Loading...
HomeMy WebLinkAbout800 BEARSE'S WAY (20) �a-v ���Es �v�� C C�.o�y�,,r�� . .. .,./.�, �-�-�-SS-µ, ��'��� 6 �—��K TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel CAL 10 AZ&- Application # Q D S Health Division Date Issued �- Conservation Division Application Fee Planning Dept. Permit Fee �3 Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address 51 _ r?— Village i Owner d Address %$r �T�&��t S Aw Telephone Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation `iW • Construction Type dam' 1cT44C - 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 Wither 5 'zj�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 � ���� ��/ S� Telephone Number Address License # f: 6 `7 Home Improvement Contractor# ­1 __,6�k G L sV Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 4 SIGNATURE DATE i FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS F VILLAGE OWNER - DATE OF INSPECTION: FOUNDATION FRAME INSULATION �.� FIREPLACE ELECTRICAL: ROUGH FINAL - PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING 4� F DATE CLOSED OUT '4 s • ASSOCIATION PLAN NO. r a, 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 Le2fty Na]T18(Business/Organizatio»/Individual): abbe,Try , �/FIA 11s'a skr Address: P0, COX 41S-0�abn a� r l ue City/State/Zip: W1- Phone#: rS g l Are you an employer? Check the appropriate box: Type of project(required): 1.DQ 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 construction 2.El 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.t 9. ❑ Building addition [No workers comp.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 requited.] 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: Z , Policy#or Self-ins.Lic.#: 10AP7600 Expiration Date: Job Site Address: S City/State/Zip: Attach a copy of the workers' compensation polley/declaration page(showing the policy number 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 Itereby cer if un a the paints 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 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#: DIME r Town of Barnstable Regulatory Services HAMyBM MASS. Thomas F.Geiler,Director �A 1639. TFpMP'IA 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, '/C/�tJ 7, .L lrj egn , as Owner of the subject property hereby authorize -1:�r� c- to act on my behalf, in all matters relative to work authorized by this building permit. 00 env. e 41 Ada, 4�.2 Nra�� (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. 6,7 Suture o wrier ature of Applicant Print Name Print Name Date :FORMS:OWNERPERMISSIONP L Q 00 S 6/2012 ..ram 1 RightFax 141-1 12/22/2011 7:19:42 AM PAGE 31003 Fax Server E 5. i, THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT AIFU MATTVELY OR NEGATIVY.LY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BX THE POLICIES nELOw,THUS CERTD ICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE TESUING INSURLR(SN�UTHORNU REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certhicate holder Is an ADDITIONAL INSURED,the pollcy(los)must be endorsed.If SUBROG TION 13 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 lieu of such endorsement a. PRODUCER CONTACT OCEANSIDE INS GROUP NAME: 52 WEST MAIN STREET PHONE o,Eat: AJC,No): HYANNIS,MA 02601 EMAIL ADDRESS: PRODUCER CUSTOMER ID Y. INSURED INS S AFFORDING C0VEItA08 NAIL N 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'I'HE INSURED NAMED ABOVE P R THE POLICY PERIOD wDICATED. N07VIT HSTANDB70 ANY REQUIRMdENT,TERM OR CONDITION OF ANY CONTRACT OR OTM DOCUMENT W1TE RESPECTTO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED BEREIN IS SUBJECT TO ALL THE TERMS,I XCLU31ONS AND CONDITIONS OF SUCH P011=.LDNTI'S SHOWN MAY HAVE BEEN REDUCED BY PAM CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POUCYEXP LIMITS LTR INSR WVD I GENERAL LIABILITY EACHOCCURRENCE f .DAMAQETORENTED S 0 CO10MC1ALOENERALUABQdTY PREMISES(Each occurcelxe IM,,EXPENSE(Any-e S I Q CLAIMS MADE 0 OCCUR person O PERSONAL&ADV I INJURY 0 OENERAL AGGREGATE S OEN'L AGOREOATELDRT APPLIES PER PRODUCTS-COMPlOP I i 0 POLICY 0 PROJECT D LOC A0O AIJTOMOHRIE UARMITY - COl IDII�D SINOLE $ . Lihdn' oh acdden i O ATrY AM i BODTI.Y M PW f , Ars j BODB.YINJIIRY S 11 ALL OWNED aVrOS ar AccideN) ' PROPERTY DAMAGE S D SCHEDULED AUTOS Ter 2aldmE i D KREDAUAO-o S 0 NON•OWNFDAUTOS S D 0 UMBRELLALLAZ 0 OCCUR EACH OCCURRENCE S 0 EXCESS LIAD 0CLAIMS-MODE AGGREGATE S D DMUCMLE S - O RL7'EM:ON S T WORKERS'COMPENSATION WC A AND EMPLOYERS LIABILTTY NIA STATUTORY YIN ! Lam ANYPROPRMTO"ARWzYJ f ED(ECITTIVE OFFICERME(BER FN N/A 6ZZUB4102P700 01101/12 01/01/13 LEACB ACCIDENT $500,000 (bLMATORY ItrNH)EXCLVDW L -FaCH $500,000 ' i ITycs,dcsenbewdArOTACRiprSONOF I,D13EASE•POLICY SSOQ000 OPERATTONSbelm iMn' DESCRIPTION OP OPERATJONBILOCAt-IONS VFIDCLRS(ARach ACORD I OI,Addilioui Remarks Schedule,irmore spice is requve1D THF.INSURED'SMAWORKERS COMPENSATfONPOLICY ANDTTSI.Itff1EDOTHERSTATrSINSI"CE ENDORSEMP171'AUT HORIZE37HEPAYMFNIrOF BENMFm FOR CLAUS MADE BY'Dir.NSURED' LMPLOYEES IN STATES 07TD'R THAN MA NO AUTHORIZATION IS OMEN TO PAY CLAIMS FOR BENEbTTS IN ANY STATE UTIIIER THAN MA IF TM UISURED HIRES,OR HAS F=,EMPLOYEES OUTSIDE i PROVIDE COVERAGE FOR AITY STATE OT'HEP THAN MA THIS REPLACES ANY PRIOR CERTIFICATE 18SUED 70 nIE CERIU ICATE HOLDER AFFECTING WORXERSC MP COVERAGE `'" G'1'iI�1;�tSfk�;r��r�M!h...�Y„fa^,,,onA)X2alz.,.w.<.;Tyr..'�i:-,._,z� �YA, 9 CuA0IC1JI. ti p:•r ... .. � ..��; .,::.aeha v.., ..._ ... ^,G�'.h`<i^: I SHOULD ANY OP THE ABOVE DEDC ED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,N TICE tMLL BE DELIVERED IN ACCORDANCE WITH THE POLICY PR VISIONS. AUIHOHm RYPRamoArIVC $YG4tYli ctcLeaw K st �t r Veda .t "a' S48$F L'O tril4P� 1:718Y 'i6caltdi I ` 1 i Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supen'isor License: CS-071402 JOSRUA L CoftN' Me - �r 1082 OLD SIG CSNTERVTiaE r i Expiration y` Commissioner 12/31/2013 &Xe Zci2coeaCG� Rice of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR License or registration valid for individul use only egistrati before the expiration date. If found return to: on: 08642 Office of Consumer a Ex i `= =--= Type: Affair s it do � Y s an d Business Regulation BENABBY INC/DISASTER BPE ' l Supplement('ard Boston,,MA 02116 ' . JOSHUA COHEN .r3t Box 480 Sandwich,MA 02563 �� — Undersecretary Not valid without signature