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0065 BRALEY JENKINS ROAD
z . y, tj ° n b 0C Commonwealth of MAssachusetts � z SheetIM ��Permit Parcel : Map r n r , Date: f', ® ���'. Permit t Estimated Job Cost:$ � e Perml Fee $. UNN Plans Submitted; YFS �NO Plans Reviewed: YES , NO i" Business License# L Applicant License 9 Business Information: Property Owner 1 Job Location Information: IMName: lvr !r f. t 1 Name: d Street: f Street: i�� i� AO n ; City/Town: 3 Citq/Town Telephone: 1 -"2W Telephone: Photo I.D.required/Copy of Photo I.D.attached: YES-Z NO Staff I®i&at J-1 f M.J_tmrestricted,ticense J-21 M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq.ft.12-stones or less Residential: 1-2 family Multi-family Condo/Townhouses Other ✓ Commercial: Office Retail Industrial Educational Fire Dept.Approval Institutional_ Other Square Footage: under 10,000.sq..ft. over I0,040 sq.ft _.. Number of Stories: Sheet metal work to be completed: New.Work: Renovation: 1IVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents'' Air Balancing Providq detailed description of work to be done: INSURANCE COVERAGE. I have a current lia ility insurance policy or equivalent which meets the requirements of M.G.L.Ch:112 Yes 9<0❑ If you have checked Ytj indicate the type of coverage by checking the appropriate box below: A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE'WAIVER:I am aware that the licensee does not have the insuranc verage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit applicatio this requirement.. Check One Only Owner ["1 Agent ❑ Signature of Owner er's Agent ' By checking this boxEl,I hereby certify that all of the details and Information I have submitted for entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and Installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 9?2 of the General Laws. Duct inspection required prior to insulation installation:YES,_____NO Fro=qs JUSDections Date Comments Final Mection Date Comments } Type of License: i 3y !aster . ate ❑Master-Restricted :ity/Town ❑Joumeyperson ignature of Licensee �ert'iit# f€ f�S e ❑Jollrrieyperson-RestriCted License Number. �s =ee ❑ Check at wvirw.rrtass MIds- - l nspoctor Signature of Perini Approval t The Commonwealth of massachusetts Departfneiat of 1n&s&W Accidents Office of Investigadoras 6O0 Washington Street Boston,MA 01111 www.massgou/dia ' i Contractors/ElecfrieLMS/Plumbers Workers'Compensation�oslzrance.Affidavit:Builders! AppikantWormation Please Print Lgehly 'name(Businessrorg oaMdividuat):, JU f h Address: v�. Citylstate/zip: Phone.#: C — �/Lt '.10 7 Are you an employer?theck the appropriate box: Type of pioject(required):: i. :am a employer with t 0 �4. � I am a general contractor and 1 ©New Contraction employees(full and/or part-time).*. have hired sub-contractors 2, ] 1 am a sole prnpaetar os partner- listed on fte avached sheet 7. Remodeling } These sua-contractors have 8. 1 Demolition sb=and have no=ployees { working for me in any capacity, employees and Have workers' 9. C3 Boding addition 4 (23o workers'co=.ins camp.insurance, 0. Electrical repairs or additions 5. We area oration and its , required. officers have exercised their I. Plumbing repairs or additions ,.❑ 1 am a.horneowner doing all work myself[No workers'comp. rigltt'of exemption pa MGL Ln.Q Roofrepairs insuzaace retpuired jl t- c.152,§1(4),and we have no 13.0 Other employees.[No workers, comp:insurance required.] "Any appli^aat drat t h=b box#1 twist also fill ootthe motion below shawing tit k workse oompmsation policy imftxmatim. t Homeowners aflw submit this affidavitmdi=a ffiey are doing all work cad then hire outside contactors must submit a new a3davitindiczfmg such. lConm actors that check Nits box must att=Ued sn additional sheet sbowing fire acme of tht sub contractors zmd state'% other pr not those mattes hove axzploy=. If the sub-conCart m bave cmplay=4 fltey must provide their worlmn1 comp.policynamber. I am an employer thatisprov ding workers'compensation insurance for my employees Below is thepouv andyob site iri•farmatian. Insurance Company Name; a�—�c e f s Pulley#or Sslrr ins.Lie,# 6�� G � v 6p Expiratiot%Date: lob Site Andress: 6 5— � 4` City/State/Zip: / / Le Attach a copy of the workers'compensation policy declaration page•(shovring 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 tip to S 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of lnvesti ations of the DIA for pl@gpce coverage verification, I'do hereby certify under of pedwy that the information provided above is true and cow Date Phone P. * OffjcW use only. Do not write in this area,to be completed by city or town offuiaL City or Town' PermttUcense n Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person Phone . I ACC) CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD, YY) 3/5/2015 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 BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE 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 the terms and conditions of the policy,certain policies may require an endorsement. A statement on this`certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Debi James NAME: Leonard Insurance Agency, Inc PHONE (508)428-6921 FAC No:(508)420-5406 683 Main Street EMAIL ,debi@leonarda en com D 4 cY• Suite B INSURERS AFFORDING COVERAGE NAIC p Osterville MA 02655 INSURERA:TraVelers Indemnity of America 25666 INSURED. INSURER B:Travelers Cas & Surety of IL 19046 Bourque Heating and Cooling Inc. INSURERC:Travelers IndemnitV Co. 25658 B&L Equipment LLC INSURER D: PO BOX 770 INSURER E: Marstons Mills MA 02648. INSURERF: COVERAGES CERTIFICATE NUMBER-Master 2016 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 DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR POLICY NUMBER MMIDD/YYYY MFF M DDfYYYY LTR TYPE OF INSURANCE LIMITS GENERAL LIABILITY - _ - EACH OCCURRENCE $ 1,000,000 A A 0 ENTED X COMMERCIAL GENERAL LIABILITY PREMISE 500000 S Ea occurrence $ A CLAIMS-MADE aOCCUR 680SB790617-15-42 /17/2015 5/17/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 i GEN'L AGGREGATE LIMIT APPLIES PER: - - PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY PRO- LOG $ AUTOMOBILE LIABILITY - -- . . COMBINED SINGLE LIMIT Ea accident $ 1 000' 000 ANY AUTO BODILY INJURY(Per person) $ ' B ALL OWNED SCHEDULED -8B791085-15-SEL /17/2015 /17/2016 AUTOS X AUTOS BODILY INJURY(Per accident) $ , X HIRED AUTOS X AUOT S EO PROPER e�aE ZIDAMAGE $ Medical Pavments $ X UMBRELLA LIAR X OCCUR - EACH OCCURRENCE $ 3,000,000 C EXCESS LIAB- CLAIMS-MADE AGGREGATE $ 3,000,000 DED' I RETENTION$ C ICUP-8B791269-15-42 /17/2015 /17/2016 $ WORKERS COMPENSATION I WC STATU- OTH- AND EMPLOYERS'LIABILITY - YIN ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ - OFFICER/MEMBER EXCLUDED? ❑ N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD,101,Additional Remarks Schedule,if more space Is required) _ Insured does have workers comp coverage. You-will receive a certificate directly from Continental Casualty. