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- &, EV3 Town of Barnstable *Permit
Expires 6 months from issue date
AUG 2 32007 Regulatory Services
Thomas F.Geiler,Director
TOWN OF L�ARN&T!-�BCE � /���
Building Division
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
i Not Valid without Red X-Press Imprint
Map/pazceI Number
Property Address ski
❑Residential Value of Work 0 0 Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address
Contractor's Name V y l fk r k -- kAQ M� Telephone Number 4 (, I (ci
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑V orkman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
2 I have Worker's Compensation Insurance 1
Insurance Company Name (y\
Workman's Comp.Policy# ` bN C Q )
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
Re-roof(stripping old shingles) All construction debris will be taken to e� '
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders. U-Value (maximum.44)
*Where required: issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owne must Pr pe Owner Letter of Permission. i
A y of th ome pro Contractors License is required.
SIGNATURE:
I
i
Q:Forms:expmtrg
Revise061306
'} tFZ § 4
J( 1 t
,1 r
` ARK HERBST
35 PEEP TOAD ROAD
CENTERVILLE MA 02632
508-420-6216 CELL PHONE 774-238-2938
A O TTED TO: WORK PERFORMED AT:
' Richar
CIO Paul Stringer -7916 SAME
-$` 167 Glen Eagle Road
!. Centerville MA 02632
We herby propose to furnish the materials and perform the labor necessary for the completion of the
following;
New Roo.-
Remove 1 layer of existing shingles '
Install 8"drip ed�
Install ice&water shield at edge
s Install 15 lb. felt paper
Install Certainteed Woodscape 30yr. algae resistant shingles
Cut ridge&install cobra vent
j Replace all plumbing boots
Storm nail all shin les
g
Replace 2 pcs. Oflead on chimney
l Seal cracks in chimney
All debris cleaned daily
Price includes material, labor&dump fees
All material is guaranteed to be as specified.The above work.will be performed in accorandance with
the specifications submitted and completed in a substantial workman-like manner for the sum of;
Five=Thousand Six-Hundred& Twenty-Five
dollars($S"a )with payments as follows; full amount due upon completion
(°l OC,`O.( i c I^i`c
*Any alteration(s)from above proposal i olving exa costs will be added under a separate written
agreement and become an extra charge.
RESPECTFU LY T. D: ec-CA—,
(..J'
f 07-18-07
' Mark Herbst
titACCEPTANCE OF PROPOSAL 3
r Y
The above price,specifications and conditions are satisfactory. We herby accept this proposal. You
` are authorized to do the work and payments will be as specified above.
P +
Signature `a
r *This proposal may be withdrawn by said c pant' if not accepted within 30 days
s ; a f
F„ e It
F ✓ � S�yh
t.
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A
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
d 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers"Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information n t Please Print Le 'bl
NaMe(Business/Organization/Individual): . ► W J \'��-- 1 o_
Address: 3S �e- .l d d
City/State/Zip: �� MA- '
A Phone.#: �be6 c4,*D &
Are you an employer? Check the appropriate boa: 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. ❑Remodeling
ship and have no employees These sub-contractors have g• ❑Demolition
workingfor me in an capacity. employees and have workers'
Y P tY t. 9. Building addition
[No workers' comp. insurance comp.insurance. 10. Electrical repairs or additions
required.] 5. We are a corporation and its ❑ P '
officers have exercised their
3.❑ I am a homeowner doing all work 11.❑Plumbing repairs or additions
myselL [No workers' camp. right of exemption per MGL 12.[;T-R—oof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' . 13.❑ Other
comp.insurance required.] ,
*any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
xContractors 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 worker'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and f ob site
information. `` 1
Insurance Company Name:
Policy#or Self-ins,Lic.#: 6 ( n L& b 6 ] 0 D Expiration Date:
Job Site Address: 'E q r� I City/State/Zip: n t 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DU for insitaAce covAtage vegificaAn.
I do hereby ce that the information provided above is true and correct
Sitmature: Date:
Phone#:
Official use only. Do not write in this area,tb 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#:
CERTIFICATE OF INSURANCE LSSUEDATE(MM/DOIYY)
PRODUCI3K THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
Leonard Insurance Agency Inc DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
P O Box 494
OsterYille, MA 02655 COMPANIES AFFORDING COVERAGE
INSURED
Mark Herbst COMPANY A.I.M. Mutual Insurance Co
35 Peep Toad Road LETTER A
Centerville. MA 02632
COVERAGES
THIS IS TO CERTEFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED,NOTWrfHSt'ANDING ANY REQUIREMENT,PERM OR CONDITION Or ANY CONTRACTOR OTHER DOCUMENT WITH RESPECTTO 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.
