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Town 4 Barnstable
' B:uilding.Division ,;?��;�:.;�:�,�.. :•�,'��:.,.., _�
200 Main St
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Hyapnis,MA 02601 �•., ?:.-.���;���;r:1}r�H .��' ';;�;� ''�
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President
58•D.ICKINSON STREET FALL RIVER,MA 02721 (508)567-4240 I ALTERN-A7M.. T1•i�"ONiPGMNLCOM
TOWN OF BARNSTABLE BUILDINGPERMIT APPLICATION
Map Parcel Application
Health Division Date Issued
Conservation Division Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Street Address S I r l
Village I n
Owner 1 S I ' I U(� Address l U i��/1 lei�(d�I C(�P�if� w y
TelephonesS��,',, 1,�� ' ` uo
Permit Request y y C G41f 07 f m
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total,new
Zoning District Flood Plain Groundwater Overlay
Project Valuation i�Construction 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 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: O7existing :0Q ne o size_
F c
ZE
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:n
v
' w _n
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ c
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
m
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name• krolTelephone Number
Address l_act c>�Ye� � License #
JDAV Liver , ffL OZI2 1 Home Improvement Contractor#
Email Worker's Compensation # 9O qq 12S 7 op
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
T-rodn N_ Ff d-FrtnM
SIGNATU E DATE
0
II. FOR OFFICIAL USE ONLY
k' APPLICATION'#
f DATE ISSUED
MAP/ PARCEL NO.
F
ADDRESS VILLAGE
f "
OWNER
DATE OF INSPECTION:
r FOUNDATION
FRAME
INSULATION
FIREPLACE
ft" ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
r GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
FROM Mac FAX NO. : 5084191437 Aug. 19 2016 07:28PM P4
Town of Barnstable
Of�r
O
VA
Regulatory Services
�g Richard V.Scab,Director
BuRdi 1g DivNion
Tom Perry,13uIIding Commissioner
200 Mam Street,B -mxis,?CIA 026.01
W w.town-harnstnbJensaus
Office; 508-862-402,3 Fax: 508-790-6230
Propexty Owner Must
Complete:and Sign This Section
Lf U �A�Ri der
as C?cv ar of the subje�z.-pr ay
hcrcby air4rize�. \ Q, to.act on ray b ehali
a
' i�alI waiters relart�to�u�k authas�d by rzus bu?di�pernrt�pdxcaro�£or.
(Addiess 01' 0b).. 0Z-(0�5 5-
Pool fences aid alarms are the sporaslbrlizvo£the agplicam Pools
are not to be filled qr u-rff=n before f-cnct is:installed.and ail'fin i
inSpectionS are performed and ancepta
Signamm of Omer swat=of Applicant
C Ica,ri s a, !-io-C OU ee,,) �. l ovr i Sc .— CLCQ Ute�--�.
z�Van}e h ut.Na=x
Q:.�rRA9S:OW*��.��Z'tTSS�+'FGCLS y�
The Commonwealth of Massach.usetts
fu Department of Industrial Accidents
'1 I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
N orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERM--MG AUTHORITY.
-ADDlicantinformation Please Print Lettibly
Name(Business/organization/Individu?1).ALTERNATIVE WEATHERIZATION, INC.
Address:2 LARK ST
City/State/Zip:
FALL RIVER, MA 02721 Phone#:508-567-4240
Are you an employer?Check the appropriate box: Type of project.(required):
1. am a employer with 16 employees(full and/or part-time).' 7. Q New construction
2.17 I am a sole proprietor'or partnership and have no employees working for me in 8. Q Remodeling
any capacity.[No workers'comp.insurance required.] 9. 0 Demolition
3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 p.Building addition .
4. I am a homeowner and,will be hiring contractors to conduct all work on my property. I will 11.0 Electrical rep airs or ad'ditions
ensure that all contractors either have workers'compensation insurance or are sole
proprietors with no employees. 12.Q Plumbing repairs or:additions
5.a I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[]Roof repairs
These sub-contractors have employees and have workers'comp.insurance.: INSULATION
14.[✓ Other. .
