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HomeMy WebLinkAbout0405 MITCHELL'S WAY yp I&OPIr`I ERMIT Town of Barnstable *Permit#o C� Evir onths from issue date 12 Regulatory Services .Fe MAM i 039. `0� Thomas F. Geiler;Director TOWN ARNSTTABLE Building Division Tom Per CB Perry, O, Building Commissioner ., 200 Main'Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRE S PERMIT APPLICATION RESIDENTIAL ONLY so 1 /� j Not Valid without Red X-Press Imprint Map/parcel Number "� Property Address "�1"b ,/� "'I C�e fit'v []Residential Value of Work (, Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ///� �®ne - S A,*/,oQiy. S y f0 Contractor's Name � C(�„Qe O. 2- ( Telephone Number P ����-)) I- chi � lr Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) K , ❑Workman's Compensation Insurance Check one: [� am'a sole proprietor. ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance . Insurance Company Name Workman's Comp.Policy# Copy of Insurance Complia nee Certificate must accompany each permit. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to f .drip , 1 ❑ Re-roof(not stripping. Goingover existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows *Where required: Issuance of this permit does not.exernpt compliance with other town.department regulations, ;e.Historic,Conservation,etc.,,,' 'Note: Property Ownermust sign Property Owner Letterof Permission. A copy,of the Home Improvement Contractors License'& Construction Supervisors License is required. SIGNATURE: QAWPFILESTORMS\building permit forms\EXPRESS.doa . Revised 070110 e _ License or registration valid for individul use only i Office of Consumer Affairs&B sines Regulation before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR Type: Office of Consumer Affairs and Business Regulation Registration:,s-1,11859 10 Park Plaza-Suite 5170 Expiration 2/4/2013 OBA Boston,MA 02116 MI AEL RENZI CONSTRUCTION i a 1 MICHAEL RENZI 'a r �3 a_ h y 387 PHINNEY S LN:;ti,` t 1' L. Not val thout signature . .CENTERVILLE,MA 02632 Undersecretary . b10Z/0£/GO Jauoissiwwop uoi;ejidx.3 ���nx�ils�� lit'I SA,amA a L8£ IZ1 a r 11aVMEK 99Z890-Viso :asuapi� = .%I!we3 Z ?Y I JOS1.UadnS.0 iit nalsuo3. sp�epuelS Pue suogeInBaH 6uippng jo pieog /i;a1eS olignd 16;uaw�edao- s};asnyoesseVq . Op1HE r Town of Barnstable y Regulatory'Services Musa. $ Thomas F.Geiler,Director i0rsa 39. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b arristable.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 fj4 ` k t 4e,* 2 k to act on my behalf, in all matters relative to work authorized bythis building permit application for. j� AAAaCke AJ- W (Address of Job) Signature of e Date V� Print Name i II If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. i I I soft T` ti Town of.Barnstable Regulatory Services BAMSTAare, : Thomas F.Geiler,Director y MAss. g �p 1639• Building Division TFc �A Tom Perry,Building Commissioner 200'Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwelling 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-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 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 persons)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&Regulatidns 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 ofhis/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. Q:forms:homeexempt - oF1HEra,, Town of Barnstable Regulatory Services ■nxxsresi,E, v Wins. � Thomas F.Geiler,Director �p 1639. ♦� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us . Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Us ing A Builder _ - I, (//a-l Ati XSA wn.?n 1 as Owner of the subject property. hereby authorize - I�Aq k.c Z .V ► ('(yt/ Ih.J 071 Uti to act on my behalf, . in all matters relative to work authorized by this building permit application for. z l S 04 i�e i( /—G✓ L/ (Address of Job) Signature of r Date J � Print Name If Property Owner is applying for pennit.please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:O WNERPERMISSION �oFSHE r Town of Barnstable " Regulatory Services sARNSUBLE, : Thomas F.Geiler,Director y MASS. $ �b i639• Building Division Al fog a 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 "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: 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. , DEFINITION OF HOMEOWNER Persons)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 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 super-visor(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 form/certification for use in your community. Q:forms:homeexempt Zi'4 201 9:14 -?i. =P..011: Bearce_insur=-n._e TO: -r:r,_ 002 0F00 �fl l'� DATE(MMIDDIWYY) AC®RD„ CERTIFICATE-OF LIABILITY INS NCE 02/24/2012 PRODUCER 508.586.3400 FAX 509.596.3700 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Bearce Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 