Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0015 THISTLE DRIVE
r :. , . t r li J,I i h 6n eOt Uf ?, say use 'x HOT Map `1 � Parcei'.07,7,�O :; Date:, �� FEB 13 2614. Estimated Job:'Cost:$ t Permit Fee: $ ��_ 00 ®F BARNSTABLE. Plans Submitted: ' S NO. 'Plans Reviewed: YES NO Business License Applzcant License*- @ 071i'. BUsine;s�I,ri�forma Property(3wner/Job location Iuformaxion: Name: MAIU." Name: i street; P ja. x as cityiTown: �rn�1'" bwo city/Town::. UNIAMAV-.�or 606. .Telephone: 9,� Telephone: 0 � P.l oto I.ID:required/Copy of Photo I.I3. attached; YES NQ Staff Initial 3-1./IVY-1-urirrestncted IacenSe t J-2/16�-2=restzicted=to:dwellings 3-stones or less an commercial up.to l(},000 sq. ft./2-stories or less 2esident a ; 1-2 family Multi-family Condo!Townhouses Other �i Commercial: Qffice Retail Industrial Educational lF'ire Dep#.Approval Institutional: bt i; S/{(puare Fatage; under 10,000 sq. ft. v aver:10,000 sq.rft. Iu�nber of Sitates x~ X y. .. Sheet metal work t®iie coaripleted: New Work: Renovation: HVAC Metal Watershed Roofing Kitchen Exl aust.System. Metal Chimney 7.Vents Air`Balancing .. .. . 4 Provide detailed elescription of work to b''done. " . rc fir. .. - ;. .. , INSURANCE COVERAGE: I have a current ' insurance p6licy arias eguivalerit rhrch rr eei�t the r quirerraents tsf,M G.L th.112 Yes; N4,[. :, . , .> If you,have:checked ,indicate tale B Ol C4VE3r7g8 t3}f.C}tBCkin `f#t#S p�?PoprI to bq*i3�E4W '. r' r. S as A SiabiE'ity insurance.policy x C)tiier typef indemitityt;`( Bond OWNER'S INSURANCE WAIVER•,JAM aw.a.re that foie licensee . v,the insurance cuverage.required by Ghapter'•i 4of the Massachusetts General.Law+s,.and that my+;$lgnatur bn this;permit ppticaticn`.wai=#tai{svArequgirde� ent @c tc®Tab y. aOWner ; Aunt ❑` Signature of Owner or Ownees Agent _ a z 6y checking thls bb Fhereby certify that all of the details antl it fomsati®n i have.suhmitted(or ei rid)regarding this application ars trine'and accurate'to the best bf_r iy iinowleclge grid that ail sheet metal work and lnstallations performed under;the'permit issued for this application wait be in cornpiiance with all.pertinent;provlsl;srti of the M14ssachusetts Buildlhg Coale grid C#iapter 912 of tEie General Duct ins , ction re uiretl rior to:insulation.inib ation YES, .. #NO:'., :4 pa q p 'Dateiugmss t COIl3illeIli5:, i. T1. r p e. ] n " h ., d,]t�it;4YY�eCiflQi1? ,N4 1 Date,,` a C6mmenfs { TyW bf.License, 3y ®'Master i sale Q Master-RE'Sin£ted r , L «.; Y .itOJoumeyperson ' . ature ofLlcensea` permit# �Jourrieypersori Restricted t Li& se.Nufter: � S Check at ; .. nspector,Signature of Permit Approval • . "he a*mo eavealth of M idsachusetts > Deparl seat of ltt"straal Al cidivsft ®,wee d le�vestzgatao s v ' `600 Washington meet ' F ' .0 www. A rraasi gbvAdza ®Yorkers'Compens Lion hiswonce Affidavit Bra€ders/Contractdrs/FIectriciansfP'lgmbers I cant Information r . Please Print Le 'bl Name(Businesslorg izetion dndividu�l)'.C ] A •�1 Afi. Amass b D City/StaW&/ SCM b � - Phoue#: Are yo employer?Check the appropriate bos ' 'Type eif'project(required):; 1. I am a employer with 4• ❑ Lam,a general contractor and,l 10 s full anditir, srt-tizi ° ha*hired,the sub-contractors 6: []New construction: emp Y� { P ). , lasted on the`attached sheet: 7. ltemode 2 � I am a'sole proprietor or partner: ship and have no employees These sub-contractors have 8. Demolition workingfor me in an ac employees and have,workers' Y� �i 9:• ❑Bufi# addition , [No'workers'conps.insurance:' comp.mS�nee# y zequired] 5 �"We axe a Corporation. IO.�Eleotricat ipairs or additions. 3.El aria a hoaoeowner,doing':a11 work officers have exercised their '11,M.Plumbing repairs or addidons ri i. ex 'on er;MGL mysel£'[Noworkers'coiup: � Pti P P2.❑ frepaus insurance required]f c 152,§l(4),,and we have no enippyees.,[No workers' 13•' Other i t `tyl� cott�p:insurance regtitued.] t,� Kj 'Any appH=t that cheeks box#I=st also 0 out the section below showing ik+,wo0C=I•:co*Cnsatian:palicy infer a i= t homeowners who submit this affidavit indicating Icy are:doing all work and thm im outside contractors N=isubrdt.a new afdavit indicating such. �Conhactats that check this box mast attachest as additiaAat sbr ..showing the'name of the sub-contraactom and state whether or not those amities have. employees. If the sub- ontraccton have employees;they must providt:their'+mi=s'comp.policy number. I am an.employer.owlIs providing tuorkers'compensadorc insurance, bo my emo;ployees:Betow,is,the po&7 and Job site imrformatrmn.. . Insurance Cpaipany Name ,..1� (` Policy#or Self-ihs Lic..Wi OIV 3 Expiration Date; ��r�� A ` Job Site Address; I� \ �`DC: CitylStatelzip._ �4 O oo�U13� Attach a COPY of the workers'co ensatimpolicy declaration,gage'(showing the policy numba.and expiration date).. Failure;to secure,coverage,as,regmred under Section.•25A of MGL c, 152,can lead to the imposition of criminal penalties of. fine tip to$1,500:00 and/or one-year:imprisonment,as well as civil penalties in the:form of a STOP WORK ORDER and a tine of up to$.250.00 a day against tfie violator. Be,advised that a cppy of this statement maybe forwarded to the Office.of : liivesti Lions the DIA for insuiance'covei�a a verification , I do hereby ce f3' _ airs and penalties:of perjury that the information provided rabow is;true and correct MY%PC $i lure: Date; '`Phone# _ 1 Off oral use.onty 13a not nriCe N this area,to be completed.by cttpor town.officiaL' p t ' Permit/License#i Ca or I owns i , ' Q Lsssnng Atxtfiorzty(circle one): 1 Board of Health 2, ruld'ng lyepartment 3 C'Ity/Towp Clerk 4:Electrical Inspector S.Plumbing Inspector 6 .®ther „ r Contact Person.. s Phone#:: co CERTIFICATE OF LIABILITY. INSURANCE °A 14/214 O7J14/2014 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 terns 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 endorsements). PRODUCER Laura J Murphy HART INSURANCE AGENCY,INC. FHONE , (608)769-7326 F1C (508)750-7366 243 MAIN STREET Arc No): PO BOX 700 ADREss. lmurphy@hartinsuranceagency.com BU=ARDS BAY,MA 025320700 MSUR S AFFORDING COVERAGE NAIC N INSUIRERA. MAX SPECIALTY INSURANCE 20079 wsUMD Sandwich Chimney Sweep ,NSURERB: ATLANTIC CHARTER INSURANCE COMPANY 44326 PO Box 90 Sandwich,MA 02563 msuRERc: INSURER 0, INSURER E INSURER F e 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 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, TN;SR AooLSUaR POLICY2FF POLICY TYPE OF INSURANCE - Policy NUMBER MMfOQMIYY MMIDD/YYYY 1.IMiTS A GENERALLIABILnY . SCO060025001396 10/09/2013 10/09/2014 EACH OCCURRENCE S 1,000,000 COMMERCIAL GENERAL iIABILM -PREMISESDAMAGE TO REN70Ee=rreance S 1OO,000 CLAIMS-MADE OCCUR MEO EXP An ono orlon S 5,000 PERSONAL&AOV INJURY S 1,000,000 GENERAL A00RI56ATE S 2,000,OOD GEPfL AGGREGATE UMIT APPLIES PER; PRODUCTS-COMPIOP AGG S 1,000,000 POUCY PRO- LOC S AUTOMOBRF LIABILITY COMBINED SINGLE LIMIT screde t ANY AIJTO BODILY INJURY(Per person) S AUTOS AUTOS SCHEDULED BODILY INJURY(per aocldenq S NON-OWNED PROPERTY DAMAGE S HIREDAVTOS AUTOS Par°cldenc S UMBRELLALM OCCUR EACH OCCURRENCE S ETCCESS LIAB CLAIMS-MADE AGGREGATE S DIED RETENTION S S B WORKERS COMPENSATION WCV01032501 08/28/2013 08/26/2014 WO STATu OTH• AND EMPLOYERS,LIABILITY ANY PROPMETOR/PARTNER/EXPOLIT e N rA. - E.L EACH ACCIDENT S 500,000 OFFICER/MEMBER EXCLUDED? (MHndatory In NH) Cl.DISEASE-EA EMPLOYEE S 500,000 If yes,desmbo under 500,000 DESCRIPTION OF OPERATIONS tA9W E.L.DISEASE-POLICY LIMIT S DESCRIPTION of OpERATioN5I LOCATIONS I VEHICLPS (Auaeh ACORD 101,Additional Reset Sdfedula,If more space Is Mgdlred) Operations as Performed by Terms&Conditions in the policy. Faxed 508-700-6230 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE D15LIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis„Ma.02601 AUTHORGMA REPRESENTATIV2 01988-2010 ACORD CORPORATION. All rights resmved- ACORD 26(2010/05) The ACORD name and logo are registered marks of ACORD I t Klass cnuset?s - Depar?ment or Pubis Safety fs;:, 2e no7I7/r�zo9Y.r!/QILCI� 6/✓ .CLOJCLC/2CCde�W _�_ Office of Consumer Affairs&Business Regulation 130-ir.:i 'rf Building Regulations and Stanp;rds HOME IMPROVEMENT CONTRACTOR Cunctrurrion•Suprni.or I & _ Family Registration: "120859 Type: sense: CSFA-058557, t 3; Expiration 3/12/2014 Private Corporatior :, h SANb`dVICH CHIMNEY SWEEP ANC'. ICEITII A CLIFF PO BOX 90 KEITH CLIFF SANDWICH IVA702563 r,. 28 EMERALD WAY•.= FORESTDALE, MA 02644 Undersecretary J,(�, , JJ/ =xPir:,tiotti Ci7mm;ss uner. 02127/2015 .''.COMMONWEALTH OF MASSACHUSETTS N o . . N I=— !" A SHEET METAL WORKERS ' N A MASTER-UNRESTRICTED O C y < ISSUES THE ABOVE LICENSE TO LLzW > � N ��W _ KE,iTH...,A-. CLIFF- w_LA U jro,c 28` EI4ERAL,D' WAY' J (t5 FORESTbALE MA 0'26(4 1530. 