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HomeMy WebLinkAbout0040 ANGUS WAY 1,fi �r Of 1 r �� �;�'�vf�, ;���fl�'�;� ,r���•t&Iti'w. ''.°'. '� a.' �fit, 4#k: 3�} .� }}hs�'ar+r� , " ` ° jr n o _ s b ° pl ° O G r o l TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel 03 Permit# 0 ;2, Y y Health Division 107— /0 -S 02 Date Issued �® 0� Conservation Division J r Fee � E D Tax Collector ;E (2 © L I oo S Y�UST BE Treasurer ('�1 D �O I 1NST IN COMPLiANCE Planning Dept. 4�YITH TEE 5 EMIROMMAL CODE ANL Date Definitive Plan Approved by Planning Board TOM R ULATIO S Historic-OKH Preservation/Hyannis Project Street Address Waj,, Village t- .VI'�(� Owner Address &15 l� Telephone '7-7 5_— Permit Request 5 Jg /I.Q,UI" t C-A hqck oIC (7 y.5.4 1.q , X �6 Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Valuation �'r � y Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting,,documentation., t Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) X - �; Age of Existing Structure Historic House: ❑Yes ❑No On Old King'sfHSghway: cW YesJ' ❑ No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other �1 Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other �► a _ Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No ! Detached garage:❑existing ❑new size Pool: ❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name Telephone Number Capizzi Home Improvement Inc. Address +645N�ewn Rmad License# CS Q6703� Cotuit, MA 02635 Home Improvement Contractor# AQC-D 4/0 !gl.428-951811-800-262-5060 Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE _" `' A FOR OFFICIAL'USE ONLY PER+II'f NO. r DATE ISSUED - i t t« MAP/PARCEL NO. . _ •-.. 4 itJ ADDRESS � VILLAGE - • n OWNER DATE OF INSPECTION:'' So vi u,, a-1 FOUNDATION } FRAME y ; INSULATION r FIREPLACE ` ELECTRICAL: ROUGH FINAL - ' PLUMBING: ROUG 1W6- FINAL. GAS: ROUGH- -FINAL FINAL BUILDING 2; 11 DATE CLOSED OUT-- ASSOCIATION PLAN NO i.7 f A 1 ��\ ��LC �097L))L04ttlM,O.U/L O�✓/�GR�tU.OP.�d Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR N" Registration: 100740 Expiration: 6/23/2004 Type: Private Corporation CAPIZZI HOME IMPROVEMENT,I Wornas Capizzi,jr. 1645 Newton Rd. Cotuit,MA 02635 Administrator y j.r ✓die �o�frma�rusea�� n� aa NicluOel�a r,6�: BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR t R• Number: CS 057032 :c.. Expires: 09/26/2003 Tr.no: 5790 Restricted: 00 THOMAS X CAPIZZI JR 280 PERCIVAL DR W BARNSTABLE, MA 02668 Administrator The Commonwealth of Massachusetts z - De artnient of Industrial Accidents 010yesa a 011ice 9 UOOS + 600 Washington Street Boston,''Mass. 02111 � z y Workers' Compensation Insurance Affidavit a name 1D'ZC71'Ylt i ���l;'I Z Q U City C� t I UL phone# I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity am an employer providing workers' compensation for my employees working on this job. company name La t2l z Z t fk('t'1 '17tQ ruVe &A pll� address<.A'�45 ,t z0 l U )(1 � � c� � � 2 f citv_ �> ! .Cot JiJ phone#• �ocy—7,ad I am a sole propficYor, general contractor, or homeowner(circle one) and have hired the contractors listed below who hi,.. the following workers' compensation polices: company name address: city phone#• insurance:co, Policy# company name• { a-d€ress•: • city phone#• insarance co. policy# r Failure to secure coverage as required under Section 25A of N1G L 152 can lead to the imposition of criminal penalties of it fine up to S1,500.00 andjo one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature Date Print name /1C71'1Z I . Phone#�0 _!V,2 D _ 7 c� Ccheck ly do not wrile,in this area to be completed by city or town official permit/license# nBuilding Department` I OLicensing Board �x F. mediate response is required C]Selectmen's Office C]llcalth Department n: phone It; _ nOther mile -revised Y95 PIA) .. r The Town of Barnstable Department of Health Safety and Environmental Services 1639 ♦'a . 