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HomeMy WebLinkAbout0073 HOLLY HILL ROAD t73 W01 I pill d o 0 a • o � i t„E Town of Barnstable *Permit Expires 6 months from issue date Regulatory Services Fee + tARNSfABLE. MASS. $ Richard V.Scali,Director 1639. Building Division ® P Tom Perry,CBO,Building Commissioner 4I L a 200 Main Street, Hyannis,MA 02601 Rap' www.town.bamstable.ma.us NOV O 2 2016 Office: 508-862-4038 Ton OF p3 ,F�apx- 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL'OR1J ABLE Not Valid without Red X-Press Imprint Map/parcel Number N9 OU /� 1 Property Address 7 t--�yIf Y i�' 1` ( 4/t ✓l JI e— [Residential Value of Work$ 3 1, 75 3 — Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address v�Y Contractor's Name E '17 ChJ 2?/1 ( /1 t.5o/l Telephone Number CqO l R ff O C7 Home Improvement Contractor License#(if applicable) 73 Z / S Email: Construction Supervisor's License#(if applicable) Qq E' 7 0 7 [ Vorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ m the Homeowner [have Worker's Compensation Insurance Insurance Company Name (2117120L(,�i°Sf Workman's Comp.Policy# In Z 6 3/31/120 f 1 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ side Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: r ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,;i.e.Historic,Conservation,etc. ***Note: Property caner must sign Property Owner Letter of Permission. A copy the Home Improvement Contractors License&Construction Supervisors License is require SIGNATURE: C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\2PI01 DHR\EXPRESS.doc Revised 040215 Renewal. ersen "'[civil J erd,.a. of&� L bal d- i;4h FAIR V' temil soutl'wn Me4,EmMad's`,ta -4s LiC, 73!HDIN Hill Rd. 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',i�&A i. 'c aikd�� atifly infor;-rtcil of BacesAdct to carom E-16b. . 1" �1�96 RM. @ 6slat , �:tke�a��a�i��t e,iihl�l�il fii u iise®Heel can a' i q�;rbtnlht a��er tie 6kL tnmr r, Is: TER F 1012512016 Oft Tf M 1HI �g$�p'.iJ��S' DAY AFYE ft THE A"�.�('�$Pp�711 S 1'1�*A • AaC�-y'�In;O,���T+,{� ��j r ?�1 - rr�Si47 '11L/1�JXI!�IMdEvL '1:5r34`14 rS A. 6 1� Y1&.H V dai1.�! .' r�l�ityn Iz*f saIr� l"-c�sul�'1. .. � ;:4i�i�Bw96r Si�+19a[wae ch" I@�iJit�t�ei I�Ia1���Bi QI�I�lF13F�V Nita f� mLiil S iks..ttijueli... tPr u °dmr� F ral5t ht Peas 2.ir 3,5. s Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-095707 Construction Supervisor BRIAN D DENNISON 7 LAMBS POND CIRCZE $n CHARLTON MA 01607 ' Expiration: Commissioner 0910812018. Office.�fCons=er,Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 � r Home Improvemenff,ontractor Registration ReplstraUon 173245 IIj Type. 18 Card E�IraUon: 9/16/2 9I1912018 SOUTHERN NEW,ENGLAND WIND BRIM DENNISON 26 ALBION RD LINCOLN,RI.02865 } ' ss. ,roar date.Address and return card.Marc reason for change. scan 0 20Mv561 Address ;Q Renewal Ei.Employment 'E IAAs Card ... (:/en Uoiit'iidirinen�/�-P�C-Y�a�rtrc�ri�e6Yd -- 6ice of Consumer Affairs&Business Regulation legisttation valid for individual.use only.before the OME IMPROVEMENT CONTRACTOR expiration date.If fond return to. ' Office of Consumer Affairs and Business Regulation RegisVaUon .-5:? Type: lO ParkPla=-Sufte'S170 Expiratlon�g�19/2018< Supplement Card :Boston.MA 02116 SOIfiHERN NEW ENGLJCNDIiWINDOWS'.LCC. RENEWALBYANDER60N + . BRIAN DENNISO,N.<< ; n ALBION RD L INCOLN,RI omit, a-�`—' Not vatid,without Signature f The Commonwealth of Massachusetts Depamizent of Industrial Accidents I Conn ess Street,Sitite.100 Boston,el,1_9 02114-2017 1Vw1V.rrlass.., dia Workers'Compensation Insurance Affidavit.Builders/Contrsctots/Electricians/Plumbers. TO BE FILED MITH THE PERl1II ING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Indiv.idual): SOAernW _rL9i4#J& (A)� Address: & olo . City/State/Zip: I D?i94 6 Phone#: -101" 2.2- G�b Are you an employer'Check the appropriate box: Type of project(required): i P4 1 am a employer with 20temployees(full and/or pan-time)r 7, ❑New construction 2.F_J I am a sole proprietor or partnership and have no employees working-for me in 8. ❑Remodeling am capacity.