6.E We are a corporation and its officers have exercised their right of exemption per MGL c.
152,§1(4),and.we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out,the section below showing'their workers'compensation policy infonaation.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
:Contractors that-check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
emp loyees. If the sub-contractors have employees, Y the trust provide their workers comp.po
licy olicy number.
I am an employer that is providing workers'compensation insurance for my employees Below is.thepolicy:and jobsite
information.
Insurance Company Name:
STAR'INSURANCE COMPANY
0849257 00 Expiration Date:02/2612017.
Policy#or Self-ins.Lic.#: ,
Job Site Address: V V City/State/Zip: ;
Attach a coley of the workers'compensation policy dec aration page(sho, 1.9 the policy number and egpiratiou date). .
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation.punishable by a fine up to$1,50.0;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 S250.00 a .
ment may be forwarded to the Office of Investigations of the DIA:for insurance
day against the violator.A copy of.this state
coverage verification.
I do hereby eertify a paains erjury that the information provided above is'true-and correeL
Si tore:
Date:
Phone#:508-567 40
Offieial.use on:Dnorite in this area,to be completed by city or town official..
Cty.or Town: Permit/License#
Issuing Authone):1.Board of hding Department 3.City/Town Clerk 4.Electrical Inspector 5.PlumbingInspector
6.Other -
Contact Perso Phone#:
y
Office of Consumer Affairs and Business Regulation
10 Park Plaza Suite 5 170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 175683
Type: Corporation
Expiration: 5/29/2017 Trig` 265489
ALTERNATIVE WEATHERIZATION, INC.
TIMOTHY CABRAL - T -- --- - -----
2 LARK ST
FALL RIVER, MA 02721 ---•--- ----. __._. ___.._-- _ --_-..-
Update Address and return card.Mark reason for change. -
vv^ �oa�cV7 Address ..^ Renewal F-1 Employment `—i Lost Card
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
� }iOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
:.
,.1Registration: 175683 Type: Office of Consumer Affairs and Business Regulation
§ � 10 Park Plaza-Suite 5170
Expiration: 5/2k7 .7 Corporation
Boston,MA 02116
ALTERNATIVE WEATHERiZATION;INC.
TIMOTHY CABRAL
2 LARK ST '
FALL RIVER,MA 02721 Undersecretary '
/ 1 :'o validiwit ut signatu
r
� l
4assk66ietts Department of Rubhc Safety
$'bard of Building Reg ulaftotts an.Stancta�tis
• �•'- j•,Z`3niVGiifiTa.�iaaae�LaS\�a ! ~ '�'•�
License:t:S-105454''�
r"
l'INIDTHY CABRA
..t
' i�DICKE_RIMS SI) 0
-Fall Inver MA 0021
,�`-' ,: •�.�w�.i��• . a, FlC¢irat101T ,��
Coffm1issioner. 0510=017 •3
ALTEWEA-01 CCOSTA
CERTIFICATE OF LIABILITY DATEIMMIDDIYYYY)
INSURANCE 618,+2016
ATE HOLDER,THIS
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFIC
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(iss)must be endorsed. if SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in iteu of such endomement(s).
PRODUCER FADDRESS:
Mason&Mason Insurance Agency,Inc.
458 South Ave. pd:(781)447-5531 , a J.(781)-047-7230
Whitman,MA 02382 info(@inasonandmasoninsurance,com
INSURERS AFFORDING COVERAGE ! NAIC�
A:Evanston Insurance Co. 00008
1NsurEo INsuRER8:safety Insurance Company 139464 _
Alternative Weatherization,Inc. INSURER C:Star Insurance Company, 100006
2 Lark Street INSURER D:
Fail River,MA 02721 —• _
INSURER E:
INSURER F:COVERAGES CERTIFICATE CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IITRR. TYPE OF INSURANCE DpO I VVV
IN 1 POLICY NUMBER b11 Myy LIMITS
A ;; X i1 COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE i a 1,000,00
—xj
� � PREMISES Esocrutrence --i�s-- 100,00
CLAIMS-MADE t_ OCCUR ! C41683 06/07/2016 06/07/2017
it 1 MED EXP(Any one person) IS
6,00
PERSONAL&ADV INJURY jS 1,000,000
3 !
