Job Site Address: 4,1 /yazemdY � City/St&A:kiCz Attach a copy of the workers' compensation policy dedaratfon page(showing the policy number and expiration date). Fame to securo-coverage as required under Section 25A of MGL c. 152 rmilead to the imposition of criminal penalties of a fine up to$1,300,.90 and/or one-year imprism i=n as well as ciml penalties in the.form of a STOP WORK ORDER and a f"me of up to S250.00 a day against the violator. Be advised that a copy of this statemeni may be forwarded to the Office of Investigations of the DIk for insurance coverage verification, I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Si tore; + Date: Phone#; y c al u36 . DO fit&* 11*6 Meat,to U cmnpleftd b�04 of UM eicigL 1 City or Town: 4 1 7 ermit/License# Isesuing Authority (circle one); ,- 1.Board of health 2.Building Departmen`3:City/—i own Clerk a.Electrical inspector S.Plumbing Inspe&tor• 6. Other 1 ' Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensaftfortbeir employees. Purseant to tis statute, as employee is defined as 11 .evaY person in the service of another under any contract of hire, .. _ or written." express or' li trial expr amp ed,.An employer is defined as 'an individual,partnership,association,core' tion or other legal entity,or any two or more of the foregoing engaged in a ' ' #-enterprise, and including the legal r esentatives of a deceased employer,or the . receiver or trustee of an ` dividiial,partnership, association or other le al entity, employing employees. However the, owner of a dwelling house aving not more than three,apartments an who iesides therein, or the occupant of the dwellamg house of another employs persons to do maintenance, construction or repair wont:on cinch dwzUfng house or on the grounds or building errant thereto shall not because f such employment b e deemed tob a an employer." MGL chapter 152, §25C(6)also es that"every state or local tensing agency shall withhold the issuance or renewal of a license or permifto erate a business or to can et buildings in the con unonwealth for any applicant who has not produced a eptable evidence of compl ante with the insurance coverage required" Additionally,MGL chapter 152,125 states"Neither the corn norwealth nor any of its political subdivisions shall eater into any contract for the p e ofpublic work until acceptable evidence of conmliance with the insurance requirements of this chapter have been pr ented to the contraoth g authority." Applicants Please M out the workers'compensation affi ' camplrtely, cheelang the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),ad s(es)and pha a m=ber(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Mab Partnerships(LLP)with no employees other than the members or partners,are not required to carry work ' compels lion insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this davit be submitted to the Department of Industrial Accidents for confuraation of insurance coverage. Al be sure to sign and date the affidavit. The•affidavit should be retuned to the city or town that the application for th ermit' license is being requested;not thaDeparinaent of Industrial Accidents. Should you have any questions reg a law or if you are required to obtain a workers' compeasatimpolicy,-please call the Department at It Cr below. Self-insured companies s'h=d s;nTer their self-insurance license number on•the ME&to line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. a Department has provided a space at the bottom. ' ��affidavit.far you to fill oaat is the event the Office of Inv has to'contact you regarding�e applicant. - Please be sure to fib in fire permitTieense number which wiz b Oed a reference�bm. lm addidp4 an applicant tat must subwitmultiple permit/license applications in any ' en year, d only submit one affidavit indicating current policy information(if necessary)and under"Joh Site Address' the appli should write"all locations in_(city or town)."A copy of the affidavit that has been officially