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HomeMy WebLinkAbout0044 HOMEPORT DRIVE 1 II Assessor's map and lot number .... .� ./ C�Je/0 ' © � — a 'y 7 7- SEPTIC SYSTEM MUST BE ` INSTALLED IN COMPLIANCE wage Permit number ....-........... . . .. WITH ARTICLE li STATE SAN1TAR C ?"ET°� �- TOWN OF BARNSTA��t��;EANDTOWN 10 3 STelu;E, "10?6` '� ` BUILDING INSPECTOR APPLICATIOhi FOR PERMIT TO = � �........... x.f............................ .... TYPEOF CONSTRUCTION ........ ................................................................................................ Fr .. :5& � .......�r...... ......19... 7 TO THE INSPECTOR OF BUILDINGS: The undersigned �hereby api'ies for a permit according to the followin information: �jf Location ...... 1......r..l..`. �..... r�. . .. .. .� L...^ v< � �1 T.. .. . ./..f................ .. Proposed Use ...lFf .'.1..� ✓ ....� .. (�� �1 � ........................................... Zoning District .�................................ ........................�...../Fire District /../s............... ............................, ............................. Name of Owner ..v/....��..�.... � ��W.�ddress ..."l.(....����Q�G T,!�.i`C�.�............... '� Name of Builder IC.IG�/C�........ .. ess ...... �./P . ...��,....... Nameof Architect '..^...................................:.......................Address .................................................................................... Number of Rooms Foundation ExieriorG���E , � �...............................................,. Roofing ..... ......... . .:....... ..................................................... Floors � � ...Interior ...... .......................................... Heating .-- ......................................................Plumbing ....................... .............................................. Fireplace ....Approximate Cost �A.��o.Q'-� ............................................................... ............ ...... W4. Definitive Plan Approved by Planning Board --------------_-----------------19 Area 0 £� .. ......... ....................... Ga Diagram of Lot and Building with Dimensions Fee / SUBJECT TO APPROVAL OF BOARD OF HEALTH �s ICE - - f I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ....... .................................................... .............. DmMartin* Vincent _ 6^ ' dpnmuez � � No —��.....�—^Permh for '_.---------- ' � . . . ' ` -------.. .....................-----..--.--- ~ ` . | - �44 � t Drive _ Location ---'�.r���� ��---'z------� - - West sport .�---..�---.--.^^�^�^=�------�---- . �����o� �e�����m � . Owner ---...������.�..��������—.^---- n � ' ' Type of Construction --..�����---..---- — .... , --------- ---.--------- �.—.—. P|c� Lot ' --��—�----.� ---.��------. ' J�x� ' om� 4 /� 77 Permit �ron�ed ..................... . lA , . ---------...�— Dote of |n ....... ...............................lQ ' . � ~ ' ^ - � Date Completed ................z/su� �' lV . . --- — � PERMIT REFUSED `................................... lg '''-----''��'' - - �------'—�_----'�'�—~—^'./.--'---- .^----`--.—..--..-----~~.------.. ` , . ...---..:...-...—.. ,.--.—~.—...---- .. �.- . . ^ - �� . ' ---------_.--..—.--... ...~---^.� Approved .'—.. l� -------------' --------.------..,....-----~—.— / '. \/ ' -------.......................................................... ' . ^ ^ '~ ` | ` Assessor's map and lot number -......... t om. t-" TT wage Permit number -' �' r� �of7NETo�� TOWN OF BARNSTABLE i MA"ST" E i 639a�e� BUILDING INSPECTOR APPLICATION FOR PERMIT TO .:.. G T........A 172 6—......... . . ..x.. . ........................ E TYPEOF CONSTRUCTION ..................................................................................................................................... ......................`.... ..... .............19...Z/ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby appliesfor a permit according to the following information: Location ...... ...?�............`.. ti-.t�.�..�.�G...�..... � '.....�.'�?./.�1 / �,lC''✓/�T............................. f Proposed Use ......... , ../.;... . ... .. 1.......�%T.f/!..... 1.- `....T1/1�.................I......................... ZoningDistrict ..... ......................... .!.............................Fire District ......... ........................ ........................... Name of Owner .................................................*1Ae /llQddress ............. E�t.../....... .��1G�C............... Name of Builder /�1'r,,G/,AJ T Tf Address ............................................................