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HomeMy WebLinkAbout0800 BEARSE'S WAY (29) �� ��s�� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel lb AV Application # Health Division Date Issuedt— Conservation Division Application Fee f Planning Dept. Permit Fee ) Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address � _37E Village 4 V "A)15 Zip Owner I Address��� O �x t.J�rr .�.� rta � n���.��� J Telephone Permit Request , ` S Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 1 0 P - Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) c2'0 Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑Crawl ❑Walkout Q O her ,5/,-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 3 Address S 5-7 T /6 License # lS 7/ <AQI> L 2� ��/)IM ©�-��� Home Improvement Contractor# �6S k Cp 4 A-) Worker's Compensation # 10�.,� �oz� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE V DATE v L Cy FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION a FRAME ` INSULATION f FIREPLACE ELECTRICAL: ROUGH FINAL ~ } PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING r .1 DATE CLOSED OUT ASSOCIATION PLAN NO. e 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/Individual): _enA Q�Q� �/ Address: P o, -Roy 41 q 1 �1�� .!)ri ue, City/State/Zip: ��~ Phone#: l'g 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' 9. ❑Building addition [No workers' comp, insurance coinp,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, 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. lam an employer that is providing worlcers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Z U r-, cl--)- , Policy#or Self-ins. Lic.#: ! A Y t7600 Expiration Date: Job Site Address City/State/Zip: S Attach a copy of the workers' compensa ion pol' y declaration page(showing the policy 111 er 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. Ido hereby cer if trn a thepains andpenalties ofperjury that the infortnatlbn provided above is true and correct. Si ature: 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#: 1 � RightFax N1-1 12/22/2011 7:19:42 AM PAGE 3/003 Fax Server n a 4 r a rrt - ISSUE DATE , r .�1 ix.5.y �. {'L o star a� .w,:---rx Tar.' 3 x,.t: IV2212011 THIS CERTD ICATE 18ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTD•ICA 21 R HOLDE THIS CERTIFICATE DOES NOT AF'FUU44TIMY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED THE POLICIES BELOW,THIS CZATIMCAT6 OF INSURANCE DOES NOT CONST7rUIE A CONTRACT BETWEEN THE 1BSUWG WSURER(S��VMCR=D 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 IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate d as not confer rights to the certHscate holder In Neu of such endorsements. PRODUCER CONTACT OCEANSIDE INS GROUP NAME: 52 WEST MAIN STREET AFC.No,Ertl: NE FAX No; HYANNIS,MA 02601 E44AIL ADDRESS: PRODUCER CUSTOMER ID V INSURED INSURE S AFFORDING COVP R a NAIC if BENABBY INC DBA INSURER A ZURICH DISASTER SPECIALISTS INSURER B P 0 BOX 480 INSURER SANDWICH,MA 02563 INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIPY THAT TILE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TEE INSURED NA ABOVE F R THE POLICY PERIOD DdDICATED. NOT WITHSTANDRIO ANY REQUIRMAENT,TERM OR CONDITION OF ANY CONTRACT OR MM DOCUMITIT WITH RESPECI'TO CH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DBSCRIDID II REW IS SUBJECT TO ALL THE TERMS, CLUSIONS AND CONDITIONS OF SUCH POLICIES,Lrb1ITS SHOWN HAY HAVE BEEN REDUCED BY PAD)CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFP POLICY E LIMITS LTR INSR WVU I GENERAL LIABILITY EACAOCCURBENCE S I)AMAGETO RENTED S O C0n,9RCLALOENSRALUABILTTY PREMISES(Each occurrmca I . - MID.B7ffEN'Ef/ury mse S Q CLALMS MADE 0 OCCUR persw 0 PMSONAI,&ADV S INJURY 11 GENERAL AGGREGATE S i GEN•L AGGREGATE LUAIf APPLIES PER `• PROOUCTS•CO)APIOP S j D POLtCY 0 PROJECT 0 LOC AGG AVTOb1OHILE FAABD,ITY co'BIB WSINGLE S L= , ch addenl � 0 ATrY AUro BODILYLNRIRY I er Perc 0 ALL OW14M AUTOS I Etr Aacl erd) S i (Per Accidcd) � 0 SCHMULED AUTOS PROPERTY DAMAGE S er iaidmt i O HDtEDAUT05 S S 0 IrON•OWNFDAU703 0 D UMBREIdAL.IAB 0OCCUR I EACH OCCURR:NCE S 0 EXCESS LIAR 0CLA114-MADE AGGREGATF, t 0 DEDUCMLE S 0 RETEhMION S S . WORKERS'COMPENSATION STATUTORY A AND EMPLOYERS L1ABU TTY N/A 7tTATUToxY WC YIN ANY PROPRIETOFJPARnr3R/ JDr,.ASE.POUICYEA HA 5500,000 EXECVDF, OF1C1bM1rTi8ER N NJA 6ZZUH-4102P700 01/01/12 01/01/0 IXCLVD7:D7 ISEASL•-EACH (MANDATORY INNM OYEE S500,000 j tryea,dawkunderDESCRUMONOF 5500,000P UESCR1PIlON OF OPERA710NB/LOCATTON.9/Yf3T[CLES(ANach ACORDIOI,Addilioml Remsrks Schelu)e,irmore:Pete,s require,0 THE 7NRURED'S MA WORKERS CO)OSt•7SATION POLICY AND ITS L TrED OTHER STATES 124SURANCE ENDORSEMENT AUMORMES TIM PAYi>SDrItF BENEFM FOR CLIADM MADE AY TILL T:7SGAED' EMPLOYEES IN STATES OTHER THAN MA NO AUTHORIZATION IS aRTA TO PAY CLAM FOR BENEFITS IN ANY STATE UMTR THAN MA IF TIDE INSURER HIRES,OR HASH=,EMPLOYEES OUTSIDE i MA=POUCY DOES NOT PROVIDE COVERAGE FOR A17Y MATE OTHERTHAN MA j THIS REPLACES ANY PRIOR CERr1FTCAT6 ISSUED 70MM CERTIFICATE HOLDER AFFECTING WOREP278 C MP COVI:RACE .r .f r s > ,z,� ?. �•?''`'.-,aaf �fx?'';�rG r3,we;p,✓ire•; - SHOULD ANY OF THE ABOVE DE8C ED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,N TICE PALL BE DELIVERED IN ACCORDANCE WITH THE POLICY PR VISIONS. BrGa.+v Mac(.ecwv mg3P.':elt+tw4'': .f48& O( U'.0 tRlelV"711r ieccYtti ': Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-071402 JOSHUA L COAN - yr 1082 OLD STAGE. CRNTRRVII LE H� I -- �'� Expiration Commissioner 12/31/2013 _ ffice of Consumer Affairs&Business Regulation �crae - -- -- ME IMPROVEMENT CONT License or registration valid•for individul use only egistration {.1 .:.a RACTOR before the expiration date. If found return to: 108642 Office of Consumer Affairs and Business Regulation Expiration 8/20/2014.-, Type' 10 Park Plaza- BENABBY INC/DISASTER. Supplement�.`:ard Suite 5170 SPECIALIST Boston,MA 02116 JOSHUA m COHEN Box 480 - �` Sandwich, MA 02563 Undersecretary Not valid without signature �tME 10�'� Town of Barnstable -Regulatory Services • E AMSTABLE MASS. Thomas F.Geiler,Director 1639• $ 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 I, L :;2/;4^ , as Owner of the subject property hereby authorize e- to act on my behalf, in all matters relative to work authorized by this building permit. 490 9Qe--V :5 4l 414k 4� (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�4 Suture o wner ature of Applicant Print Name Print Name -ao Date Q:FORM&OWNERPERMISSIONPOOLS 6/2012