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HomeMy WebLinkAbout0328 WILLOW STREET N SMEA No.53LOR UPC 12543 smead.com • Made in USA ��GYC�c �J q� T � 1�114®NMfN'A000TIIE SFI a menus +;t .. .. e� • � �. .mac- .._ -"� - - i'F.. - - _ r Town of Barnstable . Building P,ostThis Card So That.it sibleFrom the Street-Approve`d Plans'Must beRetained:.on Job and thisCard'Must,be Kept �nsreru �, Posted Until Final.lnspection Has Been Made..' bs� Permit Where a"Certificateaof Occupancy is Required;such4Building shalhNot be OccupiediU t llIFinal lnspection'has been 'made. Permit-No. 13-17-920 Applicant Name: XENNEDY,MATTHEW C Approvals Date Issued: •OS/04/2017 Current Use: . Structure Permit Type: Building Shed-Residential-200 sf and.under Expiration Date: 11/04/2017 Foundation: Location: 328 WILLOW STREET,WEST BARNSTABLE Map/Lot 131-024 Zoning District: RF Sheathing: Owner•on Record: KENNEDY,MATTHEW C Contract^oryName: Framing: 1 °Address: 328 WILLOW STREET .Contractor License 2 WEST BARNSTABLE,MA02668 Est-Pi ect cost: '$0.00 Chimney: Description: 10 x12 shed Pe mit Fee: $35.00 . ^ Insulation: Pro ect Review Re - 10 x12`shed -v Fee#Paid: `$35.00 1 q Date 5/4/2017 Final: s. ^rt ' ��. Plumb'ng/Gas Rough Plumbing: , Buildin Official g Final,Plumb_i,ng:, This permit shall be deemed abandoned and invalid unless the work authorrzed bythispermitis commenced within six rnonths�after issuance. , � -Rough,Gas.:: All work authorized by this permit shall conform to-the approvedapplicat�on and t approved construction docume is forvrhlch th's permit has been granted. All construction,alterations and changes of use of any building and structures,,shal[be in compliance with the local zoning f?y laws,and codes. l � Final Gas: This permit shall be displayed in a location clearly visible from access streetto-road=and shall be maintained open for publiQnspeetion 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 areeprovidedYonktnis°permit. Service: Minimum of Five Call Inspections Required for All_Construction Work: ------------- =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(Fraine 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: "Persons contracting 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: AII`PermitCards are the.property of the APPLICANT-ISSUED RECIPIENT Town of Barnstable �t rowti Regulatory Services Richard V. Scali,Interim Director BUILDING DEPT. 9sA MASS. Building Division MASS. `b- 16s9- A,O Tom Perry,Building Commissioner MAY O 12017 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us TOWN OF BARNSTABL>:. Office: 508-862-4038 Fax: 508-790-6230 PERMIT# FEE: $ SHED REGISTRATION RESIDENTIAL ONLY 200 square feet or less �3zS� (�;(lot,. S�-. � -E-�,.t-•�,��1�. Location of shed(address) Village - � Property owner's name �Telepho�nena�6 /D ' X fZ� # �31 Zq Size of Shed Map/Parcel# r Sig ature Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? , Q c If over 120 square feet,you must file with Old King's Highway 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,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg rell, REV:I10413 O 111-7 : .......... mm� Town Boundary 323.456 Parcels FY2017 I •'' .::'`;•. SS z1234 Address Street Numbers + `, 131-023 FQ Buildings '. •\`;•.'••��.:•� #298 -i 0 9&V0jiZBj orations of ®® Above Ground Swimming Poole OF In Ground Swimming Pools Walkways Improved === Walkways Unimproved ti?1`•~ /`: t ,;:1, `F - - - Paths _ '•�': F•::••••.