HomeMy WebLinkAbout800 BEARSE'S WAY (11) TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map �G� Parcel d(0 b - R--- — Application�
Health Division Date Issued a �—
Conservation Division Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation /Hyannis
Project Street Address D--
Villages ouj"jil s
Owner e'D�/t60 0-- 10C',(p�/(Mf1J-f,)S Address 190 1"�1
Telephone
Permit Request `� 1 As
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation 45 00 { Construction Type 9�M In'sE
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) fl
Age of Existing Structure Historic House: ❑Yes ❑ No// On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout Wither !
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: ❑ 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 D4,OAF,_ (111PZ15Z___ Telephone Number
Address /y z,) License # G5
Home Improvement Contractor# j �'�
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE 8lll l( �o-
i
!`z ,
FOR OFFICIAL USE ONLY
APPLICATION#
,I
f DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER ,
La •
DATE OF INSPECTION:
FOUNDATION
i
FRAME
f INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
. PLUMBING: ROUGH FINAL
GAS:, ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
i
7
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 f
Name(Business/Organizatio»/Individual): �QlE1U i ► J /� '� ( � r—)
Address: Roy /-/R0Zq ;off���/t� �l I ve)
City/State/Zip: Sand-gulch ,JUJOWPhoneSand-cal 899- 1/6
Are you an employer?Check the appropriate box: Type of project(required):
1. I am a employer with 10 4. ❑ I am a general contractor and I
employees(full and/or part-time).*
have hired the sub-contractors 6. �E] onstruction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. deling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp.insurance.t 9. Building addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' camp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152,§1(4),and we have no
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 state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I a»t an employer titat is providing workers'compensation insurance for rtty employees. Below is the policy and job site
information.
Insurance Company Name: zorich -Anr) 6�
Policy#or Self-ins.Lic.#: �1 1 Q 01 P !OO Expiration Date:
Job Site Address• o`Z Rity/State/Zip: s
or
Attach a copy of the workers'compensation policy eclaration page(showing the policy JberW
and expiration date).
Failure to secure coverage as required tinder 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.
Signature: Date:
Phone#:
Official use only.. Do not write in this area,to be completed by city or town official.
i
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
RightFax 111-1 12/22/2011 7:19:42 AM PAGE 3/003 Fax Sarver
TH33 CERTIFICATE Is ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TILE CERTIFICA*HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BX THE POLICIES
zuow.TWO CZATMCArg OF INSURANCE DOES NOT CONSTTrUrE A CONTRACT BETWEEN THE ISSUING INSURKR(Sl)IUTHOR=
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT;If the cartilicale holder Is an ADDITIONAL INSURED,the polloy(les)must be endorsed.if SUBRO"TION 13 WAIVED,subject to the
terms and conditions of 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 andorsament(s).
PRODUCER CONTACT
OCEANSIDE INS GROUP -NAME:
PHO No,
]_I�AX
52 WEST MAIN STREET WC,No,Exti: C,M.1;
HYANNIS,MA 02601 64ML
ADDRESS:
PKouucr.ft
CUSTOMER IV t.
INSURED INS )AFFORDING COV NAIC ft
BENABBY INC DRA INSR R A EMT
DISASTER SPECIALISTS INSURER B
P 0 BOX 480 INSURER C
SANDWICH,MA 02563 INSURER
INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS ISTOCERTrPY THAT THE POLICIRS OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTIM INSURED NAMED ABOVE FpR.THE POLICY PERIOD INDICATED.