11088 02/28/15 33009r+'i ' 4 . L License or registration valid for individul use only Restricted -One- and two-family dwellings or any before the expiration date. If found return to: accessory building thereto, irrespective of size. Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 IL lFailure to possess a current edition of the Massachusetts "— - _-- State Building Code is cause for revocation of this license. Not vali thout signature j For DPS Licensing information visit: www.Mass.Gov/DPS CONTROL# H 5 7 5 0 47 ,�oaoe�� H.5 1_ _mrg.aS- C) IMPORTANT` If this license is lost or destroyed, notify your Board at the: m moc ionsoS •`ac a'na^aD Division of Professional Licensure, 1000 Washington St., �' --- - _ 'm-_ a a 0 Suite 710,Boston,MA 02118-6100. G m�vn •s Ei `' "`; o= = Q If your name or address shown is changed, notify your board g - v _ a o s„ m o of correct name or address to insure proper mailing of next. . .. 7. ad^c 2. an ysuv O .z s ^a s Renewal Application. Always refer to your license number. M _ - o a a i�' m D m m This license is subject to the provisions of.the General,Laws "" > °'"a" -► as amended. It is a personal privilege,and must not be loaned - �d Sag Da. ow.��3 a - = m 2 m or assigned to any other person. Keep this license on your d N person or posted as required by law. Ok4N�. ow 11 6.lBarnstableU y� Regulatory; e c'es • n8as, Thom a ,F:Seiler,Director Tom Perry,guildin" 6 issioiies e - 200 AM 5tri; Hyannis,MA 02601. r wwe :town:barnstable.ma its M- { Office: 508-862-4038 Fax: 5087790-5230, {A E Propel ®wrier must { . , �Cornplete and "I'h%s Scum -If Us ri A uildeg � J Owner of the sub act xo l P aereby autlzatize m to attoil'mp'bebalf, id all 4tgs reladvPe:,to work aut}ac rmed;by,tbis building pexniit (Address,of.job),; P ' ' Pool feriees and alarms are the rasp®risibility of the applicant. are not to be filled befoie ferica ls,instaHed acid pools are' of to be , utilized until alt final sispecuons..are performed and accepted. } S e of Cwnez store Iicant Paint N e: Punt Natae' Date Q S,.-,QW. NE CAM , oF11 Town of Barnstable O„ Expires 6 months from issue Regulatory.Services Fee _ 7 a 9 16 9. �� Thomas 4 F. Geiler,Director Building Division, v Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY r Not Valid without Red X:Press Imprint Map/parcel Number ( � Property Address ❑'residential Value of Work Minimum fee of$35.00.for work under$6000.00 Owner's Name&Address it t1 � � a Contractor's Name 'i 1� �--- �,�-�- ����. Telephone<Number 6 U Home Improvement Contractor License#(if applicable)_ \,_ (,j Construction Supervisor's License#(if applicable) F- Vorkman's Compensation Insurance -- r PERNNPPFt Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance ita 0P BARN TAERI E 'nsurance Company Name Workman's Comp. Policy# -opy of Insurance Compliance Certificate must accompany each permit . 'ermit Request(check box) ` i O-Re-roof(stripping old shingles) All construction debris will be taken to v\ ❑ Re-ioof(not stripping. Going over, existing layers of roof) ❑ Re-side. #of doors Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows ` ! *Where required: Issuance of this permit does not exempt compliance with othei town department regulations,i.e.Historic,Conservation,etc, ***Note: Property Owner mus sign Property Owner Letter of Permission. A copty`of the Hon/ Im vement Contractors License& Construction Supervisors License is 3NATURE: i J WFILES\FOR.1viftuilding permit forms\EXPRESS.doe rised 070110 1; The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual); �� E Address:City/State/Zip: �r;+�1 � + Phone #: LJ A re ,youemployer? Check the appropriate box: p y 4. ❑ I am a general contractor and I IF ype of.project(required):em to er withees(full and/or p�.* have hired the sub-contractors ❑New constructionsole proprietor or partner- listed on the attached sheet. . ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity, employees and have workers' [No workers' comp. insurance comp,insurance.$ 9• ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no 12.E`Roof repairs 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 Homeowner 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$250.00 a day against the violator. 'e advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance c erag verification. I do hereby certify I-Lerteyai d e a v of perjury that the information provided above is true and correct Ila, Signature: Phone#: Official use only. Do not write in this area,to be completed by city or town'official City or Town• Permit/License# Issuing Authority(circle one): 1.Board of Health. 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person• Phone#: WORKERS COMPENSATION AND..EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Industries of Massachusetts Mutual Insurance Company 54 Third Avenue,Burlington,Massachusetts 01803 (800)876-2765 NCCI NO 26158 POLICY NO. AWC 7016215012011 PRIOR NO. AWC 7016215012010 ITEM 1. The insured Mark Herbst Mel Address: 35 Peep Toad Road Centerville MA 02632 Street No. Town or City County State Zip Code FEIN 02-MO2881 oledividui(:•' ElPartnership ❑Corporation (]Joint Venture []Association ❑Other Other workplata3s riot shown-above: 2 The policy period is from 01/102011 to O111012012 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the states listed here'. MA B. Employers Liability Insurance:Part Two of the policy applies to work in each state fisted in item 3A The(Trails of our liability under Part Two are: Bodily Injury by Accident$ _ 100.000 each accident Bodily Injury by Disease $ 503,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States.insurance:Coverage Replaced By Endorsement WC 20 03 06A D. This policy includes these endorsements and schedules:SEE SCHEDULE 4. The premium fbrthis policy will be determined by our Manuals of Rules,Classifications,Rates and Rating plans. All information required below is subject to verification and change by audit Classifications Premium Basis Rates Code trimmed FW$100 Estimated No. Total Annmt Or Annual Remunma6on Re a mewn Pre nium 4 INTRA 150148 SEE E CrENSION OF INFORMAMC N PAGE - Wrilmurn premium$ Total Estimated Annual Premium" $ As indicated interim adjust-merits-of-premium shallbe made Deposit Premium $ - _ ® Annually ❑ Semi Annually ❑ 'Quarterly (] Monthly MA Assessment Chg. $824.60 x 6.8000% This policy,including all endorsements,is hereby countersigned by 01/042011 A&mized pate GOV GOV KIND PLACING CLAIM. NAME SAFETY Leonard Insurance Agency Inc STATE. :CLASS AUDIT OFFICE OFFICE CHECK GROUP P O-Box 494 MA 5645 2 704 Ostervl'ile,:MA02655 WCQO W 01 A(11-88), kck des capyrtp W ffmtwW of the Natimmi counel on Corrowsmion IdWmnw, used with Its pwnisslon Massachusetts - Dep:u'tment of Public Sufeh Board of Building; Regulatii►ns and Standards j Construction Supervisor- Licenseii License: Cs 48546 Restricted.to: 00 MARK D HERBST � M 35'PEET TOAD.RD E �• CENTERVILLE, MA`02632 Expiration: 1/27/2012 Cunuiiissronei.' Tr#: 13699 677-11 r O.f£ce of °'n7zo�z.zea/C! o� i.c Consumer Affairs&Bti siness Reg ------_ 1 HOME IMPROVEMENT CONTRACTOR j Lrcensc or registration valid — x Registration _ before the expiration dat for rpdividul use only !; 126480 Expiration 6/8/2012 type Office of Consumer ;f found return to: 'Individual Affairs and Business Regulation MA K HER BST j 10 Park Plaza-Suite 5170 !� Boston,MA 62116 MARK HERBST �� 35 PEEP TOAD RD is CENTERVILLE x�a a Undersecretary t Not valid.wi o t signature At -.. ,.. . t n r_ pz n46 ten'n7 LJS-L�3H � g-1 PROPOS TO: WORK PERFORMED AT. y5 " Wendy Wilninski 15 Thistle Dr. Same ` Centerville MA 02632 fi 508-428-9920 '> pr -. .. .. '.:.', ;. .� .. -._fix _ •S o We herby propose to furnish-the-materials and perform,the labor necessary for.the completion of New Roof,•. Remove 1 laver of existing shingles r trr Install ice&water shield at edge Install 8°drip edge 1 . felt a er ti; Install b p p Install Certain Teed LandMark 30yr. algae resistant shingles Color.( 'Please fill in Thank You ¢ _ Cut ridge&install cobra vent z Replace all plumbing boots Storm nail all shingles F All debris cleaned r Price includes,material,labor&dump fees r All material is guaranteed to be as specified. The above work will be performed in accordance with the specifications s bitted w, and completed in a substantial workman=like Manner for sum of:Four Thousand Two-Hundred&Fifty: Dollars($4,250.00)with payments as follows:Full amount due upon completion *Any alterations from above proposal involving extra costs will be-added.under a separate written agreement and becoine� t t charge over and above said prG posaa t, �b i RESPECTF . SU ITT 5125111. . yes Mark Herbst 4 , &' ACCEPTANCE OF PROPOSAL91 The above price,specifications and conditions are satisfactory..I herby accept this proposal You are authorized1d 46',.