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0277 PLEASANT PINES AVE
�,7�' �l�Q���- �� 3. __---,vim-��,.�-• r-. __ _ r.+� . - ,��+. __ .,.: ..�.._.._._,__._R�ti ��.,�_W ��_-- - - - - _ .��_��__._ � _ .. ._. .�.. .. __ --- �....�:.-s i NO. 1521/3 ORA MADE IN USA ESSEM .. ..,y: Vyy, �.- ...._�.. ..... .. �.� � ..�. ... '. ..�—s:,�w n ,�!• LY w � v - `r_ .. _ ... � _- ,k. ., ut y _� �.....+.r1. .fii� MKv.n ... i. y � .: .. �. I� �� C 4 �, i L-�Z� EApplication number ..r..l... ..................... .... QaAP J Fee....... z?.................................... Ate. . rpI ,- ?0�9 NAMn.� � Building Inspectors Initials. . .................:..........: 1639. ,iA.. 11 B E Date Issued.... 1ta .Il........................................... Map/Parcel.. D. L ..d....4/..!........... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDO WS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 7 A*X V �1\j NUMIBFA STREET VILLAGE Owner's Name: T -le-hJsm k Phone Number 7 9-Z 36 Q' 9�� Email Address: Cell Phone Number Project cost$ Kf corn Check one Residential L-'---Commercial OWNER'S AUTHORIZATION As owner of the above prop e uthorize �61S to make application for a b din rmit ' accordance with 780 CMR Owner Signature: Date: �/J7`I TYPE OF WORK ❑ Siding ❑ Windows (no header change)# ❑ Insulation/Weatherization yD-aors (no header change)# Commercial Doors require an inspector's review 12'Roof(not applying more than 1 layer of shingles Construction Debris will be going to " f CONTRACTOR'S INFORMATION Contractor's name/� ,/ Home Improvement Contractors Registration(if applicable)# U (attach copy) Construction Supervisor's License# C S7` s 93 (attach copy) Email of Contractor /Y14"'le 4 f1 Y3 gyr�V a Phone number. "� ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTYES IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. ... .. ... . . ` Ali 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.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 G�/�i�> Date All permit applications are subject to a building official's approval prior to issuance. Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Const`gtl t—Mi� '§b.pervisor F. CS-035693 F ires: 01/18/2020 . �. DAVID A.WOODS _C ., 43 MATTHEWINAY ,.IJi4 ` 4 MARSTONS MILKS MA'02648 J_\L��`` h Commissioner I! � ✓� c�isnii2�rcuco�o�✓��aJJac�iJe%lJ I Office of Consumer Affairs&Business Regulation. HOME IMPROVEMENT CONTRACTOR Individual ; Regiistra'16. Expiration (a 32-3, — 07/30/2020 DAVID WOODS d DAVID A.WOODS\ 43 MATTHEW WAS' '>s` j MARSTONS MILLS,MA 02648 Undersecretary l Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Cons rgjttlsS '§bpFrvisor CJ. CS-035693 ires: 01/18/2020 "P 1� DAVID A.WOODS = n W'-WAY 43 MATTHE ,'1� . MARSTONS MILLS MA`02648 h Commissioner I i Registration valid for individual use only ,.' before the expiration date. If found return to: Office of Consumer Affairs arid Business Regulation 1000 Washington Street-Suite 710 Boston,MA 02118 Not valid without signature I '• 4 7 The Commonwealth of Massachusetts 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 Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip:Mo�/rG�1 /z �S Phone#: - Y/9 ?7A' 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.Ei 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 workingfor me in an capacity. employees and have workers' Y P tY• = 9. ❑Building addition [No workers' comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12. r—e airs insurance required.]t c. 152, §1(4),and we have nop employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#I 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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have 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 information. G vrt �L-/S' G� °'"'''" �� "� Insurance Company Name: W Policy#or Self-ins.Lic.#: / YZ 99 Expiration !': Job Site Address: 2 7 /'-(A24J�a AIJ' MG City/State/Zi Attach a copy of the workers' compensation policy declaration page(showing the policy Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the impo Ysiidines of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a S.ur 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 under the=and 'es of perjury that the information provided above is true and correct Signature• � Date: / 7 Phone#: 2 7®Y 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#: 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-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 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 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 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 ACORO® CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DDNYYY) 04/17/19 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 have ADDITIONAL INSURED provisions or 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 WN NAME: JIM HINDMAN Schlegel&Schlegel Ins Broker a/CNNO Ext: 508-771-8381 ac No): 508-771-0663 34 Main Street E-MAIL West Yarmouth,MA 02673 ADDRESS: schlegelinsurance@gmail.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: NGM INSURANCE COMPANY 14788 INSURED INSURER B: TRAVELERS MARCOS SILVA INSURER C: DBA EMERSON CONSTRUCTION INSURER D: 67 SEA ST APT 11 HYANNIS,MA 02601 INSURER E: 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. ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DYE LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE F OCCUR PREMISES Ea occurrence $ 500,000 MED EXP(Any oneperson) $ 10,000 A MPT9375T 11/09/18 11/09/19 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS PROPERTY DAMAGE HIRED NON-OWNED $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY B OFFICER/MEMBER EXCLUDEDIECUTIVE N N/A WC-1073205 04/17/19 04/17/20 E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) MARCOS SILVA HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN DAVID WOOD ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE DAIANE BENFICA ©1988-2015 A RD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Town of Barnstable Building Post This Card So That it is Visible From the Street=Approved Plans Must be Retained on Job and this Card Must be Kept a� �' )Posted Until Final,lnspectiori Has Been Made. • � » `d _ r-.• _ y' .. '.. Permit earaal• Where a Certificate of.Occupancy is Required;suchpBuilding shall Not be'Occupied until a Final Inspection has been made. 1 1 Permit No. B-18-1632 Applicant Name: SWANSON, LYLE A&CYNTHIA R Approvals Date Issued: 06/13/2018 Current Use: Structure Permit Type: Building-Shed-Residential-200 sf and under Expiration Date: 12/13/2018 Foundation: Location: 277 PLEASANT PINES AVE,WEST BARNSTABLE Map/Lot: 214-041-W01 Zoning District: SPLIT Sheathing: Owner on Record: SWANSON,LYLE A&CYNTHIA R Contractor Name -,, Framing: 1 Address: LACIMA 15 Contractor License: ,� 2 TRUJILLO ALTO, PR 00976 -�' Est. Project Cost: $0.00 Chimney: Description: 1OX20 SHED '; Permit Fee: $35.00 Insulation: Fee Paid:` S 35.00 Project Review Req: Date: � 6/13/2018 Final: Plumbing/Gas Rough Plumbing: Building Official �.. Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Rough Gas: 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. Final 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. __. __- - ..,_�. , Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work:E X 1.Foundation or Footing Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Perso s cont ting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT ISSUED RECIPIENT — ` Town of Barnstable �3 • SHE r, Building Department Services °- Brian Florence,CBO • Building Commissioner MAS& 163q. `0� 200 Main Street, Hyannis,MA 02601 ED www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 PERMIT FEE: $35.00 SHED REGISTRATION n RESIDENTIAL ONLY dam. 200 square feet or less •277 Location of shed(address) Village C� T�!Gt 5we),1N SdKJ Prope owner's nake Telephone number A> b5f 26 2-1 q 0`1 t .VV 41 Size of Shed Map/Parcel# Signature Date Hyannis Main Street Waterfront Historic District? O 2 Old King's Highway Historic District Commission jurisdiction? �!//��Fe� Zo�® You must file with Old King's Highway 'q/�/Sl Conservation Commission(signature is required) Sign off hours for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,TBERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. s" THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN . Q-forms-shedreg REV:08/6/17 , ID tu 0. 