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Bourque Heating & Cooling Co. Inc: B&L Equipment LLC PO Box 770 AUTHORIZED REPRESENTATIVE Marstons Mills, MA 02648 Tina Boulos/LEOTBI ACORD 25(2010/05) ©1988.2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD Rightfax N2-1 6/23/2015 5:23:21 AM PAGE 2/002 Fax Server "' ::. DATE(MWDD YYY) Acal CERTIFICATE OF LIABILITY INSURANCE T IFICATE 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 E ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESE 4TATIVE R PRODUCER.AD THE CERTIFICATE ` IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject he terms and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rightE to he certificate holder In lieu of such endorsements. PRODUCER CONTACT NAME: LEONARD INS AGENCY PHONE FAX 683 MAID'STREET SUITE B (A/C,No,Ext): (ANC,No): E-MAIL OSTERVILLE,MA'02655 ADDRESS: 286XR INSURER(S)AFFORDING COVERAGE NAIC It INSURED INSURER A: CONTINENTAL CASUALTY-COMPANY - BOURQUE HEATING&COOLING CO INC INSURER B: INSURER C: INSURER D: PO BOX 770 ENSURER E: MARSTONS MILLS,MA 02648 INSURER F: COVERAGES CERTIFICATE NUMBER. REVISION NUMBER: THIS B TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWrrHSTA DING ANV REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN.THE INSU ANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCEI BY PAID CLAIMS. BNSR - ADD SUBS POLICY EFF DATE POLICY EXP DATE LTn TYPE OF INSURANCE L R -POLICY NUMBER JLWDDIVYYY) (MKDMYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE OCCUR. PREMISES(Ea occurrence) ED EXP(Any one person) $ PERSONAL R ADV INJURY $ GEN'L.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ❑PROJECT❑LOC PRODUCTS-COMPIOPAGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED.AUTOS BODILY INJURY $ SCHEDULE AUTOS — (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTIONS $ A WORKER'S COMPENSATION AND X WC STATUTORY OTHER EMPLOYER'S LIABILITY YIN UB-SB3953OA-15 05/17/2015 05/1772016 LIMITS' ANY PROPERIfORIPARTNEWEXECUTIVE NIA E.L.EACH ACCIDENT - $ 1,000 000 OFFICER.TAEMBER EXCLUDED? rq (Mandatary In NH) E.L.DISEASE-_EA EMPLOYEE $ 1,000 000 If yes,descrim under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICYLIMrr $ 1,000000 DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIRESTRICTIONSiSPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION CAPE ASSOCIATES INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 203 WILLOW 5T STE B BEFORE TH EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANPE WITH THE POLICY PRO t AUTHOFJEo RESENTATIVE YARMOUTHPORT,MA 02675 46' j, r ACORD 25(2010l05) The ACORD name and logo are registered marks of ACORD 1988.2010 ACORD CORPORATION.All rig' ese Ved. f Town of.Barnstable Regulatory Services ` ABM ° Thomas F.Geller,Director +' Building Division �. Tom Perry,Building Commissioner 200 Main Street,Hyannis;MA,02601 www.town.barnstablema.us Office: 508-862-4038 pax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A. Builder 1'A-4^ PI( rp� ,as Owner of*.he subject propeny laetebp.autboaze '�y Ile I�t�/X�, �1 1 �(. to act on my behalf in all rnatters relative to woxb authorized by this building permit. ti ltiZ�i�� ( dress o€Job) **Pool fences and alarms are the responsibility of the applicant. pools are not to be filled before fence is installed and pools are'not to be uriliz d until all fin spections are performed and accepted. _ Signa e of Owner S' a of Applicant '1,4 14 Print Name Print Name Da Q:F0RMS:0WNER?MWSSl0NP00LS �s r = JA SM s uiaei-�azoes • • • • • . 1SSt1:S TEE fot iil,tiCEA1SE �� A MA3fi�-tI�1RE5TR.i-L�l:�I. FRBlf3 G Z.GCaNTE 131 EXETER Rtl U. 1+f1=ST =YARtAt3UT- 1 A tk2fi 3 �r91$ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map t 1 f Parcel Application # C9 0 I V " 1 Health Division Date Issued S /3111 S Conservation Division Application Few Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address ,,�; 3 a A LG V G N L,i Village L - Owner Ilk k � IA Address �� ����� r/�/�//�'/.� Telephone Permit Request M&010 On, 14 M& Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new 0 Zoning District Flood Plain Groundwater Overlay Project Valuation 000. of Construction Type "= Lot Size Grandfathered: ❑Yes ❑ No If yes, attach=8 pporting'-docu`m..entation. Dwelling Type: Single Family )N Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway�O Yes sr No Basement Type: A Full ❑ Crawl ❑Walkout ❑ Other +r Basement Finished Area (sq.ft.) O Basement Unfinished Area (sq.ft) Number of Baths: Full: existing ? new 0 Half: existing ® new 0 Number of Bedrooms: existing _Q new Total Room Count (not including baths): existing S new o First Floor Room Count Heat Type and Fuel: [(Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes E(No Fireplaces: Existing -L New Existing wood/coal 11stove: ❑Yes N No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: (A existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes YNo If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) - - Name .A��� tl, . Vkk ,ri Telephone Number S-05 Z_q 39 61 Address 4 S I'l l'T f k S j License # C 0 { / Home Improvement Contractor# / 4 2 6D Z Email Worker's Compensation # 40 0 fSI o ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Y-Ao54 L SIGNATURE I' DATE_816 h g i FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCELNO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: r FOUNDATION FRAMES 'cs1S INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL IF INAL BUILDING L a DATE CLOSED OUT ASSOCIATION PLAN NO. Dp `of fnd Ybriai d cdd=fs . ' Office oflnveffgatiow ' 690 MirSMzgton Rr'eet Bostm MA 92M Workers' Compensafion Insmrance Affdavi L-Bt tFIdadCont=brs/ElecUricians/Phanbers Alotallicant Information ' Please Pratt Leef�' SM t ST cityls'bwrlp: LIM /V/U I. 0z b 0.1 Phone#- t—,0 e) --i'q .j Are you an em ?Gheck&e appropriate bo:c Type of project(regaII eci); 1.❑ I am a c=ploprr with 6. Now crmstrn e�Ioyees(faII e!nd/or gm-t imme).* have hid$ie s ❑ a sole proprietor or partner-- ' Iisbrd on the sheet 7. ❑RemodeHng- sbip and have no eazplayem �cse� � S. []Drmoh'iicm wmidng for me is ay capacity. mPlDY� • ,ing a10T1 inemanrr$ 9. ❑BmZ`+'�'b [No warkurs'COn 3p.kSiE nrr_ . �. h. reqah m(L] 5.'