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HomeMy WebLinkAbout0009 THYME LANE y . �..r.,--...._. _ . . . , _ . _. s Application number..... ...._..........-..3.��.a. $ TOWN Of RARNSW .: 3 S ............................................ +®s. 1019 NOV 15 PS 3: 07 Building Inspectors Initials.. .............................. Date Issued.'...]��1 �.�9. DIVISION Map/Parcel....../..:.5........ 1�. ....................... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: ER STREET VILLAGE Owner's Name: �C v l► S Phone Number o,,"/7 Z�3 --:313` Email Address � ��+ - j Cell Phone Number Project cost$ L�,� �V _ Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize wlw to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK ❑ Siding ❑ Windows (no header change)# ❑ Insulation/Weatherization ❑ Doors(no header change)# Commercial Doors require an inspector's review 173 Roof(not applying more than I layer of shingles) j Construction Debris will be going to c� / CONTRACTOR'S INFORMATION Contractor's name — A Home Improvement Contractors Registration(if applicable)# /; � (attach copy) Construction Supervisor's License# ��/��cS (attach copy) Email of Contractor Phone number ALL PROPERTIES THAT HAVE ST CT S OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT. YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. f e APPLICATION NUMBER............................................................ *For TentsOnly* ' :, ' 4 .l Date Tent(s) will be erected —Rem oved on ' number of tents total Does the tent have sides?Yes No ' (Ifyes please.attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent Fuel source being used LP tank 20 lbs. or> Yes No , if yes, a gas permit is required. Natural Gas Yes No ,if yes,a gas permit is required. If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9.30 am or 3.30 pm-4:30pm. Commercial events may require Fire Department approval *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature /c� Date All permit applicafi s are subject to a building official's approval prior to issuance. i The Commonwealth of Massachusetts r 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 grint Legibly Name (Business/Organization/Individual): Address: City/State/Zip: w��i"'r o2 3 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 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 comp.insurance.t required.] 5. [ We area corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑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#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. tContractors 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: 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 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. I do hereby certify u the pains and enalties of perjury that the information provided above ' hue and correct. Si afore: Date: Al 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 Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: N. Information and Instructions 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 of public 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 insurance 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 I 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 contact you regarding the applicant. Please be sure to fill in the permit/license number which 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. A new 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 affidavit. The Office of Investigations would like 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 ce of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia i Commonwealth of Massachusetts i®t Division of Professional Licensure c Board of Building Regulations and Standards -•Constrrlftbp�rvisor CS-061665 �ires: 07/01/2021 WILLIAM E F 17 JAN SEBA$TI 3 y h SANDWICH MA7 0?` 6�ra Commissioner 1 Construction Supervisor Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.gov/dpl .Office of Consum '� Affairs and 4 Business Regulation:(odA,R) FDIC Registration Complair' , Re91stretion# 115358 Registrant FARRINGTON BUILDING&REMODELING,I_Nc. Name WILLIAM FARRINGTON Address 33 BOARDLEY RD. City.State ZiP SANDWICH,MA 02583 i ilpITtion Date 08/08R020 1 wnpla6gts Retells 'complaints found for this re8istnint '.can also Ylaw srh�8on end GuarnnN Fun_h� _ Town of Barnstable Building �._... .._ .. w _ . - .�_. ', . ._ ._ _._..,. _ .