13 _II . G �,4,5,4 i1fT vo LL d c r t•° - kp Q' ti N V, :iLu -7A IL LL dj co IL ti 1•• EtT5 v a H Ma iy - C1F tME Tp� Town of Barnstable *Permit it � Expires 6 mo t � rr v iss a Regulatory Ser vices Fee BARNSfABLE, 9� i639. `0� Richard V.Scali, Interim Director 1DrEn wpr s Building Division r''_ Tom Perry,CBO, Building Commissioner 1 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY 21 ^ _ 41 1 — ,� IS'ot Valid Wthoul Red X-Press Imprint Map/parcel Number Lf. w u Property Address 2-7-7 P-Leasa n P n e-s Ave 1() P X Residential Value of'vVork$ 4-a.. Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address P Swanson , Z 77 _sa fl� /*he.S V� . le 3Z /-u US Sve- - " Grl+ Contractor's Name Sac� rs Ho M_C=_ y" Q Te'lepphone Number W60,153•0457- IF Home Improvement Contractor License#(if applicable)/4O 6O7 EmaillwVEC0$3 IQ SMOL j Construction Supervisor's License#(if applicable) 1 E X 1— — p p,131,1 zoic _ XWorkman's Compensation Insurance Check one: X.PilEss ElI am a sole proprietor +� ❑ I am the Homeowner I have Worker's Compensation Insurance TDEC 142815 Insurance Company Name Ace Awler 1 ea ri his u rGritir c e l SBA N ® Workman's Comp.Policy# 1—RC 9 O .R STAR/ c Copy of Insurance Compliance Certificate must accompany each permit. `C Permit Request(check box) IVA —❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to _ NA —❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) J( Re-side of A -- ❑ Replacement Windows/doors/sliders. U-Value (maximum .35)#of windows #of doors:^ _ A]A —❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical & Fire Permits required. *Where re(Iuired: Issuance of this pennit does not exempt compliance with other town department regulations,i.e.Histor 7 onsery anon.etc. 'C:)1 t """Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Ho a Improvement Contractors License&Construction Supeivisors LiaAsc i re fired. SIGNATURE: li �` r "r:\KEVIN D\13uild t MESS PERMIT\EXPRESS.doc Revised 061313 OF IW E rp� + BARNSTABLE, + MASS,i63q. Town of Barnstable �0 Regulatory Services r +" Richard V.Scali,Interim Director Building Division Thomas Perry,CBO 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, as Owner of the subject propertg hereby authoriz to act on my behalf, in all matters relative to work authorized by this building perm t application for: z-77 Pleas_a v)f Piryes Avenwe (Address of Job) Signature of Owner hate ��p Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. 'rAKEVIN D\BL1i1dingChanges\EX PRESS PERMIT\EXPRESS.doc Revised 061313 The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED NVIT111 THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/organization/Individual):Sears Home Improvement Products Incorporated Address: 1024 Florida Central Parkway City/State/Zip: Longwood, FL 32750 Phone #: 860-753-0452 Are you an employer?Check the appropriate box: Type of project(required): L[J I am a emplover with employees(full and/or part-time).' 7. ❑New construction 2.❑I am a soic proprictor cr partnership and have no employees working for me in $. ❑ Remodeling 3.❑ any capacity.[No workers'comp.insurance required.] 9. El Demolition I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 4.®I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 n Building addition ensure that all contractors either have workers'compensation insurance or are sole I I.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance. r � (i.®✓ We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 1/1 ' h 9 152.§1(4),and we have no employees.[No workers'comp. � insurance required.] i 5 *Any applicant that checks box#I must also till out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. /um an emplQver that,is providing workers'compensation insurance fur my employees. Below is the policy and job site information. Insurance Company Name: Ace American Insurance Company / Phone : 866-283-7122 Policy It or Self-ins. Lie.It: #t: Plea Expiration Date: 08/01/2016 Job Site Address:Z*7 / T'lea S Q h l— P,n es A%City/State/ZiCe 'I I e.K40A C) Z Attach a copy of the workers' compensation policy declaration page(showing the policy number and expirat oni date). Failure to secure coverage as required under MG; c. 152, §25A is a.cri;nina! violation punishab!e by a !inn, t:p to$!,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. /do lrerehv cert' uo er the pains id penalties of perjury that the information provided above is trueand correct. Sii4natur . _ "' _�"� Date: I f 5_ Zb Phone#: 860-753-0452 Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License It Issuing Authority(circle one): I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: RESET FORM ACD® DATE(MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 07/25/2015 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 dA! certificate holder in lieu of such endorsement(s). PRODUCER CONTACT N AOn Risk Services Central, Inc. NAME: Chicago IL Office .(A/C. Ext): (866) 283-7122 FA c.No.: (800) 363-0105 y v 200 East Randolph E-MAIL o Chicago IL 60601 USA ADDRESS: _ INSURER(S)AFFORDING COVERAGE NAIC tJ INSURED INSURER A: ACE American Insurance Company 22667 Sears Holdinqs Corporation INSUHEHB: ACE Fire Underwriters Insurance Co. 20702 dba Sears Home Improvement Products, Inc Attn: Ri Sk Management E3-219A INSURER C: 3333 Beverly Road INSURER D: Hoffman Estates IL 60179 USA INSURER E: INSURER F: COVERAGES .CERTIFICATE NUMBER:570058793162 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'r0 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. Limits shown are as requested S TYPE OF INSURANCE S POLICY NUMBER O C POLICY LIMITS LTH INSD WVD UBRI POLIO YEFF POLIO EXP A X COMMERCIAL GENERALLIABILITY HDOG2 9 8 08 1 ffi 08701 2 EACH OCCURRENCE $5,000,000 CLAIMS-MADE X❑OCCUR AGNTED $5,OOO,000 PREMISES Eaccurrence o MED EXP(Any one person) Excluded PERSONAL B ADV INJURY $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S5,000,OOO X POLICY ❑PRO ❑ cn JECT LOC PRODUCTS-COMP/OP AGG $5,000,000 N OTHER: o 0 A n AUTOMOBILE LIABILITY ISAH08859000 08/01/2015 08/01/2016 COMBINED SINGLE LIMIT � ISAH08859012 08/01/2015 08/01/2016 $5,000,000 A Ea accident A ANY AUTO ISAH08859024 08/01/2015 08/01/2016 BODILY INJURY(Per person) O ALL OWNED SCHEDULED Z X AUTOS AUTOS BODILY INJURY(Per accident) N IiIREO AUTOS NON-OWNED PROPERTY DAMAGE X AUTOS Per accident) X — r d UMBRELLA LIAB OCCUR EACH OCCURRENCE U EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION A WORKERS COMPENSATION AND WCUC48589662 08/01/2015 08/01/2016 PER OTH- EMPLOYERS'LIABILITY YIN OH, WA, WV X STATUTE ANY PROPRIETOR/PARTNER I EXECUTIVE A OFFICER/MEMBEREXCLUDED; NIA WLRC48S89650 08/01/2015 08/01/2016 E.L.EACH ACCIDENT $2,000,QO0 (Mandatory in NH) All Other Stdtes E.L.DISEASE-EA EMPLOYEE $2,OOO,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $2,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE, DESCRIBED POLICIES SE CANCELLED BEFORE 'rH �" EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE _ POLICY PROVISIONS. Sears Home Improvement Products, Inc. AUTHORIZED REPRESENTATIVE �r'1 1024 Florida Central Parkway Longwood FL 32750 USA �/� ,XY. 6�- cJ�tR traed C�inL�i4✓na ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000034159 LOC#: ACORD® _ _ �-- ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED Aon Risk Services Central, Inc. sears Holdings Corporation POLICY NUMBER See Certificate Number: 570058793162 CARRIER NAIC CODE " See Certificate Number: 570058793162 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance INSURER(S) AFFORDING COVERAGE NAIC# INSURER INSURER INSURER INSURER ADDITIONAL, POLICIES If a policy below does not include limit information,refer to the corresponding policy on the ACORD certificate form for policy limits. POLICY POLICY I TR R TYPE OF INSURANCE ADOL SUBR POLICV NUMBER EFFECTIVE EXPIRATION LIMITS I:1' INSD \VVD DATE DATE MM/DD/YN'Y\' NIM/DUN\'1'Y WORKERS COMPENSATION B N/A SCFC48589674 08/01/2015 08/01/2016 WI I i ACORD 101(2008/01) ©2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD I �'.,r,<�mil, �.'/f'l,�P �(J�?'I.��Z�t'Yl'�iGl1G�t.2itrl.�?� s'1� ��;/�(.�'!S:�C{�E:��G'lGi�G�• .. Office of Consumer Affairs and Business Regulation 10 Park 'Plaza - -SUItc 5170 Bdston, Massachusetts 02 11 -1-101T).