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HomeMy WebLinkAbout0020 CRAIG-TIDE WAY ! a f .44 ice, R TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION f Map_ 2bL Parcel I`L+ r � Application # Health Division ; ' ���P Date Issued Conservation Division Application Fe Planning Dept Permit Fee. Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis �— Project Street Address �, l DL Village Erwalevliu,`c_ Owner s ID PvN j 1uC,�_- Address Telephone (acl Permit Request RCMUUf. s, ��PLI C� Jr' �C,�� OF S�lJiNC-,A LAG ins i 6ti lJo v�S S l t_c� E X 1 S7X yS(-, v PEnn N&S K2 PL r�CF e,e- bo&f bS 4, (Z►"L_,1 NJ(sN Square feet: 1 st floor: existing IN4 proposed �D_2nd floor: existing proposed Total new Zoning District Flood.Plain Groundwater Overlay Project Valuation 3000 Construction Type Nnod Lot Size • 2 5 Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure 192-(P 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: c3 existing 0 new Total Room Count (not including baths): existing 5 new First Floor Room Count Heat Type and Fuel: L/Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes YNo Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑. Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name _ \� C;�CP� /� Telephone Number ) Address 1155 CO tM W 4C-I pre /SW EI' License # CS— Q S�Z-7 3 M q_4� Home Improvement Contractor# 5g Email r�SNt y��'�Yi°�tvi4��NiE.�P�i t�s eo A 1 Worker's Compensation # zoo`D Z(Q IZO ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR.OFFICIAL USE-ONLY APPLICATION# 1 DATE ISSUED .t MAP/PARCEL NO. 4 .j ADDRESS VILLAGE OWNER DATE OF INSPECTION: t FOUNDATION FRAME INSULATION FIREPLACE J ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. i , 1 . + I i �ee�po�rmeaaecu¢all>i a�P/f�aeecce%ueelld- Oftice of Consumer Affairs&Buslaess Regulation L,cense or registration valid for Individui use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: {43358 Type: "6ffice of Consumer Affairs and Business Regulation x Iration:r; 71A7-Gi6,; Ltd LIablllty Corpor 10 Park Plaza-Suite 5170 P , q, Boston,MA OZ11G ' � ij 'lt i p1 CAPEWIDE ENTERPIv RICHARD CAPEN 4507 P,RTE 28 COTUIT, MA 02535 Undersecretary T�Lgt valid witho Ignature e . - Unrestricted-Buildings of arty use 9TMp'which )of — ccntwn less than 35PO cubid feet(991t1i Massachusetts Department of Public Safety enclosed gPacc- } Board of Building Regulations and Standards '. + License: CS-089273 r Construction SupervisortV RICHARD M CAPEN * 122 WHITMAR RD Fr1lurc to possess a wrrent QdMon of the Ma u�tts COTUIT MA 02635 state Building Code is cause for rewcaticn'of th(s ilcem's For UPS UcensIng Informatlon visit: www.h w.Qor/DPS ,,nn l/�r Expiration: Commissioner 11/27/2017 j ' • - I it ` DATE(MMIDDIYYYY) 61R CERTIFICATE OF LIABILITY INSURANCE ' 4,19,2016 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 endorsements. CONTACT PRODUCER .NAME: Kelly Estano Rogers&Gray Ins.-Kingston Branch n/co No E:t•508-746-3311 a/c No:877-816-2156 63 Smith Lane EMAIL Kingston MA 02364 ADOREss:mail ro ers ra .co INSURERS AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection INSURED CAPEENT-01 INSURER B:Arbella Indemnity Insurance Capewide Enterprises LLC INSURER c J.P.Macomber&Sons INSURERD: 153 Commercial Street Mashpee MA 02649 wsuRERE: INSURER F: COVERAGES CERTIFICATE NUMBER:639492864 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. IRSR ADD SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDDIYYYY MMIDDIYYYY A GENERAL LIABILITY 8500050813 4/30/2016 4/30/2017 EACH OCCURRENCE $1,000,000 -DAMAGE TO RENTE X PREMISES Ea occurrence $250,000 I COMMERCIAL GENERAL LIABILITY CLAIMS-MADE a OCCUR MED EX P(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 _ F-L AGGREGATE LIMIT APPLIES PER: d - PRODUCTS-COMP/OP AGG $2,000,000 X PRO- - $ POLICY LOC - - B AUTOMOBILE LIABILITY 1020017539 04 4/20/2016, 4/20/2017 Ea accident SINGLE $1,000,000 BODILY INJURY(Per person) $ ANY AUTO i ALL OWNED Ix SCHEDULED. - - BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED - PROPERTY DAMAGE $ X HIRED AUTOS AUTOS - - Per accident $ - i A X UMBRELLA LIAB X OCCUR 4600050814 4/30/2016 4/30/2017 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE _ AGGREGATES $5,000,000 DED X RETENTION$10,000 $ A WORKERS COMPENSATION 420052612 01 4/14/2016 411412017 X T RY LIM TS DTRH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A Leased Rented Equip 8500050813 4/30/2016 4/30/2017 LR Limit, 130,000 Property Building Limit 860,000 Business Property 80,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,.Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED.POLICIES BE CANCELLED BEFORE T Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.. ' AU„ ED REPRESENTATIVE - ©1988-2010 ACORD CORPORATION. All Fights reserved. ACORD.25(2010/05) The ACORD name and logo are registered marks of ACORD _..._ ,�- "� yflF- AIa� µr r rti_ _ 4 n :< , ; L . h , ., °� : '.--Rep a b ry eI`V�.��eS �:�� s � k I F Si'A '�' 'a`Lt s' �j� (i y'4;�$ Q,,,,, .{ ;'a "'4 AlU,3� `d �." r �,= s x - IN. mil, .:'� tm,,, y, ", vim . 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FAX :.�kr & �' .&°s8 `i. r '�.. '�. '� � e r ,3 F .' p. a ya, The Commonwealth of Massachusetts Department of I�dustrlal Accidents Off ice of Investigations quo 600 Washington Street Boston,* 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/El pease Print Label' Applicant Information Name(Business/Organization/Individual): Address: 5�J �D i�%1 �Gt S 62(�4� Phone# 5� 1 -7 City/State/Zip: ���� ' AWioam u an employer?Check the appropriate box: i ff6. FE] f project(required): 4, ❑ I am a general contractor and I New construction 1. a employer with_ip___._ have hired the sub-contractors ? ❑Remodeling employees(full and/or part-time), listed on,the attached sheet.; ❑Demolition 2.❑ I am a.sole proprietor or partner- Those sub-contractors have $ ship and have nq employees workers!1comp.insurance, 9• ❑Building addition working for me in any capacity. 5 ❑ we are a.'corporation and its 10•❑Electrical repairs or additions [No workers' comp, insurance officers,Have exercised their plumbing repairs or additions required.] 11:❑ right of exemption per MGL of airs 3.❑ I am a homeowner doing all work c, 152,§1(4),'and we have no 12.yoother7�Vl myself. [No workers' comp. employees,[No workers' insurance required.]t comp.ansurance required.] ensallon olicy Information. such. Any applicant that checks box If t must also nil out the section below showing their workers'comp P Policy formation. t Homeowners who submit this affidavit Indicating they are dheet showing ih�e nemed then hof the auire idb-conaactorarandutheir workers'comp. dpvit Indicating 3Contractors that check this box must attached on additional s „ ob clte I ant an errtployer that is providing workert'compensadon.insuranee for my employees Below is fine polls ,u�"a' i information. �B � �5 Insurance Company Name: f"� Expiration Date: Policy#or Self-ins..Lic.#: `J bZ(a�2 I City/State/Zip:upTVIt Job Site Address: 2 Cif Attach a co of the workers'compensation policy decla,atlon page can head ing the policy number of criminal penalties of a copy Failure to secure coverage as require under Section 25A of MGL e. 152 can lead to the Imposition fine u to secure co and/or one-year imprisonment,as well as civil penalties n that a be forwa de form of a STOP o�the Offffa of d a fine p of up to$250.00 a day against the violator, Be advised that h copy of this sta I Investigations of the DIA for insurance coverage verification. herebycertl under the pains and penaltles of perjurl that the information provided above is true Bird correct, Ido ly �. D to: 5 " Signature:. Phone#: SU�� Official use on1y. po not write In this area;to be t ompieted by city or Town ofj7cial i, City or Town! #. I, Issuing Authority(circle one): ' own Clerk . Board of Health 2,Building Department 3.CitClerk4.Electricai Inspector 5.Plumbing Inspector � 1 6, other j Phone#: Contact Person: , I r Commonwealth of Massachusetts Sheet.Metal Permit MapI_,4arcel Dam: -yj• _ *PRESS PMH j Estimated Job.Cost: $ '/ - AUG 12 2014 Permit.Fee: $ � Plans Submitted: YES NO � Plans Reviewed: YES NO 4#M�Business License# 5 l PPPTOWNOIFP" an �cense# - Business Information:, - Prope er/Job Location Information: y� ( \ • Name; Name: •7!