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HomeMy WebLinkAbout0020 CHURCH STREET ac) ti UPC 12543 No. 53LOR MASTiWra UN - q t Application number—" I 11 . a s • s STABLE. JUL 3 0 2019 Building Inspectors Initials............. NiRt ®y6/!�! �1 �� ._ D to Issued............ �.I. l..l.�..�.... Map/Parcel.........:. �. �. TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: dL O C.h�-f-cal S�- INS�fi NUMBER STREET VILLAGE I-MOwner's Name: ��*� �`l�/ Phone Number Email Address: Cell Phone Number i Project cost$ � �2c' Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorizes 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 ❑ Roof(not applying more than 1 layer of shingles) Construction Debris will be going to T CONTRACTOR'S INFORMATION Contractor's name Mike McCarthy Construction'' FO Box 52 Home Improvement Contractors Registration(if applicable)# Vest Dennis, `U9b-9copy) CSL-58633 HIC-169393 Construction Supervisor's License# (attach copy) Email of Contractor pia -�.-, Phone number ALL PROPERTIES THAT i1AVk STRUCTU ES OVE 75 YEARS OLD OR IF THE SUBJECT PROPERTY-IS IN A HISTORIC DISTRICT. YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. 4 APPLICATION.NUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes 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 201bs. 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 AP ICANT'S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance. Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 e." Home ImprovementContractor Registration Type: Individual Registration: 169393 MICHAEL MCCARTHY _. t Expiration: 06/15/2021 P.O.BOX 52 =_ WEST DENNIS,MA 02670 Update Address and Return Card. SCA/ v 20M-05/17 ,/P �nnvreo�urna,��o�✓�¢d:so,�iu�e/�J Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Individual before the expiration date. If found return to: Reglstiation Expiration Office of Consumer Affairs and Business Regulation 4}69393__ 06/15/2021 1000 Washington Street -Suite 710 _ Boston,MA 021If MICHAEL MCC Boston, MICHAEL F.MCCARTH.- 6RANGLEYLN. LI . :a' •,'% � CG•(aG(ci�c SOUTH DENNIS,MA. 66-0 Undersecretary : Not V81fd-vill#tiOUt signature orriitaonWealth of M'assaT; C Divlston of Protessioraal Licensfrhuz�re '1 Board of StIllding Re IMIf1H�f �c+c�ly gUlatiotts'and$taftdards; Consl rftj; yir Hal snc i fbt%KR11P st W the RigWal Mir �k ices;Oqf colkdoes t auft course 3 dOyofA1114UNt'211A1 MICHMJiyC.4 x PO BOXS2 WEST-I*NNIS i .y . . •'t+f�Ntiroa»B�r •�� i�%l �.E_�`�=dam ¢ � NATIONAL FMAR to PO - • 4Or.►TtrrTa�,..,.�. OSHA uOoTarpa".tafe �Mealth AdmiAlstratidn :, >• Nti- el:McCalth V �. _.T ! >+?�R WAY yetev,aiTOt!QurOcwpa[ a ;Hea}lti �-W 14 SafeEq. retnlr!B. in." 3,2.i Comae ;:BtHealtt , �'lfineaaasbai �-�. ;i,� rsotffel�:`tfioe The Commonwealth of Massachusetts t Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 ' www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE, PERMTITING AUTHORITY. Applicant Information *�= Please Print Le ibly Name Business/Organization/Individual): NUchikel MCCarthv.� C. Address: TO Box 52 ---— City/State/Zip; --- - --------- @S� Pfione#: -- - - Are you an employer?Check the approprlate box: Type Of project(1 egnlred)' 1.�I am a employer with �. employees(full and/or part time).* 7. New construction 2.❑I am a Sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.(No workers'comp.insurance required.]. 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required]V 9. El Demolition 10 0 Building addition 4:❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I I.0 Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.❑I am.a general contractor and I have hired the sub-contractors listed on the attached sheet, 13.❑PlumRoof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation end its officers have exercised their right of exemption per MGL c. 14. Other 1'r>./),J+.., 152.