(,1 lillprovement Cofatraiator Registration. Registration: istration: 148607 Type: Public Corporation Expiration: 10/11/2017 Tr# 270727 SEARS HOME IMPROVEMENT PR0`DQJ'C:-T-7'- ................. ..............................................ALFRED NYMAN 1024 FLORIDA CENTRAL PKVVY ...... LONGWOOD, FL 32750 ............................................................. ........... Update Address and return card.Mark reason for change. SC A 1 0 20M-W) Address r:j 'Renew al C, Enipioyinclit Lost Card ness 11cgulation 'License or registration valid for individul use only �• ,'�fi"ZPOME IMPROVEMENT C'O'NTRACTOR before the expiration date. if found return to: FiR e g 1 s t rat I o n: ..48607 Type- Office of Consunier Affairs and Busincss Regulation Expiration- 1.0 Park Plaza-Sidtc 5)70 x r a t i o n: i,1*,2 017 Public Cotporation Boston,MA 02116 'MFNT-.,P SEARS HOME IMPROVAL5, -RObUCTS INC. ALFRED NYMAN 1024 FLORIDA CENT .RA:I-. LONGWOOD,Fl-32750 ................. ............... Not valid without signature )M Massachusetts -Department of Public Safety Board of Bui!ding Regulations and Standards C'onstriiction Supervd�or w'Z� License. CS-097519 LU'BOSSVFC 827 THOMPSONRO Thompson CT 06277 Expiration Commissioner 08/31/2016 SOQ r-S A3 e r& C� i f - &9(0 - -7 Es3 • 0 4- S -a I Office Location: BOSTON Proposal Date 10/31/2015 JJobNumber 19466881 Sears Home Improvement Products,Inc. Customer Name rrs P.O.Box 522290 LYLE swANsoN � 1024 Florida Central Parkway Customer's Home Phone Customer's Work Phone Longwood, FL 32750-7579 ustom 502-5651 Home Improvement Products Phone(800)469-4663 Street Address ESTIMATE AND PROPOSAL Contractor License/Registration Number 277 PLEASANT PINES AVE MA(148607) ,95 1 City State Zip Code Siding All plumbing and electrical services performed by CENTERVILLE MA 02632 Is installation within city limits? licensed subcontractors Installation Address County BARNSTABLE (Yes/No): YES FEIN 25-1698591 Billing Address(if different from above) City State Zip Code Project Consultant Name&License No.(if applicable) RALPH MUDARRI BOSTON Description of the Project and Description of the Significant Materials to be Used and Equipment to be installed The work to be done under this contract includes the following(where checked): Specifications(9=Included❑=Not Included) Preparation: 1. 0 Obtain all necessary permits and insurance. 2. 0 Inspect surfaces in work area,re-nail loose wood,and replace rotten surface wood where necessary in work area(excluding roof,decking;-rafters,and structural members). 3. 0 Remove existing siding.. Type: WOOD CLAPBOARD 4. 0 Fir out walls on brick,block,metal,or stucco areas. Location: FRONT, LEFT, BACK,RIGHT SIDE FAMILY 5. 0 Caulk and seal around all windows and doors in the work area as necessary. 6. 0 Install approved non-corrosive starter strip. Insulation: 7. ® Install insulation of flatwall areas that are to be sided with (3/4"or 1/4"): 3/4" extruded polystyrene insulation. Custom Trim: 8. 0 Install custom Vyna-Klad aluminum fascia system. Color: GLACIER WHITE 9. ❑ Remove existing guttering.After removal,existing guttering will be: (re-attached/disposed of): 10. ❑ Install new guttering and downspouts. 11. ❑ Cover soffit areas of home with vinyl soffit system(except where noted below in"Work NOT to be done")using: (WB Max/WB Plus/Weatherbeater/Value Line/Other): Color: Pattern: 12. ❑ Install custom Vyna-Klad aluminum frieze boards. Size: Location: Color: 13. ® Window trim: (jump/butt): BUTT Location: ALL Color: GLACIER WHITE 14. 0 Custom wrap windows,sills,mulls,headers with Vyna-Klad aluminum. Color: GLACIER WHITE 15. © Remove and re-install existing: (storm windows/awnings/shutters): AWNINGS 16. ❑ Install new shutters: (Panel/Louver): Color: 17. © Custom wrap door facings with Vyna-Klad aluminum. Color: GLACIER WHITE 18. 0 Custom wrap garage door facings with Vyna-Klad aluminum (single/double): SINGLE Color: GLACIER WHITE 19. ® Remove and re-install storm doors. 20. 0 Install deluxe corner posts. Color: GLACIER WHITE Siding: 21. 0 Install: (WB Max/WB Plus/Weatherbeater/Value Line/Other): wB PLUS Solid vinyl siding. TYPE:(Horizontal/Vertical):-HORIZONTAL Color: ADOBE CREAM Porch Systems: 22. 0 Porch ceilings: Location: FRONT (ENTRY & FAMILY) Color: GLACIER WHITE 23. ❑ Porch posts: Color: 24. 0 Porch beams: FRONT ENTRY Color: GLACIER WHITE Clean up: 25. Z Clean up and removal of all job-related debris. 26. 121 Remove excess materials and re-stock each job is over-shipped to avoid delays). Additional work to be done:R&D "MANTLES" ABOVE 4 FIRST FLOOR FRONT WINDOWS NONE Work NOT to be done: No drip edge covered;no paint applied. SHED SPECIAL INSTRUCTIONS:RIGHT SIDE OF HOUSE TO BE STRIPPED, NOT FAMILY ROOM. WRAP FRIEZE BOARDS. R&R SHUTTERS. R&R AWNING ON LEFT SIDE IN BACK OF FAMILY ROOM. All of the above check boxes, "Work NOT to be done," "Additional work to be done," and Customer(s)initials "Special Instructions"sections have been reviewed and explained to me. SS1-MA (Dig.) Rev 08/01/12 Page 1 of 3 IIIII III I I III III Job Number: 19466881 APPROXIMATE START DATE and APPROXIMATE COMPLETION DATE: The work will start approximately 4 WEEKS (Approximate Start Date) It will be substantially completed by approximately 1-2 WEEKS (Approximate Completion Date) These dates are subject to change at the time the contract is accepted by Sears Home Improvement Products, Inc. ("Sears")or at any other time by mutual written agreement. Customer understands that the Approximate Start Date is only an estimated date and the Customer will be contacted prior to this date to schedule the actual start date. ASBESTOS ABATEMENT: This Estimate and Proposal assumes that there are no asbestos containing materials ("ACMs")that would be disturbed in the performance of the installation work. If upon further inspection by the contractor or others it is learned that ACMs have to be disturbed to perform work, then Customer must arrange and pay for abatement of asbestos by a qualified person prior to the start or continuation of work. If Customer fails to arrange for necessary asbestos,abatement within thirty (30) days, Sears may cancel this contract upon Customer(s)initials - written notice to Customer. If The TOTAL PRICE including all labor,material,taxes and any applicable discount is$ 40,Soo.26 Contract Price $40,500.26 Initial Payment(not to exceed 30%of Total Price unless Special Order)$ 12,1So.08 State Sales Tax( 0.00 %) $ 0.00 Final Payment(balance payable upon completion of job)$ 28,350.18 Local Sales Tax( 0.00 %) $ 0.00 Total Amount Due $40,S00.26 The form and method by which the Customer(s)will pay is described in a separate Cash/Credit Customer(s)initials ] Card Payment Addendum made a part of and incorporated into this contract by reference. .. NOTICE TO BUYER: YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY (FIFTH BUSINESS DAY IN ALASKA, FIFTEENTH BUSINESS DAY IN NORTH DAKOTA IF YOU ARE AGE 65 OR OLDER)AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. ADDITIONAL PROVISIONS Proposal and Approval. Sears offers to furnish the materials and arrange for their delivery and installation as specified on the first page and/or the attached sketches and specification sheets for the TOTAL PRICE shown.This offer must be approved by the Installation Department. If this is a credit sale or a payment on completion sale,it must be approved by the Credit Sales Department. If this proposal is not approved or the installation cannot be made in accordance with the law,this offer will be withdrawn and any payments you have made will be refunded to you.Any materials left over after the installation has been completed are Sears property and will be removed by Sears. Installation. I understand that Sears will not install the materials but will arrange for the installation. Sears is not responsible for materials or installation NOT furnished or arranged by Sears.Sears'installation contractor(s)will obtain all building permits required by local law. For homes located in historic or landmark zoning districts,Customer will be responsible for obtaining required approvals and related permits prior to the commencement of work on this contract. Authorization. I authorize Sears to: (1)arrange for a contractor(licensed where required by law)to make the installation of materials; (2)issue a work order for this installation to a contractor; (3)inspect the installation;and (4)pay the contractor when the