•. ..::•.•.. ® Stairways !°'•; ? ;•, :t.:. - :`�., y Paved Roads 131-025 Unpaved Roads, 330 _ Paved Driveways 'is : ^`{ Unpaved Driveways Painted Lines _ - Q Paved Parking Lots } Q Unpaved Parking Lots " ® Bridges Railroad PRO OS 0'X12' SHED Fences t Guardrails 131-024' 4— Retaining walls #328 �o Stone Walls Op Sports Areas `f CtD Golf Areas Docks/Piers 32:32 3X4 : I o Boardwalks Jetties J Streams Drainage Ditches 40. f Marsh Areas _ ., t .�,,,,.,.1°r`�•.- Q Water Bodies try X Spot Elevations(NAVD88) V O' Topo io ft Contours(NAVD88) Topo 2 it Contours(NAVD88) 131-030 Wooded Areas Street Trees #142 x Catchbasins :''`•.�� - v�. - �{ Monuments 35.47 Qj Lamp Posts Tower; •�•.� X -- t R Manholes O ..:30. Q Utility Poles .Satellite Dish Signs ®N Fuel Tanks / Flagpoles OM Water Tanks ' Q Utility Boxes °ti s 131;031 t 130�008 . g ;#.4 \ #0 Town of$arnStable jjD;itaC8qur6e Human-made features, AiSclaime This map is for planning purposes only.It is 1 inch=40 feet N hydrography,topography,and vegetation were peel Imes on this map are only graphic not adequate for legal boundary determination Feet Conservation Division interpreted from 2008 aerial photographs and representations of Assessor's tax parcels.They or regulatory interpretation This map does no http://—.town.barnstable.maus may have been updated from more current are not true property boundaries and do not represent an on-tho-ground survey. 0 10 20 q0 60 80 W E Zoo Main Street,Hyannis,MA o2us sources.Parcel lines were digitized from represent accurate relationships to physical Enlargements beyond a scale of l"-too'may .. Nn...nT.-•...wr Dw...,-.Al..�w......nw'n.-.wn ....---.t_—..--..4.-L.. J:-- -..r•.—. --.�....-..4:- .J�.—..—���--J.- - O a r� Town of Barnstable Old King's Highway Historic District Committee p,ECFMD KAM 20.0 Main Street;Hyannis,Massachusetts 02601 (508) 862-4787 Fax(508) 862-478.4 APR 0 5 M7 CERTIFICATE OF EXEMPTION GIB®wTH MANAGEENT Application is hereby made,with four(4)complete sets,for the issuance of a Certificate of Exemption under Section 6 and 7 of Chapter 47Q,Acts and Resolves of Massachusetts,.1973,as amended,for proposed work as described below and on,plans,drawings,or photographs accompanying this application: Data S// Address of Proposed ivgrl; Assessor's Map and lot# /3 1— G�17 House �J Street IVIUd?A) 374Cr Village: %f/Y This application is for an exemption of the proposed construction on the grounds that work: Will not be visible from any way or public place ❑., Is within a category declared exempt by the.Old Kings Highway Regional Historic District Commission ❑ Other Description of Proposed Work GelA2 rA Is VZYtFY b 5rW * AiiT�V aZ A)2P,0j)4A /St/U13L P-m ar ,_a0 Z_/AZ S �5b2' '4mo r.'vA &-"YX O Agent or contractor(please print): SWi Sty)Me SNA S Tel,.no. Address e?