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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.
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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
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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
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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
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Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supen'isor
License: CS-071402
JOSRUA L CoftN' Me
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1082 OLD SIG
CSNTERVTiaE
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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