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HomeMy WebLinkAbout0060 LANTERN LANE �O L�fer2 Lug PF `t Town of Barnstable oFt"E�rti RegulatolmWNSTABLE Thomas F.Geiler,Direct U gi h1 �, ` snxxsTaeLe. „AN. Buildin o ptEp3.�A Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.bau" 3us Office: 508-862-4038 Fax: 508-790-6230 PERMIT#c�Q/3 D FEE: $ 5 SHED REGISTRATION RESIDENTIAL ONLY 200 square feet or less ol-d L fI lY TERN L/WE , �(Y 1? fY/X/S Location of shed(address) Village Property owner's name Telephone number Size of Shed Map/Parcel# IL Signature Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? If over 120 square feet,you must file with Old King's Highway Conservation Commission(signature is required) Sign off hours for Conservation.8:00-9:30&3:30-4:30; PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN n Q-forms-shedreg REV:052813 File//it uber 050519-12 UNREGISTERED LAND Attoriter POFCHER,DISCIULLO& PETRUZZIELLO Deed Book 4675 Paize 76 Leitder: Plait Book 395 Pa ze 2 Lots 2 Owner: KATHLEEN A. DONOGHUE DARRING REGISTERED LAND Re 1. Book Street LoI(s): Date: 5/25/2005 Certificate of Title Assessors Alap Blk: Lot Census Tract NIOR T GA GE INSPECTION PLAN Scale: 1•'_�0' 60 LANTERN LANE, HYANNIS, MA N/F FABER N/F CONNOLL Y 'I 80-W '0 22.74' r 0,821 S.F..f DECK 00 N/F MANKE VETCH 00 #.60 1. l I?•,. •i 101 `---'� 00, ---- ---� � --- TO OAK HILL RD. LANTL'RN LA-N-E CERTIFICATION I CERTIFY TO THE ABOVE ATTORNEY,BANK AND THEIR TITLE INSURANCE COMPANY THAT THE MAIN BUILDING,FOUNDATION OR DWELLING WAS IN COMPLIANCE WITH THE LOCAL ZONING BYLAWS IN EFFECT WHEN CONSTRUCTED(WITH RESPECT TO STRUCTURAL SETBACK REQUIREMENTS ONLY)OR IS EXEMPT FROM VIOLATION ENFORCEMENT ACTION UNDER MASS.GENERAL LAW TITLE Vll,CHAPTER 40A,SECTION 7. FLOOD DETERMINATION BY SCALE,THE DWELLING SHOWN HERE DOES NOT FALL WITHIN A SPECIAL FLOOD HAZARD ZONE AS DELINEATED ON A MAP OF COMMUNITY #250001 0006 D AS ZONE C DATED 7/2/1992 BY THE NATIONAL FLOOD INSURANCE PROGRAM. t H OF NEIL Olde Stone Land Survey Co., Inc. J. .r 470 County Street KELLY Taunton, MA 02780- � 09N0.35038� zi Tel: (800) 993-3302 �,9�F SS►��'P Fax: (800) 993-3304PIP 4 k y PLEASE NOTE: This inspection is not the result of an instrument survey.The structures as shown are approximate nl . An i rument survey would be required for an accurate determination of building locations,encroachments,property line dimensions,fences and lot nfiguration and may reflect different information than shown here. The land as shown is based on client furnished information only or assessor's map& occupation and may be subject to further out-sales,takings,easements and rights of way. No responsibility is extended to the landowner or surveyor,or occupant. This.is merely a mortgage inspection and is not be be recorded. i 60 Lantern, Hyannis—House vacant but BOH rental inspection found basement partially finished with new walls—some sheet rocking, tile floor and segregated entrance but currently used for storage. Embryonic apartment. No history in file. .p J N � � t x pj"j d2 Cn r r� N Asiessor's map and lot'number ...... 