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Home My WebLink About800 BEARSE'S WAY (18) A TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION .a i�dS I Map °- Parcel 66p(® ( App ication # Health Division Date Issued Conservation Division Application Fee 2Z Planning Dept. Permit Fee J Date Definitive Plan Approved by Planning Board Historic - OKH _Preservation/ Hyannis Project Street Address /0� " s , < 1 Village 7� t Owner '� d Address Telephone Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation -�J5_0 D 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 LLOMer ::5A4j4=b 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) c Name Telephone Number �� Address 5d P<7—/97&) License # C5 15�� 6�- GU`�( ) 1 O-A A44 Home Improvement Contractor# 6-S �6 ke A—) Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE l FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED ~ MAP/PARCELNO. ADDRESS VILLAGE OWNER- DATE OF INSPECTION: s FOUNDATION FRAME ' INSULATION l FIREPLACE f" ELECTRICAL: ROUGH FINAL.,,- PLUMBING: ROUGH FINAL z 5 GAS: ROUGH FINAL FINAL BUILDING 4 DATE CLOSED OUT r ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents ' Office of Investigations ' 600 Washington Street Boston, MA 02111 ww►v.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizatiot>lIndividual): K��IU U/ A Dsos4'_C�' ��l(� Address: P() oy q Y1 !)r 1 ue. City/State/Zip; sardw ~ 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. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. emodeling ship and have no employees These sub-contractors have g• ❑ Demolition working for me in any capacity. employees and have workers' comp.insurance.t 9. ❑ Building addition [No workers comp. insurance p 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 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. ;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. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Z u r 1,cb -Arne�ri Policy#or Self-ins.Lic.#; a A P r- /Q0 Expiration Dat�ftmlvlvlS / Job Site Address: �S� City/State/Zip: Attach a copy of the workers' compensation olicy declaration page(showing the policy number 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 ltereby cer if un a the pains and penalties of perjury that the information provided above is true and correct. r Sign. ture: 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#: RightFax N1-1 12/22/2011 7i19:42 AM PAGE 3/003 Fax Server U. e e ^ a ta s �. ,��,t's�+0''a.xE'sl'p f,� {i!.> ISSUE DATE t r 124212011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TILE CERTIFIC!y HOLDER,THUS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED THE POLICES IIELOw,THIS CERTIFICATE OF U46MUNCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE 196UING INSUIRR(SN KUTIIORJY,CD REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT;If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)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 Hou of such endorsements. PRODVCSR CONTACT OCEANSIDE INS GROUP NAME` AX 52 WEST MAIN STREET NCNNo,Ext: (AJC,Not, HYANNIS,MA 02601 64ML ADDRESS: PRODUCER CUSTOMER ID V. INSURED INS S AFFORDING COVEItA7oE NAIL tI BENABBY INC DBA INKWR A ZURICH DISASTER SPECIALISTS INSURER g P 0 BOX 480 INSURER C SANDWICH,MA 02563 INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 18 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO'IW INSURED NAMED ABOVE F R THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIRE�rT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMIT WITS RESPECT TO CH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED IaMMN IS SUBJECT TO ALL THE TERMS, CLUSIONS AND CONDITIONS OF SUCII POLICES.L1MTrS SHOWN MAY HAVE BEEN REDUCED BY PAID CLANS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY E LIMITS LTR INSR wvD DffMI GENERAL LIABILITY , EACH OCCURRENCE I DA14AGETO RENTED S 000MMI OALOENERALLIABUTY PREMSES(Eeeh ' otturcmce i ` MED.E'XPENE(Any m,e I I Q CIALUS MADE D OCCUR peram O PERSONAL&ADV - I INJURY 0 i OF11EERALAOOAEOATE S ' GEH'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOF S 0 POLICY 0 PROJECT 0 LOC AGO AUTOMOBILE,LIABILITY COMaDMD SINGLE S LIMIT (Each aceldent 0 ANY AUTO BODILY INJURY I On Perso BODLrYINNBY I 0 ALL OWNED AUTOS j xAccldad) 0 scFCDULEO AUTOS PROPERTY DAMAGE S er am,dmt i 0 HOLED AUTOS I 0 IION•OWNFD AUTOS s 0 O UMBRELLAL.IAB 0 OCCUR pSTA7UTORY S U EXCESS LIAR 0 CLALMs-MADE S 0 DEDUCTIBLE _ 0 RETENTON E - 2 WORKERS'COMPENSATION A AND EMPLOYERS LIABILTrY YIN Lam ALNYPROPRIEI'ORJPARTCTZR/ I EXECUTIVE OFFICTXMEbIDER N NIA 6ZZUB-4102P700 01/01/12 01/01/13 LEACH ACCIDENT S500,000 EXCLUDED? (MANDATORY IN NH) E.L DIM=-EACH S500,000 i rr yes,describe wdm DESCRIFnON OF ELDISBASE.POLICY $500.000 OPERATIONS below NdrT UESCRTPTTOT70FOPERAT10N8hOCAtt0N8NEHICLS9(Attach ACORD 101,Additional Remarks Schedule,irmere space is rags acD THF.IRWRED'S MAWOREERS COMPENSATION POLICY AND ITS I IJATED OINLR STATES INSURANCE ENDORSEMENT AUTHORIZES THEPAYMEIrl`OF BENEFITS FOR CLAIMS MADE BY T1Nr.I,SUAED' EMPLOYEES IN STATES OTHER THAN MA NO AUTHORIZATION IS OLVFN TO PAY CLAIMS FOR BUTUM IN ANY SLATE OTHER THAN MA IF THE RIMIED HIRES,OR HAS HIRED,E aLOYEES OUTSIDE i MA[HIS POLICY DOTS NOT PROVIDE COVERAOE FOR ANY 6rATE OTHERTH.AN MA THIS REPLACES ANY PRIOR CERTLIFICATE 188DED TO TIES CERTIFICATE HOLDERAFFECIING WORKERS C MP G`OVERAGE ?3 SHOULD ANY OF THE ABOVE DEDC ED POLICIES BE CANCELLED BEFORE I THE EXPIRATION DATE THEREOF,N TICE HALL BE DELIVERED IN ACCORDANCE PATH THE POLICY PR VISIONS. - ...-. AIlI110RIZID RFP(tDYMATIVL' 8r(.awMacl.eaw i - a Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Super%'isor License: CS-071402 _4l rS , Qom. r JOSHUA L COAN 1082 OLD SIB G: = CLNTL�RVII�L r V4 ' S,tfl'` Expiration Commissioner 12/31/2013 V 1ZBCv/79i/7Zp92LUBCLGG� ffice 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 108642 Office of Consumer Affairs and Business Regulation Expiration g/20/2014„_ Type` 10 Park Plaza- Suite 5170 BENABBY INC/DISASTER SPECIALIST Supplement t:ard Boston,MA 02116 1 " JOSHUA COHEN � Box 480 Sandwich, MA 02563 Undersecretary Not valid without signature �tHE r Town of Barnstable Regulatory Services •. BARNSTABLE. + MASS. Thomas F.Geiler,Director Qjp 1639.rFOMP'�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 I, d//��'�L/,�� /��v2� �d'l �/'M , as Owner of the subject property hereby authorize ti E kc. A-'� e- to act on my behalf, in all matters relative to work authorized by this building permit. 00 eQ1'J-Z,3 41 Ad ' A- WV, aet�t i-� ash (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, V ` GI'0 S ature o wrier ature of Applicant Q"e Print Name Print Name ` -act) 12" Date ` Q:FORMS:OWNERPERMISSIONPOOLS 6/2012