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Sewage'Permit number .... ,)... ..-A . :.
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INSTALLED UNCON)PLIANICS
Rouse number ..................: : �
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r y TOWN , OF B A R NrS, a A LTE,4
To AF;
BUILDING, INSPECTOR ok .
APPLICATION, FOR PERMIT TO lY:.-Si le... ..
i ... ......................................... .. '
TYPE OF CONSTRUCTION .. . .......... `FL. ......... . ........... ....................
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TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ... � ..T ..:......... . .. ..:........./L,7
. ........... .... �rG-�:.L�........
'6J :.,f.� '9 ......�T. !
si LE M -eh /il/t
ProposedUse ........ /V i ........................................................................................... .........................
Zoning District .................... ...............................................Fire District ......(29,10.........C&/Fl1°Z...........................
....
Name of Owner ��'sc/a.......... ........f,�••,✓v..C... ....:....Address ...���......� � v�?..`......... ���,'�l✓ll� ...
Name of Builder'./.,/.//"! '.r-:.X(. all...�,S.�OG.........Address ..... '..... `........................ f..`...................
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Nameof Architect ...........:. ..Address................................................... ....................................................................................
-
Number of Rooms,........07.........................:.................. .........Foundation $. .........�..'tf!dt�, ,�.../
Exierior .......r44r.. ; .. ...................................Roofing ., . ...................... ........................
Floors �a G!/�i�er ...................................................Interior .. € AIL.. ........................................:.......
` Heating /. ..... ..........................................................:....Plumbing LO l............/ ..� ............... ..... „ ...... '.
k-
Fireplace ....i!-�.........................................................................Approximate Cost ..:.c' jgQ....A.. ®:.4 !........................... .......
Definitive Plan Approved b .Planning Board __!�_ _
PP Y g �-�•-1—-----------19 Area ....�.oa.. .o.....�.: ...-....../ Z
Diagram of Lot and Building with Dimensions" Fee
...................................
SUBJECT TO APPROVAL OF BOARD OF HEALTH ���
A
L
OCCUPANCY'PERMITS REQUIRED FOR NEW DWELLINGS =
I hereby agree to conform to all the;Rules and Regu.lations of the Town of Barnstable regarding the above
construction.
Name .. . ...//f,
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- - �� /I G -o3�
Y � THORi-IT3r=, 'INC.
No ..2759$.... Permit for ...V z,S:r XY...............
................. 4 _ '
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Location ....�,p .a�....22 Beech Leaf Islai Pd.
' Centerville r. `' ,• , �:.- - -. -� � Y • - , '
i .... ......................... ..................... ...................
Owner ....ThornberrY.t...ii?c-...... 4 _
` Type of Construction ....FYI._.................. . .
kr. .............................. _ ........ ............................... r « . 1 ',. 1 s • t
=} Plot ............................ Lot ............... .. ............. h
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t Permit Granted March 12,...............19 85
..' Date of Inspection ........... .. .... .........19 p
Date Completed .. .��� �P.................1zj
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TOWN OF B��RNSTABLE Permit No. 27598Building Inspectorcash
OCCUPANCY PERMIT Bond
Issued to Thornberry, Inc. Address
lot #13 22 Bee :,eaf Island Road, Centervih,
Wiring Inspector \ %) � �/ / Inspection date
Plumbing Inspector Inspection date
Gas Inspector ('—J f. /IV///. Inspection date
Engineering Department ? - f Inspection date
Board of Health 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 AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE
BUILDING CODE. o
.................................................... . 19......_._ ...........................�:
Building Inspector
( B3
TOWN OF BARNSTABLE
BUILDING DEPARTMENT
TOWN OFFICE BUILDING
HYANNIS, MASS. 02601
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MEMO TO: Town Clerk
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FROM: Building Department, '✓"
DATE: ,,�re4 7 /Sx �
An,;Occupancy Permit has been issued for the building authorized by
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Building Permit #..r- _.1�5 ' _ ............._............. ............_ ................ .. .....».....
issued to�y... or.j fie-✓.`'..: c e! �/ ��....��.�_4*� �e Lc»'» ... �Li�ry C.....................».. �
Please release the performance bond.
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Assessor's map and lot number .......... ............................