§1(4).and we have no employees.(No workers'comp,insurance required.] *Any applicant that checks box gl must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they ere doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and slate whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that lv provtding iporkers'compensation insurance jar my employees.=Below is lire pbllcy and job site• Informatlon: Insurance Company Name: N�'F►one �ic[�, �^i •F fi,rc Tr�c Policy#or Self-ins.Lic.#: 1 k/(---4`i-4 Sly Expiration Date:_ I'� ►��19 Job Site Address: City/StatelZip Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable.by•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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and t e ins enaides of perjury that the information provided above is true and correct Signature: Date: 1 fF Phone#: CS.0 ;I-h- -G TC b Off cial use only. Do not write in this area,to he 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i DocuSign Envelope ID:48122793-9348-4291-9B81-CE72402F1DEB j� e,9l 38:S`04� 'Owy ,� Town of Barnstable . -�naarstAnre : gp• Buildin Department Services , +vo `16 y' ee0 Brian Florence,CBO '°TFti Apr°, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder 1, MEGHAN RILEY , as Owner of the subject property • C hereby authorize C�,Y1 - to act on my behalf, in all matters relative to work authorized by this building permit application for: 20 Church Street West Barnstable (Address of Job) DoauSigned by: Signature of Owner Signature of Applicant Megan Riley Print Name Print Name 7/24/2019 1 10:48 PM EDT Date it ;t i Assessor's office(1st Floor): Assessor's map and lot number C Board of Health(3rd floor): Sewage Permit number vOM> ( `� t��a C'�2�` Engineering Department(3rd floor): ;STULZ � ius , House number 1639. Definitive Plan"Approved by Planning Board 19 0 MA-1 i, .ch. APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00'-2`:00 P.M.only TOWN -OF", BAR-NSTABLE G L_NSPECTOR r . APPLICATION FOR PERMIT TO Cz)r\,�,k TYPE OF CONSTRUCTION - 19 1 TO THE INSPECTOR OF BUILDINGS ! The undersigned hereby applies for a permit according to the following information: a 1 Location � �Ji^C� Proposed Use r�"' [� p r A t 2 ! l Zoning District Fire District \Name of Owner H( e. R�� �. �\ec C;�'� ,fit,. Address Name of Builder Address rc. Name of Architect .� - ,. ,�. n�� Address l7 c- .a r' C- M " Number'of Rooms Foundations n o A c- Exterior' �+���� ��>^c\a Roofing \ Floors ',� ��a,c c c�, ��.c r a Interior, �? Heating /1 o r\ 2 Plumbing 2_ Fireplace,k J\J " ''� Approximate Cost 'l) o o CO Area &W y Z 4 Diagram of Lot and Building with Dimensions Fee 40 Aic:; 4va rw 3 5 v � Q OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS ` i I hereby agree to conform to all the Rules and Regulations of,the Town of Barnstable regarding the above construction. i Name Lj Construction Supervisor's License y" MERRITT, EARLE P. & JANE S. Jr. 1-5-y- 00 y A=154-004 No 34363 Permit For Build Garaq- Accessory to Dwelling Location 20 Church Street West Barnstable Owner Earle P. & Jane S_ MPrritt, Jr. Type of Construction Frame Plot Lot Permit Granted May 31 , 19 91 Date of Inspection 19 Date Completed 19 r� P MPLETED 1/1/ r. �a041111 l Pyo�TNEro�° .TOWN OF BARNSTABLE B9HH9TADLS, i M6 9 BUILDING INSPECTOR APPLICATION FOR PERMIT TO ...... ...."""`" ' •✓ ,, !2�........................................................ TYPE OF CONSTRUCTION .......... .. .. d ....... .. ... ............19 t� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ..................::... ................. ....... ,�,�•�.. ...................................................................................... Proposed Use ............... 4"o_ a-: '............... Zoning District ......- ...;: .............. a.......................Fire District �:� �................ Aw .. r• 4?�A.;;;� Name of Ownertdre Name of Builder . . ..................Addres .'.. ..... �. . O:P. ... ........... Nameof Architect ..................................................................Address .................................................................................... 000. Number of Rooms ................%..............................................Foundation * �z. ... .............. �'OW. .......... . Exierior /' r..;.. ..L,•••...... f �-g......................Roofing .. .. . ................................................. Floors ... .-:�:.:...- ....................Interior .../..�............ � !; r................... Heating .......... `........... ..............Plumbing ............. . ..,........................................... Fireplace .........................*.... ..............................................Approximate Cost ....... .!.... .......................... Difinitive Plan Approved by Planning. Board _______________________________19 A Diagram of Lot and Building with Dimensions v�S - /e e, 6 TH D OF yl - 'PRON OS� FOR OPOSBD MF SB�'1!AGE D THE PR ATBR HEREBY ��'i r�`.:� `�-D SANS DRAIN GE 15 AND -rONNTq OF BARNSTAgLE, BOARD OF HEW" v �•�_.,. . ..gym=:��- hereby agree to conform to all the Rules and R6gulations of the Town of Barnstabl regarding the above construction. Name - ?. . .. ....... .�..��-�, crl/ /��L/ ' Merritt Earl P. Jr. //^� 7 �x� � 9� *^ � � No .— Pe,mhfor aldto =—'-- ---- . ^~ --..Z943Y.AmiqlIi.n g------------. - Locono� ������---------. .?...................... ________ ` | � | Owner .........}�nrl..P--_ _Jr,____. � . , ) Type of Construction ---..�rmo------. __________________________. '. } / Plot ............... ............ Lot ................................ Permit Granted ....... ...................lV 70 ' ^ 1 Dote of Inspection ..................... ..............l9 . ~ ~Date Completed -- ---.lV ���� K / \ / U � PERMIT REFUSED / � , \ -----`---------------.. lA � / � } ..^-------------------------. . � . � ' -------..~-----------------..� ' . ' ' . . - . ----_--~------.---~..~----- ` —^-----------------^—''----^' Approved r,.�-------------. 19 . ` ~ . ' ' ..................... ......................................................... ! / ------------'.------..i.--.--... < Town of Barnstable *Permit ue date_ ������ Regulatory Services >F e m�s MASS. Thomas F.Geiler,Director G 29 2013 Building Division Tom Perry,CBO, Building Commissioner TOWN OF BARNSTABLE200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY 3 Map/parcel Number L Not Valid without Red X-Press Imprint ( Q 1 Property Address -l �d �- V� t- b�7 Residential Value of Work$�<r�, 60) �f�- Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ` -��lv-\ALZ�l 711�Itlj <;zr- 3 Contractor's Name SL�� A � �� Lam . 06D Telephone Number Home Improvement Contractor License#(if applicable) MCS \\-L2 6b Email: :S\&Q Construction Supervisor's License#(if applicable) \mil\ A- \D(C 6�) �OWorkman's Compensation Insurance t� D c��� Check one: ! � / C�J� ❑ I am a sole proprietor � r- ❑ I am the Homeowner I�er's Compensation Insurance Insurance Company Name Workman's Comp.Policy# .St+G Copy of Insurance Compliance Certificate must accompany each permit. Permit quest(check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to N❑Re-roo (hurricane nailed)(not stripping. Going over existing layers of roof) ❑ ide -eplacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: A ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. "Where requir d: 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. A copy of the Home Improvement Contractors License&Construction Supervisors License is r d. SIGNATURE: Q:\WPFILES\FORMS\�ilding peiirut forms\F�RESS.doc DEL-1 r Revised 060513 Email: The Common g Massuchmsefts Deivarhnmt vf&d=&id Acccdentr Office 00MVfffigadons ' 600 Wwhingtoir Street Bosfan,MA 02M wwm.raamgovldia Warlcers'CompensatinnInsnrance.Affidavit:Bmffders/Contractors/ElectriciansMumbers Applicant Information Please Print Legibly Name M ionadividoao: �6�j k (pP rl- &e' ess: Qty/StatePZ: i ,)NIQrA4�n PIUme Am you an employer?Check rite appropriate boz: TSpe of pmject(required): L� I am a employer with 1_ 14 4. ❑I am a l contractor and I 6_ New constrm ion r employees(full and/orpaa-time).