HomeMy WebLinkAbout0800 BEARSE'S WAY (45) 24
4 ` TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Mud_ -bDxj Parcel 3W o`I Permit# SO7 7 3
Health Division Date Issued f 900 1
Conservation Division Fee %�o
Tax Collector X-PRESS PERMIT
Treasurer
Planning Dept. JAN - 8 2001 Y
Date Definitive Plan Approved by Planning Board TOWN OF BARNSTABLE
Historic-OKH Preservation/Hyannis
Project Street Address es cxrse,S (A)CA
Village uCXnn 1 S
Owner C Grvssnyu S CcYJ.e 'r wt4- Address 90c:2 9-kcWS tS LCJ
Telephone Ste$ - 775 - -73g1 -C,aV � -- S bl-42v•o291)
Permit Request �n Vau\OVw�l V in!J S 1cd%n S I AtV?-
37
square feet: 1 st floor:existing proposed 2nd floor: existing proposed Total new
Valuation � �MOZoning District Flood Plain Groundwater Overlay
Construction Type
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) ,t, 72-
Age of Existing Structure Historic House: ❑Yes ;i.No On Old King's Highway: ❑Yes Jd No
Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other
O
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new Half: existing new
tlumber 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 el<es ❑No If yes,site plan review#
Current Use Proposed Use
BUILDER INFORMATION
Name 6c.�%c,,n c,cAw Pr'+tp- se,vic"j];c_ Telephone Number �17—J 2 Y - 211 Q
Address 10 1 n1 ors E Sa- License# C> o967 Ry n f
Home Improvement Contractor# 23(orf S pyo
Worker's Compensation# Dyo I Zyc-913�
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO Af� I Dwm OS6r
SIGNATUR DATE
ice, •
The Commonwealth of Massachusetts
Department of Industrial Accidents
r � = ��, , •� • Ofrice ollayestlgstions
600 Washington Street
Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
name:
location:
city vhone#
❑ I am a homeowner performing all work myself
❑ I am a sole m=etor and have no one worlan in aav capacity
I am an employer provichng workers' ens=on•for my:employees:worlang on this job.
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Fatinre to secure coverage as required under section 25A of MGL 152 an lead to the imposition of criminal penalties of a fhne up to S1,M00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a flue of S100.00 a day against me. I understand that a
copy of this statement may be forwarded to the onke of Investigations of the DIA for coverage verination.
I do herehy c the pairu and penalties of perjury that the information provided above is tra:and correct
Signs Date/_�' D /
Print name C-1'► rn s✓comer Ph.# 1 -� y- 21 f t�
oiSdal use only do not writs in this area to be completed by city or town official
city or town: permit/Ifeeroe# LJ
tmentd❑checkifimmedlate rr�ponae is required IIeementcontact person• phone M, �
(tensed 9195 PJA;
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Information and Instructions .
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As Quoted firm the "law",an employee is defined as every person in the service of another under any contract
of hire, express or implied, oral or written
An employer is defined as an individual,partnership, association, corporation or other legal entity, or any two or more of
the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or
trustee of an individual,partnership,association or other legal entity, employing employees. However the owner of a
dwelling house having not more than three apartrnents and who resides therein, or the occupant of the dwelling house of
another who employs persons to do maintenance, construction or repair work m such dwelling house or on the grounds or
building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or,local licensing agency shall withhold the issuance or'renewal
of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has
not produced acceptable evidence of compliance with the insurance coverage required. Additionally,nertherthe
commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until
acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting
authority.
A
v.:_?ijiplicants r
se fill in the workers' campensatia o affidavit completely,by checking the box that applies to your situation and
€~ -u plying company names,address and phone numbers along with a certificate of insurance as all affidavits may be
iimitted to the Department of Industrial Accidents for capon of insurance coverage. Also be sure to sign and
late the affidavit the affidavit should be returned to the city or town that the application for the permit or licxose is
:= requested,not the Department of Industrial Accidents. Should you have any questions regarding the`law"or if you
:rr required to obtain a wodmrs'cantpeasatiomi policy,please call the Department at the number listed below.
:ity or Towns
'lose be sure that the affidavit is complete and printed legibly. The Depart<neat has provided a space at the bottom of the
ffidavit for you to fill rnrt is the event the Office of Investigations has to contact you regarding the applicant. Please
c sure to fill in the pcEift1lic=i0nmubcivA&1willbc uscd as a referenee-mimber. The affidavits maybe retiniRio
.r Department by mail or FAX unless other anangemeats have been made.
ar Office of Investigations would Bice to thank you in advance for you cooperation and should you have any questions.
