HomeMy WebLinkAbout800 BEARSE'S WAY (13) �a� ��,��-s- �v�-
` TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map _ Parcel d 47., � "AppTication=#'-.0
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 2rn? &Vc.
Village t..9-A bL) 11)(�
Owner lkrkYR /Z/26. D Address 416
Telephone
Permit Request 11.r/ xt ;tKu�" Qggo
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation /5'oD , Construction Type / �`a ��Ineg
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units)
Age of Existing Structure 11� Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout a-0iher
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 �J I�Ay _ �� ® � Telephone Number �����
Address License #
L,I to Home Improvement Contractor#
,1 oS Cry Worker's Compensation # �'®
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE lL a
FOR OFFICIAL USE ONLY
' APPLICATION#
DATE ISSUED '
MAP PARCEL NO. _
ADDRESS VILLAGE
OWNER :
P
DATE OF INSPECTION:
� FOUNDATION
;t
FRAME
INSULATION
s . .
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FIREPLACE
ELECTRICAL: ROUGH FINAL t�
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PLUMBING: . ROUGH 'FINAL
,r GAS: ROUGH FINAL
FINAL BUILDING
w ,
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 ` gyp- Please Print Legibly
Name(Business/Organizaliott/Individual): �'1c''�.I b� Q y i,_L.1oc ! /15C'15f real
Address: Py)a SePY� on 21)r f Ue
City/State/Zip; t�l^ Phone#: r� 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. ❑New construction
2.❑ I 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'
insurance.*
9. ❑ Building addition
[No workers comp. insurancecomp.
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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
6 '
Insurance Company Name: Arne'"Ofin
Policy#or Self-ins.Lic.#: ) !OAP /t�60 Expiration Date:
Job Site Address: t ty/State/Zip:
Attach a copy of the workers'compensation olicy de aration page(showing the policy nutuber 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 f un a thepains andpenalties ofperjury that the information provided above is true and correct.
Si ature: 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.BuiIding Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
el
RightFax N1-1 12/22/2011 7:19:42 AM PAGE 3/003 Fax Server
ISSUEDATE
= R t ra 3ds�n Ij irabyrY�f vP "r r {
HER
}ktly a r.::wcs•-r av"r �a: 12112120I1
THIS CERTIFICATE Is ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICA HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDEDOXTIMPOLICIZ9
BELOW,THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING BVSUREJgSN NUIHORFI,ED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT;if the certificate holder Is an ADDITIONAL INSURED,the pollcy(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 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 AIC No,Ext: IBC,No),
HYANNIS,MA 02601 6 MaL
ADDRESS:
PRODUCER
CUSTOMER ID at
INSURED INS S AFFORDING COVERA(ati NAIC#
BENABBY INC DBA INSURER A ZURICH
DISASTER SPECIALISTS INSURER B
P O BOX 480 INSURER
SANDWICH,MA 02563
INSURER D
INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY TRAT TM POLICIES OF INSURANCB LISTED BELOW HAVE BEEN ISSUED TO'=INSURED NAMED ABOVE F R THE POLICY PERIOD INDICATED.
