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HomeMy WebLinkAbout0039 MASHPEE ROAD i u 4X -T �4 t � t �PTiC. t iacO 6ial -� �kAet��wl� 1 LooO GAL, O 0 014 c't,�IJ • �i Tt ZS�:t wi�L�Ar� /'J = Q� F-r A4�` 7--10-76 X? ' At /h✓ '. /ram`G Nk� cs33A �' 76 ass 's map and lot number .......................................... 7 SEPTIC SYSTEM MUST BE Sewage Permit number 3 (� ................. INSTALLED IN COMPLIANCE g """"""""""""""" WITH ARTICLE II STATE SANIT Y C 1 TOWN `7NE.T°��o TOWN OF B AR1 SWA i BARNSTAHL i 01N BUILDING INSPECTOR APPLICATION FOR PERMIT TO ....... �Wr...`' . .......'.... .. ©`..S'�......................................................... TYPE OF CONSTRUCTION ...................Q.QQb........ .K..lt!`1 .................................................. ................................................19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .............4A$.kk.j......&.AN.......-....4.4) �............................................................................................ ProposedUse ...........QA......�—Ar ..........qa v 5.�-..................................................................................................... Zoning District ............ ... .�................. ..............................Fire District .....QD7K:i!......................................................... Name of Owner ...TI'4. �L� f-.... :.. R. ^!............Address ......17.!� .�...�! .^l! .. �"R�4?.S.r� ................... A Nameof Builder ..... . .....t&07.........................Address .......... ... V. ...1................................................... Nameof Architect ........!A.e"L.......................................Address .................................................................................... Number of Rooms ......t�.1.(`S.!. .................................Foundation .....4 apq.aLT;� ............................................ Exterior ........1 ..1.!1(fa.1�.�G.................................................Roofing ...........P.C�..�A ITT................................................. Floors .......... P.. .............................................................Interior .........s�!? .I..1:4q(5)k............................................ Heating ........,. T.... .!. ...............................................Plumbing .......��t�5TC ©PYE. ........ Fireplace .........Yk,5...... �.>...............................................Approximate Cost ........... f Q.......... Definitive Plan Approved b Planning Board _______ ___ 1 z_________19_� Area /�j S p P Y g .................. Diagram of Lot and Building with Dimensions Fee S31t..ry. SUBJECT TO APPROVAL OF BOARD OF HEALTH a � q2 221 I hereby agree to conform to all the Rules and Regulations of the Town of Barnst le a rd' a above construction. Name �........................................................ ...................... Baden, Frederick H. V o .....145M.-Permit for ........1�2„star , single familx dwelling Locatiow.1.....l" ;I.ghpee_.Road........... .................. .......................GAzui,t........................................... Owner ..........F.radarigk..H.....$Q4e1i................ Type of Construction ........frame....................... ................................................................................ Plot ............................ Lot ................................ Permit Granted ...... July 14 19 7.6 Date of Inspection ....................................19 �Date Completed .......... ..... ...........19 PERMIT REFUSED ................................................................ 19 ............................................................................... ............................................................................... ............................................................................... ............................................................................... Approved ................................................ 19 ............................................................................... ............................................................................... -' � TOWN OF BARNSTABLE TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Name of Architect --- �'�`-------------Addnss ---------------------------- - Number of Rooms ....../^- |/ �.I .....................Foundation -' ............................................ Exierior ........ ..................................................Roofing .......... J/- 0 . _________ ..................... F|oor� ...........^\- -��----.---------------]nt��r --- ��-----_.._______.. J {} ) r< . u4 Heating �� / ! �� Plumbing ��� Fireplace ' �� [ / \ App�i�� �� * ��� /` ---/-'�`--'------------------ --'~^—' -----''r---- - l Definitive Plan Approved by Planning Board lQ Area -'�'-�'� ^�� .^� . Diagram of Lot and Building with Dimensions Fee _.�`� ��...........______ SUBJECT TO APPROVAL OF BOARD OF HEALTH /~ . � ` . v - . ' . ' - ' � - �~� � . � ` | hereby agree to conform to all the Quba and Regulations of Barnstable above construction. | Nome ���.....-----..�.-.[�-�--�r=°------.. ' 7 �� 8odeo" Frederick B. A=7~38 ' " No ..l85.l6. it for .l...l/2_otmr� ...... ...................... ^ - . . a1oule �mm1 dvw�-lllou ' ----..~---.--..--- ../-=------- ' . Location --'�a Y . . -------... -------------- Owner . X Type o, Cononucn . . . . . ' ' . Plot .. ~~. ' ` 6 Date of | ' ~~'^ Complete ' ' . '-_. ' ' . ' -' ' - A: . ' �p - F �~~~ ~ -'--xr _ _______. . - -.-------. . . ' �--��" U . -----w.--.----..----..-------.. Approved ................................................ YA . . ' -------------'-^-----'--'---' / -----------------~--.-..~..- � ^ , � . TOWN OF BARNSTARCECAPE COD, . INSULATION 70' S = 57 PRIM GLASS SEAMLISS SPEAYPOAM SUSPENDED - SA11S OUTTSIS INSULATION CIRINGS yyS 1-800-696-6611 /E6�j7 Town of Barnstable- arn t 14/13 s able � _ Regulatory Services g y Building Division 200 Main St Hyannis, MA 02601 Date: .2131 iZ Dear Building Inspector Please accept this Affidavit as docu mentation umentation 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 (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. Property Owner Property Address Village 41111i,eft t .?p fly Pry co T Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings Slopes ( ) ( ) ( ) ( ) ( ) Floors Walls ( ) ( ) ( ) ( ) ( ) Sincerely H ry E ssi r, President pe C Ins ation, Inc. i " TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel ® Application # Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street'+Address h. Village &/�_ Owner " (t o- Address &41M � Telephone 61 9 - VL / 15 3 Permit Request 166k b WArovm, iw , Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation JI Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 0/ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other 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: ❑ 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 ❑ MQ/ If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION ar�(, /��../_- o BUILDER OR HOMEOWNER)O& Name Telephone Number !9V 9- ?'5_' /7 4 Address 55 License # l Home Improvement Contractor# Worker's Compensation # 09.4 ALL CONSTRUCTION DEBRIS RESU ING FROM THIS PR JECT WILL BE TAKEN TO SIGNATURE DATE l FOR OFFICIAL USE ONLY ,a APPLICATION# DATE ISSUED t MAP/PARCEL NO. ADDRESS VILLAGE OWNER . ! r DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL i GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION •PLAN NO. I Lr Tile Cotnmonwealth of Massachusetts r Departmont of Industrial Accidents I 1 ' Office of Investigations t 600 Washington Street Boston, MA 02111 y www,rnass.gov/d1a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrganizatiorJlndividual):� � � �t'�5AI Ley -t Addxess: r C/ City/State/Zip: Phone #: S-0 S. 7 7 . Are you an employer?-Check th appropriate box: 1 am a employer with--'�� 4. ❑ I am a general contractor and l Type of p roject(required): eiriployees(full,and/oz pact-tune).* have hired the sub-contractors 6. New construction 2.❑ 1 aazn a sole proprietor-or partner listed on the attached sheet. 7. ❑ Remodeling ship and have no employees, These sub-contractors have g• ❑ Demolition working for me in auy capacity. employees and have workers' comp. 9. ❑ Building addition No workers' comp. insurance P•insurance.$ required.] 5. ❑ We area corporation*and its 10.❑ Electrical repairs or additions 3.❑ 1 am a bomeowner.doing all work officers have exercised their l LE] 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 employ 13. employees. [No workers' ❑ Otber 6_i,4,t,(-�1•14.r 49 f comp.insurance required.] rAny 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. 