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Home My WebLink About800 BEARSE'S WAY (12) �a-v �Esr��s W q'/ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel A�tionn # Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project St re t Address Village Owne Address Telephone Permit Request - A21�rjc- _ Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation "S5_ - Construction Type ce,� ��2 iare__ Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) o?eb Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout Wither �4� 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 Telephone Number Address f-47A fi=� 5fn&j �� License # e19 7/YO 544A)'JD1',`� o � � � �� Home Improvement Contractor# A40 Y� S� coke 4V Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE U �(a �- FOR OFFICIAL USE ONLY ' - APPLICATION# DATE ISSUED " MAP/PARCEL NO. ADDRESS i VILLAGE OWNER' DATE OF INSPECTION: FOUNDATION FRAME INSULATION L , FIREPLACE 6 ELECTRICAL: ROUGH FINAL r i PLUMBING: ROUGH FINAL r' GAS: ROUGH FINAL z FINAL BUILDING DATE CLOSED OUT 6 f 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/Organizaliot>/Individual): Bena6(Qu,Tm —D/ A 171 fir° t ww j l(� Address: COX 4S01 q j�sn `�� 1�� ri tie City/State/Zip; W1~ Phone#: 8 Are you an employer?Check the appropriate box: Type of project(required): 1.X 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. ❑N w construction 2.ElI am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship 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.t 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 I L❑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 1311 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. 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: zur'ch-A(n , Policy#or Self-ins. Lic.M ^l /0 p1 P W OO Expiration Date: b Job Site Address: 11 02 1102� City/State/Zip: S . Attach a copy of the workers'compensate n policy declaration page(showing the policy nul4ber 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 fonn 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. Si a lire. 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 5.Plumbing Inspector 6.Other Contact Person: Phone#: RightFax N1-1 12/22/2011 7:19:42 AM PAGE 3/003 Fax Server ysj�rw f€c1 � F ka y+u�tl M1r {° ` j r ° 4 ref el4rpF F H# ISSUE DATE "'�T�tj •s ,x .?.,.�:•kR'•—fir ._ .ur hvr,a =.fir 12122/2011 a^:: ..rc.a..- THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICA HOLDER.THIS CERTIFICATE DOES NOT AFFDTMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BX THE POLICIES BELOW,TM CERTIl7CA'rE OP INSURANCE DOES NOT CONSTTrUTE A CONTRACT BETWEEN THE ISSUING INSGRW4SN�UTHORU= REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER. IMPORTANT:B the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed,if SUBROG TION IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement,A statement on this certmeate d es not confer rights to the certificate holder In Hsu of such andorsement s. PRODUCER CONTACT OCEANSIDE NS GROUP NAME: AX 52 WEST MAIN STREET PHONE,No,Ext: I "No: HYANNIS,MA 02601 64ML ADDRESS: PRODUCER CUSTOMER ID R INSURED INS S AFFORDING COVERA(;IS NAIC fl BENABBY INC DBA INSURER A ZURICH DISASTER SPECIALISTS INSURER B P O BOX 480 INSURER C SANDWICH,MA 02563 INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO'M INSURED NAMED ABOVE F R TIM POLICY PERIOD INDICATED. NOTwriRSTANDBNO