[No workers'comp.insurance required.) 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No x ork-ft'comp.inwmnce required.)' 10 []Building addition a.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have wdrkers'compensation insurance or arc sole I I.Q Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5. 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet ❑ 13. Roof repairs These sub-contractors have employees and have workers comp.insurance.'- / 6.❑we area corporation and its officers have exercised their rigbt of exemption per MGL c. 14.[!�Other/nJ t n tirJ t.✓ 152,31(1),and tye have no employees.f No workers comp_insurance required.) re r /a re,PT'f S t'Anv applicant that checks box.I must also fill out the section belor:shoxxin,their%vorkers corrrpensation policy information. +Homeowners who submit this affidavit indicating they are doing all work and then(tire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name orthe sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their xvorkers'comp.policy number. I ant an employer that is providing-workers'compensation hisrrrancefor nrJ'e»rPlovees Beloit is the policy andJob situ` information. ) Insurance Company Name: L' Policy r or Self-ins.Lie,n: CA 3/3 Expiration Date: Job Site Address: 73 Fk of( ' a.-(( Ref. City/State/Zip:_Cv111erVi i If— HA Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation-punishable by 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 S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DLA for insurance coverage verification. i do hereby cer ruder the p 'is and penalties ofperjrtry that the information provided above is true and correct. Si nature: q+ Date: Phone"': Official use only. Do not write in this area;to be completed by citI,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#: �., SOUTNEW-01 UOLLINGER A Q. DATE(MMFDDIYY/.Yl CERTIFICATE OF LIABILITY INSURANCE 6129/2016 THIS CERTIFICATE. IS ISSUED AS A MATTER OF INFORMATION.ONLY AND CONFERS NO,RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY 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 WANED,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). COKrACT PRODUCER NAME: CoBiz Insurance,Inc.-CO a N Et,(303)988 0446 FAx No)*.(303)988-0804 82117th St. Denver,CO 80202 EAooDRESS:CoB.izinsuran: -' obizinsurance.com INSU AFFORDING COVERAGE NAIC d INSURER A:COntinental Western Insurance Company " 10804 INSURED INSURERS: Southern New England Windows LLC INSURER C: D/t31A Renewal by Andersen I isURERD: 26 Albion Road Lincoln,RI 02865 INSURER.E: i 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 IHE..POLICIES DESCRIBED IHEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY:HAVE BEEN-REDUCED V.PAID CLAIMS. INS, TYPE OF INSURANCE. INSD yyyp POLICY NUMBER POLICY� ... :� LJMnS LTR 1,000,00q A X COMIYIERCIAL GENERAL'LIABILITY � ' I EACH OCCURRENCE 'S - CUUMSMADE FXI OCCUR I" CPA3136080 '0710112016 0710112017. PREMISES le Ea Occurrence) $ 100,0 MED EXP(Any a person) S 10,000 I i PERSONAL&ADVINJURY . $ 1,000,000 i ( 21000,0 GENERAL AGGREGATE 5 GEN'L AGGREGATE LIMIT APPLIES PER: 000,00 PRODUCTS-COMP/OP AGG ,S 2s X POLICY❑JEcaT ❑Loc EMPLOYEE.BENEFI s 2,000,000 OTHER 1 AUTOMOBILE LIABILITY � MB1�N�ED SINGLE LIMB i S 1,000,000 A X ANY Atha iCPA3136080_ 07101120,16'.071011201T.. BODIwIruuRY(P�person) S._ __ ALL O A�� OWNED SCHEDULED i I BODILY INJURY(Per accident)i S PROP rY GE NON-OWNED I (Peraedde DAMA ;$ HIRED