HomeMy WebLinkAbout1866 MAIN ST./RTE 6A(W.BARN.) UPC 12543
No. 53LOR
HASTINGS, MN
Town of Barnstable RE P
200 Main Street, Hyannis MA 02601 508-862-4038
spa .�
fOf"°�p Application for Building Permit
Application No: TB-17-3486 Date Recieved: 10/8/2017
Job Location: 1866 MAIN ST./RTE 6A(W.BARN.),WEST BARNSTABLE
Permit For: Building-Siding/Windows/Roof/Doors
Contractor's Name: TROY A THOMAS State Lic. No: CSSL-099913
Address: CENTERVILLE, MA 02632 Applicant Phone: (508) 328-1635
(Home)Owner's Name: WIRTANEN, MARK S Phone: (508)420-7989
(Home)Owner's Address: 1866 MAIN STREET, WEST BARNSTABLE, MA 02668 Q
Work Description: strip of old roof shingles on the back of home. Installing like for like CertainTe'Ahingles. bleat a wood
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-t� Z
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Total Value Of Work To Be Performed: $5,480.00
Structure Size: 0.00 0.00 0.00
Width Depth Total Area
I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before
he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568).
I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by
filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to
accept coverage.
I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have
been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the
Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and
specifications. All information contained within is true and accurate to the best of my knowledge and belief.
All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24
hours in advance.
Signed: Troy Thomas 10/8/2017 (508)328-1635
Applicant Date Telephone No.
Estimated Construction Costs/Permit Fees
Total Project Cost : $5,480.00 Date Paid Amount Paid Check#or CC# Pay Type
Total Permit Fee: $35.00 10/8/2017 $35.00 ^ XXXX-XXxX-XXXX- Credit Card
.... .
.....__._ ........................_-------
.__.._....._......_-----
._._._._.__..._..._ .
Total Permit Fee Paid: $35.00
�-
�t►,e r Town of Barnstable CPeFi t tt 6 Qel�7_(_�>g
0 Expires 6 months from issue date
Regulatory Services Fee
• anxtvsrnsre, �
MASS. Richard V. Scali,Director
1639. �0
Building Division . apt
Tom Perry,CBO,Building Commissioner N
1 200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Map/parcel Number Not Valid without Red X-Press Imprint
//� � � V
Property Addres��6 6 l)" ePVV
l cA I
U�
Residential Value of Work Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address 0
Contractor's Name Telephone Number J—o9—mob Z - d w 9
Home Improvement Contractor License#(if applicable) Email:
Construction Supervisor's License#(if applicable) PER—
° '
❑Workman's Compensation Insurance ®� I ti
Check one: 1
❑ I am a sole proprietor OCT 10 2014
4�I am the Homeowner
❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE
Insurance Company Name
Workman's Comp. Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box) J�
4&ffRe-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A cop f he Home Improvement Contractors License&Construction Supervisors License is
req
,. SIGNATURE:.
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 06,1313
s� Comrrza�rfc�ts �a��fassaeli<us�s
De}urftntwt o f huLTfti,, Accidents
- F}f we rfIM"es Egadans
600 Wass'hriFigfon Street
Boston,MA 02M,
Wn-w.7nass-gaWdia
',arkers' CompensatiaxxLis=uce affidavit:Builders/-antraactors/F-Iecfricians/Plumbers
"c-aut lufm-wafion Please Print .h-.
Name( 1O oa&dividw0: Si zv4—ae
Address: ha)\', ffi /
City/Statz/Zip:A.( d D2,6'61 e Phone 4: .�U�" 6 Z —OOU
Are you an employer?Check the appropriate box: T e-ct C
4-. , e�'a1 confracEor and I }�of�'o r J �e4uired}=
>_❑ I am a employer with ❑ I a�a$. 6_ New action.
