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HomeMy WebLinkAbout0378 NYE ROAD 1 r r z � I y Town of Barnstable *Permit# " / �1 X- S IT Expires 6 months from issue date JUL 1 3 2007 Regulatory Services Fee Thomas F.Geiler,Director &r7J191a? JIL TOWN OF BARNSTABLE Building Division Tom Perry,CBO, Building Commissioner 200 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 � Al Property Address /��7$ Iy C "d t'-Y [Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Po,4&' (-�erv-c'tr Contractor's Name 13a ('- bsk ev Telephone Number 56 Home Improvement Contractor License#(if applicable) / /STo W Construction Supervisor's License#(if applicable) DWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. . Permit Request(check box) [� Re-roof(stripping old shingles) All construction debris will be taken to s $J F—'CCC) ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders. 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. A copy of the Home Improvement Contractors License is required. SIGNATURE: / 2 Q:Forms:expmtrg Revise061306 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia k, _0 Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizationadividual): L /,yoS N•e/ -- Address: P-o . fix L t 3 i City/State/Zip: Se- DR/*"t s ty1 Qt(og Phone.#: S6 - Are you an employer? Check the appropriate bog: Type of project(required):. 1. I am a employer with 3 4. ❑ I am a general contractor and I * have hired the su.b-contractors 6. El New construction . . employees(full and/or part-::time). 2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-cofactors have g• ❑Demolition working for me in any capacity.acity employees and have workers' $• 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 ll. Plumb* repairs or additions 3.❑ I am a homeowner doing all work ❑ . g eP 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 Homeowner;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 number. I am an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site information. Insurance Company Name: � 'li Sim Policy#or Self-ins.Lic.#: P S" Expiration Date: 14 Job Site Address: xy t.� e (eel ` (fj 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 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains-and penalties of perjury that the information provided above is true and correct: Signature• Date: Phone#: VOL Dfficial 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 emptoyer is defined as"an individual,partnership, ssociation,corporation or other legal entity, or any two.or more of the foregoing engaged in a point enterprise,and inc l ding the legal representatives of a deceased employer,or the receiver or trustee-of an individual,partnership, associ lion or other legal entity,employing employees. However the re than three apartments and who resides therein,or the occupant of the owner of a d elling house having not mo ' dwelling houl of another who employs persons to d maintenance, construction or repair work on such dwelling house or on the gro or building appurtenant thereto s not because of such employment be deemed to bean employer." MGL chapter 15 §25C(6)also'states that"every s to or local licensing agency shall withhold the issuance or renewal of a licens or permit to'operate a buisin s or to construct buildings in the commonwealth for any applicant who has n t produced-acceptable evide ce of compliance with the insurance coverage required." Additionally,MGL c ter 152, §25C()states"N ther the commonwealth nor any of its political subdivisions shall enter into any contract f the performance of publi work until acceptable evidence of compliarice with the in n ae requirements of this chapt have been presented'to the contracting authority." Applicants .Please fill out the workers'comp nsation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-conti-actor(s) ame(s),addre (es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Comp s(LLC) or invited Liability Partnerships(LLP)with no employees other than the members or partners,are not required t carry wor s' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be adv%s that affidavit maybe submitted to the Department of Industrial is for confirmation of insurrance cov a age. o be sure to sign and date the affidavit. The affidavit should Accidents g In. be returned to the city or town that the applica 'on f r the permit or license is being requested,not the Department of Industrial Accidents. Should you have any ques ' regarding the law or if