-'the1wor And payments will be as specified above. N SIGNATURE: *This nrnnncni mw iwa ifhrirnwr; hy cam nmm�zrt F if nnnt we-�antcri within in riavc S � � r` �..-� -: k e i j. + k L. 2' '�"�a a�� GF' . c3x .,4`r'_M;°�k"t..'hn''.:x. `t..t' .., t- "n,3''�• t .._ee.3 ' ..6yy6: � "-,e 1er_.A `.54' t �J d s i. "� "r .!1' r '.M1 7 r.�:.+s. ��;A'���g..n L7^' vw.Y..F... '.. ., .... . .. - ��f,�w.�•c��.{ :t,F.ost+ _�''a �-r-.- �T c,�d;+`.F1.4�4.�� ;-y«'v}0"#yF3:I�+i �t r -S ✓ � �'- r , 5 r•-t.-�N s;�`Y-t�,' �r�'' ��"rrr�� �,y�h»„�}eY,y,.rG'� �,�{t� R -n'1� �f-r � t4t����'�.t .i'-'¢ ,, .'i..i«: ' y1 "e5z - yt '' o w 3:za;n '',r-�'Fp.S.tp -!`'t'r�' �`'im' �'A`"�. ` • r t x e `-`"r _ �, ^a-r",�,'., •ny° %'-c�"' "'`,y3 f,�.s `N�w�.e. ��,-'8� a` ?-rr� - t<s+ CRAPE CEO INSULATION it S � . FIRER GLASS SEAMLESS SPRAYEOAM SUSVENDED --y.Rz.naoA 'G M RATTS GUTTERS INSULATION CEILINGS R 1-800-696-6611 Town of Barnstable Regulatory Services Building Division 200 Main St ` Hyannis, MA 02601 Date: Dear Building Inspector T I Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed& { completed the insulation and-weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute r (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. ! Property Owner Property Address Village Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings ( ) ( x) ( Qd ( ) O ^ i Slopes Floors 1 Walls Sincerely„ , H y C s dy Jr, esident C pe od•I. ulation,- nc. ; v ♦e1 d.� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map pp .Parcel ��. �1' -Application lication # 0 1 Health Division Date Issued -3 Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Q�5,slY�)/ Historic - OKH _ Preservation / Hyannis Project Street Address Village C Owner Wetia,A W i Q S i Address l5 Telephone S0'8 Permit Request wAk_er'A7W40^_, — tL PK,r SCAA A-41c Ai.w-J� tyou Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation ET-Oo Construction Type �, ,t arPtzs �cN Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure 01 tv Historic House: ❑Yes ❑ No 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 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: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: 0 existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing 0 new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded 0 Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name c_oc4 b--VZov.> Telephone Number SoT-77S--I .1-I`4 Address LI SS PJ • License # 00 9 TI& 1Aa,l,-P1e VS WNIL 0160 Home Improvement Contractor# �3�� 7 Worker's Compensation # I.U�,A00 S a S g O ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE L� / ' FOR OFFICIAL USE ONLY Y APPLICATION# - DATE ISSUED MAP PARCEL NO. ADDRESS VILLAGE. 1 OWNER Ir DATE OF INSPECTION: FOUNDATION !r FRAME ti INSULATION I' FIREPLACE ELECTRICAL: ROUGH FINAL' PLUMBING: ROUGH FINAL ' FINAL GAS: ROUGH FI }. i FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. r •r The Commonwealth of Massachusetts Department of Industrial Accidents 't Off,ce of Investigations 600 Washington Street �. - Boston, MA 02111 ' s www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/El eClete Print umber Pas Applicant _ Information Narne (Business/Organization/Individual): CA ak 'f Address: YArA City/State/Zip: e� Phone #: r0 7 7 Jam' J of project.(required): Are you an employer?-Check th appropriate box: Type p � ( q [2. .(� I am a employer with 4 ❑ I am a general contractor and I New construction * have hired the sub-contractors.. . 6. ._. employees•(frill and/of part-time). , 7.' Remodeling listed on the attached sheet, ❑ ❑ I am a sole proprietor.or partner These sub-contractors have g. [� Demolition ship and have no employees employees and have workers' 9- � Building addition working'for me in any capacity. comp. insurance.$ No workers' comp. insurance 10.0 Electrical repairs or additions required.] ••°„ 5•.❑ We are a corporation and its officers•have exercised their 11..❑ Plumbing repairs or additions 3.❑ I am a bomeowner'doing all work,, myself. [No workers' comp. right , exemption per§l(4), and we have n v no 12.Q Roof repairs insurance required.] t c. 152 employees. [No workers' 13:❑ Otber/,r0a �{A i t a1� comp. insurance required.) ''Any applicant that checks box#) must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they arc 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 thepolicy andjoG site informatiom y Insurance Company Name: 1 Ar1'I't t Policy#or Self-ins.Lic.#:�(, )('.A_�57° 0 1 Expiration Date: � ITO Job Site Address: l 5�'�'e /�(' 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$250,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I.do hereby certify w e pa' and penalties of perjury that the info rna.ation provided above is true ant!correct. Si nature: Date: A Phone#: J Official ase only: Do not write in this area, to be completed by city or totyn official City or Town: Permit/License# r. Issuing Authority'(circle one): 1. Board of Health 2. Building Department 3, City/Town Clerk4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone#: r: xap'ers a Gray' t:nit. [aDa; u0'/ Client#: 4597 CCINSUL ,�CO ' ,N (CIE ` IFICATE OF LIABILITY INSURANCE nAfE(Iv4Y 071271'20'10DD1Y'YYY, THIS CERTIFICATE=IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. the teRTANll If tha certificate holder is an ADDITIONAL INSURED,the policy0es)must be endorsed.if SUBROGATION IS WAIVED,subject to til�terms and Conditions of the policy, certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder ill lieu of such endorsement(s). PRODUCERCONTAC - - / NAME, Margaret Yount' Rogers 8 Gray In,,. -So. Dennis —•----------_.._.._—_-_----_—.._ _-FAx_-_...- _.__..__.__.._._,......__..PHONE 508 760 41 134 Route 134 _1 rroixl__ " �aJc�No__..._. E•MAIL —_._..... ................. P.0.BOX 160.1 ADDRESS: South Darrnis, MA 02660-1601 CUSTOMER ID;;: IW$L1RE0 "--'-•-- INSURER(S)AFFORDING COVERAGE NAIC N Cdpa Cod Insulation Inc wsURERA Peerless Insurance _ 455 Yarmouth Road wsuaERa:Ohio Casualty Insurance Company Hyam)is, MA 02601 INSURERC:Atlantic Charter Insurance - --' INSURER D CDlnmarce Insurance Company 34754 INSURER E: — INSURER -------- , COVERAGES F: CL=RTIFICATE NUMBER: REVISION THIS IS TO CER'f IrY'I HA-I; I'HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOV FOR TH'BPOLICY'PERIOD INDICATED NOl'1NI I HS*I'ANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENI'WITH RESPECT TO WI IICH THIS CER'Ilru;hl'E MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERNIS. ExCl.1151(?PIS AND UONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED By PAID CLAIMS. TH 'f'1FE OF IN5UIiANCt NSR VO POLICY NUMBER POLICY EFF POLICY EXP MIN/001YYYY IVNA;OOIYYYY LIMITS A GENCRAL•LIABILITY GBP8263063 410112010 0410112011 EACH OCCURRENCE $1,000 000 ]( �:OM1IMI hi;iiU.('iLNt:FVAL I,IAIIIIJIY DAMAGE R-N1ED -- - _.._.1 PRLiPo115ES Ba,uz:urcon,,;cr $1DD DQ� J CI/uM5 hV1l)I° ��(1l;CUR MED EXP(Any one Demon) S$,OOO ---------- _ PERSONAL&ADV INJURY $1,000,000 +— GENL"RAL.'AGGREGATE_ $2,000,000__ lit IVl,Hli11a.(;AI I I INIIT APPI..II.-:;I°I::R — Lc)i: ... PRODl1C'I'S G(:•COMPIOP A $2 000,000 I rn r � p AuroMuaaELwaarrY 10MMBCKVMK 0410112010 04101/2011 COMBINrOSINGLCLIMIT MA, ,i.iIU I I (Ea al:mnU $1 000,000 All OW41-11A(II()'5 BODILY INJURY(Peelse rpn) $ X SCIit IAA rrl,\(II(r, BODILY INJURY(Par:lccilienl) $ - PROPERTY OAMAGL $ ...X IiIRl.li:111 11 1j (Par aconam) X IV UN LIYdIVI�I.I AUI(-15 $ _ $ B EXCESS S LA I.UA6 X OCCUR MEYAPP397725 D6117/2010 04IO112011 EACH OCCURRENCE' $1 000,UU0 EXCESS LIAtl CI_AIMS•fW1Ulr AGGREGarr: $1 U00 UUO DIJA.:11111 b ._._—_..__....._..._..__.__. NrIINnl1rl 1, 10000 C ANU EIVI1S COMPENSATION WCA00525901 61`30/2010 06/30/2011 X we STAru•_ grrl• ANU EfvIPLOYEftS'LIALiILfrY YIN .O'Y lt:i_..:...._I.......,...., il1k:HV1,-I1 IR-K1-AC.LUDF `XE(.:UIIVE� E.L EACH ACCIDLN'I' $500,000 lilTu:krVP•II NufrR I-::(CLl1DEU't (� NIA (M�Inriatoly In NI-I) u 4ws ouxnbu 1,1061 F L.DISEASE-EA L"MPL01'CE $SOO,OOO UEtiCH;I'I ION(A-(114RAIl(;1Nti below E L DISEASE•POI.ICY LIMIT $500,000 UE$CRIPTIUN Ur OYL•RATION5 I LOCATIONS I VEHICLES(Attach ACORD 1a1,Additional Remarks Schadule,u more spaca isruquirod) Workers Comp Information Included Oificors or Proprietors (See Artachad Descriptions) -ERTIFICATE HOLDER CANCELLATION 10 Days for Non-Pa ment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 01988-2009 ACORD CORPORATION.All rights reserved. ,CORD 25(2009109) 1 of 2 The ACORD name and logo are registered marks of ACORD J#S548141M53353 M EY e v V 1 Ci`�� i��4�i I��:1LY` .. • Suite 5170 x 10 Park Plaza- S Boston,Massachusetts 0211:6 {� Home Improvement CoA� actor Registration . Registration: 153567 Type: Private Corporation 206433 Expiration: 12115l201 _. CAPE COD INSULATION, INC HENRY CASSIDY 455 YARMOUTH RD. -- --- HYANNIS, MA 02601 _ Update Address and return card.Mark reason for change. Address ( Renewal Employment [] Lost Card ;-CAI ii 50M•04104-G101216 License or registration Valid for individta:lSe -^-�y o mer Affairs us'ne Regul lion the expiration date. If found return to: Of fice before p HOM� y Office of Consumer Affairs and Business Regulation Registration: 153567 Type: g 10 Park Plaza-Suite 5170 Expiration: 1.2/15/2012 Private Corporation Boston,MA 02116 OD INSULATI0',. HENRY CASSIDY.' s , 455 YARMOUTH RPM.