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Of YFIF TOq, Tow.0 of Barnstable . Permit
E.rpires 6 ntonllis from issue dale
Regulatory Services Pee t-l�- 3
sAtuas'rAsr.E, g y
ib Thomas F. Geiler, Director
�plFor��" 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 - RESIDE,NTIAL ONLY
Not Valid without Red X-Press In1print.
Map/parcel Number
Property Address �",t ( � ""`C ,
Residential Value of Work e`,kXo Minimum fee of S25,00,for work under$6000.00
Owner's Name &Address
Contractor's Narnc � tbJ `� �a�--- Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable) ��lC1CJ
❑Workman s Compensation Insurance'- - REESS PERINAIT
Check one:
g.Lam a sole proprietor h0V 4 2009
❑. I am the Homeowner
❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE
Insurance Company Name _
Workman's Comp. Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑ Re-roof(not stripping. Going over existing layers of roots
❑ Re-side
'Replacement Windows. U-Value (D (maximum .44)
*Where required: issuance of this permit does not exempt compliance with other town department regulations,i.e. Historic,Conservation,etc.
***Note: Property Owner must sign Property_Owner Letter of Permission.
e Improvement Contractors License & Construct Supervisors License is required,
• SIGNATURE:
Q:\WPEILESTORNI ss\EXPRESSPERMfT.DOC i
VA
The Cofnmonfvealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
+ d 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): ITOAA-.1
f
Address: ea b4na, l �1
City/State/Zip: a _ "Nr Phone.#:
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. 0 I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2. Lama sole proprietor or partner listed on the attached sheet. T. []Remodeling
ship and have no employees These sub-contractors have 8. 11Demolition
working for me in any capacity. employees and Have workers' 9 0 Building addition
[No workers'-comp. insurance comp. insurance.$
required.] 5. We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.[]Roof repairs
insurance required.] t c. 152, §1(4), and we have no f
_ employees. [No workers'
comp.insurance required.]
*Any applicant.that checks box#1 must also fill out the section below showing their workers'compensation policy infor ation.
t Homeowners who subrrut this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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:
Policy#or Self-ins. Lic.#: Expiration Date:
Job Site Addrese: ( 4A4A no;6rnr Lj.► City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500,00 and/or ogre-year imprisonrnent, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby ertify and r the pains and penalties ofperjury that the information provided above is true and correct:
Si ature: Date:
10 I�
Phone
Official use only. Do not write in this area, to be completed by city or town offccial
City or Town: Perrrrit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6. Other
r
Information and I.nSttuctiol's
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
very person in.the service of another under any contract of hire
Pursuant to this statute, an employee is defined as ".. e
express or implied,oral or written."
An employer is defined as "an individual,partnership,association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or tiustee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto.shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that"every state or Iocal licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall .
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority.'
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contiactor(s)name(s), addresses)and.phone number(s) along with their certificates) of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address" [he.applicant should write"all locations in,__(city or
town).".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related fo any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit
ue Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone acid fax number:
The C6mmonw(,-9th of Massachusetts
Department of Industrial Accidents
Office of Investigations.
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-.7749
Revised 11-22-06 www.maS -.gov/d.ia
�Y r Town of Barnstable
Regulatory Services
Thomas F. Geiler,Director
Building )Division
0
Tom Perry,Building Commissioner
200 Main Street, Hyannis, MA 02601
W)Vw.town.barnstable.mams
Office: 508-862-403 9 Fax: 508-790-
Property Owner 1V ust
Complete and Sign This Section
If Using A Builder
�J to co � as Owner of the subjectproperty
1
hereby authorize <5,o4-i:j YJ rj to act on my behalf,
in all matters relative to work authorized by this building permit application for.
(Address of job)
Signature of Owner 2te
Print Name
If Proper�y Owner is applying for permit please complete the
Ho meow-hers License Exemption Form on the reverse side.
i
Town of Barnstable
a of Y r �
0 , Regulatory Services
Thomas F. Geiler,Director
Building )Division
�rED � Tom Perry,Building Commissioner
0
... 200 Mairi.Street,—Hy=is,MA 02601
w".town.barnstable-ma.us
Office: 508-962-403 8 Fax.: 509-790-6230
HOAIEOWNER LICENSE EXEMYTTON
Please Print
DATE:
JOB LOCATION:
number street village
"HOMF.O WNER":
name home phone# work phone#
CURRF-NT MAfLLNG ADDRESS:
city/towo state zip code
The cturent 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.
DEYD11 ION OF BOMEOWNER
Persons)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 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 be/she shall be
responsible for all such work performed under the building permit. (Section I09.1.1)
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.be/she understands the Town of Barpstable,Building Department
nuxa.MUM inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
Signauxr of Hamco`t'ner
Approval of Building OfEcial
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 statrs that "Any homcowoc perforrrring work for which a building pa iit is required shall be exempt from the provisions
of this section(Section 1 o9.1.1 -Licensing of construction Svpervisors);provided that if the homeowner engages a person(s)for hire to do such
work, that such HOmCOwnCr shall act as supervisor."
