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HomeMy WebLinkAbout0635 LUMBERT MILL ROAD C�3� I��:�.�be� m � t J ''�.; .. . � _ � A, 4 . A � e _. e �� �� a y 70 Town of Barnstable *Permit# may' Expires 6 moutl from Issue dale Regulatory. Services Fee BAMSTABIAl 16es.1639. Thomas F.Geiler,Director AAL Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number J q I /(j 90 Properly Address �..V i m f✓��C I l\ _ ��\ /�(P/l__. .__._: . "�._,. Residential Value of Work'`ji( /. Minimum fee of$35.00 for work under$6000.00. Owner's Name&Address Contractor's Name { � � Telephone Number SQ)b J (t Home Improvement Contractor License#(if applicable)- Construction Supervisor's License#(if applicable) dv 210rorkman's Compensation Insurance i Check one: I am a so Qj le proprietor ❑ I am the Homeowner ' ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# LCYS 2Ya q; 0 Copy of Insurance Compliance Cc ificate must accompany each permit. Permit Request(check box) �Zroof(hurricane nailed)(stripping old shingles) All construction debris will be taken to �} 1 `u�a ►'l'� Re-roof(hurricane nailed)(not stripping: Going over existing layers of roof) Fj Re-side #of doors .❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows *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 required. SIGNAT a C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 r The CoMpnoyinw alth of Massachusetts Department of Industrial Accidents . Office of Investigations 600 Washington Street { Boston,M4 02111 *n0V.,ntass gVV1dia Workers' Compensation Insurance Affidavit: Builders/Contractor Iectriciansmumbet- Applicant Information Please Print Legibly Name(B esslorgmization b&zid nD: Address: C 1 citylStateJZ p: l� A 1) ire.}roar. employer?Check the appro ' to bog: T project general contractor and I g�ae of ectr (P J ���= 1. f I am a employer with_''I 4. I am a g 6. New construction employees(frill and/or part-time)-* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached s-heet . 77 0 o&"Ug ship and have no employees These stab-contractors have g_ ❑Demolition. w for me in an capacity. employees and have worloers> working y 9. 0 Building addition [No wodrets'comp.insurance:' comp_msuranoo required-] 5._0 We are.a corporation and its 10.0 Electrical repairs or additions 3_❑ I am a homeowner doing all uark officers have exercised their 1 T.O Plumbing repairs or additions myself[No workers'comp- right of exemption perMGL 12.�of repairs insurance required_]r c. 152,§1(4),and we have no employees.(No workers' 13.0 other comp.insurance requked.] •Any appfi=that checks tox#1 mm also fill ors the section below showing their workers'compensation:policy infasnatson. Homeowners who submit this affidaa-it indicating they are doing all wont and then here outside contractors mast submit a new affidavEt,imlicatmg such_ rCont=wrs thm check this box must attached=additional sheet showing the nmue of the sub-erammnors and state whether or not those entities have employees..If the sub-contractors have employeas,they mist.pmvide their workers'comp.policy mnnbeL lain an employer that is pro i&iig tvor&em'eon*wttsadon insuraurne for uty emp[oyem. Below is the pviiete and job site information. ` (` Insurance Company lame: � t''T1C� �y U CAS �� A) �'�C�Po or Self-ins-Uc_ : Expiration Date: Job Site Address:6L�� �V t m'\\ t ity/StatelZip: lah k,�,c u ni,9�, Attach a copy of the.workers'compensation policy declaration page(showing the policy number and expiration elate). Failure to secure coverage as required under Section 25A of MGL c_152 can lead to the imposition of criminal penalties,of a tine up to$1,500.00 and/or one-year imprisonment,as well as ci-vil penalties in the form of a ST`OPWORK CORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance corverage.verification- I do hemb i®ttder tyre tn�s Ltd pertta es ofpeditry tileent tJte informadonpmidedabetv is trite and correct Date t Phone#: o�7` 1-Y) -1,Mn Offleial use only. Do not write in this area,ter be completed by d0i or toted official, City or 'own: PermitfLicense 11 Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityllown Clerk 4.Electrical Inspector S.Plumbing Inspector II 6.Other Contact Person: Phone#: 6 Gf1,e�a„vnw�uaea/l�iu License or registration:valid for mdividul use only )ffice of Consumer Affairs&B sings Regulation beforeahe expiration date.-If found.return to: SOME IMPROVEMENT CONTRACTOR Type. office of Consumer Affairs and Business Regulation 2egistration:,�136160 10 Park Plaza-Suite 5170 Expiration: t6149/2012 individual n gosto ;'MA 02116 ION = 1 1110N � = IERS WAY � f% Not valid without signature MA 02601",, v!f Undersecretary i'Wssachuset s-�Depurtment of Public-S ifct. Board of Buildin-1 Reaulationi'.ind Standards Constructipn'$upervisbk Sp ecialty.License License: CS St. ,100207, Reitricted to: RF,WS .MARK LEMON ` ;PO BOX 423 ,WEST HYANNISPORT;,MA 0267 J __-.s --Ex piration`4/4/2012 Comm issioner, Tr#: 100207 DATE(MM/DD/YYYY) ,aco CERTIFICATE OF LIABILITY INSURANCE 8/31/2011 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 1S 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). PRODUCER CONTACT Cristina NAME: T. Edmund Garrity & Co. , Inc. PHCN o E : (617)354-4640 (A.IF No:(611)354-5828 AIL 545 Concord Ave. aD RESS:cristina@garrity-insurance.com PRODUCER 00005330 CUSTOMER ID N. Cambridge MA 02138 INSURE S AFFORDING COVERAGE NAIC# INSURED INSURERA:Scottsdale Insurance INSURER B:Cltation .Insurance 40274 Mark Lemon, DBA: ML and Son Construction lNsuRERc:The Hartford 490 Pitchers Way INSURERD: PO Box 423 INSURERS: West Hyannisport MA 02672 INSURERF: COVERAGES CERTIFICATE_NUMBERTER 2011. 