* havehiredthe 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 employees and bave wooers' wing for mein any��9 7 4_ ❑Bnildtng addition [No worlmrs' comp.n,atone ++��comp.+ * required] 5.�4 We are a corporationand its 10�Electrical repairs or additions 3.❑ I am a homeowner doing all work officers hawe emrcised their 1 L❑Plumbing repairs or additions mys-e-I f[No worhm'comp- night of exTmption per MGL 124D Roof repairs insurance required.]T a 152,§l(4�andwe have na- empkgees_[No worloers' 13.0 Other comp-insurance required-] "llny agp)naat that checks boa#1 nmst also M ootthe section below showing their vockets'eompensatiau policy iafn®ation Hameaa CW vrho submit this affidavit in&c they are doing mHumk mad then hie outside comtractum mmst submit a new affidavk imcri—in sack. ctna it check this hoot must attached as additional sheet shooting the name of hie sub-coaacbm and state whether trout fiese emdtks have employees. Ifthe sub-coutmdms hare emplogees,they nmst pruvide their wurkecs'comp policy ntmnber- I am as employer that is prasUfag workam'compmsdion insurance for my ettqAinyem Bdow is the policy and job site iR,formatzam Insurance Compmy Name: Policy 0 cr Self-iris-Lie_# �- 0 �{N fe (� ' - ExpirationDate: Job Site Address: CitylstatelTp: Attach a copy of the workers'compensation policy declaration page(showing the policy number mid expiration date). Failure to se=e coverage as requkedunder Section 25A o€MGL e. 152 can lead to the imposition ofcliminal penalties of a fine up to$1,500.06 andlor onL-yearimprisamnerit,as well as civil penalties in dte firm of a STOP WORK ORDER and a fine of up to$250-00 a day against the violator. Be advised that a copy of this sttatemeut maybe forwarded tv the Office of. Investigations of the DIA for insurance coverage vea$cation_ I do hereby certify uhder;t`ha `"- and pena$ies ofpetjury that ths infornzatiarn provided above is true and correct Sinattrre: � -��� Date: Phone O;(jlcraI use only. Do not writir in this area,to be campleted by cdy or town officiaL City or Town: PermitUcertse At Issuing Authority(drle one): L Board of Health 2.Building Department 3.CitdFown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone N.- 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto 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 bean 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 kmrrance 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 certificates)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 troverage. .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 contact you regarding the applicant Please be sure to.fill in the pennit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permittlicense applit ations in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"lob 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 bum 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 Commaawealth of.Massachusetts Depa-dmmt of lidustdd Accidents • Office of lmvestigations _ 6.00 Washington Street Briton,MA 02111 Tel.#617-727-4900 ext 406 or 1-877 MASSAFE Revised 4-24-07 Fax;'#617-727-7749 wwwr.mass gov/dia Town of Barnstable Regulatory Services f ALANCI'AQT� r , MASS Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstalile.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, �c"�x ALt' —M N ,as Owner of the subject property hereby authorize 5C;M0cQQA, Cam. �.��[S to act on my behalf, in all matters relative to work authorized by this building permit (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. Signature of Owner ' Signature of Applicant Print Name Print Name "Z --C Date Q:F0RMS:0WNaPERMMSI0NP00LS 62012 Town of Barnstable Regulatory Services a"m"m' M ' Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner _ 200 Main Street, Hyannis,MA 02601 i www.town.barnstable.ma.us - Office: 5.08-862-4038 Fax: 508-790-6230 ' HOMEOWNER LICENSE EXEMPTION Please Print DATE: _ JOB LOCATION: number street village . "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Persons)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- fami.ly dwelling,attached or of structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible.- To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit'application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. C:\Users\decobik\AppData\Local\ivlicrosoft\Wmdows\Temporary Internet Files\ContentOutlook\QRE6ZUBN\FDPRFSS.doc Revised 053012 I SCHIENT-01 HWOODS �CORO'° DATE(MMIDWYYYY) CERTIFICATE OF LIABILITY INSURANCE I 6/5/2013 asilS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS I 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 terns and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the I certificate holder in lieu of such endorsemett(s). 1 'PRODUCER CONTACT NAME Rogers&Gray Insurance Agency,Inc. PHONE 434 Rte 134 (AIC,Ne 99): ]—(FAXAfC No: South Dennis,MA 02660 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC S INSURER A:Western World INSURED INSURER B:ARBELLA Protection Schiappa Enterprises,Inc. INSURER c:TRAVELERS INSURANCE COMPANIES OBA Cape Cod Roofing&Siding 111 Hathaway St INSURER D Wareham,MA 02571 INSURERS: 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 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. INSRADOL 5USAPOLICY EFF POLICY EXP OMITS L7R TYPE OF INSURANCE _ POLICY NUMBER (MM/DDIYYYI� kWDD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY NPP8015494 5114/2013 5114/2014 PREMISE_UAFA— S(Ea ow,Errence $ 50,000 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 X I POLICY I I JE LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea acddent) $ B ANY AUTO 1020019209 5/14/2013 5/14/2014 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accidet) $ 1,000,000 AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X HIREDAUTOS X AUTOS PERACCIDEN UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY C ANY PROPRIETORIPARTNERIEXECUTIVE YI'� NIA 7PJUB-0499N66-8-13 5/14/2013 5/14/2014 E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBEREXCLUDED? �J (Mandatory In NH) E.L DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Certain Tegd SELECT Shjr)gleMaster THE EXPIRATION DATE THEREOF, 140TICE WILL BE'DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 20126 Lehigh Valley,PA 18002 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD ri Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 112280 r- Type: Private Corporation Expiration: 2/10/2015 Tr# 236188 TRADE CONSULTANTS/CAPE COD�J'OF-1, EMO SCHIAPPA �- 111 HATHAWAY ST WAREHAM MA 02571 � /Update Address and return card.Mark reason for change. Address Renewal I� Employment Lost Card SCA 1 0 20M-05111 QIJIB (�697L)Y167bCUCCG���O�C-/OGClJ3CGCl7CCJ6l�J Office of Consumer Affairs&Business Regulation License or registration valid for individul use only pOVEMENT OME IMPR CONTRACTOR before the expiration date. If found return to: OME ration112280 Type: Office of Consumer Affairs and Business Regulation ' ,egist : piration: 2/10/2015 Private Corporation 10 Park Plaza-Suite 5170 f; _ w. Boston,MA 02116 TRADE CONSULTANTS/CAPE COD ROOFING EMO SCHIAPPA �L = 111 HATHAWAY ST WAREHAM,MA 02571 r t Undersecretary Not valid without signature ----: vp Board of Building Regulations and Standards Cun%truction Super-6-for Sperialh E License:CSSL-101061 EMO R SHIAEP�A _ taa,-jj=n Detach Atorg AD Perfor Bons 111 HATHAWAY.STREET,r) ' COMMONWEALTH OF MASS ICHUSETTS � WAREHAII'';KA 02571 f�t BOARD REAL ESTATE �' � RE A LIC. REAL ESTATE SALE PERSOP+a } '�',.G.