[] We are it corporation and ifs 10.0 Electrical repaim or additions 3.Q I am a homcow=.doing all work officers have eaetcased their. 11.❑Plnmbingr-epah or addifions myself[No wmkme camap. night of a UM43f mperMC3L 12.0 Roofrepaizs req�red•I t: e; a IA§In and we have no MPloyees-[No work s- 11❑Other caom insurancre *+�Y appIi®tthat eberi`s box#1 amst also fII ot�the seefioa be]oq�showing tbeQworka'eempeas�ioa Po�Y in�mation, t Hem who s�itfhis attidavidmdicatmg�ate doumg.II wod�end then hue nnLdde�aema Est sabmit anepr+afdavi�iadu�g each. #Coatrarh�a ih�eheckthis box ffist azmrbed em addffiaffiI sbedshowiagthe acne of�e s¢b-�hat�s ffid s1a�whdha nr nnt�nse edifies have employees.Iftbz sob-�adaa hrn emP�9�.�Y�>��'�'�•PAY�� I am an empLryer that is praYidnzg N�orkers'corrrpensatian zntzrrmtre far my,empto3'ee� Betoty it ffte polcy and job site . u:fornrationi, I=mace Compaq Policy,#or Self-ins.ljrc #: a /(a O tn' 4 0 ' 2 14 ExgirafianDa �/ Job Site Address.• 1 ,QA t G 1/ N IC 1 S C"�Y �'�'�nil�2,V9 ILG Atfa.rh a copy of&e workers'compeasafmxL policy declaration page(showing the policy number and elan date). Fa�Zmz to sear coverage as rmquazd under Secfiffi25A ofMGL c.152 can lead to the imposition of crffiinal penalties of a fine Up to$1,500.00 and/or aae-year finprisonmeot as well as civrl penahim in the f�=of a STOP WORK ORDER and a fine of up to$250.00 a day against tire:violator. Be advised that a copy of fis sh±==at may be forwarded to the Office of 7nvestigafions ofthe DIA for insmanc o coverage veufrcaiion. ' I do hereby rnsder the yams and pertallirs ofpeUml'duct gle forma Lion prnmde i above it b-uz and carrect S• Dam M Phone#.- -� 3 C? 6 Qf 7dd rue only. Do not write in this area to be eompkied by city or tom ojkiaL ' City or Town: Peicense Issuing Authority(curie one): L Board of Health 2 Bmad epartment 3,CtfylTown di"a' 4,IlectxicalIuspecfnr 5.Phnnbingluspednr 6.Otiier CaniactPerson: Phone Information' and Instructions r jyMassachnsestts General Laws chapter I52 regu=an employers to provide workers'coanpeosatran for oiler e:mpIoy.=. Pm suani to this statute,as employee is defined es°every person in the service of another under any con Tact of hoe, f express or implied,oral or wrh=" j An employer is defined as z asu hulividuaL partnership,asso®tiam,cmporafion or other legal entity,or any two or more of f m fimgoing in a joint emtxpdsey and includmg the legal rep azitafi-m of a deceased employer.or the rs,d=or t uA=of an and Tidnal,piab=ship,association or other legal ezdity,employing employers. However the owner of a dweIIing house having not more than f b=apertr oeofs end who resides therein,or the occupant of the . dwelling house of snots who employs persons to do maiitenanc r,construction or repair work an such dwelling house or m the grotmds or building appurtmait thex efo shOnot because of surly emplaymm t be deemed to be an anploym." MGL chapter 152,§25C(6]also sfafes that'every shda or local Hemusing agency shall withhold the issuance or renewal of a license or perruit to operate a business or to construct burTdmgs ion the co—onwealt h for airy applicantWho has not produced acceptable evidence of corapliiance with the insuraam coverage requnmd." Adrlitionally,MGL chapter 15:4 §25C(7)states'Tuner the=m:n nwealfh nor aIIy of its political subdivisions shall _ .... eater into any coatrart forthepe Em aam ofyd)hr,wor3cnntil acceptable evidence of conplian=wlth the n mrm=. recpmemerds of this rhaptrr have been presented to the contracting srxthoay." APplicaats Please fill out the worirers'compensation affidavit completely,by c hmIcing the boxes that apply to your sitnation and,if necessary,supply sub-contractn(s)name(s),address(es)and phcme nunber(s) along with their cestif caie(s)of insurance. Limited LiAffity Companies(LLC),or Limitrd Liabfiity Pmtammbips(LLP)with no employees other than the members or partners,are not to carry wod=e compensatians in ranm If an LLC or LLP does have employees,apolicy is regafir4 Be advisedthatfhis affiftykmaybe submitted to the Department of Industrial Accidents for confnmation offiMn ice coverage. Also be sure to sign and date the affidavit The affidavit should be retained to rho city or town that the application for the permit or license is being regne,;sbA not the Department of Industrial sal Accide�uts. 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 collpanies should eater files self-insurance license number on the app siaie line. City or Town.Officials Please be sm a that the affidavit is complete and prkdmd legibly. The Department has provided a space at the bottom of the affidavit:for you to fill out in the event the Office oflirvestigations has to contact you regarding the agpIi ant Please be sure to fiII in the pennitAicrose number which will,be used as a reference number. In addition,as applicant that must submit multiple pecMit/oensm appliudoms m any given year,nerd only submit one affidavit indicating current policy fi fonnatiom(if necessary)and under`Job Site Addresses the applicant should write"all locations in telly or town)."A copy of theaffidavit that has been officrally stamped or marked by the city or town may be providecl to the applicantPro as ' of that a valid affidavit is on file for f rI permits or licevsMs. A new affidavit must be filled om t each year.Where a home owner or citizen is obtaining a I cm=or permit not related to any business or commercial venture (i.e. a dog license or permit to born leaves eta)said person is NOT required to complete Phis affidavit: - onhave 'one for our er�atiAn and should any , The Office of would like to thank you in advance y coop y q� please do not hesitate to give us a call The Department's address,trlephocne and Ar number. Depeiimmt of lndastdal Ac menu Mce of Xnv g$fio= Bus m.MA 0�111 Tel,#617-?2'7-49W cxt 4€6 or 1-977-MAMAFF, Fax 617-727 7749 Revised 4-24-07 mgidia : ' T Town,of Barnstable ti Regulatory Services 9 brass. Richard V.Scali,Director 4'�� ►+��� Building Division Tom Perry,Building Comminioner e 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 K Fax: 508-790-6230 Property Owner Must ' Complete and Sign This Section ' If Using A Builder I 1�A/�!� !