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HomeMy WebLinkAbout0338 AMES WAY 3 ;$ Am �'' f Na A-6V00 ` Town of Barnstable *Permit# : 0ya _ Expires 6 t ndrs ar r i stye d Q Regulatory Services Fee SAXINSTABBIMA Bard V.Scali,Interim Director a TO42017 _ Building Division RS ® om Perry,.CBO,Building Commissioner A&LP 200 Main Street,Hyannis,.MA 02601 = www:towmbarnstable.ma.us Office: 508-862-4038 Fax: 5087790-6230 - EXPRESS:PERMIT APPLICATION RESIDENTIAL ONLY Not.Valid without Red X-Press Imprint Map/parcel Number /70 (95 1 Pro a 'Address 33�Ar►1P P ttY t ot (Residential Value of Work$ /iQ 6� 2 Minimum fee of$35.00 for work under$6000.00 , Owner's Name&Address 7—orn A„i s &kay �mI-eav I(el, MA &Z(a Contractor's Name? OT `rC0 4/ 0. Telephone Number w1-WAI`A-3fy Home Improvement Contractor License#(if applicable) //Z 7 S Email: Construction Supervisor's License#(if applicable) [�VJgrkman's Compensation Insurance Check one: _ `` ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's/�) Compensation Insurance / � [l � Insurance Company Name �,"T Wj— 1 l 1 a N AJ f 5 Workman's Comp.Policy# 4 5, S S Copy of Insura ce Compliance Certificate must accompany each permit. Permit Re st(check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to e ❑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. *Mlhere required_ Issuance of this permit does not exempt compliance with other town department regulations,i.e.,Historic,Conservation,etc. i ***Note: ope wner must sign Property Owner Letter of Permission. o y the Home Improvement.Contractors License&Construction Supervisors License is it SIGNATURE: QA%)fPFILES\FORMS\building p ' .fo 1EXPRESS.d c Revised 061313 �! 1RK(�3 99 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations hI 1 Congress Street, Suite 100 �'� ,y r Boston,111.9 02114-20I7 www mass.gov/dia ricians Workers' Compensation Insurance umbers Affidavit Builders/Contractors/E1ePl V� ease Prin1t Le iibh� o A lieaut Information Na171e (BusinesslOrganiZation/Individual): The Home Depot At-Home Services Address: 908 BOSTON TPK SHREWSBURY, MA 01545 Phone#: (508) 942-6942 City'/State/Zip: Ty of project (required): Are you an employer? Cbeck the appropri a box: 200+ 4. I am a general contractor and] 6 New construction 1 am a employer with have hired the sub-contractors employees (full andior part-tune)'* listed on the attached sheet. �. �Remodeling 2. 1 am a sole proprietor or partner- These sub-contractors have g. Demolition ship and have no employees employees and have workers' 9 Building addition working for me in any capacity. comp.insurance. [No workers' comp. insurance V�e are a corporation and its ]0-�Electrical repairs or additions required.] officers have exercised their l 1.❑P tunbmg repairs or.additions I am a homeowner doing all work right of exemption per MGL 12.�PR f repairs myself. [No workers` comp. c 152, `1(4),and we have no 13 Other insurance required.]t employees. [No Workers` comp. insurance required.] 'Am app they are doing all work and then hire outside contractor`must submit a new affidavit indicating such. licant that checks box€l must also fill out the section below showing their workers compensation poh- information. +Homeowners whc submit this affidavit indicating they must rovide their workers" comp.police number. -Contractors that check this box mus attached an additional shpeet showing the name of the subl contractors and state whether or not those entities have emplovees. if the sub-contractors have employees, n employer that is providing workers'compensation insurance for my employees. Bel ows is the policy and job site lama p _ information NATIONAL UNION FIRE INSURANCE COMPANY — Insurance Company Name: 03/01/2018 XWC 65831 45 (QSI) Expiration Date: Policy$ or Self-ins-Lic. #: .