HomeMy WebLinkAbout0120 SOUTH MAIN STREET (8) t. 3: � A f
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
6G"" 17,(_3
Map Parcel
pp
A licat on
Health Division Date Issued
Conservation Division Application Fee
� ��
L21
. ('{Planning Dept. � Permit Fee
Date Definitive Plan Approved by Planning Board 31�113
Historic - OKH Preservation / Hyannis
Project Street Address 7.o 15 0S Th 01q1 #45 Sm G{.✓I.TI.y`( j/ �Gv_
Village
Owner Al*V*j� ktA�'k C%✓ Address 1 36 SOUTIA
Telephone
Permit Request 2m Q 6&4 X i KS u 14L.Ho v% a NeA D le
•
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation dD 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)
Number of Baths: Full: existing new Half: existing _. new
Number of Bedrooms: existing _new
Total Room Count (not including bath>): existing new First FlooP ' om Cods t
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other �
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing woo /coal,s ve: Wes ❑ No
cm
Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: a existing❑ nor size—
CD f
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
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Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review #
Current Use Y%"k*i H�l 14a#16 .t_, Proposed Use '4 -A*-r L
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER) - -
Name .STG(/'C.r C V" l/ Telephone Number
Address ;t O ap License.# 0 q 6 S 7;t-
West bon-ViC1(2zo_/d 101f100, Qear Home Improvement Contractor# / 7,AoX-2 19 �
Worker's Compensation # V WC 601 a61 Uld"L
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO pate
SIGNATURE�) XZW�� DATE I -X1 - 13
FOR OFFICIAL USE ONLY
. s
APPLICATION# ,
,DATE ISSUED y
MAP/PARCEL N0.
f
ADDRESS VILLAGE =3 f
OWNER i
DATE OF INSPECTION: :
FOUNDATION F
FRAME
INSULATION
FIREPLACE `)
ELECTRICAL: ROUGH `FINAL
r,
PLUMBING: ROUGH FINAL
GAS: ROUGH - FINAL
FINAL BUILDING
DATE CLOSED OUT u
ASSOCIATION PLAN NO.
Ofjtca of£rcfesttgahons. . -
_ •. 6#0 Wir&hingfarc Street '.
Workers' Compensation Insurance Afftiavit: Sidilders/Contractors/ lectricians/Plumbers
A Iicant Inforiaation Please Print Lezibly '
Name(Bnsmess/Ogm�t ona dividual): 5�'�i�e.• C.Oi./'�—� . .
' •Adt�ress:- � fret h� trv+4.rvtr �: . . .. • . . ..
City/Stafe/Zip:AAjot i t A+ I u xi-le Phone.#: Ira 4 Z f(3— 7 7 3 -
Are you an employer?Check-the appropriate bow :Type of project(regrdred);.
b. New co
I am a employer with4. ❑ I am a general contractor and I
* have hired the m*-contractors nsiraction
employees (fail and/orpart fime).
2:❑ I am a'sole proptietnr or partner- These
the'atisched sheet 7. ❑Remodeling .
ship and have no employees sub-confractors have 8. []Demolition
Y gp. ny employes and have worlmrs'
working for me is an c ac 9. ❑Building addition
[No workers' co=p.imsnrancp Comp.insi ncP$'
5. ❑ We are a corporation and its ' 10.❑Electrical repairs or additions
required] officers have.exercised their 1 L❑Phnnbing repairs or additions
3.❑I am a homeowner-doing all work
Per MGL exemption em p
right of e
ig xp
- myself [No workers camp. ' • r 12.0 Roof repairs
inn c e r 152, §1(4),and we have no
required-]t c.employees-[No workers' 13. Other �Qf
comp:insurance required.] , h' W `l
Any applicant that checks box#1 must also f Il out the section below showing&heir worktrs'ComP=sa ion•pDllcy IDf—afi=
t Homeowners who submit this affidavit indicating tirey arc doing all work and than hire outside contract=must submit a new affidavit indicating such.