AUTOS AUTOS I $ i X UMBRELLA LIAB X O UR EACH OCCURRENCE $ 5,000Q000 A EXCESS LLAB CLAMS MADE CPA3136080 10710112016 07/01/2017 AGGREGATE a DED X- RETENTIONS 0 ggmgate S 5;000,00 WORKERS COMPENSATION STATUTE ERA AND EMPLOYERS'LIABILITY YIN ,00010 A ANY:PROPRIETOR/PARTNERERECUTIVE �CA3136081 07/01/2016 07/01/2017 E.L.EACH-ACCIDENT b , NIA A OFFICERIMEMBER EXCLUDED? i 1,000,000 (Mandatorydn NH) I EL DISEASE-EA EMPLOY S If yes,describe under E.L.DISEASE-POLICY LIMIT S 1;000,00 . DESCRIPTION OF OPERATIONS below ,r DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Ran arks Schedule,nmy be allmched bums apace.Is.regWred) CERTIFICATE-HOLDER CANCELLATION SHOULD"ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION .DATE THEREOF, NOTICE"WILL BE DELIVERED IN ACCORDANCE"WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE - _ 0ISBS-2014"ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 1 �VIVE r_ Town of Barnstable .*Permit NP, ! — l< cO � p Expires 6 months from issue date ' ' Regulatory Services Fee g 2016 �p Richard V.Scali,Director ram,, RNSTABLE TO Building Division Tom Perry,CBO,Building Commissioner 20.0 Main Street,Hyannis,MA 02601 www.town barnstable.ma us Office: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY G O �/ Not Valid without Red X-Press Imprint Map/parcel Number �D j, 0 Property Address cell V L []Residential Value of Work$ / 06, CO Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address C`2`t- ti Q vi n 73 Contractor's Name_ ItAtt.B1t �� �l Gtv ,� V Tel ephone Number Home Improvement Contractor License#(if applicable)3, � Email:Z11` C L i 2 i Q � i Construction Supervisor's License#(if applicable) I/Workman's Compensation Insurance Chec one: i am a sole proprietor ❑ I am the Homeowner - ❑ I have Worker's Compensation Insurance . Insurance Company Name /����!h;a �. `-P-- M. Workman's Comp.Policy# f.�l GGV00 , 6 l 4/0 66 2-0 l S"14 Copy of Insurance Compliance Certificate must accompany each permit.' Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles).All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) t ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#Mof windows #of doors: r fflsmoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is r n' ed. SIGNATURE: ` . f. Q:1WPF'II \F0RMSlbuilding permit formsTYPRESS.doc Revised 040215 ' `I a , a �,►+E r m , Town of Barnstable :*PermitPIP Expires 6 months from issue date MAY Semces Fee BARN�.�r�F . AY 0 5 2016 MAM , �I'� Richard V. Scali,Director O"A RABLE Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.towmbarnstable.ma us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERAUT APPLICATION - RESIDENTIAL ONLY vGO 6 Not Valid without Red X-Press Imprint Map/parcel Number Property Address 14 Ce l� -�- V L �. E Residential Value of Work$ 706, OD Minimum fee of$35.00 for work under$6000.00 . Owner's Name&Address k x f C6 Vi n 73 )�O//,� ce-11&Z . ,/� Ijel �Contractor's Name IC,144 ( .�:�i `�il/�•�- Telephone Number Home Improvement Contractor License#(if applicable)�� Z� Email: i` C.e G i e:1 i 2 t.l• �p Construction Supervisor's License#(if applicable) OWorkman's Compensation Insurance . Check one: am a sole proprietor . ❑ I am the Homeowner i ❑ I have Worker's Compensation Insurance , Insurance Company Name Pa"I It rt,a o)y mil, Workman's Comp.Policy# EGG ,ryv y 6 1 t/D (06 2-0 G Copy of Insurance Compliance Certificate must accompany each permit"' j Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles).All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) El Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows IF of doors: C111's,moke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,Le.