I E
Sewage Permit number .....9.61,/0 7......................
..... ...... ........ ... ...
2ARISTABLE,
House number ..................................:.................................... 00 NAM
1639.
TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO
...........................I......................................................................
0 C, e
-A7 if.
TYPEOF CONSTRUCTION .....................................................................................................................................
......................................19.........
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ... .......................................... .. ...................................ol.!...................................................................AV
........
Proposed Use ...1�—/.M 9f�e..........r1......4M 114
7........ ............I.......................................................................................................................
C 9-0 cdle I'll 111,
ZoningDistrict ........................................................................Fire District ...................................................................
4A
Nameof Owner ........9....... ............Address ...........................y.................................i..2..................
Nameof Builder .............;.................................,;.........:.........Address ....................................................................................
Nameof Architect ..................................................................Address ....................................................................................
Number of Rooms .......7 -1 fim,4 e-,o co*c"ee t6;-
.......X..................................................Foundation ..............................................................................
4/00
Exierior ..............!�....... .....................Roofing ..........................................................................
Floors ......................I...............................................................Interior ............... ................................................
�J P
Heating (- ........\ W ................Plumbing ...... 7......................................................................
0)� V'**"*"***"*"***********"***'* ql�lloe
Fireplace ....C -��00 000-00
..............................................................................Approximate Cost ... .......................................................
Definitive Plan Approved by Planning Board --------------19- Area ............................... ......1,A
Diagram of Lot and Building with Dimensions Fee .............................................
SUBJECT, TO APPROVAL OF BOARD OF HEALTH
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of,Barnstable regarding the above
construction.
Name ..........
.0 •......................................................................
THORNBERRY , INC. A=187-77
No 27598...:'. Permit for ...lz..st4:PY...............
...........Single„Farm lY... .. liag...................
Location .. t... . ,......22-Beech.Leaf..Island Read
.................. .....................................
Owner .....ThQ rxY....lac............................
Type of Construction Frame..............................
................................................................................
Plot ............................ Lot ................................
Permit Granted ..... ch. ,2(...............19 85
Date of Inspection ....................................19
Date Completed ......................................19
l� --� cv
yoFt�Tom, Town of Barnstable *Permit#
Expires 6 n s from issue date
Regulatory Services Fee
< BARNSTABLE,
MAS& ��' Thomas F. Geiler,Director
i6
39.
ArED MA't A
Building Division
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bamstable.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 !0-7 c):2 72
Property Address g, l �� l 'A
0 Residential Value of Work Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address
Contractor's Name A cf 1�� s (i Telephone Number L, 2
Home Improvement Contractor License#(if applicable) 1,p
Construction Supervisor's License#(if applicable) ` 7 �� r
C-P R a—
IT
DWorkman's Compensation Insurance
Check one: 0 C T 19 2009
❑ I am a sole proprietor
❑,J am the Homeowner TOWN OF BARNSTABLE
M I have Worker's Compensation Insurance
Insurance Company Name PSI t 1'\
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box) i 1
El"Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping: Going over 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 exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign roperty Owner Letter of Permission.
A copy o the me rovement Contractors License&Construction Supervisors License is
.require . �..
SIGNATURE:
Q:\WMLEsTORMS\building permit forms\EXPRESS.doc
Revised 090809
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
f' 600 Washington Street
u
Boston, MA 02111
www.niass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name (Business/Organization/Individual):
Address: 61�-\
6
City/State/Zip: C 20� "��� Phone #: �� b
Are you an employer? Check the appropriate box: Type of project(required):
4 1.Ql am a employer.with 3 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'
comp.
om insurance. 9. ❑ Building addition
[No workers comp. insurance p•
required.] 5. F1 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 12.0`R of repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' .13.0 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 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.#: I b �a Expiration Date:
Job Site Address: � CJ[ `. h� `� City/State/Zip:
V
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 insfirance XI
erage erif"ation.
I do hereby certi �e der h pains a pena ie o perjury that the'information provided above is trice and correct.
f
Signature: � �� / Date:
c ..