670 Pleasant Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0. Box 1709 Brockton, MA 02301 INSURERS AFFORDING COVERAGE NAIC# INSURED Renzi Mike ' II,ISu°E=,;: Conexco Insurance - 387 Phinneys Lane NsuRERE: Centerville, MA 02632 INSURER C: IPSUPEP D: - IUSuPER E: COVERAGES 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 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR INSD Ll TypE OF INSURANCE POLiCV NUMBER POLICY EFFECTIVE I,,POLITY EXPIRATION I. LIMITS TR MILI I`ENERAL LIABILITY NN118596� OS 06 2011 I'05 06;,.2012 Ear Or,If.PENCE s. � � � � 1,000,000 X COMMERCIAL GENERAL LI-.E:u,T' i DA,n 0 RENTED 50,000 CLAIMS IJAD a i,rLL R I MED EXP(Any,ne persons ¢ 5,000 '� - PERSONAL&ADV INJURY 1,000,000 GENERAL AGGREGATE a 2,000,000 I-AGGREGATE LIMITAPPLIES PER': - _ 1,000,000 r Pc ,_ -I PRODUCTS-CGMP/OP AGG $ I X POLICY JEfT I I LJC 1 AUTOMOBILE LIABILITY COMBINED LIMIT 4' ANY rlrn (Ea a:ri j nt.i. H ALL OVdNED AUTOS .�•. ., BODILY IPIJL4PY J-SCHEDULED.=.UTGS _ - .. .(Per person} - BODILY INJURY g NON-OWNED AUTOS (Per accidsnt'i PP,OPI e D!GPh4GE (Per accident) GARAGE LIABILITY ,M1 r _ I AUTO ONLY-EA.ACCIDENT .$ ?e+lY kUTU - A P,CC I p . ^T -THAN P IAUTO ONLY: .AG I EXCESSAJMBRELLA LIABILITY S L- Ec, G UPxGICE L_I+,'CCLIR I I ._ _ A.GC, GATE 1 10EDLICTIEL_ S i WORKERS COMPENSATION AND i . - � I - NN„STP,TU- C-TH- - EMPLOYERS'LIABILITY' - T PY N1iT.^ FIR E.L.EA=HACCIDENT S - C°i � - E.L.DISEASE-EA EMPI'i ' E L DI:SELSE PCLIC��LI'•rIT 3 -OTH'ER _=T!CNS i LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE - EXPIRATION DATE THEREOF;THE ISSUING INSURER WILL ENDEAVOR TO MAIL • , 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, - BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY - OF ANY kIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. 'OCT Of insurance, AUTHORi-,EC,REPRESENTATIVE Will am Bearce, III/CHERYL _ 25 i:2001i08) ©ACORD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents '-µ Office of Investigations 600 Washington Street Boston, MA_02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers' Applicant Information Please Print Legibly Name (Business/organization/Individual):: ,' /V`,C ��,dt ' 10A.1 1. Address: 37 �1�.✓ti-c �AwR City/State/Zip: 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 employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.© I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees -These sub-contractors have g, ❑ Demolition working for 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 10:13 Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their.; ' I1.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL c. 152 ) 12•[�ffoofrepairs insurance required.]t , §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,affidavitindicating 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 pains and penalties of perjury that the information provided above is true and correct Si ature: A.4 `Date: L. Phone#: Official use only. Do not write in this area,to be completed by city.or town official City or Town: PermitlL icense# 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#: � TOWN OF BARNSTABLE.BUILDING PERMIT APPLICATION Map Parcel / Application #(72 AV-7 L.1 Health Division ' Date Issued v Conservation Division Application A Planning Dept: t Permit Fee Date Definitive Plan"Approved by Planning Board pit Historic ; OKH Preservation/Hyannis Project Street Address ✓k l�G1�e 11 J G� `1 Village ,�,✓> > Owner V/, 1Tn�A_ S.v D 4 J Address S n L L"{ l v is c Telephone 7 > �'-- �6 Z ( _� ,�e o12 ;, '� ►.� 1�.--�. Permit Request k- n8Mt t_­� '3 ox e D o u L C AI Z`I_L (4,S,pm±z 1-11 N l2 v &y v,v iT i� C�11�e� j rr�N �?��•. P 0 tar\0_P �t l.✓A1l -A./ 6 w s v I �I QA. Z��� �tiQ c t,.��a lL -r [?� lam.•. 1 iAv A�, -h fry � • e .�' � �Ci-.��v b .v� l' Square feet: 1st floor: existing proposed nd floor: exisfin� pr�posec� Total new �_ Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family GIB Two Family ❑ Multi-Family (# units) o Age of Existing Structure S 6 Historic House: ❑Yes 21;16, On Old Kings ighway::]Yet 9'No `�; c� Basement Type: ❑ Full ❑2`rawl ❑Walkout ❑ Other -n cxa Basement Finished Area (sq.ft.) 0 Basement Unfinished Area(sq.ft) Number of Baths: Full: existing l new 6 Half: existing new Number of Bedrooms: existing _new =1 Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: OIGas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes U-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) tddo Name /fin k e 7,e.,J LA Telephone Number Address 3`70 ytko,-ti&.yrJ la-vf License# Home Improvement Contractor# /it Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO 1 A SIGNATUREA A DATE to I Z. I -� T i FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS ? VILLAGE OWNER - DATE OF INSPECTION: FOUNDATION " FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL t PLUMBING: ROUGH FINAL s GAS: ROUGH FINAL ' FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. ,ti The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): � Address:- L?