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. , A copy of the Home Improvement Contractors License&Construction Supervisors License is. r red. SIGNATURE: 1 QAWPFILES\FORMS\building permit forms\EXPRESS.doC Revised 040215 A, ?'Ise C©mnromveah*rzf Ma-vsacirrrsetfs Degartrerxt vflud mlbid Accid-ews - - pie afhMMV s , 600 Wasiruggtmx,S'treet , _ Baston,MA 02HI m tt-masLgorldia Wnrlmrs' Campensat m Insnrance avit: 13.�er-dContractarsMecucianrdPh mhers Informafion / Please Print LegW NameLei nemRcc arnr_rrEi ��i �t Cjf /� Addre= l Zf �1. S Z Cit taxel /� � 62,6 6 t Phone `? �i a- � Areyou an employer?C-heekthe appropriate bcm Type of project(required:. I.❑ I am a employer with. 4_ ❑I am a general Eozrfzactrrr aad I- • employees(fall amd!`or part-time).* have lured 9e ants-coaQrattvs 6. New construction �.911 a n a sole proprietor orpattaer_ listed on the attached sheet. £..❑Remodeling sbrp and bare no employees These sub-contrac#ors have $ ❑Demolifion wading :FM mem any capacity. emplopeesaadbneviro&ers' [No wolmrs'comp.fiL,=ance cozaP_i maranc'.I 9.-❑Building addition recluiied j 5. ❑ We are a corporation and its 10,❑Elechical repairs or adclitions 3.❑ I am homeowster doing all won k officers have exxmised their 1L❑Plumbingre-pairs or additions myself[No workers'camp. TigM of em=pfion per MGL U—D Roof repairs inc�erega=ed.I 1 c.152,§1(4),andwehwveno employees.[NO vrozkers' I-❑Other c0mp.mimw T ce required_] 'tiny appiicsutdaat cber�siws R mo;#also fin ant the sechionbelow�snsvag their-wo&ee compersa&=paTscginfa�sao� - Sameowaerstelzo sntmgt�iis affidavit imfWcaH.r:g they ar�dam;sllwa�aa�tfienl�e autsid�caabscmrsanst sobmitaaetva�da�t iodicatic�rnr� fCanW,Ctocstlmt,herbtikboxmastattech sitaddiiiaoal sheet sbowingemnmneof the sub-conhoctraandStaEHtehe marnotthoseeaffaeshwe emplayees.Ifthesabtantxc±arshxqe Mnpiayees,t€ieYnaistpmvidethe&Workers'•comp.paltry aIxmbM fain an srreper fl is prvuidistg zvas�cers'coQrperzsafirrn istrnratzca for�r}�ezrrplaJ�eex $e£rie9 is t7�e po£ic�mtd jQ&aite informrrtioti . InsuranceCompanybianm- . Policy.or Self ins.Lic_4: Expin±son Die.- Job Site Addsess= CifylS#ate io- Attach a copy of the wort-ere coQmpensationpolicy declaration page(shoving the policy number and expiration date). Failure to secare coverage as requiredundes Se-c€ion 25A o€MGL r~15 can lead to the imposition of criminai pemb ies of a fine up to$U0aOQ aad.+oor one year imprism=md,as well as ci'V'R peualties.in the fort of a STOP WORK ORDER and a fore of up to 0.00 a day against the violator. Be ad;nsed 9mt a copy of this statemeah may.bur hTwarded in the Office of Investigations of"t he DJA fekr insurance coverage verification- Ida hereby cerizf tzs inform iorrprmfirbcdabmv ig bareand carxect E3Rff!nre= :�tuheandpirnaftiesvfFedulythattriff d J Date: Phone;k 7711 ' k10 — 5-5-6 7 0,6ial use azz£y. Do scat o-rr ke in tfs&area,to be competed by cUy artatrn affcia£.. . City or Town: PernAbUcense;g '" uing A_uthar€ty(Circle:one): L Board of E[ealth $nsi�Department 3.City-town Clerk d.Electrical Fnspeetor 5.Plumbing LmI=trrr S.Other Contact Person Phone#- - - 6 F. six O�'Ill�-�OII �.II Ed I52 ll employers'to provide wariceas'oaarpe M ion farfih,ir employees. Massac usefts GeneaalLaws chapter6 coritrar ofhire, p==,,Mt�this side, is defied as. _.every personin�e service of another nodes a¢Y =qzew or implied,Oral or VZ't ,' on,torpor don or other legal erdity,or any two or more An�Ivya is defied as"aa indxvi panned inclndmg th assortie.l senf�ives of a deceased employer,ar fE= of the foregoing is a join Vi t e,aodnce r associaisnn or otherlegal entity.employing�PlOy�- nt oftb rthe eceiver or trastee of an indrvidnA per, thereizr,or owner of a dwiOng house havingmore not m a than tizree apartments dw mad who resides tie ocaap & fthe- dw Mag house of ano�er who employs persons tin do maw cc,cmzhn