HomeMy WebLinkAbout0327 LAKE ELIZABETH DRIVE y
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map aa�l Parcel C�11 'Application #
M.,tN OF BARNSj
Health Division
Date Issued
Conservation Division 26Z OCT 2 4 , Application
Planning Dept. Permit Fee 3 '
Date Definitive Plan Approved by Planning Board 2r
Historic - OKH _ Preservation / Hyannis
Project Street Address 3 a� l-a-Ke- I12a"tVvi rlU-e—
Village
Owner lk ✓1✓l-e :J —Address, i0D I°�k 3 S 9,W.l,Qnn,s ray + M X
5
Telephone a��°�'
Permit Request
�A,�l1�Ob� 1 ►n 1 u vU�,� ���I
Al 9A t 6R 0IV L
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation "g d 0 b Construction Type viooCA
Lot Size Grandfathered: ❑Yes C9 No If yes, attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family (# units)
Age of Existing Structure QED Historic House: ❑Yes Of No On Old King's Highway: ❑Yes W No
Basement Type: A Full ❑Crawl ❑Walkout ❑ Other
Basement Finished Area(sq.ft.) � Basement Unfinished Area(sq.ft
Number of Baths: Full: existing new . 1 Half: existing new
Number of Bedrooms: existing —new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: id Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes U 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)
Name ( � I r u r)Orin Telephone Number
S ( �.
Address � � �>�'►�-' � license # G S- 0
e ►� t(1,5 i o-,e 0114 N\0V�f Home Improvement Contractor# I y 3 :� 58
Worker's Compensation # 00S'Y 3 70 qt,l
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE, ` DATE
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FOR OFFICIAL USE ONLY
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{' APPLICATION#
t
DATE ISSUED
.MAP/PARCEL NO.
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S ADDRESS VILLAGE
OWNER
DATE OF INSPECTION: —
1 .FOUNDATION
FRAME
s i INSULATION.+ '1 � `
FIREPLACE
ELECTRICAL: , ROUGH FINAL
i PLUMBING: ROUGH FINAL r
GAS ROUGH ' ' FINAL
{
,FINAL BUILDING} .i '
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DATE CLOSED OUT
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ASSOCIATION PLAN NO.
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
>� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information '� ll Please Print Legibly
Name(Business/Organization/Individual): ��/�Q�W i C�
Address: 53 C6 M VV\_0-V-GI ca
City/State/Zip: M G4SV L09 MA 064Qq Phone #:,56 9 4-71 — S O-7--7
Are you an employer? Check the appropriate box: Type of project(required):
1.2 I am a employer with aa— 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* 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. workers'comp.insurance. 9. ❑ Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
10. Electrical repairs or additions
required.] officers have exercised their
❑
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 L❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.] t 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 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors 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. I
Insurance Company Name: A y-vie, `�-
Policy#or Self-ins.Lic.#: 0 5 y _S -1 U H I M Expiration Date: Lt-(N- 13
Job Site Address: ?9`1 212abt h DrW-e City/State/Zip: Ceritf Milt° W o j,�,
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 pins and penalties of perjury that the in rmation provided above is true and correct.
Signature: Date: (o�
Phone#: -7 8��
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):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Client#:51439 CAPEENT
ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM1DD/YYYY)
04/1612012
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 pollcy(les)must be endorsed.If SUBROGATION IS WANED,sub)ect.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).