�- 11� aVy(q .Y,a c I � ell City/State"Zip: C ea Sob Site Address: showing the policy number and expira 'on date). compensation Policy declaration page( osition of criminal penalties of a Attach a copy of the workers' comp PMGL ` RK ORDER Failure to secure coverage as require imprisonment, asSection s well as ci lcpenalties in the form a afSTOP forwarded theOffice of d a fine fine up to$1,500.00 and/or one year of up to$250.00 a day aga a violator. Be advised that a copy of this statement may e Investigations of the D r cc coverage verification. e ains d f perjury that the information provided above is true and correct I do hereb►'certify un Date: Signature: Phone#: a Official use only. Do not write in this area to be completed by cih'or town official- Permit/License# City or Town: Issuing Autbority(circle one): Building DeparrII1e°t 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 1. Board of I-Iealtb 2. g 6.Other phone#: Contact Person: DATE(MMIDO(YYYY) CERTIFICATE OF LIABILITY INSURANCE 0211720/7 7 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 i IBELOW. THIS CERTIFICATE.OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING WSURERIS), AUTHORIZED REPRESEIJTA71VE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to i I the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights tc the certificate holder In lieu of such endorsement(s). CONTACT PRODUCER NANIE: MARSH USA,INC. PHONE I FAX TIRO ALLIANCE CENTERI.C.Ne A(C Nn: 1 355D LENOX ROAD,SUITE 2400 E42AILs: A.TLANTA,GP.30326 INSITirER(S)AFFORDING COVERAGE ! NAIC 100492-HomeD-C-AN^-17-1A INSURER A:OW R"UdbC 1r'SUMnCE Co 124147 INSURED I INSURER E•Agri General Insurance Company 142?5i I THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. INSURER c New Hampslilrc Ins Co I1 1 2455 PACES FERRY ROAD INSURER D: BUILDING C-21) A i LANTA,CIA V. 339 INSURER E: INSURER F- COVERAGES CERTIFICATE NUMBER: ATL-003746387-14 REVISION NUMBER-2 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NO I 1 STANDING ANY REQUIREMENT,TERM OR CONDITION ION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS j CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUB.IECT TO ALL THE TERMS. I EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �rSF, TYPE OF INSURANCE IAD LISU9.Ri POLICY NUIJ®ER 6 OLIGY EFF I PM6UELITDtYYYI' I Lm11r< LTR A I X I COMMERCIAL GENERAL LIABILITY 11,JW7Y 310022 03/012017 I03I012016, !EACH OCCUI;RENCE IS o.00c,0o�I ' ,-- 7AlSAGET REIJTEL I 1,00•�.0�! CLAIMS MADE X OCCUR I ?REWSE`- E2Geaorence) Ic kUMrTs OF PaUCY XS ! ,rED EX'{Aran am per) is EXc+UO I IOF SIR�iN PER QCC i s 9,OOD,OOD i iSONALB ADVINJURY c cc ! I I GENERAL AGGREGATE i s °OOC,OC. li GEML ACCREGATE UM;T A.PUS..PER f e i PRO- COMPJOP AC-G 'S 9,000,DCf. ! X I POLICY JEC7 i LLY' I I I OTHER A �;AUTOMOBILE LIABILITY 1 HWSITB�1DD27 03,D-2017 031DI2019 COL'a N'EC SINGE IJMr- 15 :,L�DD,UDL' (Ee aeddenl ^ ANY AUTO I ! I BODILY INJURY(Pe person) I E ALL OWNED SCHEDULED i SELF INSURED AUTO PHY DMG BODILY INJURY(Per acdern;'s j �!AUTOS AUTOS-0WNED PROPERTY DAMAGE s i HIRED AL70S I AUTOS I I I iPer acmderd) I I UMBRELLA UAE �i OCCUR I I I 'I l i EACH OCCURRENCE S i EXCESS LIAe i I CLAIMS-MADEI I IIIII I AGCREGATE i S i I i I I DEC I I RETENTIONS ! E. IWORKERS COMPENSATION I WLR C49112300 fN) 0310i12D17 031012D76 X I t ERH AND EMPLOYERS*LIABILITY YIN WE 023102423(AY NH,NJ,V) I03ID12017 031011201E 15 1,00D,Or<�j I C i ANY PROPmETORlPAR7NERIEXECl111� IV i N)A I E L EAG'ACCID3�1T C 'OFFICERIMEMBER EXCLUDED. I I WC 023/02424(WI) I031D7l2017 D3lDil2Di8 E L DISEASE EA EMPLOYEE S 1,DD0,CI I (Mandatory In NH) - Ii yes.desoibs under I Continued on k&Tmra)Page I - I E L DISEASE-POLICY LIMIT CESCRI—i ION DF OPERATIOrtS below II I Dr'S.CRIPMON OF OPERAMONS I LOLATIONs I VEHICLES(ACDRD un,Additional Remarks Schedule,may be attached 1I more apace ie napuhed) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION l HOME DEPOT USA.INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCE I ED BEFORE i 2455 PACES FEIIRY ROAD THE EXPIRATION DATE THEREOF, NOTICE W1L 8E DELIVERED IN ATLANTA,GA M339 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of fsarsh USA Inc I I Manashi MukheryeL 01988-2D14 ACDRD CORPORATION. All rights rese-Yed. ACDRD 25(ZC-,4/01y The ACDRD name and logo are registered marks of ACORD f - ,ter' e C J.a1cf- 2 hailer.