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0006 ISALENE ROAD
�� ���� � � � � � � '' . � � S � �� s , Town of Barnstable 11 1n g x Post This Card So That it is Visible From the Street-.Approved Plan's Must be Retained on Job and:this Card,Must be Kept, auMarnex e Posted Until`Final Inspectio,n Has Been Made._ _ �y�gy��� i Where a Cert ficate:of Occupancy is Required,such Building shall Not�be Occupied'until a Final Inspection has been_made.. i Jl1l Permit No. B-20-174 Applicant Name: William Callahan Approvals Date Issued: 01/21/2020 Current Use: Structure f Permit Type: Building-Insulation-Residential Expiration Date: 07/21/2020 Foundation: Location: 6 ISALENE STREET, HYANNIS µ Ma /Lot 267-081 Zoning District: RB Sheathing: P x Contractor Name: EFFICIENT BUILDINGS LLC Framing: 1 Owner on Record: SULLIVAN, KATHLEEN MARY g Address: PO BOX 275 ' Contractor License`: 169944 2 R WEST HYANNISPORT, MA 02672 :. µl Est Project Cost: $4,900.00 Chimney: Description: Attic Insulation Permit Fee: $85.00 Insulation: Project Review Req: Fee Paid:° S 85.00 Date. w, ' 1/21/2020 Final: le11 Ail Plumbing/Gas GG -V -Rough Plumbing: Building.Official - Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months aftevissuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for-which this permit has been granted. Rough.Gas:. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by,laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for,p ublic inspection for the entire duration of the Final Gas: 'work until the completion of the same. ' . Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this,permit. Minimum of Five Call Inspections Required for All Construction Work:J$< Y '� Service: 1.Foundation or Footing r Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "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: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT J� 1 f., Town: of BarnstableBuildl, :, ..;, . ., .,. _ ., ,� .. � ry t;t� :. . , r•mghe?Street' A rov Plan sk �R �nedon� ran �. A � �,,..,�> ,:.,t:,..,�•, , ,•..,. ;:.. , .,;;,•�> rNRlYSiA$LE; �. c _„r„ ,:;.n:�^a v .z � :�, fix- fir, r-a v. ��su ,. ✓' . 1' r t Untl!E nalans ection,Has<Been,Made., ,�..h, ,� ,.� � �- "` °Wher a�Certfficate`° f�Occu anc..�s.Re wired suchaBuildm sI�aII:No#�be,� ccu ied�,uht�l,aaFinal�lns ection hasr een.:rhade N-�,..,. •:�' Y�., . . . .... _. .; ',: . Applicant Name, Mike McMahon Approvals Permit No B-17'2858 PP - q Date Issued 09/01/2017 Current Use :.'<, ° Structure Permit Type:' Building-'Insulation-Residential' Expiration Da. Foundation: 03/0,1/2018 Location: 6 ISALENE STREET, HYANNIS Map/Lot 267 081 Zoning District: RB Sheathing: Owner on Record: SULLIVAN,CECILE M ` - Codtra�ctor Name: MICHAEL T MCMAHON Framing: 1 Address: PO BOX275 )' � `Cont actor License_GCS-068111 2 WEST HYANNISPORT, MA 02672 r -r Est Project Cost: $5,000.00 Chimney: - Description: Weatherization,air sealing,weather stripping and blown cellulose 3Rermit Fee: $85.00 Insulation: Project Review Req: Weatherization,air sealing,weather stIppingand blownFe P,ad:` $85.00 cellulose Final: Date 9/1/2017 ViAw ° '. Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: . 4 g: This permit shall be deemed abandoned and invalid unless the work authonzed by this permit is commenced within six rronths after issuance. Rough Gas All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and str� ctu uresrshall be in compliance with the local zomrig by lawsand codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or road nd shall be maintained open forpublicinspection 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#Bwldmg and`Fire Officials are provided on this permit: Service: ' Minimum of Five Call Inspections Required for All Construction Work A e 1.Foundation or Footing ��. �� , Rough: ` u,. a .. ..: :•� 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbingi.and Mechanical Installations: Health , Work shall not proceed until the