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HomeMy WebLinkAbout0063 ROOSEVELT ROAD CIO, t" � o TOWN OF BARNSTABLE BUILDING PERMIT APPLICATIONi � Map Parcel Application # Health Division Date Issued,- Conservation Division Application fee Planning Dept. ` Permit Fees Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Address &3 was-y�(� Village �v►d' Owner tk,Qrok� Address 1 to Rows-Q-v-eA ftA © 3� Telephone Permit Request A,r 641A �,,co sEr�(�o, ��s rns . R-38 00 (�'�9� Ca.1(y Asa 1s ►2 L�-pO). khau��- �,os� Mtn �, =2 9"-( "'red ,A/ 08-0). Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation O Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ 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 Alf: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new �I P_irst Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other �i,•, �0�. ' Central Air: ❑Yes ❑ No Fireplaces: Existing New d'.a Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name d G' � Telephone Number 30X-- 6-6?" 6 70 k Address D S4- License# 103 g(vf �a 11 R,`vY-/ M.A O�k4;_o> Home Improvement Contractor#, 18D W, 7 i Email Worker's Compensation # ?-WS ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE. /T//(Z 5 FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. r ADDRESS VILLAGE f i OWNER ' DATE OF INSPECTION: i ti - ,' FOUNDATION 7 FRAME INSULATION f FIREPLACE ELECTRICAL: ROUGH FINAL 1 PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT r 1 ASSOCIATION PLAN NO. Y y L DEBRIS FORM' In accordance with the previsions of MG.L c,40,s.s4;a condition of Building Permit. f�ornber is that the debris resulting from this work-shall be disposed of in, ,properly licensed solid waste disposal facility as defined by iVIGI.ci 111,s: 1st2A_ This Debris will be disposed of In; —Republic Services Dum ster: 1080 Airport Rd Fall River, MA 02720 • (LOCATION OF F`ACILIV) Signature of PermtAppilcant : Date 7 r IF 0UMPSTEq - ECG IN EXCESS OF SIX(ilcuBlIc'YARDS AP MIT'F M THE' = FIRE IEPd4RTI1lII T IS R UiIEi3 , FOR COMMERCIAL,INDUSTRIAL,INSTITUTIONAL.AN ULTI-FAA' 'RESIDENTIAL OVtR;20 UNITS DEMO- RENOVATIONS OR:ALTERATJONS OF TI«IE EXISTING BUILDING: s. CIRCLE ONE E YOU SUBMITTED?'ENE A 06 NOTIFICATION TQ THE MASSAC US S t3EP?, YES N0 i _ The Commonwealth of Massachusetts 4 Department of Industrial Accidents I Congress Street,Suite.100 Boston, MA 02114-2017 www.tmass.g ov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH:THE PERMITTING AUTHORiTY. Applicant Information Please Print Lesibly Name(Business/Organization/Individual): Insulate2Saye Inc. Address: 410 Grove Street City/State/Zip: Fall River MA 02720 Phone#: 508-567-6706 Are you an employer?Check the appropriate box: Type of project(required): J.M I am a employer with 20 employees(full and/or part-time).* 7. New construction. 2.[:]I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 1 ❑Demolition 10 Q Building addition 4.❑1 am a homeowner and will be hiring;contractors to.conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I I.R Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13:o P Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Fx Other Insulation 152,§1(4),and we have no employees.[No workers'comp.rinsurance 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 itcw affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and'state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Liberty Mutual Insurance Policy#or Self-ins.Lic.#: XWS 5641.8741 Expiration Date: 12/10/2017 Job Site Address: � o Nef� City/State/Zip: eo4L;t MA 0,1&3r Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable.by 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$250,00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification: I rlo hereby certify under lire a` s an a ties of perjury that the information provided above is true and correct.' Signature: Date: / / -7 Phone#: 508-567-6706 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): (..Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical.Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Mas husetts 02116 Home mproverri 1 tractor Registration Type. Corporation INSULATE 2 SAVE , INC. Registration:. 