�' � as Owner of the sub'ect property. - � •� J P Prix hereby authorize �_ p� 1 7 to act on my behalf, in all matters relative to work authorized by this bolding permit application for. (Address of Job) ',.Pool fences and alarms are the responsibility of the applicant. Pools`, not to be filled or utilized before fence is installed and all final , pec 'ons are e ormed and accepted. ignature of.Owner Signature of 4plic4i - Print Name- Print Name QTORMS:O WNERPERMISSIONPOOLS Town of Barnstable Regulatory Services 4 oFTHE rgtz� Richard V.Scali,Director Building Division w tenpw7�—reRTx Tom Perry,Building Commissioner MASS �E 639. AK t, 200 Main Sfreet; Hyannis,MA 02601 www.town.barnstable.ma_us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE E%EINIPTION Please Print DATE: r" JOB LOCATIOR-- number stied viinage �ot�oR�": • name home phone# woIk phone# CURRENT MAILING ADDR SSS: city/town state zip code "l se current exemption for"homeowners"was extended to include owner-occupied dwellings of sic units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor_ DEFINITION OR HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,oa which there is,or is,intended to be,a one or two- family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned`.`homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. - The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval ofBt ldingOf5cial Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S ExF1VIPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&.Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires,unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the Iast page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\wPFH EWORMMuiIdmg permit fb=\E3MRMS.doc Revised 061313 ' Massachusetts -Department of Public Safety Board of Building Regulations and Standards x s •- Construction Supervisor License: CS-103617 "} PABLO C MARTMZ 49 SMITH ST fit, y HYANNIS MA 02601 Expiration - Commissioner 11/17/2015 I /� po�wnaoauaecc /a�C�/l/�craa�c/i�seCh. License or registration valid for individul use only Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR before the expiration date. If found returri'to: OME IMPROVEMENT MENT Type: Office of Consumer Affairs and Business Regulation egistDBA 10 Park Plaza-Suite 5170 xpiration 5/20/2016, Boston,MA 02116 CIJERVO BUILDING+REMODELING PABLO MARTINEZ _ 49 SMITH ST g�i ��� i HYANNIS,MA 02601 Undersecretary Not valid witho t signature r ' /3uil�isry.eReno (2) 2X8 w/ 1/2 Plywood Header (2) 2X8 w/ 1/2 Plywood Header W LUS28Z hanger 2X4 @ 16 o.c. •• pods#. Date. 8/11/15 ale. 1/4"=V-O" Drawn. PCM lrv. • �pgg• � off 1 • cR� (2) 2X8 w/ 1/2 Plywood Header (2) 2X8 w/ 1/2 Plywood Header 0 LUS28Z hanger 2X4 @ 16" ox. Job#. Date. 8/11/15 Scale. 1/4"=F-O" Drawn. PCM Rev. Cross Section Toff 1 ARe�uo�eGiiy (2) 2X8 w/ 1/2 Plywood Header (2) 2X8 w/ 1/2 Plywood Header LUS28Z hanger o V=4 2X4 @ 16" o.c. Job#. Date. 8/11/15 scale. 1/4ea=V-099 Drawn. PCf Rev. Sht. 1 of 1 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel / Application #0d/,!�0/3S4- Health Division Date Issued Ok 1 oi1 Conservation Division Application Fee 2 Planning Dept. Permit Fee :1 rJ •J Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address I}L eiy f N K%NS Village Ce gi-eo-v" Z Ue., Owner W tL-(-( im r bl P KtA Address S /fYm e__ Telephone 13 673 -7 D / Permit Request R4,r"vae- DAM 5-ed 'S e eT R_o-c-K / N tL1;o j l e FJ"C_7-S //V 5 4m-e- T)u a Tv w-A-t--e v ��t Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new _;Zoning District Flood Plain Groundwater Overlay "Project Valuation $ o® •`'° 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 ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other 44 Basement Finished Area (sq.ft.) Basement Unfinished Area (ah 4-) -� Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor R om Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other °7f 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 APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number 7 Wi a. V -YZ '7 7 Address L. Lcw4i T)rL License # C S P 19 - 6 S 17 S_/Y (z u c(K L4—r4. -i D Home Improvement Contractor# / �f a '7 Email L&p(2_t-A o_l -7 /`'(S /V - CU -n Worker's Compensation # 1 a W C S`i zs -a 8'? ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 3 -45 FOR OFFICIAL USE ONLY r APPLICATION# DATE ISSUED `` r MAP/PARCEL NO. } ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION t FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING - 0� 11 Sklk I DATE CLOSED OUT l - ASSOCIATION PLAN NO. B -nommizoffice of Consumer Affairs&Business Reggh-tlon license or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation !" _ egistration 140427_,. TyFe' 10 Park Plaza-Suite 5170 `'" ,Expiration 10115/2015 Supplement and Boston,MA 02116 MULTI-STATE.RESTORATION INC.CAPE COD RICHARD LAURIA P O:Box 2210 g MASPHEE,MA 02649 Undersecretary Not valid without signature Massachusetts -Department of Public Safety Board of Building Regulations and ;Standards Cl/ltltl ULLII/11 �V 4/C1 V Ill/r 1 &2 V i111111V �,. License: CSFA-051784 r1's r RICE ARD D LAU,#I 1 LEAH DR L.e+G, G Rockland MA, 02370 , Expiration 04/0112017 Commissioner + d a MULTI-STATE RESTORATION, INC. FIRE* FLOOD *WIND* SMOKE*HURRICANE*VANDALISM Fed ID#050515889 CONTRACTORS REGISTRATION#140427 AUTHORIZATION TO PERFORM SERVICES AND DIRECTION OF PAYMENT 1 i 4vin q ,herein referred to as "Customer",authorizes MULTI-STATE RESTORATION,INC.,herein referred to as "MULTI-STATE",to perform any an all necessary cleaning and onstruction services on Customers'property at: r41 t of k N, f C'.?�✓1 Tvw,•l/ Telep one: and with respect to items that need to be cleaned at a remote location,to remove and clean such items as necessary. Customer authorizes /9 ;rQA6An�1L P Insurance Company,herein referred to as "Insurance Company",to directly olely pay MULTI-STATE. If for any reason the check should come to be or be made payable to the Customer, Customer then agrees to pay MULTI-STATE immediately upon receipt of the check from the insurance company. In order to expedite payment to MULTI-STATE, Customer hereby appoints MULTI-STATE as attorney-in-fact,authorizing MULTI- STATE,to endorse Customers'name,and to deposit Insurance Company checks or drafts for MULTI-STATE services.Customer agrees to pay Customers'deductible in the amount of$ that applies to this claim. i If the loss is not covered by insurance,Customer agrees to pay the total amount to MULTI-STATE upon receipt of the 'invoice.,( Signature of Owner It is my understanding that the services to be performed by MULTI-STATE will be limited to those,which are authorized by my Insurance Company. Insurance Company Name Policy Number Customer agrees that MULTI-STATE is working for the Customer and not the Insurance Company or agent/adjuster. Additional remarks: olf- I have d s document and co' el erstand and agree