HomeMy WebLinkAbout0280 HIGH STREET 0
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UPC 12543
No. 53LOR
Mpa:eu.,.m �3W
a. Town of Barn'.stalble _ g
PostThls�Card�So::T_,.hat�lt.•�s VlsiblerFrom the�5tceet FApproved�PlansMust�beRetamed;�on�ob;and�thisCard;�Must�be:Kept i
w�rM�.'`�►s ��'_� -'�'.-�' �w�� �� . .���':"� �`� � �. .tea �:� . _a . �, ., �1;���' � Permit
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Permit No. B-18-164 Applicant Name: JASON HERBST Approvals
,Date Issued: '01/23/2018 Current Use: r Structure
Permit:Type `Building=:Siding/Windows/Roof/Doors_ Expiration Date: 07/23/2018 Foundation:
Location:. 280 HIGH STREET,WEST-BARNSTABLE Map/Lot. 111 014 Zoning District: RF Sheathing:
e 0
Owner on Record TOMPKINS JOAN;K � ` s ��ContractorNamHERBST HOME IMPROVEMENT Framing: 1
Address: 279'HIGHSTREET t � `. QR
ti< 2
ContractoraLlcensel7,<13.31
WEST BARNSTABLE, MA z0261 8,
Chimney:
� pE tProJect Cost: •$7,825.00
Description: REROOFING WITH ASPHALT SHINGLES w� - x .
Insulation:
Permit Fee: $39.91
Project Review Recj:
$39:91
Final:
Date 1/23/2018
�u � Plumbing/Gas
� x
;_ Rough"Plumbing:
�•s �s' r� '2t�' s .*era.���'� a `
a Final I "PIU
mb'ng;
x Building:Official
.
Rough Gas:
€:
This permit shall be deemed abandoned and invalid unless.the.work authonzed�by this permit is commenced within siM6i the aftdN&uance.
Final Gas:
All work.authorized by this,permit shall conform to the approved appl e I a theme approved construction documeefitt r�w fo 'Efilf is.permit has been granted.
AII'construction,alterations and changes of use of any building.and structures,shalLbe in compliance.with the loca,� oningignaaws and codes.
�ru
This permitshall be displayed,in•a locatiomclearly Visible from access.str �,o t0road nd�sh�all be�malntaineed{open for�publlc Inspe ion for the entire duration of the Electrical
work until the completion of the same. 01
p � k �� a .. Service:
The Certificate.of Occupancy will not be issued until all.applicable signatures,byathe BUllding and fire Officials�are provldedson this permit.
��t s Rough:
Minimum of Five Call Inspections Required for All Construction Work; ._
1.Foundation or Footing Final'
2.Sheathing Inspection
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Low Voltage Rough:
4.Wiring&Plumbing Inspections to be completed prior-to Frame Inspection
5.Prior to Covering Structural'Members(Frame Inspection) Low Voltage.Final:
6.Insulation
7.Final Inspection before Occupancy Health
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final'
Work shall.not proceed until the Inspector has approved the various stages of construction.
Fire Department
"Persons contracting With.unregiste red,contractors do.not have.access to the.,guaranty.fund" (asset forth:in M G L c.142A). Final
Building plans are to be available on site
All Permit Cards are the property of the APPLICANT-'ISSUED RECIPIENT
Town of Barnstable
. Building .,.,.
• Post This Card So That it i Visible From th r 'coved'PlansI viust be Retain" '7 "es5t eet .Ap ed on 1ob.andthisvCard-Must.be Kept
ti�"t. -s..��.'a`'',s�..,y5�,$.,�'yz,.•, p � erm� ,
a 16 lPostedUntil,, al.InspectioAasBeen�Made v u - J
eoMa •Where ficateoof�Qceu ane �i�s Re d�uch Buildm shall tube Occu ied until a FinahInspectiomhas;beenfinacJe
Permit No.- 113-18164' Applicant Name: JASON HERBST Approvals
Date`Issued:t `01/23/2018 Current Use:-.. Structure
Permit Type,,=:Building:-Siding/Windows/Roof/Doors Expiration Date: 07/23/2018 Foundation:
Location:' 280 HIGH STREET,WEST BARNSTABLE Map/Lot: .111=014• Zoning District: RF Sheathing:
77 .
m�71f S 4 � t"b °s r
Contractor Name Owner on Record TOMPKINS,JOAN K a # I ERBST HOME IMPROVEMENT Framing: 1
r
Address: 279 HIGH STREET
ContractorrUcense 1A71331
` WEST BARNSTABLE, MA 02668, � t; <
Chimney:
Description: REROOFING WITH ASPHALT, Cost: $7,825.00
If SC ect
Descri
P �� � �5
Insulation:
Permit Fee: $39.91
.Project Review Req:
39:91 Final;
�_ ���D to 1/23/2018
Nw -0,
Plumbing/Gas
_.,
Rough Plumbing:
rrs � � Final Plumbing.
