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0029 MARSTON AVENUE
G 4 Gcq A Y' s i O tl 1-t V e, I �. . �DtSGYQS �. . 'Town of Barnstable emit: Regulatory Services ate: i oFt"e TWyti Richard V. Scali, Director Building DivisionSTABM MAM Tom Perry, Building Commissioner 039. a�0 200 Main Street, Hyannis,MA 02601 ED Mp`l . www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 TOWN OF BARNSTABLE SOLID FUEL STOVE PERMIT Owner: ` - lCt/; (r Phone: 5 �(J 0( Install at: r q �� —Village:g Map/Parcel: Date: Stove �— A. New/ sed B. Type: adian /Circulating (_ C. Manufac3 p ! T (J�•�Vtc�;r. D. No. Chid i A. New/ -istin (If existing,please note date of last cleaning) , e ate B. Flue Siz C. Are other appliances attached to Flue? PVU. "- I1 -l'1�2C D. Pre-fab Type and Manufacturer / E. Masonry: /ne fined Hearth c - C � A. Materials: dc� 1/' . c4pc B. Sub Floor Construction: Installer 4fRA.,edC i-- 0"�7 Y`"l. Name: Vk Ce�v- L*kZ* VZ �!' t Address:�C�.-cs Phone: e " Q V"k t C 6v+- �W f'-e rd� Location of Installation: H.I.0 Registration# Construction Su ervisor# OR check Construction Installing, no license required LICENSED INSTALLERS SIGNATURE;,._ APPLICANTS SIGN URE: APPROVED BY: rim Please make the s payable to the Town o Barnstable *This constitutes an official stove permit after inspection,photographed, and approved by the Building Inspector Q:forms:stove Rev 11/4/13 T7xe Commompear h of+Mimacbmsety ' Dep arkaeut a,f liukstril Accidews -- - Offlce-ef n% tA-. --oru 600 Wmkiugka,meet Boston,M102- M wnm.ma=gav1dia We rke& Cumpensafiun Insur-ance Affidavit:Builders/Cauh-actorsfElectriclans/Plumbers xplicaut Infarmaficln // Please Print Imibfy 1`=e(Bttsmeaslo izadiontIndividual7: e�l`c� r'L � AAdress: 3 fl & ityfStat�IZip �1.t Ir (f xi/4 Axe you an employer? Check the appropriate box: r Type. ant a con�actcr and I �of�oe 3 (•��d}= L El I am a employer with 4 I❑ 6_ ❑New constactim employees(full andtorpart-time)* have h'��sues 2_❑ I am a sole proprietor orpartner- listed an the attached sheet 'y- ❑Remodeling ship and have no employees Them sub-contractors have g- ❑Demolition wot ng for me in any capacity employees and have workers' 9. ❑Building addition comp-iusura=e comp-rnsuratice- 5_ ❑ ❑4Te are a cotporationand its 10_0 Electrical repairs additions 3_ ' sin a homar�u ner doing all work officers hwm exercised their 1 I_❑Plumbing repairs w additions, Myself [No workers'coutp. light.of exemption per MGL 12_0 Roof repairs insttanre requlrL•d.]T c. 152,§1(4),and we have na employees [No workem 13_❑other corrlp.Insurance requiresi.j ri apptiozatthatchedsbox-lmastalsofdloutthesectionbelowshoixingibeirwoi3c¢s'compensatioazpoke}gin • * + aameoWners VrlF6 submit his said.-Yit in cstiag�2y^�cT^ing=II:suer tb�•h;a outside contrnctan submit a new affidsrit mftrAfin scull =Ctnt[Mcros that check this bmc most sttadled an additional sheet showing tha fame of H]e soh-comic nrs and state whetfrer ocnot tiaasa entities hzve ePlayees- If the sob-contaactan hx; employees,the}mu provide their warless'comp.polio number_ I .lam arz employer fhritisprmiding ttrorke4•s'cornim snrtio.n irtsrtraacs for rtzy i?mptayeets. Betow is dtepaHry and job site informadam Insurance GompauyName: Policy;or Self-ins-11c.4--- - Expiration Date: Job Site Address_ CitystatP ziip: Aftich a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure caverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00r and/or one-year-imprisonment as well as cola/pena%es in the form of a STOP WORK ORDER-and a fine of up to$250-00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insxance.coo emge verffic,atio t_ I do herel j,certify under-tlrspairis widponaMies ofpedw y Mat the inf bnnud npras ided ab w is hus and correct Sigsrature Date: Phone 9- OUFciul use only. Da not write in f ds area,to be completed by cif}v or town ofJiciaL City or Town: Pr rtuitucense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.t✓itFlTown Clerk 4.Electrical Inspector 5.Plumbuig Inspector 6.Uthear Contact Person: Phone ih 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Ptusuautto this statute,an employee is defined