lnspecto.r has approved the various stages of.construction Final _. "Persons contractrn :w h unre iste.re contractors do not have a ss t the. grant':fund" t�fotth.'in�g it g. er d cce o gu (as se MGL c.1.42A). `t` - , . -, i p` F're De�a " men • Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT=ISSUED RECIPIENT' �N : � poW Town of Barnstable =Permit;�V�� `�i OEcpires 6.o 1, isle date Regulatory Selr-Aees - Fee 0 8 BnartsTest.ttiKAM a �$ a ; Richard V.Scali,Interim Director Building Division - Tom Perry,CBO,Building Commissioner OCT 200 Main Street,Hyannis,MA 026 Q 7 Nv%inv.ton.bamstable.ma.us rOWN OF 015 Office: 508-862-4038 �A" 8-190-6230 EXPRESS PERAUT APPLICATION - RESIDENTIAL NTIA�.. ® LE Not Valid witlroul Red X-Press bnprint Map/parcel Number 2&7 Property'�Address 6 �g lel4 e—i_R ck _ � t E�Residential Value of Work S Minimum fee of S35.00 for work under$6000.00 Owner's Name&Address CPGi�P_ S-UL;✓Gr1 6 Tsalen e Sto-ee t :wys-r c Der /I1d� Contractor's Name r4y-rn&Le,tj;0jn S / gr; ,,, � t Scan Telephone Number(4C)112 Z -Cl 9-DO _ ?— Home Improvement Contractor License--.'.'(if applicable)_ /7 3 y S Email: Construction Supervisor's License 1(if applicable) I p ci 7 p-7 19Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I°am the Homeowner I have Worker's Compensation Insurance Insurance-Company Name A e n gLL jt a1 n-&u ra Yt Ce_ Workman's Comp.Policy" WC 9 2 80 S$ 35 2 -i y Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shinM 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 • 30 (mar-imum 5)_of windows ,3 T of doors: Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *IA here required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. "—Note: Property4owner must sigh Property Owner Letter of Permission. A copy Q the Home Improvement Contractors License&Construction Supervisors License is required. - q . SIGiNATURE: ` AlY QNTFILES\FOUMbuilding permit formslEXPRESS_doc Revised 061313 i a. X- n-. %assw' _ ria €aaavea affilt 'l4. a 1 �c lQ8�41rF�Vfl�t11 Via ,DOO&.,E4�i '�,4a�€LD�ry�I�C. 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WE 0, � I����� �� a4iri ast;d. �'r31t{#F Fi93 ir�� :off �_ F.Aa1Ei 01 d m In C 4M CIE f le a i� �3':71?sdj i�.. fl�4 iddk Fda ark ifA. twift 1'd ate and hi adm��19"aiyiti r�if lar P aI� wkl ! b ggR",lilt�rP' b� alri;IFa I: n + aac�w3Et�Ii fir [ Ifi q: *I a� �t"tl 'g de I�Pb �e nP I 'si �r b P�e�irsie>w dot '� � IeJ�� i7•�i n W Im It ogee P I�6 e I, � arils soli � e�a+li5'l� �g� ��co �k1m ii al g i t e[ aa'�, �e� c a,� two", ,er�au�nP dam:� I�� i�! goy ,,lw � d � a4e a, Sri e®ft_#W BY! n a�'. aril ,ieQ a $�JM1tI 1�iR #��t �� pn+F1 Pr i�af �,t �fI @ 14me �t N l , L�l1c��Aii�FlS91�[j P w F I+1RTTIL, F11�bC1 .1 � _ r Southern New England Windows d.b.a Renewal by Andersen of SNE t Massachusetts-Department of Public Safety ` Board of Building Regulations and Standards Construction SuP en-isor s- License: CS-095707 P BRIAN D DFNNISbN t 7 LAMBS POND CIERR Charlton MA 01507 Expiration Commissioner 09/0812016 kfConsume r Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Registration: 173245 Type: Supplement Card _. Expiration: 9/192016 SOUTHERN NEW ENGLAND WIMUWS LL - DENNISON BRIAN 26 ALBION RD -- ---- LINCOLN,RI 02865 Update Address and return card.Mark reason for change. S I p zou�osrtr .: ❑Address CI Renewal ❑Employment Q Last Card - C7�c L%�nn..nau;<r./f/r c`'Q�uazu r/�:clG (lire atC psemeraffairs&Business Regulation License or registration valid for individul use only - ME IMPROVEMENT before the expiration date. If found return to: - Office of Consumer Affairs and Business Regulation �.� $, Registration: 173245 Type. 10 Park Plaza-Suite 5170 `�y� Explratlon: 91192016 Supplement'.:ard Boston,MA 02116 - SOUTHERN NEW ENGLAND WINDOWS LLC. J' RENEWAL BY ANDERSON DENNISON BRIAN 26 ALBION RD LINCOLN,RI 02865 Uadersrcretary Not valid without signature The Comnionwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston,MA 02111 www.massgov1dia Workers' Compensation Insurance Affidavit: Bnelde»IContmet®.rs/Electrici:ns/Plumbers ARplicant Information Please Print Lgdbty C � Name(Business/Organization/Individual): J /a Address.