1Contractors that check this box must atutchcd an additional sheet showing the name of the sub-contractors and state whether or not those entities have cmployccs. lf,thc sub-contractors have employees,they must provide their workers'comp.policy number. f am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: C, (2d-7 tl_ Vllljel e Policy# or Self iris, Lie, : Z Q Expiration Date: ( G Job Site Address: City/State/Zip r /r , /'� ���� 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 $250.001 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 u e pa' and penalties of perjury that the information pro videld Bove is true and correct. Sijznature: Date: L� f Phone#: O 7 Official use only. bo 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#: tcoyars: � Era '.Los.• Y IarJd: �w: Clill 4597 CCINSUL ACORD,, CERTIFICATE OF LIABILITY INSU NC"E DArI ilvlvuDaYYYyrl THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY A THIS ND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, CERTIFICATE DUES NOT AFFIRMATIVELY 01, 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 INSURERi AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the and condition it certificateholde t r is an ADD►TIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to he'el'" s offthe policy, certain Policies may require an I:nd ill lieu OI Such L ildorsaNlent(S). orszmant.A statement on this certificate does not comer riUhfs to the C.0 rT 111 C:JlC IIOIU Ii r' - rRuuul:LR CONfA T Ruqulz,u Gridy Ina. -So. Uarulis NAME: Margaret Young . --..- . _FAX_—.._._....-._......___.....__...._....._._..._ s 1 Route 134 wc.No ex :508-T60 4802 me No: 508 258 211 :NAµ- -------- _..t_._--------------- P 0 box I601 ADDResS YoungmaCrogersgray,conl RDUOCER � Suutll Dennis. NIA U2(i60-1LaU'1 cusroMtRlns — -- --_----- ._....__..___. ..___. ...__......___...__.—.__.._._..._._._..__._._._�_.— _ INSURER(5)AFFORDINCi CUVtHAGL: Ir;aUricU _ - NAICq Calla Coct Insulation Inc INSLllA:Peerless Insurance 18333--- - —� 455 Yarmouth Road wsuRERs:Ohio Casualty Insurance Company Hy Illl IVIA 02601 INSURER C.Atlantic Charter-Insurance MN Ll RU:Commerce Insurance Company . COVtltA4'c;;^ -� CERTIFICATE NUMBER: - REVISION NUMBER: ' TI-I,1 TPIE'.PULIGIF':S Ur INSURANCE LISTED BELIIW RAVE BEEN ISSUED TO THE INSURED NAMED Ah]OVE FOR THE PQLIQY PERIQD tI::;Tl.!i r1VTvv11't151'AfVpING ANY REQUIREIv1ENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CtN IIrli,:ATE MAY BE ISSUED OR NIAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT To ALL.THE TERMS. ' cnl.LuS Oros AND CON01'rIONS OF SUCH POLICIE3-LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iF7SR lti , n1•E OF INSUIu�NGk OLICY EFF POLICY ExP SIZ p POLICY NUMBER MMIeUlYYYY Nmuorm LIIVIfIS. A t;kh'k1fA1.LIAtl1t1rY CBP8263063 04101I2011 g4(g1(2q1 EAq-I iJGGUttRLNCF: b1 00-r__)),000 �I XI CUNIM1IvKC'' L QClvLtV1L a jt}q.11Y ANfAGETO�ENTEf1 PRCNIISL'::IFIA r1calffeli1 00�000_,_—_ N,to Owl(rely wlv poison) 'y5 00U __ PERSONAL.tt All INJURY ___---- f—� PRODUCTS CaNli-(Ql-'w'3 y2,000,000 Q AurolllLltslu uAsan^+ 11 MMBCl 04/01)2011 04101)2012 COMBINED SINGLE LIMIT ,'Nf AU 10 . (Ea 4-io-1) �1�DUQ p0Q . ...I - BODILY INJURY(Par u ,syn) A S.'Pn-UU L-U AUIq$ - - BODILY INJURY(Pa uuad�nl). L �-"--- '— XPROPEh''IYDAMAGE - -- ------ _ (Par uCciJ�nl) ' � NVN:.IY41V l_I I E1111\).`i $ ti urinlctLLauan occUR UU01254514645 4/0112011 041011201 [ACHOCCUr:tuNc(: �1000r000 _ { ._. .. CIAINIs 1_.. _ .._....- AGGREGATE yI 000000 l ...t X Io-n rnlnN 1 1000E -- --- --__. ..-..._ (, 'VORrU:dtS CUNIPLNSATION .. AND anlrLOYLRs LIAalLi WCA00525902 0613012011 06/301201 )( bVC STATU- Ol"t1 Y I .r`Ni two FhICitN C GNPXCLU DE I NEW APCUT W'E�YF"'IV'�I N/A- E L GACN AC410kN1 ,h4 Wulury In NR) `'---a -- 1 -ua wxauro unuur - � E.L.DISEASE-kA L-MFuI OYLE ti5gq UQU IIh iRI'IIt1N(IF t1iiIION1) ell iDISEASE POL ICY LIMIT j500,000 1 . Ut;aCnlrl lur,ur urttW I IUFrS I LOCATIONS I VEHICLES(Attach ACORD 101,Adddional RsmarIl Sdnadula,4 nwrr space rj rrquirCd) Workers Cotnp Information Included OffiCi or Proprietors (Sdd Attached Descriptions) CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES OE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ' AUTH0RL'EO REPRESENTATNt; l (01988-2009 ACORD CORPORATION..All rights reserved, ACORD 25(?OU9109) 1 of'2 The ACORD name and logo are registered marks of ACORD �sa575/M68179 . MEY 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration j y Registration: 153567 Type: Private Corporation f. Expiration: 12/15/2012 Tr# 206433 CAPE COD INSULATION INC ' � HENRY CASSIDY