CO TyPg OF INSURANCE POLICY NUMDBR POLICY EICtIVB POLICY B)(PIRATI LIMITS
I.T DATB(MMJDDJYY) DATB(MMJDDIYY)
GENERAL LIABILITY ENCRAL AGGREGATE f
COJAMMICIAL GENERAL LIABILITY PRODUCTS-COMPW AGO, f
IM.R MADC�J7CCUR PERSONAL&ADV.INJURY
wNF.R's A CONTRACTOR'S PROT. CEI O(CURRI?NCE S
FIRE DAMAGE(Airy am 11m) f
MP.D.EXPENSE(Any ono petwu) f
UTOAIOBII.BLIASILITV COM31NEDSINGLE f
ANY AUTO
ALL OWNED AUTOS BODILY INJURY f
SCHEDULED AIIrOS r penm),
HIKED AUTOS BODILY INJURY f
N-OWNED AUTOS (Pa modem)
RAGE LIABILITY PROPLItTY DAMAGE f
XCB55 LIABILITY EACH OCCURRENCE S
MBRFILAFORM AGGREGATE f
ER THAN UMBRELLA FORM"
WORKER'S COMPENSATION AND X WCSTATU OTEF
EMPLOYERS'LIABILITY S .. .
7{I)fe2-ISOi2007 uwno07 oldlolZoosBLEACH
A THE PROPRIETOR! INCL EL DISEASE—POLICY S 500 00Q
PARTNERNEXECUIIVE
(IFI•lCERS ARE' 'X E EL DISEAS E F s 100,000
.
BR
DESCRIPTION OPOPEZRATIONSJLOCATIONStVEtfICLB.SJSPECIAI.ITEMS
CERTIFICATE HOLDER CANCELLATION
StIOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE-
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL 10 DAYS WRrrTRN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LFFP,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR
REPRESENTATIVES.
AUTHORMW REPRESENTATIVE
r
�/xe -�o�rvriro�uaeal� a��/�/�aQaac�ucaelta :� ;
Board of tUilding Regulations and Standards j
License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR_. before the expiration date. If found return to:
i
Registration'`126480 Board of Building Regulations and Standards j
Expiration 6/8/2008 One Ashburton Place Rm 1301
Boston,lMa.02108 Type Individual
�� y =71
'MARK HERBST ? "1-r A r
MARK HERBST \ 3/rY
35 PEEP TOAD RD.
CENTERVILLE,MA 026324wit ----
(y;:,, 1eputy Administrator Notature
InA, t-UMMUly Wk LTH Ur* MAJJA"U,Ei15 .
Board of Building Regulations and Standards Transaction No.
One Ashburton Place-Room 1301
Boston, Massachusetts 02108
• Registration Na '
Application for Registration as a
Home Improvement Contractor or Subcontractor Effective Date
MGL Chapter 142A, CMR 780-6 Expiration Date
FOR OFFICE USB ONLY
Date
L Name tom' L lam!4-:2 20 i./+
Print the name of the individual or business applying for the registration(not both)
2 Mailing Address 1 7(.,_
Area Code�Telephone Numbs
3 (Sty h�(41P l�r^. �� 1�S State�u�?lp d�(e
4. Street Address(if different)
P ' t street and Number(P.O.Bast not acceptable) City State Tip
S. Applicant type: Individual ❑ DBA ❑ Partnership ❑Trust ❑ Private Corporation ❑ Public Corporation
(See instructions on basic regarding enclosing a city or town registration under the DBA or"fictitious name"lave-MGL c 110,ss S di:6)
6. (ace instructions) 7. Number of Employees
& Individual responsible for Home Improvement Contracts W.4-:22c% 7
9. Title of individual responsible for Home Improvement Contracts (2, �.
10. Does the applicant or responsible individual hold any other construction related state,city,town liceasas or registrations?
If yes,complete the table below. Use additional paper if necessary. Yes Nc
I--nr Emuration Name of License Holder
'
'
12. Is the applicant claiming eloemption from the rLgcnmuvu&—.
_ _ . - .. y_ o oewxe�E,I
It yes,include a copy of a current Construction Supervisor Qcense or motor vehicle repair shop Acme or segistratt m --�
13. Registration fee endowed:S Guaranty Fund fee endowed:S
Indude two separate eatiaed cba or money orders-one marked"Registration Fee,am mar' '"Guaranty Ftmd". ALL APPLICANTS MUST
INCLUDE A GUARANTY FUND FEE EVEN IF EXEMPT FROM THE REGMTRA17ON FEE.See Instructions on back for amount of fees.