[�1N I City/State/Zip: Uk Phone Are you an employer? Check the appropriate bo Type of project(required): 1.❑ I am a employer with 4. I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition workingfor me in an capacity. employees and have workers' y9. ❑ Building addition [No workers' comp. insurance comp. insurance.1 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 I LE] 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.❑ Othera,Wt)1Al t d�- 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. tContractors 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: 416 A kTthg U J t,vr* y 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 pains andpenalties ofperjury that the information provided above is true and correct. Signature: Date: Phone#: 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#: C 1 , � Information and Instructions 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 employef, 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, constriction 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-contractors)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 pen-nit 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 pen-nit 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 Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia te: 10/2/2009 Time: 4:11 PM To: Sally @ 9,15087906230 Rogers & Gray Ins. Page: 002 Client#: 4597 CCINSUL ACORD,. CERTIFICATE OF LIABILITY INSURANCE 102/09DD/YYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&Gray Ins. -So. Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 434 Route 134 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE.AFFORDED BY THE POLICIES BELOW. P.O. Box 1601 South Dennis, MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Peerless Insurance - 34754 Cape Cod Insulation Inc INSURER B: Atlantic Charter Insurance 455 Yarmouth Road Hyannis, MA 02601 INsuRERc: Commerce Insurance Company INSURER D: INSURER E: - COVERAGES 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 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY.PAID CLAIMS. TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR NSR DATE MMIDDIYY DATE MM/DD/YY LIMITS A GENERAL LIABILITY CBP8263063 04/01/09 04/01/10 EACH OCCURRENCE $1 00p 000 X COMMERCIAL GENERAL LIABILITY DAMAGE PREMISES REM GETOEa occurrence) $1 OO OOO CLAIMS MADE a OCCUR MED EXP(Any one person) $5 000 PERSONAL&ADV INJURY $1 000 000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 1-1 POLICY F1 JECT PRO LOC C AUTOMOBILE LIABILITY 09MMBCKVMK 04/01/09 04/01/10 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $1,()00,000 ALL OWNED AUTOS " BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIREDAUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Peraccidenl) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ - OTHER THAN , AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY - EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE - $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION AND WCA00525900 06/30/09 06/30/10 X WORY C IIMIT OTH- S FIR EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $500,000 It yes,describe under SPECIAL PROVISIONS below - E.L.DISEASE-POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Mike Renzi DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1111 DAYS WRITTEN 387 Phi nney's Lane NOTICE TOTHE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL ,Centerville, MA 02632 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #S46393/M46044 CBR © ACORD CORPORATION 1988 k w;w I Bo��o w mg�g�ula0o�an tan ards I License or registration valid for individul use only i HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Y Registratoh: 111859 Board of Building Regulations and Standards Expirati n - One Ashburton Place Rm 1301 2/.4/2011 Tr# 279440 Type DBA" Boston,Ma.02108 ! MICHAEL RENZI[CONSTRUCTI:O I MICHAEL RENZI - 387 PHINNEY'S LN, � i CENTERVILLE,MA 02632 Administrator Not vali th t signature -Comvnao7eciseal o�/laclictaelta a i Board of Building Regulations and Standards i Construction Supervisor License x License: CS 58266 n .