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HomeMy WebLinkAbout0225 HUCKINS NECK ROAD ��5 �c�.k+ns 1�1�ec1c �'R�, � . � . � . :. : . - , y �� �� a . �� , . r . x q i Town of Barnstable Permit# Ewes 6 months from issue dates Regulatory Services Fee . aasxsT,�sla, • - , 1639. Thomas F.Geiler,Director -_ X-PRESS�1 Building bivision PERMIT Tom Perry,CBO, Building.Commissioner / 200 Main Street,Hyannis,MA 02601 JAN 2 5 2012. Q�1/71// 12, www.town-bamstable.ma.us 508-862-4038 . wwNN 1 pg,A2g I Ht3LE EXPRESS PERMIT APPLICATION - RESIDENTITPRO f Not Valid without Red X:Press Imprint ?'&p/parce,inxn er l! . Property Address. Z Z S 14y C InI n j . /✓e, I-, C� [�]Residential Value of Work 't Cud Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address �Z(,-f Contractor's Name '► `�i' j �Telephone Number 1?lr— 7,0--Z)de Home Improvement Contractor License#(if applicable) 1 t_l 3 6S Construction Supervisor's License#(if applicable)- 1 ❑Workman's Compensation Insurance Check one: t ❑ I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name ��rl Workman's Comp.Policy#_ O Z Z�l�/37— z I U Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) n Rarnnf(h�'- irwne na.lnd)tetrinninrt nm Q innleel Alold dn-hr g ixnll be taken 4n Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows 'Where required:Issuance of this permit does not exempt compliance with other town department regulations,i.e..Historic,Conservation,etc. Ruac. i ivlJ vwuci must sign i v}►2i ay vwucr a.cuci si i caaui�niuu. A copy of the Home Improvement Contractors License&Construction Supervisors License is require . .. _ r , SIGNATURE: C:\Users\decol ik\AppData\Local\Microsoft\WindowsUemporary Internet Files\ContentOutlook\DDV87AAZ\EXPRESS.doo Revised 072110 Office Woo` &Bdsmess Regulation License or registration valid for individul w only. HOME IMPROVEMENT CONTRACTOR before the expiration dater If found return to: Registration 143053 Type Office of Consumer Affairs and Business Regulation Expiration::' 6f1E'•[2012 DBA °"' '" 10 Park Plaza-Suite 517fi K ING CONST , - Boston;MA 02116 I } z _> TIMOTHY KEATING I 54 LOWER BROOI,RD SO.YARMOUTH MA 02664 ; I Undersecretary ;{ Not valid without signature 1 • _ r �!ititiu�huseltti 'Dep rtment of Public S eta Bound of B'u ldim� Rt�rulatW and $tand4d5 Construction.,Superyisor.Specialty License ":,License: CS SL 99351: Restricted to: .RF. .. TIMOTHY'KEATING " ry 54.LOWER BROOK ROAD - SOUTH YARMOUTH, MA'02664 Expiration: 5/11/2012 ('inunisiuner �r Tr#: 99351a f ., CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIVYYY) Fo3/21/2011 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 BELUVV. I HIJ i:EK 11FiCA I E UI' INZOLIKANUL UUGJ NOT CONa.T i T U T E A CONTRACT BETWEEN WEEN THE ISSUING iNSURER(S), AUT H0 Rif ZEU REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. It SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).' NAME: Schlegel 6 Schlegel Insurance Brokers Inc PHONE —� _LAIC.No,Ext): - !(AIC,Not: 34 MAIN STREET E-MAIL — -- _— _-- ADDRESS: - "PRODUCER" -- CUSTOMER TO- ­....il.. - INSURED -� INSURER A COLONY INSURANCE Timothy Keating. Dba Keating Construction _. —�—--- ---°- - INSURER a CNA 54 Lower Brook Rd INSURER C; - INSURER D; INSURER F C(XvERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. r------- --._.