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Home My WebLink About0790 IYANNOUGH ROAD/RTE132 - CCM RE-ROOF 00..e . - Ll TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel A lica on # Health Division Date Issued Z— Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Pr ect St er et Add e'/�T /.� /ud�� L ,Village�^ Qwner� f Address Telephone �zz PermitlRequest-- Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation o ��Ponstruction 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 ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing L- new Number of Bedrooms: existing _new a Total Room Count (not including baths): existing new First Floor Room Count t Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: LI-Ses ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: 0 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 ` b &2 ® ZZ$ ! (BUILDER OR HOMEOWNER) 4 -] 1 Name vrJ Telephone Number L ( 0 l Address o L, 1"-" License# S -! MA7 (12 4 2 0 Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE ` v S 3 FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED 1 MAP/PARCELNO. ADDRESS VILLAGE OWNER ` DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH s` FINAL I PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. �✓ NOTICE NOTICE TO - TO EMPLOYEES ti EMPLOYEES � SV' V 1 --The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS l Congress Street-Suite 100, Boston, Massachusetts 02111 617-727-4900- http:Hwww.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30,this will give you notice that I (we)have provided for payment to our injured employees under the above-mentioned chapter by insuring with: Insurance Company: Atlantic Charter Insurance Company Policy Number: WCV00957801 Effective Dates: 4/5/2012 TO 4/5/2013 Insurance Agent: Segreve& Hull Insurance Associates, Inc. 305 North Main Street Andover MA 01810 Employer: Lau Design Construction, Inc. 31 Bridge Street Lexington, MA 02421 Workplace: Lau Design Construction, Inc. 31 Bridge Street Lexington, MA 02421 MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services- provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER Department of Industrial Accidents Office of Invesfigations 600 Washington Street. - Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers Applicant Information Please Print Le •bl Name(Busmess/orgmizatianlIn&vidua�:. Address: d 20 City/State/Zip: L 1�V4 4-Vv--, �Phone.#: 0 �/ Are you an employer? Check the 4roptiate bog: Type of pi oject'(requireui):• LZ I am a employer with 4. .] I am a general contractor and I * have'hired the sub--contractors6. ❑New contraction employees(full and/or part time). - . 2.❑ I am a'sole proprietor or partner- listed on the'attached sheet: 7. ❑Remodeling These sub-contractors have ship and have no employees '$. E]Demolition • working for me in any capacity. employees and have workers' 9. E]Building addition No workers' camp.insurance comp.i„�rn�„ce. requuired] 5. ❑ We are a corporation anti 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#i must also f-M out the section bclow.sho�ving their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors must subnut a new affidavit indicating such. lContr-actors that check this box must attached an additional sheet shouting the name of the sub-contractors and state whether or not those entities have employes. If the sub-contractors have employees,they must pravidt their worlo;rs'comp,policy number. Iam an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site ' information J Insurance Company Name: Policy#or Self-ins.Lic.# V`' 0 ( (9 0' I Expiration Date: Job Site Address:-I 1— Q City/State/Zip: U G "� V. j - Attach a copy of the workers"compensation policy declaration pa ge'(showing the policy numb d expiration date). Failure,to Secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of foe up to $1,500.00 and/or one-year imprisonment as-well as civil penalties in the farm 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 WA for insurance coverage yei fication I do•hereby certify under the pairis•and pen . of perju that the information provided above is Prue grid carrect- „ Si atuzre: Date: Phone FOfficial 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): . Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person• .'Phone#• . p� J/ze �arvrna�xureca/,C/i o�✓!/LaaaacfivaeCla \ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:4�1;52613 . Type: Office of Consumer Affairs and Business Regulation ; ug Ex nation:: 9/14/2012 Ltd Liability Corp 10 Park Plaza-Suite 5170 �` p Boston,MA 02116 l 1 . LAU DESIGN CONSTRGTIQN IN�'.• LUI SHUN.LAU. � K E • �....✓ 31:BRIDGE ST LEXINGTON, MA 02421 Undersecretary Not vali without sign re Nlassachusetts -Department of Public Safetj' Bo:u-d.of Regulations and Standards Construction Supervisor License License: CS 96675 LUI SHUN LAU 31 BRIDGE STREET LEXINGTON, MA 02421 �s j� Expiration: 1.1/5/2012 I Commissioner Tr#: 4684 �IHE r Town of Barnstable Regulatory Services i 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 as Owner of the subject property hereby authorize (� C�i(�( N L to act on my behalf, in all matters relative to work authorized by this building permit: --7 q L-?�- YAIVrt' (17 A ,J2-456)1 (Address of Job) **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. ignature of e a e of Plicow 41 - ( Print Name Print Name D e Q:FORMS:OWNERPEFMISSIONPOOLS 62012