installation is complete if I have signed a certificate that the installation has been completed to my satisfaction. Delays in Installation.I agree that Sears is not responsible for delays in delivery or installation due to weather,fire,strikes,war,government regulations or any causes beyond Sears'control. Oral Agreements and Changes in Contract.I understand that there are no oral agreements between Sears and me.Everything I expect Sears to do has been included in writing in this contract. Nothing can be changed in this contract unless it is in writing on a separate form accepted by me and Sears. Responsibility of Buyer. I agree that any information or measurements that I give to Sears are correct and complete. I am responsible for any special work described in this contract. Electrical& Plumbing Service. I will provide adequate electrical and/or plumbing service(s)to run any newly installed appliances or other furnishings. If the electrical and/or plumbing service(s)do not meet the standards of the utility company or electrical and/or plumbing codes,I will make the necessary changes at my expense unless Sears has agreed in this contract to make the changes. Payment.I will pay Sears the cash price that covers the price of material and installation as shown on the first page. Warranty Information.Appropriate product warranty documents will be given to me by Sears.Sears'Warranty on Installation is: SEARS'LIMITED WARRANTY ON INSTALLATION In addition to any manufacturer warranty extended to you on the product(s) used (which warranty becomes effective the date the merchandise is installed), if the workmanship (or application) of any Sears' arranged installation proves faulty within (i) one year for Weatherbeater or other brand, (ii) two years for Weatherbeater Plus,or(iii)three years for Weatherbeater Max,then upon notice from you Sears will cause such faults to be corrected by repair at no additional cost to you.If Sears determines that repair is not commercially practicable or cannot be timely made,then,at Sears'sole discretion,Sears may elect to provide replacement or refund.Service under this Limited Warranty is available by calling Sears Home Improvement Products at 1.800-222-5030,Option 4.This warranty gives you specific legal rights,and you may also have other rights that vary from State to State. SS1-MA (Dig.) Rev 08/01/12 Page 2 of 3 IIIII II II IIII III Job Number: 19466881 NOTICE TO BUYER 1. DO NOT SIGN THEAGREEMENT IFANY OF THE SPACES INTENDED FORTHEAGREED TERMS TO THE EXTENT OF THEAVAILABLE INFORMATION ARE LEFT BLANK. rt 2. YOU ARE ENTITLED TO A COPY OF THIS AGREEMENT AT THE TIME YOU SIGN IT.KEEP IT TO PROTECT YOUR LEGAL RIGHTS. 3. YOU MAY PAY OFF THE FULL UNPAID BALANCE DUE UNDER THE AGREEMENT AT ANY TIME,AND IN SO DOING YOU SHALL BE ENTITLED TO A FULL REBATE OF THE UNEARNED FINANCE AND INSURANCE CHARGES. 4. YOU MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY[FIFTH BUSINESS DAY IN ALASKA, FIFTEENTH BUSINESS DAY IN NORTH DAKOTA IF YOU ARE AGE 65 OR OLDER]AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. FAILURE TO EXERCISE THIS OPTION, HOWEVER, WILL NOT INTERFERE WITH ANY OTHER REMEDIES AGAINST THE RETAIL SELLER YOU MAY POSSESS. IF YOU WISH, YOU MAY USE THIS PAGE AS NOTIFICATION BY WRITING"I HEREBY RESCIND"AND ADDING YOUR NAME AND ADDRESS.A DUPLICATE OF THIS RECEIPT IS PROVIDED BY THE SELLER FOR YOUR RECORDS. 5. IT SHALL NOT BE LEGAL FOR THE SELLER TO ENTER YOUR PREMISES UNLAWFULLY OR COMMIT ANY BREACH OF THE PEACE TO REPOSSESS GOODS PURCHASED UNDER THIS AGREEMENT. NOTICE TO MASSACHUSETTS RESIDENTS ONLY In addition to the Notice to Buyer shown above, Massachusetts law requires that contracts for home improvement work state that all home improvement contractors and subcontractors shall be registered and that any inquiries about a contractor or subcontractor relating.to a reqistration.should be directed to: _ Director,Home Improvement Contractor Registration P.O.Box 871 Taunton,MA 02780-0871 Telephone:(508)821-9375 Please note that owners who secure their own construction-related permits or deal with unregistered contractors shall be excluded from access to the Guarantee Fund. Notwithstanding any other language in the contract or associated documents, Sears will not remove, replace, or install any heating or air conditioning system, or any portion thereof, if asbestos or asbestos-containing material is known or likely to be present in that heating or air conditioning system,or any portion thereof. If it is determined or reasonably suspected that asbestos is present,either before commencement or during performance of the work, it shall be the customer's responsibility to select, retain and pay all costs of a Division of Occupational Safety ("DOS") licensed Asbestos Contractor to remove all asbestos or verify that none is present in the components involved in the job. If the determination or reasonable suspicion of the presence of asbestos arises after Sears has started the work, Sears will immediately cease performing the work until a DOS licensed Asbestos Contractor, hired by the customer, removes all asbestos from the components scheduled for repair or replacement in accordance with 310 C.M.R. 7.00 and 453 C.M.R. 6.00 or verifies that none is present. By signing the contract the customer agrees that it understands the above. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES 10/31/2015 10/31/2015 lnE spuEOv Customer's signature Date Customer's signature Date Accepted by Sears Home Improvement Products, Inc.("Sears")on 10/31/2015 by. _ Date Management Representative SS1-MA (Dig.) Rev 08/01/12 Page 3 of 3 i - 71 TOWN OF BARNSTABLE Permit No. 25389 �. --------------------- Building Inspector cash .•.. .°ya ------�x.� OCCUPANCY PERMIT Bond Issued to Pamela Dane -Address Lot 1, 277 Pleasant -Pines Avenue, Centerville Wiring Inspector ,�� � - Inspection date Plumbing Inspecr�(r ✓ � Inspection date Gas Inspector ( J - n Inspection date XEngineering Department � tj ����r�� __Inspection date l , r Board of Health +�- �%�'!�y Inspection date THIS PERMIT WILL NOT BE VALID,'AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED. BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILLDING, CODE. Building Inspector--� 417 P�-ado SE� Assessor's map and lot number ........... .//�.. ...p..�../......... :lC SYSTEM MUST BE /�3 � INSTALLED IN COMPLI, R`�Q o-.YNE ro�� Se a e Permit number ................ . � � V!IlT� TITLE 5 /'r �.� I"D �VIRONMENTAL C(--" Z 3E3 STSDLE, i L House number ........................ wL-Gc . . a , rasa ............. . 039. 4Ala = l7/�3T�� /7T k/Sk U� OYPYa� TOWN, OF .'BXRNSTABLE���``pK�� BUILDING"`� INSPECTOR APPLICATION FOR PERMIT TO �q �w .1 l........... TYPE OF CONSTRUCTION . /AU Z r7��C� ��_1�`K ................................... ............ ..... .............. ......... .................................................... i, ............. ...................�9�� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a pd'rmiT 'according to'b - ollowing information: t ��PLEASANT PINES AVMUF� T V/ Location ........ ...Q.........I ......... l� N ��.....L ............................r... ... .... �,. ......... Proposed Use . .................................................................................................................. . ....................&f44./A/.6 Zoning District ...........�`. ...�............................................Fire District .......... ..�. ............................................................. Name of Owner ....�i /�I 4 L ZIq/VWn/ usL /�!P!Q!�C't ' //1��/✓/l�/ Address ........... .......... .... S. Name of Builder ... :�1...e... .. ... /.f�Q...................Address 1./....0,?1L0 ..5 Nameof Architect ..................................................................Address .................................................................................... Numberof Rooms ........... ?...................................................Foundation .............................................................................. Exterior NV�©.��.. �!YG�L .... C'Lij�p .Roofing ............. S/.7 ........................................ Floors ........C./Zld ................ ..... ...A'....1!00.0.......................Interior ...........6!-�g1!.41tq. 4 ......................................... Heating c L.