;. Building Official
Rough Gas:
This permit shall tie deemed-abandoned and invalidun,less the`work authorsizedJbythNpermit is commenced within six r1r6& �aft&N suance.
�- .€� U Finaf Gas
All:work authorized'by this permitshall conform`tothe approved appIica i6R.' the approved consfruction documents1or�whichithis permit has been granted. '
All construction I r i,ate at ons and changes of use of any building:and structuresshall be in compliance with the local zornng by lawsiand codes.
'This permit shall be.displayed in a location.clearly Visible:_from access streetbor road and shalllbe�maintained opO-n fi publicpinspection for the entire duration of the Electrical
qgig
work until the completion'of the same. ' ..5 �� � �
MNW, �� ,� xv v Service:
• za� '° '��P 4 , ''a ""`; �` a� sy}ski
`J^,, ,• g�' ,.,eS $� ..vs�" '�- 1x-., .The Certificate of:Occupancy will not be'issued until all applicable signatures byFthe Building;and Fire Officialskareprovided16n this ermit.
Minimum of Five Call Inspections Required for All Construction Work: c � �� ... P Rough:
1.Foundation or Footing 'Final:
2.Sheathing Inspection
3.'All Fireplaces must be inspected at the throat level before firest.flue lining is installed Low Voltage Rough:
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection
5.•Prior to Covering Structural.Members(Frame Inspection) _ Low Voltage Final
6.Insulation
7.Final Inspection before Occupancy Health
Where applicable,separate permits are required for Electrical;Plumbing,and Mechanical Installations. Final:.
Work.shall not proceed until the Inspector has approved the various stages of construction. Fire Department
"Persons contracting with unregistered contractors do not have access to the guaranty.fund" (as setforth in MGL:c.142A): Final:'
Building plans are to be available on site
All Permit.Cards are the property of the APPLICANT-ISSUED RECIPIENT
L
Town of Barnstable *Permit#
' Building Department Services Expires 6moWeefromissuedate� � I
Brian Florence,CBO s
MASS. Building Commissioner
c i�Ald 200 Main Street,Hyannis,MA 02601
www.town.bnrnstable.nro�
Office: 508-862-4038 / 8 F 5e 8-790-6230
EXPRESS PERMIT APPLICATION - RESIDENT ONLY
I Not Valid without Red X-Press Imprint C
Map/parcel Number /
Property Address a9)Q ii I � �O
❑Residential Value of Work$ ��� Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address _ )Qr,�in fin►�� t h C
Contractor's Name ��G.S i�'� ��P i��� Telephone Number aq�� Z
Home Improvement Contractor License#(if applicable) /-7 !3 3 I Email: /Lt,r6�- hD 11 V%A p,r-pVf,YYW
Construction Supervisor's License#(if applicable) /n hb 5 i
' Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
["I have Worker's Compensation Insurance
Insurance Company Name (G C.l i CC /h_So/G rr'P
Workman's Comp.Policy#_ `,Y AA R P _ U 6 � 0
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Requ t(check box)
Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to -sa✓1/�f t..�i/��
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows
#of doors:
'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:
QAWHII.ESTORMS\building permit formu\EXPRESS.doc
08/16/17
i
?Ire Commomveaith of 3fassacJFrtrsetls
Reparbment of bzd=t7ial Accidents
Office of1mvY.6gadom
600 Washurgton Stmet
Boston,MA 02111
mmumas&gorldia
Workers' Compensation Insurance Affidavit:Builders/ContracturstEIectizianslPlumbers
Applicant Informafron Please Print F.e�blY
Nam 6
Ad&ess-- S� � tial
ct51 _ ce v �rr� - i -nu--
Axe
an employer?Checkthe appropriate bo=: ' Type of project(required}:
I.U I am a employer-with �� 4. ❑ I am a general contractor and I 6. ❑Ides construction
(full andlor pa t-ime)s have lured the sub-cont moors
2.❑ I am a sale prupiietor orpartuer- Listed on.the attached sheet, 7. ❑Remodeling
strip and have no.employees . Thew sub-cm Tact=have 8..❑Deawlitioa
wod^ing fax me in any capacity. employees and have workers' 9. ❑Building addition
wads' comp.insurance comp- I
5- ❑ We are a corporatitn and its 10_❑Electrical repairs or acldfions
3_❑ I am a homeowner doing all work officers have exercised tic 1 L❑Plumbing repairs or additions