180747 410 Grove St � xpiratforl 12/2wois . Fallriver, MA 02720 w sCA I v zoM asri Update Address and return card. Mark reason for change. .._.LI_Address_0,B_newal_,O Ern t men#-Q Las#Gard S7"jG'- tY17G�xktsstlttf:CllF a {✓''�-P�1;9llfeSf-' ,-.,--, .,•"....: Office of Consumer Affairs&Susiness.Reguration HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only- TYPE:Cor won before the expiration date. it found return;to: �' i i;2SPiration Office of Consumer Affairs and Business Reguaatlon �1� xib 12/28/2018 1b.Park Plaza-Suita5170 INSULATE 2 SAWN Boston,MA.tr2118 Roland Langevin 4f0 Grove St t � fi;Et Failrlyer,MA 0272y' Undersecretary Not valid without signature r Massachusetts.Department of Public Safety € sciard of'Sujidintg Regulations and Standards t License: GSA"0386't f Construction Supervisor r POLAND LANGEVIN 66 HIOHCRE$tT Rt3 . FALLRIVEl2.MA 027 ¢ u Expiration, Conn issioner 08t2�l2Ot7 ACOORDP� CERTIFICATE OF LIABILITY INSURANCE DATE(MM12//)16 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 terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Anthony F. Cordeiro Insurance PHONE FAX '677-0409 171 Pleasant Street E-MAIL 508 677-0407 Al No: (508) ADDRESS:. hsouza@cordeiroinsurance.com Fall River, MA 02721 INSURE S AFFORDING COVERAGE NAIC# . INSURER A:Liberty Mutual Insurance INSURED INSURER B Insulate 2 Save, Inc. INSURERC: 410 Grove St. INSURERD: .Fall River, MA 02720 INSURERE: INSURER F: 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. INSR ADDL SUBIR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMMDD/YYYY MMIDD/YYYY LIMITS A GENERAL LIABILITY Y y $KS 56418741 12/10/16 12/10/17 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIAB ILITY DAMAGE TO RENTED-PREMISES(Ea occurrence) $ 300 000 CLAIMS-MADE FxI OCCUR . ME EXP(Anyone person) $ 5 000 PERSONAL BADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATELIMITAPPLIESPER PRODUCTS-COMP/OPAGG $ 2,000,000 XPOLICY JECT PRO LOC $ A AUTOMOBILE LIABILITY y y BAA 56418741 12/10/16 12/10/17 EOMBW�DS tINGLECIMIT $ 1,000,000 ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED AUTOS X AUTOS BODILY INJURY(Per accident) $ r NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS Peraccidenl $ A X UMBRELLALIAB X OCCUR Y Y USO 56416741 12/10/16 12/10/17 EACH OCCURRENCE $ 2,000,000 EXCESSLIAB CLAIMS-MADE AGGREGATE $ 10,000 DED RETENTION$ $ A WORKERS COMPENSATION XWS 56418741 12/10/16 12/10/17 X WCSTATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yyes,describe under DESCRIPTIONOF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Renerks Schedule,if more space isreguired) "For Insurance Purposes Only" CERTIFICATE HOLDER CANCELLATION 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 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: RISE Engineering RI S E 5 Dupont Ave Unit 2,.S(juth Yarmouth,N-IA ENGINEERING" I . . - I N . CONT RA CT 508-568-1926 FAV508-568-1933 Page 1 PROGRAM THIS CONTRACT 13 ENTERED INTO BETWEEN RISE N(;CC_HtS ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW ............................ ----------­­­...................- CUSTOMER PHONE DATE CLIENT WORK ORDER John F McGrath (508)420-1976 05/08122017 236549 24302 ............. SERVICE STREET BILLING STREET 63 RoOtevelt Road P.O.Box 2083 SERVICE CITY,STATE.ZIP SLUNG CITY,STATE,ZIP Cotuit,MA 02635 Couilt,MA 02635 ------_------------ __-_----------- .......... JOB DESCRIPTION, AIR SEALING:Provide labor and materials to seal areas,(Jt'your home a,--,iiiist,waSteftil,excess air leakage. This work will be perfortned. $640.00 in concert,with the use of special tools and'diaghostic tests to assure that your hionic will lie fen with a licaldiful level of Air exchange and indoor' air quality.Materials to he used to seal your home can include caulks,r(Arns,weatherstripping and other.products, Primary areas liar scaling.include air leakage to attics,basements,altached garages and other unheated a.reas(windows arc.nol generally addressed;)(8)working hours. A reduction in cubic feet per nii nute(Orn)of-air infiltration will occur,but the actual number of is not guaranteed. AIR SEALING:Provide labor and materials to install Q-Ion weatherstripping and a doorsweep to(2)dwr(s)to restrict air leakage. $160.00 DAMMING:Provide labor and materials,toxins tall a 12"layer of R-38 unf iced fiberglass baits to(100)square feet for damming $246.00 purposes.i. A'FfIC 171.iAT:Provide labor and materials to install a 6"layer of 11-22 Class I Cellulose added to(I 200).5quarc feet of'open attic space; $1.584.00 VENTILATION:Provide labor and materials to install(2)insulated cxhaust hose to.existing bathroom fati(s). $120,.00 1 COMMON WALLS:Provide labor and materials to install 2"rigid board with the required fire rating to(180)square feet of common $693.00 wall area.'Homeowner has received a copy of the EPA's Renovate Right Lead-Safe inforartation guide explaining the potential risk of the lead hazard exposure from the weatheri7ation work to be performcd.Your signature is your acknowedgenacrit of receipt and agreement to proceed. m= A 2017 Y tZ1SE.Engineering RISE5 Dupont Ave Unit2,South Yarmouth MA CONTRACT ENGINEERING" 508-5-68-1926 FAX 508-56.8-1933 Page 2 PROGRAM �- r-. THIS CONTRACT IS ENTERED INTO BETWEEN RISE NGCC-I I ES ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW CUSTOMER PHONE DATE CLIENT WORK ORDER m John F'McGrath (M)1420-1976. 