employees{full and(orparme} :�l t-ti * have hi.-rod the sub-conb:adors. �New
2_❑ I am a sole proprietor or partner
listed on the a#iached sh --t 7- ❑RPmodeliag
sbip oral hzve no employees '115ese s-ab-contractors have g_ ❑D�nolifiaa
wcrking for me in an capacity- eroplo_y ees and have workers'
t-r�T y � ) p_ O Euilding addition
K1 0,wo kk � ccMp_rn etiranre comp.*ioswance.$
5.. We aai--a co rporaficn and its 10.0 Pertrical repairs cir additions
3 1 aTA a h=eo-- er dole;011Vorie ofiic rs batm t xerased fl2f= 1 LQ Plumbing repairs or additions
X)rysel€ [No tvorbM'comp- ri&t.of esmmptionper MGL 12-[l Roof repairs
i ass tuance regw.*ed.]F c. 152,q 1(4} and we have na
employees_[No WoAcem, 13-�Other
comp.insarmce requued,j,
'Any sngecaaf that checks box rl=A also fill oiht the sec you b Jow d awmg their woffim'compensatou poHU InR3, -d»
t Homeowner who sub=it this emdxyi t i.xar ca they ale 6nmg �'�mx azA dim hire oxide coetracmrs=st submk anew:z5 dxV m6ir ft, snth_
=Cunvscmrs tvt&-Ck this box mist Tue lsed n.Mitillosl sheet s?ouseg n�of the soS nth r o4s�md st£tP xhet et ocnni these cmties Tv
®loye=.s_ IIthe svb-cMt:Rctuts h-.Ve ehnmIopes,they lust Mu'-we i=.r wtffkers'comg.policy number
I axz an e.atpL7}�sr•rhatas prmriding xtror err'cotrrpzfurfilxn iresttrartce fot >ny�etrzpLtye Hei�tr is fate pDUcy and}ob sift
%r;forma�arF. -
Lnsurance C•omparrjName-
Policy fr or Self in:s.Lic.:.k-- ExpuatioaDate:
Job Site Addiess: CitS,/Sta zip:
Attaclx a copy of the-workers'compensation policy declaration page(showing the policy number. xnd expnatiou date).
Failure to secure coverage as mquiredunder Section 25 A of MGL c- 152 can lead to the imposition of trim ina l pehaabies of a
fine up to$1,50U.0 and/or one--year imprivonment,a-s well as civil peaalhes 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 maybe forwarded to the Office of
Im;e*ptio-ns of fiae DItA for irnzance coverage verification-
.I da hereby certify u.tuler t 'ns nd ss of ry 6atthe information prcnidgd abfwe is bue and correct
SiEuatvr Date- A) V
Phone
Offu-t'rrL use arily. Da trot write in this area,:a bs campiet-ed by cifj or town offi'ciaL
City-or Towa: Pis urit/Licetue
Is.u,—Au-thor4(tdrde one}:
1.Board of Health BuRding Department I City..,Towa Qerk 4_EIectrical Lnspecfor S.Plumbing Easpertor
6.Other
Ca�ts�ct PErsun: Phone#:
6
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuantto this statute, an employee is defined as"__.every person in the service of another under any contract of hire,
express or implied, oral or-mitten."
Aa 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 st.±es that"every state or Iocal Licensing agency shall withhold the issuance or
renewal of a license or permit to Operate a business or to construct buildvzgs in the commonwealth for arn.y
applicant who has not produced acceptable evidence of compliance r ih the insurance.coverage requiree+."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the per ormance ofpublic work until acceptable evidence of compliance v.Zth the insurance
requirements of this chapter have been presented to the contracting au hority."
Applicants —
Please fill out the workers' cojnpensafion affidavit completely,by Checking the boxes that apply to your siltation and,if
necessary,supply sub-contractors)naine(s), address(es)and phone n be.,-(_) along with then cert;nc--;fc(s) of
insurance. Limited Liability Companies(LLC) or Limited Liability Pa inershivs(i_LP)ve7thno employees oher than tine
members or partners,are not regt-ue:d to carry workers' compensation msl ante_ if an LLC or LLP does have
employees, a policy is requsrtd- Be advised thaf this affidavit may be S2bL??ifted to the Department of industrial
Accidents for confirmation of is=ance coverage. Also be sure to sign ap.d date the a,ffidav t '11e az darit should
be returned to the city or town hat he application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you.have any qu.esuons regarding he law or if you are required to obtaMi a vrorkers'
compensation policy,please call-the Department at he number listed below. Sel insured companies should enter. -heir
sell in ur-ance license number on the a_upropriate line.
