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Home My WebLink About800 BEARSE'S WAY (9) �9�- 6� - �,y \ \ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel 041OR A�tJoon# CJ 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 Village- 44 A o rO Owner I� �� I'dJ{� 191�2 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 /; �5 00 , 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 ier a 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 � � > ��/ Telephone Number Address -JQ- ) *A) License # eS 4 7/�02-- S�4A?� Home Improvement Contractor# /29s� Worker's Compensation # l!>�.�'� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE 6_14 DATE /� FOR OFFICIAL USE ONLY APPLICATION# r c� DATE ISSUED MAP/PARCEL NO. i . ADDRESS VILLAGE s OWNER DATE OF INSPECTION: } FOUNDATION FRAME INSULATION - FIREPLACE ; ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL F ` GAS: ROUGH FINAL ' FINAL BUILDING F i DATE CLOSED OUT ASSOCIATION PLAN NO. i Town of Barnstable Regulatory Services y iK & Thomas F.Geiler,Director �A s639. ♦� rF0.19 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 L 4M-117?,4'y f� v�� f �� , as Owner of the subject property hereby authorize �iSGf eG��i s rc A.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. G�0 sip"atuxe o wner ature of Applicant Print Name Print Name Date Q:FORM&OWNERPERMISSIONPOOLS 6/2012 The Commonwealth of Massachusetts Department of Industrial Accidents ' Office of Investigations 600 Washington Street Boston, MA 02111 wwminass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I- �, - Please Print Legibly Name(Business/Organizalimt/Individual):��enab1�)��y��IFIA �IjSCr1j er ��'�C d(� Address: P Y)t BOY AA0Aq 21)r l l)P- City/State/Zip: Soarawl h Phone#: r- 8 Are you an employer?Check the appropriate box: Type of project(required): 1.X I am a employer with 1 O _ 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. Wemodeling construction 2.El am a sole proprietor or partner- listed on the attached sheet. 7. ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' Y9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We area corporation and its 10.❑ Electrical repairs or additions officers have exercised their 11.❑ Plumbing 3.El I am a homeowner doing all work g repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] fi 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. lain an employer that is providing workers'compensation insurance for any employees. Below is the policy and job site information. Insurance Company Name: Z � -- 1 Policy#or Self-ins. Lic.#: )V O R P /D0 Expiration Date: b Job Site Address S City/State/Zip: V !S Attach a copy of the workers'compensation policy eclaration 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 hereby cer if un a tlae pains and penalties of perjury that the informatibn provided above is true and correct. SiLmahire: Date: Phone#: Official use only., Do not write in this area, to be completed by city or town official. • I City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Cleric 4.Electrical Inspector• 5.Plumbing Inspector 6. Other Contact Person: Phone#: i T RightFax N1-1 12/22/2011 7:19:42 AM PAGE 3/003 Fax Server ,�Ia ISSUE DATE r ;iS>, �„�" '�1 S4.A•mx QS._ly'dip ;F.,a;i'#sr..Y xc.^f :.