as"_._every person in the service of another under any contracf 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 dwelliag 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 staffs 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 auy 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 in ui7ance 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 certi ficaie(s)of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(L.LP)with Do 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 insu noe Coverage. A.Iso be sure to sign and date the affidavit The affidavit should be retanued 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 f e law or i f 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-i�ce 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 pemlitllicense 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 proNdded 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 Commonwe. t&of May sssachusetks Degaztme�nt Gf Industdal Aocldents OLMM of kves&Ugatioas 6¢Q Washingto-n Sit Boston.,MA 02111 Te,1.#f 17 727-4900 W 4-06 or 1-9 hEkS E Revised 4-24-07 `Fax# 617- 27-7749 www_ as.5 govfdia Q. ho is.responsjble for makinq_app]ication for t _permit?j --_ -- ---- --� Application for permit is required to be made by-the owner or lessee or their agent of the building (e.g.; the HIC registrant). If application is made other than by_fhe owner, written authorization of the owner must accompany the application. Such written authorization shall be signed by -the owner and shall include a statement of ownership and shall identifythe owner's authorized agent, or shall*grant permission to-the lessee to a I for the permit. The full names and addresses of the owner, lessee apply applicant and the.responsible officers, if the owner or lessee is a corporate body,:shall be stated in the application. Please note; It is the res onsibili" of*the registered HIC to obtain al permits necessary for work covered by the Home Improvement . 1 Contractor Registration Law, M.G.L. c 142A. An owner who secures his or her own permits for such shall be excluded from the guarantyfun' provisions as defined in M.G.L. c. '142A. d Back to Top Q. 1Uty contractor- told me 1 need to obf a�n the permits fo - - --- - �rn construction. 1VIa 1 obtain the relevant permits from, �rny local buildin • department, or. is the contracto required to do that?� --- ------:---j While you may certainly obtain your own permits, be aware that if you do You will fall into a homeowner exemption that will dis uali eligible to-receive recourse through M.G.L c. 142A, the HIC Law o the being statutorily authorized Guaranty Fund, should a problem arise: It is the res onsibili of the rg istered HIC to obtain all permits -necessary for work covered by the Home Improvement Contractor Registration Law M.G.L. c. 142A. If the HIC.you are contracting with refuses, you may wish to reconsider using that contractor's services. oFTME Town of Barnstable 0 ' * Regulatory Serviees M+ss. Thomas F.Geller,Director '°leap' Building Division Tom Perry,Building Commissioner 200 Main Street Hyannis,MA'02601 www.town.barnsiable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property, hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit (Address of Job) Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or-utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name . Print Name Date QTORMS:OWNERPERMISSIONP00IS 0012 - �T r Town of Barnstable : - ,P` a Regulatory Services : t Thomas F.Geiler,Director MASS Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-403 8 . Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION (� ! Please Print V DATE: . c Ine 7 i `S JOB LOCATION: number street vi age "HOMEOWNER": �7 tt � a• 7 '—o' - name I ©� home phone# ,[ work phone# CURRENT MAILING ADDRESS: cl f ry / city/town 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. r DEFINMON 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-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such. "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work 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 Barn table Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and re ents. - Signature of Home o er 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 perfornung 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,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would.with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a fomi/certificatian for.use in your community. •Q:formsdromeexempt Engfi*eering Dept. (3rd floor) Map "� Parcel `,3' I R-a5 Permit# House# C1 e_J1 Date Issued /oZ Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) Fee o7�� ��. Conservation Office(4th floor)(8:30-9:30/1:00-2:00) Planning De t. (1st floor/School Admin. Bldg.) THE h D i ' 've n Approved by Planning Board � 19 ; BARNSTABLE. MASS 019. TOWN OF BARNSTABLElE° +°,� Building Permit Application roject S eet Address c /�f CcZS � Village 4L4 <AAA 0 Owner r Address Telephone Permit Request 2 4 I V i First Floor square feet. Second Floor square feet R Construction Type Estimated Project Cost $ �— Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing.Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No.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 Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name E,/\� Telephone Number Address _7?9-tZM&(n C ,/l , License# . y--'- C ►Y�{� E = Home Improvement Contractor# Worker's Compensation# ellfe j 5C3 0/9 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 DATE l/ BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) a dflJtr s� FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED _ MAP/PARCEL NO: ADDRESS VILLAGE' Y . w^+" OWNER "' F DATE OF INSPECTION: FOUNDATION , FRAME f INSULATION ; t FIREPLACE # ELECTRICAL: ' ROUGH FINAL - PLUMBING: ROUGH FINAL GAS:. l ROUGH FINAL! FINAL BUILDING DATE CLOSED OUT-. ! ASSOCIATION PLAN NO. - zH!T The Town of Barnstable Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyamiis MA 02601 Ralph G•nse.� Office: 508--,90-6=7 Building Corr.: Fax: 508,90-6730 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, dean�Least one bnt�n t�moreon f than ouzon to dwellYng nnt pre-existing to owner occupied building containing at structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. 'Type of Worst: Est. Cost CX Address of Worst: r29 �S Owner's Name__�. Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): 4 Work excluded by law _Job under 51,000. Building not owner-occaQied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UN1tEGSS'TERED CONTRACTORS FOR APPLICABLEOGRAM OR HOME �A►IOVE31ENT WORK DO tANTY FUND UNDER MGS.O 14Z.� � ACCESS TO THE ARBITRATION SIGYED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the the owner. 6 Registration No. Dar Cant actor i�iaffi The Commonwealth of.4fassachusetts aril , Department nt of Industrial Accidents t _ - F Ofliceo//nyestigat/ons 600 If ashinhtott Street Boston, Ma.u. 02111 Workers' Compensation Insurance Affidavit --- __.._. M, - ---- - - - �hplic•tnt information'• Please PRmyr leb' .._.--..... ...__._..__..._. _ 1�?1L ,�_..._....._. ..... name' T_')Io>G' (=✓l r.� locition• r)/�i2.0.�VV\_ / city <.U` 't/u I (,) 1+ nhone 0 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity . �. .- -.:_�.......��..�__�..�..�-..__ ..,.,, , .:�.,`�._�..;y.,... _-,-----Y-•- .-::,.� __ -._..ems• :- ..-_-.-.__'� rani an emplover providing workers' compensation for my employees working on this job. contnany name: address- cite ahnne#'A insurnnce co. policy# 3 o [j I am a sole proprietor. beneral contractor, or homeowner(circle Otte) and have hired the contractors listed below who have the followin_ workers' compensation polices: comnnny nnmc- address: city: nhone#• insurance co nnlic,•Of - _ .t.:: �... y..� - _ �.:a..._:...,� _ __ �_r--e-:�::�.r.�;�cT••r�wws�.,.• ^Tr,•e,_ - •e•r...