�. � r'C C11z?1 .C:.117c:-fti.>d:; r�'( Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 517 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: supplement Card Registration: 1112785 HOME DEPOT USA INC Expiration: 04/2212019 2455 FACES FERRY RD C-11 HSC ATLANTA,GA 30339 update Address and return card. Mark reason for change. C Address ❑Renewal ❑ Employment ❑ Lost Card _ Office of Consumer Affairs S Business Regulation Registration valid for individual use only HOME IMPROVEMENT CONTRACTDR before the expiration date. It found return to: ' TYPE:SuDDlernent Card Office of Consumer Affairs and Business Regulation istration , Reg " ExpiratioQ, ?G Park Plazs•Suite 5170 112785 OA/27Z201 Boston.MA 02116 I-TOME DEPOT USA INC ANDREW SWEET _ d. ithou signature 2455 PACES FERRY RG11 HSG Undersecretary ATLAN T A,GA. 30339 4 • Home Depot Contractor License Numbers: MA: 107774, 112785 Salesperson Name and Registration Number: Christopher G. Read : R-1-073-13-00024 Home Improvement Agreement Home Depot U.S.A., Inc. ("Home Depot") or Service Provider named below will furnish, install and/or service the equipment listed below at the price, terms and conditions as outlined on this form. Customer Information: Tom Digiandomenico New En7177d=uth 10393010 First Name Last Name Branch Name Lead# 338 Ames Way CENTERVILLE MA 1102632 Customer Address City State Zip (781) 953-6730 Home Phone# Work Phone# Cell Phone# tdigi8@yahoo.com Customer E-mail Address NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 908 Boston Turnpike Unit 1 Shrewsbury MA 01545 Address City State Zip or Email CustomerCancellationNorthEast@homedepot.com BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A different CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR PROFESSIONAL, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT THE CONTRACTOR GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR RIGHT TO CANCEL. Acknowledged by: X �.. 09/23/2017 Mee �' Date Customer's Signature _J' Y �....• 1 i Massachusetts pepartment of Public Safety. Board of Building R6gulations and Standards License: C.SSL-iO102 L Constroction Supervisor Specialty RONALDO SOLANO 763 WAVERLY STREET FRAMINGHAM MA•017 f Comm sslorte'r 12I436Z017. r Departtnent of Industrial Accidents Office oflnvestigations I Congress Streg Suite 106 Boston,Nair 02114-2017 -www.massgovIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/lElectricians/Plumbers Avylicant.Information Please Print Leg'b kv Name(Business/Organization&dividual).-�A Address: to e City/State/Zip: 1 6/7d2_- Phone#: 14 Are you an employer?Chec 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. El 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 8. ❑Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers' comp.insurance comp.insurance J 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 I E1 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 13.0Other employees. [No workers' comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: B 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 erage verification. I do hereby c u t e�ains aloes o er'u that the in ormadon provided above is ue and correct Signature- --- - - - -- -- Date Phone#: 15a 8 43 qs 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#: AGENCY CUSTOMER ID- 100492. LOC#: Atlanta ACC V ADDITIONAL REMARKS SCHEDULE Page 2 of ? NAMEDIN5URED AGENCY HOME DEP07 U.SA,INC. MARSH USA,INC. DIBIA THE HOME DEPO7 2455 PACES FERRY ROAD POLICY NUMBER BUILDING C-20 ATLANTA GA 3033-C 1 NAIC CODE CAAR1Eft EFFECTIVE DATE ADDITIONAL REMARKS -77 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE Gerocate 0f Liability Insurance I Workers Comoensauon Continued: ' Cartrer Indemndy Insurance Company oI NM AMtiLc potrjNumberWLRC49112294(AL.ARF"ID,lA,KS.KY,Ii M5,M0.NE,NM,ND,OKSC,SD,YJV,WY1 