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 S.'Plumbing Inspector
6. Other
Contact Person: Phone#:
1
Information and Instructions `
provide corn
Massachusetts General Laws chapter 152 requires all employers to pr e 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,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 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 permitnicense 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
Fax # 617-727-7749
Revised 4-24-07
www.mass.gov/dia
•
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Construction Supervisor License f1k
t;
License: CS 48541i
i�
4 •' r Exp1/27/2010 Tr# 14362 I� J
E x lRestnctIon—00?�
;.. _ _ i�
t MARK D'HERBSTL
35'PL.E T TOAD RD
l 4 CENTERVILLE,MA 0 632 4
Commissioner
,tom• GTE -�� �� t� � -, ,
�\ Board of Building Regulations.and Standards License or registration valid for individul use only
before the expiration date. If found return to:
HOME IMPROVEMENT CONTRACTOR ;
,w Board of Building Regulations and Standards
Registrati;o&'126480 One Ashburton Place Rm 1301
Ex pi raton 6)8/2010 Tr# 267766 Boston,Ma.02108
Indi4Vidual
;11 i
MARK HERBST ` � ?
MARK. HERBST '
35 PEEP TOAD R Not valid without signature
Administrator
CENTER VILE,MA 02632'
NTICE NOTICE
TO T
EMPLOYEES EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT UST ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you
notice that I(we) have provided for payment to our injured employees under the above mentioned
chapter by insuring with:
ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY
NAME OF INSURANCE COMPANY
54 THIRD AVENUE, P.O. BOX 4070, BURLINGTON, MA 01803-0970
ADDRESS OF INSURANCE COMPANY
AWC 7016215012009 01/10/2009 - 01/10/2010
POLICY NVIVMER EFFECTIVE DATES
P O Box 494
Leonard Insurance Agency Inc Osterville, MA 02655 (508) 428-6921
NAME OF INSURANCE AGENT ADDRESS PHONE
Mark Herbst 35 Peep Toad Road Centerville, MA 02632
EMPLOYER ADDRESS
12/23/2008
EMP�OYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE
MEDICAL, TREATMENT
The abovg ppmed insurer is required in cases of personal injuries arising out of and in the course of employment to furnish
adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act.
A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician.
The reasonable cost of the services provided by the treating physician will be paid by the insurer,if the treatment is necessary
and reasonably connected to the work related injury. In cases requiring hospital attention,employees are hereby notified that
the insurer has arranged for such attention at the
NEAREST AND BEST MEDICAL FACILITY
NAME OF HOSPITAL ADDRESS
v�},,'J-kxli
��...t�"`", �' +1°'1,:"�� t,�;v��nf�`�>.?z��s`� fv"n,,$ t Fry.,.1e �,� �'d�.:.�•'"v�.:�. 'ry .6f-k�ls�l t -;�al�a t _, �F
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HERBS�T ��
fi 9
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508=420=6216/774-238-2938
_ .
www.markherbst.com
x
PROPOSAL SUBMITTED TO. WORK PERFORMED AT:
` 3 Mrs.Richard Herold
22 Beach Leaf Island '
Centerville MA 02632
� .. 508-771-2173
t_'
We herby propose to furnish the materials and perform'the labor necessary for the completion of
P� New Root,
Remove 1 laver of existing shmples
uk} ~4 Install ice&water shield at edgee&in valley areas .
Install 151b.felt paper
Install Certain Teed LandMark 30vr,algae resistant shingles Color_+WeatherWood
t Vent ridge with cobra vent
Replace plumbing boots
Storm nail all shingles r
Y to All debris cleaned daily
t Price includes material.labor&dump fees `
X�
All material is guaranteed to be as specified The above work'will be performed m accordance with the specifications submitted
and completed in a substantial'.workman hke manner for the sum of Eleven Thousand Seven Hundred
3 Dollars($11,700 00)with payments as follows `.%@ start kh balance due in full.upon completion_
r
ra; <
r x *Any alterations from above proposal involving extra costs will be added under a separate wrotten agreement and become an extra.
t
qjl-
. charge.over and above said proposal. y+
rg S 1
RESPECTFU SU I tv
x 10/16I09
Mark Herbst s
ACCEPTANCE.OF.PROPOSAL
,. : The above price,specifications and conditions are satisfactory:)herby accept this proposal You are authorized to do thework anc
payments will be as specdietl above
r
SIGNATURE:
his proposal may be withdrawn by said company if:not accepted within 30 days 410
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Assessor's office(1st Floor): A P P R O V E D
Assessor`s map and lot number / $ppg8t8b 0 CcGns 'VtttligY fi�rOmmissldA p6 t"E
Board of Health(3rd floor): /� /( d
SewVc a Permit number e _ ...,,.�...-....�. •
Engineering Department(3rd floor): Sig ri d Date �LAHY"s tt
S .