- 911 City/State/Zip: LW' ak. �,x ®,?-g 4 S- Phone#: 1[0/— 02,2-6 " ?gam Are you an employer?Check the appropriate box: 'Type of project(required): 1.® 1 am a employer with c5;2© -- 4. n I am a general contractor and i 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors .2.El1 am a sole proprietor or partner- listed on the attached sheet+ ❑.Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. workers'comp,insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We area corporation and its required.] officers have_exercised their 10.0Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I LF1 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.[✓]rOther&i k/-e,014ee,wa 1� comp.insurance required.] -r *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 their workers'comp.policy information. I am an employer that ds providing workers'compensation insurance for my employees. Below ds-the policy and job site information. Insurance Company Name: ® aw Policy#or Self:ins.Lic.#: � ' 0 `j,V3 J pZ 3 Expiration Date: f Zwo Job Site Address: � a lets e -f71eC- City/State/Zip: /qI4 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$250.00 a day against the violator. Be advised-that a copy of this statement may be forwarded to the Office of Investigations of the.DIA for insurance coverage verification. I do hereby cerlsfy r the p andpenafties ofperjury that the information provided above is true and comet& Si ature:1` Date: /U- Phone#: Official use only. Do not write timer this area,to be completed by city or town offXiad City or Town: PerrnittUcense# Issuing Authority(circle one): 1.Board of health 2.Building(Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r SOUTNEW-01 PARKERNATHCO CERTIFICATE OF LIABILITY INSURANCE 8113I201513120/5 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE.HOLDER. IMPORTANT: if the certificate holier is an ADDITIONAL INSURED,the po►icy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to I the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT IVAM)~ 1Miils Certificate Center ; Willis of New Jersey,Inc I PHONE 87 c/o 28 Century Blvd i No,Eml:( 7)945-737$ tAtC Not(888)467-2378 P.O.Box 305191 I X-MAIL Nashville,TN 37230-6191 A°D INSURER(S)AFFORDING COVERAGE NAtC d INsuREttA.Selective Insurance Company of Southeast 39926 INSURER B:OneBeacon Insurance Company 21970 .Southern New England Windows LLC ;INSURER C:Argonaut Insurance Company 19801 L; D/BfA Renewal by Andersen 28 Albion Road INSURER D: Lincoln,RI 02885 s INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO MICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES_LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OP INSURANCE POLICY EFF POLICY EXP POLICY NUMBER MIDDNM rvmr LIMITS f A X COMMERCIAL GENERAL LIABILITY I CLAIMS-MADE L^_i OCCUR X IS 2029459 . 08110/2016 08/10/2016 I�i7dAt,E EACH OCCURRENCE $ 1,100,0011 PREmISEB(Eaocarrancel Is 100, MED EXP(Any one person) i$ n�1t00, i PERSONAL tt ADV IN URY Is 1,000 Wd , GEML AGGREGATE LIMIT APPLIES PER: �GENERAI AGGREGATE $ 3,000,0001 RO- POLICY a j C LOC (� i PRODUCTS-COMP/OPAGG f$ 3410000! OTHER: AUTOMOBILE LIABILnY I COMBINED SINGLE LIMIT X ` I Ea accident S 1,000,00 ANY ` X I S 2029459 08/1012015 08/1012016 BODILY INJURY(Per person) S I AIUT � n AUTOSCHEDULED BODILY INJURY(Per ea�ani) $ X HIREDAUTOS I NO IAUTON-OWNED I l I PROPERTY DARtAflE S �reraccid_ 1 � S UMBRELLA LIAB OCCUR EACH OCGURREMGE S EXCESS L640 HCLAIMS-MADE AGGREGATE S DED RETENTiC1S i S VNORKERS COW"$ATION i B ,AND EMPLOY0tS'LIABILfTY Y/N {i X S ANY PROPRIETORIPARTNERlEXECUTFVE 11�--::�;��-�j 1 00008802$ ;081211201510812112018 EL EACH ACCIDENT S I M0,040 I OFRCERAPEMBER EXCLUDED? N t A I ; F I yyeessddesa�e under l In NFQ EL DISEASE-EA EMPLO S 1,000,00 OESLdtIPTiONOFOPERAT10NShelow