Loading...
HomeMy WebLinkAbout0116 SEABROOK ROAD IlE �abrmK R � _ . _ PERMIT PAYMENT RECEIPT TOWN OF BARNSTABLE BUILDING DEPARTMENT 200 MAIN STREET , HYRNNIS, MA 02601 . DATE: 10/20/06 TIME: 12:03 ---------------:,--TOTALS ----- _- PE.RMIT� -P.AID`. 25.00 b AMT"-TENIIERED P 25.00 !` R M T' P P`L'I ED 2'5 0 Q' ' ' t� �;, CHANGE: APPLICATION NUMBER: 200640" PAYMENT METH: . CHECK { PAYMENT REF: 3116 � '' .' t 77 I Town of Barnstable *Permit# 206;, - bo1, 6 Expires 6 months from issue date Regulatory Services Fo- d� Thomas F. Geiler,Director Building Division OCT 2 0 Tom Perry,CBO, Building Commissioner Q ?40 200 Main Street,Hyannis,MA 02601 ��QF eqR 6 ej,;V . www.town.barnstable.ma.us NSTq .; E Office: 508-862-403 8 Fax: 5 08-790-62308� EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Qp I Not Yalid without Red X-Press Imprint Map/parcel Number V Property Address Wo S f c,` c-o a k '­R o cr.� �\`I CA nni s R Residential Value of Workl 3 7 5-D -D Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Zc kA c"�, Q C, C h C a-fY-\ Q C Q o �� to SeC rz.. 1� �cuc� , 1'1�/4h»i� �it� 07G-of Contractor's Name P�(A eC s-- \-�t,wwe q K23�ruy C YVW�J Telephone Number Home Improvement Contractor License#(if applicable) 133 irS 1 Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance } Check one: *� ❑ I am a sole proprietor -� ❑ I am the Homeowner E�j I have Worker's Compensation Insurance Insurance Company Name l7 �c �`/ /Vfu k" Workman's Comp.Policy# W C,Z- 15- 31 is 2 - Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows. U-Value (maximum .44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. SIGNATURE;'—z-� Q:Forms:expmtrg Revise071403 f s a/1CQ V07J2'lIlOJKI/Q(C�IJI O�(�J;Jp,�KIdP.� Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: 7' tion: 13 Board of Building Regulations and Standards 8/17/2007 One Ashburton Place Rm 1301 Private Corpora on Boston,Ma.02108 NICKERSON HEMENT MARK NICKER 12 COMMERE DRIVE ORLEANS,MA 02653 Administrator Not valid without si,ature I Liberty Mutual Group Llbe PO Boa 7202 Mutual® Portsmouth,NH 03802-7202 Telephone(800)653-7893 Fax(603)431-5693 November 18, 2005 TOWN OF-BARNSTABLE ATTN: BLDG DEPT 200 MAIN ST HYANNIS. MA 02601- RE: Certificate of Workers Compensation Insurance Insured: NICKERSON HOME IMPROVEMENT INC PO BOX 2476 ORLEANS,MA 02653 Policy Number: WC2')1S')18102-035 Effective: 11/6/2005 Expirat on: 11/6/200, Coverage afforded under Workers Compensation Law of the following state(s): M Employers Liability: Bodily Injury By Accident: $ 1,000,000 Each Accident Bodily Injury by Disease: $ 1000,000 Each Person Bodily Injury by Disease: $ 1,000,000 Policy Limits As of this date,the above-referenced policyholder is insured by Liberty Mutual Fire Insurance Co under the policy listed above. The insurance afforded by the listed policy is subject to all the terms, exclusions and conditions,and is not altered by any requirement-, term or condition of any or other documents with respect to which this certificate may be issued. This certificate is issued as a matter of information only and confers no right upon you,the certificate holder. This certificate is not an insurance policy and does not amend, extend,or alter the coverage afforded by the policy listed above. If this policy is cancelled before the stated expiration date,Liberty Mutual will endeavor to notifZ,you of such cancellation. AUTHORIZED REPRESENTATIVE LIBERTY MUTUAL INSURANCE GROUP This Certificate is executed by LIBERTY MUTUAL WSURAINCE GROUP as respects such insurance as is altbrded by those companies. cc: Insured: Producer of Record: NICKERSON HOME IMPROVEMENT INC PIKE INSURANCE AGENCY INC PO BOX 2476 P O BOX I658 ORLEANS.MA 02653 ORLEANS.MA 02653 llaG Department oflndustrid 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 Legilaly Name (Business/Organization/Individual): A) ," c )l f r S a h 14V V,Kt T ►-y y-C-/W 4 Address: V & K zl- (o City/State/Zip: -U'C 1.f u n s W O Zc,s a Phone#: 19,k Are you an employer? Check the-appropriate box: Type of project(required): 1, I am a employer with 40 4• ❑ I am a general contractor and I 6. [] New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet 7. ❑ Remodeling 2.El I am a soli proprietor or p artner- . ship and have no employees These sub-contractors have S. ❑ Demolition working for mein any capacity. workers' comp.insurance. g, ❑ Building addition (No workers' Gump.insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs og additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repays ox additions myself.(No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.].t . employees. (No workers' . 