HomeMy WebLinkAbout0270 COMMUNICATION WAY (30) 270 COMMUNICATION WAY
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
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Map Parcel di/ 00 ' F TTABL
Health Division aC /` / �1� 7 2 Date Issued 3f S7O
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Conservation Division Fee 't5 0 s
Tax Collector (J 01 K (�L_ ? (� 0 - - ' // Fc e �� O
C�L15i08 `';_ �
Treasurer 0 k 3 �d
Planning Dept.
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis
Project Street Address M 2-7 0 Co m tA i a 4_-aT o (A) at .L a etr y6.3
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Village 8aiN57a hie Unt rjr)
Owner ibbo h Address 9`/O ecp Net att
Telephone tee `! 7 c I 2-2-1 o S- - y3L a s5'3
Permit Request To I cTh t N e ri a 2 w at— IA e 04. I rI i e0•o o.4
Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new
Valuation W• Zoning District Flood Plain Groundwater Overlay
Construction Type
J Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. ,r
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: 0 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:O existing ❑new size Other:
Zoning Board of Appeals Authorization O Appeal# Recorded❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
BUILDER INFORMATION (((< / f-a" if
Name obi ,'L-?' '1. I c.kQ ta..:s Telephone Number S° �S'�' 3 5
Address 2-0S- YY\2 e-.► ill kc - C.. ' - A License# 00 11 Li
buy )o) Home Improvement Contractor#
m 0. 0:Z6 y 2 Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN,TO
SIGNATURE 20 ha- V1 c.4-92,c..S„ DATE 3 /2_0/ 2.
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FOR OFFICIAL USE ONLY
PBi_ IVIIT NO.
f DATE ISSUED 1
MAP/PARCEL NO. `
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ADDRESS - VILLAGE
OWNER
DATE OF INSPECTION:' .
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FOUNDATION E
FRAME ,. •
INSULATION
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FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH ••FINAL _
GAS: ROUGH FINAL
FINAL BUILDING •
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DATE CLOSED OUT . . - .-
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ASSOCIATION PLAN NO. •
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=_ The Commonwealth of Massachusetts i
, 5 r:_ �-=_ ' Department of Industrial Accidents
,l Ofllce oflnvestipatioas
600 Washington Street
• 1 Boston,Mass. 02111
Workers' Com ensation Insurance Affidavit
name: t'Y1 Ft-1 i N sT 7 E k.T e , 3n'L •
location: 2- 70 Co m rn LA h i c a^T Jio rJ S f v at !to c e'o e n c(e ni C(' P a-2-1<:
city 7 A-n i 5 i ✓r‘ o. b Lt. 0 I phone#
❑ I am a homeowner performing all work myself.
❑ I am a sole etor and have no one worker in ca acity
I am an employer providing workers' compensation for my employees working on this job. :.:.:': : : :: : ::: •' :: ::::
compsnY name::.>::'.;. :;::.;•::...: .NT,:,.,�::: . . .. ....
.city:::>::.:::.'>:::<:.: .;Q�.tt.::Gkd • i41:uLet't3:. �.•-�b ' ;::; •;:' :;:':;'>;:.:phone#. ;:;::.>:.;::::".."•.
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❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who
have
the following workers' compensation polices:
'iiani`riam .
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Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a
copy of this statement may be forwarded to the ounce of Investigations of the DIA for coverage verification.
I do hereby certify under the pauu and penalties of perjury that the information provided above is mot and correct.
signature Ib013 Y" LeiA5-r1 Date 3/. o%2 _ _
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Print name •6 0 b /1 ;c,►t e 0..-,Sc,i Phone# �/V 5— _/l*? =z 7"2-2-1
-�` offidal use only do not write in this area to be completed by city or town official
city or town: • permit/license# OBuilding Departrne d
❑Licensing Board
0 check if immediate response is required ❑Selectmen's Omer
• °Health Department
—
contact person: phone#; 0 Other
(Devised 9/95 PJA)
•
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", an employee is defined as every person in the service of another under any contract
of hire, 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 section 25 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,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.