2.::....... THE S@PTIC 's-vs-, Sewage Permit number ....5S. .... ....... .. ........................:......... INSTALLED IN i SAR39TABLE, WITH TITLL i MAGL • House number ............. .......I.......................... ...... ... .. 17AL 039- ENVIRONMEN11 2 Apr �1� TOWN :OF BARNSTALV'Lt)"�R BUILDING INSPECTOR. APPLICATION 'FOR PERMIT TO ......... .................... .......... .................................................. TYPE OF CONSTRUCTION ...................... ...ZV)C2 ...................... ...................... .................................................. .......................... ...... TO THE INSPECTOR OF BUILDINGS: The undersigned her!pL,appIi s for a permit according to the following i form tion: Location ... ...... 4 ........ ... . .2............ ................................... ....................... ........... Proposed Use .............. hP.n.-C............................................................................................ Zoning District ...... ............................Fire District ..........rl�)Q co 5 t e-- ............................................................ C6 1:1 Name of Owner ..... 601., ....).A.2, ....................�I��.....Address .. .................. (�aos ce/j ...........Address .....la��..... ......................... . ........................ Name of Builder ....................... .....i.�� .. !J.i. .... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ............... .....Qg, S. Ix? ...............................Foundation ....................co-n........... ...................................... Exteriors .............................................Roofing ................. ...................... . .. ...... Interior ................... Floors ............C.Xke-0................ .... . . . ......... . ................................................. Heating ......... ,4 ............. 1 ?Plumbing .................................................................................. Fireplace ................111.1.... ............................................Approximate. Cost .................. 0 o 0 , 0C) ............................. . ..... 617 1 Definitive Plan Approved by Planning Board Ad—IN-------j-------------19 Area ......... Diagram of Lot and Building with Dimensions Fee ............. ........................ SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. .N,e�.. ... eAE. ............A.-TA-3 Construction Supervisor's License .................................... tlSOL-�BIDZS, COSTAS , No _�.78.8.3. perm� for _l�_Sto��.___.. '' -' '' '' �. -'' --'' __Si ..I7aozi ..DvveIligC[____.. � Location .�ot-3x......6O..It�glt'pxm...I^axlp- . . ' . ____._ is_____---------'' - Owner --Cost��.�!g�le��dis.----' ^ ^ ^ Type of Construction: -�r��n�e�--------. - _----.'--------------------. . . - . . Plot ............................ Lot ................................ Permit Granted ..MaY...8......................... g 85 ~ Date of Inspection ------------1V Date Completed ~^� � . , ' r _ � - ' i ` . . . ` ' ^6 . - . . u~=° '~`~°~^~~ - - � THE / Sewage Permit numuer .,- ................................ - ` l EARNST LE, � . House npmber ----Z..----'�-_^----------` 039. ~~ Mix��� / ���� �� �J�� �� � �� � �7TOWN � �]� ���� 0� |� �� �� ���� ���� ' | �� 0NNBUILDING � NN 0 N �� 0 �� JNSPECTOR N�N00 ������ �� � ��=� � �� �� � _' ��PPLICATU��0W FOR PERMIT TO ..^�-�///- '^{.��--.....'.�/.���----.-------------.^--... � TYPE OF CONSTRUCTION -----.�����E{��i-.<.Z[��?���-.-.---------...---.-------- ` ' \ '71 ~' r��-~ ,~..--....-.�-...l..lg'.�=l ' TO THE INSPECTOR OF BUILDINGS: The undersigned h the 6o|| : Location ...��/ `.��7'-'�� +/�/ .. --.. <7________.,_____,__ Proposed+ Use ...............�7 .-.� \`. ---.-.------..-----.---___'_____.. ' \ �� / Zoning District -'!�J���L.!��\/�..:���..--------.Rve District ---��!�----.----'-----______ Name of Owner -.� ������.��-.--�~-'��o�|��!.�/.l-�A66re� -.i1'..i..�u^�`--.('./y.��.................. __ | - « Nome of -Builder -'/� L7. !�..-T' ..�C ��---'A66nss -.]�'.')-.. ...............................................................-J� / � � Nomo of Architect --------------'�.....................Address ................................................. -__________ Number of Rooms ----'��-..����3�_�����`------.Foundohon .............. ...................................... ^ / ~/ Exlerior � . --- � �4'»---------.. Roo�ng /� ���l�` .4+�{,� � � -----r--� -----� --------r----------' � .--^- 11 F|oon �'C~� Interior ----'`~-r------^-----~-'^—^--'� ------~ ----------------. . ` Heating . --- �/����-��l�l-. �!\��unn6ing � 'r--------- -'\/ � -------------------------'.-. Rnep|oco ...................... ..............................................Approximate Cost ---_.. .................... Definitive Plan Approved 6v Planning Board �9���'' Anyo -------------- ` ~ ' Diagram of Lot and Building with Dimensions Fee _______________ SUBJECT TO APPROVAL Of BOARD OF HEALTH . / . . ` OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS | hereby agree to conform to all the Rules and Regulations of the Town of Bonnmo6|p regon6i' the above construction. ^ ............ ~ . . Construction Supervisor's License -----------... TsbLERID. IS, COSTAS A=307-111 30t7-M No . Permit for .... ..t2.7863 2 Ky........... .. ............. .........siajSinge...!�amjly...Dwe.i.li.n.q.. ........ ............. ....... .. .... .. 3...0. 1 in Location,,-..X.ot..2....... ...... ... L.Aal r ...Lane A ............... H-v A a ZA S................. .. ................... Owner .......Costas ..TS0jg!.j�.jdj.,q.............. ................. ........ Type of Construction .,Fr.amp............................ t ............................................................................... Plot ............................ Lot ................................ Permit Granted ...May..A,.......................19 85 Date of Inspection ....................................19 1 Date Completed ......................................19 r}+:•`. _...._._ _. - _ a.. - �s- :�f..rX.:.�-.. ,,•:tt s'2i• ;:..' Y.X._ • TOWN OF BARNSTABLE Permit No. ---------27863__ t . , . , Building Inspector , cash ---__-_-- - _ +aim f enr�� _ .�► x / OCCUPANCY PERMIT Bona ________,__ f r Issued to Costas Tsoleridis Address lot #2 � 60 Lantern Lane, Hyannis Wiring Inspector ; r Inspection date f Plumbing Inspector f/i _ t Inspection date" �� 3 r f Gas Inspector j� �A Fit � Inspection date 7 4 A u a A .`Engineering Department Inspection date - , � Board of Heal , Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. (�` Building Inspector r TOWN OF BARNSTABLE BUILDING DEPARTMENT i seaaer TOWN OFFICE BUILDING �9► i6 q' HYANNIS, MASS.02601 �o r�r►• MEMO TO: Town Clerk , FROM: Building Departments"' DATE: 4} I An. Occupancy�Permit has been issued for the building authorized by BuildingPermit #.......... ........................ ................................................. .... ......................................................................................... . issued to ......_................ `` . ✓!.. ;2` �f�1 c% ?.........................................._..............._.... ........... Please release the performance bond. •h t l• � [ e J Xa �.( ia. J � lY C._ � in ------------ ry � i � t`.'t p r ,Yr ," r.t.. ..`. � .• : .`' fry . '� Y♦ - Y '`i 1t ni{ ` }� ij1l� .t• .1. ttJ a .g� s"� .-t a, �4 3v Ir i x f � t}i.t2 4< ~4` i�"U .� ,(} , h ♦:. . ''_awe;� ,. :? ` - ., ,� M L*•' r `.f � ,•l ' y [J .• � � •' ~ p .. t . • 1 . . _ram ♦ ftM a �ftt. rM s.`.{ r 4t a r� # r > r� wP. X.-'i ; t`. e• i�f . x s' r - r oor. " //� .<J•r s o- �� «> t . C �_ ;, �i�. e ,��� Y� I� t . x ,_ , $;•rM1 If x/I�� J �i 5 *• Nr i 't 5 ' i.Nl.. J t- a a 'r4 ice.'/ •V'V 'y A.. {+!'- Y �, _ d > Sa A ,_µ 4 7 •f <` Jk,.'�i t k.k• � t t pd•;ti ,1 �s =C R7tF1E© ,,,Pt..OT ' -Pt�.AN "•y ..Y x r�� -ii ei ask ' T ; t ��0� �fMI C .16 a YMt q...w,atZi"i rr T•vi t�..�},aJ�' ;� i ,'>i r t''i.t Swi,�`e� t �yrt t SCAM •s ,.,. .. i •>� k.: � ., ^ $ �:3 1 r r ♦,.t� 4• ti rA ,� i„rt' s� -`��4�y1 F'��.� r��a'�t(��-,.�i C// �`1. _ t T,; a, e a J^ t • ? ♦+:n`' +4r L� r ,. F '`PirAl• /�Y a►a7L'lQM.. ..4- t y k S �) ♦ t"si is 9,�' lh / '` t} t l tt j .. { a. •!f a •of .! l�,. e r i s ai�t .(r'-'..�} ', `t k �~�•,It r !_. i.2: ' e.. 'T 1�� �'^ �-:.: y,F .- ��li✓ i t 1 t 'k y,� ?RJ,.' f ls�ar� `w. ' � v r i�.>� f ;{.• P .;. t i -.:r (y�y/ ,�yrNR� <' ,t �• 't ! M :,,e{ �.y t Xntt N E'r f yl i" ✓' �1� �., `./ a 6 ,� a�, i J 4 f :i... it 7 +ic. r i. t N 7 y a _ yiy��^},I r', �`{�./•/���j/y�^�,^p .... K � t-E.f44 i' �e ��{w� �y � y i Yr r i•�' "' •Z. 4 ^a) n°� � ��! a4RM.`-.M £'� 7t��".,r 1'�'.Y+R.! 'YM:a'` t c, t.. t % a• < I> v I .� f .. L .. /t,�'a.�'• � i_. a F '_ ,.,:�. � �� i^ ry cl�� •'°� it _ 5�4 t f �� �~a � 5$- �!S 'a"i y •Rv..t+ ' x s � a � C SH'O!� 4,,.,^ ♦ F..� � <3 it �� Y y,7. CiM li ,� aiM/��F'�.