05/08/201.7 236549 24302 SERVICE STREET _ BILLING.STREET 63 Roosevelt Road P.O. Box 2083. I _ SERVICE CITY,STATE.ZIP i BILLING CITY.STATE,ZIP Cotuit,MA 02635 COtuit,MA 02635 JOB DESCRIPTION INCENTIVE:RISE:Engineering will apply all applicable,eligible incentives:to this contract. You will be billed only the NCI amount. $165;00 Currently for eligible measures,National Grid offers 75%incentive,not to exceed$2.000.per calendar year,and an incentive of I00% for the Air Settling measures. For the safety and health of your horne's indoor air quality,we might be conductinga blower door diagnostic of the available air now in your home boot before the work is begun,and after the weatherization work is complete(not to bc,conducted if asbestos is prescnf).We Willi also conduct a diagnostic assessment of the combustion fumes in the exhaust flue of your heating system and Water heater.`['his has a value of S90 and is at no cost to you.. The Permit will be secured by the insulation contractor.This has a value ofS75 and is at no cost to you.It is die horncowner's' � responsibility to closeout this„pennitby contacting their municipality at the completion of this work. i i Total: $31608.00 Program Incentive: $2, 47.25 Customer Total: $660.75 WE AGREE HEREBY TO FURNISH SERVICES COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF l _ I *`*Six Hundred Sixty&751100 Dollars $660.75 UPC)=SEEnginftring APPRO A L BY RISE ENGINEERING.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL.INTEREST OF 1%WILL BE CHARGED MONTHLY ON ANY UNPAYS.S REVERSEFOR IMPORTANT INFORMATION ON.GUARANTEES,RIGHTS OF:RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION: -AUTE EnginaAntl '#CTO�FJXC�C�EPTANCC NOTE:THIS-CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE _- 1 ACCEPTANCE OF CONTRACY•THEAB E PRICES,SPECIFICA710NS.AND CONDITIONS ARE: 30 DAYS. SATISFACTORY TO US AND ARE HEREBY ACCEPTED,YOU ARE AUTHORIZED TODO THE WORK AS SPECIFIED.PAYMENT WILL REMADE AS OUTLINED ABOVE I . rown of Barnstable R4kNTTARLF,a $taza V..scati>:Dii;e�tas x� 9- .� Toin Ptr'ry,DuAging.Lon sm ssioner 200 stain S6el 02 6e1 iv wA9wn.barnstablc ma.us Office: 508-862-4038 Fix:: 508- 90-6730 j ProppIGty T must I T ,J Builder Y &ER�rg _/"�C TH `,as he,s �Ject pVopM,y - hezeb�aui`I�c�rize in aU znmtwrt rel:atim to work authaiizedby:this bu. Ming penis 'application,for n9 °'Pool faiicts ash alarms file re�pcns b-,E, }r:of tie ap�h-caiat.1?d& :are o :ta:be: Xct r t ed lief oIe>f nc 5 ih�taRed.a d a}l lihad , a:�spectoz�s are peor'rned an�:.�c,ceped. S' anus of Owner S gna.wre d Appkaml 1 _ Iq r Prat Namcc Pn,nt Name Date '1 Q:F'ORIt9S:n11+?.?F R���:hllSSlUT1E:(?OT.S TOWN OF BARNSTABLE Z BAXISTAn i - '�,,�o MASSACHUSETTS Solid Fuel Stove Permit [ DATE OF APPLICATION ..................... ... .... ........................................... SSUING PERMIT. .......... 1. 4c. NAME (owner)4»/.v. .'1.....1..'..... ..... .! . ..... ......... NAME (Installer) ....................................................... ADDRESS ..3..... 09!3 Sc.lon..-..........0V.4.. �.h'I l� ADDRESS ........................................................................................................................... STOVE TYPE ............. ............. .................................. CHIMNEY: NEW ........ EXISTING ........................ Manufacturer ........e`..'.... ..'n CHIMNEY: Masonry ................... .......................................................... Mass. Approval � ......... CHIMNEY:. Metal ................................................................................................... This is to certify that the above installer has permission to install a solid fuel burning appliance at the listed address in accordance with an application on file with the %z N S t..a o.-•-.. Firs—Department, and subject to the provisions of the Commonwealth of Massachusetts State Building Code and regulations made under the authority thereof. /.� ` IssuedBy: ........................................ ......................................................................................Title .................. ................. ...................................... Date ... Permit to install expires 60 days after issue date Stove .................................................................................................................................................................................................................... StoveClearance ............ .....................................................................................................................................:........................................................................................................... Floor ............................. .......................................................................................................................................................................................................................................................... SmokePipe ....................... ..................................:.............................................................................................................................................................................................................. SmokePipe Clearance ...... ..................................................................................................................................................................................................................................... Chimney ............................. ............................................................................................:....................................................................................................................................................... SmokeDetector ...........................' ................................................................................................................................................................ The undersigned hereby certifi tat the installation of solid fuel burning stove and equipment made under au- thority of permit dated ........�... "�.. ................ has been made in accordance with provisio of the Commonwealth of Massachusetts State Building Code now currently in effect and pertaining thereto c C a 7 Installer INSTALLATION APPROVED .......,�..... ..../.. ..................... B,y:... Title� 1 � � at .. ...............% Aldo- WHITE: FIRE DEPARTMENT — CANARY: BUILDING INSPECTOR — PINK: APPLICANT y-.y4 y;tiv .4w+..<.�...n TXEtp�`o* .. TOWN OF BARNSTABLE i BeaaST"L 'Op M6 q. MASSACHUSETTS Solid Fuel Stove Permit DATE OF APPLICATION FRrE—D:EPT, 'ISSUING PERMIT' • NAME (owner)t /C7�,n I !" R ..... '�. ..... ..g. S NAME (Installer) ............. crf .. ... ........................................... .� n <1 ADDRESS 6 3 �U4�S c..t/t I .... (01�v« ! �1 ADDRESS ........................................................................................................................... .......n........................... ....................................................... ............ rc ► „'�" STOVE TYPE ...................:.............................................................................................. CHIMNEY: NEW ........ EXISTING ...........'.......... Manufacturer �" °i"��� �''�� �'"` CHIMNEY: Masonry ...................`�:....�.... ..................�...... ....... .................�....... ................................................................ Mass. Approval .................... .....:�'.....:................................................................. CHIMNEY: Metal ...........................................................................................:...:... This is to certify that the above installer has permission to install a solid fuel burning appliance at the listed address in accordance with an application on file with the ................................................................................................... Fire Department, and subject to the provisions of the Commonwealth of Massachusetts State Building Code and regulations made under the authority thereof. Issued By: ............................ Title [ � Date ......� ................. ...................�.................... r..........�..........r........ Permit to install expires 60 days after issue date Stove ........................................................................................................................................................................................................................................... StoveClearance ............ Q'.......................................................................................................................................................................................................................................................... Floor ............................ .......................................................................................................................................................................................................................................................... SmokePipe ...................... ................................................................................................................................................................................................................................................. SmokePipe Clearance ....... ...................................................................................................................................................................................................................................... I Chimney ............................