•
11 Applicants •
Please filloin the workers' compensation affidavit completely,by checking the box that applies to your situation and
supplying company1 ' " names, address and phone numbers along with a certificate of insurance as all affidavits y 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.
•
City or Towns
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 pernut/license number which will be used as a reference number. The affidavits may be retmmed fo
the Department by mail or FAX.unless other arrangements have been made: . . �_...._._._..�.... _..._..
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions.
please do not hesitate to give us a call.
The Department's address,telephone and fax number: r -
The Commonwealth Of Massachusetts
Department of Industrial Accidents
0Mce of Investigations
600 Washington Street
Boston,Ma. 02111
fax#: (617) 727-7749
. phone#: (617) 727-4900 ext. 406, 409 or 375
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1 , .,. 1 • I Siertkei• C161064/2002 Tr.no: 25060
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EASTPIAM, MA 02642 AdministrOtor
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Liberty Mutual 2/12/2002 11 : 09 PAGE 2/2 RightFAX
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Certificate of Insurance
This certificate is issued as a matter of information only and confers no rights upon you the certificate holder. This certificate is not an insurance policy and does not amend,
extend,or alter the coverage afforded by the policies listed below.
This is to certify that(Name and address of Insured) ,,.
1 LibTHE MAY INSTITUTE,INC. er r # '
270 COMMUNICATION WAY Niutual `,
INDEPENDENCE PARK a
HYANNIS,MA 02601
is,at the issue date of this certificate,insured by the Company under the policy(ies)listed below. The insurance afforded by the listed policy(ies)is subject to all their
terms,exclusions and conditions and is not altered by any requirement,term or condition of any contract or other document with respect to which this certificate may be
issued.
Expiration Type Expiration Date(s) Policy Number(s) Limits of Liability
Continuous* 7/1/02 WC6-1 1 1-25 1446-03 1 Coverage afforded under WC law of Employers Liability
Extended 7/1/02 WC7-111-251446-061 the following states: Bodily Injury By Accident
X Policy Term Cr,GA,MA,ME,NH $500,000 Each Accident
Bodily Injury By Disease
S500,000 Policy Limit
Workers Compensation Bodily Injury By Disease
$500,000 Each Person
General Aggregate-Other than Prod/Completed Operations
General Liability
Products/Completed Operations Aggregate
Claims Made
Occurrence Bodily Injury and Property Damage Liability Per
Occurrence
Retro Date
Personal and Advertising Injury Per Person/
Organization •
Other Liability Other Liability
Each Accident-Single Limit-B.I.and P.D.Combined
Automobile Liability
•
Each Person
Owned
_ Non-Owned Each Accident or Occurrence
Hired
Each Accident or Occurrence
$
$
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*If the certificate expiration date is continuous or extended term,you will be notified if coverage is terminated or reduced before the certificate expiration date. However,you
will not be notified annually of the continuation of coverage.
Special Notice-Ohio:Any person who,with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement is guilty of insurance fraud.
Important information to Florida policyholders and certificate holders:in the event you have any questions or need information about this certificate for any reason,please
contact your local sales producer,whose name and telephone number appears in the lower right hand corner of this certificate. The appropriate local sales office mailing
address may also be obtained by calling this number.
Notice of cancellation: (not applicable unless a number of days is entered below). Before the stated expiration date the company will not cancel or reduce the insurance
afforded under thabove policies until at least 30 days notice of such cancellation has been mailed to:
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Certificate TOWN OF BARNSTABLE ` f t ' ( /
Holder BUILDING DEPT.