-3 Aur37'90L) ✓�, - Jl�OA441 S, 1 yl 6a-10 60 Owner(please print):_ ZE'I gg�v ��k1bq r Tel no. 50 1�' 3� •a��� Owners mailing address: �tJ�LLOZJ Y A20T TAP Signed,OiwnerlContractor/Agent• For Committee Use"Only This Certificate is hereby ApprovedWenied Date: Committee Members Signatures: APPROVED �-~- APR 15 2017 Town of Barnstable Old King's Highway Committplz Any conditions of approval: C. DocumentsandSettingsldecollikv-ocalSelArigslTempomrylnternetFilesIOLK110KHExemptionForm07,.doc Martha's Vineyard Loft-Salt Spray Sheds http://www.saltspraysheds.com/mardias-vineyard-loft.html ._ The Martha's Vineyard Loft will add a LSo uchM LRw EngianTcharsacter to your property. We increased the roof pitch to 1116j > match a traditional Cape style house with 10/12 pitch (40° angle). Next,we added a 4' loft to keep unsafe items out of reach of ` children and pets. Additionally,the loft is a great place to store other seasonal items or to hang your bike or kayak. The Martha's Vineyard Loft also has a long 76fk x 6fL 36 sit $1,614 list of Standard Features, listed below, and x 8ft. 48 sft. $1,884 x 10fL 60 A. $2,100 a very impressive list of upgrades. Salt x 12R. 72 sfL $2,260 SR.x 8ft. 64 SR. $2,000 Spray Sheds works together with every 815t.x IM 80 sft $2,350 customer to create a building that meets sft.x 12R. 96 sft $2,750 sft.x 14fL 112sft $3,050 your budget, needs,and lifestyle. Finally, all 8ft.x 16ft. 128 A $3,700 8ft.x 18R. 114sfL $4,300 of Salt Spray Sheds buildings are built on 8ft.x 20R. 160 sR. $4,600 aft.x 22ft.*** 176 sft $5,300 site, no paneled or pre-fabricating 8R.x 24R.*** 192 sft. $5,800 _MfL_x-10fL-_1,00 sft $3,050 components are used. �_10R.-x-121FL- 120_sft,_-1 $3,250 10ft x 141FL 140 sft. $3,950 1 V '� loft x ft.* 180 sft $5,400 Our price includes building on-site arroc loft.x 18R.*** 180 sft $5,400 '' 10ft.x 20R.*** 200 sft $5,700 taxes. Q�J 1�1 10R.x 22R.*** 220 sft. $6,100 10ft.x 24fL*** 240 A $6,550 For those customers over the bridge, a ANY, 12ft x 12ft 144 sft $4,250 �� 12ft x 14R.*** 168 sift, $4,900 delivery charge may apply. tt��,tt�Z1 12ft.x 16R.*** 192 sft $5,200 12R.x 18R.*** 216 sft. $5,800 12ft.x 20R.*** 400 sft. $6,300 STANDARD FEATURES INCLUDED: 12R.x 22R.*** 264 sft. $6,750 12ft.x 24R.*** 288 slit. $7,250 14ft.x 14ft.*** 196 sft. $6,800 POSTS : 6-5 Posts 141FL x 16ft*** 224 sft $7,900 . ROOF PITCH: 10/12 40° an le Aft.x 18R.*** 252 sft $8,800 ( angle) 14R.x 20ft.*** 280 sft. $9,800 similar to a Cape Style building 14R.x 22R.*** 308 sft. $10,600 14ft.x 24R.*** 336 sft. $11,600 e FRONT DOOR: 3 ft. Board and 16R.x 16fL*** 256 A. $8,950 16ft.x 18ft*** 288 sft s91800 Batten 16ft.x 20R.*** 320 sft. $11,600 16 ft.x 22R.*** 352 OL $12,800 • DOOR HARDWARE: 6" Heavy Duty 16ft.x 24R.*** 384 sft. $13,800 16ft.x 26R.*** 416 sR. $14,900 "T" Hinge,with Heavy Duty Safety 16ft.x 28R.*** 448 sR. $16,050 Hasp. I NOTE: Sizes with ***indicate slab • WINDOW: Stationary 21"x 27"True required fir. hyve a floor f{ame chyr�e� Divided lit%with window box and x y usinU is si a you consent o the use o c o ies.Cookies can be manage in your rowser or device settings. 2 of 5 4/5/2017 11:26 AM Martha's Vineyard Loft- Salt Spray Sheds http://www.saltspraysheds.com/marthas-vineyard-loft.htnal /4tments Please check with local shutters OME SHED STYLES GALLERY THE NEXT STEPS for rules and • WINDOW BOX: 26"x 7" Rough setback requirements sawn Pine • SIDING: Board and Batten • ROOFING: 30 year architect roof Questions? We've Have shingles Answers • VENTILATION: 8" x 12"Aluminum Louvers Name • TRIM: Full Dimension Rough sawn ------- ---- -- ---- -----=--- Pine First Last Email * • LOFT: 48" Deep • RAMP: 3 ft. Pine Ramp --- ---- -- ----- BUILDING ON SITE: INCLUDED Question: OPTIONAL FEATURES AVAILABLE: --- — ---- • LOFT: 60"or 72" deep SUBMIT • BENCH: 24" deep, 38" high,with or