I EL DISEASE-POLICY LIMIT S 11000,00 C Workers Compensation I C92BD58352394 08/21/2015I 08/211201ti See Attached I DESCRIPTION OFOPERATIONS I LOCATIONS f VEFACLES(ACORD iOl,AddlUmral Remarks schedule,maybe atlached If mom space Is requlmd) jl THIS CERTIFICATE VOIDS AND REPLACES THE PREVIOUSLY ISSUED CERTIFICATE DATED:8/11/2015 Auto Policy includes additional insured when required by written contract/agreement as per policy form. HSS Holding Corporation,Inc.and any,subsidiaries are included as an Additional Insured as respects to General Liability when required by written contractlagreement as per policy form. .i ` CERTIFICATE HOLDER CANCELLATION I 1 i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1 THE EXPIRATION ,DATE THEREOF, NOTICE MLL BE DELPJERED IN, ACCORDANCE WrrFk THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE O 1988-2014 ACORD CORPORATION. AR rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Town of Barnstable *Permit# Cr Expires 6 months from issue date Regulatory Services. Fee LD Thomas F.Geiler,Director l Building Division o BAD Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 2,00 X i Lov r. Property Address_6,7 _ g54 A'IC- �!r LU 6YA;N/V/-s f e f-% 2-fresidential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address tC'JLC dy'/ 5�lL�r Contractor's Name elephone Number,,`�cY Home Improvement Contractor License#(if applicable) rZZ-6 3 Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: /�I am a sole proprietor L� 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/doors/sliders. 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. A co y of the Home Improvement Contractors License is required. SIGNATURE: Q:Fornvs:expmtrg Revise061306 GTE �,m, a�' Board of Building g Regulations and Standards r HOME IMPROVEMENT CONTRACTOR t Re'gistrati _ Expiration u102635 7/2/2008 1 BRAY BUILDING RE MOD Roger Bra ; ELING:C0. Y K 192 LONG POND DRIVE='; E.HARWICH, _ I MA 02645 �` I Deputy Administrator f The Commonwealth of Massachusetts ` Department of Industrial Accidents = j Office of Investigations + d 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyibly Name(Business/Organization/Individual): Address: x / 11/�et� City/State/Zip: #4oQGtJe;nV f 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 6. New construction . . employees (full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling hip and have no employees These sub-contractors have 8. Demolition working for me in an capacity. employees and have workers' g Y P ty $ 9. 0 Building addition [No workers' comp.insurance comp.insurance. required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.7 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 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 pal sand penalties of perjury that the information provided above is true and correct. 52 Sigmature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town ofj ccial City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructi®ns Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two.or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to'operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,'§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for.the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contiactor(s)name(s),address(es)and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers'compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. -The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all.locations in {city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please.do not hesitate to'give us a call. The Department's address,telephone-and fax number:. The Commonwealth of Massachusetts Department of Industrial Acoidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. 