:rasa do not hesitate to give us a calL
117
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Department's address,telephone and fax number
The Commonwealth Of Massachusetts
Department of Industrial Accidents
OMCO of ImsagaHons
600 Washington Street
Boston,Ma. 02111
® fax#: (617) 727-7749
nhnne#! (6171 727-491]n eyt_ dn6- dn4 nr 179
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yyLicenseP C6N$,TRUCTvvnI SUPERVISOR' '
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Namber��CS 64'
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Expires: !12/2001,` r, no 4429{
FRED S-HERNECKER �
VHATERT,OWN IVIA 02172'r AdrninistratorF `
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F IV: .INTERNATIONAL INSURANCE GROUP; 617-051 -3040; DEC-28-00 2:15PM; PAGE 13/15
DATE(MMIDMM
12/21/2000
FTAiaa®
HIS F'ORM
ER IS A TEMPORARY(NSURANCE CONTRACT,SUBJECT TO TFI �DITIONS SMOWN ON THE REVERSE SIDE OF T 7)95 3939 FAX
__.......------- Commerce & Industry � 6001200937
FAX (617)951-3940 _. __-•-.• ..---�_._... Ei�ifiAT10----
InterNational Insurance Group Ltd. _—_oA ___-•••ri2..01
•-' _ E--, .'--- -' _
X � � X ?tz:ot AM
01/01/2001 01/Ol/Z002 r—;125 Broad Street - ath FloorNOON
Boston, MA 02110 ---•.._—_.. .�—__._ .. .,,______....._.—.___....
—�... NAMED COMPANY
TH13 BINDER IS 18SUED TO EXTEND COVERAGE 1N THE ABOVE
P
.._..---..... •---•--...' PER EXPIRING POLILN M .
�BUBCOt?C=_—__._... ..—_._.....—__.__ DEgGRIPTION0FOPERATI0INBNEHICVIWpROPERTYpnWdIng44c"On)
COD[:_ _• ---- ..!_----_
7CrNCY 00000054
INSURED
Schernecker Property "Services. Inc. workers' Compensation
101 Morse Street
Watertown, MA 02172
CpVERA6EIFORM9 AMOUNT. DEDUCTIBLE C41N8%
PROPERTY -CAUSES OF LOSS
___.
BROAO L- 'SPEC
GENERAI.AGGREGATE # -----•-•• ..._
GENERAL LIABILITY --_-.... ----.-__.. . __•-_-_...
PRODUCTS-CoMP/0P AGO # ----_.
COMMERCUIL CNERAL LIABILITY ; -- —
PERSONAL A AOv INJURY
CLAIMS MADE OCCUR i --
EACH OCCURRENCE € -,......•-
1 —
--{OWNERS a COTRCTFUS PROT I1 FIR DAMAGE WW a+e
—;.---....... —..,.. --._.... 1 MED EXP(AM one perw) $
i RETRO fjATE FOR CLAIMS MADE: COMBINED SINGLE LIMIT- $ ------•- ------
AUTOMOBILE UAWLITY _._-_........___—..... -
i BODILY INJURY(Per per) $
i ANY AUTO ___... INJURY
I BODILY NJURY(Per etarlent)_ #__,__ .._-_-_......
I ALL OWNED AUTOS I PROPERTY DAMAGE $ -----
SCHEDULED AUTOS '
MEDICAL PAYMENTS _.__._-..,. •---
HIRED AUTOS PERSON INJURY PROT
1 NON OWNED AUTOS __.__.. ..
' UNIN6UREDMOTORl9OTORtS T �3
SCHEDULED VEHICLES ACTUAL CASH VALUE
AUTO PHYSICAL DAMAGE DEDUCTIBLE i ALL VEHICLES ----'
_ -... I STATED AMOUNT S
'COLLISION: ----- - - '--i—•--....----• _
I OTHER
OTHER THAN COL: AUTO ONLY-EA ACCIDENT
GARAGE LIABILITY OT14FR THAN AUTO ONLY.
ANY AUTO ; FACH ACCIDENT $
- , ....
AGGREGATE $
. .• --- -...
.. --- ---...
--; .. i
1 1 EACH OCCURRENCE
E1(CESS LIABILITY AGGREGATE
cND
UMBRELLA FORM SELF INSURED RETENTION #
OTI ICR THAN UMBRELLA FORM j RETR4 DATE FOR CLAIMS MADE' X 1 STATUTDRY LIMITS
—_• -- --_... ---- 500 000
EACH ACCIDENT_ —._.!..-
YMDRIER9AOMPENSATION DISEASE-POLICY LIMIT # --_--•
EMrLOYeR s LuaelLmr i DIS�E_P,,cH EMPLOYEF $ 500
cO "Om Terms and conditions as per attached InterNational Insurance Group, Ltd". proposal.
COVERAGES
MORTGAGEE )ADDIT ON7INSUW"
LOSS PAYEE i �__..._ • --_..
LOAN A
1n rNFurs t��p.AUrNORljgp REPRESENTATIVE PwIft
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