� �"i , Si ' r' t CERT1F .H.AtTfi>•, f w T SHOWN LN�CHIS ,PI.ANrtS LACAiEQ ON THE; 3ROUNC3 k ;t E �A3 SHQY�►M`HEREt 1 t 330;y; rx r f r ;. 4 E�ISTER�`� ;. Yx t[ +_ F}l v t ' J <� 'F.,<t .a .� a..,:, 1 �- _ x ` i pET(TION.ER,t: ; f, r i :i: ,.. ,, j ,• ` '� R�OISTEREQt-AND StiRV YOR, p r �. •, r t �,,, * c.. a•„ ,f' '� {t.. '�' >+a`f `� a:.. > x ., Y :�„• .S17 5. k ;.� SHEET OF SHEEtS F ' A/Z 61 '3t 5 Ai 40 4 4a 3 48.8 S!-O 12! / AI S3•o 30f T4POFG.$. ! I I p1.4 - .y-�f'....psi.. '���'�'9i.r-'-'-. .,n��lits�1#:a.'.:'<t--:.:::�•-.:.•..... _ v.u+xNvsf.air�x3.aF�'Tec.*��.:a++_�x�es.evw..=.... :. Di4mom) 49/0 S/Z 50/ SEPTIC SYSTV I�,�rvr: ILD II.4 t% h L� /7�� . z , 4N T WITH TITLL' . TOWN Rl--'!it 11 407 At/// SEWAGE DESIGN PLAN i - _ LOCATION ... ... .. SCALE l��'.?� f . DATE!� /F, // - PLAN REFERENCE /-.0.T. LAND SURVEYOR T � � ..T�LS. . ... CIVIL ENGINEER PETITIONER AOfaf4 ����nFM4 THO � � • - L " MOMAS E, KELLEY o Ke /�!J - - , 4330 ENGINEER.— SURVEYOR � p 60�0 /7� .I �. .y 9°'` fGISTER�� J`'y° 346 LONG POND DRIVE L LANO S�Q SOUTH YARMOUTH, MASS. S1pNA\-�a� 02664 SHEET OF z S It-EI'S, il/DTE-�G1 Co4�5 7b C.P,a� d TOP OF FOUNDATION ; 4"CAST IRON 12' OR SCHEDULE 40 4°SCHEDULE 40 P.V.C.(ONLY) - P.V.C. PIPE PIPE- MINIMUM LEACH CIRCULAR PITCH I/4PER. PITCH 1/¢PER.FT. PIT PRECAST --- - J LEACHING NVT •`. PIT . .e . EL„ INVERT DIST. INVERT • SEPTIC TANK p,2 w : : EL.. t.5.i�r BOX ELS.._.. _>_ �� INVERT �QQv GAL. INVERT �~a " " EL.SQ1 .. INVERT ww :�• 3/4 TOII/2� ELSE .. w o ELSD.A? w �. WASHED STONE Id MINIMUM �Z�- -� —WDIA. --j DI A---+-� Na 20' MINIMUM PROFILE. .`' OP'- GROUND WATER-TABLE SEWAGE DISPOSAL SYSTEM :`:' ---- NO SOIL LOG WITNESS D 'BY-: / j,9 . . CQ/VLa BOARD OF HEALTH DATE . !�J.... TIME.��J . . . ... TEST HOLE I TEST HOLE 2 �� �1-�+ ENGINEER pQ ELEV. .- .P 4 DESIGN .- DATA : Z4 (49•S) D �) NUMBER OF BEDROOMS Cb/ SAD CoA25�;- �'A�vD GAAVC-i—" TOTAL ESTIMATED FLOW. GALLONS/DAY G�6.0 6 .0' (e�'�,p) BOTTOM LEACHING AREA ' . : �. SO.FT /PIT C4S8} SIDE LEACHING AREA • 6190 5-3gND L�ZS"• loG� . SQ.FT./ PIT mef�► a`'^''y /'�, l42'o, GARBAGE .DISPOSAL . `I!Y ..(50 % AREA INCREASE) TOTAL LEACHING AREA • SQ.FT A4&A/ - PERCOLATION RATE . : . . 7G�. _ . . MIN/INCH- LEACHING AREA PER PERCOLATION RATE3�U./. SQ.FT. _!y WATER ENCOUNTERED NUMBER OFFLEACHING PITS APPROVED . .. . . . . . . . BOARD OF HEALTH ' ' 'T DATE. . . . . . : . . .,. . . CIVIL ENGINEER AGENT OR INSPECTOR . - •• _ ��•�1)F Mass PETITIONER o?�� Arlo q KEL F� THOWS E. KELLEY fepx . . . ENGINEER— SURVEYOR ,yam �J� 346 LONG POND DRIVE4 . ; ��4'I.�l . .!�(.': ;. SOUTH YARMOUTH, MASS; NAI; 1 . . . . . 0.4 G .Q.�. . . . . . . 