House number SEPTIC SYSTEM i639•
! Definitive Plan Approved by Planning Board 19 �� r
APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only INSTALLED��CpMPLIANCE
TOWN OF BARNS' NW nCO
®EAND
DUILDING INSPECTNREM- T#ONS
APPLICATION FOR,PERMIT TO L1 C )W X V-5 i 1 A 4 bffG MC
TYPE OF CONSTRUCTION i'p$f.!rt 0,L--
/ZO 19 910
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location 22 oe_Ac ai L F—Av;`5 1. r+a7 �> . C�,�+T�f�✓�c.c.,�
Proposed Use n -.ze-��'
Zoning District ��" Fire District ^� �/�
Name of Owner L����ta�,t'� ttis.rZolr,�_ Address ZZ �s�lk IsA;r �5� +� �•
GcN-r.-v I��„�� N'1�4. oZ63Z
Name of Builder EVE —Akt !Q Sjp I=g j'• Address_3'� C��►7 �4R r1 Rm4r%
Name of Architect N 1A Address
Number of Rooms Foundation s4-'S1S.t�i�t 1�1 Gy
vJ}fr� CE�A�
Exterior Jt�il��G�i; �G'Qfi�a Roofing ARC-w-%,r�Tt9P.,A c- G.P,P 6 V- an
"^Tr .rf- t{pL:.%�
Floors Interior
Heating LA. Plumbing L) 4-
Fireplace �L A. Approximate Cost •
Area ® G46•
Diagram of Lot and Building with Dimensions Fee
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction.
Nam
Construction Supervisor's License Q!V8 39-57�
HEROLD, RICHARD '•�
r
No 33'B27 Permit For ADDITION/ & ENCLOSE DECK.
4-
Single Family Dwelling
Location 22 Beach Leaf Island Road
Centerville
Owner Richard Herold
Type of Construction Frame
Plot Lot r
Permit Granted June 2 2, �r �m� 19 90 1 `�
Date of Inspection 7/ / lilt 19 '
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ssessoPs map and lot number
`/oard of Health(3rd floor): ,.��
Sew0ge Permit number �?f '"/ 4 J,/ �„'/ t!J •
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Engineering Department(3rd floor): r,us"
House number °° +e3,0-
Definitive Plan Approved by Planning Board 19
APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00'P.M.only {
TOWN OF BARNSTABLE
BUILDING INSPECTOR M
APPLICATION FOR PERMIT TO EQ i L-1 t,��
TYPE OF CONSTRUCTION r—\F i 5 i r>at--)'i,r4�..
19 �/o
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location e�?Z F—A<-t-i E-A ,5 l_ ��� i� �E ,��;1=L V 14
Proposed Use 0.�'� �� ` �' '��k4
Zoning District Fire District
Name of Owner \C"A f# mot ,1 Address
Name of Builder & Z r_Ate i) C Address 7 nL D -FAR r'1 -Pjcn�A•0
Name of Architect N !A Address
Number of Rooms Foundation r4S XI ,tJ C�
`n1 tt-7 G.-E DA(Z, J
Exterior tkI/JG-.1-z- c� �v�- Roofing
Floors Interior
Heating N!A Plumbing �Al
Fireplace �!h. Approximate Cost
Area /V 0 �r� �•
Diagram of Lot and Building with Dimensions Fee .1�'CX�
Ar
t
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulationspf the Town of Barnstable regarding the above construction.
Name
Construction Supervisor's License 8 395"
HEROLD, RICHARD A=j1S7-077
fF7-o77
No 33827 Permit For ADDITION/ & ENCLOSE DECK.
Single Family Dwelling
Location 22 Beach Leaf Island Road
Centerville
Owner. Richard Herold
Type of Construction Frame
Plot Lot
Permit Granted June 22 , 19 90
Date of Inspection 19
Date Completed 19
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