HomeMy WebLinkAbout0045 VILLAGE LANE I
NO. 152 1/3�--- ORA
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oFIKE> Town of Barnstable *Permit#
Expires 6 mo rom issue date
Regulatory Services Fee
+ BAItNSTABLE, •
Thomas F.Geiler,Director
Building Division /°(/
.M ` Tom Perry,CBO, Building Commissioner
QU� R� �0 Main Street, Hyannis, MA 02601
www.town.bamstable. .us ma
Office: 5q-WX*W 8 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number bL (_01
Property Address '1 J� V I. IV, CA-1
e� 1 c.e7
estdential Value of Work Mi1t4mum fee of$35.00 for work under$6000.00
Owner's Name&Address 0 r`.J,__�t
Q+rz6Le.
Contractor's Name L� J2_ �7�/� Telephone Number
Home Improvement Contractor License#(if applicable) l ��
Construction Supervisor's License#(if applicable) r 00
❑Workman's Compensation Insurance
Check o e:
am a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name'
Workman's Comp. Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
Re-roof(stripping old shingles) Ali construction debris will be taken to Gt
❑ Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
#of doors
❑ Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows
"Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License & Construction Supervisors License is
. required.
SIGNATURE:
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 070110
_ r 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 LelZibly
Name (Business/Organization/Individual): ®��� t�>r--eg
Address: n t L
City/State/Zip: tJ I tetkj IM t2 Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
em to es(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
2. am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
shipand have no employees These sub-contractors have
8. ❑ Demolition
working for me in any capacity. employees and have workers'
insurance.# 9. ❑ Building addition
comp.[No workers' comp. insurance P•
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 I I. Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13.❑ Other
employees. [No workers'
comp. insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$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 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct.
Signature \� C Date:
Phone#:
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
�oFZHEr Town of Barnstable
Regulatory Services
y sn RAW. Thomas F.Geiler,Director
�A iG39' ,��
rFa ww�a Building Division
Tom Perry,Building Commissioner
2-00 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
as Owner of the subject property
hereby authorize to act on my behalf, .
in all matters relative to work authorized by this building permit application for.
(Address of Job)
Signature of Owner Date
Print Name
If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
Q:FO RMS:O WNERPE RM ISS ION
Town of Barnstable J
�pF SHE 1p��
y�P Regulatory Services
BARNSTABrt, ► Thomas F.Geiler,Director
MASS.
1659. A,0 Building Division
TEor Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER'%
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to
be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be
responsible for all such work yerfomzed under the building permit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes, bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
Signature of Homeowner
Approval of Building Official
Note: Three-family.dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127:0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such
work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly
when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,
that the homeowner'certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used-by
several towns. You may care t amend and adopt such a form/certification for use in your community.
Q:foims:homeexempt
a
o .
Town of Barnstable
*639. Regulatory Services
Thomas F.Geiier,Director
Building Division
Tom Perry,CBO
Budding Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstabie.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner bust
Complete and Sign This Section
if. A Builder..
. I
as Owner of the subject property
hereby authorize " i✓•. to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Address of job)
P c
sihnature of Owner Date
I
Print Name
Q:Fomu:expmtrg
Revise071405
i
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
Registration"._.148999
Expiration=ala1aL2011 Trff 290092
Type a I;.rh
aL.:g ` t
ROBERT 7gROWWOUST-OW BUILDING REMODELING
ROBERT BROWN�—' _ !/�
i 563 OLD STRAWBERRY EILRD. 4S—
CENTERVILLE,MA D2633 Undersecretary
i
Massachusetts- Department of Public Safet
Board of Building; Re�-ulutions and Standards
Construction Supervisor Specialty License
License: CS SL 100878
Restricted to: RF,WS
ROBERT BROWN
563 OLD STRAWBERRY HILL R
CENTERVILLE, MA 02632
r
Expiration: 10/10/2011
(:ununissi ncr Tr#: 100878
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Massachusetts- Department of Public SAO)
Board of Buildimy Re�trulations and Standards
Construction Supervisor Specialty License
f.