to same. ,�.. Signature Date /Ji-/,/ / Printed Name P.O. BOX 2210•MASHPEE, MA 02649.866-921-9111 •FAX 774-238-4422 Client#:34309 MULTISTA ..ACORD.M CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 3/17/2015 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 BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE 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 the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT - NAME: Marla BarnOWS1Cl Starkweather 8c Shepley PHONE 401 435-3600 (FAx 401 431-9326 A/C,No Ext: A/C,No PO Box 549 ADDRESS: mbarnowski@starshep.com Providence,RI 02901-0549 INSURER(S)AFFORDING COVERAGE NAIC# 401 435-3600 INSURER A:American Safety Insurance INSURED INSURERS,AmGUARD Insurance Company 42390 Multi-State Restoration Cape Cod INSURERC:Hartford Ins Group 19682 Division,Inc. P.O.Box 2210 INSURER D: Mashpee,MA 02649 INSURERE: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE NSR WVD POLICY NUMBER ADDLSUBR MMIDDY� POLICY LIMITS A GENERAL LIABILITY EPK106790 - 1/01/2015 01/01/2016 EACH OCCURRENCE $1 000000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence $50,000 CLAIMS-MADE �OCCUR MED EXP(Any one person) $5,000 X BI/PD Ded$5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $2,000,000 X POLICY PRO- JECT LOC $ C AUTOMOBILE LIABILITY 02UENQT4762 - 1/01/2015 01/01/201 COMBINEDSINGLELIMIT Ea accident) $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS I ) NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident $ $ UMBRELLA LIA13 HOCCUR EACH OCCURRENCE $ III EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ B WORKERS COMPENSATION R2WC510288 7/16/2014 07/16/201 X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/NER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500 iOOO OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE s500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) William P Plifka address of job site=#65 Braley Jenkins Rd Centerville,Ma CERTIFICATE HOLDER CANCELLATION Town Of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE `-' 1 , 0.. �AltiE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S672353/M672348 MBB • �e �f�€� �cc�`e�s • 60 Wm*h ua Street Kastarf,MA 02M tvecnu�ur�grr��r�ut Wurkexs' CumpensafkuL=-anceAffidavit B-uAdersfC�an{ractgrsfRe-ctnciansO tubers APPEcant Inlarmatiun ' Please hint Lep_iw Name ! t Lt L- S 7-A-re /2e S TD Adaress: 6 � Pico Le_r7- `s w Gtlifstatel: Pe e Phones;�_ `f77- 3333 Are yyaanemployer:'Check t1wappr•qniataba= T of erect s I am a 1 v�ith ' 4 ❑I am a geux1 cant actor gad I 3 E e 3 e = exslo (full.Mwbrpnt-ime)* hZV5hir&th5 sub-cuss- ❑I�Tes 2_❑ I aM a soSe prophietGr orpartner- listed on The attached sheer +- ❑R modeling ship and have no employees 'These uk-mu actcu have 9- WUfEng � iition fvr me in anY CapZCity. emPlayem and have wormers' : 9- ❑Bnilrimg addition [N6worIMs' couhp_ifh.aIIarLe COMP-i+,. 5_ ❑ We are a corporaticnand its 10-0 E1ezbical rgnim or additions I El I ama�hom urr�r doing all ward officers have exercised$heir 11�Plumbing repRizs or additions o waslu:ta' �.of�.mptioa per hfQ. I.F. c-152,§I(4)=and vie lava as 12.[]1Zaaf repaug euhPloYee5_[Notes' 13-ElOther comp_insurance r�quirezL ;kny sizp that checks box�1 mnstalsa fiQ aotth�secfionhcIa-�shmxing iheswozkers�m��safioar pati[3-aahhm�fitm_ ffo- sue -TContacmrs thst check ffih bar must attached sn:d fidanid sheet sha cffig tha LBmL of flee 4�ir rs m3 s�uhetize�ncnat fr}nse enYmes fi ve MMPlUY . If the --Iq 3e r zy m—b- �ie}it are�rrrcj�Inp�r'rhrrtisgt�rt�is,�ft��rke-rs'catus�ian iresr�rrucc$far rrt��err�Iny�ss. Belo_tF is f}teg�F�c}czrtd job ester irtfnrYrtrr£ir�?tt. .. A - Insurance Gompa�I£awe: �l�10i l /icy err Self irts_Lie 02 w 6- rl U. ? l4 —15 sob AMT,=s: G� �!Z��� _�/`'K;.�S /2�.: citgtstaterzp_ C.�'N te;t u c l�.P t$A Attach a copy of fhg markers'c- hn ensafum polite-dedarstiou page-(shoring Phe policy number znd erpa-ation date): Fai3.um to secure ca7crage as retiuireaunder Sectica 25A of MGL c 152 can lead to the imposition of rnmmal penalties of a fine tip to S4500.00,and/or omE yearim ,as weil as cit l penalties in the fog of a STOP WORE{ORDER-and a fine of up to$250.00 a day against the violater. Be advised fhat a copy of this st$ternent maybe forwarded to the Office of InveuE gatiom of the DIA far inssFrance coverage vmi&ztio F dv harebl,cerhff under thcpdns anr£parzahYi s nfjse0uy thatthe infor-sudian prmilfkd?abam FS true and caFrect aftid ups alfly. .Do-trot tt'tihr in ffus area, &e cEtMPLetad by city crr tnwn officiaL city or TO'rWM ,}�r PermiUIicrose# ' fc���Qy'S lCIrGIe4Re�: . L Bw d of$ealtis 2.$ � artacnt 3.CWFa-wn Orrk 4_I=Iectrical Easpectur 5.Pf gtar 6. cosfalct 1'ersnn: glFo-nz - assacimsei s Gran al Laws chapter 152 requ±=all Moyers to provide workers'compmsaion for their employees.. Pu-saaatto this statute,an anp£ayee is defined as 1--may person in the seavim of mother under any contact ofbu-e, express Or implied, oral or written_" Am erzpkyer is detaued as pan iadividual,par amship,association, corporation or other l t�cgd entity,or any two or more of the foregoing engaged in a3aint enterp n,and inclm3mg the legal repr =tatives of a deceased employer,-or the receiver or trustee of an individual,p�ersbip,associaatioa or other legal entity,employing.employees. PIowever the owner of a dwelling house having not more than three apartments and who resides therein,br tie occupant of th a dwelling house of another who maploys persons to do maiIIteuance,construction,or repair work on such dweIimg house or on the grounds or building appurtenant thereto shaIl 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 rssuance or renewal of a license or permit tc operate a business or to constrict buildings in the commonwwealth for any applicant who has not produced acceptable evidence of compliance with the insurance.coverage required.'' Additionally,MGL chapter 152, §25C(7)staffs"Neeithea far,commonwealth nor any of iis.political subdivisions shall enter into only coirfract for the perfmnance of public work until acceptable evidence of compliance v{ith ifie insurance requirements of fhis 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 sit radon and,if necessary,supply sub--contractor(s)name(s), addresses)and phone niunber(s)along with their cer�dncaie-(s) of h srrr-ance. Limited Liability Companies(LLC)or Lim tedLiability Partnerships(LLP)vr-ith.no employees other-iha1 the members or partners,are notrequired to carry workers' compensation insurance. If as LLC or LLP does have employees;a policy is requu-ed_ Be.advised that tfiis a$davit