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Home My WebLink About0800 BEARSE'S WAY (13) TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel ®6 jo 4-D pplication # Health Division Date Issued a 1 Z Conservation Division Application Fee Planning Dept. Permit Fee ?J 5 Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address ,4F65'O A�0�,_ D �� -�-- A16 Village C4 w A/S Owner Address 40 4,njeobo, Telephone ` Permit Request ��'c9 C °r�`1 - q � Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type t Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) �.?93 — Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout Ocher �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 `�/S // 151 Telephone Number /!I Address 4/01kb License # 06 —l12/L/d..7;1 rt>40 1144 49�43 Home Improvement Contractor#/d rG Lo- � 6 Sk �L ti Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 416, l FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE r , OWNER DATE OF INSPECTION: ( FOUNDATION I1 FRAME INSULATION 4 FIREPLACE ELECTRICAL: ROUGH FINAL �:4 y PLUMBING: ROUGH FINAL F. GAS: ROUGH =FINAL FINAL BUILDING ' t DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents a 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 Legibly Name(Business/Organization/Individual):� �,� �jlQu��, _D/ A 15554 SWC-15-1 Address: 4 Rol/q �� S�,�a�-�l�r� �r i City/State/Zip; wl h 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 lured the sub-contractors 6. ❑New construction 2.❑ I 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.# 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 I I.❑ 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' 13.0 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. 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. lain an employer that isproviding workers'compensation insurance for any employees. Below is the policy andjob site information. Insurance Company Name: Z Policy#or Self-ins.Lic.#: A7 10 A P 7Q0 Expiration Date: Job Site Address: almI 1l1 City/State/Zip: S Attach a copy of the workers' compensation'policy eclaration page(showing the policy n ber 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 aaaa a the pains and penalties ofperjury that the information provided above is true and correct. Signature. A 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 5.Plumbing Inspector 6.Other Contact Person: Phone#: Right>~ax N1-1 12/22/2011 7:19:42 AM PAGE 3/003 Fax Server L t , a k^e • ;�:.�r5 t'1.�. F'a, dry ''�dR W ' 12122/2011 THIS CERTIFICATE 38 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTSFICA HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED OX THE POWCEES BELOW,TM CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(SN i UFHORPLCD REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT;If the certificate holder Is an ADDITIONAL INSURED,the policy(les)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 es not confer rights to the certificate holder In Neu of such andorsement a. PRODUCER CONTACT OCEANSIDE INS GROUP NAME: Ne FAX 52 WEST MAIN STREET AVe.W,Ed): =,No): HYANNIS,MA 02601 E•MNL ADDRESS: PRODUCER CUSTOMER ID•: INSURED INS S AFFORDING COVERAGE NAIC K BENABBY INC DBA INSURER A ZURICH DISASTER SPECIALISTS INSURER B P 0 BOX 480 INSURERC SANDWICH,MA 02563 [INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER; THIS IS TO CERTIFY TFEAT TBE FOUCMS OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TAE INSURED NAMED ABOVE F R THS POLICY PERIOD INDICATED. NMVI IISTANDING ANY REQUElF2Mrr,TERN OR CONDITION OF ANY CONTRACT OR UIIIER DOCUMENT WIIH RESPECT TO NMCH TMS CER.TEICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED BEREIN IS SUBIECT TO ALL THE TERMS, CLUSIONS AND CONDITIONS OF SUCH POLICES.LD41TS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, MR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EX LIMTIS LTR INSR WVD I GENERAL LIABILITY , EACROCCURRENCE I R29SF 0 CO10MCIAI.OENERAL 11AB P M SE9 ET(Each;Kb S occurrence)i i 0 CU MS MADE 0 OCCUR MID.EXPENSE(Airy are S SHOW P6RSONAL&AD`I S INJURY 0 I OENERAL AGGREGATZ S - GERL AGGREGATE LIMIT APPLIES PER 0 POLICY 11PROJECT 0 LOC PRODUCTS-COlN lOP S j A00 AUTOMOBILE LIABILITY COMBINED SINGLE S LIMIT chaeiden0 i O ANY AUTO - BODILYINNRY S i M Psrso 0 ALL OWNED AUTOS j BODILYINIURY S i (Per Aeciderd) 0 SC=ULED AUTOS PROPERTY DAMAGE S e oeerdent i 0 KREDAUTOS . I - 0 NON•OWNFD AUTOS I 0 0 UMBRELLALIPB 0 OCCUR EACH OCCU=" CE S AGGREGATF S 0 F-KrMLIAD 0CLADa-MADE - 0 DEDUCTIBLE S 0 RETENTION S S WORKERS'COMPENSATION WC A AND EMPLOYERS LIABDSTY NIA STATUTORY YIN ! LIM[IS ANYPROPE OFFIC ARTTIP.R/ i ,NY PROPRIETOR'sAR'DIE liR N NIA 6ZZUB-4102P700 OV01/12 01/01/13 LtiACH ACc1DEM' s500,000 IXCLUOEDi (MANDATORY INNH) EL DMO=--EACH SSOD,000 EMPLOYEE rryos,descrktrderOBSCRWILONOF ELDrr.ASE-POLICY 1500.000 OPI:RALON5 Below Dar UESC"TIONOFOPERAT10NS1LOCArtONB/VRASCLES(Abeh ACORDIOI,Additionel Rrmuks Schedule•irmae.,psceurequire,0 ' THF.@fSURED'S MA WORY.ERS COMPENSATION PDUCY AND TM LASTED OTHER STATES INSURANCE ENDORSEMENT AUIHORIZES THE PAYMENTIOF BENEFI S FOR CLAtMS MADE DY 77-r INSURED' EOLOYEES IN STATES ORdfER THAN MA NO AUTHORTTATTO)t IS OPlFlN TO PAT CLAW FOR BENEFITS IN ANY STATE OT'eER THAN MA IF TIE DISURED HIRES,OP.HAS HIRED,EMPLOYEES OVTS,'DE i MA 1TII5POLICYDOTSNOTPROVIDECOVZMOE"ORA11YCUTEOkV,THANMA T HOLDER AFFECTING WORICERS C MP dOVERAGE z� I ^CERT F r1A, THIS 70T1�yE��kl�u�. SHOULD ANY OF THE ABOVE DESC W POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,N TICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PR VISIONS. ...-. AIRHORIM PEPS EWffATIW t3rGa+v Macl.eary r. Kfp` wr,E1�3S488FQUf~Ut? trilfle['IBI.71$1 tsceYMl : i i Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supervkor License: CS-071402 JOSHIIA L COdN -- 1082 OLD STAG CENTERVIFLE ' i ` Expiration Commissioner 12I3112013 ftice of Consumer Affairs C �dac/ccaeC . &Business Regulation _ ME IMPROVEMENT CONTRACTOR License or registration valid for individul use only — `r RACTOR before the expiration date. If found return to: egistratron 1:Q8642 Office of Consumer Affairs and Business Regulation Expiration TYPe 8/20/2014:_- 10 Park Plaza-Suite 5170 g BENABBY INC/DI Su Supplement r;;ard Boston,MA 02116 JOSHUA COHEN Box 480 Sandwich, MA 02563 ^1n 49- -Undersecretary Not valid without signature �ZHE T�y� Town of Barnstable Regulatory Services v MASS. g Thomas F.Geiler,Director �A 1639. TFOMtr°' 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 1, 40-IP7C,4 600veo-Lz -721-,/1^ , as Owner of the subject property hereby authorize L//��f fC�y �'�� S Fc .� c- 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. 3 � �.7*4t/ ad Satute o wner . ature of Applicant �ee T4P Print Name Print Name Date Q:FORM&OWNERPERMISSIONPOOLS 6/2012