� 4 Ex�pi�ation 1/30/2010 Tr# 13630 • �cRestnction 1Ge - MICHAEL J RENZI5 y} 387 PHINNEYS LNG --�— �J t F CENTERVILLE,MA 02632 Commissioner f yP,,oft"eTy� Town of Barnstable --� Regulator Services BAMgrAm Y 1639. Thomas F.Geller,Director Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 - Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I f � 2V2n1 , as Owner of the subject property hereby authorize to act on xni behalf, in all matters relative to work authorized by this building permit application for: Y&A ��T� �r ll� G✓g y (Address of Job) UhL (/n �L✓a— 16 C Signature of ner Date J . JC"k's Print Name WORM&OWNERPERMISSION i r, 'E YERG:Y CONSERVATION APPLICATION FORM FOR ENERGY EFFICICIENCY FOR. ONE; A_ND TWO-FAMILY DETACHED RESIDENTIAL CONSTRITCTION (780 C1YIR 61.00) Applicant Name: Site Address: print Town: Applicant Phone: Applicant Signature: Date of Application: NEW CONSTRUCTION: choose ONE of the followin two'o Lions 780 CMR.TABLE 6107.1 PRESCRIPTIVE EMVEL DPE CGMPOrdENT CRITERIA FOR NEW ONE- AND TWO-FAIYMY BUILDINGS MA��Ilv1Ulv1 •MINIMUM Ceiling or Basement Slab ❑ Option 1: Fenestration exposed Wall Floor Perimeter U-factor floors R Value R-Value wall R-value AFUE TiSPF SEE] R-Value R-Value and Depth_ National Appliancc.arrgy 35 R-38 R-19 R=19 R-10 R-10) ConscrvaL hA(ACNAECA)of 4 ft.• 1997 as amcndcd,minimums or cater as applicable Note: This form is not required if you choose either of the two Versions ofREScheck as listed below. ❑ Option 2: REScheck Version 4.1.2 or later variant software analysis must be completed 780 CMR 6107.3.2 REScheck--Web which can be accessed at http-//www.c-,ntrgycodts.goy/rcscht--ck/ ADDZ� OrIS'OIZ ALTE ZATZONS.T 0 E�CS I'ING 13ULLDINGS.O:VER•5 YFARS OLD* *}Buildings under S years old must use option#1. or 42 in New Construction section above. Complete the following formula to determine the %o of glazing: (a) Gross Wall & Ceiling Area equals Formula: (100 x b _ a) SF 100 x - = o of glazing (b) Glazing area equals SF 6 a If glazingis< 40%.use the chart below. If gla±ing is y 40 % rocee•'d to "SUNROOM" section 780 CMR TABLE 610.3 PRESCRIPTIVE ENVELOPE COMTONENT CRITERIA ADDITIONS TO EXISTING LOW-RISE RESIDENTIAL BUM DR GS MAXIMUM MINIMUM Ceiling and Slab Perimeter Fenestration j� R- b.. ; Floor Basement Wall R-Value U-factor Exposed floorsR-value R-Value R-Value and Depth 3 R-3 7 aR-19 R-10 R-10, 4 feet EL R-30 ceiling insulation may be ased in place of R-37 if the msu a ion achieves the full R-value over the entire ceiling area(i.e, not compressed oYer exterior walls, and including any access o enin s), ' SUNROOM—An addition or alteration to an existing building/dwelling unit where the total glazing area of said addition exceeds 40% of the combined gross wall and ceiling area of the addition. Note: Owner to fill out Consumer.Information .Form found in.Appendix 120.P r Of n To`v oPermit f Barnstable ca8� TFiE Try, Expires 6 uronl6s fyout issue tla �STAB� Regulatory ulatory Services Fee �3 � � a1$� Thomas F. Geiler, Director �ArfDh"�� Building Division 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 �� In I Property Address ❑ Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address��Q Ipf1 Lf' ,���✓ OP"� �' Contractor's Name Lf� Telephone Number ���` ?149Q 1 Home Improvement Contractor License#(if applicable) f Construction Supervisor's License#(if applicable) Z ❑Workman's Compensation Insurance m zo r-SS P E IT Check one: [4 am a sole proprietor SEP ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name 60Al C 6 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 ❑ Replacet Windows. U-Value (maximum .44) "moo OJT- D8pC- *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. �.Hom provement Contractors License& Construct Supervisors License is required, SIGNATURE: Q:\WPFILES\FORMS\Express\EXPRESSPER / .DOC Revise060409 The Commonwealth o Massachusetts �\ f Department of Industrial Accidents Office of Investigations , 600 Washington Street Boston, MA 02111 ;may www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information n Please Print LejZibly Name (Business/Organization/Individual): �,l t �{ Z�„� 2 ( Q,✓J�q y 1`��" Address:� (4.1.-e City/State/Zip:. Cp ~ Vk V Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ I am a general contractor and I employees(fall and/or part-time). * have hired the sub-contractors 6. ❑ New construction 2.O am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.) 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required:] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other��1/pig 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. tContractors that check this box must attached an additional sheet showing the name ofthe 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, 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob 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 pains and penalties of perjury that the information provided above is true and correct. Si nature: Date: /f 0 Phone#: 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#: Information and Instructions 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-contractor(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 Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax # 617-727-7749 www.mass.gov/dia �I r �IHE r° Town of Barnstable Regulatory Services 9S^ hUM Thomas F. Geiler,Director ��E p1639. � Building Division ►� g Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, LIA � SF}IV , as Owner of the subject property hereby authorize , �..