0 PAN-" Building Division 367 Main Street, Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,.demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. �J Type of Work: Estimated Cost Address of Work: 1 05 VV Owner's Name: Date of Application: /o I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job Under$1,000 Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: o c)-I- � .0 2 Dat Co tractor N e Registration No. C�PIu� �o�r✓ ur OR Date Owner's Name q:forms:Affidav i a f X Z 8,+LU57A- L i� . - yxy � Posr I r oc — - ` 2 X/o _ 644 Zrr S a o rAl-r. P 1/ 6 fit' Po:57- O ')ia ('e,tiJtas�—v, s , 0)0 .II AppUcwdo_... a : , .,� 100ct4om Of 4AVpeftY= CT!tte'rV e. ~' 50 0, I � 150 0 c I a' rift' c ' _ o ;VA )40 R-p,;-,d story we111"N 150,00 ' 4 , �00010005 C re .,_._._...�... ._ .,�,.Mood Ptrl '..„ . lood� > orut PAUL hc'r� rerti " m� qr I ins�¢ct►Ott wash r � list n n' . C, gR Coe ank rut' d y,�aij es.! � :►t��fix1.1, �n lx s � ����,o � ha m-& Cna i0idt,MI,Ado dki I of$•fg-Brand. the loc,hbn, OP, "b :u t6 dwelling oee ooh �;. 'fie ca.l s orting�y taws ixl.� ew, otthe tune Wwrotnxtiort 1 :�speorto horilontcd diittem ona� scale: J:M 5 sitbark or A m�.' �r�vin vwlat�ton,e► Fotu �n�' Date: �..1. - _9 cwatbtt r mass. r+�t'l�*vit.� t<wS ChaPter40A-.. ft Vt�7. File No, _f PIAASE NOT9. the structures as sho n on 'I ; plot plan are approximaoe only. An actual ,4urvev is nece.1bary for a peecisc determination of the building location . d cn; ' ochtner'ils, it any exist. either-way dcrmss property line~, Thilij planmust not be used for recording purposes or for M in p;, ,oaring deed descriptions and must not be used for variancil or building plan putposes. This plxtl must not he used a loca; oroperty lines. Verification of building locations, prc,perty line 4imensions, fences lot cnnfigurattop curl only be actrom�ishetl ' an accurate Instrument survey which may reflect different infilemation than what is shown hereon, please note that th'lk is "N-, A BOUNUAR2Y 5t1RVW' and is "POR MORTGAGE PURPOSE!I ONLY", COLONIAL L N1: ; SURVEYING COMPANY; INC. 269 Hanover Street . ttknovei i '&ss. 02339 - Phone: 781-826-7186 F»x: 7914> &423 10 'd 99VZ 06L 909 SINNVAH-EMAOR3003H U WV 9I:60 NOW ZOOZ-0£-0 ( CAP IZZT IIOME IMPROVEMENT INC . SPECIFICATIONS AND ESTIMATES PAGE 1 OF 3 .�" (�lf CAPIZZI HOME IMPROVEMENT PROPOSAL Established 1976 , Serving the Cape for 26 Years fC ; r.y�o �z Registration #100740 _ 1.645 Newtown Road I Cotuit , Massachusetts 02635 I 508-428-951.8 1-800-262-5060 Fax 508-428-1.547 D te . Name : 1� � ��V� G-o dCe I .-Job Address : Address . // // // Town: L4U � City : 0� VdN �JUSrCr,�/� I.LJ� ( Job Phone. : Other Phone : Ll"24,1 t �U` ll ,i&4jA D I 77S /O,50 Estimator : cam/ 7 Doi 3 Job No : : , S l ! J We hereby submit specifications and estimates to furnish and install a new deck as follows : Deck and Frame : All wood framing to be . 40 P . C . F . pressure-treated wood , approved for soil or fresh water contact . Joist will be 16" on center ; any steps will be 3 ' wide minimum ; footings will be concrete to a base line below the frost line as per building code . Joist - 2 " x 8" yellow pine • Stringers 2 " x 12 " yellow pine , Hangers - Hot-dipped galvanized steel Lag bolts 3/8" . hot-dipped galvanized steel. Nails , common - Hot-dipped galvanized steel Post - ' 4 " x 6" yellow pine Post supports -Cast zinc Post straps - Hot-dipped galvanized steel Foundation 10" diameter concrete Decking with 5/4 " .x •6" radius edge premium pressure.