� ,• -... ;., hirw }a .,i.x,..: r c. ay'..'ry 1212 2/2 0 1 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTTFICA HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED RX THE POLICIES DELOW,THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE USUING INSURER(SN)IUTHORIMD REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT;If the certificate holder Is an ADDITIONAL INSURED,the policy0as)must be endorsed,tf 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 es not confer rights to the certMeate holder In He of such andorsement s. PRODUCER CONTACT OCEANSIDE INS GROUP NAME: 52 WEST MAIN STREET PHONE No,Ext: (A C,No): ' I-IYANNIS,MA 02601 6-AWL ADDRESS: PRODUCER CUSTOMER ID V INSURED INS S AFFORDING COVE N079 NAIC A 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 TM INSURED NAMED ABOVE P DR THE POLICY PERIOD INDICATED. NOFF"WI IESTANDINO ANY REQUIREMENT,TUMOR CONDITION OF ANY CONTRACT OR OTHER DOC XWT WIiHRESPECT'rOwfflCHTMs CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES AESCRIDFD IIEAEW IS SUBJECT TO ALL THE TERNS,EXCLUSIONS AND CONDITIONS OP SUCH POUCIIS.LB41TS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR TYPE OF INSURANCE ADDL SUER POLICY NUIIIBER POLICY EFF POLICY EX) LV IITS LTR INSR WVO I GENERAL LIABILITY , EACHOCCURRENCE Y 0 C010MCLV.OENERALLIABILITY PR MOMS(WNJED Y PREMISES(Each occurreaca) 1 . taD.EXPENSE(Any rme Y Q CLADAS MADE 0 OCCUR- penan 0 PERSONAL&ADY S INJURY 0 i OFIERALAOOREOATZ Y (3DI'L AGGREGATE LDRf APPLIES PER PRODUCTS-COMPIOP Y 0 POLICY 0 PROTECT 0 LOC AGO i AUTOMORn,E MARD.ITY COMBR[D SNORE Y Lim , ch¢olden i 0 ANY avro BODILY NAIRY I M Pers 0 ALL OWNED AUTOS BODILYNJURY S j er Mcideni) 0 scr uui)Amos PROPERTY DAMAGE S er aee,dent i 0 HIRED AUTOS S 0 11011•OW14FD AUTOS S 0 0 UMBREUALIPB 000CUR EACH OCCURR NCE S 0 ECCE5.5 LfAB OcuALA.fs-MODE AGGREGATE S 0 DEDUC1I81,E T 0 RETENT.ON S Y WORKERS'COMPENSATION WC A AND EMPLOYERS LIABILITY WA STATUTORY YIN I LMM AN Y PROPRMT'OR IPART HLIV MCUM0FnCZ�®ER N NIA 6ZZUA-4102P700 Ol/OU12 01/01/13 L•PacHADcmENr YS00,000 EXCLUDED? (MANDATORY IN NH) EL DISMAM—EACH SSOO,000 i LOYEE If yes,deswtcmderomemPIIONOF LDIorASE-POLICY SS00,000 OPERAIIONS belay f DESCRIPTION OF OPERATIONSILOCAITONSfVEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more spate is requited) i THE,IINWRED'S MA WORKERS COMPENSATION POLICY AND ITS LUZ=OTHER STATES INSURANCE ENDORSEIv921T AUTHORIZES THE PAYKWTn OF BENEFITS FOR CLAD&MADE BY THE.INSURED' EMPLOYEES N STATES OMER THAN MA NO AUTHORIZATION IS UNPIN TO PAY CLAIMS FOR BENEFITS N ANY STATE OTHER THAN MAZY TrM MSVRED HIM,OR HAS HIRED,EMPLOYEES OUTSIDE MA rRLS POLICY DOTS NOT PROVIDE COVERAGE FOR ANY CIATE OTHE THAN MA THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERWICAT'E HOLDER AFFECTING WORKERS C hIP COVEMkGE w� 'sP" I' SHOULD ANY OF THE ABOVE DESC ED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,N TICE PALL BE DELIVERED IN ACCORDANCE MATH THE POLICY PR VISION& ..... AUTWRIM REPRRIV47ATIVC SYGGNb MdCLP,RW ""` �.' 3 A.- .,,..., :.:=� . � .. �.�. w�;�..:ssss. �o }.: t�Ia�ti•rr��r '' aenYnd:;:. i Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supers sor License: CS-071402 TS JOSIIUA L COJhN 1082 OLD STAG. CENTLRV%LE r Expiration Commissioner 12131/2013 { ftice of Consumer Affairs&Business RIat;onccaeC ME IMPROVEMENT CONT License or registration valid for individul use only RACTOR before the expiration date. If found return to: egistration 108642 Office of Consumer Affairs Expiration 8/20/2014' Type. 10 Park Plaza- BENABBY INC/DISASTE- -'-ECIALIST Supplement r;•ard Suite 5170 and Business Regulation Boston,MA 02116 xa' JOSHUA COHEN Box 480 Sandwich, MA 02563 ? r Undersecretary Not valid without signature