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HomeMy WebLinkAbout0055 CENTERBROOK LANE ��t � Cep �-e Y-��k �- 9 � n u .. z .. . ` .. ,. :. ,. - .. a�' o u ` d. ,,.. a c f 'a ,� {:, Y t 'v. F f �1}fiy.*�� ".P-#w-5�.�'/a°`'z}' �,:!�✓t ( U� �{,,, t �'Apia, att,,..?"' ..•'' ofFBArnstable Per'niitoacp& .1� Expires 6 months from issue date s A r � r Fee Regulatory Services Thomas F.Geiler,Director Building Division s Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 T ® 2 . o www.town.barnstable.ma.us 0W/V 006 6230 . fice-.508-862-4038 Qk� Srq�C EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY � Not Valid without Red X--Press imprint P 9.1p arcel Number ( I Property Address Ss C eh1-er kro d K LcinL.. CeV4 e-{yd l.0 0 Residential Value of Work 6Z4U•go Minimum fee of$25.00 for work under $6000.00 Owner's Name&Address 'DOto��14, - (a172 Contractor's Name,N&C ACe fSo- Ou j v"Q n uC✓+W h 7 Telephone Number Home Improvem t Contractor License#(if applicable) /3 3�T nstruction-- efvisor's License# if applicable) Co p ( PP ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner a I have Worker's/I ` Compenslation Insurance`� Insurance Company Name ►J�e,r, Mut Tom'+ Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Sayre C o �Re-roof(stripping old shingles) All construction debris will be taken to I�"� ►-P �PGH� G�1 t4 r►' ❑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:Forms:expmtrg Revise071405 t 9Ze L�aonorcaouaeal�. o�'✓T/lasracfua Board of Building Regulations and Standards License or registration valid for individul use only -_ HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: R ation: Board of Building Regulations and Standards Expiration: 8/17/2007 One Ashburton Place Rm 1301 Type:.Private Corpora ion Boston,Ma.0�108 NICKERSON HOM PROVEMENT MARK NICKERSON 12 COMMERE DRIVE. ORLEANS,MA 02653 _ Administrator Not valid without si �atare i:. � Y Liberty Mutual Group Liberty PO Box 7202 10�mutu5l® Portsmouth,NH 03802-7202 Telephone(800)653-7893 Fax(603)431-5693 November 18,2005 Y TOWN OF-BARNSTABLE ATTN: BLDG DEPT 200 MAIN ST HYANNIS.MA 02601- RE: Certificate of Workers Compensation Insurance Insured: NICKERSON HOME IMPROVEMENT INC PO BOX 2476 ORLEANS, MA 02653 Policy Number: WC2-31S-318102-035 Effective: 11/6/2005 Expirat(on: 11/6/20( Coverage afforded under Workers Compensation Law of the following state(s): M Employers Liability: Bodily Injury By Accident: $ 1.000.000 Each Accident Bodily Injury by Disease: $ 1,000,000 Each Person Bodily Injury by Disease: $ 1,000,000 Policy Limits As of this date,the above-referenced policyholder is insured by Liberty Mutual Fire Insurance Co under the policy listed above. The insurance afforded by the listed policy is subject to all the terms, exclusions and conditions,and is not altered by any requirement.- term or condition of any or other documents with respect to which this certificate may be issued. This certificate is issued as a matter of information only and confers no right upon you,the certificate holder. _ This certificate is not an insurance policy and does not amend, extend,or alter the coverage afforded by the policy listed above. If this policy is cancelled before the stated expiration date,Liberty Mutual will endeavor to notify you of such cancellation. AUTHORIZED REPRESENTATIVE LIBERTY MUTUAL INSURANCE GROUP This Certificate is executed by LIBERTY MUTUAL INSURANCE GROUP as respects such insurance as is al orxW by those companies. i - cc: Insured: Producer of Record: NICKERSON HOME IMPROVEMENT INC PIKE INSURANCE AGENCY INC PO BOX 2476 P O BOX I658 ORLEANS.MA 026.53 ORLEANS.MA 02653 e commonweairn ojivassactrusens i Department of Industrial Accidents " W Office of Investigations 600 Washington Street Boston,AM 02111 ' •` www.mass.gov/dia Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians/Plubers Applicant Information Please Print ]Legibly Name (Business/organizationadividual): /U\ L I(,e(">o ( Ykc tn-tTu�w�i 7 Address: 1�o k d Ll)u City/State/Zip: U�-'-eu vt s, /W 0 4a0 Phone#: Sbk-N G-3 e4-/ Are you an employer? Check the appropriate box: Type of project(required): 1.