--�` ,�c:�`A Expiration ISSUES THE ABOVE LICENSE O: 1 Commissioner 1011512013 I TYPE EMO R SCHIAPPA {{ t ltunl��ueat.' +r=: lUlllbl `. _. -S 111 HATHAWAY ST 'N I �' J�-l:Glit lltC3iQt�Gt�Gf z'lfiJJCLCft(f38�.+1 WAREHAM MA 02 71-1326 �' l DEPARTMENT OF PUBLIC SAFETY l 1 Hoisting engineer License i 68734 9002851 10/15/13 687 i4 { Number: HE 086392 �Fald,7tar Detach Along A6 Perio tons Expires: 10115/2013 Tr.no: 5004.0 4l Restricted: 1 B EMO R SCHIAPPA JR 111 HATHAWAY ST 1 --t-. WAREHAM, MA 02571 '6 = Commissioner D 1`i(FQ c Town of Barnstable *Peru ju C� 1 Expires onths from issue date Regulatory Services Fee • an MSTABr� • $ Thomas F.Geiler,Director i639- �0 AtFp ,I�, �j Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 501-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY _ Not Valid without Red X-Press.lmprint Map/parcel Number 15 you Property Address ao C 4"'t—k S T.. 4-/, AL.", 1—t2oL 0 Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address �giwJt P M- C 0/1', t'T . Contractor's Name �� ,�, r/J ►-t ws o �- Telephone Number.Sy S -3(.2 -1& 2, Home Improvement Contractor License#(if applicable) /O EmailX-PRESS PERMIT Construction Supervisor's License#(if applicable) C S ^ Q O S`/0 q ❑Workman's Compensation Insurance Check one: I am a sole proprietor TOWN OF BARNSTABLE ❑ I am the Homeowner ❑ I.have Worker's Compensation Insurance Insurance Company Name h L Sy1✓%a .L NS_ A-q Workman's Comp. Policy# ADO I )C p 20 Copy of Insurance Compliance Certificate,must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) © Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *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. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: - Q:\WPFILES\FORMS\builringpermit forms RESS.doc Revised 060513 Email: The Comrnoaraealih ofMassachusetts Department of fndsrstrial Accidents Office of fimla4ations 600 Washingtwt S&eet Boston,MA a2111 ` wtvrt.rnamgovldia Workers' Compensafian Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information L'1 f 1�h Please Print e6bly Name(B - J iona&vidnao: J. L -rel Address: Po ��� i i g lle o��••�� �r City/Sta&Zip: L4.. Phone# Are you an employer?Check the appropriate box: T of project r 4. I am a contractor and I � (���� 1-�❑ I am a employer with ❑ � 6- ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.[ I am a sole proprietor or partner- listed on the attached sheet y- ❑Remodeling ship and have no employees These sub-contractors have g_ ❑Demolition w for me in an capacity- employees and have wodcers' offing YY 9. ElBuilding addition [No workers' comp.insurance comp.msuran l 5. ❑ We are a corporaticnand its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all words officers have exercised their I LE]Plumbing repairs or additions myself- [No workers'oomp. right of exemption per MGL 12..❑Roof repairs insurance mod]3 c.152, §1(4),and we have no employees-[No woricers' 13.®Other comp.insurance required] *Any appfi ant that checks boa#1 tanst also fill out the section below showing tbeu woskere compemadoa policy infutmation_ T Someawners wbo submit this affidavit indicating they an doing aII wools and then hue outside coatracmrs n=snbmrt anew affidwit inrivatm sndL tContmcmrs fist check this boor most attached an additional sheet shaaring the name of the sub-caaracwn and state whether ornot those e=dities have employees. If the svbtontactars have employees,HLey mmt provide their workers'comp.policy number. I am an employer that isprm iditrg workers'compemw ion insurance for azy employees. Baton:is the palicy curd job site information. Insurance Company Name: / Polity#or Self-ins.IIc.