License: CS SL 100878
Restricted to: RF,WS
ROBERT BROWN
563 OLD STRAWBERRY HILL R
CENTERVILLE, MA 02632
Expiration: 1 0/1 01201 1 .
Tr#: 100878
(:ununis�i„ner
71 r
Assessor's Office(1st floor) Map Parcel Permit# 11 T if
Conservation Office(4th floor)(8:30- 9:30/1:00-2:00) �( �l - llalte ssle�
Board of Health(3rd floor)(8:15 -9:30/ 1:00-4:45) FeeNs'
Engineering Dept. (3rd floor) House#
Planning Dept. (1st floor/School Admin. Bldg.) �e�.�!
Definitive Plan Approved by Planning Board Z 19 RN CF
4- /Z PIP4 Seqil t ai
TOWN BARNSTABLE s
CIR _ Building Permit Applicatio
Project.Street Address y i'
Village - /�
Owner �� f4 Cr/ 111�����i If/ Address CU
Telephone -CI J
Permit Request F/ /7 Ge ��✓1
First Floor square feet
Second Floor ! rC square feet
Estimated Project Cost $ Z Q a [�
Zoning District /�;I /I— Flood Plain Water Protection
Lot Size / YcP t 3—S3 Grandfathered ?
Zoning Board of Appeals Authorization Recorded
Current Use f",t f A Proposed Use
Construction Type 4-J 0 0
Commercial Residential
Dwelling Type: Single Family �� Two Family Multi-Family
Age of Existing Structure Basement Type: Finished ea- r"r •7
Historic House / Unfinished
`X Old King's Highway -P—f
Number of Baths OZ Z No. of Bedrooms
Total Room Count(not including baths) First Floor
Heat Type and Fuel Ad Central Air Fireplaces �-G S t7 /7-e
Garage: Detached Other Detached Structures: Pool
Attached Barn
None Sheds
Other
Builder Information Gj
Name i ,, v - Telephone Number 2 �'
Address Gar`/ . � License ''
#..., �U Z(•,G �� al���
U� fU Home Improvement Contractor#
eft ��✓�'/ S'�a /:;p A Worker's Compensation# �d--��
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
� L
SIGNATURE DATE Z 7
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
FOR OFFICIAL USE ONLY -
PERMIT NO. �
DATE ISSUED
MAP/PARCEL NO. '
ADDRESS VILLAGE
OWNER f
DATE OF INSPECTION: ;
FOUNDATION
FRAME
,INSULATION 2
(FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBI : '@UGH a FINAL
GAS: gOWH FINAL
FINAL BUILDING � �CZ j
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DATE CLOSED O °., a
ASSOCIATION PLA
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600 Washin-ton Street
B(won, Ma.u. 02111
Workers' Compensation Insurance Affidavit
namem r,�
location:
ci N. tzr T ,ne
rj I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity wM
E] I am an employer providing workers' compensation for my employees working on this job.
conivany narne.- X,//C /-Li/xe;J- z"a z
iddrcss:
City: 11hone#;
insurance co. c`-7
sole-p-r;piia(or, general contractor
L�omeown r(circle one) and have hired the contractors 2ted below who have
r1them'Zl lowing workers compensation polices:
company name,
address:
Ci phone
insurance co. l2olicy 4
C,
coml2any name: Ir Ott /
iddress:
ci l2bone N.
in.wrance co, lJolicy
:Attach a d d i t i6o a I's h c c t if =n`C"Ces-3'-r 7--
,,�—1 Z.——,
4ailurc to secure co%Jra-p—c'a's-ri-quired under Section 25A of 111GL 152 can lead to the imposition of criminal penalties ofs fine up toSI.500.00 and/or
unc."cars' imprisonment as well is civil penalties in the form of a STOP NVORK ORDER and 2 fine of S100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herebl-certify under the pains a 'fafties ofperjuty th the iaformation provided above is true and correct.