stamp or marked b the city or town may be provided to fhe applicantas proof that•a valid affidavit is on file for fature p ' cr licenses, new affidavit mustbe filled out each ' year.Where a dome owner or citizen is obtaining a license or ermit notrdated any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is OT required to c lete this affidavit The Office of Investigations would like to think you in advan a for your cooperation shoo d you have any questions, please do not hesitate to give us a call. The Department's address,telephone gad fag er: Tie CammanweaJ f M- w&%�se6ts Depw mmt of Indu Accidents fl�E.CE ` 600 Washl 7 Street Boston, MA 0 11 Tel. #617-727-4900 ext 406 os 1077 NIASSAFE ' Fax 4111:617-727-7749 Revised 5-26-05 WVmIIc55.0014V/Q].a Town of Barnstable P Regulatory Services MASS Thomas F.Geiler,Director 1639. 0 �'°�ED►ar►'�"1 ,f Building]Division. Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as.Owner of the subject property hereby authorize �}�/�/� �jo�c to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner ate Print Name Q ows:oWNERPERNESSION dui u$e only valid for ind' turn to. .` istraaou.date. If found lards or�ethe epiratk R gulatious and Stan j,icen St hef°r of Building I� Ol 13 ons a°a cTOR ,s Boae Ashburton-place of Butldmg GONTRD� On Ma.U21 Board VEMEN! Boston+ PRO { HOME IMP y p497 ' �stracorr� 10 �te9 � n� 1 ?pp8 oraton V _ Gore afore jePte ld �thoutst% gII 1 vID GOX,1N� lj istca DA ,�1au toy A 19 wENp�R pavid.Cox a 1'ARMpUSH, _...-.________._ CSR KG DATE(MMIDDm'YY) ,aCORD CERTIFICATE OF LIABILITY INSURANCE DAVID-2 10/04/06 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Northwood Eshbaugh Ins. Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 805 West Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis MA 02601 Phone:508-771-1632 Fax:508-862-9270 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER.A NORF'OLK & DEDHAM 23965 INSURER 3 ST PAUL TRAVELERS David Cox, Inc. INSURER C: P. 0. BOX 401 INSURER ID: S Yarmouth MA 02664 INSURER COVERAGES THE POLICIES OF INSUPANCE LISTED 3ELOLV HP.VE BEEN ISSUED TO THE INSUREC NAMED ABOVE=0R THE POLICY PERIOD INDICATED.NCTAIITHSTANDING ANY REOUiREMENT.TERM OF CONDITION OF A?JY CONTRhCT OR OTHER.DOCUMENT WITH RESPECT TC A RICH-HIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFGRCED BY THE POLL_ES DESCRIBED-IEREiN IS SUBJECT-0 ALL-HE-ERMS,EXC USIONS AC CONC ITIONS CF SUCr POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN RED BY PAID CLAIMS. IN*K POLICYLTR NSR TYPE OF INSURANCE POLICY NUMBER DATE(MNVDDIYY) DATE fMMIDD1Wi LIMITS GENERAL LIABILITY I EACH OCCURRENCE jG1000000 I COMMERCIAL GENERAL_iABILITY PREMISES`Ea azurence) S 50000 I CLAIMS MADE 1 OCCL'F MED-KP(Any cna person) S 5000 A i �-X lBusiness Owners R00309545 03/14/06 03/14/07 RERECNALLa.ADV INJURY S 1000000 GENERAL AGGREGATE s 2000000 GENI-AGGREGATELIMITAPP.IESPER: I PP.GDUCT6-COMP{OP Az,8 s2000000 •POLICY jR 1 LOC CSL 200QDQ0 AUTOMOBILE L14a:L1T1 — ANY AU-0 COMBINED SINGLE LIMITS (Ea ecciden:) ALL OWNED AUTOS BODIL"INJURY S I--�SCHEDULED AUTOS 1 (Par perscni i I HiRED P.UTOS BOOILv IN.F R'Y 5 NONLOWNED AL"r04 I(Par amidanG. i I PROPERTY CANAGE S (Par aocidantj GARAGE LLABILITY 1 AUTO ONLY-EA ACCIDENT S ANY.AU"0 OTHERTHiNJ EA ACC S AUTO ONLY: AGG S EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE S OCCUR CLAMS MADE I AGGREGATE S S DEDUCTIBLE S RETENT ON $ S WORKERS COMPENSATION AND X TCRY LIhIITS EP. EMPLOYERS'LIABILITY B At4YFROPRi-ITOR'PPRTNEP./E>ECII-IJE 16KU8910X742205 07j15/06 07/15/07 E.L.EACH ACCIDENT S100000 IOF-ICER/MEMBEREXCLLCED? E.L.DISEASE-EA.EVF_'JYEE 1 5100000 It yes,desoribe under SPE ALPRCVISIONSbalow E.L.DISEASE-POLICYLINTT S 500000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENCORSEPAENT!SPECIAL PROVISIONS 144 Pinquickset Rd. , Cotuit, MA CERTIFICATE HOLDER CANCELLATION TOWNBAR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRrrTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL TOWN OF BARNSTABLE IMPOSE NO OBLIGATION OR LABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 367 MAIN STREET HYANNIS MA 02601 REPRESENiATTVES. AUTHORI? EPR ENTATIN ACORD 25(2001108) 0 ACORD CORPORATION 1988 A ap_and lot Number ... : .... ... `�, SEPTIC;SYSTEM MUST BEE INSTALLED IN COMPLiANt� L WITH ARTICLE '1 STATE Sew et Permit number ... ..............................L.... .:......._... . �` -XI ;' SANITARY CODE AND*TOWN Q�FTNET�y : < TOWN . OF' BARNSTABLE� '� � r C'� i t+ tom t.