02664 �� y Town of Barnstable *Permit# FZHE T ~fin Expires 6 u+onl6s jran issue date t D� Regulatory Services Fee BAmsTAHLE. ` 1 yASS. g Thomas F.Geiler,Director �p 1639• Aim -r lEo nwt Building Division a Tom Perry, Building Commissioner 200 Main Street, Hyamus,MA 02601 . oWpq C6 Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid►vithout Red.Y Press Imprint .Map/parcel Number 3 D 7 I 10 D Z I 2 Property Address D LA4Vt&,Y_K- � f Value of Work / 2-6 sidential Owners Name&Address ,p7vSn fi� --77v o 5t /l Telephone Numbe n Contractor's Name r ( Z I? Home Improvement Contractor License#(if applicable) ldb7 Lf D Construction Supervisor's License#(if applicable) SUS "7�j2' orkmart's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I a the Homeowner lave Worker's Compensation nnlInsurance . Insurance Company Name Workman's Comp.Policy# Permit Request(check box) ❑ Re-roof(stripping old shingles) ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side p acement Windows.. U-Value •� _(maximum.44) ❑ Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signature Q:Forms:e.xpmtrg Revised 121901 r I Testing Data t MODEL FS TEST RESULTS p MODEL QFS TEST RESULTS r AIR INFILTRATION* AIR INFILTRATION* 1.57 psf 75 Pa 1.57 psf 75 Pa 0.05 Cfm/ft' 0.25 1/S/m' 0.16 Cfm/ft' 0.80 I/s/m' WATER RESISTANCE* WATER RESISTANCE* WTP=2.86 psf 140 Pa WTP= 12.00 psf 575 Pa @ 5 US gal/ft'/h @ 3.4 I/m'/min @ 5 US gal/h'/h @ 3.4 I/m'/min No Entry No Entry - No Entry No Entr THERMAL PERFORMANCE THERMAL PERFORMANCE (Complete unit values.( (Complete unit values.( All thermal performance SHGC,Vt values for VELUX Skylights t' All thermal performance SHGC,Vt values for VELUX Skylights are NFRC certified,labeled and listed in the NFRC Product -f are NFRC certified,labeled and listed in the NFRC Product -? Directory.(In accordance with NFRC procedures.( Directory.(In accordance with NFRC procedures.( GLASS Comfort(75) ComfortPlus(74) GLASS Comfort(75) ComfortPlus(74( Tempered,Low-E', Laminoted,Low-E', teempered,low-P, "Laminoted,Low-E', Argoh Argon Argon Argon _Gasrilled Gas-filled Gas-filled Gas-filled U-Factor(R-Foctor) 0.37(2.7) 1 0.39(2.61 U-Faclor(R-Factor) 0.38(2.6) 0.40(2.5) SHGC 0.31 0.30 SHGC 0.33 0.33 Vt 0.48 ' 0.47 Vt 0.55 0.54 FADING PROTECTION% _ FADING PROTECTION77 GLAZING CLASSICAL UV TOTAL FADING GLAZING CLASSICAL UV TOTAL FADING PROTECTION% PROTECTION% PROTECTION% PROTECTION% Comfort(751 87% #, 75% ` +� ! Comfort(751 - + 87% 75% '* ComfortPlus 174) 99.9% - 83% ComfortPlus(741 99.9% r 83% STRUCTURAL PERFORMANCE" STRUCTURAL PERFORMANCE* DOWNWARD LOAD WIND UPLIFT DOWNWARD LOAD WIND UPLIFT Laminated, laminated, 12.75(psQ 2296(psf( 150(psq 142.5(psf) HeobSlren thened ._ ,. - Heat-Strengthened > Tempered,nated 108.182(psf( -.. 2296(psf) Tested in occordoace with AAMA/WDMA 160071S72000,VOLUNTARY Tempered .. SPECIFICATION FOR SKYLIGHTS.Size 656 unit tested at a 15°roof pitch. Tested in accordance with'AAMA/WDMA 160WIS7 2000,VOLUNTARY SPECIFICATION FOR SKYLIGHTS,Size 606 unit tested at a 15'roof pitch. ., Tested in accordance with ICBO-Evoluation Services,Inc.Accepran<e Criteria for Sloped Glazing In Solariums;Patio Covers and Prelabricared r - Skylights See National Evaluation Service Report No NER 216 and, - ICBO ES Report ER6075.Model FS is WDMA Hallmark certified.See-- - • _ " Hallmark Report No.426. - t 38 . -�� f -- _, 7Yte Commott►veallh of Muss'tichttsells Uepurlrrtettl of lrttlttslrial Accidettls -- _- Mike o//nycsU981/011s _ 60O IVas-hitiglott Street Boston, Mass•. 