without shelves (Gable length) • FLOORING: 5/8" or 3/4" Pressure- treated plywood • CUPOLA: 12" & 16" pine cupola, Vinyl cupola 18", 20", 24" • ROOF PITCH: Higher pitch (12/12) a 450 angle • WINDOW: Extra stationary,opening window,or double-hung Window, or fixed or opening skylight V�C'�' • SIDING: White Cedar Shingles, Red 1��1 PQ� �3 Cedar Clapboard, Red Cedar Shingles • TRIM: Pre- primed ,Azek or �g composite Trim, Red Cedar Trim • ROOFING:Architectural Asphalt, Red Cedar Roofing • HIGHER POSTS: 74" or 8'-0" By using this site you consent to the use of cookies.Cookies can be managed in your browser or device settings. X 3 of 5 4/5/2017 11:26 AM Martha's Vineyard Loft-Salt Spray Sheds http://www.saltspraysheds.com/marthas-vineyard-lofLhtml 1 • DOORS: 3, 35,4', 5', 6', 8' HOME SHED STYLES '*LEa boarJIng'e or Touble Glass Transom Sizes ranging from 3'to 8' and beadboard, single and double row transom.Available in Pine, Fir, Mahogany,and Azek .(Prices Available upon request). All custom doors must be painted within two weeks of installation or warranty will be voided.Azek Doors should be painted with Sherwin Williams Vinyl Safe (http://www.sherwin-williams.com /arch itects-specifiers-desig ners /education/paint-and-color- technology/sw-art- pro-vinylsafecolortech.html) paint. HAVE ONE OF OUR EXPERTS PREPARE A FREE,CUSTOM Home (/) standard optional gallery request- special features features (/building- a-quote offers (/standard- (/optional- gallery.html) (/request- (/spring- features.html) features.html) quote.html) ahead- 2017.html) @ Salt Spray Sheds 1994-2016 Family Owned and Operated Building Post and Beam Accessory Buildings,Year Round,On Site 235 Great Western Rd,S.Dennis,MA 02660 •508-398-1900 office. Email Us (mailto:saltsprayshedsinc@comcast.net?subject=Additional%20information)saltsprayshedsinc@comcast.net (mailto:saltsprayshedsinc@comcast.net) Office Hours By using this site you IR var or device settings. X 4 of 5 4/5/2017 11:26 AM nsINsn Town-Boundary \;'''••, 1z3 456 Parcels FY263-7 SS �•• :•:•. Y.1234• Address StreetNumbei3 �`•�'•� 131-023 [� Buildings; #298 0 fl@Fros ..Ri18?cationsof N, •:::�. �0 Above Ground 8wimmiagPooLs 1' ".;•+•:;� `\ �,, ` �• QQ In'Ground Swiffiraing Pools �`� '-�• 1,' o walkways improved - • '�a === WallcwuysUnimproved Paths 1 •`••'• ' Stairways Pavcd Roads C^1 Unpaved Roads. 131-025*330 s•�•,-- ::•" :'•;. ,•,'Pnved Driveways ^�i••.:-• ••% Unpaved Driveways Painted Lines 0 Paved:Parking,Lots 0 Unpad�,..IarldngI:ois � Bridges^+ e Rallroa O PRO OS 01X12' SH• D Fences / Guardr% 131=024 —�— Retainis` alls #328 Stone 00 Sports A!pds GolfArcoB, tV t= 2174• Docks/Q i 32.32�} X Boardw r / Jetties t y - DrainageiL9clies 40 � Marsh Areas — Water.Bodies )� Spot Mevations.(dAVD88) 0' Top010 R Contours(NAVD88) _ © Topo 2 ft Contours(NAVD88) C_^: WoodedAreas 131-030 ® Street Trees #142 x Catchbasins O Monuments 33.67 Lamp Posts 'Towers x•� m Manholes r \ 3b - i Q .Utility Poles O•Satellite Dish i' y y sips ®'Fuel Tanks - en;WaterTanks Flagpoles ` y` Q Utility BOAeS0 Potts • Pilings131-031 % 130-008 _ 140d > \ #10 Town.of$aftStable Data 8g11 fte Human-made.features, Di8C�.117i1BT ibis map is for planning purposes only.It is, 1 inch=¢O feet N hydrogmphy,topography,and vegetation were Pam lines on this map are only graphic not adequate for legal boundary determination Feet Conservation