� �.�w Z l to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address'of Job) Signature of er Date IA'g m'e tX Print Name If—P ro e Owner is applying forpen-nit please complete the Homeowners License Exemption Form on the reverse side. Q:FO RM S:O W N ERP E RM I S S I ON t of t�ram, Town of Barnstable o Regulatory Services swxt MBLt Thomas F.Geiler,Director MAM 9�A 1639. s`�� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Officer 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: 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. 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-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 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,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 form/certification for use in your community. Q:\WPFILES\FORMS\homeexempt.DOC License or registration valid for individul use only Bo�1fd`o m mggu�at�o�"an tan ar { HOME IMPROVEMENT CONTRACTOR } before the expiration date. If found return to: Board of Building Regulations and Standards lugRegistration , 111859 One Ashburton Place Rim 1301 Expiration --2/_4/2011 Tr# 279440 Boston,Ma.02108 YP BA MICHAEL RENZI,CONSTRUCTI'ON, ` MICHAEL RENZI ; r - --- 1� Not vali thot signature 387 PHINNEY'S LNG /' / ' Administrator CENTERVILLE,MA 02632,_, K"''"" g f�"`� ✓die -C�°�n?rec�ic'ealCf o��,Z�xukU;f> .. Board of Building Regulations and Standards r I Construction Supervisor License t r P Lice se° CS 58266 LLI Ez irat►on 4 P 1I3012010 Tr# 13630 f Restncon ti MICHAEL J RENZI _ 387 PHINNEYS LN� /i` CENTERVILLE,MA 02632 7 Commissioner,k. 3 HETp�i TOWN ®F BARNST l BLE i • . BAHH9TAHL8, i "6 9 BUILDING INSPECTOR APPLICATION FOR PERMIT TO .... �4�.....�N .....���1,r �.��.�....... ............................................ ...... �/ .. .............................. TYPE OF CONSTRUCTION .........WPPP ...T... � /°s,S� a -�.,_: . ... ..................... ........... .................. ......... ...... PI.t............ ...........,9.�,3 l TO THE INSPECTOR OF BUILDINGS: The undersigned hereby {appliess for a permit according tto tpe following information: p� Location ..... D. .....Y .......!..! `-.G 14 41- .........W �.. It � -S 1. .................................,.......... .......................... Proposed Use .......h......... ........:......®.®...................................................................................0.... ........................................ ZoningDistrict ........................................................................Fire District ...................................................................0.......... Name of Owner ...!.!.� ...... ............`.`:�� ...........Address c Name of Builder �... ....b...�.v�...!.....':�.��.......Address �/_ �� �� ss s r7 A ' . t, ..... .......................................... .......................... Name of Architect ��.++� .:.yy��— � � ... �.......... ~� ` t.5? 1......................_..... ........ ...Address .........../�+........................:............................................ Numberof Rooms ._............................................................ O11� ........................................... .. Foundation ......... ........................................... Exterior ........W/i��TE.....CC-IP ��.......S!?/"4,5r1........Roofing ....... °%-.. '....... �?��............................ cr Floors .......?u.�.�.'.'.....Q .... lN�.�. ................Interior ....... .s'd�R ......W....:'h. .............:............ Heating .... .r...../7"t.. ............ 0..................................Plumbing ........l�..A'P.................................................................... Fireplace A ...........Approximate Cost d�d� Definitive Plan Approved by Planning Board -----------_-------------------1.9--------. / Diagram of Lot and Building with Dimensions SUBJECT TO APPROVAL OF BOARD OF HEALTH U -1A APIT I"' - Lea "D 4� �t1 co Lu J LU I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. .Name o � � Williams, Harold ��� �# . No —�����.' 'Permit for -------. .............. . ' ............ . —=------ Lncahon `-b�*� ................ - ' ---------f������9.................................... Owner -----.�.a.�����. -----' - Type of Construction -----_— --- . ( � ' -----.--------------------' Plot ............................ Lot ....... / � ` � �� ` Permit Granted --.April 4lg ^~ � Date of Inspection ' lA -_- -_,le-- ---� ` �PERMIT REFUSED ' -----~...-----__------- lg --------------------------. " . � -------,------'---------_--' � -------------.------------- � --------------------------. Approved ............................................... 19 ^ - ^ --------^-----------------'' --------------~----------^''