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HomeMy WebLinkAbout0004 MAPLE WAY �'P -- - - - \ r Town of Barnstable *Permit# Expires 6 m tjis��date `7 Regulatory Servi Fee:�5 ■naxsrABM •' . +� i $ Richard V. Scali,Interim Director , PRESS ATED MA't ' Building Division JUN24 70 Tom Perry,CBO,Building Cor�`ii �s ,p er 15 200 Main Street,Hyannis,MA 02�011 OF 19A RUS T www.town.barnstable.ma.us ABLE Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY (V � 14 Not Valid without Red X-Press Imprint Map/parcel Number " Property Address C Residential Value of Work$ —Ir Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ',r o N)C` vv ' ' �� �� X -��� bq N ���P aac��� Contractor's Name uuug 0 witq Telephone Number + - Home Improvement Contractor License#(if applicable) la Email.*&Qq Wif_q Construction Supervisor's License#(if applicable) q ' ❑Workman's Compensation Insurance Chesk one: A I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance - Insurance Company Name Workman's Comp.Policy# A� Copy of Insurance Compliance Certificate must accompany each permit. Permit Requ t(check box) 9 Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Ho . Impr enn t Coniractors License&Construction Supervisors License is requi SIGNATURE: Q:\WPFILES\FORMS\building permit fonns\EXPRESS.doc Revised 061313 r, . ... ... ._.. Zile Commonwealth of Massachusetts Deivartnrent of ludastnal Accidents f3ffwe of rnv_"StlgfI ors .. 600 Washuigton Street Boston,MA 02111 W ov.masSgolIdia Workers' Campensatiau Insurance Affidavit:Builders/Conti-actorslEiectriciansMumbers Applicant Information Please Print Legibly Name{BusiDelOrganizationllndividua!}: l� 2 Address: bQf,VC) AJ I n4P 0 OIph..4: q 0 . Cityf�ta ( t�lZip: � �VJ Are you an employer: eck the appropriate born; T . of project(required): 4. I am a contractor and I 3'� � l �� �- L❑ I am a employer with ❑ general 6- ❑New constructim fimployees(full and/or part-time.).* have l the sub-contractors. 2._U1 am a sole proprietor or partner- listed on the attached sheet. 7- ❑Remodeling slug and have no employees These sob-contractors have 8. ❑Demolition. working for me m any capacity employees and have workers' 9: ❑Building addition [No workers.' mn3 p.insurance comp.insurance-t required.] 5. ❑ We are a corporation and its 10..❑Electrical repairs or additions 3.❑ I am a homeowner doing all wort officers have exercised their 11-0 Plumbing repairs or additions myself. [:qo workers'comp- right.of exemption per MGL 12. insurance required.]F c. 152, §1(4),and we have no, ❑Hof repairs. employees.[No workers' 13.0 Other comp_insurance required,] *may RppUc=that checks boa#1 mast also 5ll out the section beIowshowing their wOlkers''compensation policy inffltmation_ I Homeowners who submit this affidavit milicst mg thiey ate doing all work and then hire outside contractors mast submit anew affidavit indirating sach- lContractors that check this box mast attached an additional sheet showing-the name of the sub-moors and state whether ornat those eafiiies have employees. Ifthe FA-contractors here employees,they mast provide their workers'comp.policy number. I am an empinyer that is prm idit workers'compensation insurance for my employees Below is Ste policy and job site informatkon. Insurance Company Name: Policy 9 or Self-ins-Lic.9: Expiration Date: Job Site Address: CiW StatelZtp: 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 IV GL c. 152 can Lead to the imposition ofrriminal penalties of a fine up to$1,500.00 and/or one-year itnpriso as well as civil penalties in the form of a STOP WORK ORDERand 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 Irnriesligations of t#re DIA ce:coves verifittitm_ I do it y cerh er tie ' s and a altk (perjury Statthe information prmzded a Ie is and correct Signature- Bate: �. Phone 9 o . Off tat use only. Do not write in this area,to be completed by city or town officiaL City or Town: PermitUceuse It srna 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#: 6 a Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or 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 Iocal 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 aay 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 subdlvisioas 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-contractors)name(s), address(es)and phone number(s)along with their cer tificatc.