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HomeMy WebLinkAbout0024 COVE ISLAND ROAD o"Z Cove C� U ° : n s < 3 ° .• .. .. > > - .. a ,. • ' �. ... r. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map U Parcel Application aD S �71 Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee U" Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address Village l's�i���✓�1/✓�/e Owner U`i1% mil Gr�,tifU� Q�i �9L?�J Address !/ � Telephone J-V ZE 31, 7 z z�L Permit Request zz �/� 5� �f 4 0� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation o:P f l d Construction TypeL z��o/__1-4 Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family , Two Family ❑ Multi-Family (# units) `: �r Age of Existing Structure Historic House: ❑Yes XNo On Old King's Highway:.:-0 Ye 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 0 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 � , G6� /✓y� �f /�L�6 Telephone Number Address License #_ '/10 e2� Home Improvement Contractor# J s�r-3-5 4' 7 Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE r FOR OFFICIAL USE ONLY V APPLICATION# t DATE ISSUED MAP/PARCEL NO. T ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE y ELECTRICAL: ROUGH FINAL t f PLUMBING: ROUGH FINAL GAS: ROUGH FINAL t FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. Regulatory Services s�a•+szis> Richard V.Scab,Director 9. Builiigivisitrn t . Tom Airy,Du ding Co=nissioner 200 Main Street,Hyamis;MA 02601 .. ssi town;barnstable:tiaa.as office: 508-862-4038 Fax: 508-790.-6230 Prop&r yyOwner Must Complete and $igp_ ll s Section ff Vsrn' :A Bader I; 7611 Iq I"1 ([A Iq lq i 1'X 1'ij,as Owner of the subject p opery hereby authorize -.�C11, -I, ,e , ��, ( 7 G to act on nybeh4 in all matters xelarivc to�v+ork authorized by this building pemiix aPPlication for. - (Address ofo) Pool fences and a3,arms are.the.l-esponsi iilicyof xhe applicant. Pools axe nor to be-fined car utilized-bef ore�'fente is nsa ailed and all final Wspections eifoirnedlaiid accepted. I atwe of Owner Signature of Applicant Print Name Pint Nan ' a ter) _ Date -. - • Q.FOR S:oNMEzPERrusscoNFWLS , Orah�titment of F i.jbIic Safet oard (.)f BUi1d1119-R090ations.and Standards , _ Cunsh'nctionSr.rper�isor License: CS-100988 t ; HENRY E CASS ' �\ •% �, 8 SHED ROW H4 �ja WEST YARMOUTH Expiration e Commissioner 11/11/2015 d=� Q A x Office of Consumer Affairs andBusiness Regulation 10 Park Plaza-Suite 5170 4 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 153567 Type: Private Corporation nfl�. Expiration: 12/15/2016 Tr# 259188 CAPE COD INSULATION, INC HENRY CASSIDY - 18 REARDON CIRCLE SO. YARMOUTH, MA 02664 Update Address and return card, Mark reason for change, $CA 1 ':5 20M•05/iI -[] Address E] Renewal Employment, Lost Card ' ..... ... ...._ ... eze epanr�izaruuecr�G�a��/ cuJJcro�cc4el�J Office of Consumer.Affairs&Business Regulation License or registration valid for lndividul use only ,i OME IMPROVEMENT CONTRACTOR before the expiration date, If found return to: egistratlon: '1.53567 Type: Office of Consumer Affairs and Business Regulation j xpiratlon:;-1.21-1:5/20:16 Private Corporation 10 Park Plaza-Suite 5170 *, Boston,MA 02116 CAPE COD INSULAT.P...;;INC HENRY CASSIDY 16 REARDON CIRCLE:". S0, YARMOUTH, MA 02664 -Undersecretary. qNvalid lit sign y e THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) IM ^�C DATA - _ t The CoMm'onivea.lth•of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street _ Boston, s on MA 02111 r;.:J ,www:mass-gov%dia i Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers :Information Please Print Legibly asiness/Or anization/Individual ; Y p ".�I°Jt�► e Phone #, ire you an employer? Check th. appropriate box; I, ,I am a employer with st — 4. [] 1 am a general contractor and l Type of project (required.): employees(full and/or part-time),** have hired the sub-con 6,' New construction p ) tractors Q; 21❑ 1 am a sole proprietor or partner- listed on the attached sheet, 7,t[] Remodeling ship and have no employees ''These sub-contractors have g,' [� Demolition working for me in any capacity, .-,employees and have workers' [No workers' comp, insurance -comp, insurance.$ 9• 0 Building addition required.) 5, 0 We are a corporation-and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work >officers have`exercised their 1 1'.