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4� VMS Town of Barnstable *Permit
Expires 6 months from issue date
Regulat 2`! 0 .jg , Fee
'* anxrrsrABLE, t
M"M& Richard V.Scali,Director
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BuildingDivision 12016
Tom Perry,CBO IlUui 4%MR Commi�sioner�TqBLE
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 '{ Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Map/parcel Number Not Valid without Red X-Press Imprint
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Property Address 3 lX �i U Q. U(,
Residential Value of Work$ i��•°a Minimum fee of$35.00 for work under$6000.00
Owner's Name&.Address. D) P,
Contractor's Name .J4 Ko V fCM Telephone Number MY 36o,27 YCj
Home Improvement Contractor License#(if applicable) 1 o1 8 Email: -to t^+
Construction Supervisor's License#(if applicable) 16 U00-0
6Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
I am the Homeowner
I have Worker's Compensation Insurance
Insurance Company Name qd l&&L) ,
Workman's Comp.Policy# V Z UQG6 S Q 22
Copy of Insurance Compliance Certificate musi accompany each permit.
Permit Request(check box)
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
❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows
#of doors:
❑ 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 the Home Improvement Contractors License&Construction Supervisors License is
required.
SIGNATURE:
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• HAR1Jl3rA81a3, t '
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A1� 'Town of Barnstable
Regulatory Services .
Richard V.Scali,Director
Building Division
Thomas Perry,CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601 w ,
www.town.barnstable.ma,us
Office: 508862-4038 Fax: 508-790-6236
Property 0"e' r:Must
Complete and Sign This Section
. If Using,A Builder `
1
I, Awe LAW&CA as Owner of the subject property
hereby authorize AdOAAI- ✓/d W6 J7 4V'&A to act on my behalf,
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in all matters relative to work authorized by this building permit application for: . ,
(Address of Job m .
- ��C�---�� Q-ram- .`�... • �' `7 � ;
gnature of Owner Date
Print Name ,
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the
reverse side.
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AG R& CERTIFICATE OF LIABILITY INSURANCE
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THIS CERTIFICATE 15 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(Sj,AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: B the certificate holder Is an ADDITIONAL INSURED,the poticy(lea)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and condition&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 ondarsement(s). -
P140DUCER C—TAor Anne Sanzo
HUB INTERNATIONAL NEW ENGLAND LLC �
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ooa annu.wnzo@hubfnternatonal.com
265 ORLEANS RD. '...
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COVERAGES CERTIFICATE NUMBER:36336 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 WIVE BEEN REDUCED BY PAID CLAIMS.
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Workers'Compensation benefits YA be paid to Massachusetts amployoss only.Pursuant to Endorsement VIC 20 03 OB B,no authorization Is given lo pay
claims for benefits to employees in states other than Massachusetts ifthe Insured hires,or has hired those employees outside of Massachusetts.
Thiscertificate of insurance shows(he policy in force anlhe date that this certificate was issued(Unless the expiration date on the above policy precedes the
issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass.govAwdAgmkors-a mponsationlevoubigationst.
CERT1'FICA TE HOLDER CANOULAT10N
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIATION DATE THEREOF, NOYC£ WILL BE DELIVERED IN
HUB[nit=malional NE LLC ` . ACCORDANCE WITH THg POLICY PROM ION L
285 Orleans Road - --
AU7IORDEDRFPPEBENTATIYE
N Chatham MA 02650 �'- `:( ( '
Daniel M.Cr,#*,CPCU.Vice President-Residual Market-WCRISMA
0 129.2014 ACORDCORPORATION.AN rights reserved.
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piration:.__3r2119%20.17 LLC 10 Park Plaza-Suite 5170
r1 Boston,NIA 02116 * -
ROOFING AND SIDING Q1 CA SOD,LLC.
DZMITRY LABKOVIC1 " - -
68 WINSLOW GRAY RD.-
W.YARMOUTH, MA 02673-'-`—
Undersecretary Not valid witho uy
gnature
QyofTNEro�y TOWN OF BARNSTABLE
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BARNSTADLE, i
V MPY
9 a' BUILDING INSPECTOR
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APPLICATION FOR PERMIT TO ...� ..... ..... ........ ...... ........ .... ........................... .......... ..
TYPE OF CONSTRUCTION 41. .... ... ... . .. .k .... � .. .:. .... a �✓ ��j
........ ...... ......... .............19..�1..
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
4 Location .. .. ..........�C.�.�. .. ........ :�.........a`.!��......... h .... ........�
ProposedUse b' `+wf. ... �y . . ............................................................................. .................................. .....
Zoning District ... (a......... ....................................................Fire District .. ................ i/� �✓!�..7
Name of Owner .. ............................1 ` ..... . ��L.... :......... .............:....
.......Address ....................................
Nameof Builder ....................................................................Address ....................................................................................
Nameof Architect ..................................................................Address ....................................................................................
Numberof Rooms .... ..........................................................Foundation P. .......C�.. .... ................................
Exteri( r4 '�...¢.:....... . .1�. �iGX............................Roofing ..... ............... .....................................
J
Floors ...................................................................Interior .... .... . k� ......................................
Heatinga14 ......�`....1.7... .......................................Plumbing ..... ......................................................................
Fireplace .... �.......................................................................Approximate Cost ...... t ...C)d
.......................................
Difinitive Plan Approved by Planning Board ---------------_---------------19________. /0 .9
Diagram of Lot and Building with Dimensionse`, �"
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I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
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Name �.�..............".......1,/1.1. ...........
Dacey, William E. Jr. j
DE-C 31 1971 !�
No .... 373 ., Permit for :..••one story
1.......8
single family dwelling l
Location19.a�....Knotty. Pine Lane
.....................Centerville.................................
Owner William Er.DaceyL Jr, ......
Type of Construction ......... X'ame......................
Plot ............................ Lot ........&...................
Permit Granted .......
April 7 ....19 71
......................
Date of Inspection ,4�.... G 19 7/ Nl�_.'I I '
Date Completed ......................................19
r) PERMIT REFUSED
.............................................. .............. 19
............................................................................... ,
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...............................................................................
ti
Approved ................................................ 19
...............................................................................