City or Town Offfcials
Please be sure that the affidavit is c1?mplete and printed legibly_ The Department has provided a slut-at the bottom
of the affidavit for you to ill out in the event the Office of investigations has to contact you regarding the applicant
Please be sure to fill in the permighr-case number which will be used as a reference number_ In addition, an applicant
that must submit multiple perr_itllicense applit ations in any given year.need only submit one afEadavit indicating current
policy information (if necessary) and under"Job Site Address"the applicant should write"ail locations is (cif or
town)."A copy of the affidavit that has bez-a officially stamped or ma&fed by the city or town may be provided to idle
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be ailed 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 afii dati,�t
The Office of Investigafions 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.
o Cormauv�'eatth of Ivfassachusetis
Depar`oatnt cif Industrial Accidents
Gffice of byestigatians
600 Washingto-n Strut
Easton_I 02111
T,�I, 6I7 727-49.Qo ex 406 or I-E77 I2..4SSSA FE
Revised 4-24-07 Fax r 617-727 II` 4
wvm zaas�gov/d a
Town of Barnstable
Regulatory Services
oFE rory Richard V.Scali,Director
� o
Building Division
&ARNST^BL ' Tom Perry,Building Commissioner
MASS.
1639- 200 Main Street, Hyannis,MA 02601
ArED '�A www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
DATE: /Q Please Print
p / /
JOB LOCATION: (I b G{i Qi' &'P-J � C�v
number sheet 7 - Q village
"HOIvM0WNER": )Y AIM .5--o ��C� O 2d 9
namc home phone# work phone#
CURRENT MAILING ADDRESS: //U7 V -
�! j a,{� Q
city/town stale 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.
DEFINrr1ON OF HOMEOWNER
Person(s)who owns a parcel of land oa 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 verformed 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
procedure require ents and she will comply with said procedures and requirements.
/Z'�_
Signatu/ 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 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 care t amend and adopt such a form/certification for use in
your community.
Q:\WPF1LES\F0RMS\bui1ding permit forms\EXPRESS.doc
Revised 061313
Town of Barnstable
Regulatory Services
t
�BAMSTABIX,� Richard V.Scali,Director
1639.�639. 1. Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
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)
Pool fences and alarms are the responsibility of the applicant. Pools
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
Signature of Owner Signature of Applicant
Print Name Print Name
Date
Q:FORMS:O WNERPERMISSIONPOOLS
I
LAST WILL AND TESTAMENT
of
BELEN E. WIRTANEN
I, HF:T.RN E. WIRTANEN, of 1866 Main Street, West Barnstable, Barnstable County,
Massachusetts, 02668, hereby make, publish and declare this to be my Last Will
and Testament, revoking any and all previous wills and codicils to wills heretofore
made by me.
FIRST
I direct' that all my debts, funeral expenses, the expense of my last illness
and the expense of the administration of my estate, be paid .out of the first moneys
coming into the hands of my executor and available therefor.
SECOND
I may leave a memorandum stating my wishes with respect ' to the disposition
of certain items of personal property formerly belonging to the Schooley family;
however, it will be simply an expression of my wishes and shall not create any
trust or obligation, nor shall it be offered for probate as a part of this Will.
1
THIRD
I hereby give, devise and bequeath all the rest, residue and remainder of
my property, whether such property be real, personal or mixed, howsoever described
and wheresoever located, ' to my husband, MARTIN E. WIRTANEN, if he survives me;
or if he does not survive me,
then to my son, MARK S. WIRTANEN; and if my said
son does not survive me, then to his issue by right of representation.
FOURTH
For purposes of this Will, a person shall not be considered to survive another
if he or she shall die within thirty (30) days of the death of such other.