` V�'�""� Street: pd Street: City/Town: 4aulki k City/Town: Telephone: J� -Z 0 'Z Telephone- Photo I.D.required/Copy of Photo I.D. attached: YES Z NO i se Staff laftl J-1/M-1-unrestricted license J-2 I M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. f L 2-stories or less Residential: 1-2 family •V Multi-family Condo/Townhouses Other Commercial: Office Retail Industrial Educational Eire Dept.Approval Institutional_ Other Square.Footage: under 10,000 sq. ft. V over 10,000 sq. f L Number of Stories: Sheet metal work to be eompleted: New Work: Renovation: HVAC ;/ Metal Watershed Roofing Kitchen Exhaust System Metal Chimney I Vents Air Balancing Provide detailed description of work to be done: INSURANCE COVERAGE I have a current l4ability insurance policy or its equivalent which meets the requirements of M.G:L.Ch.112 Yes g<o❑ If you have checked Y,indicate the type of coverage by checking the appropriate box below: A liability insurance policy ( Other type of indemnity ❑ Bond ❑ i OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insuranc overage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit appiicatio this requirement. Check One Only. Owner ❑ agent Signature of Owner er's Agent. By checking this box[],I hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installadons performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation:YES NO Pr-® C'�s InsileCtions Date Comments i is Final InallrStiog Date Comments Type.of License: 3y Master rise Q Master-Restricted 'itylfown QJoumeyperson Signature of Licensee ! Dermit# (� QJoumeyperson-Restricted License Number. -c zee$ ❑ Check at m a,go WW I nspector Signature of Permit Approval f D4eparfxent of I4&stdd Accidents JU Vim ebwastigatiorfs, 600 Washington Street Bost*Mgt 02111 x�w mass gov/dia Workers' Cnupensation insurance Affidavit:Builders/ContractorsMectridmfPlnmbers A ant Iic Information Pease Print Name(Busiwe C)r��viij; h S Address: j City/St#te1Zip:. Phone.#: Are you an employee fteck the appropriate boz: - .Type of project(required):; 1.�am a employer with 10 4• 0 I am a general contractor and I 6. 0 New construction . employees(fig and/or part-#one).*.. have hired fire guts-con ractors listed on lhe-attache 2.❑ I am a'sole*Prietor orPartaer- d sheet. 7. ❑Remodeling . shin and have no employees: These sub-cam have 8. ❑Demolilian _ employees and have workers' addition working forme in any capacity. comp.insurance (No works'comp.insurance 10.❑Electrical resorts or additions t ch ered.] S. ❑ We are a station and its 3,❑ I am a.homt owner doing all work officers have exercised their 11.0 PhImb*repairs or additions pelf[No wad 'cow right of exemption per MGL 12.0 Roof repairs insurance mired.]t. c.152,§1(4),and we have no 13.0 Other employees,jNo workers comp•hIMnMce required.] •Airy app3it�t that cb=f&box#I must also.fM out It station bdow skming tb i worl�s'�ensatiou Policy infMmafion. t i"iomeowneis who submit this amdr&buHc�tiag f wy=doing all work and then hive outside contractors must submit a sew s$idavit iadit�ag'sueG tContractors that check ibis box must attacbed as addit=4 sheet sbowiug lire game of the 0 -contactors and swc wbether orvot ftm cntities have emplvycss. If the sub;oatracb=bave rsployees,tbey z®stpmvide their warkcs'comp:polieynumber_ rant an emploiw that is proviefixg workers'compensatinx insurance•for my employees. Below is the po&cy and job site information. Insurance Company Name Policy#or Self-ins.Lic.#. 696 U 6 1 I •Expiration Date: Job Site Address: oa Attach a copy of the workers,!compensation policy de on page-(showing the policy number and expiration date). Failure•tb secure coverage as required miler Sec€ism 25A of MGL c.152 can lead to the impasitin of c it m penalties of a fine tip to$I,500.00 and/or one-year imprisonmem,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 violitar. Be advised that'a copyof this stxtemerit may be forwarded to tile,Office of DEggi ations of the DIA for insurance coverage ve iftation. I do hereby cerGi tender the p ' i penalties of perjury Heat the informaiiat provided above is.true aril correct Date Phone Offtcial use only. Do not write in this area,to be completed by ca y. town gfficiaL or City or Town: Permit/l'.icense# Issuing Authority(circle one): 1,Board.of Heolth.7.Building(Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other.. contact