-treated yellow pine . * *Premium pressure-.treated southern yellow pine will shrink at all seams and miters and joints with sun and rain weathering almost immediately after installation and will have knots , splits and bark.. This is the nature of pressure-treated material . Railing System: ` . Railing assembly will be 36" high , with 2 x 2" balusters to be 5 " on center an.d child-proof as per building codes . Rail cap - 2 " x 4 " beveled , style Meeting rails - - 2 " x 4 " Balusters - 2" x 2 " Post - 4 " x 6 " ACCEPTED BY ,:�,.,._ -- DATE THIS PAGE IS PAR OF AID IN CONFORMANCE WITH PROPOSAL # �OFSHE rp�y Town of Barnstable *Permit# Expires 6 moths from issue date ' •ARNSfABLE. � Regulatory Services Fee �-51 b�. `0� Thomas F. Geiler,Director /� t1�i '°Teo Mat" Building Division Tom Perry, Building Commissioner 200 Maui Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 076—1 oa Property Address A729 Q W C ,[Residential Value of Work l Z ROO . Owner's Name&Address 1�t ►'V ez Good .24 V6n CLA , IX)eC�) Contractor's NameC.4 i2I I4O DO.- " : —, � Telephone Number 7oj '9 c Home Improvement Contractor License#(if applicable) /60 7 7 Q Construction Supervisor's License#(if applicable) orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I the Homeowner have Worker's Compensation Insurance Insurance Company Name / �l ti/ 'a Workman's Comp.Policy Permit Request(check box) 3(o 03. to•S �• Re-roof(stripping old shingles)VxNT, D XIDPRESS PERMIT ❑Re-roof(not stripping. Going over existing layers of roof) S EP 0 9 2002 ❑ Re-side TOWN OF BARNSTABLE ❑ Replacement Windows. U-Value (maximum.44) ❑ Other(specify) *Where required:-Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signature _A0Wa_1:C Q:Forms:expmtrg Reviscd121901 THE FOLLOWING IS/ARE THE BEST IMAGES FROM' POOR QUALITY ORIGINALS) I m � E DATA CAPIZZI HOME IMPROVEMENT INC . �— SPECIFICATIONS AND ESTIMATES PAGE 1 8 7o Cc e r^ )� CAPIZZI HOME IMPROVEMENT PROPOSAL Established 1976 , Serving the Cape for 26 Years Registration #100740 1645 Newtown Road Cotuit , Massachusetts 02635 508-428-9518 1-800-262-5060 Fax 508-428-1547 e: 8/2/2002 Name: JAMES GOOD `` Job Address:L508/775-1050 S WA Address : 24 VAN BUKIRK WAY Town: ILLE City: SANDWICH, MA 02537 J Home Phone: Other Phone: -31 1 ( Estimator : 3/JR ( Job No. : 25312 We hereby submit specificatioi ! ,install new roofing as follows: i . I . Strip existing roofing a ��. layer - 1 layer . Anymore layers of roofin ie additional . 2 . All gutters will be cle� id nails extracted with magnets . We utili, /-- )ur exposure to personal injury and/or i '/ t behind at the job site . CG) G'1 3 . After removal of roof , , r splitting,' rot or other deterioration. C '� � (�� or wood replacement prior to commencement i l 4 . Along all eaves of houL_ • Dofing underlayment will be directly adhered to the wood th underlayment will be installed so as to extend from eave edge of exterior overhang. Waterproofing underlayment is installed to eaves to .protect against interior leakage and subsequent damage from wind-driven rain, ice and snow dams , and freeze back conditions. 5 . Install waterproofing underlayment in full width ( 36" wide) to all valleys. Install waterproofing underlayment at all vent pipe collars and any other projections and skylights . Underlayment adds additional protection against leakage at critical terminations . Over remainder of house, 15-lb. felt paper will be installed and nailed to the wood deck. 6 . Install new white drip edge to all perimeter eave and gable edges . Drip edge is instal''led to protect from leakage and rot and to provide a neat and clean perimeter profile , or copper if doing red cedar roof . 