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Home My WebLink About800 BEARSE'S WAY (16) - - °�- ` !1�'-�-ytv-y�z-� � OJT_ ,.'"`�:L�%��'�.,._ _ _ -- - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # Health Division Date Issued Conservation Division Application Fee S�} Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address Village - e Owner /H A z,-& It &0&r-9 y 4C EP P I h Address Telephone Permit Request QC �` 9� dn� �� i I%2 c. 3t 5 A6e��, k 62' Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type 1��1 Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic Hou��se��❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout It.0ther 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) Name0tts .06ri fZ7 ��/ Telephone Number Address—�/fi�f� � � �/y � l License# C`s is`2Z fb2� Home Improvement Contractor# 1�S C6L J v Worker's Compensation # �*A f7,;5b ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE I FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. } ADDRESS VILLAGE OWNER , d i R DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ; t GAS: ROUGH FINAL , r3 : i FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. t x, t The Commonwealth of Massachusetts Department of Industrial Accidents ' Office of Investigations ' 600 Washington Street Boston,MA 02111 ; ~v.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �-, Please Print Legibly Name(Business/Organization/Individual): a U� � DIWA D as4er"' ! wa1 fs Address: P( &Y 4/Rzq `� �1T J ri ye, City/State/Zip: W 1 h Phone#: 8 Are you an employer?Check the appropriate box: Type of project(required): I.X I am a employer with to 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. [-1te-modeling 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.comp, insurance 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' camp. 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. 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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Zrich-Air) ' . I n r Policy#or Self--ins. Lic.#: 1 a f' /D� Expiration Date: / Job Site Address A,6City/State/Zip: Attach a copy of the workers' compensation polic4eclaration 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 tf un a thepains andpenalties ofperjury that the information provided above is true and correct. Signahire: 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 Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: .tt . RightFax N1-1 12/22/2011 7:19:42 AM PAGE 3/003 Fax Server ISSUE DATE 12l2212011 THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICA BOLDER.THIS CERTIFICATE DOES NOT ATFUU44TIMY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BX THE POLICIES DELOW.TWe CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURZ.IgSI,�U HORIZZB REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certlflcale 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 certificate d as not confer rights to the certificate holder In He of such andarsament s. PRODUCER CONTACT OCEANSIDE INS GROUP NAME: 52 WEST MAIN STREET NC,N;Eat: FAX ,No): HYANNIS,MA 02601 EMAIL ADDRESS: PRODUCER CUSTOMER ID V. INSURED INS S AFFORDING COVERACR NAIC IF BENABBY INC DI3A 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 TBE INSURED NAMED ABOVE P DEL THE POLICY PERIOD INDICATED. NOTWI IISTANDRIO ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITS RESPECT TO WHICHTHLS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY TAM POLICIES DESCRIBED IIEREW IS SUBJECT TO ALL THE TERMS,E XCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EX LIMTIB LTR INSR WVp I GENERALLIABIITY EACAOCCURRENCE S OCOMM]^RCLILOENERALLTABa1TY (Each s REMSES ' xcurcmce i Q Cum MADE O OCCUR MED.EXPENSE(Any m e S I 0 PERSONAL,TADY S INJURY 0 ) OENERALAOGREGATE S GERL AGGREGATE I2,13T APPLIES PER ' PRODUCIS•COMPJOP S i D➢OUCY 0 PROJECT O LOC Apo AUTOMORME 11ABD.ITY COMBINED SRNOLE $ LIMIT . ch aeclden i 0 A?n AUTO BODILY INJURY I M Pers BODD.YINJURY S 0 ALL OWNED AUT08 j (PeNAccident) O 3CH RULED AUTOS PROPERTY DAMAGE S (Per amNdmt i 0 HDZIDAUTOS S 0 NON•0WNTD AUTOS I 0 0 UM M BRE[ LIAB 0OCCUR = EACH OCCURRENCE S 0 ECCESS LIAR OCLALNS-MOLE AOOREOATE S 0 BMUCMLE 1 0 Rt TEIMON S S WORI(ERS'COMFENSATION I WC A AND EMPLOYERS LIABILITY NIA ✓UL ORY YIN ANY PROPREETOR/PARTHER/ EXECUTIVE OFRCE1in.IE,1BER N NIA 6ZZU84102P700 01101/12 01/01/13 L.EACH ACCIDENT 1500,000 EXCLUDED? .L DSSEASL•-EACH (AMLCDA70RY IN NH) $500,000 EUPLOYEE rr yes,dwrk ender DESCRUMON OF LDISEA •PO[dCY 1500,000 OPERATIONS helone I ,T1rP UESCRTPTTONOFOPM7701ISILOCAttONSATMCLES(Abeh ACORDIOI.Addilioml Remuks Schedule,irmerespaceierequlreo THE.WWRED'S MA WO.RUM COMPENSATION POLICY AND ITS LIMITM OTNn STATES INSURANCE ENDORSEMENT AUIHOMES nM PAYMENIrOF BENEFI S FOR CIA"MADE BY TJR,INSURED' EMPLOYEES IN STATES U IM THAN MA NO AUTHORIZATION IS CTVE N TO PAT CLAMS FOR BENEFITS IN ANY STATE OrrTER THAN MA IF I:M INTUM HIRES,OF,HAS HIRED,EMPLOYEES OUTSIDE MA LIDS POIdCY DOLS NOT PROVIDE COVEINOE°OR AItY CTATE OTHEP THAN ASA TMS REPLACES ANY PRIOR CERFIFICATE 185DED TOT]EE CERTIFICATE HOLDER AMC17C WORFCERSC hdP dOVMkC;E <., rjN�!., �'p }_ pp,�.__ s _. _ �s�` - t _r�Y:L a _.. ..r .'-:��,S•�':, ;:'":,ate r�..'7�,;:tr3!t'`PT.:F�h.i4i - SHOULD ANY OF THE ABOVE OESC 90 POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,N TICE MLL BE DELIVERED IN ACCORDANCE WITH THE POLICY PR VISIONS. ...-. AUIHORm RIDREsanAnve 8Y(tiUU ttCl.BRRL ;.,=9'F£r..r, I Mee of Consumer Affairs&Business Regulation �~ ME IMPROVEMENT CONTRACTOR License or registration valid'for individul use only before the expiration date. If found return to: egistration _408642__. Office of Consumer Affairs and Business Regulation Expiration Type: 8120/2014 10 Park Plaza-Suite 5170 BENABBY INC/DISASTE- ------- _ . SuPPIement(`ard Bost ST Boston,MA 02116 JOSHUA COHEN 5 Box 480 =- Sandwich, MA 02563 Undersecretary /��Nolid without signature Massachusetts-flepartment of Public Safety Board of Building Regulations and -Standards Construction Super kor License:CS-071402 JOSHIIA L COVEN 1082 OLD S14G: n: CENTLRVE LE °J-J.•�:� � i '' Expiration Commissioner 12131/2013 k THE rqy Town of Barnstable Regulatory Services � snxxsrABLE, Mass. �, Thomas F.Geiler,Director 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 �iSG.f /' �� ' � S �� -1:�r� e.- to act on my behalf, in all matters relative to work authorized by this building permit. ®� eC11'J"Z- �l Qua ; �� lq a��i-� '04 (Address of J b) r � **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 Q� Q:FORM&OWNERPERMISSIONPOOLS 6/2012