/ t 1-� ....1!i.W...... ........... Nameof Architect . ...........................................................Address .................................................................................... Numberof Rooms ..................................................................Foundation .............................................................................. Exterior ....(�..�a.....TE...............................................................Roofing .....: .................................................. Floors 0%1 ���' ..............................:.......................................................Interior ..................................�:::............................................. Heating = .................................................Plumbin — Fireplace Approximate Cost ........................ " r ' Definitive Plan Approved by Planning Board -----------_-------------------19-------- . Area ' ...? ...::..................... J ........... Diagram of Lot and Building with Dimensions Fee . SUBJECT TO APPROVAL OF BOARD OF HEALTH jr I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ................................................................. ................1./ DeMartins Vincent A=268-125� r V. 1 dormer No ................. Permit for .................................... ............................................................................... 44 Homeport Drive Location ..........................................4..................... West Hyannisport ............................................................................... Owner Vincent DeMartin ................................................................... Type of Construction ........frame .................................. ............................................................................... Plot ........................ Lot ................................ August 4 77 Permit Granted 19 Date of Inspection ....................................19 Date Completed ......................................19 PERMIT 'REFUSED ............................... ......... 19 .° '�. ............................ ................................................................................ ............................................................................... ............................................................................... Approved ................................................ 19 ................................................................................ .................... ......................................................... ., Permit#Engineeri Engineering Dept.(3rd floor) MaP oC"s Parcel lo� � !i JHouse# Date Issued , R-7 q!7 44 r floor)(8:15 -9:30/1:00-4:30) Fee oZS, D� - (4th floor)(8:30-9:30/1:00-•2:00) - or/School Admin. Bldg.) INE by Planning Board 19 ;� • BARNSTABLE. MARk rFO 39.p� TOWN OF•BARNSTABLE Building Permit Application oject reet Address Tr //-3 64-c os, „�— y` Village , e.j.�J s�o A:•r Owner �, �/ L(C . ��„� � _ Address r T -Telephone Permit Request • First Floor 7d o square feet Second Floor 44.6 square feet -Construction Types Estimated Project Cost $ 4 7j Zoning District Flood Plain Water Protection Lot Size 7a o Sn .�T Grandfathered ❑Yes ❑No Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure J o Historic House ❑Yes pfiro On Old King's Highway ❑Yes ©-No Basement Type: ❑Full 216rawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing 2 New Half: Existing New No.of Bedrooms: Existing t_New Total Room Count(not including baths): Existing_( New First Floor Room Count Heat Type and Fuel: las ❑Oil ❑Electric ❑Other Central Air ❑Yes @ No Fireplaces: Existing New Existing wood/coal stove ❑Yes Q1�0 Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) 2-Koone ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# 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—/�e�i� SIGNATURE — DATE 7/ 119 Yl BUILDING P RMIT D O HE FOLLO G REASON(S) • .� Kt r_ FOR OFFICIAL USE ONLY PERMLT NO. r t% -k DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE- - " OWNER F s DATE OF INSPECTION: � , F FOUNDATION r - FRAME INSULATION FIREPLACE , ELECTRICAL: ROUGH FINAL F _ PLUMBING: ROUGH • FINAL ' GAS: ROUGH FINAL FINAL BUILDING f DATE CLOSED OUT _ ASSOCIATION PLAN NO. • F s < ti I The Commonwe"i of Massachusetts x Department of Industrial Accidents Office offmVesMgadoos .. - 600 Washington Street -' Boston,Mass 02111 V*J Workers' Compensation Insurance Affidavit v name: �f ��iI�IIZ.� �••�. �T.rtit�a� �ocation: ,,/"citv W. rf r S one# I am a lioificowner performing all work myself. ❑ lamas ole r net or and have no one wor1a in amp ca acity ��% %%/�%///%///�%// � //�l0/%///��,'////.�///////%%%%%%%%%�/G/%//////%/�O%%%%�;;�:: ❑ I am an employer providing workers` compensation for my employees working on this job. company name: address: dtv: phone#: insurance co. P01IcV Al ❑ 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• city: ohone#: Insurance cm ::. >:; :.