�n t< !! t . W i 3) H STABLE, " 39 = BUILDING YINSPECTOR OYPT Or s APPLICATION FOR,PERMIT TO. .................................................................................... '. TYPE OF CONSTRUCTION ................................. t ....................... ............. ................. -..............._ r ..........19 t ------TO"THE INSPECTOR- OF BUILDINGS: The undersigned hereby applies for a permit according to the .foliowi information: Location ..... 2*'*'** ......................... ... .................................... ....... /L -x-Y......................... .............................. ProposedUse .. ......... ............... ......................... .......................................................................:.............................. Zoning District ................Fire District Nameof Owner' ................Address ................... . .. ................................... ................. Nameof Builder .............................................:......................Address .................................................................................... i s Nameof,Architect ................................:...............:.................Address .................................................................•................... Number o .Roo. ..... .... ................................................Foundation ...... �...�.................................................. oofng ........Exterior ... ... .................� .....................................................R �...... . ................................................... Floors ..................Interior ....... ./ ram.. .................................... .�. ..................................... Heating .... /.�..."_....`�':"............................................:Plumbing ........ r..La ...................................... Fireplace ......................................Approximate Cost ...... 0 ... ...... Definitive Plan Approved by P nning Board ________________________________19________. Area /�`o0 ...f • Oo Diagram of Lot and Building with Dimensions Fee .......... . .......................... SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of-Barnstable regard' the above construction. CSi Name .................................. ... ................................. I- Small, Alan G/ / li'341 - - . one story, ........ i • - �j ;Perrriit for; Single family` dwelling �... . ............................................... Monomoy Circle - Location .. .......... ........... ..... . - Centerville ^ ..................................... ..........`..... .`. .......... Alan Small Owner ..............................................:......: ........... frame ,. Type of Construction .......................................... t , ..................................................... - ................. Plot ............................. Lot ............ #58............ April 26 f 76 Permit Granted • t ....19 OA Date of Inspection .. /7b... ...,....19 Date Completed .... 7vl.............19 r a PERMIT REFUSED r ........... ..................... 19 - r h .• ........................ •............ -m................................... • r•. • ,} ~� _ J _ !. ........... .... ................................................. ...................................................... .......... Approved • r I 1_..pT 5�5 e 12t N } I ( 4 1 WILUAM y4 f. . � Ka 19334 qOSTE �rl/p SU��'•'� Shlo wN 01V TH/5 104,4AJ F "5 TO 7N� �oN/tiG /3� LAWS OF 7746' ?Uwe/ �U �`i