Person: Phone j A��® CERTIFICATE OF LIABI ITY INSURANCE DATE 22/2°DY014YY) s/ 2/24 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AN CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EX. END 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 poll (!as)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endo ement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Debi James Leonard Insurance Agency, Inc PHo E (508)428-6921 Fvac No;(soa)azo-sao6 683 Main Street a� Es:debi@leonardagency.com Suite B INSURE S AFFORDING COVERAGE NAIL Osterville MA 02655 INsudERA:Travelers Indemnity of America 25666 INSURED INSUIERB Tray®lets Cab & Surety of IL 19046 Bourque Heating & Cooling Inc. INSUI'ERCTravelers Indemnit Co. 25658 B&L Equipment LLC - ' INSU ER D: i PO BOX 770 INSU ERE: - Marstons Mills MA 02648 INsuRERF: COVERAGES CERTIFICATE NUMBER3taster 2015 11 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 A14Y 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 TERFIS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I SUER LTR TYPE OF INSURANCE OLI POLICY NUMBER MMIDD EFF MPM/D Y EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000:0 0r� DAMAGE TO RE X1 COMMERCIAL GENERAL LIABILITY NTED PREMISES Ea occurrence S 500,OOOt A CLAIMS-MADE ❑X OCCUR 680SB790617 ; /17/2014 /17/2015 MED EXP(Anyone person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,00G GENERAL AGGREGATE S 2,0001000' �GEIVL AGGREGATELIMIT APPLIES PER: - PRODUCTS-COMP/OPAGG $ 2,000,00� I POLICY PRO- L� S __. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT —I Ea accident 1,..G00,0U^ j }[ -88791085-14-SELi BODILY INJURY(Per person) S B + AUTOS AUTOS i /17/2014 /17/2015 ANY AUTO ALL OAMED SCHEDULED BODILY INJURY INJURY(Per accident) NON-OWNEDPROPERTY -------........- .} X HIREDAUTOS X AUTOS a tDAMAGE S Medical pavrnents I X j UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 3,000,000 C i EXCESS LIAB CLAIMS-MADE AGGREGATE S 3,000,00 DED RETENTIONS -8a791269-14-42;; - /17/2014 /17/2015 Is WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y!N ANY R �EXCLUDED?�CUTIVE 6S59iJ8-5839530-A 1C - /17/2014 5/17/2015 OFFICER/MMBER N/A E.L.EACH ACCIDENT $ 1,00. ^i3 1, - D (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 1 COG'_,OO J! If yes.describe under - --- DYSCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1 000_0^Ot. j1 i I I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional RemaiksSchedule,It more space is required) - I j i CERTIFICATE HOLDER CANCELLATION j SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOR E THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. I Bourque Heating & Cooling Co. Inc. B&L Equipment LLC AUTHOPO Box 770 ' ED REPRESENTATIVE I Marstons Mills, MA 02648 } Tina�Boulos/LEOTBI I_.�is[cr,� . ACORD 25(2010/05) 4 ©1988-2010 ACORD CORPORATION. All rights reserved. INSn25 oninnst nt Thn arnpn nnmu and Innn iro of Arnan �_ L 06/16/2014 15:23 7818493260 JONMACQUARRIE PAGE 01/01 Town of Barnstable RePlatory Services t nomm F.Geller Direct , or Building]Division Tone ferry,Building Commisdoner 200 Main quaei Ry Ws,MA 62601 WWWAOWo.bareslable.me.as Office: 508-8624038 Pax, 508-790-6230 Property Owner Must Complete and Sign This Section U-UsiW AJDWIder a9 Owner of the subject property hereby authorize �{V uJMBIN net 6n my behalf in all matters relative;to work aathotized by this buildiug p=niL (Address of job) / 626 3 Z "Pool fences and alaans are the responsibility of the applicant. Pools are not to be filled before fence,is installed and pools are not to be utilized.until all final inspections are performed and accepted. S o $igstau=of Applicant —bawl d hb� vvr v-�-- Pzint Name Pdmt Name Date Q:F0RMS.10WNHRPERIv=I0MV0LS f �IjASS�CF3ITSET'T DRI1/ER'S ,:. LICENSE 42 ASS j 9H END 4d NUMBER w a i`'163 NONE EXP /S}�565C80A7�3/2� .. r--' j.,. ',•-4b 0 J'2J'ZV�� s ROBERT G v .. 8 MAR14 CROOKED CARTWAY 4szyssn STONS MILLS,MA 02M&1008 5 DD DS 13•T013 Rev 07-15-2009 /t • et_ !: COMGWONW ,EA T— OF NIASSACHUSETTS L e s N • HOARD 01F.. SHEET METAL WORKERS. 1(8SUES..THE.. FOLLOWING:. LICENSE MASTER UNRESTRF:CTED o 2OSERT G 90URQUE , c k)u u 14 CROOKEfi7 CARTWAY' `� a U 17 MARSTONS MILLS MA.02648 1008` 64 O I2$!16 208664 l ``