BARNSTABLE COMPLEX Linda Marchant
MAIN STREET Authorized Representative
L BARNSTABLE MA 02630 J Office/Phone WESTON,MA/781-891-8900
Date Issued: 2/12/02 Prepared By:LM
This certificate is executed by Liberty Mutual Insurance Group as respects such insurance as is afforded by those companies. BM0068
I FEB-15-2002 FRI 04:51 PM MARKETING ASSOC FAX NO, 9651843 P. 01/03
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AC'O/�D 7,-, '11 - Liido _ 0yoI
-^TM CERTIFICATE OF LIABILITY INSURANCE
PRODUCER
OATE
Mar/eating 61 THIS CERTIFICATE IS ISSUED AS A MATTER OF I
9 AsNocjatos rnwurance ONLY AND CONFERS INFORMATION
150 Wells Avcnua HOLDER, THIS CONFERS
DOES UPON THE CERTIFICATE
OR
—^— ALTER THE COVERAGI; AFFORDED BY THE _____IIELOW.
INSURED ""`— '•—•��—...� INSURERS AFFORDING COVERAGE
May institute, Inc. —— — --
INSURER A_ ___
One Commerce Way VA P'OEGXrAiS_C2 ,^ ~— _
INSURER
Norwood, MA 02062-0000
J INSURER C; I
T ��1 � INSURER D: —.. 1 ~��
COVERAGES • �_`—
INSURER E:`
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE S
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INDICATED.NOTWITHSTANDING
INsrfi —w^�. AND ISSUED Off
TYPE OP INSURANCE _ CONDITIONS op SUCH
POLICY NUMBER �— POLICY EFrECTIVBTPULICY t4xpIRATION
A GENERAL LIABILITY DAyEInn MlUnrvy I n - Li IA up Y
C3 4 4 791 6 71 �� M1-LIMITS
.Z
COMMERCIAL GENERALLIA$IL1TY 09�0 /2001 09/01/2002 EACH OCCURRENCE
e — �.4.D�412D.
CLAIMS MADE �OCCUR FIRE DAMAGE(Any one rJ,u
J a _z0aiarz
"' —•iMCC)EXP(Any one one l 8
• PERSONAL a,ADV INJURY ^ g ��- 5��
GEM.AGGREGATE LIMIT APPLIES PER: COMP/OP AGG 6 ENERAL AGGREGATE 21?IZl7QQ�
G
POLICY ppr)- 3D.aa_D.QD.
!' T i LOC PRODUCTS•
AUTOMOBILFLIAHILITY —'— 3012011ap
_, ANY AUTO
cOMBINEO SINGLE LIMIT— ALLOWNI'DAUTOS (Ea accident)
c
` SCHEDULED AUTOS �— —
Him)AUros BODILY INJURY
(Per por5ore s
NON•OAUTOSWNED 70S •' —�•-. ._
BODILY INJURY
-- u (PL`r iCC dmttJ 6
IAANYI-AUTO
GIA1tILi7•YPROPERTY DAMAGEry(Per8cPo6rit) 8
AUTO ONLY-EA ACCIDENT 0
- OCCURRENCE -.---
-�__• OTH>:R THAN EA ACC 8
EXCESS LIABILITY "
AGG 8
.___I7 OCCUR ri CLAIMS MADE EACH •^`
AUTO
5
AGGREGATE 8�,~_'�—"
DEDUCTIBLE
0
WORKERS COMPENSATION AND �T ��—
EMPLOYERS'LIADIIITy STA'I'U- e
WC `
lityll c OTH-
E.L.EACH ACCIDENr a`^—^
•.____
E,L.- EMPLOYEE $DISEASE-EA
OTHER �—'
E.L.OISCA$E-POLICY LIMIT 0
1111 DESCRIPTION OF OPERATIONS/LOCATIONS/— VEYIIOLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVI610N$
Ri': 270 Commun.icat.iona Wad, Hyannis, ,MLA 02602-1883
CERTIFICATE HOLDER MI ADDITIONAL INSURED; INSURER LETTER;
._ CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIMF.D POLICIES BE CANCELLED BEFORE THE EXPIRATION
Town of $arnstabxn
Buildin De DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 2,�_ DAYS WRITTEN
g pSrtlR®n t NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
Minn metre®k
IMPOSE NO OBLIDATION OR LIABILITY OP ANY KIND UPON THE INSURER, ITS AGENTS OR
$arnetable, MA 02630
REPRESENTATIVES,
AUTHORIZED REPRESENTATIVE
C3/7./47 ,„
ACOIiD 25^S(7/97)
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IDACORD CORPORATION 19RR
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RF s4 BARNSTABLE FIRE DEPARTMENT
�•",tr. y " 3249 Main Street— P.O. Box 94
m 1927 • Barnstable, Massachusetts 02630
* 508-362-3312
FAX: 508-362-8411I
WILLIAM A. JONES III HAROLD M. SIEGEL
FIRE CHIEF DEPUTY FIRE CHIEF .