NOTWr EJSTANDR7O ANY REQUIR I,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTIB RESPECT TO CH THIS CERTIFICATE MAY BB
-
ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED BEREIN W SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES,LDffTS SHOWN MAY HAVE BEEN RIDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EX) LEMTS
L'IR INSR WVD i
GENERAL LIABILITY EACAOCCURRENCE I
000bIMEtCLll.GF'�IERAt,l1ABId'TY PRE14SES(Eech S '
exevreeexe I
. MID.WEN'E(Any eme S
Q CLALY.S wr,E 0 occuR. Perim
PMEONAE,aADV f
INJURY
0 ) GEIr-RALAGOREGATE S
OEN'L AGGREGATE LIHUr APPLIES PER
PRODUCTS-CO1010P i
D POLICY 0 PROJECT U LOC AGO
AU701,110AILE LIABILITY COMBINED SINGLE S
7aMIT
ch accident)
A1fY AVM BODIPers LY INJURY S
M i
0 ALL OWNEDAUTOS BODILYINJURY S i
i (Per Aeciderd)
0 SCICDULED AUTOS PROPERLY DAMAGE S
er aaidmt i
0 HIREDAUTOS S
() 11024•OWMID AUTOS S
0
0 UMBRELLAPB 0 OCCUR I EACH OCCVRR?FCE
Td S
0 E(CESS LIAR 0 CLALNS-MODE AGGREGATE S -
0 DEDUCTIBLE S
0 RVIUM.ON S I
WORKERS'COMPENSATION I WC
STATUTORY
A AND EMPLOYERS ISABIISFY NIA mm
YIN �
ANTPROPRBTO"ARTNER/
E)aCUITVE OFELG'�stlblESffiER N NIA 6ZZUB-A 102P700 01/01/12 01/01/13 LEACH ACCmENf $500,000
EXCLUDFD7 L O7SEA3L•—EACH
(MANDA70RY IN N}0 - - TOYS $500,000
i
rryes,describemdorOBSCRFPHONOF L..DI;ePS-POLICY
OPERATTONSbelow ,. 000,000
DESCRIPTION OF OPERATIONSR,OCATIONSATMCLE9(ANaeh ACORD I OI,Addlliomi Remsrks ScheduMe,it meve spice is requvee0 '
THE.MSURED'S MA"NO.RYM COMPENSATION POLICY AND ITS LR.fft'eD OTHER STATES LVSURANCB MMORSENUan AUTHORIZES THE PAYMETneOF BENEFTfS FOR CLAD&MADE BY IK INSURED'
M,IPIOYM IN STATES OTHER THAN MA NO AUTHORIZATION IS ONFN TO PAY CLAIMS FOR BF 4UM IN ANY STATE O!D(ER THAN b1A IF 71,M INSIJRF:D HMM,OR HAS FIRED,EMPLOYEES OUTSIDE �
MA M POLICY DOTS NOT PROVIDE COVERAGE FOR AITY ITATE OTHER TRAM MA
THIS REPLACES ANY PRIOR CRRTWICATE 1881)YD TO TILE CERTIFICATE HOLDER AFFECTING WOR=C MP dOVMGE
-. ;CFI_T,�1`•.)c(l1,�r'����Ft,.'�s�i,.ay.r,aa.Sx�r ram,<, r�r.,.�; .:.,'x�",;���S;yn.r�CxAl9CIfiE. .S��IQ: , � •�,� ,�.� c .�.n"'',�",�? I?'.:,xrY' 2a:yiz:
SHOULD ANY OF THE ABOVE DESC ED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,N TICE INILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PR VISIONS.
..... AUFHOUM RJPRYSFNJATIVC
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Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supen'isor
License:CS-071402
JOSHUA L COAhN -- r
1081 OLD STAG .
CENTERVIOZ
i
Expiration
Commissioner 12/31/2013
Lam—
&Xe ePonvr�WiacuecclC�o� aJaac�uaeC .
_ ffice of Consumer Affairs&Business Regulation
ME IMPROVEMENT CONTRACTORLicense or registration valid for individul use only
i
gstrab
e on before the expiration date. If found return to:
n 108642 Expirat n Type' Office of Consumer Affairs and Business Regulation
io gj�4�2014 10 Park Plaza-Suite 5170
BENABBY INC/DISASTER• SuPPlement(:ard Boston,MA 02116
,SPECIALIST
JOSHUA COHEN
Box 480 n}
Sandwich, MA 02563
Undersecretary
Not valid without signature
THE rOwti . Town of Barnstable
Regulatory Services
RMWAy MA sBIEg Thomas F.Geiler,Director
rF039. a 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 /s�,f ��� (i S �c � 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.
A7o
Goo
Suture o wrier ature of Applicant
Print Name Print Name
Date
Q:FORM&OWNERPERMISSIONPOOLS 6/2012