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i
ALTERNATIVE
WEATHERIZATION
Date: l A 9�z BUILDING pEP
T.
DEC 31 1 2020
TOWN OF 0.4
Town of Barnstable RNSTAOLE al
200 Main St.
Hyannis, MA 02601
Re:Permit#6— AD — � &,41&-vi
Ile,
Villa e:"
g
The insulation/weatherization work at 42 P 3r/L;�ffL— _
has been completed in accordance with 780CMR.
Regards, f
Timothy Cabral,
President
CSL-105454
C ..
58 DICKINSON STREET FALL RIVER,MA 02721 (508) 567-4240 ALTERNATIVEWEATHERIZATION@GMAIL.COM
I
pFt > Town.of.Barmtable *Permi QI3
p� Expires 6 months u jo
Regulatory Services Fee
BAMSTnBLE,
MAW
�E 9- Thomas F.Geiler,Director , 13
Bull din g Division
�l
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis;MA 02601
www.town.baimstable.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 � � � �
Property Address -CD 9(_'QrCat LaI� ��e: �n99
Residential Value of Work 3}a r Minimum fee of$35.00 for work under$6000.00'
Owner's Name&Address('Y1�6 ►�r
rtCkr'CI r
e Yl 1-e.
Sprink e ome improvement
Contractor's Name 199 Barnstable Road, Hyannis MA 02601 Telephone Number 508 775-1778 Ext,.10,
Home Improvement Contractor License#(if applicable) 103757
_Construction Supervisor's License#(if applicable)
CS-006643
]Workman's Compensation Insurance
'' nes ® 1 .
Check one: Pr'7
El am a sole proprietor
❑ I am the Homeowner APR l
® I have Worker's Compensation Insurance 2 1013
Insurance Company Name A.I.M Mutual Insurance Co. ,`OVV
n
Workman's Comp.Policy# , 7004943012013 �STgQ(y�
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box) Yarmouth Transfer Station
Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
Re-side
#of doors
❑ Replacement Windows/doors/sliders.U-Value (maximum .35)#of windows
❑ Smoke/Carbon Monoxide detectors 4.floor plans marked with red S and inspections required.
Separate Electrical&.Fire Permits required.
*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 th a Improvement Contractors License&-Construction:Supervsors License is
1 f
SIGNATURE:
C:\Users\decollik\AppData\Local\MicrosoMWmdows\Temporary Internet Files\Content,Outlook\QRE6ZUBN\EXPRESS,doc
Revised 053012
r
4
NAM Town of Barnstable
Regulatory Services
Thomas F.Geller,Director
Building Division
Thomas Perry,CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038
Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
M iC" Coo vc-� t
as Owner of the subject property
hereby authorize Sprinkle Home Improvement to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Q Bria.rdac - lct C��I��r�G�e_ rvt►4
(Address of Job)
Signattife c3Own r Date
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the
reverse side.
C:\Users\decotlik\AppData\A=I\Microsoft\Windows\Temporary Intemet Files\Content.OudookMDV87AAZ\EXPRESS.dm
Revised 072110
' The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
' 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le0bly
Name (Business/Organization/Individual): Sprinkle Home Improvement
Address: 199 Barnstable Road
City/State/Zip: Hyannis, MA 02601 Phone#: 508 775-1778 Ext.10
Are you an employer?Check the appropriate box: Type of project(required):
1.a am a employer with 10-12 4.,❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7.•❑Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
workingfor me in an .capacity. employees and have workers'
Y P h'• ❑ Building addition
[No workers' comp.insurance comp. insurance.: 9. .
❑ We are a corp
oration oration and its 10.❑.Electrical repairs or additions
_ 5.
3.❑ I am a homeowner doing all work officers have exercised their 1 i.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12rof 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#I 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: A.I.M Mutual Insurance Co.
Policy#or Self ins.Lic.#: 7004943012013 Expiration Date: 1/01/2014
Job Site Address: tD cled,.W CCV1U_ City/State/Zip: CSi,4e"c. -e M.-H
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' a coverage verification.