4 617-727-4900 exfi 406 or 1-877-MASSAFE Fax 4 617-727-7749 Revised 11-22-06 www.mass.go�/dia �oFIME T�,y Town of Barnstable Regulatory Services SUBM Thomas F.Geiler,Director `bA 3639' b Building Division lED H1A'� Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-8 62-403 8 Fax: 508-790-623 0 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 b7 this building permit application for; , (Address of job) r Signature of Owner Date Print Name QFOPM-S:O VPM-RPETWSSION Engineering Dept.(3rd floor) Map '-7 • Parcel j �` " Permit# :26 r 6 House# - Date Issued —9 � .Board of Health(3rd floor)(8:15 -9:30/•1:00-4:30) - �: 5'a Fee Conservation Office(4th floor)(8:30-9:30/1:00=2:00) f INSULLE® I2lonnin —1 Arlm, Bldg) L1ANC De lm d 19R� + - FARNSTABLE MASS. TOWN OFBARNSTABLE Building Permit Application Proje et Address Village Z 4E.5r ��7®�/(f/��11�% OwnerC&.167 Address � /M0/16 Telephone 'Permit Request 46,"7- 14 11A- 72 0, ZgYZSTA- 6 Zih i1 ir0 h� First Floor square feet Second Floor square feet Construction Type ,! Estimated Project Cost $ /,5 1 DO® Zoning District Flood Plain Water Protection Lot Size Z 0, Grandfathered ,A Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure %,-? Historic House ❑Yes ANo On Old King's Highway ❑Yes kNo Basement Type: ,Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing L New Half: Existing New No. of Bedrooms: Existing 3 New i Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: kGas ❑Oil ❑Electric ❑Other Central Air ❑Yes kNo Fireplaces: Existing l New Existing wood/coal stove ❑Yes 4No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) None Shed(size) a ❑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 SIGNATURE C �� j r �j /'L / DATE BUILDING PERMIT DEN qF0Xk.FOLLOW NG REASON(S) y Jt • FOR OFFICIAL USE ONLY cy PERMIT NO. �/ V ' DATE ISSUED I ` _ 1 MAP/PARCEL NO: ADDRESS VILLAGE { OWNER - � X ' . I f � i ,� • _ � � � `' .~ DATE OF INSPECTION-' FOUNDATION Dt--)o FRAME INSULATION 'FIREPLACEf T s` ELECTRICAL: ROUGH - FINAL _ PLUMBING: ROUGH FINAL - GAS: �' } ROUGH ,FINAL' FINAL BUILDING. DATE CLOSED OUT r t ASSOCIATION PLAN NO. r t ' � 7 The Commonwealth of Atassac h uscttt Department of I11(hrstrial Accidents ,1 ` ° „ - 1� Office ollnvesligallons 600 N'ushitrrtun Street Bmtorr. A1uas. 02111 ` Workers' Compensation Insurance Affidavit ltitilic.int infortnation': — PlcTse PRINT IEihj'�""" name: ocati n:A� city lil�l /7 r/ /�Jj��t?�� phone# 775 _ 3/Y 3 I am a homeowner performing all work myself. 1 am a sole proprietor and have no one working in any capacity • �-v... .-nw•....�r-rP.....�..-........�.._,..1rovY'r.f+vfrl T"'�w!'.- -i7TT.w^' ., - ........�. CI I am an employer providing workers' compensation for my employees working on this job. cons an• name: address: t city: phnne#- insurnncc en. nolicv# 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: comnanv nine- address: cih: phone#• insurance cn. nolicv 0 � - •,-,- `Y.'=.. � _ �..:Y.._ ...,._ _- ��r'_'�-"tb::��ti�iT"f�wws;�-� --:T.r._.�.; _ ....•ram...�i•.-._..".�_ comnan.' name: address: city- phnne#- insurnncc co, policy# Attach additilinal sheet irIItCCSEary� =._"==;_.r _ +--"r.'. .. .�.r' �' .f."""%�•.%':':' ;'r:.::.•�'�'y='.%'�'_;+..- "_�,. •—• :+y.. - - - =�. �::� :ii•-�tom__.....:---� �=e►__ ...._._��.:- =s i=�� yir?.r��ie•.w�r.:.i. Failure to secure coverage as required under Section 25A of 111GL 152 can lead to the imposition of criminal penalties of a line up to S1.500.00 andiur une%ears'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. 1 understand that n cope of this statement ma} be forwarded to the Office of investigations of the DIA fur coverage verification. 1 do herebt•cerrifi•under the pains and penalties of perjun•that the information provided above is true and correct. Signature D./t :A'GL./�/I�GY/l+C.J Date Print name C at �� �l�L�l I�t Phone# T r al use only do not write in this area to be completed by city or town official r town: permit/license# rIBuilding Department IC3Licensing Huard check if immediate response is required 135clectmen's Ofrice f ollealth Department contact person: phone#: r'1Olher i. r i rt�ne::S, �P)•V Information and Instructions ' 'any a��, •�t ry a5,:2 x. tl o.