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Home My WebLink About0800 BEARSE'S WAY (21) 4 NO 4-t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map L�'f°� Parcel o Application #o? o? 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 R !5; GDii Village 4q P P l)G S Owner Oi�LLa, 4�6 y au Address Telephone Permit Request ar, TZ 5 S .v Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation IrOO 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 ❑,Aher t�� N 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 ` ,:5AS/AL L157-- Telephone Number �r gt-oa—/li3 Address I�Yt� 9 '�/0'pJ o License # rS 102/ yD_,�— b Home Improvement Contractor# .�65 C Worker's Compensation # l�� O'� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE I �-- I " FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED ' MAP/PARCEL NO. } ADDRESS VILLAGE OWNER L • 'DATE OF INSPECTION: FOUNDATION FRAME 7 INSULATION s FIREPLACE ELECTRICAL: ROUGH FINAL " PLUMBING: ROUGH FINAL a " GAS: ROUGH FINAL r FINAL BUILDING r� DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts �. Department of Industrial Accidents ' Office of Investigations 600 Washington Street Boston,NIA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): ��Q�QI,�ty�, D/ A '7)) 4,e �j f Address: P() Boy /_/Rn/q T�'1 3�:bf tLC n .1)r 1 ue, City/State/Zip; wl^ Phone#: r8 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 hired 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' comp.insurance. 9. ❑ Building addition [No workers 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 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. lContractors 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 nay employees. Below is the policy and job site information. Insurance Company Name: e , Policy#or Self-ins. Lic.#: Expiration Date: r Job Site Address City/State/Zip:i�fn4Qlls _ Attach a copy of the workers' compensation polic declaration page(showing the policy n ber 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 thepains andpenalties ofperjury that the informatibn 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: �a RightFax N1-1 12/22/2011 7:19:42 AM PAGE 3/003 Fax Server tov �tt}Cs H, THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTD'ICA HOLDER THIS CERTIFICATE DOES NOT AP'FIRMATIVF.LY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED THE POLICIES DF.LOP/:THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE 78BUING INSURER(Sh KUTHORMD _ REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:H the certlficale holder Is an ADDITIONAL INSURED,the pollcy(tes)must be endorsed,if SUBROG TION IS WANED,subject t0 the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificated es not confer rights to the certhIcate holder In He of such endorsements. PRODUCER CONTACT OCEANSIDE IRIS GROUP NAME: 52 WEST MAIN STREET PHONE No,Ext: AJC,No). HYANNIS,MA 02601 E'MaL ADDRESS: PRODUCER CUSTOMER ID T. INSURED INS S AFFORDING COVERACi NAIC A 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 CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TAR INSURED NAND ABOVE F R TIM POLICY PERIOD INDICATED. NOTWTIUS'ANDRTO ANY REQU1RFlAE�r,I,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUXWT WPIK RESPECT TO WHICH TBIS CERTD?ICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED II REDI IS SUBJECT TO ALL THE TERMS,E XCLUSIONS AND CONDITIONS OF SUCH POLICIES,LAIITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPEOFINSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICYEXI LDHITS LTR INSR WVD GENERAL LIABILITY EACROCCURRENCE S .DAMA0ETORENIF.11 S 0 COMMMCIALOENSRALLIAM TY PRD4=S(Fed, xcurceacd ` IdED.EXPEME(A,ny m,e S I 0 CI AAIS MADE D OCCUR persw 0 PERSONALdAD`/ 1 . INR1RY 0 } OENERALAGOREOATE S GDT'L AGOREGATE L U41C APPLIFS PER PRODUCTS-COINIOP S D POLICY o PROJSCr 0 LOC ADO AUTOMORME r.IAflD.ITV COI =SINOLE S IIAd37' , ch tceldent � 0 ANY AUTO BODILYDIRMY S er Port i 0 ALL OWNED aUTOR BODD,YINJURY S i (Per Aecida,l) 0 SCFCDULED AUTOS PROPERTY DAMAGE S er accident 0 KREDAUTOS S 0 110N•OWNFDAU70S S 0 0 UMBRFI,LALIPB 0 OCCUR EACH OCCURR:NCE t 0 EXCESSLIAD 0CLAD4-144DE AGGREGATE S . 0 DEDUCTIBLE 1 . O RETENTION E S W ORKERS'COMFENSATION WC A AND EMPLOYERS LIABU.PI'Y WA ETAIT71oaY YIN ANTPROPRMTOR&ARnFEW j EXEOUITVEOFFICFS/MD,(BER N N/A 6ZZUR-4102P700 01/01/12 01/01/13 LEAcxaccmELrr $S00,000 EXC7.VDW L DTSEA3L•—EACH(MANDATORY IN NH) wYEE $500,000 i Tyn,describemdcrDESCRIIMONOF ELDUEEASE.POLICY i1500.000 OPERATIONS below Ltt&r UESCRIPTION OP OPERATIOrOSA,OCAt10NNATMCLES(Abeh ACORD I01,Addiliorul Remsrks Seho6At,itmore spite it rdquires0 ' THY.DJSURED:S MA WOR ERS COWENSA71ON POLICY AND 0 LDdMM OTHER STATES INSURANCE F.I'TDOREEMI27T AUTHORIZES THEPAYMENItOF BENEFTFS FOR Ci.Aoa MADE BY THe T:3SURED' EMPL.OYEHS IN STATES OTHER THAN MA NO AUTHORIZATION IS OMM TO PAY CLAA(S FOR BDMFM IN ANY STATE OTHER THAN MA IF TAE DTS1=UMM,OR HAS HIRED,EMPLOYEES OUTSIDE i MA TM P012CY DOES NOT PROVIDE COVERAOE FOR ANY ELATE OTHER.THAW MA j THIS REPLACES ANY PRIOR CERTIFICATE 1SST,ED 7071rE CERTIFICATE HOLDER AFFECTING WORKERS C MP EOVMkGE ..'f/.•. ay SHOULD ANY OF THE ABOVE DEDC 90 POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,N TICE MALL BE DELMRED IN ACCORDANCE WITH THE POLICY PR VISION& _ AUIHORIIFIs RFPRROWATIVE r $YI4iAL acC,eaw . L:t) I Massachusetts-Department of Public Safety Board of Building Regulations and-Standards Construction Supervisor License: CS-071402 JOSHUA L C N 1082 OLD STAG, ,: CLNTLRVIFZ.E22, r y lvo- Expiration Commissioner 12/31/2013 P� &2e cPor�v��woacueaCG�a�C��cvj Rice of Consumer Affairs&Business RegulaHooe ME IMPROVEMENT CONT License or registration valid for individul use only RACTOR before the e egistrati p x iration date. If found return to: on 108642 Office of Consumer Affairs and Business Regulation Expiration 8/20/2014 Type' 10 Park Plaza-Suite 5110 BENABBY INC/DISASTER.SPECIALIST Supplement e,ard Y Boston,MA 02116 JOSHUA COHEN Box 480 Sandwich, MA 02563 ' — Undersecretary Not valid without signature BIKE l Town of Barnstable Regulatory Services yi ssBis n � Thomas F.Geiler,Director �A 1639. ♦0 TfDMa�6. 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 /nJ � 11Vd 1-,o` J' ��rin , as Owner of the subject property hereby authorize 01s0-f ky' 4 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. G�0 S' atuxe o wrier ature of Applicant aj-e4) Print Name Print Name Date Q:FORM&OWNERPERMISSIONPOOLS 6/2012