7 . All - existing vent pipes will receive new aluminum vent pipe .flashings with neoprene gasket collars , or copper if doing red cedar roof . ' ACCEPTED BY DATE THIS PAGE IS PART OF AND IN CONFORMANCE WITH PROPOSAL #25312 G The Town of Barnstable ' �m� Department of Health Safety and Environmental Services Mop'' Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner SHED REGISTRATION Location of shed(address) Village y Cc"f'yQ lGi� �a 5dW Property owner's name Telephone number © . Size of Shed Map/Parcel# 7- q Signa a Date Hyannis Main Street Waterfront Historic District? As 0 Old King's Highway Historic District Commission jurisdiction? N `6 i C / Conservation Commission(signature required) THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN , a Q-forms-shedreg i i r - yInspecctorl ucanx= o o e locctfori of-property: e n to r vi c e to 150.00' 00 7,2k O /O Q ;2 story 150,00 �Nh 52 r ref 802 �8 2500010005 C . C tN OF M� i- S l Mood vane, flood/ zone. ss+� PAUL s� here1 certifWy , Mortage ioc a rec�-fyr VE nnQQ / a e ll mc 131 1� dw &r Tydweling y showm hereon,doesnor.cfa.U. in,aspeaca TEMAP.00d 4 0 TE. O hazar& area wttK am of�eetive date of 8 49 85a" ghe locah'onl oP� "� Su" y the dwelling does utie cmfo_rm,r a t e local coning 6y-laws er✓'t' w dune tthe oFconcmctwn with, respect-to horizontal dimer"(Oi;a� Scale: setback r %tkt cnui Lts oris mmpr-from, vtolatwn a 4o-reemenx-' Date: "tLon, under glass, General,Laws Chapt-er40A SectLory 7- File No._ PLEASE NOTE: The structures as shown on this plot plan are approximate only. An actual survey is necessary for a precise determination of the building location and ,encroachments, if any exist. either way 'across property lines_ This plan must not .be used for recording purposes or for use in preparing deed descriptions and must not be used for variance or building plan purposes. This plan, must not be.used to locate property lines. Verification of building locations, property line dimensions, fences or lot configuration can only be accomplished by an accurate instrument survey which may reflect different'information than what is shown hereon.- Please note that this is "NOT A BOUNDARY SURVEY" and is "FOR MORTGAGE PURPOSES ONLY". COLONIAL LAND SUR�JIJYING C011�IPAN INS. z 269 Hanover Street - Hanover, Mass. 02339 Phone: 781-826-7186' Fax: 781-826-4823 TOWN OF BARNSTABLE BUILDING PERMIT-APPLICATION ` Map Parcel Permit# 3 5- (,e y Health Division J24/IOW-" ), Date Issued I P7 (ce Conservation Division '' Fee. °� Tax Collect SE P711iC SYSTEM RUST DE Treasurer ��� INSTALLE®:IN COMPLIANCE Planning Dept. I WITH-TITLE 5 . ENVIRONMENTAL CODE AND Date Definitive Plan Approved by Planning Board TOINN REGULATIONS Historic-OKH Preservation/Hyannis Project Street Address - e Village Owner Z9 X&s Address'oW IA•,% HtlK;,�le /,),V/ _S"q-d4 weW Telephone 77S= SD /,53o•- .31/O r Permit Request l7 C-X/Sri 4s v Square feet: 1 st floor: existing proposed 2nd floor:existing proposed Total new Estimated Project Cost� Zoning District Flood Plain Groundwater Overlay R . Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) ' Age of Existing Structure Historic House: ❑Yes ) No , On Old King's Highway: ❑.Yes WNo Basement Type: ❑Full ❑Crawl I 0 Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) " Number of Baths: Full: existing new Half:existing new Number of Bedrooms: existing new ' Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel; 0 Gases ®'Oil "Ll Electric 0 Other Central Air: 0 Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:0 existing ❑new size Pool:0 existing ❑new size Barn:0 existing ❑new size Attached garage:❑existing ❑new size Shed:O existing O new size Other: Zoning Board of Appeals Authorization U. Appeal# Recorded❑ Commercial ❑Yes XNo If yes,site plan review# Current Use -Proposed Use �H P 1 Z Z i BUILDER INFORMATION Name P45t g Telephone Number YZS 5',S'®6 Address /6 `/5 /YEI.� -6wgi License# LPS 07 3 7 eyes-�f-3'1- r/s,;; Home Improvement Contractor# 7007 �/o Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �lf>�- ��dtlfi e- yCGc SIGNATU DATE -- FOR OFFICIAL.USE ONLY ' - l* � �R i s• "'. � x M r - a fit• F PERMIT NO. DATE ISSUED _ MAP/PARCEL NO. i— ^h A - �s✓� � - y/ yr '.a` `� ` E'4. .. ... � � - t - -.c � . ADDRESS F t f ? . 'VILLAGE OWNER DATE OF INSPECTION FOUNDATION ' FRAME INSULATION r: FIREPLACE ( . ' ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH i > FINAL GAS: ROUGH; e� - FINAL, w FINAL BUILDING q� �/� I dZ7 � r. • s� t f e .. DATE CLOSED'OUT ASSOCIATION PLAN NO 4 µ E r ' f j i °. The Town of Barnstable Department of Health Safety and Environmental Services `�°r ,'r,¢A�►`� Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. . �Lts r►l n Type of Work: YIN y L Si A,ti!(, l Tim at V gA6E Est. Cos no 0Z Address of Work: Y() 144C Owner's Name --jt9e&-_5 Date of Permit Application: L'/1 L . I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTEERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. eH P t 2-Z C �p ' OR Date Owners Name _. - -_-_ a Commonwealtho Massachusetts 5 .. .T.- -- - Department of Industrial Accidents.:- awcc filmroS029oos . - 600 Washington Street __._ •`� Boston,Mass. 02111 Workers' Com ensation Insurance Affidavit name: . location: city phone# ❑ I am a homeowner performing all work myself. . ❑ I am a sole opnetor and have no one workin in a�capacity y %%%////%///// 'D//%// %//////%/%%%%////%%%%%%%%%%��%%/G%///%////%////////////l////%%/%/O///%//%%/!///%'/!/��///%/'/////d//O%/%/%%/////%/O//%/%�/0iy///lO�l��IpITDlIO� I am an employer providing workers' compensati n for my employees working on this job. m an name.. 11 I. gdatsSsVVMMs ::.:::::......::::::...:..:....::. : a ;. hone# "'.< . . ........... ............................::::::..........:.::;?:::::;:?;::::;;::.:.:..::::::::::::::::::::::.:::::?;;.::...: .:..............._....::.....:::::.....::.: }::?:i.:.:.;:::.:. f`insuran 1 %a A - 1 . ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who , have . , ti the following workers' compensation polices:..................:......................:...::.............:..:....:.....:..:::........ .... ...,. -::-%.. ......... . ..::. ::::.:;:::::;::::::..... ::::.:.:;:: comnaav name. ::: :':»> .......:::::::;::;; :>::>;, ?<::-::?:::::::;:: ;.::; .;::.;.;: .>:;;.:.>;:-:-:>;»>:.::-::>::::>:>;;::::::::::.::x; ............................................... ... ::::.:::...... address :,:.:::. .......................:......;:::....: ;:.::.:::...................... :.:. :•. ::::::.:.....:. .............. ..................... ..... ............................................................ .............::...:..... .....................:..............:..:......:.........................................:::::::::::.::::•:. :.•:::::.,-:::::::::::.,•.:::::::::;•}::•;:.;}:.::-;:.;?.......:.::.... :::::::.::::::..:::::::::::::::::::z. <w•.:: ..::: '::i r v:.M.