��... ........................................................................................................................................................................................................................................................ SmokeDetector .................................................................................................................................................................................................................................................................................. The undersigned hereby certifies. that��the installation of solid fuel burning stove and equipment made under au- thority of permit dated ......,t .................. has been made in accordance with provisions of the Commonwealth of Massachusetts State Building Code.now currently in effect and pertaining thereto ................. .............. F > 'ZP + Installer INSTALLATION APPROVED ....... ............................................... By:............. Title .......... dated �. ................. .................. WHITE: FIRE DEPARTMENT — CANARY: BUILDING INSPECTOR — PINK: APPLICANT 1 Engineering Dept.(3rd floor) Map 0,3oj Parcel /.3� Permit# House# _ 6 3 Date Issued 7 g Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) _ Feg_S" ZS_f v U Conservation Office(4th floor)(8:30-9:30/ 1:00-2:00) (� aT r 7- _ of 1HE 19 1 - BARNSTABLE. ' t639,E TOWN OF BARNSTABLE Building Permit plication ojecf Stree ddress Village Iq Owner Y ddress g� Teleph Permit Request First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ �j D cfz) Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family LY Two Family ❑ Multi-Family(#units) Age of Existing Structures Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No 47 Basement Type: p'Pull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing v2- New Half: Existing New No.of Bedrooms: Existing 15 New Total Room Count(noXas ing baths): Existing �� New First Floor Room Count l Heat Type and Fuel: ❑Oil ❑Electric ❑Other Central Air ❑Yes � 10 Fireplaces: Existing / New Existing wood/coal stove es ❑No Garage: ❑Det hed(size) Other Detached Structures: ❑Pool(size) . ttached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information —OF Name Telephone Number 7 A ress b License# Jr J ` A I Home Improvement Contractor# 3 7 Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE ✓ /6 BUILDING PER T ENIED FOR THE FO LOWING REASON(S) r ,..a- � �;� . _,. �{!ii'+�'St�X�.M�.�'.w�✓+Mv?.fib.'.<�+.�.m�i"+ioH'F•.L9a'�'.Jiaj'ti�+:Cl� '�!2��t���j,K2,irt�.�'SP �J:�u�M... t��'�.","`.a�1yC "�'�,'�'s.�v�;�.�,.u`�,�t...g�"Y;�?s '`...�:':-'' ,A�'1�;�� � .. -- ry� � � 1 � ♦ .� � •l - SH N6-L8S -Tfl r . 4 - ' Shin/tS i '�o�' bond• z'xy`,rt?oj ra f-fe/� CL'o„�s� ' Y raJN /".-/I7oP PtATC • tax y� PuCuN /•r/L�S10+No. L`x N` Py�uN y :5�`cpx P�ywood U �a.�+bLDX 4NbTr- ALL 9Earw foil dirncnsran-I i r LOT 37 �6ss �' 16 0 0� LOT 36 ors' i D� 20, OOO-:&sf � sO x , <O _,' °0 LOT 35 , FLOOD ZONE "c"_ FO UNDA TION CERTIFICA TIONREs ZONE. "RF" TOWN:BARNSTABLE SCALE'- 1" — 30' PL. REF.36608 C ELE V N�A I CERTIFY THAT THE ABOVEFOU - THENDATION GRO GROUND IS LOCATED ON AS SHOWN, AND e��``N of M ,/ YANKEE SURVEY CONSULTANTS IT'S POSITION_ DOES __ Pain �� 143 ROUTE 149 P. O. BOX 265 li AfARSTONS MILLS MASS. 02648 CONFORM TO THE ZONING LAW � MERITHEW No. 3209a .z TEL: 428—b055 SETBACK REQUIREMENTS OF Fs 9FGI5TER`�� Q��aG FAX 420—5553 BAR_NSTABLEtiat LaN s° JOB PAUL A M RIT HEW DA TE.•VW93 NUMBER 50293_ 9,4-e �V�yyLa nv*-'Wa�Li � 8558 ;1 DEPARTMENT OF PUBLIC SAFETY 58550 ONE ASHBURTON PLACE , RM 1301 BOSTON, MA 02108-1618 CONSTRUCTION SUPERVISOR LICENSE Number: Expires: Restricted To: 1G ' , r`. JAMES D MCGRATH �� :�. Detach bottom, fold sign on PO BOX 708 "J' back, and laminate license card. S DENNIS , MA 02660 Keep top for receipt and change of address notification. HOME IMPROVEMENT CONTRACTOR ; ' Registratioa 109374 Type - INDIVIDUAL Eipiration 09/11/96 PINE HARBOR BUILDING CO.,INC.� JAMES D. McGRATH a 0 BOX 708/120 61 WESTERN RD � S DENNIS-MA 02660 - �'� .- _�:-a.`��w•P.usar:Jdb1�1�5�:'.i; '!�4e"�"�7:� 'L"ut.._...._,,^?'..:,±.�„�7`e?a �`.,saF�,;., •�s1; Suggested Affidavit for Home Improvement Contractor Permit Application For Ofnce Use Only NAME O ITY/TOWN Permit No. �� LU( / - X4 . Date / AFFIDAVIT Home Improvement Contractor law Supplement to Permit Application MGL c.142A requires that the"reconstruction.alteration.renovation,repair,modernization conversion inprovement removal demolition or construction of an addition to anv pre-e�asung owner-occupied budding 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 exceptiops,along with other requirements. ��^^ ��/�� Type of Work: l_On4ro O �'1'� Si' �tL�JEst Cost 0 o dress of Work_ 0 OSE(/E Z �� �tl , 1 0.2.6 3 Owner Name: �0 h �� �-- 1-ld me - �f21 Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law —Job under S1,000 _Building not owner-occupied _Owner pulling own permit _Other (specify) Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. Signed under penalties of perjury: ` I hereby apply for a permit as the ent of the owner: ru_� Jar10q37V Date ntra a Registration No. OR: Notwithstanding the above notice I h v for as the owner of the above property: Date Owner Name OWNER: : ..�� Map r.o t _ DA_T_. - The Th e Commonwealth of:Llassachusetts � Department of Industrial Accidents ;3 is meeo!III,rest/gat/ans 6061 Washington Street Boston, /Vass. 02111 workers' Compensation Insurance Affidavit location- vt7 L(/L� C;N � �" [ h .) C am a homeowner performing all work myself. ne= ( am a sole proprietor and have no one working in anv capacity =ar roviding workerscompensation for my employeesworkingon this job. . addre '} cirv: one# in uranceco. y0 6 ��'G� I am a sole proprietor, general contractor. or homeowner(circle one) and have hired the contractors Iisted below who have the following workers' compensation polices: c m . vn me addr • c•tv: i c licv--# c m any name! a d dre c'tv: in ur. a o IF one Yea to secure coverage as required under Secties in of r ofa 152 can lead to the Imposition of criminal penalties of a One up to S1.500.00 and/or one years'Imprisonment as well as evil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me- I understand that a copy of this statement may be forwarded to the Ol ice of Investigations of the DIA for coverage verification. I do hereby certify under th pai and p es pe at a information provided above it true and correct Signature Daze Print name Phone# official use only do not write in this area to be completed by city or town official city or town: 'TOWN OF permit/license fl Building check irimmedinte response is required ❑LicensL:So*rdCISeleetcontact person Health phone is: ._.,_QOther, lfe-Ial JA)5 PJA1 Assessor's office(1st Floor): Assessor's map and lot nUmJDer i 63 3 �F-PTiC SYSTEM MUST BE Conservation r - INSTALLED IN COMPIJANCE Board of Health(3rd oor): WITH TITLE 5 Sewage Permit numberY NVIRONMENTAL CODE AN® : s�3ri►nti 963 EngineeringDepartment(3rd floor): TOWN House number era r� Definitive Plan Approved by Planning Board ` t9 APPLICATIONS PROCESSED 8:30 9:30 A.M.and 1:00-2:00 P.M.only Fla, , TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO �t� J c J T Y fG r.��G`� yl� Z vr,� (v.�?✓/ TYPE OF CONSTRUCTION 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location Ii7 3 2r- aS ,, y a-- If 7` ` cJ 4 T � v Proposed Use ✓..1 ^- Zoning District Fie District `(j Name of Owner � f�ddress _ 9J - U � Z%X -2 e 5 Name of Builder b 44 4Z 1 � r�;�.� .� Address Z � �: . 16 35 G� ,J0 C�2;>c�� }�f far,, �r✓✓�)�C Name of Architect �_ �,� /� � Address Number of Rooms— Foundation Exterior 1,°r�e — Qs-,2 s -S t, °`-�, �� Roofing �� P L",( - Floors IC-\-Arim 30 Interior Heating �'`C `t �+�% �= S Plumbing Fireplace S Approximate Cost Area Diagram of Lot and Building with Dimensions Fee //, - OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. 4f— Name '. l/ Construction Supervisor's License C) McGRATH, ROBERTA e: --No 35898 permit For One Story Single Family. Dwelling Location Lot #36, 63 Roosevelt Road Cotuit , Owner - Roberta McGrath Type of Construction F r a m e Plot Lot Permit Grant d May 25 93 ! Date Date Compl€ted-• 061s 19 r J { f PRICE & MYERS, P.C. ATTORNEYS AT LAW 6F BAYBERRY SQUARE 1645 ROUTE 28 CENTERVILLE,MASSACHUSETTS 02632-2936 WILLIAM A. PRICE,JR. TELEPHONE (508) 790-1221 THEODORE J. MYERS TELEFAX (508) 790-1238 f i flay 19. 199,3 To: Mr. Joseph DaLuz Building Inspector Town of Barnstable Town Offices . Hyannis, 'MA 02601 . STATEMENT Re: Contiguous ownership of 63 Roosevelt Road. Cotuit . MA being shown as Lot 36 on Land Court subdivision plan 36608-C and also shown as Parcel 138 on Assessor's Map 39. Current Owners : John F. McGrath & Roberta A. McGrath Date Acquired ' . May 5. 1993 Date Registered: May 5. 