__ n s �� 1Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept BAMSTv$ 6'& ,�$ Posted Until Final Inspection Has Been Made. Permit ' a►Aa+' (Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. Permit No. B-19-2680 Applicant Name: Jonathan Whipple Approvals Date issued: 08/20/2019 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 02/20/2020 Foundation: Location: 9 THYME LANE,OSTERVILLE Map/Lot: 165-006 Zoning District: RC Sheathing: Owner on Record: FRANCESCONE,MARK&SOUKAS, Contractor Name: JONATHAN N WHIPPLE Framing: 1 Address: 25 RUSSELL STREET#2 Contractor License: CS-078683 2 BROOKLINE, MA 02446 1 Est. Project Cost: $ 1,970.00 Chimney: Description: Insulate crawlspace wall with R10 Rigid Board and weatherstrip Permit Fee: $85.00 door. Insulation: Fee Paid: $85.00 Project Review Req: _ _ Date: 8/20/2019 Final: Plumbing/Gas Rough Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuan icta Final Plumbing: All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Rough Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. Final Gas: f The Certificate of Occupancy will not be issued until all applicable signatures by the Building and-Fire-Officials are provided on this permit. Electrical Minimum of Five Call Inspections Required for All Construction Work:; f% 1.Foundation or Footing Service: 2.Sheathing Inspection .' f 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Rough: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation 7.Final Inspection before Occupancy Low Voltage Rough: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Low Voltage Final: Work shall not proceed until the Inspector has approved the various stages of construction. Health "Perso on with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT • Final: `�J consarvWon o s .I .............. li 1 11/14/14 Thomas Perry, CBO Town of Barnstable Building Division 200 Main St Hyannis, MA 02601 RE: Insulation Permits Dear Mr. Pent', This affidavit is to certify that all work completed for insulation work at 9 Thyme Lane (application #201204703) has been inspected by a certified Building Performance Institute (BPI) Inspector. Ail work performed meets or exceeds Federal and State requirements. Sincerely, raml G Conor McInerney -- ConserVision Energy rn . 376 ROUTE 130,SUITE C SANDWICH,MA 02563 508-833-8384 WWW.CONSERVTODAY.COM TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map I Parcel Applic ior, # Health:Division Date Issued �J 1 Conservation Division Application Fee Planning Dept._ •• Permit Fee Date Definitive Plan Approved by Planning Board ok 13r7117- Historic - OKH Preservation/ Hyannis r - y - Project Street Address L, Village Owner �1\ (1 SU t! \0�� Address_ � �lp:� ML. L a Telephone Permit Request ` r Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 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.-Hghway:'ca Yew❑ No Basement Type: ❑ Full ❑ Crawl ❑ Walkout ❑ Other 3 . _ Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.# Number of Baths: Full: existing. new Half: existing new,-2, Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count 0 Heat Type and Fuel: 0 Gas ❑ Oil ❑ Electric 0 Other — Central Air: ❑Yes ❑ No Fireplaces: Existing. New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: 0 existing ❑ new size — Barn: ❑ existing ❑ new size— Attached garage: 0 existing ❑ new size _Shed: ❑ existing ❑ new size — Other: Zoning Board of Appeals Authorization 0 Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use _ Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Ckno)"c' �s� �r Telephone Number Address 1�, ��1• GO License # `0-"k rwi5 S W L , A&A 0-196Z Home Improvement Contractor# Worker's Compensation # U C.!1&X S )5_31 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 3 11-2 I 1> 4 s FOR OFFICIAL USE ONLY •APPLICATION# r ; .,DATE_ISSUED s 'MAP-/PARCEL NO. ..... ADDRESS VILLAGE ,2 OWNER DATE OF INSPECTION: ' _rFOUNDATiONl f;AT; w FRAME i • a',INSULATION'J ; FIREPLACE ELECTRICAL: ROUGH -FINAL PLUMBING: ROUGH FINAL GAS ROUGH ,t r ' FINAL i s 3 -FINAL.BUILDING": DATE CLOSED:OUT . . ASSOCIATION PLAN NO. ' The Commonwealth of Massachusetts , ': `FiintForttn S x Department of Industrial Accidents Office of Investigations I Congress Street, Suite.]00 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors%Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):CONSERVE ENERGY INC. d.b.a CONSERVISION ENERGY Address: 376 ROUTE 130, SUITE C City/State/Zip:SANDWICH, MA 02563 .Phone #: 508-833-8384 F1Are you an employer? Check the appropriate box: Type of project(required): .® I am a employer with 6 4. I am a general contractor and 1 employees(full and/or pan-time)." have hired the sub-contractors 6. ❑ New construction I 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' 9. f-1 Building addition [No workers' comp. insurance, comp. insurance.', required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions 3.111 am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions myself. [No workers' comp. right ofexemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.