ed an additional sheet showing the name of the sub-contractors and staff whether or not those entities have
$Coniractnrs that check this box.must attach
employees. If the sub-contractors have employees,they must pmvidb their worloas'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: A W'1 jet,bl.�tad! ��'1�• C.O'. —
Policy#or Self-ins.Lic.#: VlN C. 60�Z 6/�oI LO/j Expiration Date:
Job Site Address: Ito -f3,0L k smauir S City/Sta zip: l'ANM��;" W 1 A
Attach a copy of the workers'compensation policy declarafion page'(showing the policy number and expiration date).
Failure to secure coverage as requ�md tmder 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 tine violator. Be advised the a copy of this statement may be forwarded to the Office of
Inye dilations of the DU for insurance coverage verification.
I ilo hereby certify uxder the�pains•anjd�pen,alt{ies ofpadury that the information provided above is true and correct
Sitnratare Date: i'Z' "�.�
Phone#
7.7
Offzcial use only. Do not write in this area, tb be completed by rity.or town official i
,City or Town: PermitlLicense#
Issuing A-uthority.(cu•cle one): .
:1.Board of H6alth 2.Building Department 3.City/Toyfn Clerk 4.Electrical Inspector,5.Plumbing Inspector
6. Other*
Contact Person: Phone,#:
2/5/2013 6 : 26 : 05 AM 8935 ® 02/02
CERTIFICATE OF LIABILITY INSURANCE ' DA02/05/2013TE Y)
02/05l2013
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((es)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). ���p
PRODUCER 05012-001 NAME:CT
George A Tetreault III ,EIo.E,t): (413)245-7600 FA/C.No.:
PO Box 467 FA�Sss:
Brimfield,AAA 01 01 0-046 7
INSURERS AFFORDING COVERAGE NAIC R
INSURER : A.I.M.Mutual Insurance Company 33758
INSURED
INSURERS:
Carroll Custom Contracting Inc
INSURER C
20 Wigwam Road INSURERD:
West Brookfield,MA 01585 s
s
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.
I TYPE OF INSURANCE I POLICY NUMBER PMAD/YYl Y LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $
PREMISES Ea ocau ence
CLAIMS-MADE 7 OCCUR MED EXP(Any one person) $
PERSONAL&ADV INJURY $
GENERALAGGREGATE $
EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $
LICY RD OC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accdent
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY IN URY(Per accident) $
AUTOS AUTOS
HIREDAUTOS NON-OWNED PROPERTY DAMAGE $
AUTOS er accident
$
UMBRELLA LIAB HOCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS MADE AGGREGATE $
DEERDg RETENTION $ yyC 7� $
AND EMPLOYERSF`CIABILRTY X TORY LAM OER
oIPVoMPREOP $ 1,000,000
A XXBt� fNJ NIA VWC6012619012012 4/3/2012 413/2013 E.L.EACH ACCIDENT((fManddatoryInNH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
DE 4WIIONOUPERATIONSbelow E.L.DISEASE-POLICY LIMIT $ 1,000,000
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DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required)
Workers compensation coverage applies to MA employees only
CERTIFICATE HOLDER CANCELLATION
SODEX
Attention:Risk Mgt Dept SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
9801 Washingtonian Blvd THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Gaithersburg,MD 20878 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
®1988.2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
4638
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• �y�pFtHEl�yo� :.
�' sAxxsrdere, � .
MASS. Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
Building Division
Thomas Perry,CBO
Building Commissioner
200 Main Street,'Hyannis,MA 02601
www.town.barnstabie.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner-of the subject ro e 1 P P rtS'
hereby authorize She vc, -e- V v O It to act on my behalf,
in all matters relative to work authorized by this building permit application for:
1av S VV\Pk1Y1 S? Ce-vtJ;CV (A t
(Address of Job)
Signature of Owner Date
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on,the
reverse side.