GEN'L AGGREGATE LIMIT APPLIES PER:
3 ! GENERAL AGGREGATE S 2,000,000
! —1 PRO• --
POLICY JECT `` L ;
J i1: ( PRODUCTS-COMPIOP AGG s 2,000,000
! i OTHER: i
j AUTOMOBILE LIABILITY
B �1 (Ea acddr—.) I I j s 1,000,000
L--1 ANY AUTO i 237702 04/08/2016 04/08/2017 BODILY INJURY(Per person) ,S
ALL OWNED TIAUTOS
SCHEDULED
I AUTOS AUTO�WNED ! BODILY INJURY(Per accident) S
NON
X HIREDAUTOS
i�
! ! I y
X UMBRELLA UAB X
--i °ccUR 1 I EACH OCCURRENCE !s 1,000,000
A ExcEss Lwe CLAWS-MADE 1 �TBD 06/07/2016 1'06/0712017 I AGGREGATE E s
! DED I RETENTIONS
!WDRKERS COMPENSATION s 1,000,00
I AND EMPLOYERS'LIABILITY ! i STATUTE I _ER ��C ANY PROPREMS R PXCLUDEIEXECUTiVE Y� C 084925700 04/04/2016 04/0412017 E.L.EACH ACCIDENT 'I s 500,000
i OFFICERIA9EMBER EXCLUDED? N/A
(Mandatory NH)
describe under i 1 E.L.DISEASE-EA EMPLOYEI- $ 600,000
If yyes
I DESCRIPTION OF CPERATIONS belay E,L.DISEASE-POLICY LIMIT (S 500,000
I
ji
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remnants Shcedule,may be attached It moro`apace to required)
Nat'l Grid Corp.Services LLC,d/b/a National Grid,d/b/a MA Electric,d/b/a Boston Gas and Action Inc as additional insured with respect to the GL anc
contracted with Certificate Holder.Kathy Tobin gABCD,Tremont St,Boston;Nstar Gas&Electric-James Care @ New England Gas,46 North Main St,Fail
RiverMA 02720-AI Mickee,GLCAC,305 Esses St,Lawrence,MA;Columbia Gas of MA are Included insured with respects to GL.Only for the following
projcect,Weatherizaiton Installation for Low Income Housing are Additional Insured with respects to Auto Liability per terms and conditions of form SCA 005
(02 16).Form Available Upon Request.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
National Grid THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
40 Washington St ACCORDANCE WITH THE POLICY PROVISIONS.
Westborough,MA 01681
AUTHORIZED REPRESENTATIVE
I \
0 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
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DATE
REGlSi 3ZED ""10- Suv-vEYovQG'
THIS CT�At-I IS uOT BASED OlhA AW 057E2V1LLE o llrr_I�SS; a
I�.IST'Q�JMEtJZ' `jl1iZVE`( THE OF�•,�T� tv:e::== APPI_t CANT )LP
' 1•-c!npr'S u-Seo To OETEZMtW- LoT t._IMC-15
As-� map and lot number .. .. 1..... 9�UST
SEPT{C SYS BE
INSTALLED 1 � COMPLIANCE
Sewage Permit number ............................ 9.1..................... WITH ATM ",E II STATE
SANiTX' y CODE AND TOWN
�Q�oFT"EToyo TOWN OF BARNSTAEBVERS. :
r^ Z BA"STOMLE,
1639' ` BUILDING INSPECTOR
APPLICATION FOR PERMIT.TO .................... ....
TYPE OF CONSTRUCTION ................ ...... /t ✓'' -�..............................................................
7/. .........19.
TO THE INSPECTOR OF BUILDINGS:
The undersigned ereby applies for a permit according to the following information:
Location .. ...... . S .......... .................... ..... 1.f:..... ....... .... .........................