FIFTH
I give to my Executrix or Executor, whichever the case may be, the following
v
' powers, in addition to and not in limitation of his/her common-law and statutory I
• powers:
(a) To retain indefinitely any investments and to invest and reinvest in
corporations, of trusts and of
stocks, shares and obligations of
. :_ .-.. r:-: .•.. .. writ' v:.cn.., .. _... .:... ..
investment companies, or in any other kind of personal or real property,
notwithstanding the fact that any or all of the investments made or
retained are of a character or size which, but for this express authority,
would not be considered appropriate for Executors.
(b) To sell, exchange, to lease and to make contracts concerning real or
personal property for such considerations, and upon such terms as to
credit or otherwise as my Executrix or Executor may determine, which
leases and contracts may extend , beyond the term of the settlement of
my estate or the term of any trust; to give options therefor, to execute
deeds, transfers, leases and other instruments of any kind.
(c) To hold bonds, shares or other securities in bearer form or in the name
of the Executrix or Executor or in the name of a 'nominee, without
indication of any fiduciary capacity, to deposit cash in a checking
or savings account in a bank, without indication of any fiduciary
capacity.
(d) To improve or develop real estate; to construct, alter or repair buildings
or structures on real estate; to settle boundary lines and easements
and other rights with respect to real estate; to partition and to join
with co-owners and others in dealing with real estate in any way.
(e) To employ investment counsel, custodians of estate property, brokers,
agents and attorneys.
SIXTH
I hereby nominate and appoint as Executor of my Will my husband, MARTIN E_
v
WIRTANEN. In the event my said husband predeceases me, declines or is unable
to serve as Executor, then I hereby nominate and appoint in his stead my son,
1 `
MARK S. WIRTANEN, as Executor. I further request that anyone. serving in this
{ capacity be exempt from giving any surety or sureties on his or her bond as Executor
or Executrix.
J
v I, the undersigned Testatrix, do hereby declare that I sign and execute this
instrument or,�jUj 1-/ l6 , 1991, as my Last Will, typewritten on three (3) sheets
of paper (including the attestation clause and signature of witnesses) upon the
margin of each one of which I have also written my name, and that I sign it
willingly in the presence of each said witness, and that I execute it as my free
and voluntary act for the purposes herein expressed.
Helen E. Wirtanen
2 -
We, the undersigned witnesses, each do hereby declare in the presence of-
the aforesaid Testatrix that the Testatrix signed and executed this instrument
as her- Last Will in the presence of each of us, that she signed it willingly,
that each of us hereby signs this Will as witness in the presence of the Testatrix,
and that . to. the best of our knowledge the Testatrix is eighteen (18) years of
age or over, of sound mind and under no constraint or undue influence.
of
L` of �` t�', L . tko-
COMMONWEALTH.OF MASSACHUSETTS
Barnstable, ss: 1991
N
Subscribed, sworn to and acknowledged before me by the said Testatrix' and
the said witnesses on this day of ;/ i 1991.
I
Notary Publ c
My commission expires: y`n U
ti
1
3 -
Town of Barnstable *Permit#
Expires 6 months from issue date
Regulatory Services Fee
039. �e Thomas F.Geiler,Director
�EDN1P�� Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 X-PRESS PERAPHT
Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLJUG ;G 6 2004
[lap/parcel Number •d. Not Valid without Red X--Press Imprint
' 1— D / TOWN OF BARNSTABLE
operty
r Address
r
Residential Value of Work z_ 40 Minimum fee of•$25.00 for work under$6000.00
►wner's Name&Addresses,
;ontractor's Name Telephone Number
come Improvement Contractor License#(if applicable)
;onsttruction Supervisor's License#(if applicable)
]workman's Compensation Insurance
Check one:
I am a sole proprietor
I am the Homeowner
I have Worker's Compensation Insurance
nsurance Company Name
Vorkman's Comp.Policy#
;opy of Insurance Compliance Certificate'must be on file.
