HomeMy WebLinkAbout0041 LAKE STREET '�/ � eke S-,�,
f
i` TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
C �. t', �ilt W
Map V � Parcel u U ^'litApplication # 0
Health Division0 Date Issued
Conservation Division Application FeEL 57C
Planning Dept. ,. ._ . ... t�=��- ��,... Permit Fee
`N 1
Date Definitive Plan Approved by Planning Board P
Historic - OKH _ Preservation/ Hyannis
Project Street Address t'� I IAVV e -TS ` IM A to 2 S'
Village
i C� AC-
Owner A AJ•0 Address L.ALC,. S }— �r��J, 1- 1("1•�
Telephone '7 7`� 2 — W �f ?
Permit Request /-i r �P „fie PS 0-riv s wy 12 —
1 =t- ,X& `T' I rVv AX -c
V.N �> �� S� 1 n� i Jl G-�t�V } r �1 iti..� �e M,e �4- Ce • C
Square feet: 1 st floor: existing proposed 2nd floor. existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation oZ 6811. '5"/ Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family 0" Two Family ❑ Multi-Family(# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old Kings 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 baths): existing new First Floor Room Count
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
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)
_- ��S _ to
Name d f`l t � Telephone Number C
Address 1�D �S by D-s"� License # ( a a - �
f Lz- = k 0 tik MA Home Improvement Contractor#
Email ,v(_r t—'%1k l 991 Q_ . 1. (�A/'%A Worker's Compensation # I 1A
CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TOca a(�DATE�/,� Z 6 /0
FOR OFFICIAL USE ONLY
t' APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
Office of Investigations
1 Congress S&e4 quite 1 it
Bostsi; M4 /2114-2017
ww w mass gov/dia
workers Compensation Insurance Affidavit: BuMeasfCon6etors/Eleetricians/Plumbers
Ayplieant Information Please Prfmt Leah
Name(Busmes/Organaation/In lm&al): r4, 7L l'' 4 l;.,�u/c. ,,
Address:
,,
City/State�Lip: S;' z�cQ�" �- /Ulft'lion 7/ Phone#:
Are yoy4n ernpIoyer? Check the appropriate box: of ro'ect
'j 4. I am a general contractor an e project( r
1. am a employer with ❑ d I 6. (]New constivction
employees(full and/or part time).* have hired the sub-contractors
2.❑ I am a-sole proprietor or Partner-
These on the attached sheet 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
worldng for me in any capacity. employees and have workers.'
[No workers'comp.msur ace comp,ins>lraace-i 9. []Bw7ding addi�oA
required-) 5. [] We are a corporation and its 10.[1 Electrical repass or additions
3.❑ I am a homeowner doing all work o1r"have exercised them 11.❑Plumbing repairs or additions
myself [No workers'comp. right of exemption per MGL 12.E] f repairs
insurance required]t c. 152,§1(4),and we have no
employees-[No workers' 13. Other [� t�� Z
comp.insurance required] '
"Any applicant that checks box#1 must also fill out the sccdon below showing Zhar viod s'won polky a mnd=
r Homeown=who submit this affidavit indicating they am doing all weds and thin hue outside c ontcuftrs mast submit a new affidavit indurating such.
�Coanactois that check this bax must attached an additional sheet showing the--of the sub-ooetr rs and stale whedw or not those cuddes have �
:,-aployees" if the sub-eo�have empinrees,they mid pwv*t!cir waxkets'camp-policy mamba t I
am an employer that isprondmg workers'compensation insurance for my employees; Below is the policy and job site
nformadon. A
{.
-
isuraace C v�D Company Name=
olicy#or Self-ins.Lic.# V L47,,4 S7, Expiration Date:
►b Site Address: y l �, s_ S - Y City/SW&zip: �,+�., / ()of(� 3
ttaeh a copy of the workers' compensation policy declaration page(showing the policy number and epiration date).
lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ue up to S 1,500.00 and/or one,year imprisonment;as well as civil penalties in the form of a STOP WORK ORDER and a fine j
up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
restigations of the DIA for insurance coverage verification.
i
o hereby certify and a and ena&W o e ' that the in ormation provided above is hue and correct
store: Date ` . OLId_I , E
)ne 2OV
rffrcial use.only.. Do xot wate in this area,fw be cowl etpaby c4 ar o,ffic;,a]
-ity or Town: Permit/License#
ssuing Authority (circle one)
.Board of Health 2.Building Department 3. City/Town Clerk 4. EIectrical Inspector 5.Plumbing Inspector
Other
;ontact Person: phone#:
"R ght;ax C3-2 8/4/-2014 8 :44 :21 AM PAGE 9/022 Fax Server
Ac®iz®
CERTIFICATE OF LIABILITY INSURANCE GATE
�i- 08-042014
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 endorsemerrt(s).
PRODUCER - - .. CONTACT
NAME
VIVEIROS INS AGCY INC PHONE FAX
140 PLYMOUTH AVE A c w.Esc: A.0 No):
FALL RIVER,NIA 02723 i
.. INSURER',S)AFFORDING COVERAGE NAICS .�
_ INSURER A-ACE AMERICAN INSURANCE_COMPANY -
„
INSURED -- INSURER O: -
RETROFIT INSULATION CORP '
PO BOX 105 s INsuRER c: ,
SEEKONK,MA 02771 INSURER D
't
. 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.