—T gam -• -- 6alid h t si ture HYANNIS,MA 0260.1 Undersecretary alassachusetts" 0c•hartntrnt of Public Saich Buard (ifBuildin�o Regulations and Standards Construction Supervisor License License-CS 100988 Restricted to: 00 HENRY. CASSIDY 1�SHEDROV1l ; - u WEST YARMOUTH, MA 02673 � � Expiration: 11/11/2011 <.„uituisi ncr Tr#: 100988 460 West Alain Street � HOUSING h 698 EN ER ;7,&HOB- REPAIR ASSISTANCET (508) 771-5400 F 'JM790-2425 CO R `1�.�N "I°'�Y on all lines W' ?vw.hac9,-,xcapecod.o'rg HOME OWNER WEATHERIZATION WORK PERMIT& FUEL RELEASE: PLEASE FILL OUT AND SIGN THIS FORM IF YOU ARE THE APPLICANT HOME OWNER. I :';`e'._ , >4 ;. F ' L hereby consent to and agree that weatherization work-may be ' done by the Weatherization Program of Housing Assistance Corporation ( herein after referred a's "Agency") on the property located at: r The wcatherization work done will be based on programmatic priorities and availability of.funding and it may include all or some of the following measures: Weather-stripping&caulking of windows and doors, insulation of attics, sidewalls &basements, attic and other ventilation measures and possibly replacement of badly deteriorated windows.Iri consideration of the weatherization work to be done at my home I agree to the following: 1. 1 give permission to the "Agency" its agents and employees to travel onto or across said property with such equipment and materials as may be necessary to perform weatherization wot n said property. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the ` "weatherized unit'on an ongoing basis for no more than five (5) years after the weatherization work is completed. I have read the provisions of this agreement as listed and freely give my consent Home Owner: (Signature) i.;/•,.s L urt/ f A'. ti -% "< i`• k_-.i. f Agent: (signature) < Date: - • (-HAC approved Weatherization Company: CokN - Caliber Building&Remodeling Cape Cod Insulation Cape Save Creswell Construction Frontier Energy Solutions Lohr& Sons Peter Smith Resolution Energy Rock Solid Construction All Cape Insulation Its'q ISCI�1`LI J�•h,r_aL'ti`e ;� :nn t._lr a.doc:�:c Town of Barnstable 4HE Regulatory Services °F l°� ti Thomas F. Geiler,Director Y Y Building Division Y BMWSTABLE. Y . 9 MAC Tom Perry,Building Commissioner �Atf1639 MA'S p`� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Approved: Fee: Permit#: HOME OCCUPATION REGISTRATION Date: Name: Lb•P✓)"-b�' J Phone#:.'5 q— J C.Q V) a'ru�iAddress: I�P Name of Business:_C(lae `9/ (IQ/e Type of Business: t�n-ht VI e4 Map/Lot: I C) 1 I t C)0 C7— INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector, a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit, located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings, and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter,odors,electrical disturbance,heat, glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials, in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. I • There is no commercial vehicles.related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity, and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Hcme Occupation. • No sign shall be displayed_indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised"as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. I,the undersigned, have read and agree with the above restrictions for my home occupation I am registering. Applicant: Date: 6 7 Homeoc.doc Rev.5/30/03 YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in town (which you must.do by M.G.L. - it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office,_ 1 FL:,'367 Main Street, Hyannis, MA 02601 (Town Hall) and 200 Main Street Offices at the Licensing counter. DATE: 11 f U Fill in please: APPLICANT'S YOUR NAME: CIA I' BUSINESS YOUR HOME ADDRESS. fS le r ` TELEPHONE # Home Telephone Number: - - NAME OFINEW BUSINESS w ✓t` TYPE.OF BUSINESS IS THIS A HOME OCCUPATION? YES: NO Have you'been.given approval fro the building 'vision? YES NO Lrr / ADDRESS:OF BUSINESS' !' AP/PARCELyNUMBER When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. MUST COMPLY WITH HOME OCCUPATION 1. BUILDING.COMMISSION 'SO F CE RULES AND REGULATIONS. FAILURE TO This individual has b nforme of any permit requirements that pertain to this ty l�is�irf W RESULT IN FINES. Au onzed Signature** COMMENTS: 2. BOARD OF HEALTH This individual his b'en informed othe rmit requirements that pertain to this type of business. A�.orized Signature** COMMENTS: .. 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: a Loi '7,5 --- a 24-� .f-� 'dC S,000 � - tC i� �'-� t .: ems:t'►.is ,,t �,` - �` __ tom' 1 , apg1-ICra ' - ` 3 32 Loy- 73 F24wT /O ' S�z�Er /o f�2o FAO S SEPTIC 5y57-EM CONST2UC7-/0N S/-HA[ L CONF02M TO MA55 . l�ES/ _/�j ,PLOW .3G'O EN G OAJry,GrvTAG CooE TITLE IT Jo TOP 'OF A 71 O NS ouNDAiron/ P2o;aoS'6:a L-EAC,41 A MAA/NOLE Ca✓E,2 TO EX TEND Tp W/ TN in/ t F20i..q -5 I /8„CoVG--� I D/ST. STp Box zJUll/ �w"Mi�,J v� T� A r. /O rL remit �� /FOO �9�N '�I;'v TCf/ ^"-_. Q �� CA cN T 2� Mini �ircfi . ., P/T /NV&E2T CA TY /NVE2T ..' SE l01T/G ELEV (WA TGrzT/GhYT) �OTTOiN O /N t/E2.T /"✓.�/ r Ct•c fit_' l PIT'' / _ NU CAA e8�1GE Gfi�I/vD�,� < 6 .e41- C TAni FOB S fJUTG_-' ) A/VD LEAC TO eE OFE�NFC7,eCEL7 ./,.,/ S TEE C. 2. 'S,4-/Q,V2. , �` t" tern �. ,y._yo..t..oAD/�:/ " 2< /4 TD�y L,G1NE ''_ ` ..;r;\`;r\r� Z),e/VEVI/AY NOT TO 8 i IDE Lc � -S s i rz 74 r 1-15-000,9 a .d 2D e c'• .,�}� �iN 'x Wit' L7,g71 - jJ C? V't t tt: w! r3 LJ/x_L7//uG S ETL3AC ' 7;5 %`._. SE P T I C 5 y5 T&M SNA [� GONFO2M TO MAsS .' ,UESiGN. 'FLOGV ;_3.G'0. E J V/.e on>r f En1'T�L CODE T/7-� �T . .4/a/o rowiV OF 13,41,77A�q.41.�Z {` ,L G.4 G,y .12-4 7E A4EA47-11 4 T/ONS E co�� ® rE nfz:> 7- co `CA'ST /Sox,. �I A f7•�/TCf-/ �sFL.O�—nrE—�—} •iG/dr � 4' ®/ -� L, A. C � /Q" L,q c/ f4" ✓4 A /Poor 2 �?/A/ /ZPo�c.i ,,• p/T /ivVE.2T. /Ni%E eT V CA 'PQG/ Ty SE AT1C TA ti fLEV• NO .G �cz- P% GA cre A A Cc 1 Npd.lS, o.vt �ouc/b EFE7C,F-AfC C S OUTLETS . ' TO 8E o .tzE/n/FQ. CIa STEEL \f7 VE W4 Y n/O T TO 6E- .L i _ sessor's As map and lot nu er .. ........ a ; „r s, wYNSP AiG SYSTEM MUS 7 ..0'..... ..... INSTALLED �N CONjp T B u Sewage°Permit number ARTICL LIANCE a SANITARY It STATE yoF:THE rot y U CC E AND TOWN �P o ,TOWN OF BARN . Z 8ARNSTADLE, • "AB& :�� u= BURIL:DLHG INSPECTOR p •t679 ♦ r „ APPLICATION? FOR PERMIT TO .... . C�L +1.... ................................ ............... TYPE.OF CONSTRUCTION .... .°. c ., ....... ..................... ..................... .......................... .................... ............19 . TO THE INSPECTOR OF BUILDINGS: The undersigned -hereby applies for a permit according to the following information: Location .. .............`..� ....... .L`�`. . 041....................��.'� .19���.... 't... ��.............................. ProposedUse ........................ ...... .........:......................................................................................................................... Zoning District ................ -.C- '::.:.. . Fire District, ..��.:.�:.�.........G. ..1................................... ll_ ff ' IL�tlJ �' Name of Owner ..J.'� �a V� ......: t I tic EJ ' C` ?...........Address .......hT. ............................... .................... Name of Builder .. V�...... 5.. �.. ,......Address ............t . 'n..� .. ....l...... .................... . ... Nameof Architect ...................................................................Address ..................................................................................... Numberof Rooms ....... ............................................Foundation .......... . ......................................................... Exterior .... "...�........ ...............'e..: ° ........................Roofing ........ r............................................................. Floors .............I ..`'`: ,. !..................................Interior ..............�Z.............. rr ....................................... • Heating .....Plumbing ............................ :. ............� � ........ �.. .. ............ ......���. ............... Fireplace ....:.......` :....: :�'P �L. �\..................Approximate Cost .............�.. .r� .................. t..... Definitive Plan Approved by.Planning' Board ------------------__------------19________. Area60..`L..e .............. 'Diagram of Lot and Building with Dimensions Ct Fee ......l.�.c.. ... ......:.............. SUBJECT TO APPROVAL OF BOARD OF HEALTH hereby agree .to conform to all the Rules and Regulations of'the Town of Barnstable regarding the above construction. Name ........: ................. .................... ........ Welninski,. Frank No ,, 18847 P ..... ermit„for one story, ..................... . single family. dwelling r Locatio/..,.,Thistle Drive _ s N ... .. .. Centerville Owner . ......Frank Welninski� ` h w ... .............. i ......... , Type; x of Construction .....frame ..... ... ... .......... - •. - . ....................... . ........................I........:..... Plot ...f....................... Lot ...........#74............ Permit Granted': D cember...l...:.. .19 76 n ed • v Date of Inspection ..... Date Completed � ...........19 PERMIT REFUSED ; ......................... ......... .................... 19 i .................................................. { .......0.............................................. ......................... ......... .................................... ..........p ............ .................................................... Approved ........................... ................ 1.9, 1 ................................................................ I + •- -.... .rt. . . �. , 5.:, ..✓.:'t• ,.r . ..r:- '�:.(vv'- .w.l+i:it "* ;L:.a-....:�..-'•3+II. . .i_73..:..c. ».-. .... ... �.- .. ..... a..-. . .. ...•,.-.�..�.:w,:-..�,�.. Assessor's map and lot number ...�. ............................. ~' Sewage Permit number(. ............................ ...................... , T"Ero TOWN OF BARNSTABLE Z MAWST"LS, i 16 9a,�� BUILDING INSPECTOR ON APP I ATION- FOR- PERMIT TO ......�.. . ........... ................................................................................................ L C TYPEOF CONSTRUCTION .......................... �:!'.�-,-....:.._...................................................................................... .......".. ...............................19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location Lr.j 14•c J .,... ('t'.!, 19�t.i 1/1 j �`S S ........ ............ ............ .:............. ....................... ......... .....f......................................... ProposedUse ......r..`.. �..... . ..., .�--................................................................................. .............................................. C :.............r........:. Fire District .. �..^ .. .........`r' .................................. �Zoning District ............................................ L ! Name of Owner �.A;... ,........ `.�f!......S.��.�...........Address ....... .?.................................................................... Name of Builder .......r.!.......... ' . e.. ........Address (......1 L6 � 6 / Nameof Architect .................................i...............................Address .......................... ...................................................... Numberof Rooms ........ ............................................Foundation .......... .............................. ;,G W; ..:................... Exlerior ......Roofing . ........................ �-:.................. '„!, 'k ............................................................ Floors ............. !.. ................................Interior' ............... ................................. Heating ........... .............Ik. .......Af/A�(..............Plumbing ................../... `"'?! .c..... .................................. 2 / 6;1r � Fireplac ....................... — � ................ Approximate Cost ........................... ....................................... ............... F Definitive Plan Approved by Planning Board ________________________________19________ . Areaj�. .....�1.............. Diagram of Lot and Building with Dimensions Fee ...................... SUBJECT TO APPROVAL OF BOARD OF HEALTH • E . I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .... 'a�,�``-- `................ ............ .......-....... w Welninski, Frank A=171-76 18847 one story, Nod , Permit for .................................... sf.ngle family dwellin . ..... ........ t ................I.............................. . ........... . Location ........Thistle Drive ............................... ......................... ............................... 6wner .*.........FrAi*.Weiln*I I ski ............................................. Type of Construction ........frame...................... ........................................................ ........... .......... Plot ........................ :.....Lot ......../It74 ...................... 76 December 1 Permit Granted .................r......................19 Date of Inspection ......... ........................19 Date Completed ......./...........................19 PERMIT REFUSED ................................................................ 19 ....................... ..... .... . ....................................... ... ............................... .............................................. ...... ............................................................................... Approved ................................................ 19 ................................................................................ ............................................................................ � ��.� /� ��s �� �Y � �1�1 ��-�z� ��� S� �� � S (�� �? � _ �; � . . _. t _ � . a(/ 214, / ,S7 7� s Son e b � c-sd� Y TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel 0 7(� Permit# LE/ Health Division '/P� l'6 ��� j Date Issued A' ,5 03 f i� 1 3 Conservation Division 11 E0 7. Application Fee Tax Collector Treasurer o'Z D IV�-� �/03 Permit Fee4,36), �� L_ oi7 ---WTIC SYSTEM MUST BE 163TreasurerF7f `i d INSTALLED IN COMPLIAX'X-, Planning Dept. WITH TITLE 6 E���'i e'��,l���ENT�L CODE" i � Date Definitive Plan Approved by Planning Board TC9iS 14 REGLILATIOIN' Historic-OKH Preservation/Hyannis Project Street Address )xt v,6 77 Village Owner 41-rAl1)!K S'- 141P i A//Nskl Address Telephone Permit Request 1�iy � G`y2�y cD fc /46,a on®Y &/AN, � a"t& Aj4,PPE Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District $ Flood Plain Groundwater Overlay Project Valuation ( a Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family ;Iii� Two,Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes XNo On Old King's Highway: ❑Yes o Basement Type: Aull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) _ Number of Baths: Full: existing 2: new Half:existing -�" new Number of Bedrooms: existing `7` new -� T � , Total Room Count(not including baths): existing new First Floor Room Count 4 Heat'Type andFuel: ❑Gas 00il ❑Electric ❑Other Central Air:,, ❑Yes b�No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:0 existing ❑new size Pool: ❑existing ❑new size Barn:O 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 �odc27' Telephone Number ` �(J�"" 6Z— 70.0 Address 201 ?a1mArk. S`r, 4WAn Jvcs tiZt4 02-b0I License# 063 92 -3 �2h11114b- 1 PO Box I?" Home Improvement Contractor# tJ1f9 1ko-yL-szori5 �N� ,T � Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE f�3 A,, DATE FOR OFFICIAL USE ONLY { 4 , PERMIT NO. DATE ISSUED _ MAP/PARCEL NO. ' ADDRESS VILLAGE ' r OWNER }� DATE OF INSPECTION: FOUNDATION C)'t 1: FRAME _ ^D INSULATION ! FIREPLACE ;. ELECTRICAL: ROUGH FINAL r I . PLUMBING: ROUGH FINAL GAS: ROUGH - FINAL • - FINAL BUILDING • 2 5 "U 3 DATE CLOSED OUT f ASSOCIATION PLAN NO. 1 � - The Corrcmonwealth of Massachusetts :- - =-- iDepartment of Industrial Accidents efflce afloyes[Igatfans 600 Washington Street , Boston,Mass. 02111 •c' Workers' Com ensation Insurance davit name: location: Tigs giVE 3 L one# �© '�6 Z 3o � �V c _ ®� . ci .: I am a homeowner performing all work myself. - I am a sole rietor and have no one work1% in ca acitp ///%%/ % have One % %/%//%/t/11,%es/wo//rking/o/a//this job/////////////////////// ///% co en5ation for my emP oy orkers din w 4GC-'::2?,},{{4:!r •i G}�:28:' +` ;•:i:•: ..o:•a{.; o er rove g ... .r, :k.., em 1 ?- :';i:'::..:t.n:.y GG• { G •::i7•}}rr.,}.L,r.SY$}:'}n::i::6i': ;4•{r34v :;#•X;:4.4,}:• ::i{vr.•'r.,L,'r\4'+• v`\ T'r':}' •ta•t},• am an y .. .r:,..:•n. n,...:....:.:. ...... I P r .:........:.::::. 4>.,•.: .......:••:r r+..a.K4:.w•...,• .}......i v4}.......... •::::::a•;,::.:.:..n::4;v' r%�'i'k'' 2.l,Nv. ........ .v.... r Pn.v..f. .,.,. ..........w....:::f:•.:v.•.:'.w:.}:}.r'•}:ii%}:}•}i:i:•'::{:.vn•.+.x..r ...... .............:..t.. ..�.Y. ...ti.....,...#...,. .....x.. ..n....:.. ,..........r. ..v::•:v..::}2 Y.fi't:•7i.:}nn 7,.:f. :#±•!t•ct#:�4•i„•4'•4}h#r Yn+'•ti4t•`}:xr�tC: �•. �:r;•i:tt; v.a ...4. ..f.,....... •..h r....}}?.v .:}v}'.•• :i;,R,. a�%:%irr.%:i�Yf4$.,. .......•::::..,.:•::}}:x..:.::b:r....,�:t::f....a}:•:n•. ..:7,••:.: ..:::::. ..v.:•., .... : .... ,.....x:�•::•...::}. ,,r. : .. .. .}{:.:;:7:�::4;:{:rr .r.'�.. ..r...,: ..Y..:},{....,.{...,,.:•... ::{.;,,{.:}:{.}z:Yt`.•i:..;..;:.,.: .:x•{.:;..;.,.;:,; .,.}... n••'S.•+t:4R..k G::n•. ..:.: ....r.. ....... ....,.v:t.'••{n;{.}:•}•:•.:4•r.., .:::•..r ...:•±:•.....,........n.:.:G:•:v:}:. ..:•:::.:..•.:.;•:{•:•}:n.'•:..:•.;..:;.:}:•ri:•?i%:•±'4r:+:`tan;{.r{.n.{.:.}.k%:••z:Z.4:r}•:;%;r:•�•{.:t4:.fi,}:+:{..fi.., ,R:.:::.•::::•:..•4::;:•:!...4::::.:..•:::.:4. :.i,..r{:v....n;.4;:.+.....:4.v.44:{%:::nw.,.v..r......;;•,•h....r.vt`:nnv:}::!:v:•:•vr....h:.....,n:n:7�..v:•:fin'nn.....}.......... :-{::••.....n:{.;.... .<:.... .::y.,.x ..wzr ....•.:.7......':•:{......... :::?v::.....n.:::Gi.. ..:•.v.....,n.:.;;1..:.v::1..x:xnn....n.... � ... .....{{.3..}.}:{•}.vnv•........v...•...R4:•i::i.....�,.}.n...{v ...{i rn..± ....n.:n..:....;..:??...n..... :.:........ :.,........>. Y............ ....}......1...... .. .:... ...:.:...... ,.... n.........n•..........'i•.,:7•.v:••:.::....n.,...' .... $ir"rii:.i,'i}k4+:;:•.v:{!vi+,;;}•+L +,•Y•i:.v:••.'.w::..;v..:::r.,,v:n4::..r.;...}.:..r.;.?.�{a..,.•:.4,?••i,;••.w:n •.,v,.,::;,?•:::n .n+4:.:..n.:•:•.. .....:.. ....; ...n•xr:::�t:.;,;,vv�Y r.• ..:.4:.nn 'vv•?r,vrQr n•{±•...•;;., •.h:•.v:..,n•:.,•:....,.•::.v:..•;}.::•R:v.nv;,,.<;r,:..}:::.•},a..;.::o•.,:.:v.}:...2.n........n . .r�{i�n•rk::+tr'y{k':•'.t.'•}::{;,{•r,F '•$.i,7•':` }kn..::::;t....;.. ..:.:+v•:•n;::n.;};:{,;r..:.v:+:..v.....:. • n...n'::.w::?i•:4{•iry±}'• r.. ... e'... .... ...... ..... ...:.:.... :..r.? .. i..;.r,}}+fi"^'-", Xi;::•r:,:•rtn: }.,+�v y{ 2{ ,''•.v;'::tiiii nalq 4%..n J'Ri:±2:'v 4'f-4':i4.:•';4 n ? \:1g7 ��� n:<, :..;$,...v:?::•.}}:+.^::}..}. h:•. .r.R.••.v.'}'r•r.•.�..4,i;•#,^.;tir:•:r Rtii;•r:k•,•:;:r?ik,} ,•Y`:,•�t`,• }Y. i�.}}h?:.••• +tl yAS:•y}.r;:ry r,:.t:,:•::,:::br:{•:....::.: ::}+:{:y:,';%:•i:•i'`,}�±:•i}}}�}v}.v.{::., :{.{{.. 4rh n .vCn irrh..,. .� .. W,,. '{•{^v,• t .:.}•:4:{?:..'{•:tif?:•:fi:.. iv.., .{ .7:•}r..: i•:?..vi,}..v?:•vr:....J,, .r.C•S}t••7..,v7.•.+a... L•.dr.:::.,n.. ,k:'kG•r. v..',A•r ' ...... ....:.v:•::v:{{{• v..r}.. .,...-$.....:.,..r .w}:4::::isv4::n.n:L?......:::..,.vvr.•:•fr:f..}viii:% ::i:{:... ,r...r 1:.::'•.. •�.. } r:4.. a:~.•.. :.za�'a7r ..,.t.n,,, +.L•i•.v., .;}.a:.v.:}a.Y} 4}$ :r$.},{.;Y;•: ,....n• ,:•4i}}?4.•:}•.?•.;•.•:...ta.r.,..a.:•:•}in?:�S'.:•r;.: +;:;}:::••:,...... .. h..... ...... ........ ;...t•) ...,.....:.:£...x..:a:.•7. .:..R.i;.?.{..:::t•:::.y{•±:•::;bi;.iiti,+;:4:{;?,•:.:.:•:::..n•.,t.... n}x}7}$a••,+.'•,y;:.•,'•;N?'}{.t.Rn•::`�+io-s.•};rkr:•$:•}:4:%.;,.}v...;.x,.,n..b. .r. v7.,Y•x.:4•;.}:.wio:t•::,:::•Gzr:.a:a. ... n.St•:.:•:}.a:±::.:+,...r,:..;r.,;:}:{•Y•`•:{c+xw;::.y::....;.:.,:i;{.}:•.;:•{+•.v::::::;r{. n {..••:.n...:.v .....+,;. ....:Y. ,ntx:,v, ...:::2•. ...:......t•..;{.r...n.•::vn.::.::nv#:..;.;,v{••.v{{:.r,•.n.........:::::r. .r.t .4...........v..r.:±::...v...f{R.:.,:•..... r,.....:.,:.v..n .,:•.,... .•,.}.::...........:••.:..rrr:b•....... .. .. ........ .. .:.�.�. ::?{4:{•. ..b.;r.$tt$,2%:% :fir%-;#?;r�xg74'•xb?•;ikY;rt.: . ?;•r::G}}}}••.,:•±±.'•n..:v:>{}.,::.•r{•+.4•:.}:f•,4 y .vv: „fi yr :}.L•.i:4.e... t. f•..}rb.., :•'n:v,:!:}r� .`"#:%.r t•n:.C}r4 ; }:4Y....v:,.•.,.},;....:::R4•:..,.}y..;.::.:.:Yk,..<,:Li f..a.::i.:.:a...,.::•}}L•v .:... ..•::. ...:......:: ..�.,:. .:rr.....±:..R. ....:..r.:::.;:•}:•w:i•;:•:t; <`}';i9{•: .�,•.;,s; ..•::•},.ta:,,,.•.4. .:,b.}, vR; :!, ,�•t' };a7#4,r}.K '`` •x,n...n.4'•..... .... ...•:::.•:;: .+.•4Yi rr..;... $, "*Y:'. :• •.T• •+`••. �y�''�.:••? `fii:$:S•:t {'# h •.:........... ..... ...:::r,....,.{•}Y?x:.•....... }}?;v,•}.•.Rv.r.$,:v+,�,}iii:•.`i;:::L:;?h;{{.}::::�•::. vy,.}i:)`:•vkin,}v}:.:i:•v�},r•},, }, •i}::':•:::4••}{i;{#+:,'`:.. ...,!::{+`:'r'''}.•.ti':vt�.:44;•: yf:CS`S.. .•r•:v.w•t:•;R{{r... :•..,vr :r:i:;i..:rr•:',.',Ga??,., .,i•,w•h.:2ti'.?,&i#i::.�.•..ir}:n,,:k.',�:,,b::.t•Yv,±.t�. } ,•r.4:}•} . � .:$:''&.?•i ..�..;.:'•z'•}Y;:....;{::;{{;.}:r•:;:•+ ,L.{,'+ ..`:v. :..f, ...{......: $::t%:•:`t2<±%:k:,v,'4::.,+:r.,`+,v ;;:fi •::4. kr. :.i r .•} ..4. `:'4.v.:r. <r'Ei•:i}$:+S}''•'i?:. ..}..:•}:ia:•%}}% .\., .:{•.{{{•}•• rb:. ..'}. ..... ::...:..::r•.v:::•.{a:4;4:}'a:{:?r.'+2}z•.n..3:.....a •'#''.:$.^"...... :..t:v.+•,...........n....•.... .. .;} }.,. . ..:.^.:: •,.brTY•. ,:........r... ..........r.... r ... ::.....�. ....?c..::,,;:;:ti•%.:�:::};:'ir';•;;;.}•4ir`.}..v:.:•:v•..: ............:r: .,.,::{.t.r7,...:. .;.;!;.,ri'+'.::, n. ...,::•.:a:•,:....r.:..v:.:;..}; n:...b.x:'{•.:.n.. nn•.:•4; :....v•:{: h ..4.•::'•:.w:.:..+,•;.•.! ... {, .....{::: .: '.4:.•..h },•••Tri4ti`•'�i•'.{'Rrf.•:.}Y:?rn•{}.w::.$}rr:; '\`{% :,}•A,•,y;,,;,;, z;4..•::v„y{•:.:...v.::nr.v...:•rn4.:.vrvn•.....4..;C,,,rt.:•:•::...4.;}:..,•.r.,.;R>�;.•r....L:•.:.:::r.. :...... �t ,ht. 'x�},:. fi#....4::.4......... R`:%:••,•. {.:.,..,•.tr:.,......,{.:• .. ...:.. ....... +•v.;... ....:#•r.....•r::.....R.}•.:•:..r...... ...:.{.:•. ..:•.v:...t•.;;?{i.;.::{•}••}:2•r.,• �` r.}, . rr$.................::......S:r.....,:• ....:v:..:.,R.}.a:.......{.,..}.t....,... y.::.....::}••;.. 11oI1 .....•.........•R•.?,......,,... .. {. . ................ .:.:. ......,�..... ri.. :.... ......, ..,:a.:•::•::•r.v:•;R;:;;•x•.j:};.i; ?,}.:}:::..... +:.:....::. .. .. •.r a ,,{;;ii..�_.u:+.":. '�t''�:}i;:;:::.{_.,... •.,Y.�{:•::R....::.t•.:v: ...•:.:•.:..trr•}:5:. :'#J:..:s.rr:•:.:;,;:r•.x.:.,n„:....:,},..•:}$........::::.•.:.:.,.... .;.n. •::: ...:..::;;• ... .:•:t••:.:. ;;}k. $+k••f• :}i%: ..•$}y$�} ;.. .R::.:•:....;....v...v....:•.:r,.;.r.G+.••.::.,+.n. •}:....X;J.,i•.:.v::.:::•:•....n,.;;... ......, :::..:v:::r.:;; •.•.{•r}'''7:{;fif?Ri• x`'{•.:}.:±%'ri:k:'i r :;:5;,..,4.G.v.+•:}`x.4 .•#.,{.:•rti: :+'•Y.+.:+Jnv;n.,}. i•t{.{{. ,;Rr.• •;:}};•}:::::.::.,.. .v5•:?. Kti. W 74:. .:t:.$•%i:}%iiY::<':.• +x•:s:`•r• n.ai... ,,i:}}:fi}:{. k:••:?.5,,,..:Y�...;,.,.:}F;.,.,t,.,+$;.;•;R.:}�;'•'?'�:,+3,�?:;,.+.fi{{,7• 4`%` `•�'. ;.¢..:;.i}:.vv.i..r.'}..v.: ::•.:i}is(::•:i:i:i}:;'?::$:%:L%}i:+}.: ...ib ax¢\n4.};.}rv.. :}..;: ::'4.� .}h r N.• •• is?Y.<'•}.•:n,r. :{.}xv±,•::%.:::{:+':.i.t:. ••:,{{•:'t•:h}r•4:••.:•.,}:+}Yi• ! f:rr ) } vti:4::x4R{.. :;z.{;... .X}y'•@?',4n•3:.r.•+ :�:t nR:.LR�ir.,:;�,,, i<.. .},. �Q R•}':{•7:•i:;vi: +%:%:3}}�:i%}t4:•.v:n••.:x k-} i+.iti•:•T... ::.v....• .{{+/.v.%::v...• ..i:+.{'.k}r ..r7..: r{v?''' fi'•$:•: '{L •:{#v :n ......:.:.::•.;w.•::REEL, ••fi.a}}$ii}}i}:,i.. :'•x:}4:{4}kv ...n.:•}}:n}::.±±}:4:{?:.v:. .n.+...:\v:•xr:v n... ....�. ..',•�.i?• $E}${:t i:4. y y } ... 4.}} ..4...v.t•;..... •::}+bi:{±i:;:.}:•:•.:•:: ..}.G} '`4.... ..G. ;:% :v:MF:i:7nw.:RYJ\Xr..::�#'{. W:•t•: •v•:,:v:a}}:::::4::•::::;•:{:v.,..• :..,{:••.•:•:;4rv•:^i•.}y:•'-`r�Sx:.,::v:nv::w:•.t......,r..v....r.xn::•r.:4}:.... v.:::i{:}., (. ....r:::':'t'^L.7 n.. �:+ ..}.,,. +;;;}n.,rvn.;:•.:••:+.::•:;:::n#'ti•.:;;v::.: },•f:•:}.•.: $.{i4.}•:.v;.:vr?1:•v:.:{'iv•::}.v:.v•.:..vvw.::.w::L•i{•;•:.}.•v.:}}:;:};:{i?:::i,4:{a:v•.:•: y,.:S.v:�•:.v{•}.:uv::.+•.vr'`n•.!....•i:{i:•:•:.Q..hh.. . .,.4•<..{•::r:.::::::..:::{:....,..::.: ..:h ht:,::?}:'•rr.,•{•r.•\•,',;.�:•7••7:.,-0�•.{ •}::rn7Y:•Yr}:•::;r':'.:7•.}7::...... ,..i..,. �lit{v:��j•:... :.::::R'}Ai{:}:;;}r{:}rY•+iC.r:•:::. Av.,.;::}v..v,:.v v:,,v bYx,.....;... vx::.:... :..n.::wn+:::. ...•.. ... 4}#:,'7.}v,•:":.:•Y.;.%:?v+•••::..n.;:y.v Gii.;v v}::?•}rL':4'4 �R.•;.:.,r;i.v,..• ,ibi}:•i:ri7Y•7 v::... •:,n+:i•:;�•:ir:..:.::.}tt}:;;•;,•::..rryb{.{vi.�`i•'t•,;.;:•#:{t:�$$:•:•.;:::.:y{..4;!}}:n}}•vi4±?i:•yY..}?:..}.4'{:...Y:• .. ...... � I am a sole proprietor,general contractor, or homeowner(circle one) and have hired the contractors listed below who • haVe:he following.w...uo.•workers' rrs' C`n)..�.:}:....'..,„e,,II:%Sr`?a$tioa}:n,.:,ol{.i,vces:?:i ::•}:::•a}:::.%:r ;:<.::::.}:.}::.7::;.i.•$.`•:::::.:.{ ,}:v':•.%yY:/?'':.�:{'..:, }�:iN.:.,•?:f}'•}4:}.}!:•}rY{..R�{,n.:...,..:...:f}3#•..,,: n�: f..MC.4,:i;•$y...rrr;r ~ k"i 4.;.a ;,:4?•.'4,� fAee•��w}...;.{.,:.r 4,.[,..v.:..Yr. ::!r'?•:•.. n n, 'fyrv,: .,'•ii+`•'t ... ..::•.t••.,•.,....::::.. ..... .:,r n.. .....,r•{+..}Y:•:•...:...}Y:.:.....;?.....::::t•:::......:•47}.•:.•z:+:{.;};{n;..•::::.••..+}:tii;:i r::.r: ....x.r......:.....:•......r.:.... ,kG?..n.,. .rr.,•.:....:. .:.......?•,.,...,.....:::::.....,..:.,•}:•!.::�•...:: :4.i.rY:•:n•::::•.:t•}.•niYr,r•}}S.v'•.;: :t}..,. ..•,•..•rrrr ''''•.iJ:• +.2:•.cb,}':•`yy"•i'•}•. }rA�^���,,',.v. ., }<. .,. .. n•R•i,:. f:.. }.:,. 74R.r. Y?,. v.!k.:2#•:.::•!a�? nw..r..x.Ct4. 4}:57n•. :•.{:•'•:• .R•+::x+. ::xr;G:,•,ni•:vb.•v.•.• .fY n,r.. • •:::•}:•}:i.}:•}}::•±:i.}}}:{•::......:... ......4.ti :r.,r....:r..:...t}.:+.,. ,......:•::'.. ,,rrrr:.. •r....:r .t. ...... ..:... ..:... .. .. ..t.,..L. ..}..: ..,. ....:?'•:Y.vz•}••:;•:.<•:xx•}2:•G:•'•:.