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Home My WebLink About0800 BEARSE'S WAY (23) v �I li 1' ` TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map I/ Parcel z)% /0 9y Application Health Division Date Issued I Conservation Division Application Fee Planning Dept. Permit Fee o Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation /Hyannis Project Street Address Village ton)I e— Owner r2.w RA PZ, Address Telephone Permit Request 14— LA,:2 sLI*i to �_t- 05 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation /S 00• Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) c>1 Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout 0Ptl er 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 D/SA��L Telephone Number �"�D Address ! -4/y License # C 7-- ,07 ? b a7/4y-b lo L ', �� v Home Improvement Contractor#/0 S —1 fps \ [JG Worker's Compensation # �� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE (e �--- FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP PARCEL NO. { ADDRESS VILLAGE _ OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION } FIREPLACE ELECTRICAL: ROUGH FINAL } ,4 PLUMBING: ROUGH FINAL GAS: ROUGH FINAL ' FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. t , s 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 Legibly f Name(Business/Organization � b/Individual): enab �f��, �/FVA �l� Qr" r.t I {S-LS Address: P()I Roy 41 So/q i'j � l� !)T 1uP_ City/State/Zip: W1^ Phone#: rg 8 r l Are you an employer?Check the appropriate box: Type of project(required): I.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. ❑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 comp. � [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 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 am an employer that is providing workers'compensation insurance for ney employees. Below is the policy and job site information. Insurance Company Name; Zurc o Policy#or Self-ins.Lic.#; O A P 700 Expiration Date: l Of Job Site Address: ot) �Aty ate/Zip: i Attach a copy of the workers' compensation policy decl ration page(showing the policy n er 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 informatibn provided above is true and correct. Si ature: Date: Phone#: Official use only.. Dv 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 RightF'ax N1-1 12/22/2011 7:19:42 AM PAGE 3/003 Fax Sarver Ji a , .ns:r vaf:'.•F:.: ��,�,,..' •°i k 1 :,,_ �.. :'pia'' ,.rw•ir%z r..c- ;rovs`�.-s o—zF;.r 1'1JZZI2011 THIS CERTWICATE IB ISSUED AS A MATTER OF INFORMATION ONLY AND CONKER-NO RIGHTS UPON THE CERTIFICA HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIMY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED THE POLICIES BELOW,T=CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE 1E8U1NG INSURER(SI�UTHORI7JED REPRESENTATIVE OR PRODUCER,AND THE CERTTFICATE HOLDER. IMPORTANT;If the certificate holder Is an ADDITIONAL INSURED,the poNcy(les)must be endorsed,If SUER00fl,TION 13 WANED,subject to the terms and conditions of the policy,cartaln policies may require an endorsement.A statement on this certificate d as not confer rights to The certificate holder In Neu of such andorsement-. PRODUCER CONTACT OCEANSIDE INS GROUP NAME: 52 WEST MAIN STREET PHONE No,Ext; FA/C,Net; HYANNIS,MA 02601 E•MaIL ADORE98: PRODUCER CUSTOMER ID R INSURED INS S AFFORDING COVERAGE NAIC f1 BENABBY INC DBA INSURER A ZURICH DISASTER SPECIALISTS INSURER B P 0 BOX 480 INSURER SANDWICH,MA 0256E INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 18 TO CERTIFY