may be submitted to the Department of Indusdial Accidents for confirmation of insurance Coverage. Also be sure to sign and date the affidavit The affidavit should be mtumed to tfie city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questons regarding ine 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 then self-in si C4-,license number on the appropriate line. City or Town Officials . Please be sure tbat`the affidavit is complete and printed legibly. The Department has provided.a space at the bo n. of the affidavit#you to fin out in the event the Office oflnvestigations has to contact you regarding to applican"t Please be sure.to fill in tine pennitlIicense ntmmber which wM be used as a refiemnce number. In addition,an applicant that must submit multiple pm iitllicense applitations in any given year,need only snbmif one affidavit indicating curer-nt 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 maybe pr oyided 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 Yentnlre (i e, a dog license or permit tD brmm leaves etc.)said person is NOT required to complete this affidaYit The Office of Investigations would like to thank you m advance for yotn caoperafion and should you have any questions, please do not hesitate to give tis a call. The Department's address,telephone and faxntnnbe-n ` a E.oI7 maaw�'aMLofMassachus�, D,--pa-emeat Gf lilchrstdal A(Y--id emts = Of kcvftFo-n� �astm,IA G211I Tel A 617 727-490--0 Qxt4-46 or I-R77-hE4,SSAFE . . Fax 4 617-727-774 Revised 4-24 D7 gov/dia i �'&M 9 BAUSTASLE [ ,fVIT 51 1 i I 13f� 'x 12 '/D ,B 17B �p'�x l5"Cl "-x 6q`3 ,, .J-60 I000S k( Ge PTe (-ut E ! Ism 3&21°7 Town of Barnstable *Permit#�'o� OIL Expires 6 months from issue dale PERMIT Regulatory Services Feey r� D MAR 2 1 2007 Thomas F.Geiler,Director 5 ti {fie= ,,�iV�TP►E�LE Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA_02601 www.town.barnstable.ma.us Office: 50&862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY 71 1, Not Valid without Red X-Press Imprint Map/parcel Number 5;? d o Property Address LAD ,[Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address �l'k A PV_X e_-.-l4 1 Telephone Number ,So% 5O 9 4 b'•!-y -� Contractor's Name a�J _�� .-� Home Improvement Contractor License#(if applicable) �2�6�5� Construction Supervisor's License#(if applicable). Yworkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner [� I have Worker's Compensation Insurance Insurance Company Name LL G M_V1_A Workman's Comp.Policy# w� 3��160'A (9� Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) (�Re-roof(stripping old shingles) All construction debris will be taken to A(i A_PQ1r1 ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *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 Improve ent Contractors.License is required. SIGNATURE: Q:Forms:expmtrg Revise061306 The Commonwealth.ofMassachusetts Department of Industrial Accidents' ' k Office of Inyestigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation InsuranceAffidavit: Builders/Contractors/Electricians/Plumbers Applicant Information P, Please Print Legibly Name (Business/Organization/Individual): q Address: l City/State/Zip: j���Phone�#: Areeuu an employer? Check the appropriate bog: Type of project(required): 1.L°�1 I am a employer with 2 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hiredthe'sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7.. []Remodeling ship and have no employees * These sub-contractors have 8. ❑Demolition working for mein any capacity. workers' comp;insurance: g ❑Buildingaddition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.�]Electrical repairs or additions required.] officers have exercised their 3,❑ I am a homeowner doing all work right of exemption per MGL 11.❑P umbing repairs or additions • Y myself. [No workers' comp. c. 152, §1(4), and we have no 12,ERoof repairs insurance required.]t employees. [No workers' 13.❑ Other comp,insurance required.] . 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hue 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. dam an employer that isproviding workers'compensation insurance foamy employees. Below is thepolicy andjob site . hformation. nsurance Company Name: U e6 co_ 1 'olicy#or Self-ins.Lic.#: n t:�:> Expiration Date: ar) " �'77 ob Site Address: �� �Y <?�Z -�.S �-LJ City/state/Zip: l%�`tJ` .Vtii(Xi 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 . ine 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 if up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of avestigations of the D1A for insurance coverage verification. 'do hereby certi nder the pains and penal ' of perjury that the information provided above is true and correct i afore. " c;�( Date: 'hone#: S50 11 �. _ 1J L4 / O Of use only. Do not write in this area,.to be completed by city or town official City or Town: PermitVicense# 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 4. 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 lure, 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 j oint enterprise,and including the legal representatives of a deceased employer, or the recekler 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." MC-IL 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 requrements of this chapter have been presented to the contracting authority." .Applicants Please fill out the workers' compensation affidavit completely,by chepking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLP.)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 policy.is required. Be advised that this affidavit may be submitted to.the Department of Industrial ees a o q employees, Y. _ Y P 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 ofthe 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 thatmust 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 inay 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.There 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. T'ae Department's address,telephone and fax number; The Co=owmalth of Massachusetts Depaxtmptof ln4wtdal Accidents Gmee of Investigatims 600 Washington Stremt Bostch,M&02111 '�T, 1, # 617-' -4-900 ext 40.6 or 1-$•77-MASSAFE Fax.# 617-727-774.9 Revised 5-26-05 �. ass.gov/dia ; . �ofz►ETo Town*of Barnstable P Regulatory Services +91AR1VrABM Thomas F. Geller,Director c►,, °�� Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, S� PL-k S kA , as Owner of the subject property hereby authorize L-V JZ--�L k&/'--LALj to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date Print Name QTORMS:OWNERPERMISSION r Boar o Building Regina ions and Stan ands One Ashburton Place - Room 1301 Boston. Massachusetts 02108 :Home Improvement Contractor Registration `0 Registration: 128957 P - Type: Individual c Exp(ration: 8/14/2007 Oliver.Kelly 3" Oliver Kell 9 Peregrine lane a ;. S. Yarmouth, MA 02664 ry Update Address and return card.Mark reason for change. 