Effective Date:031D12D7 i Expiration Date:03101016 + (EL)Limit 5,000,OOD Carer:New Hampshire Insurance CompaM - Policy Number.WC 023102422(DC.DE.HI.IN.MD.MN,Nr,NY.RI) Ef)eefive D&I 0yO1120'I7 Ezp rafim l)WE:031012D1 E (EL)Limit 5 i.ODO,D00 (amer.ACE American Insurance Company Polity Number WCU C49112282(OSIXAZ G1..ILNC.OR,VA,WA) Effective Dale:030Y11J17 i Expiration DM 0=2DIE •. I (E 1 Limit 5i,000.000 I SIR..S1,O0400D SIR IT fie SWUS 01 AL CA.ILNC 0R,VA,WA i I Cartier Nalionat Un10T FuE InSUMnce Company Policy Number XWC OB31k(OSI)(CO.CT,GA,ME,MI,NV,OF:,P/-UT1 Effective Dell D3r01r101 i Expiration Date:03101201E (EL)Limit.S'..OD0.0� i 5 i3ODD'OOD SIR for the states of COAT-I'V,MI.OH,PA.UT 1 S750.OM SIR for Dre slate of GA i SM'OM SIR for the State a'CT I I Cartier Nay"�u,,Dion Rn:Insurance Company oC6M3145Iasi,(MA)Eftecfive Date:O12D17 r�ration Dam_03101201E (EL)Limit:51,DOO.OM I SIR SSOD.ODD 1 TY Empioyem X5 Indemridy Camedili i'as Urinn Insurance Company Poi¢y Number TNS C41E13202 UX) Effective Dale:03MW7 Expialror Dale:03101201E (EI:;Limit s10.0130.11W SIR s i.DDD.ODD C 200B ACORD CORPORATION. All rights reserved. pCORG 101 (2008101) The ACORD name and logo are registered marks of ACORD f'w _AP / I�IZ�IO 0 � 1bo5 )y oFcwroN Town of Barnstable *Permit# Expires 6 months jronr issue(late Regulatory Services Fee Thomas F. Geiler, Director Building Division Tom Perry, CBO, Building Commiss o r a i I 200 Main Street, FIyannis, MA 02601 - www.town.barnstab le.ma.us Office: 508-862-4038 8- 90-6230 EXPRESS PERMIT APPLICATION - RESID AL ONLY Not Valid withottl Red X-Press lirtprinl Map/parcel Number 05 Pro AddressA/Y) � W C � �,� n J 6 Residential Value of Work �/ Minimum fee of$3S,00 for vyorlt under$6000:00 vm e � ,fie Owner's Nam & N e Address � C/'e1� 1 6 Contractor's Narne /V t'V (J �(/ C'Il(f Te phone Number r Home Improvement Contractor License#(if applicable) _r d�� I33 Con uction Supervisor's License#(if applicable) Workman's Compensation Insurance Check one: ❑ I3,F6 a sole proprietor ❑ am the Homeowner X-PRESS t�} I have Worker's Compensation Insurance . o Insurance Company Name �/ /f1j1 c Workman s Comp, I olicy# `� Copy of Insurance Compliance Certificate must accompany each permit. Permit Request (check box) ❑ Re-roof(hurricane nailed) (stripping old shingles) All construction debris will be taken to Re oof(hurricane nailed)(not stripping. Going over existing layers of roo fl. Re-side . #of doors ❑ Replacement Windows/doors/sliders. .U-Value (maximum ,35)#of windows *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 Home Improvement Contractors License & Construction Supervisors License is required. 3IGNATUIZE: - 2:1 W FILESIFORMSlbuilding permit formslEXPRESS.doc The Commonwealth of Massachusetts Department of Industrial Accidents r Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): DON)US 6ati's il Address: City/State/Zip: 00g/ Phone #:. SOS 16d2 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I a employer with 4. ❑ I am a general contractor and I 6. ❑New construction mployees(full and/or part-time).* have hired the sub-contractors 2. 1 am a sole proprietor or partner- listed on the attached sheet, 1 7• ❑ Remodeling ship and have no employees These sub-.contractors have 8. ❑ Demolition working for me in any capacity. workers' comp, insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] -officers have exercised their 10.