THAT THE POLICMS OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO'IW INSUAW NAMED ABOVE P DR TIS POLICY PERIOD INDICATE. NOTWnWTAT DINo ANY REQUMVdZNT,TERN OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WI IH RPSPEGTTO WHICH TIES CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED BERM IS SUBJECT TO ALL THE TERMS,I XCLU31ONS AND CONDITIONS OF SUCH POLICIES,LNITS SHOWN MAY HAVE BUN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NU5fBER POLICY EFF POLICY E LIMITS LTR MR WVU I GENERAL LIABILITY i EACa OCCURRENCE I Kh 00010M ALOENERALLIABQd PREMISES(EachTY .DAMAOEa; E0 S occurcmce � p CLAIMS MADE 0 OCCUR pees EXPENSE f/,rsyone S I anon 0 PERSONAL&ADV $ INJURY 0 ) OPNSRALAOOREOATE S CEN'L ACn3RE0ATE L➢E TAPPLUS PER 0 POLICY 0 PROJECT 0 LAC PRODUCTS-COI�AlOP S A00 i AUTOMOBILE LIABILITY COMBII.'PDSINOL.E S UMIT ch accident) 0 ANY AUTO BODILYINJURY S ae person) i 0 ALL OWNED AUTOS BODB.YIWURY S I (PerAcciderd) 0 SCHEDUuo AUTOS PROPERTf DAMAGE I er aeeidmt i 0 IIMAUTOS : I 0 I10N•OWN7D AUTOS S 0 0 UMBRFLIALIAB 0 OCCUR EACH OCCURRENCE S O EXCESS LIAB 0 C[.AAdS-MADE AOGREOATE S 0 DMUCIIBLE S 0 RETE7TfLOh1 S S WORKERS'COMPENSATION WC A AND EMPLOYERS LIABU TY NIA RTATUTORY LNM ANY PROPRIETOR IPARTTH..R/ EXECUTIVE OFFIZERn,22,1BFR N NNA 6ZZUH-A102P700 O1/Ot112 Ol/Ot/l3 EL FACHACCIDEW S500,000 EXCL UDFDT (MANDATORY INNM EL DISEASE-EACH $500,000 LOYEE I Tyes,describeledmOUCRUMO14OF I DNEASE.POLICY j OPFRATIOMbalm 1, 1500,000 I)aCRIP'10MOFOPERATI0IV81LOCATfONRlVMCLES(Attach ACORD101.Additional Remarks Schedule,ifmore spaces requlreA THE IfSUREO'S MA WORXF.RS CO10ENSATION POLICY AND ITS LNITED OTHER STATES INSURANCE ENDORSEMENT AVM0RIZ 11MPAYMENITOF BENEFIT'S FOR CLAMS MADE By Ti r,NSURED' EMPLOYEES IN STATES OTHER THAN MA NO AUTHORIZATION IS OrVFN TO PAY CLAMS FOR BENEFITS IN ANY STATE OTHER THAN AAA U THE RIMED HIRES,OR HAS HIRED,EhIPLOYEES OUTSIDE � MA[=POLICY DOES NOT PROVIDE COVBRAOE FOR ANY STATE OTHER THAW MA � THIS REPLACES ANY PRIOR CERTMCATE ISSUE➢TO 77M CERTIFICATE HOLDER AFFECTING WORKERS C MP GTOVMkGZ ^:CFiIIT!1` A, .,• �' ' Y 5� � ,ehr a`z;_ .:. �_ ,_. _ :,,... ..-.��.,;�.�.'�.��8,...5§,,.�v.,r, z 1's�o,z..,,.,-.,,:�.,..,,.a.._.,:x�" ?�-:yt!.1 rxAl��iEE Ir':0: , �; s .�•a'L < <�r,.s.?_:.��;�r"'.s:h<�' SHOULD ANY OF THE ABOVE DEBC EID POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,N TICE HALL BE DELIVERED IN ACCORDANCE WITH THE POLICY PR VISIONS. _... AUrHOMM POMMZM'AT1VE $YI.U.eL I�i ttcl.-GLi'V t51tt4T6N>ABY raeetTc; I I Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supen'ior License: CS-071402 JOSHUA L C00fiN 1082 OLD STAG. CENTERVH;LE i Z4,� ��`` Expiration Commissioner 12/31/2013 (poa��w�iac�eal _ toac�ccae _-_ fice of Consumer Affairs& C� Business Regulation ME CONTRACTOR IMPROVEMENT License or registration vali&for individul use only egi before the expiration date. If found return to: iratlon 108642 Office of Consumer Affairs and Business Regulation �..' Type: Expiration g/20/2044 10 Park Plaza-Suite 5170 BENABBY INC/DISASTER SPECIALIST Supplement(:ard Boston,MA 02116 JOSHUA COHEN M1Lr tr '' Box 480 Sandwich, MA 02563 — Undersecretary Not valid without signature i �IHE ln, Town of Barnstable Regulatory Services 9sntuv r.E� Thomas F.Geiler,Director 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 as Owner of the subject property hereby authorize /sG.f '-�Vqee', Net 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. Sip"atuXe o wner ature of Applicant Print Name Print Name Date :FORM&O WNERPERMISSIONP Q OOLS 6/2012