0 Address ❑ Renewal Employment Lost Card, DPS-CA1 0 50M-"04-G101216 .V ' I..i+berty dqutttal�xd�itp Libe X Box 7202 mutuils Portsmouth,NH 03802-7202 Telephone(800)653- �,_ wFa 31-5693 CSt� January 9,2007 TOWN OF BARNSTABLE ATTN:SALLY 230 MAIN ST HYANNIS._M1 02601- RE: Certificate of Workers Compensation Insurance lnswed: OLIVER KELLY 9 PL•REGRIINE LATE . S YARMOLTM MA 02664 Policy Number. WC2-31 S-338804-026 'Effective: 12282006 Expiration: 12f282007 Coverage afforded under Workers Compensation Law of the following state(s): M.4 Employgrs Liability. Bodily Injury By Accident: $ 100,006 Each Accident Bodily Injury by Disease: $ 100,000 Each Verson Bodily Injury by Disease: $ 500,000 Policy Limns As of this date,the above-referenced policyholder is insured by Liberty Mutual Fire Insurance Co under the policy listed above. The insurance afforded by the listed policy is subject to all the teams,exclusions and conditions,and is not altered by any requirement,term or condition of any or other documents with respect to which this certificate maybe issued. This certificate is issued as a matter ofinformation only and confers no right upon you,the certificate holder. This certificate is not an insurance policy and does not amend,extend,or alter the coverage afforded by the policy listed above. If this policy is cancelled before the stated expiration date,Liberty Mutual will endeavor to notify you of such cancellation. AUTHORIZED REPRESENTATIVE U BERTYMUIUAL INSURANCE GROUP This Cerfiftw is eaerukd byLIBERTY H AL INSMAME GROAPas mspeets uca as is af'oadea Dy arose coupwo. cc: Insured: Producer of Record: OLIVER KELLY SANDPIPER INSURANCE AGENCY INC 9 PEREGRINE LANE 12 ENTERPRISE RD S YARMOLT$MA 02664 HYANNIS,14A 02601 t,ar�tn Assessor's office (1st floor): a.:P-TIC SYSTEM MUG Assessor's map and lot number Z�.*.*. y LBoard of Health (3rd floor): INSTALLED !N C®MSewage- Permit number .......::....... WITH TITLE �. 9lbDLE.x Hasa . Engineering Department (3rd floor): ,Vj0NMENT Q" ,639, 0� House number L' �.............................................. V�.`tf � d9�,_'_ �`Dmpj APPLICATIONS PROCESSED_ 8:30-9:30 'A.M. and 1:00.2:00 P°M.` only♦ a TOWN .OF BARNSTABLE BUILDING -INSPECTOR APPLICATION FOR PERMIT TO �7�l ( .t......... ..... � �......../...2 ..5 .......................... TYPE OF CONSTRUCTION ........... ..v. ( .. 0 ............................................................................ ............................................ ...19-0- TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: r ���Ce Y �/�aJlG/nos.... . p � ✓lLocation .... ................. .......................L....C..,..C..� .................. �.cwlw.c Proposed Use �...............................:.................................................................................................. Zoning District .............. .°G.J.'.........................................:.......Fire District ......:... ................................................................... ..Name of Owner 1(-..4 .................................... 5.. ...Address ... .. .. Jew_' !32 l l.. ? .............................................................. Name of Builder ....r...................... .................. C<.......Address ................... � Name of Architect /.. al�hl, 'f (7G 17.... K% 6� /117- ®"T ....... .............Address .................................... ................................................ r Number of Rooms ............ .. ...............................................Foundation .... ......!✓ Exterior .... ..49P-5...l.S.t. J�.`. 5.......................Roofing ....... SP. }L .................................................... Floors �C.,.Y..40.0.6P.................................................Interior ��y GJi�C,L :........................... .......................................... - p . .Heating ::�:.......�:�.�. .......Plumbing ..........[ 4� /1 Fireplace ................ es.......................................................Approximate.Cost ......... ©�........................................... Definitive Plan,Approved by Planning Board ___UVL.__:___6------19 b_+., Area /. ...!� ... .......... ..... Diagram of Lot and Building with Dimensions Fee e�.......... .................... SUBJECT TO APPROVAL`"'JOF BOARD OF HEALTH D• '011 0 Q q�. ° OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of t 'To n o rnstabggar i th ove construction. Name ....... . ......... ............. Construction Supervisor's License ��`*.... ................... LEBEL SOLLOWS TRUST -- _ k No .3 l7 8 5 3... Permit for ..1.?. Story.............. �.. .....Single Family Dwelling - - •Lot 280 65 Brale Jen�ins Road " rLocation .............. .........r......................... .Y........ „ -Centerville y ,_ ........................................ t✓ Owner Lebel 'Sollows Trust - ... Type of Construction ..Frame ; t. ifs Plots `................. Lot '..=.F June 12- -%, 8 7 Permit Granted ........................!........:......19 tiDate,of Inspection :..;7"� ........R...19 Date- Corriple ed . ........ ... �............ r 4 A ,• .. • Dom' ., b Assessor's office (1st floor): TNE FT Assessor's map and lot number � ;ti - .. .�� -'.. . ��' o�y Board of Health (3rd floor): Sewage Permit number ............... .......................................... 13AHa9TGDLE, ingineering Department (3rd floor): House number ....... co �e39. APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2.00 P.M. only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ...... (Lb......../...... D(JS �............................................................ GtJoco �� TYPE OF CONSTRUCTION ..........................�..�9��..�--til..�.......�..�............................................................................ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .... 9.. ..7..6. ✓p.....I�.2f}L Y.... �!t/�G//us.......9� � ) C2v/ LG.L� ProposedUse �f..... I ...................................................................................................... tl� ZoningDistrict C .................................Fire District ........... . ..........