1993 Title Reference : Certificate of Title No. 130 ,015 The following lots are contiguous to said Lot 36: Lot 37 on Land Court Plan 36608-C (Ass. Map 39.. Parcel 139) Lot 35 on Land Court Plan 36608-C (Ass. Map 39, Parcel 137) Lot 50 on Land Court Plan 36608-C (Ass. Map 39. Parcel 152)* Lot 61 on Land Court Plan 36608-D (Ass. Map 39, Parcel 150) * said lot 50 only abuts corner of lot 36 I . William A. Price , Jr . , Esq. hereby certify that the current owners of Lot 36, 63 Roosevelt Road. Cotuit . Massachusetts, at no time during their ownership have contiguously owned the above-mentioned contiguous lots. I also certify that the last owner of record of any of the contiguous lots and Lot 36 was the Atlantic Savings Bank who acquired title on October 21 . 1977 being Certificate of Title No. 72174. Respectfully submitted, l/I/G�� ��✓Gr2.v� William A. Price. Jr. i 0 LOT 37 00 SO QO ti 1� 000 , o� LOT 36 20, 000fsf o , � l O 0 gyp• (�``�.l ` 0 'Z o LOT 35 00 - � o FLOOD ZONE "c"_ FOUNDATION CERTIFICA TIONREs zoNE.• "RF" TOWN. BARNSTABLE SCALE 1" = 30' PL REF.36608 C ELEV NSA I CERTIFY THAT THE ABOVE FOUNDATION IS LOCATED ON N of j Mgs�gc YANKEE SURVEY CONSULTANTS THE GROUND AS SHOWN, AND ti IT'S POSITION _DOES PAuL 143 ROUTE 149 P. O, BOX 265 A. CONFORM TO THE ZONING LAW MER THEW MARSTONS MILLS MASS. 02648 No. 32098 Q TEL: 428—6055 SETBACK REQUIREMENTS OF 90�� 9FGIST ER�� s - FAX 420—5553 __ _ BARNSTABLE �`�,oNgI LANosoQ --�-��-- — --- JOB PA UL A. M RITHEW DATE. -19L93 NUMBER 50293 _ __ _ -� -- VtLVw TPS 4 'A1P4+tT S41yc,LES -L 4vi'ELl rm LLLJ n �� AW4.4SATER —� ��i --- � 2.T.14SLi. Lt.n•4. 24a'tA KStA ria2011UiJC.4•n.0-- .� �: � p" . 4 0.4• �=tA VtElpy KITCNEIJ.T1SEerENT :. i Ga: u E'ED,�ET?A0.CL .. I -AWM.[CAYN:xial'XlT.CNo•� IEFf EIEVXTT6N z�n,_vn yT I - -- ----- ILI" „17 \ wsPHw T iH�N4lC$ I 11. ALVN.4uTTER — I ` \vHITL C{Mq.SNI,N LLCS —+ u 1 ~1 i 1 P x.a—:oL. EI_EVhTTOh! - . _-�zrrirr-crr..TIDN 1 , n • r'T• _ a 6 =RCL57E2-:5u 14 Z1.Di CV, r II 4wntR c. `� O O = Li I •I � O aI I i ._./ �I(, =s i ; .11.vn�C I'S�Nlr7. ---- I � �' 1 5;+-TRGCAet r rj�I Gf ' I S: I � V� o 4-'uk•CONC S�3�v/ N I ♦ y I L b p v s 12. I c I rTcED ra - ------------ 6I '' .:'.-. aU-o- I • rLIIIC>0 J__ MOW R/'FTL@S - III,PLIWoct).. -� 1 Ltl- 4x-� 4L4/cOVEKO L`�) - :G_COUAR.TIES i2 ny ---�30 iR' UV-77. - 3U.TH S LPL. \aS SIMrP.•4Cy. 2aU u5.J5T5 �I, I . "�.EE?::l K' .. :.1'STRn➢r'4 C• � I I O' ',, • 51ILETROCK t I _ LIv,N SEnFZ'_;�•„� I D 11 k l T C�4 I h /.� /{ 1, i�2.'O C'RT7ER T � NC, 4�ZCX.F1.__S i I i _ I I iI Inc._ pi _3ECTION./�_/�C��':•i'o-).. ..-._--- _. -._ _ _.. -.-_-�E�TIOtJ R_:6(rr�..-ro-) • II - 1 _..--.. 14.-4' Z.4. • , �.L 1 r -- 1 of t4 I �. i i�.z�caTux:wucEw.roc�s•¢ '�I ;I OaiCnrrm-ctr.GE0.._... �I � i m J CAMVACT F4L Y A 1 I � 4 � mt .. .... y '.a•F:k.. _.a.,.�.+ ...i., � �`- ,�.x...� THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) Im ^P LC DATA i .. ,r..; ^�•,r,�,srms:a<sc7,lam__,.:-fF .<�s!:e�i�'t"r`'-T,�I -i ,,: TOWN OF BARNSTABLE, MASSACHUSETTS �u ILDING PER Ili-1-35898 GATE -' 19 PERMIT NO. APPLICANT ADDRESS IN0.) /(STREET) (C ONTR'S LICENSE) I PERMIT TO (_ :;TORT NUMBER OF - --- . — (TYPE OF IMPROVEMENT) NO. (PROPOSED USE) 'DWEU_ING UNITS �7.� S«rf.`Ci%:v i _4. }iiJ 2i.C.y. L..;i-.1:._. �... - i ->,`t ZONING AT (LOCATION) . �C-,,: J ll ' (NO.) (STREET) DISTRICT— BETWEEN AND AND (CROSS STREET) (CROSS STREET) SUBDIVISION LOT _ LOT BLOCK SIZE BUILDING IS TO BE FT. WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION (TYPE) REMARKS: - 233 AREA OR VOLUME ESTIMATED COST S • fi',� PERMIT (CUBIC/SOUARE FEET) OWNER i%y. C' ADDRESS 5�• - = =•h% . 3 / BUILOI4G DEPT. By --_FR-OAl T_HE'_DEPA"R'T MENT'-O-F"Y U 5 LIiC'W"QRKS-."-rHt 155V NN CE OF-THIS-I'E RM7"r UVIE 5'-NU"I"-'HE L t ADt Int AYYLI"IANC rKUM I nt LvNUI"I ivNzo OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF THREE CALL -APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE INSPECTIONS REQUIRED FOR PERMITS ARE REQUIRED FOR ALL CONSTRUCTION WORK: CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN ELECTRICAL, PLUMBING AND. 1. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS.' 2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL `FINAL I INSPECTION ,C LATHE FINAL INSPECTION HAS BEEN MADE.3. FINAL INSPECTION BEFORE - OCCUPANCY. POST THIS CAR® SO IT IS VISIBLE FROM STREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 65 .f Cam. 9 /, 3 HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT 1 n BOA P OF HEALTH OTHER SITE PLAN REVIEW APPROVAL WORK SHALL NOT PROCEED UNTIL THE INSPEC- PERMIT W!L L BECOME NULL AND VOID IF CONSTRUCTION INSPECTIONS INDICATED ON THIS CARD CAN BE TOR HAS APPROVED THE VARIODUS STAGES OF WORK IS NOT StARTED WITHIN SIX MONTHS OF DATE THE ARRANGED FOR BY TELEPHONE OR WRITTEN CONSTRUCTION. PERMIT IS ISSUED AS NOTED ABOVE. NOTIFICATION. ."" Permit No. TOWN OF BARNSTABLE 35898 . BUILDING DEPARTMENT I ' I TOWN OFFICE BUILDING Cash ,,,,,,,,,,,,, 7 .Yl X 6�9 HYANNIS.MASS.02601 Bond CERTIFICATE OF USE AND OCCUPANCY Issued to John & Roberta McGrath Address Lot #36, 63 Roosevelt Road Cotuit, Mass. USE GROUP FIRE'GRADING OCCUPANCY LOAD THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. September 28,.., t9 93 Cat!,....../,1�t�/. ' . .. ... ... .......