QAWPFILESTORWbuilding permit fbmis\EXPRFSS.doc
The Commonwealth of Massachusetts William Francis Galvin Public Browse and Search Page 1 of 2
The Commonwealth of Massachusetts
William Francis Galvin
Secretary of the Commonwealth,Corporations Division
One Ashburton Place, 17th floor
Boston,MA 02108-1512 ..
1 'S Telephone: (617)727-9640
CAPE REGENCY LANDLORD MA LLC Summary Screen
Help with this form
,��Re'quest?a tCertdlcate,m. w
The exact name of the Domestic Limited Liability Company(LLC): CAPE REGENCY LANDLORD MA LLC
Entity Type: Domestic Limited Liabili , Company(LLC)
Identification Number: 001072688
Date of Organization in Massachusetts: 02/21/2012
The location of its principal office:
No. and Street: 120 SOUTH MAIN ST.
City or Town: CENTERVILLE State: MA Zip: 02632 Country:USA
If the business entity is organized wholly to do business outside Massachusetts,the location of that office:
No. and Street:
City or Town: State: Zip: Country:
The name and address of the Resident Agent:
Name: MCR&P SERVICE CORPORATION .
No. and Street: 99 HIGH ST., 20TH FLOOR
C/O MURTHA CULLINA LLP
City or Town: BOSTON State: MA Zip: 02110 Country:USA
The name and business address of each manager:
Title Individual Name , Address (no PO sox)_
First,Middle,Last,Suffix Address,.City or Town,State,Zip Code
MANAGER LAWRENCE G.SANTILLI 120 SOUTH MAIN ST. `
CENTERVILLE,MA 02632 USA
The name and business address of the person in addition to the manager,who is authorized to execute
documents to be filed with the Corporations Division.
Title Individual Name Address (no PO sox)
First,Middle,Last,Suffix Address,City or Town,State,Zip Code
SOC SIGNATORY LAWRENCE G.SANTILLI 120 SOUTH MAIN ST.
CENTERVILLE,MA 02632 USA
The name and business address of the person(s)authorized to execute,acknowledge,deliver and record any
recordable instrument purporting to affect an interest in real property
Title Individual Name Address (no PO sox)
First,Middle,Last,Suffix Address,'City or Town,State,Zip Code
http://corp.sec.state.ma.us/corp/corpsearch/CorpSearchSummary.asp?ReadFro'mDB=True&... 3/4/2013
The Commonwealth of Massachusetts William Francis Galvin- Public Browse and Search Page 2 of 2
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REAL PROPERTY LAWRENCE G.SANTILLI'
120 SOUTH MAIN ST.
I I I CENTERVILLE,MA 02632 USA I
Consent _ Manufacturer _ Confidential Data _ Does Not Require Annual Report
Partnership X Resident Agent For Profit _ Merger Allowed
Select a type of filing from below to view this business entity filings:
ALL FILINGS
Annual Report I l
Annual.Report-Professional
Articles of Entity Conversion •'i
Certificate of AmendmentA I
' @w Tiling
jKETT
New Search ?
Comments
O 2001-2013 Commonwealth of Massachusetts
All Rights Reserved Help
http://corp.sec.state.ma.us/corp/corpsearch/CorpSearchSummary.asp?ReadFromDB=True&... 3/4/2013
Massachusetts Department of Environmental Protection -
Bureau of Waste Prevention • Air Quality 100173131
BWP ACC 06 Decal Number
Notification Prior to Construction or Demolition
(when fi ling out A. Applicability
forms on the
computer,use
only the tab key A Construction or Demolition operation of an industrial, commercial, or institutional building,or
to move your residential building with 20 or more units is regulated by the Department of Environmental Protection
cursor-do not
use the return (DEP), Bureau of Waste Prevention-Air Quality Control Regulations 310 CMR 7.09. Notification of
key. Construction or Demolition operations is required under 310 CMR 7.09 (2)ten (10)days prior to any
work being performed. The following information is required pursuant to 310 CMR 7.09.