❑ 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 ❑ Roof repairs ;Y employees. [No workers' 13, ] Other comp, insurance required,) Y.. *Any applicant that checks box NI must also fill out the section,below showing their workers'c t Homeowners who submit this affidavit indicating they are doing all work and t ompensation policy information, hen hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attaphed an additional sheet showing the name of the sub-contactors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp, policy number. I am an employer that is providing workers'compensatlon insurance for my employees. Below is the policy and fob site reformation, Insurance Company Name; i Policy # or Self-ins, Lie, #: 9 00 . Expiration Date: L Job Site Address:,g�4Caye �f�Lhw� ; ��' ��1�_ City/State/Zip: Attach a copy of the worl{ers' 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 t$ 50. 0"0a d and/or ai one-year i mprisonment, 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 insura Coverage verification, I do hereby certify d the pal an penalties.of perjury that the information provided above is true and correct, �. S i 'nature: a Date' ' o� � f Phone#: r 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; ,; CAPECOO.27 BDELAWRENCE ACORO'" DATE(MMIDD/YYYY) �.; CERTIFICATE OF LIABILITY INSURANCE 6/3o/zo15 THIS CERTIFICATE I 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(les)must be endorsed, If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may requlre an endorsement, A statement on this certificate does not confer rights to the certificate holder In Ileu of such endorsement(s), PRODUCER CONTACT NAME: 434 Rogers Rio&3 Gray Insurance Agency, Inc. PHONE FAX ( ) IAJC.No.E i JC No; 877 "816.2156. South Dennis,MA 02660 EMAIL ADDRESS: _ INSURERS AFFORDING COVERAGE NAIC 4 INSURER A:Peerless Insurance Company•see LIBERTY MUTUAL INSURED INSURERB:ATLANTIC CHARTER INSURANCE GROUP Cape Cod Insulation, Inc, INSURER 0 18 Reardon Circle INSURER South Yarmouth,MA 02664 INSURER E; 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-7 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. AODLSUBR ILTR TYPE OF INSURANCE POLICY NUMBER MMIDDY EFF MMIDD EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE 0 OCCUR - CBP8263063 04/01/20.15 04/01/2016 PREMISES(Ea occurrence) $ 100,000 MED EXP(Any oneperson) $ 5,000 PERSONAL&AOV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑JEST LOC PRODUCTS•COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY , COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTO$ SCHEDULED AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIREOAUTOS AUTOS Per accident $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ CEO RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER _ B ANY PROPRIETOR/PARTNER/EXEOUTIVE WCE00431901 06/30/2016 06/30/2016 E,L EACH ACCIDENT $ •1,000,000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory In NH) _ E.L.DISEASE•EA EMPLOYEE $ 1,000,000 If yyes,describe under 0 SCRIPTIONOFOPERATIONS.below E.L.DISEASE•POLICY LIMIT 5 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLE$�(ACORD 101,Addltlonal Remarks Schedule,may be attached It more space Is required) Workers Compensation includes Officers or Proprietors, " Additional Insured status Is providedunder the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Cod Insulation, Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE' DELIVERED IN 18 Reardon Circle ACCORDANCE WITH THE POLICY PROVISIONS, South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ©1988.2014 ACORD CORPORATION, All rights reserved, ACORD 25(2014/01) The ACORD name and logo are registered marks'of ACORD 1 s: 06 130 44 �0 Town of Barnstable *Permit# Expires 6 months from issue date Regulatory Services Fee --- 163q �a� Thomas F.Geiler,Director X-PRESS prEp�� Building Division JUL 0 8 2013 Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town..bamstable.ma.us TOWN OF BARNSTABLE Office: 508-862-4038 Fax: 508-790-6230 ExPREss PERMT APPLICATION - RESIDENTIAL ONLY /77 D Not Valid without Red X-Press Imprint Map/parcel Number Property Address o'�Li cr, IQ ❑Residential Value of Work$ Zo ,Ott Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ,�4+ w C 7-VIX (F IER Contractor's Name ,2�((_ $�., Telephone Number -7-741 d3 —�Lj Home Improvement Contractor License#(if applicable) 991 Email: io 1 f Co nC Construction Supervisor's License#(if applicable) C f--jq A.