© OcherWEATHERIZATION comp. insurance required.] *Any applicant that checks box#1 must also till 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 cuntructurs must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet shuwutg 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. I am an employer that is providing workers'compensation insurance fur my employees. Below is the policy and job site information. Insurance Company Name: SELECTIVE INSURANCE COMPANY OF THE SOUTH Policy#or Self-ins. Lie. #:WC7956539 Expiration Date:3/15/13 Job Site Address: City/State/Zip: 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 MG L 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. I do hereby certi under the ains and eenalties uUerLiity that the in ormation provided above is true and correct. Signature: Date_ 1 Phone#: 508-833-8384 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 Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Client#:68880 CONSER (N1d/ODlYYYY) ACORDn. CERTIFICATE OF LIABILITY INSURANCE DATEo3115/2o1z THIS'CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 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(ies)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 Ileu of such endorsement(s). PRODUCER CONTACT NAME: Rogers&Gray Insurance Agency,Inc. rrPHONE 508 398.7980 - 434 Route 134 I fE A�°Eatt: _ (AIC,No): South Dennis,MA 02660 ADDRESS: 508 398-7980 INSURER(S)AFFORDING COVERAGE NAIC 0 - - — INSURER A;Selective Ins.Co.of the South INSURED INSURER B Con-Serve Energy,Inc. ,r - - —— 376 Route 130.STE C INSURER C: Sandwich,MA 02563 )INSURER D: _ +` INSURER E. t INSURER F: COVERAGES 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 CONTRACTOR 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. LTIR ADDL SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE IN R WVD POLICY NUMBER mwa MM/DDlYYW _ LIMITS A GENERAL LIABILITY X , S2011299 3/14/2012103/14/2013 i EACH OCCURRENCE IS1,006000 X COMMERCIAL GENERAL LIABILITY 0gtt��,E p RENTED � PREMISES iEa occurrenajl :S 1 O�_O ODO CLAIMS-MADE AI OCCUR I MED EXP(Any one person) S 10 000 FPERSONAL&ADV INJURY ,s 1,000 000 GENERAL AGGREGATE .s3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: -PRODuCTS-COMPIOP AGG :.s 3 000,000 r___- _ X POLICY' ,PRO• 1 LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _ Ea acadenl S _ ANY AUTO BODILY INJURY(Per person— ) !$ALL OWNED SCHEDULED BODILY Per a— caoem IS _ AUTOS i AUTOS _ I ); NON-OWNED ' ; PROPERTY OAMAGE - HIRED AUTOS I AUTOS S � i (Per ecaden0 S A uraeRELLaIwe X I OCCUR X S2011299 03/14/2012iO3/14/201 �EACHoccURRENCE $1,000000 EXCESS ` X CLAIMS-MADE{ AGGREGATE s3 OOO OOO 'DED- X RETENTION 0 _ __ I 1s A WORKERS COMPENSATION _ ) �WC7956539 3114/2012 j 03I14/2013 X WC STATU- ; BOTH- -'" AND EMPLOYERS'LIABILITY YIN ' i 7OBYLws_ ER—j-- ANY PROPRIETORIPARTNERtEXECUTIVE�� EACH , I E.L. ACCIDENT i$100 000 OFFICER/MEMBER EXCLUDED? I T`•,N I A ! — _ (Mandatory In NH) I E.L,DISEASE-EA EMPLOYEE!$100.000 If yes.describe under I DESCRIPTION OF OPERATIONS below I _ } E.L.DISEASE-POLICY LIMIT '000,000 1 . I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) Excluded officers under workers'crimp-Conor and Courtney McInerney. Blanket additonal insured coverage applies under CGL CERTIFICATE HOLDER CANCELLATION Thielsch Engineering,Inc. THE ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 195 Francis Ave. ACCORDANCE WITH THE POLICY PROVISIONS. Cranston,RI 02910 AUTHORIZED REPRESENTATIVE ©198 -2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S788991M78898 DDR t-%\ `office ofumes` r's` Uu �e iAloip License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date, If found return to: Registration: 171251 Type: Office of Consumer Affairs and Business Regulation v: {{.. Ex iration: 3/1/2014 Partnership lU Park Plaza-Suite 5190 :r' P ;f Boston,AIIA 02116 CON SERVE ENERGY CONOR MCINERNEY /1 i 376 ROUTE 130 SUITE C (� ' SANDWICH,MA 02563 Undersecretary — — —-" \ot valid without signature Massachusetts- Department ail'Public Safvtt Bu.wd of Building Regulations and Standards Construction Supervisor Specialty License License: CS SL 102778 Restricted to'. IC CONOR MCINERNEY 39 SIASCONSET DRIVE SAGAMORE BEACH, MA 02562 Expiration: 8/19/2012 f'iu�un issiuner T ro: 102778 OWNER AUTHORIZATION FORM 1 (Owner'sName) owner of the property located at i (Property Address) a j (Prop rty Address) hereby authorize P (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to pe orm work on my property. i O ner's Signature - 6 /////7-,---- Date t ` D F= JUrj 1 2012