>:<.. 'alley# ...::... .._ :> <;:. . camnanv name: address: city: phone# insurance co. .. iiiy FaOnre to seavre coverage as required under Section 25A of NIGL 152 can lead to, imposition of crtrninal penalties of a One up to S1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP♦VORK ORDER and a One of 5100.00 a day against me. I understand that s copy of this statement-may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby c under the pains and pen 'es of perjury that the information provided above is tni�rand coned Sighs Date �7 .2 y 1i5,9 F- _ Print a-7 Phone# Fdtyortown: ly do not write in this area to be completed by city or town official permiNicense# (]Building Departrnent 1]Licensing Board m�edlate response is required ❑Selectmen's Office❑Health Departmentn• phone#• ❑Other (tented 9l93 P1A) 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 co= 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 o: the foregoing engaged in a joint enterprise. and including the legal representatives of a deceased employer, or the receive.- 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 building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renes of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who h: 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 and supplying company names, 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 v o. are required to obtain a workers' compensation policy,please call the Department at the munber listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of th 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 permitilicense number which will be used as a reference number. The affidavits may be returned io 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. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents 0111ce of Invesugadons 600 Washington Street Boston, Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 eat. 406, 409 or 375 I The Town of Barnstable sum Department ebartm ent of Health Safety and Environmental Services �,, $ t Building Division 367 Main Sttea,Hyannis MA=0I OfBcc 308-790.6=7 Raiph C m�issio:._ Building cn Fax: 508.790-6730 For otnce use only Permit as Daft AFFIDAVIT HOME IMPROVEMENT*CONTRACI'OR LAW SUPPLEMENT TO PERMIT APPLICATION MGL a 142A requires that the "roconstrucdon, alterations, renovatim repair, moderni=d0fl- conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at lnst one but not more than tour dwelling units or to structures w?tich are adjacent to such residence or building be done by registered contractors, with certain exceptions. ng with other requirements. Type of Work: t.Cost - Address of work: 7Z Owner's Name Date of Permit Appilcntion• I hereby certify that: Registration is not required for the following reason(s): Work escinded by law Job under SI.000. �.,_4uilding not owner-occupied q Owner pulling own permit Notice is hereby given that:OWNERS .PULLING THEgt OWN PERMIT OR DEALING WITH UNREGMTERED CONTRACTORS FOR APPLICABLE B051E IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARAfM FUND UNDER MGL r. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a.permit as the agent of the orrrter: Dare Contractor Name Registration Na. OR , v VRe S 1. nine Da e • TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION .Please print. DATE PT _ ..... . JOB. LOCATION Number, Atreet address Se on of town "HOMEOWNER" Nam Rome phone Work phone - - PRESENT MAILING ADDRESS ' City own State Zip code he current exemption for "homeowners" was extended to include owner-occsri Swellings of six units -or less and to allow such homeowners to engage an in :ividual for hire who does not possess a license, provided that the owner cts as supervisor. EPINITION OF HOMEOWNER: erson(sj who owns a parcel of land on which he/she resides or intends to r- ide, on which there is, or is intended to be, a one or two family dwelling ttached or detached structures accessory to such use and/or farm structure: person who constructs more than one home in a two-year period shall not bf onsidered a homeowner. Such "homeowner"- shall submit to the Building Off_: n a form acceptable to the Building Official, that he/she shall be respons: or all such work performed under the building permit. (Section 109.1. 1) .he undersigned "homeowner" assumes responsibility for compliance with the r uilding Code and other applicable codes, by-laws, rules and regulations. he undersigned "homeowner" certifies that he/she understands the Town of arnstable Building Department minimum inspection procedures and requirement nd that he/she will comply with said pr cedures and requirements. OMEOWNER'S SIGNATU �-- � PPROVAL OF BUILDIN ICI Ote: Three family dwellings 35 , 000 cubic feet, or larger, will be required 0 comply with State Building Code Section 127. 