-n-:n•wv.....v. ....,.............................................. . .........................................................................v............,.....................................:. •:n�.............w:::::::•:::::...n•.}v::Y!•}:.:.::•:::::::::..:::::::..�:..::.�::..:.:::::::::.�:':::.�:-i.i::-::.�::::::::•:::::::::::::::::::::::::::.�:::.�::::::.�:::::::::::.::�::::.�::-.i;v::..�.�::::::::.:::�:::.�::::::•::::::, }:'....:::•::::::::.�...............:.:.................................:!a?.:V:4:i• ........... ...... ...:..;v.., 4. .......w:i ................................. ................:...............::...:::::::::::::::::....... .................:.............. aLXti::Y:Nv.:}:-R :;Cti ti i):j;>,:ii:4:v ;:iv;{i;'(:;:}:.....ji:i:;}:j:i::}:S}YL:ii::::isL:r::s:::?:•i}i??::Y?:{!?:;(:�?:::?!ii ni:}iii'�i.:v' Si'i4i::w.::...nv ..........:................. ......::.:........................................:....................................................:.�::::: ........................:.::::.:::::::........................ .tt.:::: ::::::::::::::::.�:::::.�:.�:.�:........: ...... ................ .v.:}.... n::n.• ::::..:.:...... ......................................... ...::::.�:...:..........'isrii::}:•?:{}}:iii;.?:•?}?:4Jp}}:i•:}i?}??????:::::::ni!.Y''::'•.-:: ....:......... ..: ::::::::.:.:::::::::::.::.::::.:.....:.:............:...:.:........:...:. ....r.v:::::.::••:::,•Y::::•.}:n:.}.----v??:?:...,'r:4ii-::.i:^:n... .. ......................................................................................a:.:..:: ::?:::fi.::::::::.,•::::::.....:.... ...... .:::...........:..............:.,:......................... .: ."0.!?:::ii:::*.. bsntarrce:co._ _ ._... _ ............:,....-. ...:......,.. olicv#:;>.::: :;:;:;::»;,::<:::,:»::;» :......:::::::::;.::. i,.,!<i.?:.?:,?;.!:> '.^c::!.:•?;?}>X.-X:::.,:. .... .....:::...:. cQmoanv?narQe:: : ::: ::::::::::: ................ ... _. _.. ......... _.._.. :.... 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Oliev ::::::::::.;;::.?;;::.?:.;;:.;;?;?;; ;}>::::::::.::.::::::::::.:::::::::.:::::,..::.::::::::.::::.:: FaOme to secure coverage as required wider Section 25A of MGL 152 can lead to tie imposition of c iadnal penalties of a One up to Smsftoo andtor one yeah'hnprLwr®mt p weR u civO penalties in the form of a STOP WORK ORDER and a One of$100.00 a day against me. I understand tint s copy of this statement may be forwarded to the Offiee of Investigations of the DIA for coverage ve�on I do hereby cceerdfy under the pains and penalties of perjury that the informs don provided above it&w and correct . Signature (%YiL �2 c '`l CcYGc�i '. Date //'7�/Y 0 . Print name �ez02I Cx - ,C�( +ScN .� Phone# t/-� 6— 9 1� official use only do not write in this area to be completed by city or town ofIIdal . . city or town: Peru dUllcense# QgIIpditg Depa� ❑check if 3amtediate response is required ❑ Omce (]Health Department contact person phone#; — ❑Other Ormd 9/95 PIS - !k f ��_'�, ✓,te Vi anv!)zont .�i 4�,���,uJeG�t i i DEPARTMENT OF PUBIIf SAFETY ;: •-' CONSTRUCTION SUPERVISOR LICENSE { Numbe Expires: Restricted To -- 00 s ( FREDERICK V RRSCH III ` } �°�►+��, �i;z.e•F'iF£8 BOURNE..RD PLY-MOUTH, Mk 02-3£0 ;"^RJV`;^=ti- CCN7.,=..C7CP,5 FE G:S Pe^,T:CN �f cca--� c= E� ilc_ rc F.ac-ja_ ns a�c Ste��ares i —t0 rl P 130_ hassac„us=__s C2_CS V _N- CC;tiT-=..CTC,r --- - - - - ------- ---- ----- ------- - - a — P"' VAT= CCr-CR,-=Cti _ 7 __.'i�...._. .. o=5 Nc', • - t�r'G.�r»LGnttrL/Gi pP.�� :�i�d1i: i 6i ;1.r3!.0 SAF;i( C: I:i'e:Z 1?jZ5,1??? { �. THCX�S 1 UPUZ: A • .. .. •.... .. '. r. J { U :Aovc7folc V. a-,-- _ E