mysdf o workers' _ right of exemption per MGL 17❑Roof reps
i tee required j T c.152, §l(4h andwe have no
employees.[No wow' 13.❑Other
conp.insurance required_)
•ftaytq Hc=9astchecUboxI%1attestalsofiRaot:ihesectianbeIowsltov¢iagtiieirtvaakerecomp®sad pelieyinfiooasCiam
Mmaowmn who subunit dus affid2t�t ithxrxatW P they ate doing alF war}and dtea hat outside conmi mast submit a new affida ft radiating sack
fCmtttact. ff=,bPr7rtY5boXMmStsftrh M addibnoal dhegt stewing the name of dte sUh caMscm M tmd stile whether or not those entities have
employees.lfthesub-c==ctamhaveemployee%&eYatnsipwvidetbesr workem'c=ip•policFnumlrer-
I am an eiiiployer thatis prouidirg workers'conWmsdion insurance for mS*employees Sel"ow is the patfey and job she
information.
Insurance Company Nature: AC 6,d l a j-N.S (,)<A oek-
Poficy 4 or Self-ins-Iic---N- ell 61 g R —30() f� Fkpiratiaa Date:
Job Site Address: 2f'o
Attach a copy of the workers' ensation policy dedaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a
fine up to$00D 00 andlor one-year uuprisoumerd,as well as civil penalties in the form of a STOP WORK ORDERand a fine
of up to$250-00 a day against the violator. Be advised that a copy of this statement maybe fix yarded to the Office of
Investigations of the DIA for ihsumm coverage verification_
f do herby under.the ' smd °allies afpetyuty thatthe infibrma&raprovided abm a is hue and carrect
Si Date:
Phone g_ 7 7 Z i a-7
0,o'rcial use anty Do not write in this area,tit be camp&ted by city ar town ofidat
City or Town: PermriVLicense#
Issuing Authority(circle one):
L Board of$ealth 2.Buil fing Deparraent 3.City/rown Clerk 4.Electrical Fuspector 5.Plumbing Inspector
6.Other
Coact Person: Phone 9:
laformation and lnstruCtionS '
Massacj=etts Ge'neral Laws chapter I52 reqaires all employers'to provide woiteas'compensation for their employees.
pmmum3tto this statute,an errrplVw is deemed as.'_—c M7 person in the service of ano tb=wander any contract of]rim,
express or i mpHed,Dial or wrb=L"
Air esrrplvyer is d:efined as"an individual,partammEp,assoch d=4 corporaion or other legal enmy,or airy two or more
of the; going engaged is a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individnA paitrimsbip,association or other Iegal 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 -
dweai house of mother who employs persons to do maiuntmanre,construction or repair work on such dwelling house
or on the grounds or building agp thereto shall not becanse of such employment be,deemed to be an employer."
MOL cbapter 152,§25C 6)also stairs that"every state or local licensing agency shall witTihold the issuance or
renewal of a license or permit to operate a business or to construct bmldmgs in the common wealth for any.
applicant Who has not produced acceptable evidence of compliance with the insurance.covex age requn—ed."
Additionally.MGL chapter 152,§25C(7)sites"Neither the commonwealth nor any ofits political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliaaace vM i the insl c.6.
requm ezueats of this chapter.have been presented In the ea*�cting auihoi*." =
A.gpHcants
Please fll out the workers' compensation affidavit completely,'by chwl&g the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s), address(es)and phone Tn— e;z(s)along with their=tficate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liabii[ity Partnerships(LI.P)with no employees other than the
members or parin=s,are not requited to cry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidayit may be submitted to the Department of Industrial
Accidents for confmmafiou of insm-mce coverages Also be sure to sign and date the affidavit. The affidavit should
bo retomed to the city or town that the application for the permit or license is being rcquesbA not the Department:of .
had" frial Accidents. Shouldyou have awry questions regarding the law or ifyou are requfted to obtain a workers'
compensation policy,please call the Department at the number lht::d below. Self-insured companies should enter their
self-insurance license member on the appropriate line.