DiviSYon interpreted from 2008 aerial photographs and representationsofAssessor's tax parcels.they or regulatory interpretation.This map does no may have been updated from more current are not a boundaries and do not 're resenrazr on-the ouad, 0 10 20 40 60'�` Y 80 W E .http:%/www,town.bamstablem&us prop.rtY P 8r y aooDtainStrcet,.7i nnb,MA o26oi sources.P,•rrcel lines were digitized from represent accurate relationships to physical Lnlargementsbeyondascaleoft"=1o0'may •• Wnn,n Tn..w,..COw..,w,..l,ln Aw"n,.rn�•w.wnw" C 4�. Town of Barnstable ermit: d p j Regulatory Services ate: oFtr'e loi�ti Richard V. Scali, Interim Director . Building Division �� f t r f f BARNsrABLE, ' Tom Perry, Building Commissioner MASS. v� 1639. ,0� 200 Main Street, Hyannis,MA 02601 QED PAA�A www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 TOWN OF BARNSTAB-LE SOLID FUEL STOVE PERMIT r: Owner: —�IAW- &2211d/6� V Phone: Sb� • 3�6 -a�k� Install at: 3.;'-k Gu&y QU ) Village: Map/Parcel: 13 102-4 Date: Stove A. New Used C:7 I B. Type: adia Circulating ca C. Manufacturer: SbZL1-L- Lab. No. D. Model No.: �#(�p� l v -`; Chimney ca A. New/ xistin (If existing,please note date of last cleaning B. Flue Size (4 a 6 C. Are other appliances attached to Flue? f11 D m D. Pre-fab Type and M acturer rn E. Masonry: ine nlined Hearth A. Materials: f,�9(�. B. Sub Floor Construction: 1 Installer Name: Address: Phone: Location of Installation: H.I.0 Registration# Construction SS ervisor# OR check ✓ Homeowner Installing, no license required LICENSED INSTALLERS SIGN APPLICANTS SIGNATURE: 4- 0. - APPROVED BY: /Z fz-�F— Please make checks payable to the Town of Barnstable *This constitutes an official stove permit after inspection,photographed, and approved by the Building Inspector Q:forms:stove Rev 11/4/13 Town of Barnstable Regulatory Services °F rqy� Richard V.Scali,Director Building Division awxtvsTasie. ' Tom Perry,Building Commissioner Mass. 9�A 1639. `0� 200 Main Street, Hyannis,MA 02601 lent www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: 3 LLO7� WAT l number street village "HOMEOWNER": ti dame home phone# work phone# CURRENT MAILIi IG ADDRESS: 3 U2&oto 79 city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"li eow r"certifies that he/she understands the Town of Barnstable Building Department mini ins a "ores and requirements and that he/she will comply with said procedures and require ignature 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. 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: Aff>T L `5Cy1 b7.6�0I one #: SG 8 '3� • �11n 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 employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2. 1 am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. Demolition workingfor me in an capacity. employees and have workers' y p �'• 9. Building addition [No workers' comp. insurance comp. insurance.1 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. Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13. Other (�Z �LA.(Lr U.M D comp. insurance required.] ,$`'b *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 IA for surance coverage verification. I do hereby certi de t e and enalties of perjury that the information provided above is true and correct. Signafore: Date: / 5 Phone#: sb g •3�0• �: 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#: