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8 Town of Barnstable *Permit#
r 6 months from issue dafe
Building Department �eMAM w
�
b
-01 Brian Florence CBO
�srrsrnsLE.
ft_, ,� Building Commissioner
' 10
Ep MAr #j 200 Main Street,Hyannis,MA 02601
� ww"w:town.bamstable.ma.us
,Office. 508=86P4''�8 Fax. 508-790-6230
EXPRESS MAI( APRPLICATION - RESIDENTIAL ONLY
j `K
r n ok Valid without Red X-Press Imprint
Map/parcel Numb r
Property Address /Os
Residential Value of Work$ 8 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address r o Cts� S �l�tZ�t 7 v S'
Contractor's Name VGt �[� s l(1 C.l7(��' Telephone Number 7?el
Home Improvement Contractor License#(if applicable)&j S0e45 Email: QGt f a606s 78(0 00• co'.
Construction Supervisor's License#(if applicable)CS-09/O� Q
❑Workman's Compensation Insurance
Check one:
.124_am a sole proprietor
❑ I am the Homeowner
.E"I-.have Worker's:Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit R quest(check box) D
fss9.,L Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to /,ha
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
ZOV Re-side c�
Replacement Windows/doors/sliders.U-Value a aCJ (maximum.32)#of windows S3
#of doors:
*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
ed.
SIGNATURE:
C:\Users\decolhk\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\9NNOKXYW\RESIDENTILONLYEXPRESS.doc
09/26/17
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 Legibly
Name(Business/Organization/Individual): U I C , r,k-17— Q,(D bS
Address: ? Q, e>0 X 30
City/State/Zip: - M06 � o 0�07�Phone#: ��y" 3S3" 85�
(V
Are you an employer?Check the appropriate bog: Type of project(required):
1. I am a employer with 4. I am a general contractor and I
.employees(full and/or part-time).* have hired the sub-contractors 6. New construction
2. I a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
s •p and have no employees These sub-contractors have 8. Demolition
workingfor me in an capacity. employees and have workers'
Y p tY• 9. Building addition
[No workers' comp.insurance comp.insurance.$
required.] 5. We are a corporation and its 10. Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. Roof repairs
insurance required.]t c. 152, §1(4),and we have no
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.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify der he p and penalties of perjury that the information provided above is true and correct
Signature: Date: 0/9
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):.
1.Board of Health 2:Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
i.ew�.a.eeuacc.ca ucNaeeuceu�+e raven.uaacap _
Boarcf.of Building Regulations an&Standards
License: CS-081040
Construction Supervisor ,'.
PATRICK H JACOBS
iow
28 WHITTIER OR MR
DENNIS MA 02638 a
Expiration
CoMmissione.r 04/04/2018
;$.
4Qftice of Coosamer Affaers&Business Regulahou
OME IMPROVEMENT CONTRACTOR j
�• eg�strat.on .�165888 � ;YPe ,,;
Expirattons 4/� DBA
b*P JAC08S CtJSTOyCyIC� R-sf`Nj
S REMOfJELING
PATRICK'JACOBS`"- v�3� `.c�'l ' r
7
DENNIS MA 0263$ "z h Uudei'secrefary `
0
February 6, 2018
VIA: FedEx&Email
Town of Barnstable
Attn: Building Department
200 Main Street
Hyannis, MA 02601
Re: 105 Lake Elizabeth Drive Craigville, MA
Gentlemen,
Please be advised that we have authorized Pat Jacobs of P.Jacobs Custom Carpentry&Remodeling(P.O.
Box 344 Yarmouthport, MA 02675)to act as our Agent and General Contractor in regards to repairs and
renovations being done at our Property located at 105 Lake Elizabeth Drive in Craigville.
We anticipate Pat replacing the roof,siding,windows and trim on the house.
Please let me know if there is anything else you need from us in this regard.
We look forward to working with you and please let us know if there are ever any issues.
Sincerely,
Bradley W.Jordan
17 Burgevin St
Kingston, NY 12401
845-590-3040
Cc: Patlacobs
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y w \: Y 'ny F. d K F R y f
r x aEXPIRATtON Np1IFICAtION �� 34` �' �#t r y x s
( HOMEOWNERS POLICY-PR 0RAM '
a
fTHI91S-Np7 A eINOER OF ttJSUitANCEr f.. F r
e
MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING A88OCIATlON s ; i`
z a # ti^ z', s z u:, .- a ,n +.v. a �' y�e t ; n
;, TWO CBntOf Pieta,Stl8tOn,Massachueotts 021081804 3 ,,,n,, 4�r c,l aS �,,
f ks4b u•�°- 3 t`� FTJ c - R' x kwa - 9 z �, .c 'i .,4
(617)723 3800 (800)397�8108
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3 .I ,rl" T_ 1 4 Y I. b �� z
POLICY NUMBER , J fi`Y EXPIRATION DATE ' " ii
1298458-4 y p(/�(� y
11.
4 ay `' `''Y ,Y•.1 Sg dY+ f 4. v, !'OG/GM11 c 7 f ,� ' 4 -.k L 2
E '4" j"k Yi r Y� y ,a�. 1 zi.'r r r -ry r- =-y.rts.4,--- a��'`('t`z�r c �k r.K
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_NAMED INSURED-A MAILING ADDRESS;' r p p l x a
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BRAbLEY JORDAN AND TODD JORbAN , PIKE INS AGCY INC -
. BURGEYIN STREET S rj K Fad e s 3 p BOX$743 Y t i 4 ;.; ^ z. a
KINGSTON NY 12401s k $ORI EASS MA .02853
The pai villl a re at 12'01 A M standard Ume,an the exp�ra0ort date shown and wilt npt autpMW6ily b4 renewed Tohren�w your m$uran e z �k4� z
. ._ .
( return the tear-otf porfiion of the t2enewal Offer/Premium Imrorce with either the Premium Due or Mrmmum Due . a "�
P r r �% ,�x
THE RESIDENCE PREMISES COVERED'BY THE POLICY IS LOCATED AT '" i,,�"� '�* w c �i �t A-- 1
s `w 'r .
103 LAKE ELIZABETH DRIVE,CENTERVILLE,MA 02632 ,
Y SM! �, `4,,,,, 4.,vr s"Y`a}eA �, Y 1}_`, di.,08I i.-fi tirR L k L ,ss #Y- y .+` r.
This offer applies to the", idenee Pramrsea:Coverage>is provided where a Premium or Umit of Liability!s shown fof the CovErag� ` —I s
,;v & a �i .k#.r^ f `p d r 9 r +, s,4 n x , j f �R�,S L. `�i, 'r _ ib
SECTION i COVERAGES i 4 x a,�, ,, � LIMIT OF LIABILITY ,, - � % PREMIUM
t { ;Y, ''iu'+F '�'Y,l r4.43 9 S A i l X '1"5 l T 4 L hi 41 'i +Y i $2}NI V
k DWelfing': fi y r r $476,OOQ � .I a ' a, f `.
{ x g u
,,, S ,B r .Otl{ax:+fitfllCh)fe3' t: ' 't% ~c '"1a s •rt' K�,r *' w ' :.' f'' r4^�a.&x'�' <`�'k`vc d$47 800 "'?, E. '^` Y ' ', ,s-, .°
r t.. „ `4/`n� '�,, ,i- ,xara .h "gjyi > >£+/ t r r«a k'vt '*' rr Y f, m y.-"` b �: 'U 4'�"}�k{
YC� Personal Property n � k Y $238,004 F
!J "-': �f�ffei°s"`� w,yv. 4ti vu h 5,r.agi,;.4 p+"' ty, A a:t`�f�r a L } ,., k�9 �� %l z S .�, rkpY y, Je ,ar ds}51 t -> 3{r"Y;� Y 'r ,�'' w= :
x .fps a C , k, .1;x $142r800 a Y �r> rti r S s't " t t :
SECTION ifCOYERAGES y, g
s; +! �y •r` �,k 'i is f r a: R, �, 5 - c r b
;,k.,.:•. .� d `_, : h e4i g _ 1. ? ?t ,r�k�fu s .. r*"Ey�>h;t�x'�`� 4„ ..!"�rx �;r.,'ql�.� ``t5 ,OI K-aU 3.�' ,1 k rr"s �.,s x ,
E Personal laabif"rty each occurrence ' ` _ $500,000 ` S24
\ s v w I .'fix ' ��-, #�'IL. rr s $1,000`" N,�, L' � % t'n �',�" _4
F Medical P ants to Others each rson° ! r
*• � TOTALBASE:PREMIUM£ $2,594
",DEDUCTIBt E SECTION I $2500 t�CCEPT WINDSTORM AND HAIL$9,520(2%of Coverage A Limit) ' r , ks� 3x ;, # t
s L - x .a i sa'rz t, x, "p y'°f" x1- i, .�., `*.- q '`'z",¢ {c '.z.`, =w
w RM&ENDORSEMENTS made part of this policy at the tl►ne of issue t_ a� � r "!
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HO 00 l 3 10100 6PECIAL�FOR(�1 t ry KY `_ ..,, t'�: A
"HO012'0h ; /0f SPECIALPROVISIONS MASSACHUSETTSi,t t � r+ � yi 7 1y +"�2 �Y `'
HO 0312' 10%00�WINt7STORM Oft HAIL%DEDUC fIBLE s` z � �, `� ��' r .r �$8S1" .:
w ,�' r,,, � a *'i;, ++ry .0 st z ,t„,�Pg a-Y 4 `�- '1 s& ,^a. a +, - ,
`f{0 04.19' ttI/00'/PR�•E1�1115 S Aflre[{kRM OR FIRE PRO7ECTfAN SYSTEM .i n < , m r w ' �I- - ":�_ r " r' " -359
24.�'a Credit,,. 'F`��',"z..''40"�.,*4p..th`y3.''7 .'.r ,..�q'-h, xt,. 's";h r., .;,."r"• d. x„j� `+L. 4 j„,�. Y s-k a,`n 1, F 4 w.daix,'d`a �3 n {✓'.. _
HO 04 27 4/02 'IWTED FUNnGtgYlt,WET OR DRY RFJ FOR BACTERIA CdVERAGE_r " %, "#` �.. j
as �,.' .3sK r:,1r 'a�elt�tln l lJ$1dr1n3U 4 a .z �z s7> z5„,'`y',`.�',7r�,x i�'p' ry'4�a'� r+a{,+7"�c? "r+zh :,y�..'' .zR- e tt it r.. 'z .s i r .,
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�� HO 04 90" 14/00" PERSONAL pROPERTY,REPiAC1=MENT COST LOSs�SETTLEMENT ;� t } Ads $386 `.
< �, :+ ,p, #,' .fl axe ¢� :.s - n` + `'F, a r -.-III
Fi0 04 08 16/60 NO SECTION II{LIABILITY FOR ii(3PE DY CARE COVERAGES axe # k
NO 1810' 1/09 WATER EXCLl1SI0N ENDORSEMENT# :'
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iATI IMPRNAATfON; 1 FAMILY ' Frame :. ?ERRlTORY 37 PROTECTION y
a a m $* aF'ndb'U � t :,:M fis .i^ S : �� H 2 .r -"� X:.
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S " a M,. 2 `. � z� s m
s
Town of Barnstable Building
�P, s
ot`This' rx .�
'" Posted Until Final,Inspection HasBeen Made 3z a � •< , ,i639. ed' -• a i .. a r, (�a,•.. as ;;<
° Where a Certificate.,of Occu ancy s�Re,• red,such Buil,d�ng shall Notbe Oa cupped until a Flnal,anspect�on has beenarnade
Permit
Permit No. B-18-530 Applicant Name: P.JACOBS CUSTOM CARPENTRY& REMODELING Approvals
Date Issued: 02/23/2018 Current Use: Structure
Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 08/23/2018 Foundation:
Location: 105 LAKE ELIZABETH DRIVE,CENTERVILLE Map/Lot 226 051 Zoning District: CBDCV Sheathing:
_.
Owner on Record: HERZOG, ROBERT&ELIZABETH ,Contractor,Name ,,P.JACOBS CUSTOM CARPENTRY Framing: 1
&REMODELING
Address: 61 LOUNSBURY PLACE 2
. Contractor License �165888
KINGSTON, NY 12401 a w Chimney:
Description: Re-Roof(stripping old shingles) Re-side Replacement Windows(55) Est Protect Cost: $85,000.00
U-Value.28. c Permit Fee: $433.50
Insulation:
Project Review Req: Femme Paid $433.50 Final:
VII� 77
` Dater 2/23/2018
Plumbing/Gas
'
Ruh Plumbing:o g
IMF a
m �.. Final Plumbing:
Building Official
Rough Gas:
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after ssuance.
" Final Gas:
All work authorized by this permit shall conform to the approved application and the approved construction documen8' r which this permit has been granted.
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by laws,and codes.
This permit shall be displayed in a location clearly visible from access streetor oad and shall be°maintained open for public inspection for the entire duration of the Electrical
work until the completion of the same. Service:
_ g
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are providLis permit. Rough:
Minimum of Five Call Inspections Required for All Construction Work:,".." �•• .
1.Foundation or Footing Final:
2.Sheathing Inspection
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Low Voltage Rough:
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection
5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Final:
6.Insulation
7.Final Inspection before Occupancy Health
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final:
Work shall not proceed until the Inspector has approved the various stages of construction.
Fire Department
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final:
Building plans are to be available on site
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT
i
01/.1,211~�95` 11;3b ' °+91*508!906230 PAGE 01
. i ��I �low
Town of B �-
�xnstable `Permit# r7
RegulatoryNAM Services �►6�..�.��AWW d,*
as
�a Thom F Geiler,Director Fee 8�
Building Division
Tom P"R Bnadt Commissioner
Office: 5o9-862.4038 200 Main Street; Hyam b,MA 02601 Del 1 /r
Fax: 508-790-6230 Tp 1V Z004
/ ZAI I - ID N'I?AI, 1VMap/parc0l NumberNoMAMMioru RsdX P��B linp�int
5i
ORmIderfidAWKY071-
Value of Work
Mtnlmnm fee oi-SZs.00 for work ender
4wmr's Name&I Address $6000.00
i;4,o
/0✓� CO e Z z,oG Q,� e� a2__Zz
Contractor's Nano �
Home Ioyamant Telephone Number A
Contietetor License#(if applicable)
Construction supervisor's Liceme#(if applicable)
]Worlobaa
Sean �=
'S Comp Qon j
Check one:
am a Sole proprietor
am the Homeowner
I have W-kees Compo mv.Manx
ostaance C=WW Name
lorkman's tom,Policy#
'opY of muranee CompUance CettlUcate'mnst be on file.
mWt Repast(check boot)
) Re Wof(Stripping old ehhWes) All
�nst<uct<on debris WO be taken tor�� �'r /
❑Re
roof(not
"PP.4 Goingover— egg laYM ofrood
4 R"de
Replacement Windows. U•Value
*Whwc teVind: Ltuenes of t&pmit dose not eft"time�Ss other toavII d
eP��t i•a Hinxic.Comern*n,etc.
H�oPai'tY O�nntaam amentt�Property Owner Letter of Perndon.
Cepactors License is required.
tature
:m:e�pmtra
�000
f 01/12/1995 21:30 915087906230
PAGE 02
Town of Barnstable
q
Regulatory Services
+ha a Thom F.Geiler,Director
Building Division
Tom p
erry, Bnildin
20p M _ g C omm�sioner .
a�Streek Hyannis,MA 02601
www.tMi.barnstable.ms.us
Off'": 508.862-4038
Fax: 508-790-6230
J. Property Owner Must
�mplete and Sign This Section
If Using A Builder
�, � // as Owner of the sub'ect m
heiebyauthori2e - � p ��'
to act on rw behalf,
is all matters relative to work aut6orized by this b
ey
_ �g permit application for,
(Address of Job
Signature o
r
Date
Pri t Name
Q!FOI m;OWNMWthWSroN ,
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
�P ,
Map 2� ' Parcel drr✓ .- Permit#
Health Division �,,,,.m��. ar- � S�sbr.,.� D� f Date Issued l�-,;?Cod
Conservation Division Fee X2,�- zic)
Tax Collector '
Treasurer
Planning Dept.
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis
Project Street Address OS- pk
Village
/ Z 4 �rr�T
Owner Address ,ei .
Telephone �� 332-: 6300
Permit Request ✓► , tr UJ A-t,L g +
Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new
Estimated Project Cost AZy ' Zoning District Flood Plain Groundwater Overlay
-Construction Type-1 CM c�
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
k
Dwelling Type: Single Family Q1- Two Family' ❑ Multi-Family(#units)
Age of Existing Structure Historic House: ❑Yes @�Ko On Old King's Highway: ❑Yes ❑No
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
umber of Bedrooms: existing new
Total Room Count(not including baths): existing new First Floor Room Count
V `
Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other lye/V&-
Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No
Detached garage:❑existing ❑new size Pool: ❑existing ❑new size Barn:❑existing ❑new size
Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review#
Current Use Proposed Use
BUILDER INFORMATION
Name /2O r2-® ccr..J Telephone Number
Address t f' d ' - "J License# lr)&
Cni (6Y2-U l U C Home Improvement Contractor#
Worker's Compensation# O)C`t-0 Zf- 6-3 73
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WIL BE TAKEN TO
po
SIGNATURE DATE _ �Z GfJ��
FOR OFFICIAL USE ONLY -
.. �ZMIT NO. ; ..
DATE ISSUED 9" • r
MAP/PARCEL NO.
ADDRESS .,: 'VILLAGE
OWNER • � - j.. t _ �
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION C -
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL '
FINAL BUILDING
DATE CLOSED OUT '
ASSOCIATION PLAN NO.
: . . = The Town of Barnstable
Department of Health Safety and Environmental Services
rug►' Building Division
S
367 Main Street,Hyannis MA 02601
Office: 508-8624038 Ralph Crossen
Fax: 509-790-6230 Building Commissioner
Permit no. ;
Date
I
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMHH 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: �� Estimated Cost
Address of Work: [ �� ( 6�-� �L�zi���/�-► '�d�
Owner's Name:
' Date of Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
C)Job Under S1,000
Building not owner-occupied
Owner pulling own permit S
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner:
Date Contra or Name Registration No.
f
,;r r OR K
Date Owner's Name
t .Y,
q:forms:Affidav
— Department of InduS&W Accidents
_ 600 Washington Street
Boston,Mass. 02111
Workers' Com ation Insurance davit
INNS
e:
ch
city
❑ I am a homeowm IxsfOzming all wodc mysWL
----------
lam sole star and have no One woddn is
oa this'ob.
I am an emplworkers oa for my
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HOME IMPROVEMENT CONTRACTOR- !.
s. Registration 126560 f
Type INDIVIDUAL ,
Expiration 06/21/00
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ALBERT R. BROWN
34 HORATIO LN
( `o HPfERVILLE MA 02632
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DEPARTMENT OF PUBLIC SAFETY
C.ONSTRUTIVN_SUPERVISOR LICENSE
Expires:
Resfirt
ALBERT R BROUN
34 HORATIO LN
CENTERVILLE._NA 02632 `
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