c��or repair work on such eIIing house or on the grounds or bmldmg appmbma _atfheretm sball not because of sack emPloym.entbe deemed to be an e,¢tploye MGL c3apte5152,§25C(6)also staiPs i "every sia1E or local PiCeasiag agency Shan withhold ffie issaance or reneWaI of a Iicermse or permit to operate a business or to contract buildings is the comrnDnwealth for=Y applic=tWho has notprodnced acceptable evidence of cumprance with the sxsur-ance coverage required-" MGL chapter I52, §25CM states ableitber the coMMorrW alfb.nor�y of its poEdcal snbdivisiOms shall Adrli ionaRy, f Itc workm�l acceptable,evidence of compliaacew�the,ir=M3r6.. ewer min any contract athe perf==ce opub requix�uie�s of this chapter have been presented to the contracting aofaoia-7 APPficas�ts . easafion affidavit completely,by chi rk�,a&f-boxes tip apply to Your��on.and,if se Plea fr7l out the wozT�s'comp s alo withtheir certffic�(s)of necessa yY supply�r(s)name(s), addresses)and phone number() other than the h=anre Limited L�M-Y Campa ics�C)or L=itedLiab�itY Pattaersh�s 9T P)ono eaaployees mernbers or partaers,are not regm rcd to carryw��' compensation msmance If an LLC or LLP does have policy is - BeadvisedthatthisadaYkmaybe to,thr,Depa--,finentofndnstrial mP-o ees a Also be sure to sign and dafE;he xf=—da vit. The affidavit should Accidents for confirmation ofmsrsnce coverage. notfireDeparEment of be mt=ed to the city or(tmwn that the application for the permit or license is being regaested, n have nay gaes'tions regardmg the law or if you are rued to obtain a workers' „ , Ay fs Should yo antes should enter their compensationpolicY,PleasecalltbaDepadMeutatthen=berlistedbelo-W Self-insrseacomp self-ij�ce license ummber on the appIriate Ime. City or Town Officials f Plase be sdre that the affidavit is complete andpradtalegiibly. The Deparfineatbas provided a space at the bottom e of the affidavit for youth fill out jr the event the Of6ice oflnvestigationsitas to conactyouregard>ngthe applicant used as arefereace anmber In addition,an applicant Pleasebesineto fllmthepen $Ilicensemtnber which vMbeus da need onlysobmitoneaffidavitindiCatrngcent tip most submiti multiple pem>itlIicemse applitafions in any given Year; or policy in foio atian cif necessary)�d ffider"Job Site 4�ss"the applicant should v rite"aII locations in ( Y town)"A copy of the-affidavit that has been officially stamped or mar3red by the cif}'or town may be provided to the applicant as proofthat a valid affidavit is on file for�p=4s or licenses Anew affdavitmvst be filled out each year.'Where a home owner or cifi=is obtaining a.license or pennit not re7.atedto any business or commercial vent« (ie_a d en Clog licse orpem3h to bran leaves eta_)said person is NOT reqlirEd to complete this affidavit The Office of Investigatrons would IBM to thank you is advance for your cooperation and should yon have any q=ftons, please do nothesifafe to give ins a calL The Department's address,telephone and fez number_ ' ?tilt MMWWMjtbE Of chnsdbl. ' Dagar mt of Ix bist ial ACCUent-S Qffl=ofInve5tg-atio= 6Q4 ash 9tGII o M&02111 TeL 4 617-7274909 Qxt 4-06 car 1-9 MAS F Fax 617-`2"-7M Revised¢24-07gf c's Town of Barnstable Regulatory Semkes Fji hard V.ScA Director BuIdbig NvWoij Tbamasretry,eBO Ending Commissioner 200 Maze.Street, Hyann%MA 02601• Ww—.fmwn.barnstablema.aas Office: 508-862.4038 Fay 508-790-6230 ]Property Owner.Must CO Mplete and Sign This Section If Using.A BuUder Pi qao- 2S Owner of the sabjeaproperty hereby authorize Le-, tc to act on my behA in RR matbets relative to taoxk wathoxiwd by this btading permit applzcId=fon -73 Alt 4tI RJ. (Addaew of Job) O l signature Da3e E D Piint Name If re Property Omer is applying for permft, reverse side. se please complete the