February 27, 2002
Peter DiMatteo, Commissioner
Town of Barnstable
Building Department
200 Main Street
Hyannis MA 02601
Sir:
I have reviewed the renovation plans for May Institute 270 Communication Way
Building 1 and have suggested the following:
1. Exit signs in the front office at both doors.
2. Doors to swing out, in the d' ection of travel, to be considered egress doors.
3. No additions to fire al s tern are required.
Respect y submitted
Harold M. el
Deputy hief
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION I&L)R.); --ala r g'?/-'
Maa" / cel J ' i 1 Permit#
g sbd d�
Health Division 3 I l `f Date Issued 0 0"I3' S-
Conservation Division Fee 17
i RO
Tax Collector O Application Fee /004,
2a
/4 1) to\ 1"3\
Treasurer
Planning Dept. Checked in By
Date Definitive Plan Approved by Planning Board Approved By
Historic-OKH Preservation/Hyannis
a) 1/71 NU,Ce2770-u5
Project Street Address/ c,? 9 0 c L
Village .9a_ ` NNis r t
Owner 16attiis df&e Gei4 Address �c> ,fJ 7 fr
Telephone SDe— — 7)S— - 3/ , (-,` 'z .
Permit Request 3-7-)2iia 4 up &Qoaf 4vx ./,5F * s� ."--J
S' ,.04/p5 f®g
Square feet: 1st floor: existing proposed 2nd floor: existing proposed I Total new r
Valuation o2o? 000 ' Zoning District Flood Plain Groundwater Overlay
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 0 No
Basement Type: 0 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: ;0 Gas ❑Oil ❑ Electric ❑Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage:0 existing ❑new size Pool:0 existing 0 new size Barn:0 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
BUILDER INFORMATION
Name Rie,-031e(' 240.er--4. Telephone Number „rej — 726— 513)4-
Address n24) /ZJh 7`W _5-7' License# Cs O673 E4/
)476!{.v.v/S Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO LDorA,po,Ce—
SIGNATURE DATE AO —/a —as'
FOR OFFICIAL USE ONLY • .
•
PERMIT NO.
•
DATE ISSUED : *
,r,
• MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
r
T - .
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DATE OF INSPECTION:
FOUNDATION
FRAME •
-
i (-
INSULATION -?
FIREPLACE 'r. •
ELECTRICAL: ROUGH FINAL •
PLUMBING: ROUGH FINAL ' r '
GAS: ROUGH FINAL
FINAL BUILDING
r
DATE CLOSED OUT
'ASSOCIATION PLAN NO.
,
/
Town of Barnstable - '
Regulatory Services
. ovi,„:0„,\I„
�*.
�, Thomas F.Geller,Director •
9i, ';`3 A•:t' Building Division
QED o Toni Perry, Building Commissioner ,
200 Main Street, ljya•nnis,MA 02601 . - .
'ww.town.barnstable;nza.us
Office: 508-862-4038 .