PRODUCER WrT Linda Taddia
Rogers 8r Gray ins. Kingston Poe 508-746-3311
A�C�Ia Et;_ Ne;877-816-2156
63 Smiths Lane UNLESS: Itaddia@rogersgray.com
Kingston,MA 02364-3700. INSURER 8 AFFORDING COVERAGE NAIC A
508 746-0065 INSURERA:Arbella Protection CID 17000
INSURED INSURERB:
Capewide Enterprises LLC
J.P.Macomber rli Sons INsuRERc:
PO Box 763 INSURER D:
Centerville,MA 02632 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 CONTRACTOR.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,
LTR TYPE OF INSURANCE ADDL UB POLICY EFF POLIC EXP
POLICYNUMBER MMMD MMIDD LIMITS
A GENERA,uAmLrrl CPP8500050813 4/30/2012 04/3012013 EACH OCCURRENCE _.$1 000 000
X COMMERCIAL GENERAL LIABILITY RA SEsT ENTED
1 ,occurrence -$250 000
CLAIMS-MADEIX OCCUR MEDEXP(Anyone person) $5000
PERSONAL 6 ADV INJURY $1 00O 000
GENERAL AGGREGATE 32 000 000
GENIL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000
POLICY PRO LOC $
A AUTOMOBILE LIABILITY 58944400004 4/20/2012 04/20/201 cEo8,Wde01sINGLELlMIT 1'600,000
AryY AUTO BODILY INJURY.(Per person) $
ALL OWNED r.--1 SCHEDULED 'BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE
X HIRED AUTOS ,"X AUTOS Per eoddent $
$
A X UMBRELLA LIAS OCCUR 4600050814 4/30/2012 04/30/2013 EACH OCCURRENCE $5 000 000
EXCESS LW& HCLAIMS-MADE AGGREGATE $5 000 000
DEDk X1 RETENTIONS10000 $
A "10RICE'SCOMPENSATIONCO" NSATION 0054370411 4/14/2012 04114/20/ we srnru- OTH-
AND EMPLOYER&LIABILITY
ANY PROPRIETORrPARTNEWEXECUTiVE Y f N E.L.EACH ACCIDENT ESOO OOO
OFFlCER/MEMBEREXCLUDED9 a N/A
(Mandatory In NH) NO EXCLUSIONS E.L.DISEASE-EA EMPLOYEE $500 000
N yes describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500 000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,It more space Is required)
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
6 198 -2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD
#S80369/M80368 CJF
(Jne anzmzonc�rea�C�z �Ca��a.rha�el7f
�p ,� License or registration valid for individul use only
Office of Consumer Affairs&Business Regulation before the expiration date. if found return to:
OME IMPROVEMENT CONTRACTOR Type: Office of Consumer Affairs and Business Regulation
egistration: 143358 10 Park Plaza-Suite 5170
xpiratlon: 74/2014 Ltd Liability Corpc: Boston,MA 02116
CAPEWIDE ENTERR 856 L;L:C.
RICHARD CAPEN
4507 R RTE 28 �p
COTUIT,MA 02635 Undersecretary Not valid withou 'gnature
i P�tas acl?essetYs 0epartroent of Public Safety
803fe1 of et.ilding Regulations at,d Stas day ds Unrestricted-Buildings of any use group which
(anoructiun Super%kor contain less than 35,000 cubic feet(991MI)of
License:CS089273 A
enclosed space.
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RICHA D M CAPEIJN 11
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Failure to possess a current edition of the Massachusetts
�,.�..• - ►+► `'+ Expiration State Building Code is cause for revocation of this license.
Commissioner 11/2712013 FmUPSUcensinainformationvisit: www.Mass.Gov/UPS
°FIKEr _ _ . . - Town of Barnstable
Regulatory Services, 3
s,uuve-rABLA ' Thomas F.Geiler,Director-
9�AjF Building Division
D N1A
Tom Perry,Building Commissioner �• `
.200 Main Street,Eyannis,MA 02601
` www.town.barnstable.ma.iis
Office: 508-862-4038 ' Fax: 508-790-6230 t
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Proper,ty'Owner Must
Complete and Sign This Section
If Us in ABuilder `
as Owner of.the subject property -
hereby authorize r 1' -2 i�
c Li-G to act on my behalf,
in alTmatters relative to work authorized b" is'bdding permit application for:
(Address of Job) '
. . .r Sig •
nature of Owner .} Date:
. ,• z ' �'` .. ' •ram ,-
>; r3aK 3s 1 '
`Prim Name
If P_rope_y Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side, y
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TOWN OF BARNSTABLE
1ABJSTAJ1LE
APPLICATION FOR PERMIT TO
TYPE OF CONSTRUCTION
BUILDING INSfEGTOR
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TO THE INSPECTOR OF BUILDINGS:
The undersjgned hereby applies for a permit according to the following information}—
Location L.
JiLS.!&L.9^.v.x 'Proposed Use
Zoning District Fire District
Nome of Owner 0..f ,,.0 /J Address £.1 ,
Nome of Builder MM!.D..3.:...!:A6LB Address •;.;££D...£y£v.£.®.
Name of Architect Address
Number of Rooms 2.,Foundation ...5£k.Ay.:..8A?..?/.-:T:.S >
Ex.erior MlZJCAL £.!.2!i..!G Roofing
Floors ..£Li:ii;:££;2.£^2i:£:i£....w..a^r.in,erior A
Hecing Plumbing ...<yZ£...LLL 'ifV
Fireploce 0£t...££2:.d,2i:::2'I J.l:;.::.Approximate Cost I.l34..aC)a ;
Difinitlve Plan Approved by Planning Board 19
/frDiagramofLotandBuilding with Dimensions
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I hereby agree to conform to all the Rules end Regulations of the
construction.
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reoardiilg the above
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Grogan,Rev.David S.
11/2 story,.,12656 „,
No Permit for
single family dwelling
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fraigvallo
Owner .??.Y.'...
Type of Construction
^f-y-^/;Lot
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Permit Granted SSPi®-!!!???...??19 ^9
/e of Inspection /.!~.3:..^.19^^/y^Ay S '
Male Completed 19
PERMIT REFUSED
19
Approved 19
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