Homeowners Licen kremption Form on tie ' Q�� peanitfOrmslEXf'RFS3.dnc ' RsvLwd 040825 t � t o � v M � n0 n O SMOKE DETECTORS REVIEWE TA LE BUILDING DEPT. DATE FIRE DEPARTMENT D TE BOTH SIGNATURES ARE REQUIRED FOR PERQTTIN 71 ATTENT{ON; MASSACHUSETTS LAW REQUIRES ` CARBON MONOXIDE DETECTORS IN ALL RESIDENTIAL DWELUNGS. IN ADDITION TO THE FIRE ALARM CA- INSPECTION, THE INSTALLATION OF o i" CO DETECTORS, IN ACCORDANCE WITH 527 CMR 31.00 WILL BF ` VERIFIED PRIOR TO SIGNING THE t C? BUILD ^ PERMI (o r a Vie.. od Le r Fr -� 13 A 4 :� ,* �+(' �t� - _ i ..J 4 A� " �. `. r `'� �ti�Q� o� � � �-- � � �� . l � � ; f TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # Health Division Date Issued ! /. :3 Conservation Division Application Fee_J �O Planning Dept. Permit Fee ,y Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address _73 go V #11// A 14 01 Village CP� Prr' V% Owner &fry c4n4 g l� Address 73 //o//Y Rd- Ce,�ai Telephone D .Permit Request For ��.,��3 P� E4&C, -45 Fr 7h50441 o,) �h- Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain' Groundwater Overlay . Project Valuation$-/a,000_ 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: a<511 ❑ Crawl ❑Walkout -❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) �'�a Number of Baths: Full: existing on- new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing /0 new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other --� Central Air: ❑Yes ffff No Fireplaces: Existing New Existing wood/ oal stov& ❑ s ❑ No r Detached garage: ❑ existing. ❑ new size_Pool: ❑ existing ❑ new size _ Barn: Q�6�isting anew-nsize_ Attached garage: 2 existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: --a Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ rC° � o.o Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number 8 2-3 Address g 4f) S'��s'f License# CS — O aw,CA M 4 Home Improvement Contractor# 0'9(,p q� &►abbe �ac. OA- fJi5"-Iw Sr���,'���S Fr Worker's Compensation # /09 P 7•a O ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO IpoU�e,- /30 SIGNATURE DATE ���/ 13 • FOR OFFICIAL USE ONLY ,t APPLICATION# - 3 DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: t1FFO:UNDATI.ON-jup.Rnmit imal o, _ FRAME A INSULATION- FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL " FINAL BUILDING ? /3 DATE CLOSED OUT- ASSOCIATION PLAN NO. The Commonwealth ofMassacchusetts Department of IndusteW Accidents Office of Invadgations 600 Washington Street Boston,MA 02111 www.ma.ss gov/dda Workers'Compensation Insurance Affidavit: Builder's/Contractors/BlectriciansMiumbers Applicant Information Please Print Legift Name(13usinesa/Organizal7on/iudivtdual): „� � _� p*�/� S j Address: P,o 'X 4RD/L? -regn r l U City/State/Zip: w1 phone#: Are you an employer?Check the appropriate box: Type of project(required), 1- I on a employer with 10 4. 0 I am a general contractor and I, 6. ❑New construction employees(full and/or part-time).e have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance gyp.insurance.* required.] 5. [] We are a corporation and its 10.©Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11,❑Plumbing repairs or additions myself,[No workers'comp. right of exemption per MOL 12.[]Roof repairs insurance require&] t c. 152,§1(4),and we have no 13.0 Other employees, [No workers' comp.insurance required.] *Any applicant that checks box#1 must also fill out tin'section below showing then workers'com sa pention policy information. t Homeowners who submit this affidavit indicating they are doing all wont and than hire outside contractors must submit a new affidavit indicating sends. tContractors that cheok this box must attached an additional sheet showing the name of We amb-contractors and state whether or not those entities have emptoym. If the sub-contractors have employees,they Mat provide their workers'comp.policy number. I am an employer that Is providing workers'compensation baurwnce for my employees. Below fs the porky and job site informatiom Insurance Company Name: er Policy#or Self-ins,Lic.