Fax: 508-790-6230 -
• Property Owner Must
Complete and Sign This Section • '
If Using ABuilder
b y Stuart Bornstein ,as Owner of the subject property
•
Michael J. Roberts.• •to act onrnybehalf;
- 'hereby.authorize .- . .
in all;clatters relative to work authorized bythis building permit application for;
•
31 Thornton Dr. , Hyannis
(Address of Job) .
•
10/12/05
sign. of - • Date
Print Name ' '
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` c , °rill, G— GG' ea /i.
' r t, �, rr , BOARD OF BU1LDll4 EGuLATro'Ns .
° 1 '� , s0 License CONSTRiUCtI0N SUF ER`VIS°OR t
1 ups ' Number CS
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1'' ` ,_aipf.4 Expires_021:13r-2006'
4 r +:'n% vti; xd ,N r 00
Restricted
- MIC'HAEL J ROBERTS
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1 ,.. .„. ,.UTH , Pa�T,C'6 �' finis,_ oner.`
CENTERV.ILLE, MA 0202 • Acting;
0
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Mdp I 1,L) Parcel O 9 10j0 Permit# 5^) ? SP- Pk
Health Division (5► & 6-,00 5 Date Issued w — °
CONNECTED SEWER ACCOUNT 17
Conservation Division 0 7 5-C? Fee
Tax Collector Application Fee /V
Treasurer
Planning Dept. Checked in By
Date Definitive Plan Approved by Planning Board Approved By
Historic-OKH Preservation/Hyannis
Project Street Address a- ?Z2 ' 0//l4WiJ/�-%/o/J W74 U/►'/% l—
Village
Owner STaeY F'oR N S 7'E/Ai Address ?-/YA//i✓/S Dii/ez ®'9i'/c ()mesa;e-/
Telephone
Permit Request 1/'5 A-Ge— NCO Z-6 _ ,ODhie ,4,10 ,0n-s$ r ea(C, OR I..4c,
' A)0 A)C. L410 ' l3 ,AJ 6 th( PR pL,4aJJ ,)i►.67 r cr—
owlinuive caltp-te,+ tAketze4. / 5 T Ftaate.,
Square feet: 1st floor: existing Moo proposed 64 i . 2nd floor: existing proposed Total new
Valuation "7. Zoning District Flood Plain Groundwater Overlay
Construction Type Woe' O F,ieb4
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 ,lNo On Old King's Highway: ❑Yes No
Basement Type: ❑ Full 0 Crawl 0 Walkout ❑Other S L A B
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
(\i
Heat Type:af d Fug 4;> Ga ❑Oil ❑ Electric ❑Other
Central Ai EAYe`s 0 NI Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No
1.6
Detache .garage existing?O new size Pool: 0 existing ❑new size Barn:O existing ❑new size
Attached.. arage❑exist tp ❑new size Shed:❑existing ❑new size Other:
Zoning Board(Appeals Authorization ❑ Appeal# Recorded❑
Commercial c .Yes O No If yes, site plan review#
Current Use 1gRNif /nett eAte- L4 B Proposed Use 5 4-i 1 4— flDc 'ro,a a ri-i c e
A2 6 S Loive,-- o A "--Ye"
avo s ro 8e 3 r,�,e
BUILDER INFORMATION
Name kt 1d'iA) I!New,/ Telephone Number .570?— ?!6— l 7
Address -7'HO US OM OAKS t i VE License# C S 0 6 a 76
Cg - S t ' 2. 1 /Y),4 0 26 3 f Home Improvement Contractor# // 3 83
Worker's Compensation# U 5 9 7?X y
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO YA,ern Dart/ `7-4 tAis,c t L
9n1-`r -J
SIGNATURE JE _ DATE 6/a'7/e,
e
FOR OFFICIAL USE ONLY
r
a .
PERMIT NO. ".
r'i
DATE ISSUED t - ►:, •
=.. j
MAP/PARCEL NO.