•..r,.:rr:4%:#%>,:•......:•.,•.......:.i:�t•}};.:z7yi:Y.fR+}xr£..n .v. ...........rt............ ...h. . ........,..r•::•} .. n, r..v,.rr.....{•:..:•v..:...v.v:x:.v:Lv:7:::::rx:::•.....::w::,....,..... .... . .....,...,. .....,.,:.....r 4•,r.. .:. ::. ..rr„....:. ...n..........r....... .,:•...... v.. i.,.- .,...,i;;y,w R}'" } s},'!?, �'' :•.�.h };..:k f R:•::.;R.::':z:..).... ;,, :nrii>Kv.`�•.v:77•:•.:a,.n+r:}::;:.:.....r.... r•f...R. u'r i,•;R, n� $-., ,:'�•t, :'... •o-',}: •:1,...n G :•%i;;r:;},:y:{::#:„:%%i:'•1+:i•. 4<:�5?{•'k;:.�•;:n.}.t4:rn}••„•2�i: 'g' •$�.�+.#r`�• w'�Co��.�.�r#•.r±'^%9°:•?�t' +r..a... r:.b:.i•.b.• w }�k,�:��x.;•$'}"•,::Jgr:v}:7k,.,.,}A:r� �:• f'o''fn• .�.. :£,.,.J.:•. aIIie(: ::$:<:ii:::.:i;?:;:•#%#�i::<# <:«�:: :, R• . .;.. .f :�.'{i r. �. , .x .i . y: *} a.. �q1 :'.?:4r x`R:}:....:.. v.}......, !.4};}';•:L•rv.,t... :JarL: .L:.y'r:% : �•}i•:%i'Lv+-•.•}.�$'n.. : •?•:'•-i+::•: :ri'{.ti:�e n,..•,�.. , }n •:}•. ;+:r+ :h J.4 �e'. nv: ........:n:v::...•.•'.•}" .rn4.•:.•. '4 .. (' ....v.4,4}•L::+:•.?b:.n. G:•{4:v}.v:::..±}}:•i±:•:;•:vx::::`v{{Q}%.. rv:,.4 r t..:.,•.. ::.::....;.;!+:}::: <: `i.4.. .GR;,Yv�,4.@,.. :}'!,'••'.'!•.K:3 :+:i;.;,:}t{. .:. :i,?%7�•r.'`x+ .•.�'�•.a4b. .• k': c;:i• ,,,?•... „}},;y,,,: i..:: .:.t..,n: :?{}R:}Si%+` .r,.}.,i.'Y ::.,,...Sn}:•:•}.. 4.....i1�+..�'. •.< , .r. :.>.,.,., :k:#,$ r ..:?t•:+:,r,:}.t•.r>S.c/az?:;a:}•r•$::#;,;::{r:..;,;..::.v. "?{. .:.R•x{•?•}}}}:}:•:;•;;•.,•vr• .rv:.:G-. k.a..> ,r.... n,R n. .n,...Lr:,r,{.:r;;::•}•'•••'•}••}}7:iiokG:t:w::{4•....;:{: }:pp ;ry;,,:•,, . nv:. •.rv.:v...•::•:•.v:,r,k:;.•.'.. .}:+. 4.}:y?J:}�Rv.4..::•.•r v::••.•:,a}v.•:• 4R•:•::.,.,..:}.?::•r•.....v,.,.},4::•.. v..:X{+.:;..{;:..{+}%r.:r.......{iii��;r:4.;. .:??butt•..: ../.. •:v:•:r.r•..v}w:?:.::••. ... .R•:•w•.•:.4.•?•;, :?:....,;.,4...?+i.:v.i•.•::{•.v.•..•.v:�;{.}.v:;.•::::n•}:?:{::.:•}}•+{:;........... rrr.:?.,v.....;r.::..r...::•...r.r. ..,}::....:....::••..:#::•:•;.. •.,•.......t:r.::::........::..........:::•...:•. .,.. ..;;. ...... ,...,... re�J:;k%:Y't:{+;•r.;.:} •, •ta;:i:};...,i4Y;•:'. ;t:f''oi4.{�ii?:: 74,a,,{,:•:.r1;.:4:+:•':•::a:}77:•:•:•.:x.:';:?:4,::?:}'•.:.ay y}:•.,R:4}$::•'.:.:.,L};7:tfi.'•,[::�.....:: ......... ..}:n.. �,.:; .,n',:,•..:}:'?,..),..,.....}... ,•:.<fi::7•'i{#.,"??:4;a`•T:4ti#•n'r}•,Y'.v>k�,,7GG,°,r.: {;t;,rr:4: '%Hrr' 'x�:': S$' `• .%c>Y•'Y9,C.:L4:{:•} ...:....:.vR:....•:r... ......wi v.v�v•.:::+4.:.•.{•.•:•}.?,�:.::. n•.vv•:'{%$:%R+..•{,ir,;;•:`vf+.is+ir•$}''}br Y.� L•,++,}v,{� �?� SS..,,.......• r....r.•:. ••r..::}.,,v:t.....:• ::•}.±• >;a>Yy :%;,•.•?:y: .}.R., } R•a; .,y> 7:.•,f:4f{Aa C9� i� 1EtTe :r{{•:•.}::±}.{:{. . � ;,tyr$ e„•+; r•N::.}.:{•{;,n.-. , t?;+r.+::•{,.z}xn:?r}'C.:'•:n'FJ•;•.+;;:$. ,G. •...,'L,.�,R y{, .i;i`�', }y:..•'+ ±rrj�+�r�3'?{' y.. 4:•�%:}'ri: { ".;{\n:�;•!i{.,.;f;.:Rrn:,:r,${:.'2•. :a r...v.{R}•:.:,v.};.',.. v;. .:•..z.....::. ...•}..4:: n•r:.} r..., ,. ...f v.{•.,t. .0.r. ..zR•. ...}. t,:.:..:•n.<:•`C:i>:2Yt%$br:;{•}::% `,v,.'•9G•.,G:{•:a:�.,!•.v?er.{.:.;.:3i.:7.a,:., .... n o } 3 . k• $tilit: vrr... fr ;r 4#y fi'#%.Y•3;..}k'Y.;+, .::.:{{••:.t•.:..r:::•:.4.+,;3},,;. {rn:n}�.v, .}{}.,f'f: ±., ..tv •::br•z}}:{;.}.•:.n•.. ,:......:.,:•:}:::r.}:... }••...c}.;..,...;.v:+.:.:•}•$...r+.t. .r. .:. ..r...,•!?:r r .:k;•:4.....n.•::::::. •±.., }':%'r:%ri%ir:t.:;•:,...... q,. + .. c..•p: .:.,:•:!•...•.;is?n<,,:.n4:}.r;;.!.a.:. :Y.' ..1R.•#:C, s< .... .5.....,• . . r "•4??'. ?v :;:{ r}vq;}:i:.i:•{{.'ty;;+Wji:: #. ''R:?#�;?y!,'S?%'P•f• ':,r'i{`•'fa✓::;} {..+}f.:::•.•L,:.,:., n} {., gir4Q:aa..t•::{.,?z•r.{r...:t:!:.,r.....:.5 ,,, ...:::,...::w;+::7,•n.::.....t•'„±• . n•:.4r;n:,.:.. .. ...............:::: ...-:•::..,,{:.ii::�i::{{{47:%:;?i:','is3�'!•'r;;•'#:?c�•,:.`�':#j•!•'+4'{.}'r:•.�+r���fC':2;4✓t•y r�`'C'2,K,..#`,<�:{" :R'. ��{^r•"rj,:,'•. ti•r 4't��:NG}�:: ,ir: .}7,v.•$$.} .?/;'•.4:• .'` ' 't:. ?� .X•`�•.vi:?!:;<$+ +{:•f i i;.fi%i'•:$u:....-vi:r:iti • •}i}:i}' :•.....;r, ..?. ... }:,ry:n. : : ." .:.'{}:.. ? :2r.:'• 'ii ..'.:?%;t:}}::.::;}7: �,J..x::r<:'•.?:a•>•;:?:.:a 4..a.n.l.t.. r±%i.�.,.:• {f.. tr+a•3:� :.tr.�, ?+•'y$'.4 ... .��•S`.c• 'k'+ :. .,}.v::{4}:4,;•;{:;2i#}rr}v.4}yb.L•:::ti'•'%%.y!f� t:ti<h {{ Q ??..,,$#•'}i;^.,';::S:i};fi: {':'%'r'i}7, R±�.. h..vr i r},?n::�`:.;.}•.,+• $?r#:;$i r S fiv• { fi x.3 {; n�+ ..'N...}i{�4.r. .+r7i G4..... '+...•::•.}}r•i}5;::::.v-: k.R..•...}r {n, x.x..';tv+:•. $' '+v.9•v:b:{::•;ii.•Y'•:. ?:,k .:.;;?{{{:;::`.:,'!.+i::••.•.:�z};.....,...,•.{v,y.,r.>.':+r.:.;• ,.:r:•...,,;3#:;n,n.,i;:•R•:bffrY•:{;i:;r.::iyy.x+.+•:.}•%±:{•:i:7. •:.::: {,• .Q.x:Rvn:rAv•. .:.{.;L.,•,:•::.','.':i.n p,.. {vF. :,},•.•,v i{: .•}.•.7.:::f4'}.;...?,.{v bntnv::•'jr.,..••. ::nv:i+:;4:::±.?4'%:%i}i:y'•\;},. 11�����;�,:'?#:i:vi? v:iti••.v•{.;i••x::.+.•}r±..v::i;:;;::•+f,.G#;.Y;{+}:v'{,{::?};:#•:�:}v4 R:•:>'l:k, 'tYv•'•;:}::.;x...:G....$::•'�...,..:n:�• : k}:.:x.;:+i.:{• O LS a. ..:.}r...;:.:+f.+.:{vb.!;:..;,S.S;.{ r.:...::'{'4'?%v'�'},4`,{vf,.�}a?,:�+,'••t,r:,.. {4:�:R•;•,2Y, •.4... ����/ •yx{.,}+::...tv...;}::::...}:r4v.••+r`.''Gv+}'»4:{•,t�};};:.v..{+ik it.,;.fo!:'t':r:;ky+'# :$;;x^'tfiia$ifi'•.•:%4Y•}:•}.;n•..,k:..:r::.};..:. <;:7'${//���/ tw,i;:};;}:Srinli.�•.$::{.;:}'f.•'.%}.:,::7}.t1tv'i.. .. {f?•[}i'r,�Y•{:}rii {•Si};+'w%i$i`.?}i,.t%$4'4'$%{?`i':$:Y+Y•'''l:n•`.wwiir'•y:;7:':'7'yi.:','v+.;�•',,'}�fr,+•'_^,��;' .a}i: 35':i•'Yf.s:}•};#:;`•; •,.•,;�•i:};;::•+{} ..kt{.t•++.? r.;:.bi:•39°!!%..}:.};,;r }1#j }�•t{,n` ..\6 •w•r r�f# .{..;..2 :•4i•}.{nv•: �+'t"`'`..ta.}r.:,•...{�+r.t.. ..,k}:.R �,i;.(.;:ii; ........... v•.vi:.•:•'7:+.+?ii'::S:ii•:},;7'$r'.^n}. .+: .v..4•::•'i•r...n r}:•{..;,i:".}:{::}: :}• •Yr::..:::::•,•v,. t•:. n ..:i. .2}:: ..a.r.... . :.{ fi.:••• :: ,t#•:}.}r•Y:?•.,c,,:•ivk=4rrr7r.•Y. •! :3.a4C { 4�{ ;?..:rn .v.:... .:rr.:•.,..;<+.K.7;{r:::t•G4 r,.;,.}:::•;,:..••t•:::•}<}n�•::•YR••R•.v?:•:;:::p%}}•%$•$;::•::R,.t{,o-:.{;:•.::...,�:V.,•n�'S.•.• .•:•��'.•:•`•'fi}.35��...?....�.rR,:. }}.:r..:.•::}.•:..::?±v;::G:f•?•:'.Q:;:iti:/r•Y+.;•{v:•.•.v::i•;rh7 :7•.4:...vn;..; t.; r4?rxx.•r:•:::::v:rv::.•:•7v::r.•n.;;{•::v:::...v::•:.4..:i}{+.::,•.t#:'7:aX{t'•.J.•.,:........w.. ... i•:'r•.. ..x:....r..,.;:+.....vn ..r}'f{:.n.•:v:?:•... ,v$•:1#'.v...v!r....v;{.:..:..v...:vw;,, ....n.v.t..,wn,... ....•v.••;i#•ri'•.v:. r•.:.:,x:.....•r:v...:,..?,v. .,Yv:.n..::::: .. :$...:.:.rv;::• ....,;.,,r...:::t:.v.....v,.,.;r.:r}...t.:.:.......... :..:. r...... .i. .,,:..: :.:.,....: .. ...�•.:r?:...:a•:::.:........ { ,fir::• ?r. :.•r....:R.:::: .,.::.... ...n..iv,•R,.. ....7.fi:+,•::,...?}}:¢:•,• .,.... .n:::•::., C <:......... - .Y;::n...i::{.;i:;;:„.:•:,::;{$i?r+.v b'ui.;:,Y+k :,{•.a'y. , .....,....,.,:::..:.:.k::..d...,:,... ...7......,:,n..Ln,::•.•.....::::•.:......{.,{.,.;. .. :r .::.. ...•) n,..:.•}'ai; ^;:, z.•:•.a7 .x...:.•r.,.....:.......:•.+:.. ..:r.} r.. .•'+v ..}...{., ......,•..r...•....::............ v....•.... ..::::::v.}:47}:;+i h}'{.;.•v+'$:$�i:%'i`•'i: •'#v:•:},h+.v n:•fi: $R•:: :}'ti'v...$ },::.•..::::::::....... :..•.,.,,+}...}?.v..•.•::t,•r:.,}.::±:::'.......... ::,v:;:::.:}•}:<•}7}}:•:::{:•.v.;.;;.: .7?.+%3•:.r+.a°r.: r.t, n>::•.•a....rY.:..}ne. iv:n.,rt::•. itiS}',:��}5:•!,{: r:•. •:?a:::!•}.fn,•............ .........,.v::;v:::::4••r.:a;:::•:.....{. R... .•i..;n+�f.;z'?ti.:.•.}•',...4:•:• ?r.¢:..}Y,iY•}:9.Y"•}+.:• :v:`,n.•:}' + 3�.+'•,}71fi Huse:.. :{}.}vG:.?n;,};.,v'+}w:::•• ..s•.::r4:w• .n.,..., .. n%. SII{F•Zl :{:;:rr.:...::,vfni,aa:•::4}+•?••::.v:•. a +}.: ,:4. .,•:r•:#•:r7:::4 }r. :•t,+::.•..SQL' {r.. :r..z::.,.. : ..<...:n::.•;.:;•.r>.?,.±•,n}<;••:.:•:$:;:•::yv.:.v:.v .4.::.•:is +�•••nRk• . .�.$$tk;.,•,.:nf.. ...;;{.,;. •,n 5. w+z?anz••}}}n`v.ti:. •r•4'•;%+:i+Yg+„a%;}.:b.:.v.+,:,4•.. ••r.•t :2}k#xLR•r:} ,J•.'f!v; ..}.}.k% ...R:v.i{:•::. :•:$:}}.v.:..7..:fi:• iy.i;•.•;%...t.. ,•+.+4•>t;::•:}• .?i.. }f r ...v..... •} $R"%v•:{i••?r..'#4}ari:.•a.}:. $.ii$:;:$i:�:•RL?aR:b}:•}.}.:b. ..•}... ;..:<. .t;.;4:±r:�}.`•}}:•fi#.;6� :. . :::is::•::::::?•Y:.:•.:•:{.:4::•}r:.}:. ,,, ..••..t::;.}n,•.,•:7t{.Y..r,:•.•}'•.:•}7i:•}i•:t:G$iz:;.;a.}•;.,.:.::'.r•:•r'?:}••:4:.{:. r:+.....,:.;....:}.•::......::r..r::i} ..n,•:+vr.L#:i�:.•.... .::••... .:.,r....... ...,.::: •:::•.};{..v:.vr:.b:::•}.L•::.t':•::•:4}},..•Rk#;>.}.;.,,:}R}n`•::..}}..v..•:. r{...:...n..•:;......v.n..a\b.irr.... ,.n..::•{r. :?• n4.:2..:?.S n....v.•:::•.•v:r.,...•..v},}}}'v.... ..:47}}:... :•;:;:..i;,.$. : n•.....r..:....r...:...:...........:•.zr.... .•., :aS,.,C,.:....r........,{...:...,•.........:•}..;.r..... ,.....:.,:?:::..vim•.,•::.: nr ir.,y�.};G;h7X%r'#:{,.., .Y, '? ::R.. i•:::.v:•::nf•::• t.:ib:}.k,:n•:•}:::::.;L•}:., ..,.,,•..•:::..:.... r..::::•::,,,..:?.:•.•••.•:::;::v ..... .. .. ..:•:...::,;.:.k.,y.,•;>;'.:±Cats:•}'a•;k�%ar'1°4{" is}yr{::i:,,..i, :�?,:•; 2+n}•44:;?.r2:�::2 .:{.f..:.•..R:r,.:;:''..;:+::•::v•...•n.::::•:}:}i:Rv.+.,bn.,..... ... :••::'.•:{•}:..::v•{:.