0, Construction Control. HOME OWNER'S EXEMPTION The code state that: "Any Home Owner performing work for which a- buildin pewit is required shall be exempt from the provisions of this section (Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided that Home Owner engages a persons) for hire to do such work, that such Home 0' shall act as supervisor- " Many Home Owners who use this exemption are unaware that they are assuminc the responsibilities of a supervisor (see Appendix Q, Rules and Regulatic: for .licensing Construction Supervisors, Section 2. 15) . This lack of awar: often results in serious problems, particularly when the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the inlicensed person as it would with licensed Supervisor. The Home Owner ac as supervisor is ultimately responsible. . ... To ensure that the Home Owner is fully aware of his/fier responsibilities , ,==unities require, as part of the permit application, that the some Owne _rtify that he/she understands the responsibilities of a supervisor. On .ast page of this issue is a form currently used by several towns. You ma care to amend and adopt such a form/certification for use in your communit i j i i CAPE COD INSULATION K F N" FIRER GLASS SEAMLESS SPRAT FOAM SUSPENDED GATT$ B"`T RS INSULATION CEILINGS 1-800-696-6611 Town of Barnstable a � Regulatory Services , Building Division 200 Main St Hyannis, MA 02601 cn Date: y110/I3 c Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed& completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. Property Owner Property Address Village y Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings ( ) ( ) ( ) ( ) ( ) Slopes ( ) ( ) ( ) ( ) ( ) Floors lE(.,e e S ( ) ( X) ( Zv) (X) ( ) Walls rnE2R lI Sincerely He E Cas y Jr, President C e Cod I ulation, Inc. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION / ^ ao 13 o i1a Map la(b Parcel Application # Health Division Date Issued 3 Conservation Division Application Fee w Planning Dept. P mit Fee t Date Definitive Plan Approved b Planning Board Pp Y 9 Historic - OKH _ Preservation/ Hyannis Project St re t Address Village 1 /6 OwnerAu"191, / Address Telephone Permit Request .f U/ ! ��'l� �O 'zS /G ID Vl�lt, bp JAk ` 41 Square feet: 1 st floor: existing J proposed 2nd floor: existing proposed Total new `Zoning District Flood Plain Groundwater Overlay Project Valuation r✓' 0� Construction Type��0^kt,.") Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family M` Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout. ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq � w a Number of Baths: Full: existing new Half: existing F Ze W M. Number of Bedrooms: existing _new �+ Total Room Count (not including bath;): existing new First Floor Roo, Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove.,❑ ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size —Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals AutJ�orization ❑ Appeal # Recorded ❑ Commercial ❑Yes o If yes, site plan review# Current Use Proposed Use I APPLICANT INFORMATION 1 I/� 14(V IL ER OR HOMEOWNER). - Name Telephone Numbers 6, �75' Address it License#VV Home Improvement Contractor# �6 Worker's Compensation # W e,'DD 451_6 J D ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL PE TAKEN TO SIGNATURE DATE ! r -a ti FOR OFFICIAL USE ONLY E: APPLICATION# k DATE ISSUED F - ` MAP/PARCEL NO. ADDRESS VILLAGE OWNER 4 DATE OF INSPECTION: p ' FOUNDATION FRAME INSULATION FIREPLACE - ELECTRICAL: ROUGH FINAL . PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. n 1 I 1 f n Ca '\1assachusctts - Department of Public Safct� Boartf of Buil-tlin- Regulations and Standards Qonstruf-tion Supervisor License Licenr: CS 100988 r,. HENRY CASSIDY �. 8 SHED ROW ' ' WEV 1¢ARMOUTH, MA 02673 Expiration: 11/11/2013 ( luomissilu+ea' Tr#: 7620 Office of Consumer Affairs and Business Regulation -; 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 153567 Type: Private Corporation Expiration: 12/15/,?bl4 Tr# 233831 CAPE COD INSULATION, INC HENRY CASSIDY, 18 R EA R D O N CIRCLE ----_----------.--._.____._._ ._. _..._........ SO. YARMOUTH, MA 02664 - - Update Address and return card. Mark reason for change. Address 0 Renewal [] Employment �__I Lost Card i'�flr lr`O.I7t IIl,(%FlLK3[it/�!C Ct`�'([(7JJC7('�f6JN�t v\ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to; i egistration: 153567 Type: Office of Consumer Affairs and Business Regulation xpiration: 12/1`5/2014 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 CAPE COD INSULATION;•'::INC HENRY CASSIDY 18 REARDON CIRCLE SO.YARMOUTH,MA 02664 _of val' (t22?Zho NN The Commonwealth of Massachusetts Print Form ==T^ � Department of Industrial Accidents h'�v l f � Office of Investigations 1 Congress Street, Suite 100 Boston MA 02114-2017 • i, f4/ www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Naine (Business/Organization/Individual): a Address: la &/dO14, lit r�it city/state/zip: VA IMF' Phone #: yJO�- 11,, - IZ I _ Are you an employer? Check.