Signature Date
Print name Phone
0 official use only do not write in this area to be completed by city or town official
c I
c 0 77 permit/license N MBuildinjg!Department
city or town:
C ic
jLiccnsing Board
rr
.f. [jSelcctmen's Office
0 check-if immediate response is required
CD11calth Department
t t s phone#. r10thcr
,o Econtact person:
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t Application to
®7 Q2A
Opt "Qopb`HP�►
`s Old Kings Highway Regional Historic District Committee
in the Town of Barnstable for a
CERTIFICATE OF APPROPRIATENESS
Application is hereby made, in triplicate, for the issuance of a Certificate of Appropriateness under Section 6 of Chapter 470,
Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on plans, drawings or photographs
accompanying this application for:
CHECK CATEGORIES THAT APPLY:
1. Exterior Building Construction: ® New Building ❑ Addition ❑ Alteration
Indicate type of building: 0 House ®, Garage ❑ Commercial ❑ Other
2. Exterior Painting: ❑
3. Signs or Billboards: ❑ New sign ❑ Existing sign ❑ Repainting existing sign
4. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑.Other
(Please read other side for explanation and requirements).
TYPE OR PRINT LEGIBLY ` / ` _ DATE I• L5 • 27
ADDRESS OF PROPOSED WORK II 11 V11�aq U'1 NA Barn ASSESSORS MAP NO. 15C-7
OWNER bOnaw as part of
ASSESSORS LOT NO.
HOME ADDRESS �C> SoX S07t_ y� TEL. NO. _ -�Z• �295
FULL NAMES AND ADDRESSES OF ABUTTING OWNERS. Include name of adjacent property owners across any public
street or way. (Attach additional sheet if necessary).
OF
_Lincoln ��a�a, �� � s -T"etb,t� �r Sat-►dvit�h o25103
AGENT OR CONTRACTOR TEL. NO. —771- 5DO0
ADDRESS 1550 %— M ttlC C=03
DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done (see No. 8, other side), including
materials to be used, if specifications do not accompany plans. In the case of signs, give locations of existing signs and proposed
locations of new signs. (Attach additional sheet, if necessary). A
1 Wo• t �lcrital �taTLt'G �'lovse W/Y 2•Caw. Cam.eo� �3+f
}Trt� ay Cencldsed) wI � 6ymmev- (? Z* Vre
Qy-
Signed
Ow r Contractor-Agent
Spacertielow rrnerfor=Commit,tee use.
Re!e",ceiveclLby H. V .� y
Daf The Certi ' e is hey Da a t5l
L Tim,
�g v
al,�xovertf ❑ IMPORTA If Certificate is approved. approval is subject to the 10 day appeal period
provided in the Act
OLD KING'S HIGHWAY HISTORIC DISTRICT
S P E C S H E E T
FOUNDATION S"
f��1 con re�e
SIDING TYPE �..c.S�apbwds dry e COLOR
rar�1 �.1r,�no
CHIMNEY TYPE_16V ek-
COLOR_}
ROOF MATERIAL Aaha�� COLOR_ ja�laek
PITCH_8/12 Ma1r� �obr,,g 1?.,/IZ C� aaraa
W I NOOWS_ �e t1► to S I ZE Z1Dx�(� zl x 9
TRIM COLOR i P
DOORS I,, . r--W y
COLOR
SHUTTERS _ e /-►,ry,,,
GUTTERS '�
I
DECK [ l2 X 221
GARAGE OOORS�poG` •
COLOR VWeA dr 1en
Notes : Fill out completely. Including measurements and
materials/colors to be used.
Three copies of this form are required for submittal
of an application . along with three copies each of
the plot plan . landscape
when applicable. plan and elevation plan; ,
•Plot
Plan need not be -Certified". but shou I cl ;r.•�«
all -structures on the lot to scale .