(�6�"7 3 9 ❑Workman's Compensation Insurance Check one: 13 I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to 31 W 2,14Yv ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign.Property Owner Letter of Permission. { A copy of the Home Improvement Contractors License&Construction Supervisors License is required. `1 SIGNATURE: Q:\WPFILES\FORMS\b ding permit forms\EXPRESS.doc Revised 061313 the Commonwealth o,f' assachasdts art o,f ln&strial Accid 09we of Inmfigafions 600 Washington Street Bostm.CIA 02111 wwmmasxgov1dia Worlmn' Compensation Insurance Affidavit: Buiders/Cm ' ians/Plumbers Applicant Information Please Print lAyIlly Nam Citylsta,&Zip: Are you an employer?Check the appropriate box: Type of project(required): 1.ElI am a employer with 4. ❑ I am,a general contractor and I 6. ❑New construction employees(full and/or part.-time).* have hired the sale camhactaas 2.Q�I am.a sole proprietor or partner- wed on the attached sheet. 7. ❑Remodeling ship and have.no 1 T�sub-contractors have ems. $. ❑Demolition wo dng for me in any capacity. employees and have wodm'[No workers' comp.insurance comp.nisuran_ce 9:1 ❑Building addition required-] 5. ❑ We are a corporation.and its. 10.❑Electrical repairs or additions 3.❑ I am homeowner doing all work officers have exercised dwir ILEI Plumbingrepairs or additions myself [No workm'comp- right of exemption per MGL 12.❑Roofrepairs insurancerequhm&]i c. 152, §1(4,and we haw. no employ-[No workers' 13.0 Other comp.insurance required.] ''Amy applicant diet checks box#1 must also fill out the suction below show mg their workers'coo flon policy information. I Flomeownets who sal mit this dfiftur indicating they ne doing all wo¢k amd then hue outs&conuxtors mum subunit a new afidaeit indicating smch- lConuactors that check this boa mast attached an additional sheet showing the rune of the sub-ca mwmss and:stale Whether or not flu se entities bwe employ. If the sub-cnnttactots hoe employees,they must provide their workers'comp.policy number. I aryl ari employ,w that is providing wvrken'compensation inmrance for ply omplojwes. Below is the policy an d job site information. Insurance Company Name: Policy#or Self-ins.:Lic_#: Expiration Date: Job Site Address: City/State/Zip: i Attach a copy of the wGrkers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGrL 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 fi nvuded to the Office of Investigations,of the DIA for insurance coverage verification. I do hereby c under the pains au -penalties ofpedury that the information provided above is bee and correct Si Date: Phone#: Official use only. Do not write in this be completed by city or town of4ciat City or Town: PermitUcense.# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.fhty/rown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 .� Town 'of Barnstable Regulatory Services ! BARNIc1`ARf .,R R '' Hues �, Thomas F.Geiler,Director s6;¢ �m Building Division Tom Perry,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 Tbis.Section If Using A Builder I, (3 , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit (Address of Job) *Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. S• tore of Owner S tote of Applicant Print Name Print Name Date Q:FORMS;OWNERPERMISSIONPOOLS&2012 Town of Barnstable Regulatory Services s" ' ' Thomas F.Geiler,Director MASS Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Officer 508-862-4038 _ Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: munber street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: - - - — s cityhown state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one i home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building Remit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town-of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this.exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. . To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. C:\Users\demUilc\AppData\L.ocal\Microsoft\Wmdows\Temporary Internet Files\ContentOut]ook\QRE6ZUBN\EXPRESS.doc Revised 053012 t Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supers isor 1 & 2 Family License: CSFA-057394 _ ROBERT G W A115iI 160 HIGHLAND Cotuit MA 0263�' = ' Jam• n S4�`� Expiration Commissioner 06/02/2015 ✓�ie oan7�no�eu�Pa�C�.