ADDRESS VILLAGE •
OWNER : . f_/
. !c 1 ,
"
DATE OF IN ''" CTION: + ft..''
f -_
FOUNDATIO
FRAME 6f 0(< 7 _./- 0 C P
INSULATION • e1`S.V L OTC 7 -O ( I " —-
M
FIREPLACE ' •
-
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0
ELECTRICAL LOUGH FINAL
S ,. .
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL _
FINAL BUILDING 0 `c -7 - -0 S� Pk I
r
DATE CLOSED OUT -
/
ASSOCIATION PLAN NO.
4rN
_ _ The Commonwealth of Massachusetts
-- Department of Industrial Accidents •
1 — . 0fff6s illanesUUitIOHS
. 600 Washington Street
Boston,Mass. 02111
Workers'Co m ensation Insurance Affidavit-General Businesses ��/
_.gam;,.. -5.�. ..
fi ^+3:1
Einat1
/I2,ti /1 cI1'2 /11 R- - I) • . -
address' P'0 B O}X 605
city itic,e i t`f C6/ -ri't • state: MA np: .d Z8 C® uhone# SDI-glS 2"O z-3 2--
work site location(full address):
go 7 C Oman i1JJ LeecrtoAi. 604-Y e)A/i i /—/--/ I/x.4AM 5 /rm.
❑ I am a sole proprietor and have no one Business Type: ❑Retail❑Restaurant/Bar/Eating Establishment
working in any capacity. 0 Office❑Sales(including Real Estate,Autos etc.)
❑I am an employer with employees(full&part time). ❑Other
ri;//1////,/01/7.�.3,,1111%.4/0,////////y/// ,,D////////.l�/.Ll'//��//////////!/1/// „ozAr/J�%///////%/////////d//l%//Ao /%////////%y//////i'//////////.1// ,c0%//e'//%/.%///D//�/,04°
I. I am an employer providing workers' compensation for my employees working on this job, .
,: . .:. '�` . .: •� C ; ede /:
companV name: :.,':, ;;f:;
....:.'.. ..,'-:::...:.::•••::... ..- ••
address 'tv9[ i� ♦rtit
ty;•.,. 3 4; •:,• - phone# •03 ,..
^!� "1 6... .r '✓. !• ..
„.•,. .
Insurance.co:•. "'
workers'
llowin
/ fo the
elo#...,
who have g
tractors list edb w
t con
theind ender
I am a sole proprietor and have hiredindependent
compensation polices: . . • ,
.,-S: .f• .,.f:: i•.
•
addressb. : :.• ` .,.
phohe'#f ''• t• .,1., "1 '
•' _pC,.:4.• ,!^ '•oho If
-# 'If.••
company flame
address:
ci{in: • . • •
•. .•
: . .. , :• • phone it.. '. . ... . ' ' '• .• • • .t'
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me.I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify er the pains an enalties of perjury that the inform anon provided above is true and correct
Signature
1 �V/� (�/�=m�i$f Date /z7/o if-( Phone# So? a�� 1 g 75.
Print name '{a:. ��-y'T_ ,zi wr �_iw.. Y=
�'=%,5:.'s7cr�,rr.=°J=-*:�2-,ztr`:�=s�r _ +;e_"_-:�r:7 •c"r.f..>"--e.�::;�_o•�-,:.:.,4_.._ ,_`' :
''' official use only do not write in this area to be completed by city or town official
permit/license# []Building Department
city or town: OLicensing Board
OSelectmen's Office
0 check if immediate response is required DHealth Department
contact person:
phone#; ❑Other
1 (revised Sept 2003)
.,
I
•
•
Information and Instructions
•
Massachusetts General Laws'chapter 152 section 25 requires all employersthe another provide
workers'vice ther under any contract ensation for their
employees. As quoted from the"law", an employee is defined as every person
of hire, express or implied, oral or written.