£e.7ie�C.............................................Plumbing C�...KJ rTs. Fireplace ................. ...............................................................Approximate Cost ...............7,61-- ..' ....................... ...... Definitive Plan Approved by Planning Board -----------_-------------------19_______. Area ......C.2/z/...... 5 .. Diagram of Lot and Building with Dimensions Fee /0 0�-...... ... 0............... SUBJECT TO APPROVAL OF 60ARD OF HEALTH ,�J� 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. l nn Name ..` i? 'l.,t l!ll D Construction Supervisor's License �Q..� DANE; PAMELA 2 �tor No`. .. 89.:.. Permit for ..... ...........X ..Single Family Dwellin ...................................... ......................�............... Location Lot—1 .......2.7.7...Pl.easan.:t..P.ines Ave.. Cer�. axv�11e................................. Owner ...PPI]AP14...DAIle.................................. Type of Construction Frame...............I............. ................................................................................ Plot ............................ Lot ................................ �7 .1 Au ist 4. Permit Grante ........9[............. t...............19 83 . Date of c w ......... ..........19�J :Date .Completed .. ✓� i� .............19 '" J 1 r} v y • 1 /o Pk�• too� . 0 T TA, qZe o 41 -1 - � F•oV b^T1O� ... � � � I . M LA G A2 kc>F. �-• � �Ropoc¢Q l o "2o, l b L9 V ett-o wz V / 4b - • • 0 F- s T ►1G W e_L_t__ Ir p _� - Wd ILCL 13 LL c Lu tv � sLu Q ! w � ' v M d _ =aC4 - _ La Q � ` i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 7 All Map ` Z/ Parcel v Permit# g 9 G i Health Division G Date Issued d " Conservation Division < e / es / �� S�E�` '"` Fee o Tax Collector ftrF, �� ` , 06 Treasurer ° ff SMNG SEPTIC SYSTEM Planning Dept. in by UMffWT0 we*MUROOMS Date Definitive Plan Approved by Planning Board Approved By Historic-OKH Preservation/Hyannis Project Street ddress _ 7 7 � Village Owner /'L—_. Address Telephone D "— 3 `Z_ Permit Request-' ZZ X 6 Square feet: 1 st floo�isting proposed 2nd floor: existing`s proposed Total9new clikk Valuation 1 Zoning District Flood Plain Groundwater Overlay ;a Construction ype L71 sA Lot Size _ Grandfathered: ❑Yes ❑No If yes, attach supporting f1oc umentatn. t Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) ca r- n c) it Age of Existing Structure `Historic House: ❑Yes Q44- On Old King's High ay: ❑Yes ❑ No Basement Type: ZWull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) `� Basement Unfinished Area(sq.ft Number of Baths: Full: existing 2. new Half: existing new Number of Bedrooms: existing new 11�� Total Room Count(not including baths): existing new First Floor Room Count ' Z Heat Type and Fuel: Gas ❑Oil Cl Electric ❑Other ` Central Air: es ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing: ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:- existing ❑new size Shed: sing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded Cl Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION - Name � vl"�C�/�-e Telephone Number �3 Address 7 �PS iL1 i' License# Home Improvement Contractor# Worker's Compensation## ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO SIGNATURE DATE / a .n i`e '•'O FOR OFFICIAL USE ONLY 1 PERMIT NO. ^DATE ISSUED 4^ MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE"OF INSPECTION: FOUNDATION, FRAME INSULATION:, FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL V GAS: ROUGH FINAL d FINAL BUILDING N ° 0co O DATE CLOSED OUT", - ASSOCIATION PLAN NO. 03 The Commonwealth of Massachusetts Department oflrridustrial Accidents Office.of Investigations 600 Washington Street Boston,MA 02111' •°i www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricialas/Plunabers Auplicant Information Please Print Legibly Name (Businesslorga=ationadividual): ----- Address: City/State/Zip: Phone#• _ Are you an employer?Check the-appropriate box:. Type of project(required):- 1.❑ 1 am a employer with 4. ❑ I am a general contractor and I 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 ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ®'guilding addition Oe_ [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or.additions TPA] officers have exercised their 3. I am a homeowner doing all work right of exemption per MGL 1�1.❑ Plumbing repairs or additions myself [No workers' comp. C. 152,§1(4),and we have no. 12.❑ Roof repairs insurance required.].t 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 anew aff davit indicating such.=Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp..policy infommtion. lam 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.Lic.#: 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,.OQ 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 thus statement maybe forwarded to.the Office of . Investigations of the DIA for insurance coverage verification. I do hereby fy un er the pains and ties of perjury that the information provided abo a is true nd correct: Si afar Date:' 4 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 S.Plumbing Inspector 6.Other Contact Person: Phone#: I nformation and Instructions , Massachusetts General Laws chapter 152 Yequires`all employers to provide workers' compensation for their employdes. 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. association,�rporation or other legal entity,or any two or more An employer is defined as-::su�pdividpal,•;partpershrp;: of the foregoing engaged in a joint enterprise, and inchiding the legal representatives of a deceased employer,or the receiver or trustee of an individual,P artnership,association or other legal entity, employing employees. However. .e 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 workvu such dwelling house g appurtenant thereto shall not because of such employment be deemed to be an employer." or on the grounds or buildin MGL chapter 152, §25C(6}also states that"every state or local licensing agency shall withhold the issuance or zenewal of a license or permit s 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." ter 152, 25C states `Neither the commonwealth nor any of its•political subdivisions shall Additionally,MGL chapter § (� enter into any contract for the performance of public work untiil acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. 12 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),addresses) and phone nnmber(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 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 . 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'n that must submit multiple permit/license applications in any given year,need only submit one affidavit in 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..Anew 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 NOTrequired tD 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 of JnVestigations . 600-Washington•Slreet� . Boston,MA 02.11L. Tel.#617-727-4900 ext 40.6 or•1-877-MASSAFE Fax#617-7274749 Revised 5-26-05 www.mass.gov/dia i Town of Barnstable pFSME�pV_ Regulatory Services zSTABI Thomas F.Geiler,Director ""M Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us fice: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION / Please Print j DATE: JOB LOCATION• 7 Z22 , street AJ village number "HOMEOWNER" / -'� t home phone# ^ ork phone# name CURRENT MAH WG ADDRESS: 2 i 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 su eg rvisor. 