t 455 YARMOUTH RD. = � t HYANNIS, MA 02601 .. . � >Jpdate Address and return card.Mark reason for change. `r `❑ Address ❑ Renewal ❑ Employment Lost Card DPS-CAI 0 5OM-04/04-G10I216 - Office o mer Affairs Bus'ne Reguh tion License or registration valid for in dividu! use c^!y HOME ' ryelik� t � before the expiration date. If found return to: Registration: 153567 Type: Office of Consumer Affairs and Business Regulation Expiration: 1,2/15/2012 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 OD INSULATION ]N-C--- HENRY CASSIDY;iq r Ic 455 YARMOUTH RD HYANNIS,MA 02601 � ' ti Undersecretary - P11 t si tune Massachusetts Department of Public Safety Board of Building Re'oulations and Standards Construction,Supervisor License License:'CS 100988 HENRY_CASSIDY' 8 SHED ROW WEST YARMOUTH., MA 02673 -Expiration: 11/11/2013 ('ununissio4er' Tr#: 7620 ' mass save J1Y1t}O1:11lOuQft MnIW PI!{Ga+e[y F r. - � i k PERMIT ALITHORIZATIOIV 1=ORM '1,`�1�^('i, •� owner h f o the property located at: (Owner's Name) (Property Street Address) (CityfTown) hereby authorize C, a A T-7 i ota 4j_"- •„ p (Parfi pating Contractor) an authorized Participating.Contractor for the Mass Save Home Energy Services Program under the direction of Conservation Services Group,to act'on my behalf to obtain a building permit and to perform insulation and/or weatherization work on my property. Owner's Signature Date. r r r _ Town of Barnstable *Permit# 0-co00 01 y�� Expires 6 mo itfts from issue date wP Regulatory Services Fee » DARN$rAsLE, • Thomas F.Geller,Director MARS OCT + ' Building Division Tom Perry,CBO, Building Commissioner TOWN OF BARNSTASLE 200 Main Street;Hyannis,MA 02601 www.town.barnstable.ma.us Office: "508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint 0Map/parcel Number_ �� ��0 Property Address —3c, fL� C`• C (�ti ❑Residential Value of Work j ,30 c Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address , Contractor's Name bG ye_�-Vc � _,,�` ,,,��,�,�. Telephone Number . Home Improvement Contractor License#(if applicable) G s 3-;1 eua ❑Workman's Compensation Insurance Check one: P�i am a sole proprietor W AQ',i ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side WReplacement Windows/ oor sliders.U-Value (maximum.44) *Where required: Issuance ofthis 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 is required. SIGNATURE: L Q:Forms:buildingpe s/express Revised 123107 i a an ar S ice i `r rt eN►sp i I, gonl' ctio�Sup Con CS g2082 sfru _ ; 1i fG Lice�? Tr# 21313 i -.416120111 3 w JO S HN L RWEIR Commissioner i„ 21 WEST MA 02780 0-7e �o�. 0 � a�1ua�lta Board of Building Regulations and Standards License or registration•valid for individu►use only . HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return Board of Building Regulations and Standard s Registration ;455850 One Ashburton Place Rm 1301 j Expiration 5/14/2009 Tr# 25.. 03 Boston,.Ma.02108 { ` Private Corporation ` I.. ABOVE&BEYOND HOME IMPROVEMENT INC z,r C� -- JOHN REIS 21 W.WEIR ST `P of val►d w►t signature N ' bout si n Administrator TAUNTON,MA 62780 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): �Q r�� I r� � �i —/--� Address: �J. LAJ Z ,/ I�S+ City/State/Zip: IAc,, vxAo,,. 0ALt 0017 Phone Are you an employer?Check the appropriate box: 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 am a sole proprietor or partner- listed on the attached sheet. 7. [g,4emodeling ship and have no employees These sub-contractors have g• ❑ Demolition workingfor me in an capacity. employees and have workers' Y P ty• � 9. ❑ Building addition [No workers' comp. insurance c p. insurance. required.] 5. LLT 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 q ] employees. [No workers' 13.[�Other�/ ..a comp. insurance required.] *Any applicant that checks box 41 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 under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: l d 6— Phone#: 016 016`7 —` 2 Q 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#: s Town of Barnstable 16 Regulatory Services A Thomas F.Geiler,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, � \ kr� ,as Owner of the subject property r� FR���ti hereby authorize I 06'.9 1 13 a-,,,J h����� to act on my behalf, in all matters relative to work authorized by this building permit application for: 25 (Address of Job) Signature of Omer Date �-+ 11 wr' r Print Name Q:Forms:buildingpermits/express Revised 111101