❑ Electrical repairs or additions 3.ElI am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ her of 13. . Ot repairs insurance required.] t employees. [No workers' 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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 1 am an employer that is providing workers'compensation insurance for_my. employees. Below is the policy andjob site . information. p Insurance Company Name: �7 l M findvk J/VS 0 Policy #or Self-ins. Lic. #: `a d od Expiration Date: I) Job Site Address: -_S A Ih L' L,4SICity/State/Zip: 'l�iC z 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 un the pains and penalties of perjury 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#: 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 an of its political y p c al subdivisions shall enter into an contract for the per formance formance of public work until acceptable evidence P p vidence of compliance with the P p 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 maybe 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 bum 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 5-26-05 Fax # 617-727-7749 www.mass,gov/dia. raze Common weal ill of Ma5sachiiset:.S :r.. DQpartiYf2!rt of Industrial,9ccicletsts Office of lrvestigalio,-is 400 Rashingtor S;,Les Workers' Cotnpersation Ir_stirance Affidavit; Builders/Contra Please Print Plea t Print tioibiv Applicant Information j; I n.� ',..,A ii ..S�l J it.•i"" l •r' y' t�/''iJt°' ti.l�.•9':.r f:'-%� --. v ame(Business/Orvanizationilndividurtl): U -1% P Address: City/State/Zip: (� �� Phone#:.Are you an employer.'Check t e a propriate b [6N oject(required): V,6 4. 1 am a general contractor, and 1 construction 1. 1 am a employer with v have hired the sub-contractors employees(full and/or part-time).* odeling listed on the attached sheet. 2.❑ (am a sole proprietor or partner- These sub contractors have Demolition ' ship and have no employees employees and have workers ilding addition working for me in any capacity. comp.insurance.*- [No workers'comp.insurance ctrical repairs or additions required.] 5. ❑ We are a corporation and its3.❑ 1 am a homeowner doing all work officers have exercised their tng repairs or additions myself.[No workers'comp. right of exemption per MGL f rz airs c. 152,§1(4),and we have noher pj �A/ti insurance required.]t employees.[No workers' comp.insurance required.1 'Any applicant that checks box kl must also rill out the section below showing their workers'compensation policy information. +Homeowners who submit this affidavit indicating they'are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the subcontractors 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: 22 Expiration Date: Policy#or Self-ins.Lic.#: © J j City/State/Zip. 3 Job Site Address: Attach a copy of the workers'compensation policy dec aration page(showing the policy number and ex ' tion 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify and tiepains and pen of perjury that the information provided a ve is true and c/rect� Date 0 /JJ Signature: Phone# Official use only. Do not write in this area,to be completed by city or town official City or Town: permit/License# Issuing Authority(circle one): I. Board of Health 2.Building Department 3.Cltv'.TOw'n Clerk 4.Electrical Inspector Plumbing Inspector 6.Other Phone a: Contact Person: 10/27/2010 13:01 1508756BB23 THD AT HOME SERVICES PAGE 01/02 OP 10: EL CERTIFICATE OF LIABILITY INSURANCEF-_I_DAT 10121` "'21110 N0 THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S� AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. Itd ORTANT: If the certificate holder is an ADDITIONAL INSURED.the pollcy(ies)must be endorsed_ If SUBROGATION IS WAIVED,subject 10 the terms and conditions of the policy,certain polictse may require an enclontement A statememt on this ceffiicate does not confer rights to the certificate holder in lieu of such endomeman s PRODUCER 508-972-OM Na�TA LJM Insurance Agency,Inc. 508-079-5299 ;N01e �rt>_... ---Inlex_„ 327 Union Avenue EMAIL - Framingham.MA 01702 Wwtmsr Eva Kromer tOkKUPRU-1 _.._ •_ _ INaURENS)AFFORMG COVEaxacS__ N_A_!c$ INSLRtEo DainiusKuprusevicius MBURERA:National Grange Mutual 351 Engamore Ln. INWJ iB: Norwood,MA 02002 INSURER¢: INSURER D INSURER E: INSURER F: , COVERAGES CERTIFICATE NUMBER: REVISION NUMBER; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD' INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCVMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 15SUED 