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-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 re�onsible for all Stich work er pformed 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 requ' is and tha e/she will comply with said procedures and requir ts. Signature of H er 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 peradt is required shall be exempt from the provisions of this section(Section 109 m-Licensing of construction Supervisors);provided that if the homeowner engages a persons)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 can t amend and adopt such a form/certification for use in your community. i AppUcant= Bakw locatiom of 4woperty: ceAtervi e� o Z o a w d I I z 159.32-` M ~ shed (^ Pore w l`J CO J�ev,) z deck m 2 srovy o dwalItrny Porzh Lc t.. 2 t U gp,.55 ID A M¢ 7G Z f jo d fuvW ; 250DD1 0005G f04 Zone.. G o+��.vA 09 ,9 him certify'�ia Uus YT1�Ot tga u1sj3eCtlOTL 1�A�S.p�-�>r' e P AUL T. '��i� ,t.., GROVER 'Q�' �d�� "`N w� No 313 t t Tu d*Uth ern. da&r r t in specica TE f ood� 0� TE h CZ a witK Gr m Aec the &t'� o - a; MA 19- Sara rdw lomhbi;r 0P11 tln yo the dwelling does cc rrm fTo tu toecr�.,porting 6y-laws toefe at * oFcor�sftvaton wid�t, Wpectto horizmfl. durrie ui6nac scale: i' = 40' sett, . M%Ui "n'<e�zs or� is a n�.pr' m' rm vwLa ht n. mf6rcenUrLe Date: 3-30-04• t G1"Loty under Alas. &aural laws �,40A•_Sect't0YL T File No-0—c�� ,PLEASE NOTE: The structures as Shown or, this plot plan are approximate only. ,4n actual survey is neocssary for a precise determination of the building location and encroachments. if any exist. either way across property lines. This plan must not be used for recording purposes or for use in preparing deed descriptions and must not be used for variance or building plan purposes. This plan must not he used to locate property lines. Verification of huilding locations, property line dimensions, fences or lot configuration can only be accomplished by an accurate instrument survey which may reflect different information than what is shown hereon. Pieaae note that this is 'NOT A BOUNDARY SURVEY' and is 'FOR MORTGAGE PURPOSES ONLY'". COLONIAL LAND SURVEYING COMPANY, INC. 269 Hanover Street - Hanover, Mass. 02339 • _Phone: 781-826-7186 - Fax: 781-826-4823 � i °FAME Teti Town of Barnstable Regulatory Services r. r. BAJWETAB1 M.AM Thomas F.Geiler,Director 'OrEp.�,,ola 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 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work:, 7)e e / xv stimAt d Cost Address of Work: �. L/ ZA,/ e� ✓� Owner's Name: �'��'S' .'9i� Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 ❑Building not owner-occupied []Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH.UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Na a Registration No. Date Owner's Name Q:fo :homeaffidav �" 6A rl /2 F-I r-I I -- - I Ui dyi � '�e P oo Id ,�,� �� /� �/ �� 45 / �Z i Town of Barnstable Regulatory Services 8ARMASS.� ' Thomas F. Geiler,Director Building Division Thomas Perry, CBO,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 PLAN REVIEW Owner: 11 1�ct`2�� Map/Parcel: 2- 1 A O Gl I Project Address `7 ? �e�S[?�yl� Builder: U W h Q The following items were noted on reviewing: Ij Reviewed liy: C Date: ,/ -2 D -0 5 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION --Map `'T Parcel ©`r' 1— /0/ Permit# s: co . s Health Division c;LO9q ac%6 Date Issued o� Conservation Division ���3�O S SEPTIC SYSTEM MUST B ee 3 O Tax Collector �— INSTALLED IN COMPLIANC co VNTNTI'TLE5 Application Fee Treasurer ENVIRONMENTAL CODE AND TOWN REGULATIONS j Planning Dept. Checked in By Date Definitive Plan Approved by Planning Board Approved By Historic-OKH Preservation/Hyannis t N - Project Street Address Village �T;,, - (�� / Q Y—i'1 S Ifs Owner Address YY)Q d,VmA-T i t CO-PlQ rot Telephone SDI Permit Request - ` dvC 'MC�_Cn --oc3o `a c rn Square feey;�j�st floor: existing proposed 2nd floor: existing proposed Total new AP Valuation' Zoning District Flood Plain Groundwater Overlay � Construction Type lj3o�-�C15Yv0_ Lot Size • 4 to CR_(,r4_ Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: 0 Yes '�(No On Old King's Highway: ❑Yes , O'No Basement Type: 't(Full Cl Crawl ❑Walkout O Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing , new Half: existing f new Number of Bedrooms: existing 3 new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: 1$-Gas ❑Oil (%Electric ❑Other Central Air: t�_Yes ❑ No Fireplaces: Existing T _ New Existing wood/coal stove: ❑Yes XNo Detached garage:O existing ❑new size Pool:O existing O new size Barn:O existing O new size Attached garage:l�,existing O new size Shed:0 existing ❑new size Other: Zoning Board of Appeals Authorization O Appeal# Recorded O Commercial O Yes O No If yes, site plan review# Current Use x- Proposed Use BUILDER INFORMATION Name b dt�k G-�Vav>AVC VaA✓ _66 42-Ar wrl Telephone Number g 7 4 Address 0 Lhash,,r,t_ License# .'�0 ip `(Gar w.d y"Ck, tNv,k G a G''I Home Improvement Contractor# i Lt(0 1-)0 Worker's Compensation# ALL CONSTRUCT( IS SULT G FROM THIS PROJECT WILL BE TAKEN TO SIGNA � DATE U r FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED` MAP/PARCEL NO. c ADDRESS 7 VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME � Q� INSULATION Vog"O! FIREPLACE =Q ® f.. ELECTRICAL:W S OTC FINAL PLUMBING: fro two&H FINAL' GAS: ROUGH / FINAL �� FINAL•BUILDING y r C (� -0 I / DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents Office of lnm6gations 600 Washington Street, 7`4 Floor Boston,Mass. 02111 Workers'Com ensation Insurance.Affidavit:Building/Plumbing/Electrical Contractors' name: 1 V 1 WE A V M C,k Lye address: 16 ci s c vx y r a-S Jam— - city state: �IM� zip: ©a phone# 5� work site location(full address): 11'1 P k(AS411,F \tvi'L'S:l J U 3�— ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction Wemodel Iam a...'sole • proprietor and have no one working in ncl.aac.ity. 'DBuilddin Addition ddito:n i"IMMM", . '" PeR1 ^Talf-10 111 ?" sM' ] man •'`•":�K.`P,�`.�._`.".,'; ?: '::Cf`fb.y r'.V, employer providing workers'compensation for my employees working on this job. cornyanv name• ---- address:' city phone g: insuranc[et c Doliev# '�:i3'VaJV�:Mi,Y'�5`�I4ti!R9�'iIIfl��G1.�.YV�r�R•LLl�IW.Si'AfFnC' .D w filt�d••}�►BLL'W\�!.�—'Nt�J:SX'�1�Vliq✓.�.,•l•'tY•�2C� It 'Y rry J•••• !+�••r w • ..' v ':4:'{:�. �-;'a..r.�ka":�3i?�10.rq>3�s'u,�tm. I am a sole proprietor,general contractor; r homeowner Ircle one) and have hired the contractors listed below who have the following workers'compensation polices: company name: address: OYNQ.4`(1iY city: phone M 71 S y la(�3 insurance co. Policy# �l , ..�,• �. >a+.•1. �m f�' a as:. scar-�>,2� JG� r• •r: a••+-h �,•.., o ya5:. � .t.:�y'',�1 :,@. . ,�'},F°� `,"..'. t...c� .. ./N4i1NM. 'rl,Ytt"�1�7,:3�,m,.�.�:7'•L�Un9:.•:t•:.L�.•:wi.i:• �.. h G` Y: ft � v �%vr+�l.' �'E..t?i•Z,s�:�.•l'"�`e 9t, .4,�'� 6`r2 .>f;• ...,���;� 'company name: address: city: phone#:. insurance co. polig# MyrM ,>. q•.�-... - : 'iii•.5` .'. -. a� r 'o. �rf tg•.r r >�.. dl?to ��.�. >�:,. . • '�'�,r+~ •ad��. fcfi• ,'� � ,w `��.f4b�:s�.°a�' `'.r�.,r�. Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1;500.00 and/or one years'Imprisonment as well as civil penalties In the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a' copy of this statement maybe forwarded to the Office of investigations of the DIA for coverage verification. ' r do hereby certify under the pains and penalties of perjury that the Information provided above is true and correct. Signature ` Date to Print name �a C 1�V(1 �Q V Phone# FS & official use only do not write In this area to be completed by city or town official city or town: permitllicense# ❑Building Department ard ❑check if Immediate response is required []Selectmen's Office contact person; phone#; ❑Health Department ❑Other. (revised Sept 2003) ' r> Information and Instructions Massachusetts General Laws-chapter 152 section 25 requires all•employers to provide workers' compensation for their '. employees. As quoted from the"law",,an employee is defined as every person in the service of another under.any contract of hire,express or implied;oral or writteg. j An employer is defined as an individual,partnership, association,corporation of 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 br 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 i or building appurtenant thereto shall not because of such employment be deemed to bean employer. MGL chapter 152 section 25 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,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 in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits 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. i - •,~' � ° '�'•o- •�'': u� •L i aa n: r � s . r City or Towns 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,,�hi.ch will be used as a reference.number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for.you cooperation and should you have any questions, please do not hesitate to give us a call. 7f •i• } yry�'s�.�'Soti ! .�:�� '•� "k. "RF:fS 'tad i�a :.•.' .K4. The Department's address,telephone and fax number: r The Commonwealth Of Massachusetts- Department of Industrial Accidents Office of Investigations 600 Washington Street,th Floor Boston,Ma. 02111 fax#:(617)727-7749 phone#: (617)727-4900 ext. 406 . I o� a roe Town of Barnstable Regulatory Services JIMMSTABTS.