�.................................................................. . ......... ,) oux a2 T )3 2 '(,q ail0�S Name of Owner .......v .............................. ..Address ... ��. .. ........................................... .............. �� , Nameof Builder .... .....................................................'.../..........Address ................. ..........`../......................................,.............. ' /�✓dslS/�C C/ S.f ?.! :.....Address c�� 9' JN P Name of Architect ........ .... ................................ .................................................................................,.. Number of Rooms .......Foundation ... - ?...1... ...............:..........................a.. 'T. Exterior .... P .../..�11 f- SP�AL7. Roofing t �. ..�'-�t"�C Interior Dey &Jj4L L Floors 4-.y .............................. /� A7-4 s Pleating ��� Plumbing ......... Z Fireplace ...eS.......................................................Approximate Cost .......... )..0.00.................................. ............ Definitive Plan Approved by Planning Board ____ ----- Area Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH t� OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the own of Barnstab el regarding ZWabove construction. .- r 4. ( '" 1��/ , Name �.. / ... .- $`...:'. .......... Construction Supervisor's License_.-O..............................- `� LEBEL SOLLOWS TRUSTt J7l A=171 No .... 0853.' permit for ....12 Story Single Family Dwelling ............................................................................... Location ,,.Lot #280 , 65 Braley Jenkins Rd. .............................................. Centerville _ ............................................................................... Owner ..Lebel Sollows Trust ................................................................ Type of Construction .....Frame...... ............................... ................................................................................ Plot ............................ Lot ...... ................. June 12 , 87 Permit Granted ..................... .................19 Date of Inspection ....................................19 Date Completed .............:......:.................19 /Ilk, r 11 ,. � ..w„_,..;;4,;: �..�r. . :,u, v'ro• �t� '»sty-�� .ww-��rr..w:x*��"�,�;.�'".�'„',,.�....;..,..,;:rp.v-:��,n�y,r«, �;+��:*n.�'�-ra.:�+-���^•�^'-,;;:r='�+ � TOWN OF BARNSTABLE Permit No. ..3.0.853 BUILDING DEPARTMENT D°8:wi I TOWN OFFICE BUILDING Cash i6�9• HYANNIS,MASS.02601 Bond X CERTIFICATE OF USE AND OCCUPANCY Issued to Lebel S011ows Trust Address Lot #i:280, 65 Braley Jenkins Road Centerville, Mass. USE GROUP FIRE GRADING OCCUPANCY LOAD 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. October 28, 19 -` -- - ":e�l .. Building Inspector �4 1 TOWN OF BARNSTABLE BUILDING DEPARTMENT 2 IsanT U TOWN OFFICE BUILDING raa i619. � HYANNIS, MASS. 02601 MEMO TO: Town Clerk FROM: Building Department DATE: 4 An Occupancy Permit has been issued for the building authorized by BuildingPermit #.... �J �` ��............................................................ ................................................................................ . f issued to �>, °��J QG vu�S........... .......... ��,(f.�i., a„ec' r c/. i.GiS F" Please release .the performance bond. _ WN OF laC7.SJ+�Y A BARNS ARNS.♦!\ 84ILDING ' TABLE, • P � {{33 n SAT.' UL3 i DATE J111'li 19 L;/ PERMIT It 4,Y A'R""jS: '1 •i. � {A,APPLICANTt - Leb 1 So110w0 Development .ADDRESS 131 Old Rout& 132,E HyaS'n61s+ 008121 /'°'T"�'( { �, ��•• - ], - (NO.) (STREET) NUMERf. (CONTR S LICENSE) n R� rM > �u.9.`�d• (�t111ell�ng �, -( 1Z )..STORY rTi.i1�g'.�f? &1Q :F.V f3�11e �. lZg 'DWEBLING UNITS 1 r7 z ' kx SC .`,(TV PE OF IMPROYF,MENT). NO. (PROPOSED USE) .� C 'fATiWOCATION) lot #280. 65 Braley .3enkinc, Road, Centerville, ZONING .DISTR ZlC (NO.) (STREET) BETWEEN— AND (CROSS STREET) (CROSS STREET) LOT .. "^SUBDIVISION," LOT BLOCK SIZE ,'- BUILDING IS PTO BE FT. WIDE BY FT. LONG BY FT.-IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION - .- o TO TYPE�9 USE GROUP BASEMENT WALLS.OR FOUNDATION GILt R +X •_.. _ (TYPE) REMARKS .,.. >: Sewage #C86-SZS zP AREA OR # ; '' 24 'f - t. '1•`' ,� YI ham§ f - SONU :' VOLUME ;� 1 ��1 $[�•a C•';.... } A "tT 6pU, t PERMIT 1Q3• /5- r , ESTIMATED�COST FEE (CUBIC/SO UAR El FEEL). 1,. •� h et A r ^ a ?4u Lebel 5011uw sts It , k s r sI Efx OULe. �3 �/i�f?iiIil, 1." BUILDING OEPT •t ADDRESS' *xA: BY 44. iTHIS PERMIT CONVEYS NO RIGHT TO.OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANY PART THERF�OF, EITHER TEMPORARILY OR a 'PERMAN ENTLY. ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST" ;.BE AP t PROVED#BYw THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM?THE'D'EP.AR.TMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS :.`OF'A�NYI.A�P,PLICABLE SUBDIVISION RESTRICTIONS. .MINIMUM' OF... THREE CALL APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE `.INSP,ECTIONS`•.REQUIRED FOR CARD KEPT POSTED UNTIL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR FALL.,,CONSTRUCT.ION;WORK: ELECTRICAL, PLUMBING AND DA MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATION'S. c I FOUNDATIONS OR'FOOTINGS. x2. B.R10R;TA)..COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE'OCCUPIED UNTIL ? + „--MEMBERS JIINSPEADY:.TO BEFORE FINAL INSPECTION HAS BEEN MADE.3 FIN A.L,eINSPE.CTION,�BEFORE. '� - - . yOCCUPANCY:: ,;k- - 'y�yJ OST THIS C ® SO IT• IS VISIBLE FROM STREET ' ,'BUILDING INSPECTION APPROVALS' PLUMBIN INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS fi <: t 2 as - 2 i Z �F b A 3$ _'. HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT ' OTHER L n BOARD OF HEALTH �, ��`r 5 S 2�fi• �ial �� �s ,. 5 ` WORK SHALL NOT PROCEED UNTIL THE INSPEC- PERMIT W!L L BECOME NULL AND VOID.I F CONSTRUCTION INSPECTIONS INDICATED ON THIS CARD CAN BE TOR HAS APPROVED-THE VAR IUUUS STAGES OF WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE ARRANGED FOR BY TELEPHQNE OR WRITTEN :'CONSTRUCTION < I' PERMIT 15 ISSUED AS.,NOTED ABOVE.'" h NOTIFICATION. i r S • f� 4�- • . off' 10 �� 0 • Cv of O,Ec�L �RJ�� QC /Q ooEQ .-f- 9 7,9) CERTIFIED PLOT PLAN _ LOCATION: C� FOR: :5000.o4JS Q�!/�Gai��'ylL<<�It "� SCALE:/''=30' DATE:�y"fE tZ .9e7 REFERENCE: Q e-= ,��7- z d i9,s s/I/o p�✓ I CERTIFYTOTHE BEST•OF MY KNOWLEDGE AND BELIEF FROM INFORMATION ACQ T H A T T H SHOWN ON THIS PLAN IS L ATE D N -H-E GROUND AS SHOWN l EON. OF ,DOSEP96 AT R FE SSI O N AL L SURVEYOR M. MONAHAN,JFL � J. M. MONAHAN, JR. & ASSOCIATES No. 13M PROFESSIONAL LAND SURVEYORS & ENGINEERS -ISTEvyp� TOWNE PLAZA - 900 ROUTE 134 SOUTH DENN.IS, MA. 02660 SUR J.N: �7-SS' - =