-ti�. �nl � .. {„ Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers-compensation for the.'employees. As quoted from the "law". an enlpinrec is defined as every person in,the service of another under any ,contract of hire, express or implied. oral or written. An empinrer is defined as-all'individual. partnership,association, corporation or other legal entity, or any two or more _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 dw-elling house of another who employs persons to do maintenance , construction or repair work on such dwelling hog or on the grounds or building appurtenant thereto shall not because of such_employmeitt be deemed to be an employer MGL chapter 152 section 25 also states that every state or local licensing agency sl►all withhold the issuance or rencival of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant -.f•ho has not produced acceptable evidence of compliance with the insurance,coverage required. , Additionally. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter 1l,. been preserved to the contracting authority. r. . -777 f Applicants Please fill in the workers' compensation affidavit completely, by checking the boa tltaf applies io your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested. not the Department of Industrial Accidents. Should you have any questions regarding the "law"or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. .7.7777 _.. _... ......�r... .. . .._.. .. _,... . ...� �.._....,..— Cityor,rowns _.. __._..,:. _...,._. _....._ , .._.._ .:. ..__..m..•.. _.... Please be sure that the affidatit is complete and printed legibly. The Department has provided a space at the bottorn of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Plea be sure to fill in the permit/license number which will be used as a reference„number. Tice affidavits may be returned t, the Department by mail or FAX unless other arrangements have been made. The Office of Investi=ations would like to thank you in advance for you cooperation and should you have any question please do not hesitate to give us a call. I The Department's address. telephone and fax number The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 : .�. : The Town of Barnstable UBMAEM - ALAM �0�' Department of Health Safety and Environmental Services Eo5" Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: --7;illl-o(,1216 / Est.Cost / Address of Work: Owner's Name Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR Date Owner's Name • t • TOWN OF BARNSTABLE , ,BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE • .l r�. - JOB. CATION LO al �✓t� � S Number Street address Section of town "HOMEOWNER" Name r� Home phone Work phone PRESENT MAILING ADDRESS It-la" 90�' psi i�'?YI-Nm soe r as City town State Zip code The current exemption for "homeowners" was extended to include owner-occupiec dwellings of six units or less and to allow such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Person(sj who owns a parcel of land on which he/she resides or intends to re- side, 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 Offici on a form acceptable to the Building Official, that he/she shall be responsih for all such work performed under the building permit. (Section 109. 1. 1) The undersigned "homeowner" assumes ..responsibility for compliance with the St Building Code and other applicable codes, by-laws, 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. HOMEOWNER'S SIGNATURE � ^ a APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be required to 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 building permit is required shall' be exempt from the provisions of this section (Section 109.1. 1 - Licensing of Construction Supervisors) ; provided that if Horne Owner engages a persons) for hire to do such work, that such Home Ownez shall act as supervisor. " . Many Home Owners who' use this exemption are unaware that they are assuming the responsibilitiesl*� of a supervisor (see Appendix Q, Rules and Regulations for .licensing Construction Supervisors, Section 2. 