Make all certified sheds or money orders payable to"Commonwealth of Mamdtasettr'
Pursuant to Massae Laws Chapter 62C section 49A,I certify order the penalties of perjury that I,
to my best I and belie&have all state to returns and paid all state tortes required ender law.
Signature of applicant or apptcant's remtative Title held with applicant
A false answer to any question in this application constitutes grounds for suspension or revocation of the applicant's registration.
. "�� T)6�)7/pZ04t/UP.CLLIit O�ii I�GQ.000LC/7,UQE�.6 �.. ..
DEPARTHENT OF PUBLIC SAFETY
CONSTRUCIIOM SUPER9ISOR LICENSE -
Nn�ber :';,.Expires:
' �-Restri0ted Fo iG
,» PAUL,J HAZIOLA
HYANNIS, NA 02601
+'`=• Tile C!I/rJ/r1 U/r 11't'ulllI of Ifassach usctts
In
Deparrnrcfrt of hrditstrial.4ccidc�frts
�i'.:,, b011 !faslting-tnn Street
%0` : Btrstutr, MUN.'r. 03111
'' Workers' cnsation Insurance Affida�it
1 orkers Comp -- ---
.�. ._ . -- ri
li�tn inf rm tt►n• _.
__ -- —
P
I am a homeowner periormine all wart: myself.
I am a sole proprietor and have no one working in any capacity ,_,,,�.,..`.._...—•..�..--
C I am an emplover providing workers' compensation for m,% empiovees working on this fob.
ennt tam• name! T -
tdtlrrcc, 7 4 I-e `✓caSS .
nhnne 0•
am a sole proprietor- sever 1 contracto or homeowner(circle otre) and have hired the contracto s listed beio%v
G the following workers' compensation polices:
cnm am nntnc•
atitirccr ,�•,
hnnc�•
cin•-
''
incur-incr rn. _ _- :T•_.-.._.s, ' �._ —
conillinv nnmrr
;ltldresc� .
insurnnee en.
hnnc it•
cite-
eiic•� �_
.. ..... •.......,_„ ._yam..-..
Attach additional sheet if necesiarv� ;�.::I =~-•";""""'
Failure to secure covent:e as rcgwred u1.nder section:SA of;11GL 15_can iead to the imposition of enmtnai penaittes al a line up to S1S0U.Ul
unc cars' imprisonment as ttcll:ts cis ii penaitics in the form 0172 STOP WORK ORDER and a fine of S100.00 a day against me. 1 uaderstanc
cop.*of this atatemcnt may be forrn•arded to the Otlice of 1tn•cstit;ations of the DIA for cotentre verification.
1 do llerchr crrrif under the pains t cnaltics ojperj •that the information provided above is true and correct.
Sianatum Date -
Phone 0
Print name
'�o�c•J t, ,��nlv do not write in this am to 6c completed by city or town oRciai
prt-mit/liecnse 0 MUuiiding Department
cite nr tmcn• �Ucensing Huard asciectmen's 0MCC
r-+l tralltl t)Ctta rtm[SIt
iassachuse:tts General Laws chapter 152 section 25 requires all emplovcrs to provide workers' c(linpensatioti for thci
nployces. As quoted from the "lacy". an einpigrec is defined as every person in tilt service of another under any
mtract of hire.express or implied. or.-if or written.
.. N
;I LIMpinrer it�'def ined as an individual, partnership. association. corporation or other legal entity. or anv two or more
foreaoina en�_a:►cd in a.joint enterprise. and including the le-gal representatives of a deceased employer, or the
=ciyer or trustee of an individual . partnership. association or other legal entity, employing employees. However the
•ner of a dwellinu house having not more than three apartments and who resides therein. or the occupant of the
.-cliin" house of another who employs persons to do maintenance , construction or repair wort: on such dwelIin`_ hou.
oil the _grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
3L chapter I52 section 25 also states that even-state or local licensing agency shall withhold the issuance or
icival of a license or permit'to operate a business or to construct buildings in the commonwealth far an}-
iiicant who itas not produced acceptable evidence of compliance svith the insurance covert c required.
Rionali . neither tite commonwealth nor am• of its political subdivisions shall enter into anv contract for the
formanee of public work until acceptable evidence of compliance with the insurance requirements of this chapter ha
n presented to the contracting authority.