�a
B. General Project Description
1. a. Is this facility fee exempt-city, town, district, municipal housing authority, owner-occupied
Instructions residence of four units or less?❑Yes ❑✓ No
1.All sections of b. Provide blanket decal number if applicable: Blanket Decal Number
this form must be
completed in order
to comply with the 2. Facility Information:
Department of Cape Regency
Environmental
Protection a.Name
notification 120 South Main st. `
requirements of b.Address
310 CMR 7.09
Centerville MA I F -
c.Ci /Town d.State e.Zio Code .
(508)243-7735
f Tele hone Number area code and extension E-mail Address(optional)
20,000 2,
h.Size of Facility in Square Feet i.Number of Floors
j.Was the facility built prior to 1980? ❑ Yes ❑✓ No
k. Describe the current or prior use of the facility:
nursing home
I. Is the facility a residential facility? ❑ Yes ❑✓ No
�c m. If yes, how many units? Number of units
�° 3. Facility Owner:
�N Athena Healthcare
o a.Name
�0 135 South Rd.
b.Address
Farmington CT
co c:CityrTown d.State t; e.Zip de
C (508)494-2132
f.Tele hone Number area code and extension) E-mail Address o tional
0 Dave Laakso
�Q h.Onsite Manager Name
ag06.doc•10/02 BVWP AQ 06•Page 1 of 3
I
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention - Air Quality 1100173131
BWP AQ 06 Decal Number
Notification Prior to Construction or Demolition
General B. General Project Description \tlon (cont.
Statement:If )
asbestos is found
during a 4. General Contractor:
Construction or
Demolition Isteve Carroll
operation,all a.Name
responsible parties
must comply with 120 Wigwam Rd.
310 CMR 7.00, b.Address
Chap 7. and west Brookfield MA 01585
Chapterer 21 21 E of the
General Laws of c.Ci /Town d.State e.ZiD Code
the Commonwealth. (508)243-7735
This would include, f.Tele hone Number area code and extension .E-mail Address(optional)
but would not be
limited to,filing an Steve Carroll
asbestos removal h.On-site Manager Name
notification with the
Department and/or
a notice of
release/threat of C. General Construction or Demolition Description
release of a
hazardous
substance to the 1. Construction or demolition contractor:
Department,if
applicable. same
a.Name
b.Address
c.Ci /Town d.State e.Zip Code
f.Telephone Number(area code and extension) g.E-mail Address(optional)
h.On-site Manager Name
2. On-Site Supervisor:
On-Slte Supervisor Name
3. Is the entire facility to be demolished? ❑ Yes 0 No
�N
�0 4. Describe the area(s)to be demolished:
�0 drywall ceiling was removed due to sprinkler pipe
N
�0
-� 5. If this is a construction project, describe the building(s)or addition(s)to be constructed:
replace ceiling
�
�0
ag06.doc-10102 BWP AQ 06-Page 2'of 3
i
Massachusetts Department of Environmental Protection ■
Bureau of Waste Prevention • Air Quality 100173131
Decal Number
B W P AQ 0 6
Notification Prior to Construction or Demolition
C. General Construction or Demolition Description (cont.)
6. a. If this is a demolition project,were the structure(s)surveyed for the presence of asbestos
containing material (ACM)?
❑ Yes ❑✓ No
If yes, who conducted the survey?
b.Survevor Name
c.Division of Occupational Safety Certification Number
7. Construction or Demolition: 03/04/2013 1 03/10/2013
a.Start Date(mm/ddlyyyy) b.End Date(mm/dd/yyyy)
8. a. For demolition and construction projects, indicate dust suppression techniques to be used:
❑ seeding ❑ paving❑ wetting ❑ shrouding b. If other, please specify:
❑ covering ❑ other
9. For Emergency Demolition Operations,who is the DEP official who evaluated the emergency?
a.Name of DEP Official
b.Title
c.Date mm/dd of Authorization
d.DEP Waiver Number
D. Certification
I certify that I have examined the ISteve Carroll
�o above and that to the best of my a.Print Name
�o knowledge it is true and complete.