Proposed Use .......!JQ
'. ..........................:................................................................
...........................................
Zoning District .......!..`.:.. a........ ... ...........................................Fire District ..............``yL��K?...��......�'` ..............
r
Name of Owner ....... ........ �!�'�`��.......................Address .
Name of Builder ..........................................Address
Nameof Architect .....................I.............................................Address ....................................................................................
Number of Rooms Foundation .......... `................................................... �1�....... ......................................
Exierior ............... ...1.....r..................................................Roofing ........... .-. ..........................................
�� /� ............................................Interior �p G
Floors ..° .......... .... .
Heating1 l !�/I .......................Plumbing ...............�,..............................................................
Fireplace ............Approximate Cost.............. --..................................... ? cS:fJQ............/.....................................
Definitive Plan Approved by Planning Board -----------_------_-----------19________. AreaS�!..° .. .....................
Diagram of Lot and Building with Dimensions Fee /
SUBJECT TO APPROVAL OF BOARD OF HEALTH
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regardin the above
construction.
Name ................ �.�.� '. ..................................
Capmwide Development '
. \ �
' 19286 one oco�� _
................. Permit for .................................... .
. ` .
o1oele fmm1ly dnwelling
�r----'' ------- .
Se�� ����o�madm �a^
�
� x .
Location_ .~— ......................................................... '
^ ' ,
� Ontervillm
—.--------------.----------. ' .
~
Capnsvida Development
Owner _----.---------''��------'
' -
frame
Typo of Construction ...........................................
' =c-------------------------' '
#65
Plot ..... ...................... Lot --'�-------' '
,
. ~ . .
! -parmh Granted —. lO .' ........ 77
�
'-Dote of Inspection �?���/I—��— --]9
. _ .
�
Date Completed ----.�.lA
^
. PERMIT REFUSED
__--'-------..--------- lQ
..-------.--.-------------.`—. .
. . ,
^
—._----..------------------..
. ^
~'
..-.--.--.---------.--,—~-----
~.�----------..----..-----..—
-
. .
'
Approved ................................................. lg
----_-----------..—.:_____^_...
-------`-------------.—..,...�.. .
|
.
Assessor's map and lot number ;;' v '!.. .
Sewage Permit number ............. ..... .....................
TOWN OF BARNSTABLE
FTHETO�
L BAB39TADLE, i
16 9.a' BUILDING INSPECTOR
APPLICATION FOR PERMIT TO .... :...:. ..::. .......:. .... .......................................................
TYPEOF CONSTRUCTION °..................................................................:..................................................................
.......................... .................19........
s '�'`
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ...:.. ......�.
..
ProposedUse ...........:...............::'.... ......................................................................................................................................
Zoning District Fire District .:. ........
i
Nameof Owner .............. ......::: ......... ...............................Address ......... ........ ......°... :.................................................
Nameof Builder ....................................................................Address ....................................................................................
:�
Nameof Architect ..................................................................Address ....................................................................................
Number of Rooms Foundation °
Exterior ...Roofing ........ ....
Floors .Interior .....`...
Heating :...:......:,...<.............................Plumbing ..................................................................................
Fireplace ................ .:...:.:.::..:...................................................Approximate Cost ......._:... ..: :::...............................................
Definitive Plan Approved by Planning Board ________________________________19________. Area ..................:......................
Diagram of Lot and Building with Dimensions Fee
SUBJECT TO APPROVAL OF BOARD OF HEALTH
I
I
i
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ................. .:... .............................................
Capewide Develop me A=122-a6 (not plotted)
19286 one story 'No ................. Permit for ..................................e
single family dwelling
....................................................................
1
Seth Goodspeeds Way
Location . .........................................................
Osterville
..............................................................;................
Capewide Development
Owner ..................................................................
Type of Construction
frame -
...1.
........................................ . .............. 4. ) ... ................
Plot 4665
Lot ..... . .,..
Permit Granted ........June..10................19'� 77
Date of Inspection .........................:..........1'9'
Date Completed .............................:........19
PERMIT REFU ED
........................................ ................... 19'
...... eV ...........