you are required to obtain a workers' compensation policy,please call the Department a e number listed below. Self-insured companies should enter their self-insurance license number on the appropriate City or Town Officials Please be sure that the affidavit is complete'and print d legib The Department has provided a space at the bottom of the affidavit for you to fill out in the event the 0 e of Ines ' tions has to contact you regarding the applicant. Please be sure to fill in the permitgicense number w h will be use a reference number. In addition,an applicant that must submit multiple permit/license applications any given year, eed only submit one affidavit indicating current policy information(if necessary) and under"Job Site ddress"the applic hould write"all locations in (city-or town)."A copy of the affidavit that has been officially stamped or marked by ty or town may be provided to the applicant as proof that a valid affidavit is on file for fu a permits or licenses. A ne davit must be filled out each year.Where a homeowner or citizen is obtaining a lice a or permit not related fo any bus* or commercial venture (i.e. a dog license or permit to bum leaves-etc.)said pe on is NOT required to complete this affi The Office of Investigations would like to thank you in a vane for your cooperation and should you have uestions, please do not hesitate to give us a call. The Department's address,telephone-and fax number:. The Commonw th of Massachusetts Dgpartment of.In ustrial Accidents Office of In .estigations 600 Waslun on Street Boston, MA 02111 Tel. 4 617-727-4900 ext 406 r 1-877-MASSAFE Fax##617-727- 749 Revised 11-22-06 www.rnass.gov/dia a�./G�aQaa�lZ��aetta\ ' \, n�' Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR 1 Registration ]45504 Tr# 130121 lug Expiration 2/212009 Private Corporation TYP?, 4 B.L.MOSHER CONST INC.Y BERT MOSHER 74 SEARSVILLE Administrator S.DENNIS,MA 02660 i-- License ar registration valid for individul use onh, before the expiration date. If found return to-- Board of Building Regulations.-and Stand i One Ashburton Place.:Rm 1-401 Boston,P.ia:.02108 Not valid without signature ACORD DATE� CERTIFICATE OF LIABILITY INSURANCE 04/3M/° - 04/30/20072007 ." PRODUCER (508) 790-1919 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Sandpiper Ins. Agency," Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 12 Enterprise Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis MA 02601- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:Penn—America Insurance B.L'. Mosher Construction, Inc. INSURER Granite State Insurance Po BOX 1131 INSURER C: INSURER D: S. Dennis MA 02660- 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 POLICY EFFECTIVE POLICY EXPIRATION LTR 114SRD TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MMIDD/YY) LIMITS A GENERAL LIABILITY SUB1015606 11/29/2006 11/29/2007 EACH OEECCURRENCE S 1,000,000 AMAGX COMMERCIAL GENERAL LIABILITY PREM SES Ea tJ7uEr RED S 50,000 CLAIMS MADE F_X�OCCUR I / I I MED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,000 POLICY JJECT LOC AUTOMOBILE LIABILITY I / I / COMBINED SINGLE LIMIT S ANY AUTO (Ea accident) ALL OWNED AUTOS. / / I, I BODILY INJURY SCHEDULED AUTOS (Per person) S HIRED AUTOS / I / I BODILY INJURY NON-OWNED AUTOS (Per accident) S I I I PROPERTY DAMAGE (Per accident) S . . GARAGELIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO I I I I OTHER THAN EA ACC S AUTO ONLY: AGG I S EXCESSIUMBRELLA LIABILITY / I I I EACH OCCURRENCE S OCCUR F_j CLAIMS MADE. AGGREGATE $ S DEDUCTIBLE I I / / S RETENTION S S B WORKERS COMPENSATION ANDWC8859394 11/30/2006 11/30/2007 TOR LIMITS X ER EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S 1,000,000 OFFICERIMEMBER EXCLUDED?If yes,describe under EL.DISEASE-EA EMPLOYE S 1,000,000 SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/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 /4. DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FOR INSURANCE PURPOSES ONLY FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHOR ACORD 25(2001/08) ©ACORD CORPORATION 1981 n;INS026(0108)m ELECTRONIC LASER FORMS,INC.-(800)327-0545 Page 1 of: t. ,e 13 a�DO? wt) l v I ' ob6 K.. (L �n ze 1,ft, 1�6 0,,�, 0,/ � u m t R e �, , . , {;: ,._. r. � - �•N. ��� ���� . �, . . As`sbssor s map and lot number .................. ....... ... . SjPfI..... THE 7/ MUST BE F Sewage Permit number ..: .......... �( - F ,....... N �°; � � .��N..G,: ..,. 1i JHHST/1DLE, • i House number ...: ........ . .....! h!�........ ... f °c.,. S •� a O 9 ENVIR p E TAL Y ti 0 YpY d\ TOWN OF . BA�RSTABLE- BUILDIN'G INSPECTOR, APPLICATION FOR PERMIT TO ....... � �:.. �-� �E- ?' ? �1 , TYPE OF CONSTRUCTION � ...:.............. .., ..... ..a!...............19.S- i TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ...... .... ....... ° . .. ...... s? . ..................:........................ -• p- ...................... .........................................................:...... Proposed Use .......... (` - ...... ............... C� Zoning District C� ` .........Fire District ............1�,�, _ ........... g'C r. ........................................... .... .............................................,.... Name of Owner `.& .................Address ... c...ic_�.. �. Name of Builder .................:Jc) !!M V...................................Address ..........sG.!!e!.`q_. ................................................... Name of Architect ''"� ......................................... .....................Address .................................... ............................................ Number of Rooms ..................... .......Foundation .......... ............ .................................. B AC.,)! i r� ��:�.. �� r ....Roofing ........ pp�i.9 t- Exterior ................... ..... . .... ........ , j Floors Sf'/0 .f.N... ................................Interior S.dae Heating :.�'..`.® �f T': :. �� L. :.. ......Plumbing �! (pad Y............................................... Fireplace ........... (.s...........................................................Approximate Cost ................ ................ ff Definitive Plan Approved by Planning, Board ________________________________19________. Area ......1. ...S.:..:......... .. Diagram of Lot and Building with Dimensions 1 Fee ............ ...` ................ SUBJECT TO APPROVAL OF BOARD OF HEALTH ^/ V Ilk VA N fo �CTZ3 � lG� OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of thWT,.ownofT nstable regar ing the above construction. !Name ... .............. ...... ................................ ' Construction Supervisor's License .......................... ......... Q.,LD STAGE INC. fo ...26;:396... Permit for ...One Stor _ Single_ Family Dwelling - ............. .............. ► r Location Lot 23, 378 Nye Road 3t Centerville...................................... Owner ....... Old..Sta. g ... e Inc.......... ................................. ...... .. ... .. ...... + .. ;�x ✓= Type of Construction .. Frame fU I Plot ................................Lot............a................... t Permiti Granted ....August 24 , rf 19 84 • 4 N lt�.,z � 319Date'of�.lnspectio . .'. r 1' Date Complete .mot. °4.:.�'�r� .....fl 17� �Gcc Cr �.� - ti r f tl 1♦. 1^. r 3 •;4 • . +M1 I :V.'. " , • t•`'e7 W+'.♦ry♦', '' ♦ - j i' -� _ �.7_, .. • ,tom - nGry .. ^ de ♦ tom• � ..a 4 � L r♦� '� y Y.'/ , ., "u ..a� ��� .ram r:? i. ,�. .. � t � '�� ♦ ' , :— . ' i ' J:- a 't•• � st. �; y " { * -µ .a 1 C r� b* T r' 31 L .t.Y ';`` T, `a-4 � x .,f, � ♦ •^� Sa,, 1^.I� 6 ! ♦' � jj . {.. x.. ,. e -PLO El I F I �4 .. .... ♦4 n ff L �0 • F�"� �J" 1 'r 1 ; L; �' - wC E Tt f"Y T R:A T `l�H'A Z S ,. S.RO.W ON . THIS PLAN z EX �STS 0 T"f�! � ' . f 0 0 U D �fide C, 0'� -0 R�14 Tl ' I#�Er �'<!�'�`� RE 6!�l A T �0� S;. �,�, f. 0' . Y � �'' .r ♦ • •n 4 ...w.l•.;—...•.—•�',+�«. •.n Jf'.`i.""'^^tt'.sa.�-i=: •r , .. , A l TOWN OF BARNSTABLE Permit No. _.-.-------------------- Building Inspector Cash OCCUPANCY PERMIT Bond / Issued to Address ',-)t 23, 378 Nye Road, Wiring Inspector 7 ' ��. -- Inspection date Plumbing Inspector - ' 1 ! " ti Inspection date Gas Inspector Inspection date Engineering Department '4<« '` Inspection date Board of Health � /��c� Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. ..................................................... 19............ .............................................._.................................................................. Building Inspector 1 TOWN OF BARNSTABLE BUILDING DEPARTMENT �saaeT� _ TOWN OFFICE BUILDING HYANNIS, MASS. 02601 MEMO TO: Town Clerk FROM Building Department DATE: June 27, 1985 An'Occupancy Permit hash been issued for-the'building authorized by Building Permit #... 26896 Old Stage Inc. issued to ................. ...... _.».»...» ...».... »»._.. .»»»........................................................................... ... »» ... »:.......»... ». Please release the performance bond. I