City or Town Officials,
Please be sore that the a$zdavit is complete and printed legibly. The Deparfinent'has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigadions has to contact You regarding the applicant
Pleas a be se to fill in the peunh/licrose nivnbes which will be used as a reference number 7n addition,an applicant
u
that must submit mvldple pen itllicense applit:ations in.any given year,need only submit one affidavit indicafng current
policy information(-if necessary)and under`Uob Site Address"the applicant should write"all locations in (citY er
town)."A copy of the affidavit that has been officially stamped or ma dced by the city u town maybe provided to the
applicant as proofth�at a valid affidavit is on file for futin 'permits or licenses A new affidavit must be failed out each
year.Where a home owner or citizen.is obtaining a license or permit not related to any business or commercial venture
(Le. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit
The:Office of Inves6gati=would lice to thank you in.advance for your coop mad on and should you have any questions,
please do not hesitate tb give us a call.
The Departments address,telephone and fax number:
Tba *of M hmsetts ,
Depattr mt of did Acaidenis
duce of fave&#gatio=
6Q4� �n
Bwtoa.,MA EM IT
Ta 617 727-4900 ext 406 Qr I-M-MA.SSAFE
Fax 9 617 727'74
Revised¢24-07 .magogfelia
Herbst Home Improvements LLC
35 PEEP TOAD ROAD
CENTERVILLE MA 02632
774-238-2937
www.herbsthomeimprovements.com
PROPOSAL SUBMITTED TO: WORK PERFORMED AT
Joan 280 high st bamstable
We herby propose to furnish the materials and perform the labor necessary for the completion of:
New roof
Remove one laver of wood shingles
Install ice and water shield at eves
Install new drip edge
Install Certain Teed diamond deck roof paper
Install Certain Teed landmark TL shingles$9,990.00(copper valleys included) .
Install CertainTeed landmark PRO shingles$7,825.00 -
Replace all plumbing boots
Install ridge vent and azek ridge boards
Clean all debris daily
All material is guaranteed to be as specified. The above work will be performed in accordance with the specifications submitted
And completed in a substantial workman-like manner for the sum of:choose from shingles installed
Dollars($ )with payments as follows:deposit of 4,000 and remainder upon completion
*Any alterations from above proposal involving extra costs will be added under a separate written agreement and become an extra
charge over and above said proposal.
RESPECTFULY SUBMITTED-
17 '1
i -
on Herbst
ACCEPTANCE OF PROPOSAL
The above price,specifications and conditions are satisfactory.I herby accept this proposal. You are authorized to do the work and
payments will be as specified above. "--
SIGNATURE: 1 G c /�/
*This proposal may be withdrawn by said company if not accepted within 30 days.
Massachusetts Department of Public Safety:
3. Bo of Building Regulations and Standards.:.,.
License: CSSL-106051
Construction Supervisor Specialtyr�
JASON HERBST •'; s.`ram:
35 PEEP TOAD ROAD
CENTERVILLE INA 02b32� .fit
Ekpiration:
.Commissioner 0101/2018
Construction- u*r\isor Specialty
F...Restrjcted tq:•s
CSSL-RF-R�. ows and Siding
CSSL\NS-
''.: ossess a current edition of the Massa
chusetts
se-
failure to MASS.GOV IDPS
• .State Bu►Idi�9 Code is cause for revocation of this licen
pig Licensing
information visit:WWW _ =
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''iv �^ •" rn � "„�. �;, � r• .. ..cJ/ze omzric�zur �� c ..
ofCousumerAffa�rs BcBusmeSs.Rggulahou
a��L''icense orvregrstr`ahon valid fdr indmduause onl :'
�tr=y i HOME IMPROVEMENT CONTRACTOR_ ' t
before the expiration date. 'If found FetArn to.• ` .