�,R
TOWN OF IBARNSTABLE
CERTTFICAT � OF OCCUPANCY ►�
PARCEL ID 000 000 074 GEOBASKr ID
ADDRESS 45 VILLAGE LANE PHONE (508)362-6295
WESTf, BARNSTABLE,MA ZI:P . 02668-
LOT 1 BLOCK 4 LOT SIZE
DBA DEVELOPMENT DISTRICT
PERMIT 23729 DESCRIPTION
PERMIT TYPE BC00 TITLE CERTIFICATE OF OCCUPANCY
CONTRACTORS: NICKULAS BUILDING CO. Departmenttof Health, Safety
ARCHITECTS: and Environmental Services
TOTAL, FEES:
BOND $.00 Ox
( CONSTRUCTION COSTS $.00
* BAMMBLE, s
MAS&
OWNER NICKULAS BUILDING, 1639. A�O�
ADDRESS ED MIS
PO BOX 507 BUILDING DIVISION
WEST BARNSTABLE,MA BY
DATE ISSUED 06/12/1997 EXPIRATION DATE V
TOWN OF BARNSTABLE
BUILDING PERMIT
( PARCEL ID: 000 000 074 GEOBASE ID
ADDRESS 45 VILLAGE LANE PHONE (508)362—€3295
WEST;}`$ RNSTABLE,MA ZIP 02668—
LOT� 1 =�' BLOCK LOT SIZE
DBA DEVELOPMENT DISTRICT
PERMIT 2117.1 DESCRIPTION SINGLE FAMILY RESIDENCE
PERMIT TYPE BUILD TITLE NEW RESIDENTIAL BLDG PMT
CONTRACTORS: N I CKULAS-BUILDING CO. Department of Health, Safety
ARCHITECTS: and Environmental Services
TOTAL FEES: $43.4.00
BOND $.00 �TME
CONSTRUCTION COSTS $.00 j
101 SING��, I',AM HOME DETACHED 1 PRIVATE P i'.�:q ?Exe�
* BARNSTABLE. •
• . • ,.. t. MASS.
OWNER NICKULAS BUILDING,
'ADDRESS
Pb, BOX 507 BUILDING DI SION
WEST ..BARNSTABLE,MA
... DATE,,I,SSUED 02/18/1997 o EXPIRATION
- ' c� �.`'• TOWN OF BARNSTABLE
{� BUILDING PERMIT 4k `
' PARCEL ID 000 000 074 GEOBASE ID `' t
ADDRESS 45 VILLAGE LANE PHONE (508)362-6295
WEST ABARN.STABLE,MA 4 ZIP 02668—
LOT 1 " BLOCK LOT SIZE
DBA DEVELOPMENT DISTRICT
( FAMItY
PERMIT TYPE BUILD TITLEIP` TON NEWGLE RESIDENTIALECE BLDGNPMT
CONTRACTORS: NICKULAS.' •BUILDING CO. Department of Health, Safety
ARCHITECTS: and Environmental Services
I TOTAL FEES: '
' $434.00 �VIE
BOND $.00 .
CONSTRUCTION COSTS $.00
101 '81NGLE_FA.M HOME DETACHED 1 PRIVATE P f H?�.. M�pp,AQp1639.
B s
OWNER NICKULAS -BUILDING; • EDN11r►I�,
ADDRESS
PO BOX" 507 I BUILDIN
s
WEST BARNSTABLEY Y. A' BY�
DATE', ISSUED' 02/18/1997 EXPIRATIONiDATE
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.EN-
CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR
ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS
PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS.
MINIMUM OF FOUR CALL INSPECTIONS°REQUIRED 'y.:,
FOR ALL CONSTRUCTION WORK: f APPROVED PLANS MUST BE RETAINED ON JOB AND
�/ WHERE APPLICABLE, SEPAR
1.FOUNDATIONS OR FOOTINGS THIS CARD KEPT ATF�
POSTED UNTIL FINAL INSPECT16A' P U1.RE'�
2. PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICAT
(READY TO LATH). PANCY IS REQUIRED,SUCH BUILDIK
3.INSULATION, J OCCUPIED UNTIL FINAL INSPECTION H
4.FINAL INSPECTION BEFORE OCCUPANCY. f'xt-
A P P R OV E D
N
TOWN OF BARNSTABL
' BUILDING INSPECTION APPROVALS 1 PLUMBING INSPECTION APPROVALI ❑ GAS WIRING
7,FoZ, At v w� ❑ PLUMBING, 8, I'LDING
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EATING INSPECTION PPROVALS ENGINEERING DEPARTMENT
J f� /
rp A� S 6r
7 2 HEAZor3q I
OTHER: SITE PL N REVIEW APPROVAL
Ida
.WORK SHALL NOT PROCEED UNTIL PERMIT WILL BECOME NULL AND MOID IF CON- INSPECTIONS INDICATED ON THIS
THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS`-NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY
VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA-
TION. NOTED ABOVE: TION.