#: o20O 1 x O ;L6 1 Expiration Date: Job Site Address: , �ZD C�u-e �+ S2` w �a^� vs�.✓��. City/State/Zip: /"Iq ro o3(0 6 W 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 31,500.00 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 cppy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance:coverage verification. I do hereby certiry render the ans and penalties ofpedwy that the information prmided above is true and correct tore: Date: 2Z)! Phone#: 34L- i O,,Uciai 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.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 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 insuirance 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-contractors)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 lime. 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 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 bum 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 Gommnnvvealth of Massachusetts Department of Industrial Accidents Office of kvestigatioas 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 14M MASSA FE Revised 4-24-07 Fax# 617-727-7749 • www.=ssgov/dia E T Town of Barnstable Regulatory Services RARNMASS. � Thomas F.Geiler,Director 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 I,-� G —`e h N2 r %e--TT,��' , as Owner of the subject property hereby authorize lly C-ZIJ �/�- a to act on my behalf, in all matters relative to work authorized by this building permit (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. Signature of Owner Signature of Applicant Print Name Print Name Date QTORM&OWNERPERMISSIONPOOLS 62012 Town of Barnstable Regulatory Services ` •natvsrwsLirALAM Thomas F.Geiler,Director �En 19. �`0� 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 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&ReguIations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would'with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. i C:\Users\decollilc\AppData\Local\Microsoft\Windows\Temporary Internet Files\ContenLOutlook\QRE6ZUBN\EXPRESS.doc Revised 053012 91?e &omwwnweald Office of Consumer Affairs and Ifusiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 102149 Type: Individual M Expiration: 6/30/2014 TO 223946 JOHNJOHNSON ` w John Johnson PO Box 118 160 Church St W. Barnstable, MA 02668 Update Address and return card.Mark reason for change. t-- Address Renewal Employment ❑ Lost Card -CA1 0 50M-04104-G101216 Massachusetts -Department of Public Safety . Board of Building Regulations and Standards Construction Supervisor License: CS-005409 JOHNJJOHNSO$ PO BOX 118 - i W BARNSTABLE Expiration 06/21/2014 Commissioner Assessor's office(1st Floor): _ Assessor's map and lot number - Q.D 7 '� �� t� poi TM E To` Board of Health(3rd-floor): Sewage Permit number � `' Ffr,- C, ISF7—i4= 5V1TrLNVi M(9 � Engineering Department(3rd floor): ^ "'fit "�+' COO ylassar'Uenct House number .i"d-�ITLE °° i630• Definitive Plan Approved by Planning Board 19 t►'' Ek it ,-,Jb,E NTAL CO + APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only t T UVAI REGULAMW,-:-, A P p rt o v ETOWN ' OF BARNSTABLE Barnstable Conservation{Cor:.miss' �l I L D I H G INSPECTOR J OR PERM9JT0 C3/\A C"r Jc� R r t i ed PE OF CONSTRUCTION 19 QT TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location C�yt"C.N S\-r-eeA r nS bit Proposed Use (� �^ CA r G A r p,t. � Zoning District V2 Fire District Name of Owner ER Ae. R. awe_ S. �ecr;�� 3c, Address c)-0 C` ,. c\, Name of Builder ac7`n n �j�n S a n Address ' 6 o rCA, S�- Name of Architect T' \, ���.r\5.,� Address b O CJ— &'- Number of Rooms Foundation Mb n Exterior �"��Z- S�'�^c�� Roofing 2---SS I� �����►�`� Floors yr C��crlz.