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 NAY HAVE BEEN REDUCED BY PAID CLAIMS. SR TYPE OF INSURANCE IGY EFF POLICY EXPI LTR P NUMBER MM o" MMIDOIYYYY LINKS, GENERAL LIABILITY EACr1000URRENCE S 1,000I000 . A X ••,ry1MEiRVALGEWP.AI.LIAOILFTY MPK5580X 10119tto 1011gill OAMAGPREMISET Euo Itv.. •J ` S 500,00 11LAIM MACE n OCCUR - - Mf1�E1C 1AnY une oereonl S 10,00 PERSONAL G AOY IN.ykY S 2,000,00 GONGRiV.AGGREOA:E S 2,000,00 •?EVLAr-C.F.Sr.ATFLIMIra74`LIESPER. PRODUCTS-COMPIOPAGG 4 2,000,00 Poxy PRO- IOCJFGI , ALROMOBILRI,IA9ILITY COMOIN@DAt,JFI.F1un ; ANY AUTO Ica acudm tl nvndEGA.UT;,,, BODILY BJJURY(Per parw) BODILY PIJJrRY I%icrnlwlrl S :fHENJLEOAnTOF• PROPFRTYDAWE -- - •NOCE-AhJTOi iP9f 8/:CIC2M) f Nh1.1•Q VfNEO NJTO S •UMBRELLA NAB OCCV11 EACH OrOARENCC EXCESS LIAO _ CLAIMS.-Di A'GREGATE 5 DECUCTIKE S REIEnI:0I1 i f VWWS tS COMPENSATION WIC STAI 11 OTM- ANDWPLOVERWLIABILITY YIN T AIN PP.CNuIETORlPARTNERIERECUIIVF OFFI.CF.R:•r_JAVRMLUDED, MIA E.L.EAC"ACCIDENT ; (tWryFtory in PM) EL 015EA9F-EA EMPLOYE( f ' It yli.Aaocri6m uMw - _ . r4F$C.r.!PTIr,N rr OPERATIrdNS Wall - E.1.01SEn6E POLICvuMIT S orscmpTIONOF OPERATIONS t I.11CATIONS I VEMCLEB(AReth ACCIRD W1,AdatIMN ROMM Rcllsduls,If Man opus Is resImmq) HD AT-HOME SERVICES,INC.AND THE HOME DEPOT ARE INCLUDEDAS ADDITIONAL INSURED WITH RESPECTS TO GENERALLIASIUTY INSURANCE CANCELLATION:30 days CERTIFICATE HOLDER CANCELLATION THDATHI SNDULD ANY OF THE ABOVE DOCR®ED POLICIES BE CANCRI I ED BEFORE THD AT-HOME SERVICES,INC. THE EXPIRATION DATE 11 4MOR M0710E WLL BE DELIVERED IN dpa THE HOME DEPOT AT HOME ACCORDANCE WITH THE POLICY PROVISIONS. SERVICES 2990 Cumberland Pkwy,Ste 300 AUTrlowz®aEPaEsar"T'vE Atlanta,GA 30339 ®1980-2009 ACORD CORPORATION. Ali rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD �llce 'V�rnvnxo�iuNx�lle c�i�.c�eoar�uaeCG� I Office of Consumer Affairs&i Business Regulation License or registration valid for indietul n only _- �- I before the expiration elate. If found return to: s tom_ OME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Itcgul.,tiore Registration ,126893 Type: 10 Park Plaza-Sui.c 5170 Expiration, .813l2012 Supplement Card Boston,MA 02116 The Home Depot`,At-Horde Services DARREN DEMERS r i 2690 CUMBERLAND PARKWAYS q}AWA,GA 30339 Undersecretary Not valid without signature i i - ConstrLsr:tion Supervisor l.lcense w License: CS 103400 Restricted to: 00 c. .� ae Wnj tus KupfuseviciuS W Engai�ote Lane _ No(wood, MA 02062 cc Expirfficion: 8J21/2813 93 ('unlivi•yiMrr ^� .�9R $�Il arils Udcegu a ons artd S 'Boar of Bu 011c Ashburton Place -R.00m 1.301 Boston 'Massachuseus 02108 orne 1 covememt CoAtTICtOC 399 pis"Ibn, 1 TV", ODA lull 285244 Exi"1100; 819t2011 UAINIUS CIONSTRUCTIOId _. iDAINiUS KUPRUSBACIUS , 919 FAST ST- _. ............. V�ALPOLE,MA02081 _ , .___ .__ V�datc Adwass a4obalur V44 card,k%rk Mom ffor t1�a*ge. AA&M �;j Reacv�s� C: 1�4y}Oa n1 t_ LW Card EP94AI 41 40k(aWtMWF0RMA2W1mXG btrodMvelld for ird m oolY L, e !!s retfwr"ft �e 'tFavva�eona- �e4'ae ti�ex>cpiretteu dgttr, if td4n�d I Board of Building Regulations pail Standards Be9►rd Of Bui �R$u3H1ioA!and Statxbrd da i HOME wFLOVEMEN'T CON Oao AdtWVAOu`I�ea!Am 1301 Re9isfr8tiori: 183349 Expii�ttion:,6 2011 Two 285244 7YPei..DBA DA1NIUS GONSTRUCTIOPD _ v+►�d wi etaige�lw! .__..._ _.... OAINIUS KuPRUSEVICIUS 919 EAST ST pdmieytrnlor WALPOLE,AAA 02081 r 10/11/2010 16:47 15087568823 THD AT HOME SERVICES PAGE 01/08 HOME IMPROVEMENT CONTRACT PLEASE READ THIS / Sold,Furnished and Installed by: Date:�J© (/C 6 T14D At-Home Services,Inc. Branch Name: Bosom d/b/a The Home Depot At-Home Services 345A Greenwood Street,Unit 2.Worcester,MA 01607 Toll Free(800)657-5182; Fax(508)756-8823 Branch Number:31 Peden TD#75-269MM;ME Lie#C 02439.RI Cont.Lick 1642'7 CT Lic# 5522: A Horn T provement Cot>its�t�x Reg.411,26891 Installation Address* f p`p(r�3 City rate Zip Purchaser(s): Work Phone: Home Phone: Cell Phone: Horne Address: Ve— it O City State Zip � ✓V (If different from Installation Address) &mail Address(to receive project communications and Home Depot updates): ❑1 DO NOT wish to receive any marketing entails from The Home Depot Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, Of and IiD At-Home Services.Inc.