Registration:, 1Z1331 Type:
Office of Consumer Affairs and Business�Regulat>on
10 Park'Plaza`;Surt_e ST20 Expirationj�}g LLC
71
.B:oston,:MA�0211b z,r
s HERBST HOME IMP tE
-EiEME�L-�
JASON.':HERBST =L.
36 PEEP T
OAD RD
_ CENTERVILLE,MA-
4. 02632'-r....,'.
a sal-`..-�X"°•. Nt t. ga...u eaUndersec ry.
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1
ACo® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
�� 1 01/18/2018
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 lieu of such endorsement(s).
PRODUCER CONTACT
NAME: Larissa Camba
LEONARD INSURANCE AGENCY PHONE 508 428-6921 FAX
0. IC,
No
E-MAIL Larissa@leonardagency.com
683 MAIN STREET SUITE B INSURERS AFFORDING COVERAGE NAIC#
OSTERVILLE MA 02655 INSURERA: ACADIA INS CO 31325
INSURED INSURER B:
HERBST HOME IMPROVEMENTS LLC INSURERC:
INSURER D:
PO BOX 254 INSURER E:
FORESTDALE MA 02644 INSURERF:
COVERAGES CERTIFICATE NUMBER: 230952 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.
INSR LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MMIDDPOLICY/YYYY MM/DD//YYYY LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-MADE OCCUR MA N D
PREMISES Ea Occurrence $
MED EXP(Any oneperson) $
N/A _ PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
-
POLICY JECTPRO LOC PRODUCTS-COMP/OP AGG $
PRO
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $
AUTOS AUTOS
HIRED AUTOS NON-OWNED PROPERTY DAMAGE $
AUTOS Per accident
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $
DED I I RETENTION$ $
WORKERS COMPENSATION PER ERH
AND EMPLOYERS'LIABILITYSTATUTE
ANYPROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH DENT 100,
A OFFICER/MEMBER NIA NIA N/A MAARP300898 11/18/2017 11/18/2018
(Mandatory In NH) E.L.DISEA$j.&A EMPLOYEE $ 100
l yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEW POLICY LIMIT? 500, 0
N/A 00 a
�o
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached If more apace is required)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B. authoriza�'g is gi to pay
claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outsi a of Massacchusetts.,
� II+
This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the abovl4olicy cedes the
issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass.gov/lwd/workers-compensation/investigations/.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS.
200 Main Street
AUTHORIZED REPRESENTATIVE
Hyannis MA 02601
Dariit3l M.-Cr 4y,CPCU,Vice President—Residual Market—WCRIBMA
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
I
Town of Barnstable,Planning 8t Development Department
{ . Old Kings Highway Historic District,Committee
200 Main Street,Hyannis,Massachusetts 026QI
R Phone 508.8.62.4787 Email cruu.logan a.town.bamstable.ma.us
CERTIFICATE OF EXEMPTION
Application is hereby madc,with four(4)complete sets,for the issuance of a Certificate of Exemption under Section 6 and 7 of Chapter
470,Acts and Resolves of Massachusetts,1973,as amended,for proposed`work as described below,and on plans,drawings or photographs
accompanying this application:
Date f/�3'!. Address of Proposed work, Assessor's Map and lot#
House# P D Street �-.. villager
This application is for an exemption of the proposed construction on the grounds that work:
❑ Will not be visible from any way or public place
❑ is within a category declared exempt by the old Kings Highway Regional Historic District Commission
❑ other 1
Description of Proposed Work: I p� 1 rrx�� ,►�1�_e %`1 L L �1(� r / ��11 C
Agent or contractor(please print): / R` - Tel.no. 7 R Zl 3 7
Address 01j, C: N-4ry r lif— rVE 11 6 26.Z L
Owner.(please print): ��CG ✓1 7 o rr,� ./-'rj S Tel no. f e' -312—
owners mailing address: a 7 FE A ti;th 0147
Signed,Owner/Contractor/Agent
Checklist
ri Four complete sets of the application and supporting documentation
U $_Filing Fee(see attached schedule)
For Committee Use Only This Certificate is hereby APPROVED/DENIED Date:
Committee Members Signatures:
,PPOVED
NOV 15 Z917
�Mvlio11b.misrab'.e Conditions of approval:Old Kitk3's Hfgh+vay
CrAnmitles
OKII F.xrmpdbn Fam 2017