)hcants
se fill in the workers' compensation affidavit completely, by checking the box that applies to your situ_"-,:on and
)Iyin ► company -,tames. address and phone numbers as all affidavits may be submitted to the Department of
strial Accidents for confirmation of insurance coverage. Also be sure to si-n and elate the affidavit. The
ayit should be returned to the city or town that the application for the permit or license is being requested.
he Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are required
-,:ain a workers' compensation policy. please call the Department at the number listed below.
or Towns
be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of
Tidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pleas
-e to fill in tite permit/license number which will be used as a reference number. The affidavits may be returned to
_partment by mail or FAX unless other arrangements have been made.
)ffice of Investigations would like to thank you in advance for you cooperation and should you have any questions.
do not hesitate to alive us a
cpartment's address. telephone and fax number.
The Commonwealth Of Massachusetts
Department of Industrial Accidents r i
Office of Investigations
600 Washinbton Street
Boston,Ma. 02111
fax #: (617) 727-7749
phone tT: (6I7) 727-4900 ext. 406, 409 or 375
ac I-J.00"D
�,, ► -1-�I ��C.J�.��S U c✓ � 2.�-� � v s ti��-C., � r N Dom �
e-A,
�—' SAr9 � �X� s�6( !,Jam ',� S � ��� )�� A/vD fJ4 p fl-A--C C � ► �� � ,t � -- �/��f2
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a�lC G.�rNr>o�✓ � ?a�" �`!/��
J �
�THE t
The Town of Barnstable
KAM Department of Health Safety and Environmental Services
9.
BuiIding Division
367 Main Street,Hyannis MA 02601
Ralph Crosses
Oflice: 508-790-6227 Building Comrr
Fax: 508-790-6230
For office use only
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization,
conversion, improvement, removal, demolition, or construction of an addition to any pre-existing
owner occupied building containing at least one but not more than four dwelling units or to
structures which are adjacent to such residence or building be done by registered contractors, with
certain exceptions,along with other requirements.
Type of Work: G�i!v Dow %�,�j�el�&X(--Est. Cost �C�C�Cf uc�
Address of Work: !a 7 1.e�'�' 'e=`'►-t�-�- 15 i� 'etii �e'c�' (�
Owner's Name
Date of Permit Application: 6
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under SI,000.
Building not owner-occupied
Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGMTRED
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 agent of the Owner. _
/ 6,/ �3 -7 A-2.1"L
Date Contractor Name Registration No.
Assor's map and lot number ....�.....1.•-f 1...: ,:.�. �'I i - r 1
C 3 —77 .
� P7'11r SYSTEM MUSTBE
is
........... r INSTALLED IN COMPLIANCE
Sewage-Permit number ............. . .......'..........,.... t' Wi7HtRTICt E I! Si:.TE f ..
TOWN
SANITARY
r' Qy�F7NE ♦�jp�o 1 T® N OFiKBAR" N' STABLE
5TAIILE • ..'1i BAflB
9 1639 + � �U G SECTOR
Apo,i639• .\e� � +
'EO mxf,* C t+ I
!!/// /KJ'•
APPLICATION FOR. PERMIT*,-TO ......................... .. ......................................................
TYPE OF CONSTRUCTION
.......................19
TO THE INSPECTOR OF BUILDINGSAfopermit
The undersi ned hereby applie according to therollowing info tion:
L
� Is .......................
Location .�` ................... ............:...�A �P................. ...
Proposed Use ........... �......................... ........................... .......,.........................
....
Zoning District ...... ...... ............................. . .........................Fire District :........W4.. ..............................Name of Owner ...:.... . ...... ...� ...... ... .._.. .. ...........Address ./... ;' ' ......,... .................S •
Nameof Builder ................ .............................Address ........................-...........................................................
Nameof Architect ..................................................................Address ....................................................................................
....:..........Foundation ..... ............. r..............
Number of Rooms ......... ............................. ..............�
Exterior r",..,r � ..4��s... .f! ................ ..... . roofing ............. v ........ .......,,... ...... ...............y2 i!........
Floors ...................Interior
Heating .......... 4. ..r, ...�.►�4 ..........................Plumbing . .... ..J�.........�.,�......... ...............
Fireplace ............................... ............................................Approximate Cost ................. ... ...
��� ..`...._ ... .......