02111 Workers' Compensation Insurance Affidavit r ttatrSt: lJ r ►t 0.S �� �J�I.� I � _ ls�catio rilVP.t/YL> 1 S -7 K_-b22 ❑ 1 am a h neowner performing all work myself. 1 am a sole proprietor and have no one working in any capacity (] 1 atn an employer providing workers' compensation for my employees working on this job. f9.tUMI LZ��A t� 3 ro Vt P% 414- city: �.-4J� '. ^�� y,��-- 1►ltone n: �� � ��� insuLrtnce c9_( T L/t''' � 1_t.3_C � ��0� �G J�cyJf CA L$,C- 6 0 IV I ant a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who lia.. the following workers' compensation polices: roRIVAfly name address• city' phone H: L0MA11.S.4_C_t)' P9 III cy y r' Y phone H• Il1�p�A1lCSS9 policy H �i Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to 51.500.00 andio, one years'Imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the 011ice of Investigations of the DIA for coverage verification. 1 do hereby certify under the pains and penalties of perjury Ihat the information provided above is true /and corJreecct: Signature l V//t Date r • r r r r,.... 11rint mmne � . p:! ��C�L �._,f {�.� 1'honc H �>�� 1 " A �� r I (check icial use only do not write in this area to be comphegcd by city or town official rcrmiUliccnsc H Building Department y or town 1 ❑ i ❑Licensing Board if immediate response is required ❑Selectmen's Office ❑Ilcallh Department ntact person: phone H; f IOlher �y A r ..• •(('' �X-, VO.771/1JL09lIlK'!L(.(.IG O�i��QAJO.d1CFOP.G(4 lioard of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 100740 ' Expiration: 6/23/2004 Type: Private Corporation CAPIZZI HOME IMPROVEMENT, T66mas'Capizzi,jr. . } 1645 Newton Rd. (G_:. +✓ - Coluit,MA 02635 Administrator k .. , :.,. . ��ZP. V/CY7�24'7Y��itl%u/r�/nw,/a 6�a�����GI.�Gy7:l^'^^^'.""'•' - •1 p y- BOARD OF BUILDING REGULATIONS P t License 9PNSTRucT10N SUPERVISOR ke Number•.CS ' 057032 Blrti�date 6 7,2V 1963 ires:0912f 200 Tr.no: -7171.Q , Resitficted: AO - _ Tt 10MAS X CAPI731 i 1645 NEWTOWN RD COTUIT,rMA 02635 � Administrator ` v CAPIZZI HOME IMPROVEMENT INC . SPECIFICATIONS AND ESTIMATES PAGE 6 OF 6 STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT OWN THE PROPERTY LOCATED AT ZP IN ^J MASSACHUSETTS. r I +HAVE AUTHORIZED TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT,IN.ACCORDANCE WITH 780 CMR, THE MASSACHUSTTS STATE BUILDING CODE. I GIVE MY PREMISSION TO LESSEE TO APPLY FOR.A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: OWNER'S ADDRESS: s OWNER'S TELEPHONE: I �" 00 t `"( ` LESSEE'S SIGNATURE: LESSEE'S ADDRESS: - LESSEE'S TELEPHONE: I APLLICANT'S SIGNATURE: T APPLICANT'S ADDRESS: 1645 NEWTOWN RD., COTUIT, MA •02635 APPLICANT'S TELEPHONE: 5081428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: I RESPONSIBLE OFFICER TELEPHONE: ACCEPTED BY DATE THIS PAGE . IS PART OF AND IN CONFORMANCE WITH PROPOSAL t