� Thomas F.Geiler,Director fpi, ".� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Fax: 508-790-6230 Office: 508462-4038 Permitno. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,za c onvers ied ion, improvement,removal,demolition,or construction of an addition to any pre-existing cuP building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. �6 �"t, Estimated Cost3 Type of Work , Address bf Work' Op�ner'sName: Date of Application:_ a 5� I hereby certify that: Registration is not required for the following reason(s): nWork excluded by law ❑Job Under$1,000 []Building not owner-occupied []Owner pulling own permit Notice is hereby given that: UNREGISTERED OWNERS PU�,LING THEIR OWN PERMITMEtOR DEALING IlYIPROYEMEN WITH DO NOT HAVE . CONTRACTORS FOR APPLICABLE IJNDERMGL c.142A. ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Contractor.Name Registration No. ate OR 23 ate Owner's Name Q:forms:homeaffidav i Town of Barnstable Regulatory Services • i xszae . ; Thomas F.Geiler,Director Mass. 9. A Building Division AtF p�.l Tom Perry,Building Commissioner 200 Main Street, Hyannis,Na 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: 2 3 Jos LOCATION: 27 Z Z //v n tuber / street / / village �L "HOMEO`NVNER": name 7 home phone#` work phone# CURRENT MA]LING ADDRESS: 7( /^� �s��v /!/ 4"A I,— r— 4 v -,7-,7e,_ 2,,f- city/town state zip code The current exemption for"homeowners"was extended to include owner-occugied 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. undersigned" meowner" that he/she understands the Town of Barnstable Building Department minimum inspe on proce equirem is and that he/she will comply with said procedures and requireme i mature of Homeo 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 fomJcertification for use in your community. Q:fornwhomeexempt �.--�� � � �� n O \�-�- i -� � � �r � � � � � � �.,( _� ^I ( � I �, � � �� -, � � o .� -� �� � ._ �� �'� • � � � � ,- -,� � � �, � y � � � _ � � I �- �� � �- � Y � 4 I - YERVAND GHAZARYAN 17 CHESHIRE RD W. YARMOUTH, MA 02673 (508)-775-4663 (774)-836-5505 Name: David Baker Job Address: SAME Address: 277 Pleasant Pines Ave. Phone# (508)362-5421 Centerville, MA We hereby submit specifications and estimates to finish and install new roof ' above the front door with 2 supporting columns as follows: 1. Build a roof above the front door using 2x8 for the rafters and 2x10 for box frame; and 2x10 for ridge using 3" framing nails. Apply '/z" plywood on to rafters. 2. Install all the trim boards as needed using pre-primed pine. 3. Install 12" sonotubes with concrete mix where the columns will be sitting 4' deep and 1 foot showing above the ground. 4. The new roof will be supported by 2 around columns(10" diameter, 8' high) with Tuscan caps. 5. Along all eaves of new roof, Ice&Water Shield waterproofing underlayment (36" wide)will be directly adhered to the wood deck. Waterproofing underlaymentis installed to eaves to protect against interior leakage and subsequent damage from wind-driven rain, ice and snow dams, and freeze back conditions. 6. Install waterproofing underlayment full width(36" wide)to all valleys, at all vent pipe collars and any other projections and skylights. Over remainder of house, 15-lb. felt paper will be installed and nailed to the wood deck. 7. Install new white drip edge to all eave edges. Drip edge is installed to protect from leakage and rot and to provide a neat and clean perimeter profile. 8. 9. At all eave edges of roof, shingle starter strip will be cut and installed with sealing strip at lower edge of roof in accordance with manufacturer's specifications. This provides a watertight and wind-resistant termination for your roof. 10. Shingle caps will be cut, installed and fastened over the ridge vent (if required) into decking with 2 '/Z-inch coated roof nails secured. 11. Storm nailing: Since we live in a severe region, we undertake additional (storm) nailing compliance with the recommendations of the National Roofing Contractors Association and the manufacturer. Securc new roof with 50% more nailing, upgrade minimum standard [4] four nails per shingle to [6] six nails per shingle,I '/4"long. Nails will be galvanized with a rust-inhibitive coating. 12. Shingle installation: Supply and install roofing shingles according to the manufacturer's specifications. Match the shingle color as close as possible. 13. The new roof will be supported by 2 around columns(10" diameter, 8' high) with Tuscan caps. L ^ The Townof Barnstable & Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508 790-6227 Ralph Crosson Building Commissic F= 508 775-33" For office use only Permit no. Date AFFIDAVIT t HOME MOROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION I 4GL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement, removal, demolition., or construction of an addition to,any pre-adseing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered eontractors,with certain c=Vtior>s, along with other requirements. nn Type of Work: h- d/i & Est-Cost 00 Address of Work: Oaner.Name: ' Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under SI,000 Building not owner-occupied Owner pulling own permit I Notice is hereby given that: - CONTRACTORS OWNERS PULLING THEIR OWN PERMIT OR DEALING W>'TT;UNREGISTERED FOR APPLICABLE HOME IMPROVEN!>r' T WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGI-r— 142A SIGNED UNDER PENALTIES OF PERJURY I hcrcby apply for a permit as the agent of the cm-ner. 4,19 A 4-, ,p D.S7 38� Date Contactor name Registration No. OR n^ A Owner's name • ._� `��' The Commotta•ealtli Uf Atassachusettc -- •!:�: _... �_:.�y: Department of Industrial Accidents offceofimestloaUoss ;- 600 If ushington Street Boston.Mass. 02111 Workers' Compensation Insurance.Aflidavit ----', .----• -� - ..__ ,-•—c •^--ter•-� ---•�— caniM name! g lac tion- city phone# 0 1 am a homeowner performing all wort:myself. rl I am a sole proprietor and have no one working in any capacity `rIA��T�.. ...• 11,177 .:4 .- •.:.e--...�-._w°-:..�..,>;.:..-.�.rs..-a�t...�...P_tea....::..:...,...4�=�._-i._.�•`.. �MwIOryO� I am an employer providing workers' compensation for my employees working on this job. cmmnanv nnme: address: 7RD. 2p,( Iao cih• r//C• phone#: insurance co. policy# �J /Dues 9�0 I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name: address: cit2: phone#: insurance co. nolicyAl �. ^�r:. :..•-- — r'tnl.7:..4:..:aa�ys'?rr�?""T�""f'�e'7iF' '�7REiRT47�S?•1� tS'!r:T�SET 7t?!'+•[!n'• 77-7*—r company name• address, cl•• phone#• -insurance Atiach additional'sheet if neeess I 7y ;; ;+;IM '+' Failure to secure coverage as required under Section 25A of hIGL 152 can lad to the imposition of criminal penalties of a fine up to SI.500.00 and/or uncyears'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a flue of 5100.00 a day against me. 1 understand that a copy of this statement mad•be forwarded to the Once of Investigations of the D1A for coverage verification. I do hereht•cert' It der the pals nd enalties of perjury that the infomration ptmvded aboveis true and erect Sienature / am Print name s l�h N D _HDa,t°o 0 45 Phone# —T J Z7'Vr' 7 if ocial use only do not write in this area to be completed by city or town official city or town: permit/license# nBuilding Department Otrcensing Board ` 0 check if immediate response is required QSelectmen's Office C311altb Department contact person: phone#; MOther information and Instructions Massachusetts General La+vs chapter 152 section 25 requires all employers to provide workers' compensation for their employees. 'As quoted from the "law", an emplirnee is defined as every person in the service of another under any contract of=hire, express or implied, oral or wrinen. An enrpinrer is defined as an individual, partnership, association. corporation or oilier ;cgal entity, or am two or more of the force=oin engaged in a joint enterprise, and including the legal representatives of a deceased employer, or tiie 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 d+vellin�: house of another who employs persons to do maintenance, construction or repair work on such dwellin, Douse or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 1'52 section 25 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 commun-VIT21111 for any applicant who has not produced acceptable evidence of compliance with the in coverage required. Additionally. 