Definitive Plan Approved by Planning Board _______________________________19_______. Area ' .......................J�/
141
Diagram of Lot and Building with Dimensions Fee .............. ............................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
f
I hereby agree to conform to all the Rules and Regulations of th own of Barnstable regarding the above
construction.
Name ............................... ................ ...... .. . ...............
Ginn, Russell E.
^ { 19104 one story'
.40 ................. for . . ..
'
' l� �ao�� '�n�x�����
-- . ~
--.
/====7,Gl l Drive
Location ---.�������----..-------..
' Centerville
..—_...---.—.—.---.,.—~--------..
' Russell E. Ginn
Owner .......
'
Type of Construction .......�--ame........................
^
_--.--.—~~..---.--.---.------- . .
`
Plot --.---.�_'—.. Lot .--.#l6-----.. _
. . .
l l3 ��
Permit Granted —. ]p
,
Date of | .lg
Dote Completed .. ---.]�
' PERMIT ������0
' '
. .
---..—.---.—,..------,—.—.. lV
. .
`
--.--.-_----...--.—,—.—..—..-----'
-._--~-----_--,--....—,..,------... . .
. '
� ..� .................................. . , .,~.. . .,—..
. . —. —..—. —. ,
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3-BEDROOM
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TEST
SEPTIC, �.
LO T. LD T. /7
701 of Ex i s
N FOOAIP = /00.0 1 N .
/00. oG ..._
GL ENEAGL E DRIVE
H OF 91.4ssq
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o� RICHARD yG
DAMES
O'HEARN
►4.•27671�a CERTIFIED " PLOT PLAN /N
v c►sT�
J
I CERTIFY THAT THE RICNARD U.
SgOIWN ON T14IS PLAN /S LOCATED 191 MAIN ST. (RTE. 28)
ON THE GROUND AS INDICATED AND WEST DENNIS ) MASS.
CONFORMS TO THE z?ON/NG LAWS
OF PIgleA/sL!2o-,F MASS. DATE: 4 �/ 2 7 SCALE; 30 `
' 40B NO. O 3 6 CL/ENT.•
•� S 7� 7
ArE lRtG. LAND ,,SUi4VEYOR DR. Q Y: R.D* SHEE TL OF
L
ngineering Dept. 3rd floor) Map,: Parcel ! ermit# s Z_
O
House# Date Issued
,Board of Health 3rd floor)(8:15 -9:30/1:00-4:30) ?• N-IVI�j �� ?ee � � �r-� `r ,
l.. Conservation Office(4th floor)(8:30- 9:30/1:00-2:00)
f -
Planning Dept. (1st floor/School Admin. Bldg.) SEPTIC S UST BE
Definitive Plan Ap roved by Planning Board 19
INSTALLS LIANCE
TOWN OF BARNSTABd TON
N NON DE AND
TI®NS
Building Permit Application /
Project Street Address 147 (9 leap ��1--� Jk D. ��� G�T �Cv
Village
Owner CNC-i Address SiaF -
Telephone
Permit Request 0
First Floor 11.20 square feet Second Floor square feet
Construction Type I'` I,* G.-)o0 �'p L C,,CA ,
Estimated Project Cost $ ��a Ou U
t
Zoning District Flood Plain N Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family (/ Two Family (J Multi-Family #units)
Age of Existing Stru ure ,,?.S Y,J Historic House ❑Yes On Old Kin 's Highway ❑Yes ❑No
g g y
Basement Type: dFull ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing New Half- Existing New
No.of Bedrooms: Existing New
Total Room Count(not including baths): Existing New First Floor Room Count
Heat Type and Fuel: f]/G1a ❑Oil ❑Electric ❑Other
Central Air ❑Yes 0 Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size) /— J2 ❑Rarn(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 JPAvL. /W.4ZZOI—A4- Telephone Number 90& - W 6?— JA:K y
Address /_7(,o (.�l�ri'E X40S) [,J`dam License# ® S17 7-9 y
/7IA12S ait/ h2,/l J Home Improvement Contractor#AX_11)1c,a.c�
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 (�
BUS � E FOLLOWING REASON(S)
FOR OFFICIAL USE ONLY
PERMIT NO. Lt
DATE ISSUED
MAP/PARCEL NO. }
t �
ADDRESS VILLAGE
OWNER _. -
DATE OF INSPECTION: .
FOUNDATION _
FRAME
INSULATION -
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: RQyUGl4 FINAL
GAS: FINAL
FINAL�BUILDING- E •.
eihs
. H
DATE CLOSED O.LFP�`
ASSOCIATION PI,,A 0.