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Home My WebLink About800 BEARSE'S WAY (10) ►�-� �� - 6,_ o T ` TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION t�C�So� Map Parcel Ai3 is ion # Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address c � Village cfi 14 fu YO g S Owner e �xL� /-�a A S, Addressir� � Telephone Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation /5 —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: ❑ Full ❑ Crawl ❑Walkout 4j t?ther 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: ❑ 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 7/,4A��r� Telephone Number os —Wf Address rf1 License # elS ' Home Improvement Contractor# /0 d �I GZ(�(,(�� Worker's Compensation # �/d ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE �- FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED i MAP PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: '! FOUNDATION FRAME 4 INSULATION if FIREPLACE { ELECTRICAL: ROUGH FINAL `? PLUMBING: ROUGH FINAL f GAS: ROUGH FINAL FINAL BUILDING r< DATE CLOSED OUT ASSOCIATION PLAN NO. 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 Please Print Legibly Name(Business/Organization/Individual): � / A eLLEII Address: P() Ro AM-OZq City/State/Zip: (��h Phone#: 8 Are you an employer?Check the appropriate box: Type of project(required): 1.X I am a employer with 1O _ 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. �iemodeling slip and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp, insurance comp.insurance.# 9. ❑Building addition 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 MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I ant an employer that is providing workers'compensation insurance for nay employees. Below is the policy and job site information. Insurance Company Name: u rcJn a , Policy#or Self-ins.Lic.#: )V O R P /00 Expiration Date: Job Site Address: ity/State/Zip: 5 Attach a copy of the workers' compensate n policy declaration page(showing the policy n ber 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$250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of Investigations of the.DIA for insurance coverage verification. I do hereby cer if un a the pains and penalties of perjury that the information provided above is true and correct. Sign A h 6 Date: Phone#: Official use only., Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector S.Plumbing Inspector 6. Other Contact Person: Phone#: I RlghtFax N1-1 12/22/2011 7:19:42 AM PAGE 3/003 Fax Server �•.��,4'F -r a ,j�l :i r$ ,� .. ' ay¢I LI''sw -v1ob, Rr 3d? e, E1� ' rf tt r. s q r 15�SNUwE DATE n l Fl .f..,eF r... > ♦ _ �:��M1✓.G:.: -.... al _3 S 1..,.:..r Y THIS CERTIFICATE 18 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 BX THE POLICIES BELOW,THIe CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE TSBUING INBURER(SN)LUTHORiT,I'.D REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT;if the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed,it SUB ROG TION IS WANED,subject to the terms and conditions o►the policy,certain policies may require an endorsement,A statement on this certificate d as not confer rights to the certificate holder In Neu of such andorsement s. PRODUCER CONTACT OCEANSIDE INS GROUP NAME: 52 WEST MAIN STREET acNNo,Ext: AJC,Ne]: HYANNIS,MA 02601 '-AWL ADDRESS: PRODUCER CUSTOMER ID V INSURED INS S AFFORDING COV55 a8 NAIC# BENABBY INC DBA INSURER A ZURICH DISASTER SPECIALISTS INSURER B P 0 BOX 480 INSURER C SANDWICH,MA 02563 INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO'gM