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. . yin. ;• ••e i Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying-company names, address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverace. 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. w......+•-.e...u�--. ': :'.:�'�:• .. .;.. .. .... .. - .. «i:i '.:a.'•� rPr%'r.•+��r;.Mb`.Y,r''.S'.i`7d.! {��'':•.r `al .. City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. r-.r...R.--, .sae- ... _ - - •:.... ':.. ..� -• -- '••.;;o;::.::�::--�e.-• ::7z:- ::,:�::•:'-�' The Department's address, telephone and fax number The Commonwealth Of Massachusetts Department of Industrial Accidents office of Investigations p•` 600 Washington Street Boston,Ma. 02111 fax#: (617)727-7749 -. phone#: (617) 7274900 ext. 406, 409 or 375 �lze -�anvnzo,uuea/�,/ o���ac/uwel� OEPARTHENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE Huber: * Expires: Restricted To: 00 AHN 0 BOURQUE ta�uw� D t3ot++� 468 CEDAR ST pOWN981 VEST BARNSTABLE, HA 02668 I HOME IMPROVEME .T. ;CONTRACTORS REGISTRATIO Board of Buildir ' ' 9,fiegulations and Standar One Ashburt on'gPlace — Room 1301 Boston , tassachusetts 02108 HOME IMPROVEMENT CONTR CTORa . Registration 109751 �'�" Expiration 09/24/96 -Type - PARTNERSHIP ��''�� BOURQUE 5& COLE CU TOM HOMES JOHN D . BOURQUE 8 DRIFTWOOD WAY MASHPEE MA 02649 I ter ` f Map* �/`1 Parcel `f Permit# Conservation Office(4th floor)(8:30-9:30/1:00 2:00) [�s Date Issue '1 q —%( —[ Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) ?w€ A> Eee 4152`9<1' Engineering Dept. (3rd floor) House# BARNSTABLE. SAdd 19TOWN OF,BARNSTABLE Building Permit pplication ProjectVillage ` Owner h Addressj�,,LL_ 'Telephone 42- .5Y 95 Permit Request h4tg: 'l aZ _ G� ,First Floor square feet Second Floor () square feet Estimated Project Cost $ �. Qv n Zoning District Flood Plain Water Protection Lot Size - , � Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Q.it,� LlJrLc.2 . Proposed Use 2 Construction Type Commercial Residential Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure �! Basement Type: Finished Historic House ill D Unfinished V/ Old King's Highway U Number of Baths J , 5 No.of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel -XAa� Central Air Fireplaces 11 Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other Builder Information Name pU,QQ C/B��' Telephone Number .342 Address �O- 73o X /dDs License# 57�j ff� �&eS4d N S /�i S �/li4 l�?(,4�.� Home Improvement Contractor# 1()p 7Sr Worker's Compensation# OC l 11�?q6 NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE '-71 BUILDING PER IT DENIED FOR TA FOLLOWING REASON(S) I FOR OFFICIAL USE ONLY { P MIT NO. V� D l ISSUED /PARCEL NO. t ' DRESS VILLAGE OWNER r DATE OF INSPECTION: FOUNDATION FRAME• INSULATION VS FIREPLACE ' ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING ( a_9 'O5 DATE CLOSED OUT ASSOCIATION PLAN NO. ! i , -� +y. rr..�(... s-a -. �. .• J w ...� '•V. .. I�_. [ �. i cf' -r _!T ;°ti_.4.., _ -_`y i- ,•..+"i +�-F`c^ ..-+.+-:•y+r.'v+•- `oFtMEiq,• - The Town of. Barnstable • BARNSTABLE. • Department of Health Safety and Environmental Services MASS. t63q. `0� �f ° Building Division 367 Main Street, Hyannis, MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner Inspection Correction Notice Type of Inspection ` Location (`er-e-f4-, ,j ?�OVOefm`it Number Owner Builder One notice to remain on jobsite, one notice on file in Building Department. The following items need correcting: c O(A CAA 00 _D " 1 1 E Please call: 508-790-6227 for reeinspection. Inspected by J Date Assessor's map and lot number tow 1 (/ M -'Sewage 'Permit number ..............- ....................................... D Z BABd9TABLE, i House number ...:..................<:.... Z 7 '.................:....... wC-Gc/ ' qo rasa O 1639� 9� O/✓G - G G D YPY:A, TOWN OF BAR.NSTABLEO"`��,� TJ ; BUILDING INSPECTOR APPLICATION FOR PERMIT TO ......Cr� .. P '£L L.1AJ..............................................:.......... TYPE OF CONSTRUCTION ........................./V .........7..;/`!/LI�� ..... LL /V. ................. ............. �� TO THE INSPECTOR OF BUILDINGS: F1'mm;iaiaccording The undersigned hereby applies for a p to the--ollowing information: Location ........ Q. '...1 .. Pleasant Pines Ave= 'cNT / V/CL.�`............................... Proposed Use .... .............. .............................. ........................ ............................................L .............. . ............ ................. ..... .. . ZoningDistrict ............C�.�...�............................................Fire District .........�.�..0......................................................... Name of Owner .... ...........Address � Z5?AFi4 'E....11. �.i ...... ............ . ./..✓. /✓,($' .. Name of Builder ...4V<..l...c... ..l / /�'I Q...................Address l./ .C#1 .6T .5/ CiA) 1;eV/ � Nameof Architect ..................................................................Address ...............................................................0.................... Coil c�£7� Numberof Rooms ........... ...................................................Foundation .............................................................................. Exterior Roofing .....................( ........................................................... Floors /2i ..... ....W.QQ. .......................Interior ........... y! L. -.............0............... Heating /e--......................................._`.Plumbing ....................... ..,.. .... 5..............................0...... .................. Fireplace ..................................................................................Approximate Cost ...... ...................................`........... . . Definitive Plan Approved by Planning Board ---------------____------------19--------. Area .......................................... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH 1 i 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. p Name . �.e��... �..................................................... c�4��35 Construction Supervisor's License °''.............................. ' 3. DANE, PAMELA A-214-41W!-3-1 4 1<1:61 t AC.. WOO)25389 2 Story No ................. Permit for .................................... Single Family Dwelling.............. .............................................................. Location ..Lo.t...1.........2.7.7...P.le.a.sant Pines Ave. ..... .. .. . . .. .. .. .... .. ................... Centerville ............................................................................... Pamela Dane Owner .................I................................................. Type of Construction .......FrAme .... .. ...............;............ ................................................................................ Plot ............................ Lot ..'.............................. Permit Granted ...Au.gus.t...4................19 83. ..... ....... .. Date of Inspection ....................................19 Date Completed ......................................19 too I 7 SpHALT / a"CDX ILL .. GFHTL& sL V earSOFF IT Stiy s - I KA T VtNT-GOAM. rvloL 3x4TvP PLATE f Imo'. t (LAPBOA'CD. �, a-ax8 PfAD'LRS E 6 8'�oGG �4cOf` o �P.11 M01) S,Kt"-1x3. i4't37r. li S�iF_ I � j -.7-4"yTVD I S c3D5 n :'Rocrc a LoZ DEc fT Iljil i, =1-1 t1yy j _ i. AATL H ul RRttL�j�I li iII bx9aE4�n j Don1Z ax 4 5 H of i I I ' ' MATCH SUES { f0 AAA O* 5 - ,,I��I I SE i pt O? soy ti; 1 � e -A I WI ' I L I j [SEE LVM-ewR fi4D I loY6 PT (CjT> �! ' S P1 Cis )o SONA ,a I&H Iwo G7GS �}j I I i j jII ; 1 � I ► j l 1 eAMI iJCr ECT/UA) _---- Lu!^I DOW DOOR ,GN E DV L E _ _ .OTHE I t _ ! L'T t 1 j NVnnBEk -- JA F #5 Vf LUX S K�_..�J-- — ._---.------ -_--I i-a S y 1 � I Y o } K n x] ry w " � o C'6 O l W lu s 0 a �] n w . N 0•n I _- — - m ao Q M¢J 1- \ IXnKa33`C � N.71ywI Z`T ' 3 o a _ m I ) m LI A 1 I ui j L I W J; �I I. 1 E±d �----- I i � � i 5TEEPI-ICrJ PAMELA J)RNE � SCALE: �I F APPROVED BY: DRAWN BY ,� C -p F DATE: a�ply .�G REVISED _..-.. �- HA ko..a a•N.A:L-6-A3 U O'J $04�- 774F 61p7� DRAWING NUMBER aN�. Lo o K A D D 17 lY)e�J ✓ o f i I 17 i EIsVI�TIO� I i