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. INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD/YYIY MM/DD/YYYY TYPE OF INSURANCE GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO PREMISES EaEoccurrence $ _NTED 50,000 A CLAIMS-MADE ®OCCUR CPS1399527 /7/2011 /7/2012 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIESPER 'PRODUCTS-COMP/OP AGG $ 1,000,000 X POLICY PRO LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED AUTOS BSTLT 6/14/2011 6/14/2012 BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NOWOWNED AUTOS $ $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESSUAB CLAIMS MADE AGGREGATE $ _ DEDUCTIBLE $ RETENTION $ $ C WORKERS COMPENSATION X WC STATU OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? © N/ 0515N280` /18/ 011 /18/2012 (Mandatory in NH) L.DISEASE,EP EMPLOYE _S , 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E:L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION (508)862-4784 'SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE:CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Barnstable 200 Main Street Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE W Garrity/RATHY1j— ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD 'H" . Town-of Barnstable Regulatory .Services -Thomas F.Geiler,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street; Hyannis,MA 02601 www.town.barnstable.ma.us. Office: 508-862-4038 - Fax: 508-7W6230 P �Y Pro a Owner Must . Complete'and'.Sign This Section If Using A Builder I, �,��n h ` V d� -- ,as'OwnerPof the subject property t hereby authorize. �, � 'to act on mybehalf, -4 in all matters relative to work authorized by.this building per fit application for: (Address of job) . tieofer Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the y reverse side. . C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZTXPRESS.doc Revised 072110 Assessor's map and lot number .....� .... ...................... ` ;L ?NETay 0/,( . P Sewage Permit number ........................�...}......................... " " Z BARNSTABLE, i House number ............... ..... _ ................................, 9�0 M639 0� MPY Ar. TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ........................ o> .........+;..��................................ TYPEOF CONSTRUCTION ..................................................................................................................................... .......... ...? !.:..-....................19,. v TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit�according-to the following information: Location ...�.':%:..... �! ....... /I/J!�•c9F%• 11!/.�...! .� �.. rtr%•.� •fi/// ..... e7 -. . Proposed Use ........./!.i/_.l�•• . s r�//1. .......� s ._f /.....r..:........................................................................................ Zoning District ................... ..:....................................Fire District ......... .' ................................................. Name of Owner !........................Address aJ`". � ............................................ ................................................................... i Nameof Builder ....................................................................Address ..................................................................................... Name of Architect ....... �S' c� .............Address '' s?yv / ���,"f ' Number of Rooms Foundation .. .......�...•f T� .......................................................... Exterior .:1.�'............�j� /� S � �.fs;'-! /'�Y��!�........Roofing ...�� �� ............................ Floors .....:: /) .Interior .............!,..•GJAlI........................................................ Heating !. In..........................................................................Plumbing .. G:.................................................................... Fireplace ... .................................................................Approximate Costi:.n.�j............ Definitive Plan Approved by Planning Board ________________________________19________. Area !. ..................................... Diagram of Lot and Building with Dimensions Fee ... j........................................... SUBJECT TO APPROVAL OF BOARD OF HEALTH ti- 4 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name �`!�..�i....:�t . . '. i Cauley, G. M. jA=147-90 ' r 1 No ...... 979 Permit for .......one.... .... Y.......... single family dwelling................. Location ..........635 Lumbert Mill Road : ............................................... i Centerville ............................................................................... G. M. Ca yle Owner ........................Y............................ I...I.... Type of Construction ..........frame..............••„•• .. ... 1 .................................. . .............................:....... r Plot ......................... Lot .......... .1Q................ January 19 79 Permit Granted ........ :..............................19 Date of Inspection I...............................19 Date Completed ...................................19 ;1 PERMIT REFUSED ......... .... ....Ali. .. .................. 19 ............. ^ ............................ ............................................................................... i ............................................................................... Approved ................................................ 19 ............................................................................... a ............................................................................... CSC