ANY REQUIRRAI.FNT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUXWT WITH RESPECT TO CH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED BEREW IS SUBJECT TO ALL THE TERMS, CLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMTS SHOWN MAY HAVE BEEN REDUCED BY PAM CLAIMS. INSR -TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFP POLICY E LIMITS LTR INSR WVD I GENERAL LIABILITY , FAC71OCCURRINCE S MAMAGETO RENTED s 0 COMMEtCLV.OENERALLIABBITY PREMSES(Each oocvrrmca i MED.EXPEICE(My one S p CLALMS MADE 0 OCCUR persm PERSONAL&ADV f INJURY 0 ) OENZRALAO0REGATa. S i GEN'L AGOREOATE LIFdTT APPLIES PER 0 POLICY 0 PROCT 0 LOC PAOOUCIB-CO&IIFlOP S JE AOO AUTOMOBILE LIABILITY COh1BINED SINGLE S LINUT (Each eeeldenl 0 ANY AUTO BODE,YINJURY I M Person) j 0 ALL OVnfM AUMS I BOD¢YINJURY S i er Acciderfl) 0 sOtGDULEU AUTOS '*=TYDA` S «aw, i 0 H RED Avro dmts S 0 ITON•OWNED AUTOS S 0 0 U�RELLALIPB 0 OCCUR EACH OCCiJRREHCE S 0 EXCESS L1AD 0 CLAIMS-MODE AOOREOATF. S - 0 DEDUCTIBLE I 0 RSFNMONS S WORKERS'COMPENSATION f WC A AND EMPLOYERS LIABILITY NIA FFATUTORY YIN ANYPROPR OFFIC RME..R/ 1 E7TcROPRMTTr_RAdEMIBER N NIA 6ZZUH-4102P700 O1101/12 01/01/13 L EACH AccIDlstrr s500,000 EXCLUOYM (MANDATORY WITH) EL DISRPSE-EACH 5500,000 EMPLOYEE rr yes,douribewdor05SCRUMONOF LDMEASE-POLICY 5500,000 OPERATTIONSbelow f UESCRIPTIOJTOFOPERA1701I81LOCAttONAIVBFRCLES(AbchACORD101,AdditionalRemarksSchedule,itmorespiceitrequiresp THF.WSUREDS MA WOM RS COMPENSATION POLICY AND ITS L11 TTF.D OTHER STATES INSURANCE MMOREEMENT AUIHOR1E1:3 THEPAYMDTI`OF BENEFriS FOR CLAMM MADE DY'Dre..INSURED' DaLOYEES DE STATES OTHER 7HAN MA NO AUTHORIZATION IS drIM TO PAY CLA M FOR BWEFM IN ANY STATE UnER THAN MA V TrM B1"M HIRES,OR HAS HIRED,EMPLOYEES OUTSIDE � MA WS POUCY DOTS NOT PROVIDE COVERAOE FOR AITY STATE OTHER THAN MA THIS REPLACES ANY PRIORCERITFICATE 189M TO TILE CERTIFICATE HOLDERAFFECTING WORKERS C hip LrOVERAGE C€,IfTJ(s(# S?TAS VAt9CE �W t) t ..... , SHOULD ANY OF THE MOVE DEBC ED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,N TICE WALL BE DELIVERED IN ACCORDANCE WITH THE POLICY PR VISIONS. ... AUnI0RM FZRE5MArIVC 8rlawMacleaty _ �LC.CORYT2�""4U9/,4 � ��;',,� ,�4:. ,:.� y.:c.. ��r �^t,,.,e��3Y�• "?a�,.'fn�.t46&IlOU�'C'0 �tf't�Iti4'I'��IV;f1U`i':� `'1�3cair�i: i ' i • f Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supervkor. License: CS-071402 3OSHUA L COi i N 1082 OLD STAG_ vw CENTERVI RLE ` Expiration Commissioner 12/31/2013 ct ��e (poa�7rnoiacue�lC�a�C� �daalccaea MCC of Consumer Affairs&Business Regulation —- - License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: - a egi rat Expirati Type: ion 108642 Office of Consumer Affairs and Business Regulation on ' 8/20/2014 ,. 10 Park Plaza-Suite 5170 BENABBY INC/DI"SASTERSPECI,q�IST Supplement 4.ard Boston,MA 02116 JOSHUA COHEN Box 480 Sandwich, MA 02563 Undersecretary Not valid without signature C y DIME l� Town of Barnstable Regulatory Services * iwxtvsrwaLE. y� MAS& g Thomas F.Geiler,Director 039• '°rFp,�,pIA 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 I1.v1'0Lf /' , as Owner of the subject property hereby authorize w-eci ' t, S rc A/ e- to act on my behalf, in all matters relative to work authorized by this building permit. (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. /. ` G�0 Satuxe o caner ature of Applicant Print Name Print Name Date Q:F0RMS:0WNERPEFMISSI0NP00LS 6/2012