ROTWITIISTANDIZ10 ANY REQUMMdENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO CH TEIS CERTIFICATE MAY BE
ISSUED OR MAY PERTAIN,TM INSURANCE AFFORDED BY THE POLICIES OESCIMED MREIN 18 SUBJECT TO ALL THE 77YJAS, CLUSIONS AND CONDITIONS OF SUCH
POIJCIES.LINIITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY E LIMITS
LTR INSR WVO ",VDDIYYYY)
GENERAL LIABEUTY i EACHOCCUMNCE I
.DAL4AGETO RENTED S
0 COnZRCIAI,OENERAL LIABILITY PREMSES(FA6
LEED EXPENSE(Arq-e S
CLAM MADE 0 OCCUR Perim
PERSONAL&ADV 3
INJURY
oEmzRALAG3RwArz S
GEN'L A430?XOAT%12W APPLIES PER:
PRODUcr3-CO111PIQP I
0 POLICY 0 PROJECT 0 LOC AOO
AUTOMORME(JABTLJTY Colamm SINeLE
L%w
Pch icclden�
0 ANY AVTO BODILYDTJURY I
ft Perom� I
BODILTINJURY I
0 ALL OWNM ATIT09
(PerAgeldat)
PROPEM DAhIAQE
0 SCHMUIID AUTOS �P(C=jdent)
0 itRED Auros
0 11011-OWNED AUTOS 9
0
0 UNSRELLALIAB 0 OCCUR i EACHOCCU=- CE
a E(CESS LIAR 0 CLaM4_1tADz A00REGAn
0 DEDUCMLS
0 RUrEMMON S
WORKERS'COMPENSATION WC
A AND EMPLOYERS LIABUJTY N/A STATUTORY
YIN
CRnMIBER I'mc""IDEI'rr $500'000
EXEUTM OR1C7A14 T PROPRMTORIPARTtrW [ N NIA 6ZZUBA102P700 01101/12 01101/11
EXCLUDEM
(MANDATORY III L DIS=--EACH
LOYEE 3500,000
IT yos,douribe wder OBSCRIVRON OF 1 DISEASE.P OLTCY $500,000
I OPERAT1109S below
D92iCPJPTIOliOYOPZRATIDIIMOCAttON,IfVFJaCLIS(AbehACOFLDIOI,AdditioulRernuksSchedWe,if(r.ore space isrequit&eD
THE WSUREDIS MAIRORYFM COMPENSATION POLICY AND ITS tZZM OIMM STATES 124SUILANCE DToO7UMM AUTHORIZES THE PAYXDTTtOF BENEFITS FOR CLADa MADE By THZ T'ISUUZ'
DaLO YM IN STATES OTHER IWAY MA NO AUTHORMA11011 IS a UNA TO PAT CLAM FOR BENEFITS IN ANY STATE CTrMR THAN MA U THE UlMnm MM,OR PAS LURED,EWLOYESS OUTSIDE
MA.THIS PO LICY DO M- 140T PROVIDE COVERAGE FOR AITY STATE OTHERTHAN MA
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED 7 0 71 M CERTIFICATE HOLDER AFFECTTIG WORKERS C IDiP COVERAGE
4
IT 7
SHOULD ANY OF THE ABOVE DEDC 0 POLICIES BE CANCELLED BEFORE
T
THE EXPIRATION DATE THEREOF,N ICEKLLSEDELIVEREDIN
ACCORDANCE VATH THE POLICY PR VISIONS.
I AUMOXM R12REENTArM
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-071402
JOSHUA L CO
1082 OLD S7 G .
CENTERVLE y �'
!ss,
Expiration
commissioner 12131/2013
r
��e �po�r�vr�wazcuealC�rz, �_
� czfactc�craeC _. _
ffice of Consumer Affairs&Business �— - - _------
Regulation
— ME IMPROVEMENT CO License or registration valid for individul use only
NTRgCTOR before the expiration date. If found return to:
egistration 108642
TYpe:. Office of Consumbr Affairs and Business Regulation
Expiration
8/20/2014;;; 10 Park Plaza-Suite 5170
BENABBY INC/DISASTER,SPECIA�LIS7 Supplement(::ard Boston,MA 02116
t f I
JOSHUA COHEN
Box 480
Sandwich, MA 02563
Undersecretary
Not valid without signature
�ZHE Tqt� Town of Barnstable
Regulatory Services
9snx" is� Thomas F.Geiler,Director
�A 039. �0
rFnN,p�° Building Division
Tom 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
as Owner of the subject property
hereby authorize _aeci ' S �,c e, to act on my behalf,
in all matters relative to work authorized by this building permit.
A.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 wner ature of Applicant
Print Name Print Name
Date
QTORM&OWNERPERMISSIONPOOLS 6/2012