�r e__ Interior Heating A n 2 Plumbinge-- Fireplace A-.7-^ Approximate Cost' C7a O �� _ O� Area &LA I y Z4' -0�S�o� Diagram of Lot and Building with Dimensions Fee v U OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction'. Name Q Construction Supervisor's License �� l 7�RITT, EARLE P. & JANE S. Jr. •• No 34363 Permit For Bui d Garage Accessory to Dwelling Location 20 Churcht St -t- West Barnstahlie Owner Earl P. Frame Type of Construction Fr f y q Plot Lot Permit Granted May 31 , 19 91 r Date of Inspection Q 19 Date Completed 19 } • � " M n Application to OPPNS COPEN`'pP�Pi+P�' • ' E� Old Kings Highway Regional Historic District Committee in the Town of Barnstable for a CERTIFICATE OF APPROPRIATENESS Application is here ay made, in triplicate, for the issuance of a Certificate of Appropriateness under Section 6 of'Chapter 470, Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on plans, drawings or photographs accompanying this application for: CHECK CATEGORIES THAT APPLY: 1. Exterior Building Construction: ❑ New Building ❑ Addition ❑ Alteration Indicate type of building: ❑ House ®'C`arage ❑ Commercial ❑ Other 2. Exterior Painting: 0� 3. Signs or Billboards: ❑ New sign ❑ Existing sign ❑ Repainting existing sign 4. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Other _.... (Please read\other side for explanation and requirements). 1 TYPE OR PRINT LEGIBLY `�lJ• �A�ns�A b\� DATE ` ZR\ R� ADDRESS OF PROPOSED WORK Can JrCA" S�ree- ` ASSESSORS MAP NO. ( S LA OWNER EP AQ- Iftne e CC rr. (t ASSESSORS LOT NO. HOME ADDRESS P,C) C��rc,� ���r2-2� t '.� "ArrnJ�aTEL. N0. . FULL NAMES AND ADDRESSES OF ABUTTING OWNERS.. Include name of adjacent property owners across any public street or way. (Attach additional sheet if necessary). 2-a-g' AGENT OR,CONTRACTOR N��n �c7h/�S�^ TEL. NO. 71 ADDRESS — DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done (see No:S;-other side), including materials to be used, if specifications do not accompany plans. In the case of signs, give locations of existing signs and proposed locations of new signs. (Attach additional sheet, if necessary). cJ pp lL �n S•�e ,r.�a\\� G rA..:-\e Cyr \3\c,•� ors C-oo-' �oJ�Q Signed Owner-Contractor Space below line for Committee use. 7 Received by H.D.C. Date The Certifi ate is herebyed 64✓'�V�� t , 10 L ?� V ® ?fool,Time ' �� By kO Approved J�� ��It�1h ORTANT: If Certificate is approved, approval is subject t"the10 y appeal period provided in the Act. Disapproved Ll MA7 O�•.�ne.c' �3� � �� �Q.�� �rac-:al. Cam,.Ss� Arc o.+.r.� C�►.J rc� b ` A r n A\Ikb\C� PICA IZ .Qw�r,S�Ab�Q, 1 3 I'D , r O '09'1 OKHRHDC APR 3 j. hP �/ rNN l:• vJ N ma — ,Q,`� /�OBERT A. Fi./ROAi?�j ,frbee¢r L.. Goo yp.v ` bAN/6.L �/ /S/CKFb.CO Te• T aooK /Z86 P.naar 70 u 5 55 49. 40" a " .. 000000t `}J � STCN6. �A'L-L m�iGOd d L P f3 K. /04S PG. 77 v PL. 5K./77 Gas. 5 7 } !!LL U J �J I � lam!`` • r � N 1 � to � v nest N • W to kin .. mCO q Q. �HRH') o. Z3/.74, C.8 Fvo.••..; T• 73.80 Q J As 14-Z.y/ In � Q •,C.F3.Fwo. SZ sl c v53•37'LO' {.•'C.6 ScT'..D KiNG'S IIIG"'iW • � o.11 C,q.F.vv. .1/ S3. 3 7'ZO'JI/ C H U0C,L., ivl/->& ST�E� 7 T Y k/AY Wesr Fj�.R�./STA$t,.6 I M�•.ss• i COMMONWEALTH DEPARTMENT OF PUBUC SAFETY 1010 COMMONWEALTH AVE.OF a MASSACHUSETTS BOSTON,MASS.02215 � ENCLOSE CHECK OR MONEY ORDER EXPIRATION DATE CONSTR.LICENSE SPERVISOR FOR REQUIRED FEE, 06/30/1991 RESTRICTIONS o EFFECTIVE DATE LIC-NO. o MADE PAYABLE TO NONE Ob/30/1 4$9 005409 "COMMISSIONER OF PUBLIC SAFETY" J O H;ti J J 0 HN SO N m (DO NOT SEND CASH). 16b CHUIRCH W SARivSTA8 ^9A 02663 PLEASE MOTE FEE INCREASE (BUSTING OPR ONLY) FEE: =sue x-+ � 00 EFFECTIVE FEB . 1 1489 ��{HEIGHT; NOT VALID UNTIL SIGNED B�IIC EN$EE AND OFFICUILY :C�'. 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