-... ... ................. ..... `.. � ....... l f Building Inspect(fir' f Assessor's office(1s or q ¢ � Assessor's map of er THE>'0 Conservatio � � e� Board of He 3rd fl r) a Sewage Pe it umber p��J W •Engineering Department(3rd floor): House number Definitive Plan Approved by Planning Board 19 ®®�� APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.onlyi � TOWN OF AARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO �c re-ein co/ rc TYPE OF CONSTRUCTION — LU b o Cat TON- M 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location _ (o .� y o S V E,r� �f ®-� ( ) f, Proposed Use ! / �y` s - A Zoning District RF Fire District Name of Owner 1"I �'( M C P rai {� ' Address b 3 r`ooselJ e Name of Builder rb, a L�,i d GV u ",,r q e.L Address 3 a Ro/ Name of Architect T Address /--f Number of Rooms L Foundation l b � � G D k O7- k-e-/V- L A's Exterior C ed e g s- S °r 1 t', 9 12 C -r Roofing a S PA re Z4 Floors In Interior Heating Plumbing Fireplace Approximate Cost ,5 00 0 o t, Area / 7 �42 Diagram of Lot and Building with Dimensions Fee J�®i L� b �3 Lot 37 1a' Lp 1 `Oec ?` add . 6 O 0° OCCUPANCY PERMITS REQUIRE�FOR N`ZWDWZLLIN�GS �-, I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construct' n. Name <i Construction Supervisor's License J MCGRATH t No 3 6 8 8 7 Permit For BUILD PORCH Location 63 Roosevelt Rd, Cotuit r' Owner Mr. McGrath Type of Construction Plot ,Lot Permit Granted July 19 , 19 94 t Date of Inspection �� 19 Date Completed� 1Z ✓, T', --. it r �'r � ^ � !�., ..a ,<� •,>. y ' Sys. , �,,,,, r` f � s _s•r , •ti ! Y� COMMONWEALTH DEPARTMENT OF PUBLIC SAFETY OF ONE ASHBORTON PLACE s� I �a f+ MASSACHUSETTS BOSTON,MA 02108 LICENSE p �p CONSTR. SUP ! CAUTION~ " m "EXPIRATION DATE —1841 ERVISOR 06/22/1996 EFFECTIVE DATE LIC NO. I FOR PROTECTION AGAINST RESTRICTIONS ' 1 G THEFT, PUT RIGHT THUMB 1 & 2 FAMILY HOME a 03/31 /1994 050096 PRINT IN APPROPRIATE a " � , DAVIO . G H. BOX s 38 JONES —RD MASHPEE MA -02649 I �( B . ING OP RATOR, ! m j MC NCL�I Ptia PHOTO(BLASTING OPR ONLY) F FO 0.00 q�,,,.o FEBEEB 1 6 1994 T. .` cc NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY I -: p HEIGHT: 4t STAMPED-OR-SIGNATURE OF THE COMMISSIONER 1959Month IY ow , THIS DOCUMENT MUST Bf O`Y n CARRIED ON THE PERSON Cl t. SIGN j ? �h^P'�+• SIGNATURE OF LICENSEE THE HOLDER WHEN EN OTHERS-F ;HI-THUMBPRINT GA It rS, y e _ COMI IUNER ' 1A —MINTOWN OF 2NSTABLE BUILDING. �RMIT - - __ CO MMO TH OF )�A$-SACHUSIFi TS DErAR TMN'T OF L'�'DUSTRlAri►ACCIDIIN-Js f 600 WASHINGTON STREET fames JI Ganaoec BOSTON, MASSACHUSETTS 02111 Co:—Kseoner �(` /���/7]���(�,t�}�r 7�TTM TD. ��T . -W0�•••.a,.aVf.W11'1111�1JAl1Qlt11`WV.illil�l ♦ f......-ti•..•:,.� nw CE.AFFMA R. • witht a�nndlaoe of business! � � .�-:;.-�•- " '� - principal P ksidcnac ac 1 - ta ' • (GrylSaaclZip) do hereby Da fy,under the pains and per=1e=of pcqury.tl= J I am an employer providing the following workers'ccmpeasation eovet-sgc for my arsployres wor1dng on this job. Insurance Company _ Policy Numbs I am a sole proprietor and have no one g me - I far m (] I am a sole proprietor,goner-j contractor or homeowner(eirde one)and have hired the ebntmaors listed below Who have the following workers'compensation insurance policies: •- - __ Name of Contmaor Insurance Company/Policy Numbs Mine of Contraor Insurance Companylpolicy Number I\'amc ofContnaor In=ncc Company/Policy Number D 1 :m: homeowner performing all the work:myself. NOTE.Plcasc be aMnrc t.^.at mile I60raeowOcr:woo eraalov persoas to 20 eanateaan(c occxtruetioa or rc:pairwvrl-on: d•«cliinr of not more teas:t�rec units it:%'I tie bor;cowaer also res;c"or cc 6C Frouaes appurtenant hereto are act ceaer:Ih• conspr crc2 to be c�Vlo,crs tr ccr tic�orL-crs'Co`:)cs:.satioa A"(C:.C 15'_.scc 1(5)),appliatioa by a boracowocr for:Iicct sc of or permit may e.jucee the ICC21 sutus of as err:)lovrr under tie�'orlers'Cor?ensatioa Act. , L.,cc t s:::c-c-:w'V be iorwrccc to&--✓_:,-c-.t c{i:c; :r':.�Acddcna'O t�cc of Insur^cc for co•c:-=c `'c'! -.:cr.�.c - - . .-i<c :c ccic—sc s rcck;::cr- Erse:fcc=c.25.-Ai N'C-L 5 c_-.ic:c to t:._ i... o:ition crc ^i�J per-- cca:i:cr.[ci: is-c ci V: tc S::GG.GG ^p Gori Orcr. _.r.c.o:i:-�; o:uc to c-c�•c=:�.�c\::�ca:::iu i� �c torn o(_stop Zinc o!S 100.OG:Cav p �::ns:nc. `�. f Sitncd this , (J d.. or l 19 Lic:s:,rPt.ra-cc t t �.."Mor:r-crr nt f• 4' r i GI ge l� << O C; ii 'j - P°s.i I . 1f I +1 w t % 'Olt VC(-v ee L' Fx'lI A-A---H A } s ® ;t re 1� . Mi Til. �.y ✓ IVpOA C �Sir