❑4 am a employer with/- 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet g ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5• ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeo A per do�Wg all work right of exemption per MGL 11-❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.E ff Roof repairs insurance required.] t employees. [No workers' 13.0 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 $Contractors that check this box must attached an additional sheet showing the name of the sub-ccntraators and their workers'comp,policy information. I am 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. #: Expiration Date: Job Site Address:_ SJ� ('(y f��h���� C >-te City/State/Zip: �YHPryf 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: /a -12,4 Phone#,: SZ�' Z yc-3Gd-/ 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): I.Boprd of Health 2.Building Delaai tment 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other' Contact Person: Phone#: i Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employee,.4 K Pursuant to this statute an employee is defined as"...every person in the service of another under any contract of hue, 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. United Liability ComT ►les(L L Q 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 . t 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 permit/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 a 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 burn leaves etc.)said person 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 Departtnent of Industrial Accidents Office of Investigations 600 Washington Street Boston, IviA 02111 Tel. _ 617-727-4900 ext 406 or 1-877-MA SSAF E. Fax 1 617-727-7749 Revised 5-26-05 ww-w.m2ss.gov/cia 1' �T. t Town of Barnstable °^ Regulatory Services 98 � Thomas F.Geller,Director Building Division. Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA b2601 www.town.b arnstabl e.ma.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section_ -If Using A Builder i I^:E p R oT H V 1 //Y K ,as.owner of the subject property herebyanthorize t(1 C_K Z aS-t4 I'nc•to act on my behalf, in all matters relative to work authorized bythis building permit application for. S.S' (2E/Y7XRBRQ�ZAlyk C!§/YT,eR✓/LZ_E IAA (Address of.Job) D L11 D d Signature of er Date 210 eo 7'/x Print Name - Q:FORMS:OWrIERPERMISSiON . , v TOWN OF BARNSTABLE Permit No. -------_27749 Building Inspector s.urrm. Cash --------=---{�-------- ---- 7 1619. 6 9. 'x OCCUPANCY PERMIT Bond --___-_ � 85 Issued to Greenbrier Corp. Address lot #8 55 Centerbrook Lane, Centerville Wiring Inspector Inspection date f Plumbing Inspector Z (N� Inspection date Gas Inspector �y R � t' :o try e Inspection date, UAA�-f YOP Engineering Department Inspection date Board of Health y� qy ���l ��� a� 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.. � .....:Ll�l l.�r�of"/��.....v' -� .c-:e'er-! �' Building Inspector Y j TOWN OF BARNSTABL,E BUILDING DEPARTMENT _ » S TOWN OFFICE BUILDING i6 9 HYANNIS, MASS. 02601 '�o ror►� a MEMO TO: Town Clerk FROM: Building Department DATE: An Occupancy Permit has been issued for the building authorized by BuildingPermit #....». ....�.. . f. _........................................................».» ....»..»». issuedto .»...»....»....» »»»»»..».....».::L1/�£ 2 t . ...!7".....s....................»....»»...........»...».»..»»................»...»».... N Please release the performance bond. ' z 4 �-5 o p 0 i1 _N 30 r - �+s,s o v ! . t . vX/ U � oT 7 3 77-b 13 Y 5 err, -i r 1, CERTIFIED PLOT PLAN ' , G �ZN OF R9A Lo T 8 A/7—& 3' �D O K �} c sq. ROBERT B. �+ ELDRFoQE IN No. aa SCALES /". -f 0 f DATE,. :4 o/8S fF E`E /NQ c e�ENAFe Ic2 I CERTIFY THAT THE 0ll y�A7; () CLIENT gN01MN ON TH13 PLAN '13 LOCATED v ®1$TEREO REGISTER 8�0 6 ON THE GROUND A9 INDICATED AMO LAND ,10® NOS f #. ':CI,VIL CONFORMS TO THE ZONINB l.A1E8 EN0INEER EYOR QJt.BY� GF 8ARN3TAB , MASS ' f T 12' MAIN S T R E.ET yl a g RelK . _ H YA-N hl I S, MASS. : SMEET.:�.OM��._. A E RES. LAND SURVEYOR Assessor's map and lot number ... ..... ? ..'..17 ��;,.., ` . tNE Olt g ropy y Sewage Permit number ....... ^-T-7............................. �p �+ r y b�bE.+PTICe Sp�gtle{���Ty ,y5�.r�'+�, AHHSTAD i xr7. ;NS fALLED IN n c.i d H LB, R NA/6 Howe number � ..................................... r..� aN:- �.6r�.: 0� .......................... I" p ac = WITH TITLE 5 oho V a� 9 TOWN OF BAR" hE BUILDING INSPECTOR . / P APPLICATION FOR PERMIT TO ...::.. .... s � :� 1 \ ..' .......... .......................:.......... TYPE OF CONSTRUCTION ..... ..............:................................................................ .................. . r.........19.. s' TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a per. it according to the following information: �i /location Q...... ��i .. 1 ... 1 � ��i'... � .1.f1.1.. �................................ ............ .. ........ ........ rlProposed Use ...... fPe..... j ........................................ ... ........................................................ ...................Fire District ......� .....0.............................. Zoning District ....R. ..... .............................. ........................ Name of Owner ...ti.:� .. �� 1.... /.. 6- ...�` � :.Address ..... A...... ir......... r c Name of 'Builder ... Ge.�'!'1.. (f �e.(�.....�q/F...(.Address ...........` .�0�.. .. ....................'......................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms .........co...................................................Foundation ...J.