i k
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F.
u� Application to
JpN�GNO�t J,N t
OPPN �tNNStP'M,GNS
0pE'• N�s`��I.
Old Kings Highway Regional Historic District Committee
in the Town of Barnstable for a
CERTIFICATE OF APPROPRIATENESS
Application is hereby made, iri triplicate, for the issuance of a Certificate of Appropriateness under Section 6 of Chapter 470,
Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on plans, drawings or photographs
accompanying this application for: .
CHECK CATEGORIES THAT APPLY:
1. Exterior Building Construction: IS New Building ❑ Addition
❑ Alteration
Indicate type of building: 5g House ®, Garage ❑ Commercial ❑ Other
2. Exterior Painting: ❑
3. Signs or Billboards: ❑ New sign ❑ Existing sign ❑ Repainting existing sign
4. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑.Other
(Please read other side for explanation and requirements).
TYPE OR PRINT LEGIBLY ` / DATE_- 1- W • 27
ADDRESS OF PROPOSED WORK �/�i1aq Yn ASSESSORS MAP NO. 15;1
OWNER 11ornalcl IVIG��.t��✓ a - 4
ASSESSORS LOT NO.
HOME ADDRESS SoX 507yWA-1—
TEL. NO. 5
FULL NAMES AND ADDRESSES OF ABUTTING OWNERS. Include name of adjacent property owners across any public
street or way. (Attach additional sheet if necessary).
�aIL
1 � �31d�► ��� Sol � L38m s��ble
Uri e>ln �l�atr4� Telb�, �Ir Sat�dvi�h o25r03
i T
AGENT OR CONTRACTOR G TEL. NO.
ADDRESS j550 V
7.
DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done (see No. 8, other side), including
materials to be used, if specifications do not accompany plans. In the case of signs, give locations of existing signs and proposed
locations of new signs. (Attach additional sheet, if necessary). AV IV,
Two• eel` �1a-i�a1 ale house •�atr- Cam.
tip
r� �►y (encld�) ' �ul� c me+r cv� `1
A p p u
WED Signed
ow r Contractor-Agent
Swce iieiow i6rie�fo=Comm�taee use.
Oa' t �� F The Certific is hereby C ��
i, e
,, n
Ti
TrJ`V a OF BARIN
v KING'S HIGF4W�Y �
IMPOR NT If Certificate is approved, approval is subject to the 10 day appeal period
provided in the Act
~f
OLD KING'S HIGHWAY HISTORIC DISTRICT
SPEC S H E E T
FOUNDATION
�«rel Con GYete
SIDING TYPE ��,S�apb�vds 4 r 0
�d h nelA ,r�_COLOR ti`Ihcke o1 a�j/
CHIMNEY TYPE_ 'L-5y c- COLOR
ROOF MATERIAL A
COLOR 6laek
PITCH 8�12 Katy, �lonr� 1?.,112 C� uar�tg
W I NDOWSe tiL1t'lp
SIZE Z'xQS�ZbX �9
TRIM COLORiP
DOORS I / ,�►�'��� I /�,v ����.,1
COLOR
SHUTTERS
acres �Yeeh
SHUTTERS__ ey�
GUTTERS
DECK P.7 C IZ x -7
GARAGE DOORS
i COLOR
Notes : Fill out completely. Including
materials/colors to be used, measurements and
Three copies of this form are required for sunmittal
of an application . along with three copies each of
the plot plan . landscape plan and elevation plan; ,
when applicable .
•Plot plan need not be "Ceirtified" , but shoulr
all structures on the lot to scale .
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