Many homeowners who use this rxcrnptian arc unaware that they arc assurmng the responsibilitics of a supervisor(see Appendix Q,
Rulcs&Regulations for Licensing construction Supca-visors,section 2.15) This lack of awareness oflLn results in serious problems,particularly
when the homeowner hires unlicensed persons In this case,our Board cannot procmd against the unlicensed person'as it xlould with a licensed
Supervisar. The homeowner acting ss Supc visor is ultimately responsible.
To ensure that the bomeowncr is fully aware of his/her responsibilities,many communities require,as part of the permit application,
that the homcowncr certify that hdshe undcrstards the rtsponnbilitirs of a Supervisor. On the last page of this issue is a form currently used by
it several towns. You may care t ad and adopt such a forr
men r�certification.for use in your community.
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�x Board of Building.Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
-
Registrakyw 101149
Expl�M=6/ 5/2010 Tr# 267680 L
? t= ,��ype�IndlYidual� -
E=
JOHN P.'DUNN
e-
John Dunn; j� ?
80 MARIE ANN TERR, �'!V I
CENTERVILLE,.MA 02692 Administrator i I
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yEngindering Dept. (3rd floor) Map Parcel zU
House# �� /a_' Date Issued -46
Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) - .-J e�,AFee O))
Conservation Office(4th floor)(8:30- 9:30/1:00-2:00) SEPTIC SYSTEM MUST BE
Planning Dept.(1st floor/School Admin. Bldg.) INS IALLED I ! NCE
Definitive Plan Approved by Planning Board 19 "'� WITH
TOWN OF BARNSTABLE
Building Permit Application
Project Street Address
Village ee 1Pl-eft-1-d(,Lr'
Owner 4,Ga Q OG1CI W00UP Address ez H-4tV 2&o0,,52 ,
Telephone 6-V F— 'JY�X-8—16 494av Cr
Permit Request
First Floor square feet . Second Floor square feet
Construction Type Re 9 vZr12::Z
Estimated Project Cost $ j 0J AW 11
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
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 Half: Existing New
No. 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
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(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
Name Telephone Number S"` 7 �-�
Address License#
Home Improvement Contractor# a �
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 Leo DATE j,L7vh(j
BUILDING PE IT DENIED FOR THE FOLLOWING REASON(S)
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_\ The Commonwealth of jVassach uses
� 1 Department of IndustrialAccidents
� -- � Dfliceo/Intresdgel�its
600 Washington Street
Boston,Mass. 02111
Workers' Compensation insurance Affidavit
it rhnn
1 am a homeowner perforntin8 all work ttlyself.
❑ lam a sole proprietor and have no one working in any capacity
❑ I aryl and employer providing workers' colpensation for my employeesMMMM working on this job. �� ` '
rMupare x n . .
!n.Sllra ce olie #
s
❑ I atn a sole proprietor,general contractor,or homeowner(elrcle one)and have hired the contractors listed below who have
the following workers'compensation policesrgn a.
nt ftn e;
h nr#
MITI!an
d
..
Failure to secure coverage as required under Scction 25A of diG i.152 can lead to the imposition nferiminal penaitics eta fine up to$1,.500.00 and!
or
one years'imprisonthent as well as dvil penaltie.9 iu the furm of a STOP WORK ORDER and a Tine of S100.00 a day against me. T understand that a
copy or this statement maybe forwarded to the Mee of Iovestigstinna of the 171A for coverage verification.
I do herehv cerfijy raider the pains a enahies ofperistry 1/1at the;nformalion provided above is[rue and correct.
Signature G (�
atc
Print natric hcnc.jif
nifcial use only do not write fa this area to be completed by city or town otficini
city or town, periniNicense# Building Dcpartmem
check if immediate response is required plAcensing Board0sclectmen's Ofrce
OHcalth neparlment
contact person: phone#; -Other
r'
(miud E199 p]A?
}
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' cornpensatior for their
employees. As quoted from the "law",an employee is defined as every person in the service of another undef any
contract of hire, express or implied,oral or written.
An employer is defined as an individual, partnership,association,corporation or other legal entity,or any two or more of
the Coregoing engaged in?.joint enterprise,and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual ,partnership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and•who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business 6r to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the iosurance coverage required.
Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the
performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have
been presented to the contracting authority.
s
Applicants
Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and
supplying company names, address and phone numbers as all affidavits may be submitted to the Department of
industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The
affidavit should be returned to the city or town that the application for the permit or license is being requested,
not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required
to obtain a workers' compensation policy,please call the Department at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number: � '�
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of lnllestigauens
600 Washington Street
Boston,Ma. 02111
fax 4: (617)727-7749
phone#f: (617) 727-4900 ext. 406,409 or 375 12
1 _
OFVE rW�.
ti0
The Town of Barnstable
BARNSPABM •
9� � Department of Health Safety and Environmental Services
pTFOMA'�p Building Division
367 Main Street,Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
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: �j' 5✓ / 7�/��'J` �Est.Cost
Address of Work: Z// /1A d=2�,6? 4,31
Owner's Name LeW-
Date of Permit Application: (( �o
i
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under$1,000.
Building not owner-occupied
Owner pulling own permit
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 agent of the owner:
AA,/h 10
D to Contractor Name Registration No.
OR
Date Owner's Name
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Assessor's"map, and lot number ......./ ....................... ( �t
SEPTIC'SYSTEM MUST BE
INSTALLED 'IN COMPLIANCE
c Sewage,Permit number ..... ....
WITH ARTICLE III STATE �
SANITAR .o!�
:. �ofTHETo�: r ` TOWN`: OFRAREN IIA PAN
A
r^ Z BAHH9TADLE,
i639` BUILDING INSPECTOR'
c ~� APPLICATION FOR PERMIT PTO C�i .... !�-�:.........
TYPE OF CONSTRUCTION .. ......1.. C .. .................. ..................... ....
e ........ . ........... A
.... '
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TO THE INSPECTOR OF�`BUILDINGS:
The undersignej hereby applies for a permit according to the followinginformation:
Location ........ .. ..................................................................
ProposedUse ...: .. ... . .... ...... ........... ..............................I.........................
/
Zoning District ..... .....:..... ........... ........... .........:................Fire District .... .. ..........�.....................
Name of Owner ..................�'� ....Address 3,m...... .... ..l l . .... .. .. ........ . ?1��.AV
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Name of Builder ......�e' Address
.................................................
Nameof Architect ..................................................................Address ....................................................................................
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Number of Rooms ..:...............................................................Foundatione,�
...� ..... ...........................................
Exterior ...�� ` ' .... "..... ..........Roofing ...
Floors .................Interior ..................
Heating. ...........T.. .......Plumbing ........�.....................................................................
Fireplace ............Approximate Cost
Definitive Plan Approved by Planning Board _________________ ___________197s
Area ..........................................
Diagram of Lot and Building with Dimensions Fee � � S
SUBJECT TO APPROVAL OF BOARD OF HEALTH
J
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Nam _ .... ....... .. .. ........����..
........................
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Capewide Development Corp.
singl� family dwelling
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Caz��mrvllla
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Capewlda Development Corp.'40
--_ .------------.---------
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� frame'
' Type of Construction -------.--.�---..
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428 '
"Ph� --. . �t ' '
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Approved ................................................ iV
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Assessor's map and lot -number ........ .................................
6; S-
Sewage Permit number ...........................................................
INE
TOWN OF BARNSTABLE
BAWSTLBLE,
,639 BUILDING INSPECTOR
APPLICATION FOR PERMIT TO ...............ILf-4 .vv_.4,E........................................
........... ... .. . ....... ......
TYPEOF CONSTRUCTION -? .......................................................... ........... ..................... ............
A
...............;.............................. 19.:.
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according t,o the following information:
LLB
Location ...................................................................................................... ..............................................................................
Proposed Use ..... ..........
........................................ ............. .................................................................
ZoningDistrict ........ ... Fire District ..... . .......... ....... ....... .... .. ................7..............I..... . ........ .........
b"771,44 zf 11i"e - - /_Name of Owner..................................................... .....Address .....................
Nameof Builder ............................................Address ........................................................... ............
Nameof Architect ................Address ....................................................................................
Number of Rooms ............... Foundation
..................................................F ................. ....................................I.........
w 1 44 6-1rA0,4
Exterior .....................................................................................Roofing ............. .................... ................ .........
Floors ................. ......................Interior ......................................................................
Heating2
..........;�......................................................................Plumbing .........................................................................a.........
Fireplace ................../............ ..................................................Appioximate Cost ......... .............. ................
Definitive Plan Approved by Planning Board '71 1 ---------197 Area ..............................................
Diagram of Lot and Building with Dimensions Fee .....................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
72
I,,<-P7
I hereby agree to conform to all the'Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ..............................................................................
Cmpew1da Development Corp. A=148-1
� Vol
'
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' .
18335 l 1/2 story,
. No ................. Permit for ------------ '
/ ` � . .
single family dwelling
h~ .............................—'--',------------'' -
/
' �� Badzada Lane °/
Location �[onj............................................................
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�C�vner --r^---^ Corp.
.
, Type of |
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/ Granted . '
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.
> Date of Inspection
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� Date Completed .
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