("The Home Depot")agrees to furnish,dallvof whi her and raare innge crporatcd in the to thistion `Contrlactrby this all materials described on the below and on the referenced Spec 5heet(s), reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively, "Contract")- Job#: am.miitok—) products: S $tteet S)#: Project Amount _ ORooting iding Windows ❑]nsula6cu+ � $ ❑Gutters/Coven ODtny Dtxirs ❑ ❑Roofinfi Siding Windows insulation $ []Gutters/Covers []Entry Dome ❑ ❑Roofing Siding Windows insulation ❑Gutters/Covers Ogntry Doors El- Roofing Siding ❑Windows ❑Insulation $ ClOutters I Covers ❑Entry Doors ❑ -- Mb itnum 25%Dapnstt of Contract Amount doe opon execution of this contract. Total Contract Amount Maine Pumbaserx may not depmit more than one-third of the Contract Amount Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion Certificate (one for each Product as defined by an individual Spec Sheet)and pay any balance due. .As applicable.each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. The home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at its discretion,if The Home Depot or its aurhorived service provider determine-that it cannot perform its obligations due to a structural problem with the home,environmental hazards such as mold.asbestos or lead paint,other safety concerns,pricing errors or because work required to complete the job was not included in the aContrec"t.] Pavment Summary: The Payment Summary# l included as part of this Contract, sets forth the total Contract amount and payments required for the deposits and final pay ents by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note: there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product is complete. In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus any other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAX WITHHOLD AMOUNTS LOWED TO THE HOME DEPOT FROM THy, DEPOSIT PAYMENT OR IMITING THF,HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH R PAYMENTS MARE, WITHOUT AMOUNTS' A ranee and Authorization: Customer agrees and understands that this Agreement is Ilse entire agreement between Customer and The Home Depot with regard to the Products and Installation servicess and supersedes all prior discussions and agreements,either oral or written,relating to said Products and installation.This Agreement cannot be assigned or amended except by a writing signed by Customer and The Home Depot-Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has received a copy of this Agreement. Acustniner,'s e ted by: J Sub U /©� X -6) 6 ^fv Si atu ate S le ltant?s st ature r.� Duo }( Telephone No- ( L !`j- ✓yV— Customer's Signature Date Sales Consultant incense No. CANCELLATION: CUSTOMER MAX CANCEL THIS (as applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION �7 //,f( `�fA) BY DELIVERING WRTTTFN NOTICE TO THE HOME / Lr y"t DEPOT.BY MIDNIGHT ON THE THIRD BUSINESS t -�-�'� DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. 1 T OF THIN CONTRACT NOTICE,A.DI)MONAL TERMS AND CONDrrIONS ARE STATED ON THE RF VRRSF:SIDE AND ARE PAR 11-30-00 GSC White-Branch Fite Yellow-Customer Pink-Sale$Consultant TOWN OF BARNSTABLE �, •'e Permit No. t DMITAX Building Inspector � �YLCash ---------------- ---- •O +079• a YP'f�� OCCUPANCY PERMIT Bond ..--____ ``No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. ........................................ . .............................................»..»».»..».».» Building Inspector .FROM ,y yv4 r 4 TOWN OF BARNSTABLE F BUILDING DEPARTMENT Mr. Francis Lahteine 367 MAIN STREET Town Clerk HYANNIS, MA 02601 -; Phone: 775-1120 SUBJECT: FOLD HERE - DATE June- 30, 1980 MESSAGE Work has been completed under Building Permit #22187 (J. P. Breen Co. , Inc. ) . Please release Bond. SIGNE DATE - R'fPLY SIGNED N87.RM1 _ RECIPIENT: RETAIN WHITE COPY,RETURN PINK COPY PRINTED IN U.S.A. AssessorYs map and lot number .. ... .... 