#: Q 7 Expiration Date: ILOWLT Job Site Address: ' 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 MOL 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 farm 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 ce diepains and,penaMas ofperjrtry that the tnformad6n provided above Is true and correct. Si Date, --- Phone a#; Official use only. Do not write In this area,to be completed by elty or town ojfidat i City or Town: PermitUcense# Issuing Authority(eirele one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: CERTIFICATE OF LIABILITY INSURANCE DATE(M041201 YYY) TNU&COMFICATE 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: OCEANSIDE INS AGCY INC PHONE FAX 52 WEST MAIN ST (A/C,No,Ext): (AIC,No): E-MAIL HYANNIS,MA 02601 ADDRESS: 28GDS INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: AMERICAN ZURICH INSURANCE COMPANY BENABBY INC DBA DISASTER SPECIALISTS INSURER B: i INSURER C: INSURER D: P O BOX 480 INSURER E.- SANDWICH,MA 02563 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THI TO- ERTIFY THAT THE POLICIES OP INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED_ NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMIDDIYYYY) (MWDDIYYYY) LIMITS GENERAL LIABILITY CH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY AMAGE TO RENTED $ CLAIMS MADE 0 OCCUR. REMISES(Ea occurrence) MED EXP(Anyone person) $ PERSONAL&ADV INJURY $ 0 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROJECT LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND X WC STATUTORY OTHER EMPLOYER'S LIABILITY YIN UB-4102P700-13 01/01/2013 01/01/2014 LIMITS ANY PROPECERIME B R/PXCLUDRIEXECUTIVE � NIA E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED) (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1.000,000 If yes,describeunder DESCRIPTIONIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPR TA E _ 1 �� ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved. Town of Barnstable Regulatory Services Thomas F.Gol",Diretor Building Division Tow Perry,BuRding Commtxs mex 200 M&sates Hyamis,MA 02601 wwwto arnstabb-ma.►ts Office: 508-862-4038 F= 508-790-6230 Pfoperty Owner Must Complete and Sign This Section. If Use A Builder I, ,� .mot t r�N t`� ,as Owner of the subject prop" he�teby authorize_ 5 AS't a ti pQ�•�.,�r�� to act on my behatfy in all matters relative to work authorized by this buflding pe=mi t. (Addtess of job) "Pool fences and alaxms ate the responsibility of the applicant. Pools are not to be fxIIed or utilized before fence is installed and all fiat inspections are performed and accepted. Signs f Owner Signature of Applicant dXwo& print Name . Print N me QTORNs.,OWNMUWtRMnUOOLs&MI2 � [ Massachusetts-Department of Public Safety f.hoard of Buildin g,Regulations and Standards. Construction Supervisor License; GS-090865 X`s XXNNETH +M P 21 ROSEAN FE Il i Fairhaven W OZ°719 Expiration .coinrnissioner 01/0 5120 1 5 � ie ptJ'����ro� Office of Consumer AffaxrsQ�/n Business e u anon g 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improveroe!Oontractor Registration ': 5 Registration: 108642 _ Type: Supplement Card ;,•p ,': _ a,f=?,.,.tlr« s Expiration: 8/20/2014 BENABBY INC/ DISASTER SPECIALI KENNETH PARQUETTE 9 Jan-Sebastian Way .f., .. Sandwich, MA 02563 ... ' ;. .... ; v- Update Address and return card.Mark reason for change. sca I Co 20M-OS/11 Address 0 Renewal Employment 71 Lost Card - - � CJ�io�anUrrzoryec�ea�o�C��a�czc�ur6eCY - ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation egistratign;.