�...Q.<.!l.C.... . . ..................................:� Exterior ......'^� C.. f.�./, .. ��' ....5-✓ ,�Roofing .... .... .�... 5v.�.��....................... V1 . . .f... -'�' ... Interior ....... .... . c ... Floors L ............................... Heating .....1.. .. ... r'� Plumbing �t ...................................... g � ........ ........... Fireplace .............................�/ ....................Approximate. Cost ..y ... ............................ . . Definitive Plan Approved by Planning Board -----------___---- -19____ Area .... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH � c � \\ OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I "hereby agree to conform to all the Rules and Regulations of the Town of Barnstable r rd n he oye construction. Name v �4 Construction Supervisor's License ........V•..� L � • yf - L .-C2EENBRIER CORP. A=1.72-10 No ...2.774•ti9• Permit for .......I...stox. .. i. g1E.r J .......... amily...duel•li.n-g.............................. _ <• , Lot #8 Location 55....QeXi arlar�oCak. -F Lax3 �...Gente>;Vi.11e................................ Owner ...............GY M.xlklx.]..�z...Coxp........... Type of Construction f. me...... ........................ Y ................................................... Plot ............................ Lot ................................ - Permit Granted APz.U..12.....1985 Date of Inspection ....................................19 Date. Completed 44 r.....z.7:..........19�CS"� - .ss � ,,Assessor's map and lot number .........................�..... ....... THE IL $ (I Sewage Permit number .......�": ................................ 1 Z 33AUSTODLE, i House number r rasa ........................................... o 1639- 'EO M a�9 TOWN OF BARNSTABLE BUILDING INSPECTOR Q.s �- APPLICATION FOR PERMIT TO ...........::...................... ....................... ... ...:.�./?C, .................................... TYPE OF CONSTRUCTION ......!h.•„ l�r ...j:`.' ?`!! 1. ................................................................................. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: r ..Location ..... .......... .... �/J• � fl if? ....... '1?, P,/",,1, if� f. .................... ... Proposed Use ......:; .!t. .. !.. ..... rti ........................................ ... ........................................................ ... ... ..... ..... ZoningDistrict .... .........................................................Fire District ...... ./....y ................................................. Name of Owner ...691escln ( !� ...5,. �/^ :.Address ....., .1� �l lJ/J.......... ............................................................ Name of Builder ....�:-�rT'Pj'7.. .). .lr ( ..... fi.Add ress ............. ................. '� ........................................... Nameof Architect ..................................................................Address ........................................................................./.......... f.n �r6-- E'C' Ci'P i', Number of Rooms ............)'?...................................................Foundation ... ... ...././......!/.............��.......................... 1.�/ �f� /d7G, /' (.c)/�/ S ./rT a.'..7�t / c ; Exterior .............�....,...................,f....................�........... .•..Roofing .............:...................................... ................................. Floors � / f•,s'` �C .T .......P .........................Interior ......:�?�....... °�. '. �©. .................................. �...... � Heating ..... .. . �...,. ... ............. ...... 6. ..........Plumbing ........... . ........... ........................................... Fireplace .............................. .........................:.............Approximate. Cost .... '�. 6................................... Definitive Plan Approved by Planning Board _______________S� j_19____ Area .......................................... t j� � Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH 3 Q OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regard'i he bove construction. Name ............................... V............... ........... ./....... Construction Supervisor's License ........�/,...... .;1. .:/...71 GREENBRIER CORP. A=172-10 No Pert-,It for ..atora�� ..� ing17 . 2 49 .....tdm7li...dwellang........................ ......... o aLocation f... . . ...Gt b ok Lane, Centerville Owner .....Qx.ee br-ier...Cox Type of Construction .....f aMe........................ ................................................................................. Plot ............................ Lot ................................ Permit Granted ............AP.r?.j....12......1985 Date of Inspection ....................................19 Date Completed ..:...................