}:•:i+;{.M>}:ti�::'� .5j?C;x }}v, ....•..r:..n.: .x, .. .2x..F;Y.'?:;?'L{;::};•;r}: n::;{:;$7:•.. .Y'p�:}}H.• 'f.•:4}:4 +{:4:•:: rrn;7v.. { v.4. •r,7:; �. n0.•.. rf. R':.:. •h .4 .{;±'{{•:iz:+.%:%:%:t}i±} {ii{ii4}:i4,;<G:n:•: x.r 2.. }•;;•}rr•i}::L:?4n`:%$i .rb.47'.. .J.,,. ��+' ess {:titi.,..xn,. 4.•.Lvl.•t, ..},: f.•1:}l+v h„r{•':• .4r'ii.• \'4:+'`i. .....:..r ...v, .....r. .............v:::::.:•••±:•}}}:{•:: :....... .r..v}:{{..;.;;.?:::• :$;w•!n}i:4!'t%'ti$ii:::;;•R:w.r.3},JK. .},v:'.��.ri:...anr'/.•.{>{.}±:•i}�:• . ......:..:.r......,...r ..:.... ....',:.}. r..:.:..........:.....................:..,r x}::::w:;:x•r:•:t::•}'•:R}:::::::::'rv:::r:•}:+.. .{ i ......:.......::•:.........:+.....:::....r.?.......k,.:+......•:..:. ......:•:.x.t.....:::::...........::......... ...::........,.:.........} .....:•:.:.::...bo.} ::•t2n:.n.n�'.ru,.:n,r:.`:`r••}•:i34�:4:?•+.;:•:,:3.•:r:,;::.:a.if:n.;7,;}.t.`w..........;:•:}7.:}:i..:{:...: r,.. ....... r{:......... ... .,.4..r.......n.:. ... ..:: +:x::'• r......ri},4};•R• .}v; ..:..,n•........ .................r.....n. ...•$..{.n ....... n.....:vii{R:•:•':v{R.,}:::::::.}:••.•?•i::::+:•±::..v:v:+:•... .'#iv•. vl,.,•:::.{•.;............n...... ...�..::........:.........:+n..•v..,..v• ...,.....}..fn....n...h........ .,v.,•...v:v.....;.,, v•.•. •:. •....... ......... ...:,v 4,'::'•:x}r4} it#y;.`;-i,:; .. .,. ..v+. r... ...}... ..n....t..• .:.r,..}.{v:..v:.:,;..;,,....:•:::::: .........,.;...n:'R:.:L•::•+ar±i::%fi!!..t•.,4;i:::ai:';iq;.;hJ:.,cf;},..:. .. :.. ....::. ..............::........ ..,J......r.:..tt{t............:.:........... ....:•:r::.v r::r;::nt{.;{?.}`:!ii},}{J$iY:,i.;...v••},}a}:•t.+r:.t:....,}:•.}R}:•.:•''S,.�t, F V:;.,.}:•:r}•'t i{.::::: .vr.:b::R,:.•vr::::v..:,.:vn•:•;:.:+ wn{•.•...•rt••::..:•::t::••..,.....,.. ..i:..• ` .. ,•it•.... .;`a•4:}:i: n.... ....... ...............:......... ........ ........::•w:::::::{:.:}'?.+}±:±i::vi:%iiY•..r........:::•:};+.}•{?;{r.+;.4i v:.:.vy{,' v.,.}:,::{:{{..... ,...7ntL•r y�:•i• } .:..:::::....:::.,..::•:::...........• ..........•:::n•:.....•;.+.t:•:•:•...,.::r•:::,x.•./.•:.:•:: v.?r :r.;:. r{:r:..::Rn :rYGk.•:'.., .. .. ...::........:......... ..........:.. ..,v: .........:.:.:L...r.:...2;?....n .. : ....:v4:?{•F.•}:i•»y;:;•}5±.;:.i'+:::i•Sh:.}R t;}.r. ,r'.�1F J9, rf.t r:±•r£'•it :::f+rrF_.r: .,a;r$�•v ,ir�,${%i•.:7•,±az�,•{{r{Vt�t�?< GL.•......... ,r•r. n.R.x:::r.:•:r•:x.b:...•::•::•\.....r::::::.•::.....;;}z.,{ir•:.v:......., v..r4{::1z.•.vn..,r :'•::.n i+#•{.,;n, +.b•..•7.: ..........•:,...•v.i{ •+:vn.{{tv,... .rr.n...n{•:x.....;.,:v.v....,.....n•:r..... ;::4{:;;{.}?:Lr{.}}'4•.v.,:...•.,h.: •# yr:.....{V .. S.:}.:\ yy-��.k•':$: G i'ri i:$:{�,•vn z... ..R':..:.{•..... ?n?...... :.}•:.v... .A.... .v.2 .,!•:7?}'+}{.}ri:`•iit•vn?•.;{:• ,n,}.. •+-0,v:•n :hJ... .. ..:,L:•±::0'•.. •..2n. i. rri:b:•$• :.i:+.^: :.'{r+•fiv'i a.+i:+}.`4+:n .1.,•, rn;v{+ir:}}'::{r•. .v:•n..y;•.vn,•.i;%}'ri{r:Y+.i(•}p;v }..yr,{{i.'t:;;::;%i!,::#::,%:::.:.?:7{:.. f•+:4:.•::.:S.....v:.,:..{k:`.':{,•:.:•:r............. , .t.. .��..±Y•}::::•:.:::7.•. .. ... :..r {..n fil:•.•.:+.n:::k4:.v.•...,.f•w:n:}}:•:R;r.;.vi:•�•?.,:}}}•r:.};:.}; .{.c��,.::}:::::,.....:• :<i2�::•t#}';:} ' #`:2':'•2'#:xi:b}i4:xi�.^.: !•.vnt;ty:rw:;?:}::•p:..:4}; :;•:.\••:• ra.;: ,.,..n:,.;., h...... .r.:tv?r..:}::n........,..:.T.}:•'.:: r...:G}::{•.4...}::::•:.•^••:.7:::... .{4$v v-•{v••{f:.t.;. R}v..::x:.v{v{:;{;?tir::•:.:. ...i::.. f }:4..,•:.t:•}:4}}:.:•:::•.•:}.:•....:ti}.":n.?,S°;�•tr:••f•;S}. •i}.:H?•Y::;:.:•rn:::.:•,•.::..1 .... r'•;v::n.............;...... .n:•, { } "• ...•::.•,v4,•.vn4nv.:.::';{•}f{i{{;•:ii•}}:::r...... i .. E tUATslice:eo•`i>:;E;:.•}ii. :.>•:;`•rir:<#::.}::.•t:,,....t penalties of a flneup to s1,500.Q0 andlor • osition of criminal Faifare ser¢re cove sts required under Section ZSA o[MGL 152 can lead to the imp a line of 5100.00 a day against ma.I underst and that n one yam'imprisonment as Wen as dvit penalties in the form of a STOP WORK ORDER and coyy of thin statementmap be forwarded to the Office of Invest(gations of the DIA for coverage veriScation "2.,.` " that the in armatian provided above is true and eorred h, I do hereby certify under the paz»s and penalties ofP�7 f � Signatures e� " ` C? . x n G\C �C-e-t�PIE lone# Print name offldaluse only do%Lotwr te ite in this area to be compled by city or town official perm-Kit/llcense# ❑ mg DeP ' city or town: ❑Licensing Board []selectmen's Office ❑ check if immedlaie response is required _ ❑Health Department []Other phone#; contact person: rre,:;.ad 9/95 PIA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the `law", an employee is defined as every person in the service of another under any c9ndract 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 section 25 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 shall enter into any contract for the insurance coverage iperformance of pnblineither c work until commonwealth nor any of its political subdivisions acceptable evidence of compliance with the fi rance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names,'address and phone numbers along with a certificate-of fimu _n_ce as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of incumce 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 obtaini a workers' compensation policy,please call the Department at the number listed below. VEIN City or Towns 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 petcens0 number which will be used as a reference nii&ber. The affidavits may be retarne3 to the Department by mail or FAX unless other arrangements have been made. ; The Office of Investigations would like to thank you in advance for you 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 Juvestlgatlons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 .,u .,o a. (4117) 727-4900 ext. 406. 409 or 375 oME,� Town of Barnstable Regulatory Services STABIX, Thomas F. Geiler,Director �$ s639• °� Building Division pjFp Mp�a . 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. L >/_ J cam„ ec- EstimatedCost�Es6. U© Type.of Work: ©n574iYeco.� y A�o�0 Address of Work: /� �IfISTLF �IZ 01 C 7-�R y!cC.E . /(ifs D,26�z Owner's Name: <b lv rAJ S R Date of Application:-- 00' a 7 I hereby certify that: Registration is not required for the following reason(s): []Work excluded by law Mdob Under$1,000 []Building not owner-occupied []Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR'OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR ITRATIOAPPLICABLE PROGRAM OR GUARANTY FUND UNDERM HAVE 142A. ACCESS TO THE ARB , SIGNED UNDER PENALTIES OF PERJURY I h reby ap ly for a permit as the agent of the owner: aY a 0632Z� Dat - Contractor Name Registration No. OR rl�mer'e Name °FtHE T Town of Barnstable Regulatory Services 4 aexxsresr.E, •Xnsa. Thomas F.GeRer,Director 1639. ,��' ildi Bung Division��TfD MA'S A ' Tom Perry, Building Commissioner .200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Property O p rty caner Must Complete and Sign This Section If Using A Builder u 1 as Owner of the subject property hereby authorize /C d 1a t—K E GkC—e#'U 1 F to act on my behalf,. in all matters relative to work authorized by this building permit application for: i(IIF r � Dzb, Z (Address of job) Signature of er Date Print Name - Q:FORMS:OWNERPERMISSION OT BOARD OF BUILDING REGULATIONS icense: CONSTRUCTION SUPERVISOR Numbet� 063223 'I� r C 4Ec��r �1 U8� 04 Tr,no: 1555 j Re ROBERT R MCKE�H� "/ , PO BOX 305/166 H��. [ Eas•e b 7r MARSTONS MILLS, -0 648 Administrator i I yr'cL� � r i✓ �'•'_' . xJ 1: f �• re CJOpp t1 �'cr 5� 3z0,0 L o r 73 40. �.0.., F'20NT Si CIE /p P20 po5 i SEP T f G 5 YS TaM CONS T�CJG T/ON —3 E3 E-D je, SyA[_L CONF02M TO � ENV/.2 orvy,CrV TA•�, COoF_ Ti TL� Jt 4/VQ. TOI:c/i%/ OF . ..2.4 Tom. 1 TU P p;z' y.EA G T/-/ 7ZZ---6 UL 4 T/O NS "0 4-YMP 71On/ �2 o;ao S�z� L:E A q� NNOLE CO✓E,e- Tp �X.TEn/D Tpp .//M,aL WI 7-:4 irV 71 CY A/< 2c7i+, F D/ST. /0 M/n/rMUit/ - -_ _✓: 3..n4,AJ 4. D/A. : NV47Z-AZ Q CO Di L E /FOOT /O"M/N A O Ow " L/niE MAN !�/Tcy ^'�—_ 4` / .4'cic 07 . Z' Mrrvrc Al R/T 4Foor .11 GA L L O ni /Nv r a 5Z.oT/C "TA/,/.e L EV. .:. CWA TC/z T/G A/T/1 �1'. //U I�p I$oTTa1M G ' A10 GAX->B;AGE G,e/nfDE,2 20' M/n%iwlCfM T - "sr LUC,4'7-IOti eEF E 2 EnfC� r� O•L ,7. • FO,� - ,�5 o u 7-4-;6=rs� ,•gN,Zj L E.4G TO 8E OF .: 'E i�/FQ<2CEL STEEL T� �c LbA /vE w,aY !$ «C7✓ .2" .SyS'T" /�iJ U/uL55 14 _ 02 63Z - �ol3E�T ,v`�lI�C�Nf Al : Aft To . ZL 1 y - ..........._._ _ - -- ;6xvsriwc- WP.bE /<�firr ` [.�.vE /S CgQ ovE Ceh-bF- M'4x B ecac oval, CoaueEr� 21 `�� f'a9e *Aeap5 �a r;�e�.10" rkn. iCA��1rJ65`; $�T�+ 51A�5aN•A STEPS _ Ed uv _ _ .. f E �i ZY 8 pT 1: s er y b�iSocaC �CPGK � i ;�! T!p 411#w ,� :V4 II y� r Ylioll Ir • � W E N'a y W�z.t�E�.3 5(c.( Ill i I I + Pry .. � 1 �O?JT OF d-o&tsr �j-- P�2oPoSE� � C Op