ILTR TYPE OF MURANCE JAINDSMRJI 1M10 POLICY EFF POLICY EXP }
POLICY NUMBER (MMI00l-M IMMy _ - LIMITS
tRAL LIABILITY
I
H OCCURRENCE S
COMMERCIAL GENERAL LIABILITY - - "
AGE TO RENTEDCLAIMS-MADE OCCUR ISE`E7P ) S
PERSONAL&AD-J!NJURY. S
GENERAL AGGREGATE S
rGEWLGGREGATE OMIT APPLIES PERCOMPMP AGG SICY
! PJECTRO- I LOC ! - S - -
AUTOMOBILE LIABILITY . (eMB�INEEmf SINGLE LIMIT g
ANY AUTO
SCHEDULED. BODILY INJURY(Per person) S
ALL OS .AUTOS
AUTOS - 1 BODILY INJURY(Per accident) S
NUTOS ED
HIRED AU70S AUTOS g
UMBRELLALIAB OCCUR :
- �` - EACH OCCURRENCE .. S . .
rc1CCESSLUIB. tXA:kS-rdADc AGGREGATE
S
DED RETENTIONS
S
WORKERS COMPENSATION
AND EMPLOYERS'LABILITY .. + .X WC STATU- OTH-- .r
ANY PROPRIETOR PAP.TNER/EXECUTIV+Y;N ,, • I TORY ut&TS... , ER
OFFICEFcM1EMSER EXCLUDED? NIA 6S02US 0 Y_ El.EACH ACCIDENT $1,000,0�
Tnaedatnry v,NH) 8 02-2014 08-Q2-2015 -
,M,res.tlewibcunocr - 4705P815 - I E.L.DISEASE-EAEMPLOYEE $L000,000
DESCRIPTION OF OPERATIONS below - _ El DISEASE-POLICY UMR $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VENCLES IAkaoh ACORD 101,Addoonaf Remarks Schedule,U more space Is required) .
THE INSUREDS MA WORKERS COMPENSATION POLICY AND ITS LIMITED OTHER STATES ENDORSEMENT AUTHORIZES THE
PAYMENT OF BENEFITS FOR CLAIMS MADE BY THE INSUREDS MA EMPLOYEES IN STATES OTHER THAN MA. NO
AUTHORIZATION IS GIVEN TO PAY CLAIMS FOR BENEFITS IN STATES OTHER THAN MA IF THE INSURED HIRES,OR HAS HIRED
EMPLOYEES OUTSIDE OF MA. THIS POLICY DOES NOT PROVIDE COVERAGE FOR ANY STATE OTHER THAN MA, '
CERTIFICATE HOLDER CANCELLATION
BPI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE
107 HERMES RD SUITE 110 CANCELLED BEFORE THE EXPIRATION DATE THEREOF,
MALTA.NY 12020 NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
POLICY PROVISIONS.
AVrHORIED REPRESENTATIVE
t
ACORD 25 2010/05 C�i 1988.2010 ACORD CORPORATION.All rights reserved. -
{ ) The ACORD name and logo are registered marks of ACORD
co
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
'• Boston, Massac _ s
Home-Improvement C etts 02116
for Registration' K.
. ' Registration: 160461
=u ' Type: Private Corporation
�l
RETROFIT IIVSULATION f .^f y � �17 Expiration: 7/29/2016 Trek -252915
C. � 1
JOSEPH REILLY
. P.O.`BOX 105 �r,.:�.:..,f�
•SEEKONK, MA 02771
Update Address and return card.Mark reason for change.
scn+ ci zoM-os,ii Address Renewal [] Employment U Lost Card'
Go- jerckidalla
Office of ConanmerAttaira&Business Regulation License or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistratlon:x Type: Office of Consumer Affairs and Business Regulation
piratlon:t:7 � }g.N Private Corporation 10 Park Plaza-Suite 517t)
;,;
1='i; ;.:.'l`'':•......' ,. � Boston,MA 02116
e : RETROFIT INSUTATI�SN;r�fs(�•,!' .
JOSEPH REILLY
644 RODMAN ST
x FALLRIVER,MA 02721
Undersecretary 00talidwithout signature
_.......
'tti8 -; of Public Satelyr
of I6ubkAh0 RftW na and
B4aat r
C 6�ensQe aeennn Su!wrsisoar Sneciah%.
ft
L , L-1'0,2T71 ;
JOSMX112 daf Wit-
Pq Box 103
41
x e . Exftirrstion
Town of Barnstable a
F. egulaozy Services
�" " �;• lichard V.ScA Director
aL
bAlddng DivMsion, w
Tom Perry,Building.Commissioner ;
200 Main Street;Hyannis,:MA.02601
ivWw towo.barnstab)e.ma ns _
Office: 50.8402-40'5$ Tax: 5087790-6230
Property Owner Must
Cox-aplete:and Sign This Section
it Ussn ABader .
' t, 1 G� "t as 4ivner of t�1e spb eGt ro
heir byauth 1.1W__Pve�A f Tn s d J�o/J to act on inp behalf,
in all Matters.relative to WorkautYmimd bydiis bui ingperrnit application for.
(Addrds of fob}
T601 fences and a3,a ms are tile respbns 4hy'of T4e applicant. Poo]s
are nbi.w:be`.fiffed ofuttLizedbefore fence's: nsuI' d-.and all final
'0 axe..Qead imerl. , d accepted.- `"
ignatu�a of-Owner Signaiuie:of•Applicant -
Prid Na= i Print Name
Q:FoRMs:ovN.."tK-.41ssIoxPOOLs -