INSURED NAMED ABOVE F IR THE POLICY PERIOD INDICATED. NMwJTEsTANDRTo ANY REQU1REdL TT,TERM OR CONDITION OF ANY CONTRACTOR OTIIPR DOCUMENT WITS RESPECT TO CH TMS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED MAW W SUBJECT TO ALL THE TERMS, CLUSIONS AND CONDITIONS OF SUCH POLICE.L M[TS SHOWN)JAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EX LIMITS LTR INSR WVD I GENERAL LLTBD,ITY , EACTt OCCURRENCE I RMIS 0 C0MMERCLIL OEMRAL LIABILITY PMSE( RENTED S PREES(Path occmence NIED,EXPENSE(Any we S I Q CLAWS MADE OCCUR. � � ersen PERSONAL&ADY S INJURY I 0 NERALAGOREOATE S i 0 OEN'L ACOREOATELRATr APPLIES PER: ' PRODUCTS-COMPIOP I j 0 POLICY 0 PROF-CT U LAC AUG i AUTOMORTLE IJABD.ITY COMBIPIFD SINGLE S I%= , ch sadden i 0 ANY AUTO BODE,YWAIRY S M Per; 0 ALL.OWNED AUTOS j EODILYENJURY $ 1 er Acciderd) 0 SCHMULED AUTOS PROPERTY DAtfAGE S er nemdmt i 0 H=AUTO$ S 0 11011•DWWJ)AU7OS S 0 0 UMBREUAIIaa 000CUR acHoccvRlezrcE S 0 ECCESSLL4B 0 CLAna-wzF AGORECATF, S 0 DMUCIIBL.E S 0 RE7EMDONS S woRKERS'COMPENSATION I WC A AND EMPLOYERS LIAInLMY MIA 1TCA7TJTORY YIN LIMITS ANYPROPRIEIOR/PARTITER! I EXECUTIVEOFFICERIM IBER N N/A 6ZZUH-4102P700 O1101/12 01/01/13 LEACHAacmExr 5500,000 EXCLUDED? OU"ATORY IN NIT) L DME=.•-EACH $500,OD0 i LOYEE ITycs,dwribeundwOTACRIP 014OF I DISEASE-POLICY1500,000 OPERATIONS below Adsr DESCRIPTION OF OPZRAT30118fLOCATION3/YETTICLE9(Attach ACORD 101,Additio,ulRemvks Schedule,it moreepue is required) THE.WSURED'S MA WORKERS COMPENSATION POLICY AND TIS LRATED OTHER STATES EMJRANCE DMORSEMENT AUTHORI=7ABPAY9ENT'OFBM4EFS FOR CLAThm MADE BY 7Hr,NSURED' E1,1PLOYSES IN STATES OHM THAN MA NO AUTHORIZAT10N IS ONEN M PAT CLANS FOR BUMFM IN ANY STATE r TIAR THAN MA IF'GtE DISURED HIRES,OR HAS HIRED,EMPLOYEES OUTSs'DE j MA MPOUCYDOFSNOTMOVIDECOVERAGE°ORNTYGrATEOTHERTHANMA ' THIS REPLACES ANY PRIOR C'ER IMCATE ISSUED TO 111E CERTIFICATE HOLDER AFFECTING WORKERS C MP CIOwRCGE I a - .. ..:: — s t .�.n.. t ... .. c.; .� z. - -r. '.":.a:�s. '`.:�}Y.+`s..wf.Y,"k+ ;�:✓wl;i` CERT.I�',!<Cli#o3IS?3�A1�R..�§:.,,.zq, �aTSxe:x, �c �.:., xti �y a CL 41A�E 74 t):i, .. .... ... - SHOULD ANY OF THE ABOVE DESC EM POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,N TICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PR VIEIONSL - --- ADIetOR1TtD PBREs�IrAnve i BrlawMa:cl.ecuv -;tCCbRDri'� h001% 3 iy s__, Tat fZ R x w -,-�.6 1• r.Y�.,.Sr :�C....r,-,a. � s. .".. ,... :.._..� :FP..3 7��,4.,r�r,�1.��-�LWT.�-'q0 •... i I Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supen-itior License: CS-071402 JOSHUA L COIhN 1082 OLD STXG CENTERVIF M y �' �L• >> Expiration r Commissione 12/31/2013 =r ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CO NTRACTOR before the expiration date. If found return to: 41 egi tion ra 108642 Office"Consumer Affairs and Business Regulation Expiration g/20/2014 Type. 10 Park Plaza-Suite 5170 g BENABBY INC/DIS'4STER SPECIALIST Supplement(::ard Boston,MA 02116Is , JOSHUA COHEN s Box 480 - 4 Sandwich, MA 02563 Undersecretary Not valid without signature IME T° Town of Barnstable Regulatory Services • BMWSrABLE. 9 MASS. Thomas F.Geiler,Director 16;pr6. Building Division Tam Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder 11ad oei-I LI M , as Owner of the subject property hereby authorize --Oec i dt r rc ,c..-' c- to act on my behalf, in all matters relative to work authorized by this building permit. .2 (Address of J b) ` **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. S'ature o wrier ature of Applicant Print Name Print Name Date Q:FORMS:OWNERPERMISSIONPOOLS 6/2012