15) . This lack of awarene: 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-' actir as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his/her responsibilities, man co.'nmunities, require, as part of the permit application, that the Home Owner 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 to amend and adopt such a form/certification for use in your community. Town of Barnstable Building Department Complainulnquiry Report Date: �✓r — 1r� Rec'd by: Assessor's No.: Complaint Name: � ' — Location G Address• M/r •e " Originator Na,ne: Street: Village: State: Zip: Telephone: D/E Complaint Description: Inquiry 0 Description: For Once Use Only Inspector's / Action/Comments Date: b I b' 2 Inspector. v ROO ` 1 Follow-up Action Additional Info. 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I ldyartni�s, M9 02601 I Lit LAMO w ap YJ Parcel �1s� O ermit# Conservation Office(4th floor)(8:30-9:30/1:00-'2:00) q1j Date Issued Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) q^ ;-"wllel 4�/Wee j Engineering Dept.(3rd'floor) House# P SEPTIC S T BE liefiffoopp"Mt 19 , INSTALLED ANCE TOWN OF BARNSTABff 6MENTAL CODE ® TOWN REGULAT90N J . / Building Permit Application / Project dress ��S���r�,� &e..o'l r + Village /7 Owner 4feC:/.t- J LI/y 1)�h v�- Nil J1 � a ar_Wddress 1.SF,It✓Lt. Telephone Permit Request �/3,,L;/a?;n4 144U,• ,. m 0 M First Floor_ square feet Second Floor square feet Estimated Project Cost $ 141066 Zoning District Flood Plain Water Protection Lot Size - 23 Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use L°° "" '� Proposed Use Construction Type W-001 T/'c rn to Commercial Residential t Dwelling Type: Single Family ✓ Two Family Multi-Family Age of Existing Structure 3 & t Basement Type: Finished Historic House Unfinished Old King's Highway Number of Baths / ,✓ No.of Bedrooms 3 Total Room Count(not including baths) J First Floor Heat Type and Fuel ok,6 Central Air ®& Fireplaces / Garage: Detached Other Detached Structures: Pool Attached Barn None ✓ Sheds Other Builder Information Name Telephone Number 7 F10 Address ZV -okn Y e— 1?0410q License# S Y3 0 Home Improvement Contractor# //4 S-3 3 Worker's Compensation#,3 0 3 3 0,/04 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 / L1/ SIGNATURE G DATE 9 /i If BUILDING PERM DENIED FOR THE LOWING REASON(S) FOR OFFICIAL USE ONLY _ r P MIT NO. - = DO ISSUED M; P/PARCEL NO. ADDRESS VILLAGE t - OWNER 3I DATE OF INSPECTION: ': FOUNDATION FRAME: INSULATION � ' r � ,, _ • 1 - - w -: _ FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ti GAS: ROUC�3I '. FINAL FINAL BUILDING I�r ' DATE CLOSED OUT r ASSOCIATION PLAN NO I : The Town .of Barnstable NAM $ ' Department of Health`Safety and Environmental Services Building Division 367 Main Strut,Hyannis MA 02601 Office: 508 790-6227 Ralph Croce Building Commissio Far- 508 775-3344 For office use only _ Permit no. X. Date : ' AFFIDAVIT i HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION .MGL c. 142A requires that the"reconstruction,alterations,'renovation,repair,modernization,conversion, improvement,.removal, demolition. or construction of an addition to nay pre-cdsting owner occupied p s which are adjacent building containing at least one but not more than four dwelling units or to strncttues to such residence or building be done by registered contractors,with attain exceptions, along with other requirements. Type of Work: ��a /l, aid; r- Est Cost 1 Address of Work: .�5� •ti Oaner.Name: Ce c./t �� ��:I/w Date of Permit Application: t///r I hereby certify that: Registration is not required for the following rtason(s): _Work occluded by law ob under S1,000 Building not owner-occupied Owner pulling own p=# Notice is hereby green that: CONTRACTORS OWNERS PULLING R OWN PERMIT OR DEALING WITfIL7I�ItEGIS'fF.ItED FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. ate Contractor name Registration No. OR n Owner's name ` The Commonwealth of Alas. tuseas ~ - rij '�` —_.