°��Zacu�iu°elta. License or registration valid for individul use only -\ Office of Consumer Affairs&B siness Regulation l before the ex station date. If found return to: HOME IMPROVEMENT CONTRACTOR 1 p Regulation Reg istration:,.;.:141991 Type: Office of Consumer Affairs and Business _ - 10 Park Plaza-Suite 5170 Expiration 3/3/2014 DBA t , Boston,MA 02116 HA BORSIDE REMODELING._., ROBERT WALSH;: 250 CAPTAIN CROSBY ROAD CENTERVILLE,MA 02632 Undersecretary . di4otv�aVidw, bout signature • , ! ✓ �''- � 680LSL LO Bey OLOL f090[f0 5 {rJ,r''-��! , ' � BMJLOVW S1lItN_SNOlStIVW � t 1S 1(iN NM LL a $� '' e. 80tl tr. max. .� �{y�➢II 7os st t�FjzL ��Ssv���8s e - 4 «w.. {. Engineering Dept.(3rd floor) Map l 6? T Parcel O S G/ �-�� Permit# House# Date Iss ®— Board of Health(3rd floor)(8:15 =9:30/,1:00-4:30) `' N j" Fee- � 1� p I Conservation Office(4th floor)(8:30-9:30/1:00-2:00) /d 2�i� N�� PlanningDept. 1st floor/SchoolAdmin. Bldg.) �Nv/RO�rrl%' °���%a � P ( g) 7*0�61 b Definitive Plan Approved by Planni,ng Board ��ED 6AP�►� TOWN OF BARNSTABLE' Building Permit Application ` Project Street Address j2 Ll 'Ccait s.1��. ��Q l �N� C�v� (4 , Village Owner �u��.. C�wv.w ,��lnc..v. Address Telephone Permit Request C-- 4_0%w+%_ � i A t ' � First Floor 'Xub square feet Second Floor I square feet Construction Type Estimated Project Cost $ 11 UU� Zoning District Flood Plain Water,Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family 2' Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes p'No On Old King's Highway ❑Yes ®-No Basement Type: Ej Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) J 'Jou Number of Baths: Full: Existing New Half: Existing — New No.of Bedrooms: Existing New ) Total Room Count(not including baths): Existing t Newer—First Floor Room Count Heat Type and Fuel: ❑Gas krOil ❑Electric ❑Other Central Air ❑Yes RrNo Fireplaces: Existing 1 New Existing wood/coal stove ❑Yes ®'No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) EfAttached(size) a_t Y_1--— ❑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 Name Vko! ,C,, Telephone Number -7-7 Address /LJ'Z_ 1 ,,� License# 9( U 7/ C11�e✓ 0 V L. VAA ox 3 L Home Improvement Contractor# /0o 71 S Worker's Compensation# V( f Q(., -O-j- NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CON�STRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO / r SIGNATURE f�� �g� DATE 110, o2 5 BUILDING PERMIT DENIED F.THE FO LOWING REASONS) s FOR OFFICIAL USE ONLY PERMIT NO. _ DATE ISSUED _ t e MAP/PARCEL NO. ADDRESS VILLAGE ' OWNER DATE OF INSPECTION: FOUNDATION FRAME J `F INSULATION r FIREPLACE ELECTRICAL: ROUGH FINAL.! PLUMBING: ROUGH FINAL IM r GAS: co t ROUGH r.FINAL f _ FINAL B'UILD'IING; ` 47) DATE CLOSED'OUT ASSOCIATION PLAN NO. , Af- _ --- e Commonwealth of Massachusetts -4- : :- • a :-- , The of Industrial Accidents :-- _ Vince off,*8suffatioos 600 Washington Sheet _..-. `� Boston,Mass. 02111 — Workers' Compensation Insurance davit iffZ11iiiiiiiiiiiiiiiiia ffzlliiiiaiiiiiiiiiiiiiiiioiaiiiiiii�� name: location city I phone# ❑ I am a homeowner performing all work myself. i . ❑ I am a sole r rietor and have no one kin ' capacity, %// /J� �'I am an employer providing workers' compensation for my employees working on this job.:: :::.: : ::::::::.::::. omaanv names :. :.. :::. ::. ..::•: ..... . .... � �.. :•.......:..... ,; :,:.::::.::: :.:::. .:::::::.:.:.:..::::... cites?;:.. .,,.,:::.....: .. .... �{.,.. . # n hone#...... 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I mderstand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby cadfy under the pains and penalties of perjury that the mfornuaion provided above n true and correct Signature Date 12.5 A� . - Print name a:�G!� Y� 1 ri Phone# �7 S� 917 U U official use only do not write in this area to be completed by city or town official . city or town: permit/Acense is (]Building Deparhuent OLicensing Board ❑checkif immediate response is required ❑sdectum's ofilce Mealth Department contact person: phone#; — ❑other Ormed 9/95 PJA) .