.... � ..........t..............
........................... ................................................
Approved -.......... 19
...............................................................................
...............................................................................
- oFIKE A Town of Barnstable *Permit#
O,^ Expires 6 months from issue ijae
eAMsrAJIM : Regulatory Services Feeo
•
Thomas F.Geiler,Director
p'ED1A°`� Building Division
Tom Perry, Building Commissioner
200 Main street, Hyannis,MA 02601 XopRESS PERNiIl'Office: 508-862-4038
Fax: 508-790-6230 AUG� 4 2003
EXPRESS.PERMIT APPLICATION - RESIDENTIAL ONL
Not Valid without Red X-Press Imprint TOWN OF BARNSTABLE
Map/parcel Number E 2- Z e 16
Property Address 1 7 0 S 0 0 0 d S P Q CI S W 00,
❑Residential Value of Work 3 6 y 0 .06
..
Owner's Name&Address Lg&LY l S ° h d .L a L 4 C L G t'
17o S (ZA ti C�cs0dS?e,edS wov
Contractor's Name Yh`t r 14 e-q u c�r SO h S Telephone Number Y'Q t� S 3 $-Z 9 6'
Home Improvement Contractor License#(if applicable) / o -1 7 C/o
Construction Supervisor's License#(if applicable) O
r1 .
❑Workman's Compensation Insurance
C; Check one:
[9 I am a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Permit Request(check box)
[:]'Re-roof(stripping old shingles) All construction debris will be taken to
EgRe-roof(not stripping. Going over i 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
Q:Forms:expmtrg
Revise053003
Town of Barnstable
ti
Regulatory Services
* anaxsrABM •
MASS. g Thomas F.Geiler,Director
t639. �0
'O�FOI,,or► Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I ,as Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Address of J )
i ature of er Date
Print Name
Q:FORM&OWNERPERMISSION
e
. 9
i
IBoard of Buildin '' r•L`'
g.Regulations and i%/tom ti''
If HOME I 'F- Standard
PR,VEMENT CONTRALTO B• °� ?` `= ma/�� rn '.
Re tr 10- R.
p���#-�_t�7y`40 �� {n � '•N�STiRUCI�'J'r��rU`.,�FTIIO S
004 ,N'umwbe tf`"wRSpR, E
nership
I MARTINEAU AN N�8
IPaul Martineau
rt6ws Land
10
o ing
Pcasse"t;'
_ MA 02559'
' __ - - � .i:� r ,:a PO•CAS ET' i(�'M;,�,1�;Yp'y�q `�`e ''�� c.;; �.
.t *> -7A_11Ya.
i
F
1ME r Town,of Barnstable *Permit# (CJ 1�
'ba Expires 6 months from issue date
Regulatory Services Fee
•nxtasrABt.E, �.�.
• .
9� Mass' mp Thomas F.Geiler,Director
1639. 10
A'ED ' Building Division PERMIT
PER��
Peter F.DiMatteo, Building Commissioner
367 Main Street, Hyannis,MA 02601%Ni OCT 9 Z001
Office: 508-862-4038
Fax: 508-790-6230 TOWN OF BARNSTABL`E
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number .v w 141
Property Address 1-7 o ,ie 16 &L k'VgU r-
[residential Value of Work
Owner's Name&Address :1pCGn 7 1j=Lg21J lC!
n Contractor's Name ( lam/,--7Z t' MP r f�l Telephone Number 4/3
t:' Home Improvement Contractor License#(if applicable) /d U
J Construction Supervisor's License#(if applicable)
pKorkman's Compensation Insurance" - J
Check one:
j ❑ I am a sole proprietor
❑ I Vn the Homeowner
D41have Worker's Compensation Insurance
Insurance Company Name ;:7 ,r 1C
Workman's Comp.Policy# c2 0
Pemut Request(check box)
❑ Re-roof(stripping old shingles)
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
Replacement Windows. U-Value ,,3L (maximum.44)
❑ Other(specify)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
Signature fwduLtLif
Q:Forms:expmtrg:rev-070601