<' ow.42-..., Type: 10 Park Plaza-Suite 5170 Expiralio'n Y :0I2 t4,. Supplement Card Boston,MA 02116 =..:-.: BENABBY INC/OISASTEP, PEC'tALIST KENNEI'H PARQUETTE:z'!;_-;,= Box 480AIM Sandwich,MA 02563 Undersecretary Not valid without nature Main Level Q� • Wnp.a Raom in m ' 11'6" mot .,i 4ntnlFove. �_ 1 1j it tO LMua.flvs91 stm's 7o i, P HARwav fi � 11 l • GJ . U Main Level CONNOLLY-SKETCH 6/17/2013 Page: 2 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M A C(�� L' DATA Assessor's map and lot number ............. SewagePermit number .......................................................... °`T"Er°�.� TOWN OF BARNSTABLE Z BA"STODLE, i "6 BUILDING INSPECTOR Opp 0 MAY fL APPLICATION FOR PERMIT TO ... .. . ...........N�^''..�L/.4 : ..................................................... lTYPE OF CONSTRUCTION N�Q.... t �!Y► ..... . ........�' ` `� �.`-` ` d ... ..... . ......... .......................... ............. .....................7/..................... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a /permit /according to the following information: Location ...�C.c:..c '.C: .A, ... .G. '). 4,,........ .:�... .�..........h.�Ar1.^r. ........................................ ,CJ proposedUse ....... .u: ,. G�:.. . ................................................................................................................................... ZoningDistrict ..... . .D...I.................................................Fire District ............................................................................... Name of Owner .....LNs. Y.!.41,»1....C....}C cr 2,,....Address ... . ......(.�.r.l..� ? `::�: ..........................ti Name of Builder .. :L!i.l.l.l!l.i..i..: t r.i........Address�. ...:..... .�............ ............ .... ..................................................... Name of a4rd�ii�t ...........�..�5.l.:.!.!.!.....: .c... ,:...........I. .Address .......1 ..:.r .7<.:../..... ..................................... Number of Rooms .............1...................................................Foundation ...... ��U......?.;c�2...... .. ........................................ Exterior ........ !......./.... .f:.`.t.'.J. .....a..................................Roofing ............ ..`:. .: .1................................................. Floors ...........llc:,/4...............................................................Interior ....... ::!:::4.: i,.c. ..:4.................................................. i Heating .........;%c..........r.:.,............:...i` ............................Plumbing ...................... ... .................................................. Fireplace ....... ` .s,. ...............................................................Approximate Cost ......... .....1. V r; , Definitive Plan Approved by Planning Board ________________________________19________. Area .......................................... Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH 4 0 3C.0 iL n V' `;--- 56 aa,o b y I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .....F�G :.:....: I...�lf�..: Kieffer William � - ~ 1�� gle family dwelling �. '��'' �ocoyW�� ~e nte^,~~^~ � 4fOwner ~^^^^~~ C. Kiel; ' -- —'---' --' Plot Permit Granted ............lep.t.e.mbe.r...2.....19 75 Dote of Inspection -_- Completed_ _ /.................................19 � PERMIT REFUSED � ^ --- ............................................................ . .............. ............................................................... ' ' ........... —....—.---~—.._----.~—.---, m _---. --- .. .�...................... � [/^LJm� � / x Approved ................................................ lA ^ . ' ----------------------~^--` � � ---------------------.----,. . � �