(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. 'lire affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Departinent 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 th.e 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 ad.ditiou, 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 bum leaves etc.)said person is NOT required to complete this aifida,-it. 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 Massar-husats Depaziment of Industrial Accidents Mice of Rwestiptioas 6O0 Washingtan Strut Boston,IAA.02111 Tel.#617-727-4900 ext 406 or 1-977-MASSAFE Revised 4-24-07 Fax# 617-727-7749 www.mass—gov/dia E Town of Barnstable TH Tp� Regulatory Services v STAB MASS..IEg Thomas F.Geiler,Director �Arfo;A. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us a Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, � M C ►"`'� , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit. 64�t (A� (IA o ort (Address o ob ( J ) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of ner e of Applic t Print Name Print Name Date Q :FORM&OWNERPER.MISSIONPOOLS 6/2012 AFIRE Town of Barnstable y� Regulatory Services EARNSTABLF, Thomas F.Geiler,Director �`�'�f ►`�� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOVINIER": name home phone# work phone# CURRENT MAILING ADDRESS:__ cityhown state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- fami.ly dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. , The undersigned"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. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Sec ion 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. C:\Jsers\de.coilik\AppData\Loca]\Microsoft\Windows\Temporary Internet Files\ContentOutiook\QRE6ZUBN\EXPRFSS.doc Revised 053012 u Massachusetts -Department of Public-Safety Board of Building Regulations and Standards Construction Supervisor Specialty' License: CSSL-099138 - JAMES P CURLEYF 287 FULLER ROAD =� Centerville MA,04632 Expiration 01/28/2016 Commissioner, V�B l(J67%YAiZIYJLLUCCLLCIL Q�C-/G�LJD[7,C�LLdBZZ4 - • -. Office of Consumer Affairs&Business Regulation License or registration valid for individul use only (•'�iOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: <:>12431 p Type: Office of Consumer Affairs and Business.Regulation .. 10 Park Plaza-Suite 5170 j7 Expiration 6/1/20.17 dndividual Boston,MA 02116 - James Curley i= at An- James Curley `` R. - e y _ 287 Fuller Rd. Centerville,MA 02632 Undersecretary LI-Ko' valid without signa re ri TL! PPE ._:. P,,� ;¢ CONSTRUCTIO 016 F�Lc�?�= Lr 798 MID-TECH DRIVE,WEST YARMOUTH,MA 02673 PHONE: 577,_TUPPERCO CONI-778 5010 V 7 13 NOV 4 RM 3- 0 DIVJ_�_'ON Date: :) /',/`f L/ Town of Barnstable Thomas Perry CBO 200 Main Street Hyannis, Ma 02601 (508) 790-6230 fax Re: Insulation Permits Dear Mr. Perry This affidavit is to certify that all work completed for permit application `6,,� Issued on l G fd/i i3 has been inspected by a certified Building Performance Institute (BPI) inspector. All work performed meets or exceeds Federal and State requirements. S.incerely,'°� IL t RiL9se pper CS-69058 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Application � Parcel A lication L Health Division Date Issued l �� Conservation Division Application Fe Planning Dept. Permit Fee . Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address Village Q,d. 14PI.ie f7AJL,_r Owner G _ Inc e—o/J Address—4ela• .71,9 Z augn%ao Telephone 60 8 " :7:7 Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay ; ®1 o. Project Valuation o7 �loo� Construction Type n --, o Lot Size Grandfathered: ❑Yes ❑ No If yes, attach sup, orting do umejtation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's ighway:4p Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑ Walkout ❑ Other v, Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ 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 Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) -- Name � Telephone Number Address In, License# 0 129" 0(0 gd 4279 D210 7,15 Home Improvement Contractor# 102/ Worker's Compensation # &C 506559 30/ 200`7 ALL CONSTRUCTIO/ DEBRIS RESULTING FROM THIS PROJECT WILL BET N TO 4Ire Ck SIGNATURE DATE �� w` s FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED 4 € MAP/PARCEL NO. t ADDRESS VILLAGE { OWNER DATE OF INSPECTION: i r t:rFGUNDATI.©N:uw " FRAME INSULATION _f E w �- a FIREPLACE r ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. t' The.Commonwealth of Massachusetts z Department of IndustrialAccidents Office of Investigations a . 1 Congress Street,Suite 100 Boston,MA 02114-2017 ' wwiK.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Apulicant Information Please Print Legibly Name (Business/OrganizabonMdividual): Tupper.Construction CO: Inc Address:. .798 Mid Tech Drive. City/State/Zip:West Yarmouth, MA 02673 Phone#:(508)778-0111 Are you,an employer? Check the appropriate box: Type of project(required): ] ❑� 'I am a employer with 4. 0 I am a.general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. 0 New construction 2.❑ I am a sole proprietor or partner- _ listed on the attached sheet. 7. ❑Remodeling. shipand.have no'em lo. ees These sub-contractors have. p, Y S._❑Demolition . working for me in any capacity: employees and have workers' [No:workers comp.insurance comp.insurance. $ 9. ❑ Building addition .. . 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 1.1.0 Plumbing.repairs or additions right of exem tnon: er MGL .myself. [No workers' comp.. � p � p a 2.❑.Roof repairs c. 152 1 4 and we have no insurance required.] ' _ § O, employees.. [No workers' 13:❑ Other comp. insurance required,] *Any applicant that checks box#1 must also fill out"thc: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:imst submit a new affidavit indicating such xContractors that check this box must attached an additional sheet showing the name of the sub-contractors and stare 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'comp ensation insurance for my employees' Below is thepolicy and job site information... Insurance Company Name:,AEIC Policy#or Self-ins:Lic #: WCC 5005593012007 Expiration Date: 10/3/14 Job Site Address City/State/Zip; a�a2I1.tQ � la� Attach a copyof the mork rs' compensad n policy declaration page.(showing the policy number a expiration date.).- Failure to secure.coverage as required under Section.25A of MG.L c. 152 can lead to:the impos3tion: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 S250.00 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 in ance coverage verification. I do hereby certify, a aims and Penalties o y h' p of perjury that the information provided above true.and correct Si afore: Date. 1J Phone#: d 7 � Official use only. Do not write in this area,.to be completed by city or town official City or Town:. . Permit/License# Issuing Authority(circle one): , 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: : . . . . Phone#: . �A CORD - - (MM/ D/YYYQCERTIFICATE OF LIABILITY INSURANCEF77 10/07/2013 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 holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to: 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 