132 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workm'compensation policy information: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such lContractors tbat.check this-box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy inforraton. I am an employer that is providing workers compensation Insurance for my employees. Below is the policy and job site information. I Insurance CompanyName� _ ) �Je r U 4 1 Policy#or Self-ins.Lic.#: W C 7,- It I IG Z-/ 6.3s- Expiration Date: Job Site Address: SeC4 hnc k X c`' d City/State/Zip: MV4 on G Z Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a fine up to$1,50q.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 DLA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature:------- L—` Date: 16 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.CityfTowu Clerk 4.Electricai laspector.5.f lurd bing Inspector 6. Other Contact Person: Phone#: 7 .Information and Instructions p, Massachusetts General Laws chapter 152 requires all employers to.provide workers' compensation for their employees. Pursuant to this statute, 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 apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on 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, §25C(6)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,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of industrial Accidents for confirmation of inm=ce coverage. Also be sure to sign and date the affidavit. The-affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials . Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom. of the affidavit for you to fill out in the event the Office of Investigations has to contactyou regarding the applicant. Please be sure to fill in the permit/license number wbieh will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that.a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture . (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this afdavit The Office of Investigations would hlse to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ent 406'or 1-877-NIASSAT'E Fax It 617-727-7749 Revised 5-26-05 WWw.Il32.SS.DOV/l3'la 6 Town of Barnstable you regulatory Services. YFrAB USS..;, Thomas F.Geiler,Director Building Division.' Tom Perry, Building Commissioner 200 Main Street, Flyaanis,MA b2601 www.town.b arnstable.ma.us 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 ILVt`c(ct;` S o ri l�p�M 1A4,P oVekJA<o act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Jo ) . a o er Date Print Name QT0RMs:oWNB M'nsS1GN Assessor's map and lot number o ' ` Sewage Permit number ........................................................ ::... QyO*THE rO�yl TOWN OF BARNSTABLE i i BAHBSTABLE. S BUILDING INSPECTOR Apo,1639• `00 t x , f` APPLICATION FOR PERMIT TO ...................,.... ................................................. ..........,....�................................... TYPE OF CONSTRUCTION TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following' information: Location ..........................:...... � ................................................................................................................................ ProposedUse ......:..........................................................................................................................,.................,......................... Zoning District ................ ... ..................... Fire District ............,,..................... aNwger mf O ........Address ......... ?nx.....1 ..................... ; ` U Nameof Builder ....:...............................................................Address .................................................................................... t .- J Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ......................,................,..........................Foundation .....��:.:... S ............................................... Exierior ......... .............. .. .. ..............................................:....Roofing .......... ... �~— .e/l Floors .......... ��-T ............................................................Interior .......... .................................... ✓J� ....................................................Plumbin % 3 -,? . n J Heating U g ..�. ................ .:j. .�..................................... Fireplace ....... . Y .......................................................Approximate Cost ........ y, .G...................................... Definitive Plan Approved by Planning Board ________________________________19________. Area ...24h..................... Diagram of Lot and Building with Dimensions Fee �7� :'�� SUBJECT TO APPROVAL OF BOARD OF HEALTH " 3s . 24( 4 I hereby agree to conform to all the Rules and Regulations of the Ton of Barnstable regarding the above construction. Name ..../��.... ..................... ..... ..... ..: Danielle const sewage 341 ....... Permit for Dwell.jag..