'ermit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to__�� 1
❑Re-roof(not stripping. Going over existing layers of roof)
Re-side
❑ Replacement Windows. U-Value (maximum.44)
•Wbae 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.
Home Improvement Contractors License is required.
Signature �j,�jL
Application Ito:
Odd Kings Highway Regb ial His s District Committee
in the Town of Barnstable for a
CERTIFICATION.OF EXEMPTION
)piication is hereby made, in triplicate,for the issuance of a certificate of exemption under Section 6 and 7-of-Chapter 470,,
,ts and Resolves of Massachusetts, 1973. as amended for proposed work as described below and on plans,drawings,or photo-
aphs-accompanying this application. : `
YPE OR PRINT LEGIBLY DATE
DDAESS OF PROPOSED WORK ASSESSORS MAP NO. ---.
WNER �,/IiPT�-�V ASSESSORS LOT NO. .
IOME ADDRESS �R�fi %yam/�l/ .5� �� AtiJP�IS'/A/�L�✓/�� �TEL.N0�L�2-- ZC.2—
%GENT OR CONTRACTOR
►DDRESS / �JUTE l�, TEL. NO.
'his application is for exemption of proposed exterior construction on the ground that.
] (1) It will not be visible from any way or public place.
] (2) It is within a category declared entitled to exemption by Old King's Highway Regional Historic District Commission.
(Check applicable box).
)ROPOSED WORK: Describe and furnish plan of proposed work,showing location on lot,and, if an addition is involved,show•
ng location of existing building.
SIGNED -,Zzz. 9/ //S/lP�•t� __.__
Owner-Contractor-Agent
Space below line for Committee use. . ,
• I
Received by H.D.C. The Certificate is hereby
Date
Time
By Date
IKE Town of Barnstable *Permit# ?
Expires 6 inonths front issue date
BAMSTABLE.
" Regulatory Services Fee
9�
i 6 9. Thomas F.Geiler,Director A 3 p�0
Building Division
Tom Perry, Building.Commissioner X-PRESS P °�:F
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 JUN 9 2004
Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIA .MF BARNS-f, .1,..
Not Valid without Red X-Press Imprint
Map/parcel Number ` /1 D
Property Address 1yad;2 f,, � ��1
Residential Value of Work Z22��2
Owner's Name&Address T ZE �/1 1, i
Contractor's Name iAill �n. Telephone Number� W02 0
Home Improvement Contractor License#(if applicable) f
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I 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 be on file.
Permit Request(check box)
Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows. U-Value (maximum.44)
*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.
Home Improvement Contractors License is required.
Signature
Q:Forms:expmtrg
Revise053003
Applioati'ori lto:
►'v�•P* Old Kings Highway Regionaf•HisOcic District Committee
in the Town of Barnstable for a
CERTIFICATION.OF EXEMPTION
Application is hereby made, in triplicate,for the issuance of a certificate of exemption under Section 6 and 7-of_Chapter 470,
Acts and Resolves of Massachusetts, 1973, as amended for proposed work as described below and on plans,drawings,or photo-
graphs accompanying this application. (/
TYPE OR PRINT LEGIBLY DATE 9
ADDRESS OF PROPOSED.WORK ASSESSORS MAP NO..
OWNER ' � L //(/f[ �O/� ASSESSORS LOT NO.
HOME ADDRESS cS �W� TEL. N0. _ J�
AGENT OR CONTRACTOR
ADDRESS. TEL.NO.
This application is for exemption of proposed exterior construction on the ground that:
❑ (1) It will not be visible from any way or public place.
❑ (2) It is within a category declared entitled to exemption by Old King's Highway Regional Historic District Commission.
(Check applicable box)
PROPOSED WORK: Describe and furnish plan of proposed work,showing location on lot, and, if an addition is involved, show,
ing location of existing building. U 9
SIGNED 2=� G s
Owner•Contractor-Agent
Space below line for Committee use. .
i
Received by H.D.C. The Certificate is hereby
Date
Time
By Date
Approved ❑ The categories of work entitled to exemption are listed on
MennnrewaA F7 the back of this form.