I do hereby certi der Ins and ppenalti�es of perjury that the information provided above is true and correct.
Si nature: 1 — ? Date:
Phone#:
508 775-1778 Ext. 10
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
�. 212IX2012 11 : 39 : 11 AM 8740 ® 02/02
712/21/2012
MM/DD/YYY)
CERTIFICATE OF LIABILITY INSURANCE
THIB eE6t'PIlIq►TE IS ISSUED AS A MATTER Or INFORMATION ONLY AND COarERB NO RIGHTS UPON THE ceRTIrICATE HOLUZR. THIS cBRTIrICATE {
DOE: NOT ArTXRYATIVZLY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE ArrOBMW BY THE POLICIES BELOW. THIS cERSIrICATE OF
INSURANCE DOES NOT CONSTITUTE A CONTRACT HER 3031 THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE
CERTIIICATZ HOLDER. - - -
IMPORTANT: If the certificate holder to 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).
wDD°QA CONTACT
Bryden & Sullivan Ins Agency i rum Tax
Inc (A/C. N..
/C --
IL
88 ralmouth Road ADDRESS:
PRODUCE
Hyannis, MA 02601 CUSTOMER IDO.
INSUan(s) Ar RARDIR COWRARC S ruc R
xRSURED INSUaeu A: A.I.M.- Mutual Insurance Cc 3 3-7 -
Sprinkle Rcme Improvement Inc
xrsvaEa.:
199 Barnstable Road INSURER C: -- — - —
Hyannis, MA 02601 INSURER D:
Irsumm E: -
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
Tale IS TO czaTIFY THAT THE toLlCas Or ZSURANCE I"M BELOW NAVB HER zssvm TO=z aS=ES NAMED ABOVE NOR Tas.VOLXCY PERIOD raDLCATam.
N*Twrm R%mxltG ANY RNO u==T, MW OR CONDITLON Or ANY CONWACT OR OTHER DOCM=T Wrm RNWMCT TO WHICH THIS CXRTIr==N01Y BE ISSMM OR MAY
PERM=' Tax INSUR"ex ArrORDm BY Two ROLM= Dnscaxe D HNRN3 IS sV8jxcT TV ALL Tax "=a, NSCLUSZONS AND CONDITIONS Or SUCH POLIc=S. Lnms j SHOIM
MAY BAVR SEEN! REDUCED BY PAID M--. -
POLICY MMSER POLICY Err POLICY R LAPS
Lu TYPa Or XISVRANCX <nuAAJrr+rr �cuewn+Tr, -
GaBAL LZABILXTY - ri"OCCURAECE s
�colaeacEw cerapw LxABILxn DaaQ TO RVITED
PRDIISEf IEw.000axcewoe) 0 —__
��CLAIM9 INDC �OCCYa I 1 IUD CEP (Ay owe MEwen) P
a I I PERSON c ASP Iwax D --
DMDAL iDDDCDATC
O¢R'L AODRCDAT¢LIMIT 1,111101 ER:
❑POLICT []PROJECT❑LOC - - PRODUCTS- COIN/OP ARR 0
' S
COOED SISOLE LIMIT
AUMI)B=LIABILITY .. (ee f.denel N
❑ANY AUTO BODILY IBM= (Der pvasaw)- I
❑ALL dtNeD AVT09 - - - ----
' OODILY IlQJOS(per-eeeibat) R
❑SCHCDUL¢D AUTOS -
eROPOITY DJ•OA$
- ❑BIPED AUTOS - ! lPei epClOa,t1 0 .
[NON-COW CD AUTOS
CIUMORMA LLAB O OCCUR EACH OCCUaRCNCC 0 !