*................. ..................... .. . .........0�..........a................... Location ....................................F". lY,@Inn1&............................. Owner ..D.a.nie.l.l.e..Const. .. . ...... . . .. .... ... ................................... Type of Construction .......ftaMe........................ ............................ ............................................... Plot ....... ... ........... Lot ................................ Permit G .....Granted ...........2......1975 Date.of Inspection ...................).............. ... 19 Date Completed ............. /...............19 PERM'141EFUSED ................................................... 19 ................. .................................................... ............. ..... ......... ... ...... ......... I...... .7.4........................... ............. ............................................................................... • Approved ............................................. 19 . ............................................................................... ................... ........ .......) ................................. -Y Assessor's 'map_•and.:lot!number .......................................... SEPTIC ST . Y . T'E wti INSTALLEN 11PLIAN C. D I r .......µ WITH ART I", E li S AT a Sewage Permit number ... ...... .. r. SWTApy C 4 REGU AT TDWly ,! �FTHETO�} w r TOWN OF' BARNSTAB 'PAUSTAB "u` BTUI LD1#6 INSPECTOR 5.,4 'EO MPY�'' p ;x:+. y f 71 APPLICATION FOR PERMIT TO .... ......................... .........................Vi... .............................. TYPEOF CONSTRUCTION ...............��LUG...... ... ..................................................................................�..... .............................. r�.....19...1...��- TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .... ...... ...1.v.... .............. l......................................................... ............ ProposedUse ...0. ... ....... ............. .. ......... .............. ............................................,.................................................................. 4s. ............................................Fire District ...... . ....................... ........................................ Zoning District .....................I 1V.zName of Owner ... _ .......Address ....... rfJ. Nameof Builder ....................................................................Address .................................................................................... i if Nameof Architect ..................................................................Address .................................................................................... Number of Rooms Foundation ...... .........1................................ ....................... ................................... Exierior / ........................Roofing ..........f Floors .......... .. ...... ................................................................Interior ..... ........................... .................................................. � J Heating C '. .. .................................:..................... Plumbing ......�^ ........ .�................. 1 Fireplace ...... .' ......................................................Approximate Cost d Definitive Pla Approved by Planning Board ---------------____-----------19________. Area .57.6... . ........................ Diagram of Lot and Building with Dimensions Feef./7!- --s. SUBJECT TO APPROVAL OF BOARD OF HEALTH 35 3S 2y I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above ' construction. !� � Name ( ................................ . Danielle Const. sewage 341 _ r No .179.65. . Permit-for .Mvp- .l 1na................ ............................................ ...!" ............................... , 4 Location r IV; � Y,- ;. -S4&br6ok..Rd:. .................. t `• ,. - ....................Hyannis,............................... ........... ., Owner..--..k......Aa1T�7.�1le,Const.. ... ............ R Type-of Construction Fr. 9......... ... f`.. .......... - ..... . :^....... ............................ 4 M r .-Plot ..3©7...18............. Lot ..........-.................... � t Permit Granted- .......... October.........2. 19 75 Date.of Inspection .......... �19 i - ,. _ _ Date Completed ..........y� V - � 1 J -PERMIT'REFUSED _ ......................... .............::.............::".'".... 19 u + •✓ .................. .. - .................. ,w.`r.. .................. 1 ..... ...... ........................ ............................ _ + ' �J � j✓. t��i� '.,.. Approved ................................................ 19 p j> VA ............................................................................... .. .- vi 2 a ul'Pat < d N INI 4-1 tis ID 4 5 d �