80---L'lz sy SEPTIC SyMM 1MU0T @@ Sew.pge Permit number ..:........................... ......................... ..C.>,,i�-2� INSTALLED IN COMPLIANEE �Py�F714ETO�o TOWN OF BA k&DEAND EaEasTADLE. : '�' gRtl<3` REGULATIONS C ,639. 0 M DUILDINA INSPECTOR =� � PY a' .• ,. ` i 4 APPLICATION FOR PERMIT TO +'. ..... .. l.. . 12X4............ ......... i p C%� f, Ao TYPE OF CONSTRUCTION .................../o�..................... ................................ ............... ..............19. r� TO THE INSPECTOR OF BUILDINGS: <' The undersigned hereby applies for ermit according to the fo wing�formati . .................................................... Location ...........................el.f........L�rk' ....!'� ......... . e o ProposedUse .... �tt `:. J...e.... ................................................................... ZoningDistrict ........................................... ..^... ............:.....Fire District ..................... .. " .. ...............................i Name of Owner .... a^.. Address ..�.... '� e� ". w .3 Name of Builder \ ..-'L.... ....... ........: .....................Address ......`..`............................ Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ......... . ...... ..... ...Foundation ...........,. .. .... -.. Exierior .... . . .!�r �`.Q Ia ......4"(4.Roofing ........... ..... --�//�.:....................................... Floors .•�C.r! �f�'�N.�...............................................Interior .........�. ... . .. ... ............... ........... Heating .... ... .....Y1/....................................................Plumbing .............�... ...... ........................... on Fireplace PP �0�.�D.d•••............ ... ..�........................•..............•....•..•.A Approximate Cost ................. ..................�.... Definitive Plan Approved b Planning Board -----------_------_-----------19________. Area ........z F...5 ... pP Y 9 Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH , I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name , .............. . .............. II` - J. P. DI�IEN CO � �� No -.2��87 �Perm� for .{}���.. ---. ' / _' ----. ---�~. ( . . . __.S�.ncfle... y..I}Wg.jling____. ' ' Location ��t_�4I_338_�me/�..�b�l�___. Centerville -------..^,,=^=`=-.------------ �,vnor .�J�-I`�-Br���...��..,_Zoc.__... Type of Construction .....������-------- -----..---------------.----- ' 1,k� Lot . ---------. ^ ----------.. - � Permit Granted 8�av 9 ^ '� '��� 80 � ..~. ----..~-..�.�-.. -. Date of Inspection .�--..lg /_ � � ~ . Dote Completed ��� . .lQ ' '' J''''' ------ ' ' PERMIT REFUSED -- . ~ � ' ~~�� �� ' �r ~~. ' - -^ '' ''-' xv� ................................................. ' -~. ' ' - ~.,' . � ( . . -'--'--------�--. l� � � `_,� ' . . -------------.-.....-.-~----- � ' ............................................. •..3h Asv 077 /C , � J f, ��'� GS//�'I�7 � �, /�. •Y/.,�' �__. ...,_.............. .._.. ._...W..... .— A�... ...�, ...... .. —..,...._.._._..._.._..-,.. ..._........_._... � CAI S 9", »,S � 11Q� /Tfv, /�lG n ck )7 Y2'0 77,5,4*-*1 C� 0/ Na .2 Qa, Jai C a't` �-O �C o T� /�,� t�1 ���", tl! � '� �!. `�1 Prl �j s�r'yr� �o /S*�cl.�',� . L r/ Vr r�r•a »7P/rrf�� r J �wil., 46Af Yp 0 77 0�t7 Owo t . _ Z 116 Y Go C 4z_ 1 f 0 :r? Yre/c -�-/ `rr Z more ev / 77c /7. '7` s V-7 "' ///z o 7 a�j k /e, c��'d .�� B�i�M. /''rye � O.� � 1. ��' zd �os t i �� j �� • o} Z4 = �HOF � ;i" OF"'�ss x Z IL 4 y�N Q FRANK (� 00 FRANK CONERY C4NERY N . 6232 Ap No. 6573 0 4 one U = �C7STE�� v�FSGisfi� sioNAt-E)' p ' - i Qp. ,, 1 — W to / PLAN of LAND �16��'� Y��.l t e- MASS. i ' OWNED 9Y Al • i . `�, `0` w q�' w FRANK.CONERY 5 TRENTON ST. . + �' . • ' • • o ': �.,. Hl"ATtifNtS: NtASS. 010 ' ... x RE615T-RED'E"INEER 6 LANDStJRYSYOR SCALE 1 IN FT. OV- 7/B 0