An employer is defied 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 section 25 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,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 in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please
supply company name, address and.phone numbers along with a certificate of insurance as all affidavits maybe submitted
to the Department of Industrial Accidents for confirmation of insurance coverage. Ms o 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.
rxez
City or Towns •
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. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.•
•
•
The Office of Investigations would like to thank ybu in advance for you 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
Department of Industrial Accidents
rite of Investigations
600 Washington Street •
Boston,Ma. 02111
fax#: (617)727-7749
phone#: (617)727-4900 ext.406
r
06/23/2005 23:05 5083621313 REALTY EXECUTIVES PAGE 01
Jun 15 05 03:16p 6083820233 5083620233 p.2
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_.��'1 'town of Barnstable ' •
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,
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or9 Services . .
•
•
•
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.nnaiamaarnsta O.as
OM= 501.86 4036 FCC SO$.790-ei30 •
• Psoperty Owner Must
. • Complete and Sign Th is Section
• If Using A Builder . '
13A� 'V'; ei v Owner of the sub ectpropexty
. , . :betabrxtbarkic4j4 It OASsOi.alii&644(SO4 1.14 ••'. •tonct on zarbeinit; .. • •• . •
- m sinittoza neaeth+em vomit a shosized bytbb btuldhsg permit apprgation fou •
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19/18 38Vd 19NA /TUI 9Z995LL80S LE:68 S00Z/ZZ/98
` tf BOARD OF BUILDING REGULATIONS
,i,- t raise 1 C�STRUCriON SUPERVISOR
Number.. G ` F 061876'
fir. Yxs.�*-•
w 3' f ® 4t 2f-:41 Tr- no. 12386
e �, n R
KEVIN:W GRAtdE { _-t =.'SY
.
RO BOX-895 �
BREW:STER M_A 0263:` -- ' /�/�
Coinmi¢sioner, ,,
Efte -6,. �ntaruuea of_
i�czooacfu
Board of Building Regulations and Standards
1 W- HOME IMPROVEMENT CONTRACTOR
=C Registration: 115383
Expiration:.2/16/2006
Type; Individual
KEVIN W.GRANELLI
KEVIN GRANELLI
442 THOUSAND OAKS DRIVE �,„, , ,w
BREWSTER,MA 02631 Administrator
-
BUSINESS OWNERS
TO
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� Fill mplease: YOUR NA
L �
APPLICANT'SYO
� BUSINESS - `^//.^T./ ,', `Teleph ne Number (Home].
TYPE 0
TELEPHONE BUSINESS
NAME OF NEW BUSINESS FruwN Hfdiccu Ecubordin-vb
IS THIS A
HOME OCCUPATION? ,E. NO
the build
Have you been given approval f ing division9 D Ni F.
siness.there are several things you Au-st do in Aer to be in compliance with the ru NW.
'''��
� starting - � _ .
steb�' |�ia�o' /standodoaa �tyouinoUCan|ngcna /n/unouuu// may need. ` __'-- 'a
eecert�catootthe Town get thebU�nes-s certificate UP
be1om\ you may ap�yfor nbuaino
t�gfoUoV �QofficetOng'- sure you h8yo8Uthoreq�r8dpern �aeDd |
Yarmouth �d 6 & oh and you will find the followingoffk.mo
GO TO 200 & e/n St ~ (corner
' []�F/��
� 1' BU|LD/ydGCOK4pN|SS|umE permit requirements that
This individual �fo ���'f any porn� /x�
AuthorizedS�noturo ,m ,
-
COMMENTS: .
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O�� OfHEALTH a--This indk�due| has been informed ofthaporrn�requirennentsthotperCaintothiotypo ofb business. `
AuthorizadSignatura^^
COMMENTS:
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This )ndi�duo1has been inforn�adof the Uoonsmgraqu u/u� �/ ^�". ^" ~.. .'r-
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Authorized na
COMMENTS: '
��UF| �b�P�� in ' �omm� hmh��� you must bvN8lSJL
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