I []SZCeSS LEAD CLAM MADC - i AOOAEGATE
❑DEDUCTIBLE
EIRETEOTION S
1C lTNlp- MTIF :
NORaRs CONVERSATION
AND zwx4Yaa LIABILITY -THE PROPRIETOR/PARTNERS/ _ E.L. CACH'ACCIDENT 0 - 500,000
EXECUTIVE OFFICERS ARE
A
® _ncl ❑ excl 7004943012013 E.L. DISEASE POLICY LIMIT. a 500,000
01/01/2013 01/01/2014
E.L. DISEASE -CA 13MOVEZ R 500,000
cmrclTs DESCRIPTION Or OPnurxots OR -
1 .
CERTIFICATE HOLDER' CANCELLATION ---
CERTAINTEED,5 STAR•CONTRACTOR SNOWED ANY or THB A80VR 6Nst3tI8NG P0LIC1aa 8i CArCNLLm BEFORE TH8 --
�.°ESPIRATION DATE TENR=F, SOTX=W= RN.DNLIVMW IN ACCORDANCE-SPIT% THE
P.O.B OS 20126 POLICY PROVISIONS.
H , P - AUTHORIZED REPRESEUTAT IK "-
A 180021 �
'�7
9351 r
I
Unrestricted -Buildings of any use group which
contain less than 35.000 cubic feet(991m;)of Massachusetts - Department of Public Safety
enclosed space.
Board of Building Regulations and Standards
Conctructtnn Supcn i%sir
License: CS-006643
BRAD K SPRINKI-E
I"L 3TWWPS LAN'
Failure to _
Possess a current edition of the Massachusetts W BARNSTABLE MA. ,
State Building Code is cause for revocation of this license.
For DPS Licensinginform
ation
visit:
w ww.Mass. ,GovJOPS _..
Zxpirat+o^
Commissioner 10/08/2013
Office of Consumer Affairs&Business Regalafion License or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
1' .., istration: 103757 Type: Office of Consumer Affairs and Business Regulation
::expiration: 7/9/2014 Private Corporatior, 10 Park Plaza-Suite 5170
SPRINKLE HOME IMPROVEMENT,INC. Boston,MA 02116
Brad Sprinkle
199 Barnstable Rd.
Hyannis,MA 02601
Undersecretary Not valid witho signature
%Ckr 28,13 09:18a Michael Conrad 508-790-7884 p.1
L
TOW'1 0� :tfilTR
rdy Town of Barnstable 7013 mAR 28 AM 9, 25
0
Regulatory Services
suss.
Thomas F_Geiler,Director
f26ygL Building Division
'Tom Perry,Building Commissioner ® � ��j
200 Main Street,Hyanais,MA 02601
`vwwaown.h arnstabl e_ma.us
Office: 509-962-403 9 Fax: 50 9-790-623 0
Property Owner Must
Complete and Sign This .Section
If Using A Builder
I, as Owner of the subject property
berebyautborize Sprinkle Home Improvement to act on mybehaIf,
in all matters relative to work authorized by this binding permit application for.
(Address of Job)
02
Signature of Owner Date
Print Name
If Property Owner is applying for permit please complete the
Homeowners License Exempdon Form on the reverse side.
- n-Ff1RM:f1WNF.APFRM7.CC1n1J -
--� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
I O
Map 3LOq Parcel l' Application#
.4Health Division.
onservation Division' Permit#
Tax Collector e- Date Issued
Treasurer Application Fee pp
y
Planning Dept. hermit Fee
..Date Definitive Plan Approved by Planning Board p 5
T �
Historic-OKH Preservation/Hyannis 1 Ej,-
Project Street Address
Village
Owner Address
CD
Telephone
Permit Request
.0�,�04 �
Square feet: 1st floor:existing proposed 2nd floor:existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) ~
Age of Existing Structure Historic House: ❑Yes o On Old King's Highway: ❑Yes U440
Basement Type: ❑Full ❑Crawl ❑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: ❑Gas ❑Oil ❑Electric ❑Other
Central Air: U. Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No
Detached garage:❑existing Cl 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 rD�
Name 2���5� � 1' o L Telephone Number D
Address SO� G ': ��,�9� License#
C• ./�. , ��� �= Home Improvement Contractor#
Worker's Compensation#NG, _41S
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO
SIGNATURE DATE �` lf�
FOR OFFICIAL USE ONLY
PERMIT NO.