endomement(s): PRODUCER NAME Lora Lowe Southeastern Insurance Agency, Inc. PAONN (508)9974061 FarcNe:(508)9907273I 439 State Rd. E.MaL ADDRESS- P.O. Box 79398 PRODUCE CUSTOMER ID#: N."Dartmouth, .MA"02747 INSURERS)AFFORDING COVERAGE NAIC 4' INSURED. "INSURER A: Arbella Protection Insurance Tupper Construction Co LLC. INSURERS: AEIC INSURERC: CNA Surety 27 Roberta.Drive INsuIiERo: West Yarmouth- MA 02673: INSIiREeE: - - INSURERF: COVERAGES - CERTIFICATE NUMBER: 2013/14 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO'WHICH THIS " CERTIFICATE MAYBE 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 ADDL U DYEFF- MMI,DDY.� . . . : . . LlMrrS. . . . . - L7R TYPE OF INSURANCE - '- INSR WVD POLICY NUMBER _ - GENERAL LIABILITY" 9S0000974 11/01/2012 11/01/2013 EACH OCCURRENCE $ 1,000,00 " X COMMERCIAL GENERAL LIABILITY DAMAGE AMA SETO RENTED occurrence - $ lO0,OO 1 " CLAIMS-MADE OCCUR . S.,OO . MED EXP(Any one Person) ...$. . . A 1,000,00 PERSONAL&ADVINJURY. $ "GENERAL AGGREGATE" $" 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS'-COMPlOPAGG $ _ 2,000,00C .POLICY' : PRO- -JECT. "LOG ---$ - AUTOMOBILE LIABILITY. 5666240000 12/01/2012.12/01/2013 COMBINED SINGLE LIMIT M :. . ANY AUTO (Fa accident) $ " 1,000,00C . ' - BODILY INJURY(Per person) ALL OWNED AUTOS - A X SCHED BODILY INJURY(Per accident) _$ ULED AUTOS X HIREOAUTOS: PROPERTY DAMAGE . . : (Per accident). . . . INC X NON-OWN ED"AUTOS $. UMBRELLA X OCCUR 460NS836 03/01/2013 11/01/2013 EACH OCCURRENCE S 1,000,00 EXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,OOO OO( - A: . . DEDUCTIBLE - - - S - RETENTION $. . . . . - . - . .. - . . . . . . . . . 8 . WORKERS COMPENSATION WCC50OSS9301200 10/03/2013 10/03/2014 X WCsraru X H . AND EMPLOYERS'LIABILITY Y I p. 70RY LIMITS ER ANY PROPRIETORIPARTNER/EXECUTIVE RICHARD "TOPPER is E.L.EACH ACCIDENT. - 8 OFFICER/MEMBER EXCLUDED?. a NIA $ 1,000,00 (Mandatory In NH) '" I. LUDED"FOR. WC:COVERAG E.L.,DISEASE-EA EMPLOYE .$ 1,000,00 If;as,describe under - E.L.DISEASE POLICY OMIT $ ""1 OOO,O DESCRIPTION OF OPERATIONS below C and or theft o money & or 7106881 .0212312012 02/28/2013 Limit: of $10,000. roperty. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Add$ional Remarks Schedule,Irmo space is required) . CERTIFICATE.HOLDER . CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES.BE-CANCELLED BEFORE THE EXPIRATION DATE: THEREOF,: NOTICE WILL BE DELIVERED .IN ACCORDANCE WITH THE POLICY PROVISIONS." "For Information.:Purposes Only" Tupper Construction Co LLC AUTHORIZED REPRESENTATIVE - 27 Roberta.Drive W" armouth, MA 02673 Lora Lowe ©1988-2009 ACORD CORPORATION. All rights.reserved . " ACORD 2!i(2009/09) The ACORD name and logo are registered marks of ACORD #3ttH.LRIY a i+1 ttFi3K111 11Mt t tt 1'ttU1" tNrw t t Massachusetts.`-Department of Pubiie Safety- 107 Hon"Pka SLOS t10. ¢ Board of Building Regulations and Standards Mrdrs.NY 12 (077)271•1274 C.„na rurti�n Suits r�Isu;�. . vvww*,carn License:;CS-069058 � i RIC R HARD S TUPPE 79 B MID-TECH DR WEST YAKNIOUTH ' ? Commissioner 42/31/2014 <._r.�• �f�REVERSE SIDE iDR DESISNATtDNB AM E><PiN,tt i�t WtE3J �.: , a goo a.fi ©f1'ice of.(:oosuro:r Affairs&�B auncsa"fusulettmr....._ People Helping Peopte wild a Safer*rldT' , WIHARf HOME iAAPRBVEMENT CQN7RA4TOR Regist►atign: �� 845 Type: Mt i1CR ex ` z xEitpirrition: e/2 t4 ndividual �,� ' t TUPPER �� is g x Rrchard:;Tupper� i RiGNARGI'TIJPPER, u{'} a •" i TupperiGonstruction 28 Rocerse Drive ; � a , 8uildang Safety yProfess�onat ' � � k Fr, r � W,YARMi3UTri,N!A 026,13 ttndrrserrcie a e' < n a « r t ry . fi Wmbe# 81581,19 EXp'4/3012014[[ F i - - I OWNER AUTHORIZATION FORM 1, (Owner's Name) owner of the property located at (Property:Addres 4EAVA ( operty Addr ss) hereby authorize 6 . (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work.on.my property. . Owner's Signa ure 1 Date t -