*teppropriate box: Type of project(required): I.FJ) I am a employer with 20 4. ❑ .1 am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2-❑ 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 working for n:e in any capacity, employees and have workers' 9. ❑ Building addition (No workers' comp.insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.El am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof r.epMrs c�Q insurance required.] .t c. 152, §1(4), and we have no 13. Other We�`����i � employees. [No workers' comp. insurance required.] 'Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'ontractors 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. [['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 infvrtnation. /� rr G Insurance Company Name: d 0 h(,,, IV1 (I�G V1 G Pi 'In � • Policy #or Self-ins. Lic. #: WG� OOP 2� q0 Expiration Date: Job Site Address: City/State/Zip: j 1►Vt I _ Attach a copy of the workers' compensation policy declaration page(showing the policy numller 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 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 tine 01'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 cer/i tiller the pains_nil penalties of er'urp that the information provided above is true and correct. Si nature: / Date. Phone#: Official use only. Do not write in this area, to be completed by city or town official 4 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 S. Other Contact Person: Phone#: N v GlIentif:450 CCINSUL, A CORD,, CERTIFICATE OF LIABILITY INSURANCE 1 77 �------ I Tii F,�I,�- V A OF - Y A ND CONFERS NO RIGH T 8Ur(Kf F�T E_PT1FJ-AfTH�0CG7_:F 0212_0 2 CEK*1IFIC:AT- 0 0HS N0-'AVIRMA IVCLY QR NEGAIIVE_yi\Vik I'M.EXTEND ORALTERTFIE COV:I:ACQ AFFORDED UY Till POLICIES HIJ0G- I _1� CLFTIFICAT:()F INSURANCE DOES NOTUM11"JIF ACONITUCT BEIWEEN'IHE 1J5.11NG IN'Wl�I: Au HQIULL)FFPQ ,M:N A 'iV_ C)I�t "L)TI-IF CERTIFICATE H6_1.1 R, 1uCt I N'P 0 1 -rA N Lj 1 cj u I I u 411 A 0 11'IUNAL IN i U 0 L,wldolxecl.If 16N (11 hok, A '-'utj I vl l0ol ju alk v411((QIhumunL.A t�tujojIjLIjj 111L.Pik!(it HVIIN to(Itt; Ay lkl-i. —So. uVwI(Ilk; NAME "ll )idle[Y!.,LIIIQ jmc No fm - --------- 6 u I . ......... -------- 16 133 r.:"Ijl:- cod fnsulatlon 11 10 L'"114 1C)"1116l-II'LIA4:E)CQIIIJ)FLlly 't' YOMMLIM AdMill(4 4,'t .................... IVIA 02tj(')I ,Ill,QrCQ 11161.11'clilCe Coijjpljjy 34 -I ........... ------ L'Lk I]FICA I L NUMUER; 'i 1-0-111E llj�(j-r ,.I1.11'VVI I I l.,.i f Af,4I)jjj(, ANY fAVE BEEN i�, _ IqAhiL--D ABOVrz 1:1 It A I I KNI OR 10111 OF AljY CONTRACT OR OTHER DOGUMEN I WI-1-1-1 . . MAY Ul.: OR MAY I-1f-_'Rj-A1N, THE INSURANCE By'MIS POLICIES DESCRIBEL) ilfft ' ra-SlIt-Cl To WSIONi ANO k"UNIAVIONS OF SUCH POLICIES, Llwl"� SFicjwju EIN IS SU0JCGf CO All- HIF Lr-LN RCOUCM BY PAID CLAIMS A N G L- RF__ ,Lq , F, J', 1.1,�RAL (JAW1.1 I V (A-W-flAk.HAH11-11Y Quu MAW- [50 ci)CCUR ........------ tAff)t:)(t'(PiqK±1 pn1LOnL__j, ......... 1�1=,IlSUPW1.,A Aov INjully L'i I ......Q.001'q ..........__­__'...____._ ppq PhOOLIC I"S•I-.QMl I AG _j 'l2MM8CKVNjiN ;:' ................... 00011-Y INJURY(P. x I�;1(�I,(�C-I�u 1.c o ___ __ 1,10011-V INJURY(P­ jktj PROPE XONJ4535 121 207�0410JI c' ql4i�104�J3U12U 1" 16 lk,)N YIN ­ . _­`� ^'I AW) I.IA�jjjj IN v I , v I lvg . C) NiA 011 ACC.101�pfl' Nh) '12 0 G.L.01�XAN P0W',VI_Ih(If I V1,0 0,0U0 WN 01 1 10N,'I LOCA I MN S I VLHICLCS(ALI-1,ACORL)tu I,Aajhf.'­,..... IV lokillflyu) Worlkvra comp Infullflulioll (.;kjfjcjjalLia0ilitywIIQn ro(julrod by written or aqjreQmellt. CANCELLATION GQ0 1(l6LJlZA(AojjjjjC SHOULD ANYOF THIE A15CV15 Qf`iCJeWUI PQL.jCIE',i IIE 11-11P EXPIRATION DATE TI-11HRECIF, NCJ'lt(:V,, WILL htc UC-LiVI:kt,I) IN ACCORDANCE WI1'I­( THE PCILK'Y PROV121OW4. Liu -2U-11JACOND(:0141"(1114AIJON.All 091I1u 1o41v0d. !u wm) I ot flip ACORD 11LAIIII5 alld 1000 and I'Llillhitwod marks UACORD mky = Y two PARnCIPMMG mass save - CONIUM PERMIT AUTHORIZATION FORD owner, of the.property located at: (Ownerls Name;printed) 6 (Pro ity StreetAddress)---' (City/Town .. ) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my:behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signaturer Date e. FOR CSG OFFICE:USE ONLY. Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced.project:: Particip ting Contractor Date Rev:12132011