DATE ISSUED " t
MAP/PARCEL NO. 'y r
ADDRESS .°; VILLAGE
OWNER
r
f
DATE OF INSPECTION:
FOUNDATION
s- I
i
FRAME
INSULATION
� •Y: r
FIREPLACE
# ELECTRICAL: ROUGH FINAL
r _ -
PLUMBING: ROUGH FINAL r
GAS: ROUGH FINAL f
FINAL BUILDING F l
DATE CLOSED OUT
ASSOCIATION PLAN NO. - ,
The Commonwealth of Massachusetts -
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Conipensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ' Please Print Legibly
Name (Business/Organization/Individual): dllmz
Address: YW a a �/ o
City/State/Zip: }/�i�// �v Phone#: ,�5dX �
Ar ,6u an employer? Check the appropriate box: Type of project(requireed):
LEI I am a employer with 4. ❑ I am a general contractor and I 6 New construction
employees(full and/or part time).* have hired the sub-contractors ❑
2.❑ I am a sole proprietor or partner- listed on'the attached sheet t y ❑ Remodeling
ship and have no employees These sub-contractors have 8: ❑ Demolition
working for mein any capacity- workers' comp.,insurance. 9. ❑ Building addition
[No workers' comp:insurance 5• ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11-❑ Plnmbing repairs or additions
myself.[No workers' comp, c. 152,§1(4),and we have no 12.❑ Roof 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'
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 subcontractors and their workers'comp.policy information.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name: L
Policy#or Self Ms.Lic.#: Expiration Date:
Job Site Address: ,� � /���� City/State/Zip:C VZ� 2 j - ems�; /f �
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration da$ej
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500,.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and en Itie of perju hat the information provided above is true and correct
Si afar Date:
Phone#; 92 -
'Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority (circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing inspector
6.Other
Contact Person: Phone#:
nf®rmati®n and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. . ;
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the .
receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states`Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-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 pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would lie 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. 1617-727-4900 ext 406 or 1-577-MASSAFE
Fax#' 617-727-7749
Revised 5-26-05
WWW.III2SS.gt)V/di.a
Town of Barnstable
P .
Regulatory Services
" B N ss M 4 Thomas F.Geiler,Director
Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
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.
Type.of Work: % �/1�dCG� Gt// C'r - Estimated Cost
Address of Work:
Owner's Name:
Date of Application:
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 BULLING 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 a owner:
ate Contractor Name Registration No.
OR
Date Owner's Name
Q:fonw:hommffidav
Town of Barnstable
Regulatory Services
MMAMSr"B'Y.' Thomas F.Geiler,Director
pTfO�. A Building Division.
Tom Perry, Building Commissioner ,.,.- ,.. .. ..
200 Main Street, H.yannis,MA b2601
www.town.barnstable.ma.us
Office: 508-862-4038 - _ ___ - Fax: 508-790-6230
Property Owner Must
Complete and Sign.This Section--
If Using A Builder
as Owner of the subject property
hereby authorize o M I t--c-. to act on my behalf,
in all matters relative to work authorized by this building permit application for:
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(Address of J b)
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S Date
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Print Name
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QTORMS:OwNERPERMISSION
Board of Builder
b. ons and Standards License or registr
E IAO NT CONT ation valid for individul use only
TOR before the expiration date.•If found return to:'
Re ist 10649 Board of Building Regulations and Standards
r /2006 One Ashburton Place Rm 1301
zi !dual Boston,Ma.02108
THOMAS A.HILT
THOMAS HILCH
82 Old Chatham Ro t HARWICH,MA 02fi45
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