-rt-...i--= w company nntnc• address- city nhone#• insurance co policy# .Attach additional sheet if necessary '—'.r^- + -j� T ""%^, '' w' =''_ '"-�� •:.,, '`^ Failure to secure covernac as required under section 25A of NIGL 152 can lead to the imposition of criminal penalties of a line up to 51500.00 andiur one years* imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of 5100.00 a day against me. I understand that a cope of this statement ma% be forwarded to the Office of investigations of the DIA for coverage verification. I do herehv ccnijt cr t and petr of perjure•that the information provided above is true and correct. Si=nature Date T/2 Print name �" �./IEc�Q.t�l Phone# official use only do not,,rite=hi, ea to be completed by city or town official sin or to n: Permit/license# r'tBuilding Department DLiccnsin-,board 0 check if immediate response is required DSeleetmen's Office t `• 011calth Department contact person: phone#: r'IOther r information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' ce)mpettsation for the; erployees. As quoted From the "law". an emph► ree is defined as every person in the service of :uu►ther.under any contract of hire, express or implied:oral or written. Aa etnplurer is defined as an individual. partnership, association, corporation or other legal entity, or any two or more the foregoing engaged in a.joint enterprise, and including the le-al 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 haying not more than three apartments and who resides therein, or the occupant of the dwellinu house of another who employs persons to do maintenance , construction or repair work on such dwelling IioL or on the :rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer MGL chapter 152 section 25 also states that even, state or local licensing agency shall -vvitlihold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant Nrho has not produced acceptable evidence of compliance-vvith 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 11: been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers 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 Nvorkers• compensation police, please call the Department at the number listed below. C:;ty 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. Plea be sure to fill in the perrnit/license number which will be used as a reference number. The affidavits may be returned t the Department by mail or FAX unless other arrangements have been made. Tlie Office of Investigations would like to thank you in advance for you cooperation and should you Dave any question please do not hesitate to `_lye us a call. . ' nw.r-.w.Vs...•1�.+.--+.+Aw..+. ......-+.�•.+w.•r+•.+NNL•ln_7'_'�"' Tile Department's address. telephone and fax number: The Commonwealth Of Massachusetts A-2 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 avb �31 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTIN.�GS (Print or Type) III ST"LL Mass. Date ��-Io _191iS Permit Building Location Location o21 (i art tCgSTu s jgyp Owner's Name 1(5 -vz,� 64LL Pd�•( Type of Occupancy New = Renovation V Replacement ,. Plans Submitted: Yesr No jj ¢ M W iA Y = 5 V7 N N U ¢ ►• _ yr W ¢ O V v ¢ < Y Z Z O W O u < ¢ ¢ 0 am W i J W 0 n a c o a ¢ W Z U W W Cr¢ ¢ I-- �- _ 41 yA 0 < � Cr¢ ¢ W W fn c 0 F� Z J F Z W W 0 O > U. E. W < W > ¢ W 2 < ¢ < < O O W a O 1111111 SUB—BSMT. BASEMENT i 1ST FLOOR 2NOFLOOR 3RO FLOOR I 4TMFLOOR STMFLOOR STMFLOOR ?TM FLOOR 8TM FLOOR Installing Company Name SNOW,,,; PT.ITMRTNr: ;4F.ATTNG Check one: Certificate Address P.D. BOX 39 ❑ Corporation W BARNSTABLE, MA 02668 Partnership Business Telephone 362-9111 Firm/Co. Name of Licensed Plumber or Gas Fitter CHRTSTOPHFR SNOW INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes MC No ❑ If you have.checked XW, please indicate the type coverage by checking the appropriate box. A liability insurance policy V( Other type of indemnity❑ Bond C OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass:, General Laws, and that my signature on this permit application waives this requirement. Check One: Owner❑ Agent ❑ Signature of Owner orOwner's Agent I hereby certifyy that all of the details and information I have submitted(or entered)in above liabon are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issu s applicatio will be in complian ith all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen BY T of License: `��; Plumber n r or itter Title Gasfitter Master Uanse Number 10705 ON/Town Journeyman y\ V p� 9i �r� I