�•�r Department of Industrial Accidents 600 If'asidit.-pon Street Boston.Mays. 02111 Workers' Compensation Insurance.ARdavit _._ __. .. leRtllica—nt reformation:" Please PRINT 1pja�� "'' `�'�`� _ - !�-r~r-1C loan ion- GAJ er V i• 1 �A4C... 0�2.l?-2- nhnne# V -7 F16 1 am a homeowner perfo ing all work myself. I am a sole proprietor and have no one working in any capacity 1 am an employer providing workers' compensation for my employees working on this job. comilan 1,`*-4C 4 /9Q. SL-11 q address: �l � nIr /(OF city: Cr r. 0.2 d 3 9' nhone#: inutrnnce ce_ Rey# 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—phone#• insurnnrr rn volley# """rrr..•c;.:..,ps.r-=-bra':•:- -.es;^sT?!SF:sS -', - - -------- •�7RFR:' :r.+t. ei?tiy!•_+!R+^'abe�43�s!R•1^'•—.-71 r� any name• address: rt•: phone# insnrnnrn rn policy Al ;Atiachadditional*sheet ifneeasary�:••� ' —` =•� � '" " .';rs�, Failure to secure coverage as required under Section 25A of hIGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a copy of this statement maybe forwarded to the Once of Investigations of the DIA for coverage verifteation. I do hereht•cerrify unr er the pants and pe Mittes perjury that the inforntation pnnided above is true and correct: r• Signature ate Print name °�/� A one# oifcial use only do not write in this area to be completed by city or town ofilcial city or town:n: permit/llcense# nBuilding Department Licensing Board ` 0 check if immediate response is required QSelectmen's Office �liealth Department contact person• phone#; nOther (mysed R95 PJA) - Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employces. 'As quoted from the "law", an emplm+ee is defined as every person in the service of another under any contract of hire, express or implied, oral or,%+Tinen. An empli,yer is defined as an individual, partnership,association. corporation or other ;::gal 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 1'52 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonvealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally.neither the commonwealth nor any of its political subdivisions shall enter into'any contract for the performance of-public work until acceptable evidence of compliance with the insurance requirement's of this chapter have been presented to the contracting authority. L.�.wr.rw.-��—.��!1!w• _ ra. 1'+wY �y:w P� �.�[i'.:�I";l U`'.1 i:fAa .r+,,t`'..1r .. • ,. .�.�.•,,.':• .,.�....:..�� p�S•f;':;:: .,. .�,s•t'ij:.'.1�a�'•.. '� _ice` .M+..f�^:a:W'":�.i t .,. . i r w.ti. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance 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 for regarding the"law"or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. ^w�.s�w.� .. .•::.' .`•7 71 77 �w'r ..3 �4i1 .r..ai�.fih^q,1 u.:'{1�7�y 'Yw"F!'•.M. •• City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. ; The Office of Investigations would iike 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 office of Investigations 600 Washington Street -- Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 ext. 406, 409 or 375 DEPARTMENT OF PUBLIC SAFETY : ONE ASHBORTON PLACE BOS.TON,MA 02108 ' LICENSt CONSTR. SUPERVISOR EFFECTIVE DATE L)C-NO. 06/30/1993 005432 o' g MARK A STANLE1 i ° 14 OXNE-R RD Z. CENTERVILL MIA 02632 m NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALL' STAMPED-OR-SIGNATURE OF THE COMMISSIONER IGNATURE 343EE -- O,.IER Il�tas�ok � �: --_--_;-_ ✓/ie e,wmanuiea/!�°�✓ ar/utdella 1 iJSA HOME IMPROVEMENT CONTRACTOR Registration 116533 Type - INDIVIDUAL, Expiration 06/23/96 ',. MARK A STANLEY ;. MARK A. STANLEY '�T Q o� U/OXNER RD ADMINISTRATOR CENTERVILLE MA 02632 I i. 1L.UU ' 34 .00' 11 ' 18.00, 35. 7.00' b 10.00 , ADDITION 0.03' �. 1�0 8.00'� CD�- 13 -fl i SK�CT f VvlJUv v 0.09' -0.�3 �l i /toc 2 s%c �Jr