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Home My WebLink About0800 BEARSE'S WAY (19) s GJ�/ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION a Map cl'/ Parcel 4099 Application # Health Division Date Issued 1 Conservation Division Application Fee J Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Stre t Address r2✓53 _ � d— u Village 1) Owner 6WA) -10m,7+�Mf5V299f Address Telephone j Permit Request � t:)1 ?> Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation /Yo o. Construction Type L-.,>1� 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 ®�er �G-4 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 'iPt1 Telephone Number Address 34) � 1-4 f'1) License # 05 6 Home Improvement Contractor# /4 6 v (O- �A_) Worker's Compensation # `11,9Q. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# z DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER r r ' - DATE OF INSPECTION: FOUNDATION FRAME INSULATION r FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ' r r GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents ' Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia r Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLibly Name(Business/Organization/Individual): 6bu�:L / � �J Qr"- Address: P )t s ��( � �q jign � j'j !)1't I�P� City/State/Zip; W/h Phone Are you an employer? Check the appropriate box: Type of project(required): 1.X I am a employer with 10 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New .onstruction 2.El 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' insurance.1 9 ❑ comp' Building addition [No workers' 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 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. 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 am 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,Ch-Ame�rl'<fGn Policy#or Sel£ins.Lic.#: Expiration Dater Job Site Address City/State/Zip: Attach a copy of the workers' compensa ion poll 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 hereby cer if un a the pains and penalties of perjury that the informatiSn provided above is true and correct. Signafore: 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 M i DIME r - Town of Barnstable Regulatory Services s • BAMSTABLE y Mass, $, Thomas F.Geiler,Director �p 1639.rFD Mai" 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 M , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit. (Address of J b) f ?tole **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. GIO Sip"ature o wrier ature of Applicant Print Name Print Name Date QTORMS:OWNERPERMISSIONPOOLS 6/2012 f RightFax N1-1 12/22/2011 7:19:42 AM PAGE 3/003 Fax Server ISSUE DATE j SP.- y a:Y i13Av R11.. ram+a G s <p� s e s wr: r x'Ii L2/22l2011 THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICA HOLDER TH]S CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED THE POLICIES BELOW,THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSMUR(8h)I.UTHORTMD REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT;If the certificate holder Is an ADDITIONAL INSURED,the po0cy(les)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 es not confer rights to the certificate holder In Hsu of such endorsements. PRODUCER CONTACT OCEANSIDE INS GROUP PHON: 52 WEST MAIN STREET NC,o,E><: A/C,No): HYANNIS,MA 02601 E4ML ADDRESS: PRODUCER CUSTOMER 10 T. INSURED IRIS S AFFORDING COVERAGE NAIC# BENABBY INC DBA INSURER A ZURICH DISASTER SPECIALISTS INSURER B P 0 BOX 480 INSURER C SANDWICH,MA 02563 INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER; THIS IS TO CERTTPY TRAT THE POLICIS OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO T IM INSURED NAND ABOVE F 3.THE POLICY PERIOD INDICATED. NOTwIT-asTANDRIG ANY REQU1R 43—NT,TERM OR CONDITION OF ANY CONTRACT OR armR DOCUM F WI R RESPECT TO WHICH TIIIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED BERM le SUBJECT TO ALL THE TERMS,I XCLUSIONS AND CONDITIONS OF SUCH POLICIES,LDIITS SHOWN MAN HAVE BEP2J REUVCED BV PAID GLAIM5. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY E LIMITS LTR MR WVp I GENERAL LIABILITY EACAOCCURRENCE I s 000M1dEtCL%L0ENERALLTASEM PREMSES(Each occurceace i • i )&D.WMrE(My ere S , Q MALMS MADE 0 OCCUR persm PERSONAL&ADV I IN.RIRY 0 � OEN�ERALA60RE(iA7E S OEN'L A0OREOATELU5rAPPLIESPER: ' PRODUCTS-0010tOP S I D POLICY 0 PROJECT 0 LOC A00 AUTOMORH,F,MR1.ITY COMBmwsruoLS S Q�itLENT ch eeclden 0 A1rY AUTO BODB.YINJURY I M Pers 0 ALL OW6TDavrbR BODR.YINJURY S j (er Accidere) autos 0 aCHmULED PROPERTY DAbIAQE S er aemdmt i 0 HIRED AUTOS 1 0 110N•DWNFDAU70S 1 0 0 UN(HREUALlaa 0 OCCUR EACH OCCURR NCE S 0 EXCESS LLAD 0 CLAIMS-MADE 0 DEDUCMLE s 0 RETENP.ON S 1 WORKERS'COMPENSATION WC A AND EMPLOYERS LIABU.FFY NtA STATUTORY Y N LIMITS ANY EXECUTIVE EFRC-Ha,1B/ EXECVIIVEOFTIC.R/MES.03ER N NIA 6ZZUBA102P700 01/01/12 01/01/13 .L.EACHAccIDErrr SS00,000 EXCLUDW -FAcx (MANDATORY MNH) L DISEA DISEATE SSOO,000 It yes,describe under DESCRUMON OF L Dhr.AY-POISCY OPFRATTONSbelow 1, s500.000 DESCRIPTION OF OPERATIONR/LOCATIONSNMCLES(Aboh ACORD 101,Addiliomi Remarks Schedule,itmore spice is require( THE.INSTRIED'S 1dA WORKERS COMPENSATION POLICY AND ITS LI1,=OTHER STATES INSURANCE ENDORSEMENT AUTHOR=THE PAYME)TIcOF BE:45m S FOR CLADAS MADE By TW.TNSURED' E%OLOYEEB IN STATES OTHER THAN MA NO AUTHORIZATION IS GnTN TO PAY CLAIMS FOR BENEFITS IN ANY STATE CIPHER THAN MA IF THE nrSURER HDiES,OR HAS HIRED,EIAPLOYEES OUTSIDE � MA=POLICY DOES NOT PROVIDE COVSRAOE"OR AIIY STATE OTHEPTHAN MA - I THIS RBPLICES ANY PRIOR CERTIFICATE IRSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS C MP(rOVERAGR a j l:FiRl'��`,I:tA,,�_. �d��Ft,.�s§,�zv,,,,.P z�S�oz.,..ti��:.5 1, i4:.._:zip 1�YM i MllaaWL�r A'i!•tQ: r Y °.i]--,�'a,y ,,::h•s,�'S''Y,,Ar� t � SHOULD ANY OF THE ABOVE DE8C 90 POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,N TICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PR VISION& ..... AUMORM REPREMITATIYY SYGRW MGtGL6RW :xtCbTt1Y1 OU91.4.�r : : ✓.% .,:�a::. :7 K, swC£�:._ ..:_ a< w ,R.- if east �:oROOMtl rrl�le"r" 'W i i Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supern-i1or License: CS-071402 8tJOSHUA L CQIhN - "��, 1082 OLD STAG CENTLRMII Iv y Expiration Commissioner 12/31/2013 t7 ��ze�por�vi� izcuealG� , ��aadac�uaeCtt - ___------- ffice of Consumer Affairs&Business Regulation — ME IMPROVEMENT CONTRACTOR License or registration valid•for individul use only before the ex gyration date. If found return to: egistration 108642 Office of Consumer Affairs and Business Re ulation Expiration Type::8/20/2014i•1 10 Park Plaza-Suite 5170 g BENABBY INC/DISASTER.SPECIALIST Supplement r,:ard Boston,MA 02116 a JOSHUA COHEN " Is Box 480 Sandwich, MA.02563 Undersecretary Not valid without signature