The signature below subjects the b.Authorized Signature
�N signer to the general statutes lowner
�o regarding a false and misleading c.Position/Title
�o statement(s). Icarroll Custom Contracting
d.Representing
03/01/0203
�(D e.Date(mm/dd/yyyy)
O
rm�d -
�Q
■ ag06.doc•10/02 BWP AQ 06•Page 3 of 3■
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.Massachusett's-D.epartment of Public Safety j
Board of Budding Regulations an&4idhdards
Constructiun Supcn-ist)r
License:CS-096672
STEVENACA60LL�
r ZO WIGWA]YJ�RO
R. WEST MOO K)FIELD MAfi 0 585-
""71i'941'. t
' Commissioner Expiration I
= 02/11VO14
�re �aaletocfll�it.q��''C'�if�uc�iiJelt I
Office of ConsumerrP¢7l�Affairs&Busidess Regulation
VXLME IMPROVEMENT CONTRACTOR i
gistration 112228Typepiration 6l4/2014 CorporationCSTOM-,CONTRACTfNG INC:
Al if
STEVEN 'CARROLL �
20 WIGWAM RD.
44 a
WEST:BROOKFIELD MA 01:585 +
Undersecretary
- �•.., Goriimonwealth of AAassachusetts
t: irexw.— CM(MG r-1 0 )
3 Liceiq®Nuinbw, Date of lesm motion;[' sk .
3104086.BC OW 0/2010 16 z a:
�., g Caylrown WEST
� RB561C60tIS None . �•r.,K :�r � --a' �, ! a 3
1..20 WIGWAM R6A 1
:`.WEST BROOKFIE
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HOME IMPRQVE1vIENT.-C NTRACTOR
`ClRIOT -
S�EuEN
20 GWAP",Y
I SROi2S � MA
01585-3201
IM T
CARROLL CUSTOM CONTI2CTING
XPIR S
FF GTIVE" f 1/30/2013
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WASTEWATER TREATMENT
PLANT ROOFTOP UNITS:
FIRST FLOOK PLAN
RTU #5 and RTU #6
I f WASTEWATER TREATMENT PLANT
DpOFF. OFF.
OFF. OFF. -
OFF. OFF.
OFF. OFF.
STAIR #102 #104 #106 #108 ACTIVITIES LAUND
CONE.
OFF. 0 6 STAIR 3
LIVING s.
_.
-ROOM ti
WEST
,. #101 STANDPIPE
STANDPIPE . CONNECTOR
STAIR 4
FIRE-ALARM ANNO FOR STANDPIPE „ a
8
LO 8Y �
RECEP. „
DINING DINING
#1.01 #103 #105 #107 #109 1 i COUNTRY VV P #103
CONF KITCHEN LOUNGE
r .
- ----- 4 : GAS METER '!r► '
105
p }. 90�
t OXYGEN STOR. #I I'I ' #110 "FD9 ,, FIRE ALARM EE ,e y HOUSEK -PING
ce a '4
co ELES. METER rt '� ' ��[� #I07. 3.
�I, ANN®NEIATOR
#102ci-
-- - ----- J
#112' .� #113 E.
#I09 .
3 i #104 ,t ,
p C] #115 #114 #106 '
F-- CAPE REGENCY
'Nurse & Rehab Ctr
LIVING
#117 #116 #108 ROOM h
(EAST)
BROO'KSIDE AT REGENCY "'
#119 #118 Assisted Living
#I21
STAIR 2
STANDPIPE
i
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