—' --- LTR TYPE OF INSURANCE !INSR WV0 I POLICY NUMBER ( PWDD EFF POLJTCITE)1� (MMIDDIVYYY} j +MM/DD/YYYY)- LIMITS GENERAL LIABILITY I , A GL3594908 03/10/11 03/10/12 1EACHOCCURRENCE S1,000,000 iX COMMERCIAL GENERAL LIABILITY i I - r DAMAGE TO RENTED- I S ZOO,OOO PREMISES(Ea occurrence) PERSONAL d ADV INJURY $1,OOO,OOO GENERAL AGGREGATE —`S 2 r 000,000 GEN'L AGGREGATE LIMIT APPLIES PER ,PRODUCTS-COMP/OP AGG s2,000,000 ' PO POLICY _. FR , AUTUMOBILE LIABILITY i - 1 I �COMBINED SINGLE LIMIT �� ' f I(Ea accident) .ANY AUTO BODILY INJURY(Per Person) S ALL OWNED AUTOS I - j !BODILY INJURY(Per accident) S SCHEDULED AUTOS I i - "---- PROPERTY DAMAGE-- Q - NON-OWNED AUTOS --S I UMBRELLA LIAR OCCUR E EACH OCCURRENCE i(($ EXCESS LIAR v._CLAIMS-MADE ? ! ,`AGGREGATE 5�� DEDUCTIBLE }}. I RETENTION $ B WORKERS COMPENSATION s - 0224N37-2-10 :03/09/11 )03/09/12 to H.AND EMPLOYERS'LIABILITY Y r N-I ANY PROPRIETOR/PAP.TNERJEXECUTIVE L EL.EACH ACCIDENT S 100-,000 " OFFICER/MEMBER EXCLUDED? i NIA w^^ I If yes.describe under + DESCRIPTION OF OPERATIONS Delow E.L.DISEASE-POLICY LIMIT ; S SOD. OOO I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101.Additional Remarks Schedule,d more space is required) - - - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVEi� 71 e O 1988-2009 A ORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD the CornmonweaNt of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 fvwrt.mass gov1din Workers'Compensation Insurance Affidavit: Buiilders/Contractors/Electric ansll'imloers Applicant Information Please hint Legibly Name(Business/Organiretion&dividual): ✓,- Ire, fin r Address:.__St( City/State/Zip:-I�q- r+c.r 00 6d_/ Phone Are you an employer?Check the appropriate box: Type of project r 1.[2 I am a employer with 4. ❑ I am a:general contractor and 1 b_ ❑.New construction employees(full and/or part-time).•. have hired the subcontractors 2.❑ I am a sole proprietor or partner- listed on the attached.sheet.'. 7. Remodeling ship and have no employees These sub-contractors have 8• ❑Demolition w for me is capacity.' employees and have workers' working Y� tY• - 9. Building addition [No workers'comp.insurance comp-insurance_-' required.] 5• ❑ We are a corporation and its M El Electrical repairs or additions 3-❑ I am a homeowner doing all work officers have exercised their i L❑Plumbing repairs or additions . myself[No workers'comp• right of exemption per MGL 1_. Roof repairs insurance € c. 152,§1(4),and we IN have no- employees. ' recpmed.} o workers' 13.11 Other comp:insurance required.}' 'Any applicant that checks box#1=2 also fill out the section below showing their wa ten'compensation policy information 1 Homeowners who submit this affidavit indicating they are doing all want and then hue outside contractors mast submit anew affidavit indicating such.. +Contractors that check this"boa must attached an additional sheet showing the--.of the sub-contractors and state whether or not those entities bare employees. If the subcontractors have employees,they must provide their workers'comp.policy number. lam are employer that is pmiding awrkers'congmtisadon insurance for my employees. Belo",is the policy and job site information. Insurance Company Name: ZI Policy#or Self--ins.Lic. l}Z?4741 27•-2 /U Expiration Date. Job Site Address: 22 14VC P,�,, City/State#Zip: i 0-1 f-r<4V 2 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 g1,500.00 andfor one-yew imprisonment,as well as civil penalties in the form of a-STOP WORK ORDER and a.fine , of up to$250.00 a day against the violator. Be ad%nsed that a espy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereky certifi,nnder t e pains.and penalties of pedury that the inforrnation prm-7ded abmw is to:e and correct :aiimatttre.: '- Date: / ?-r r'z j oF� ` BARNSTABLE ; 6. Town of Barnstable Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder , I 4S �i2 as Owner of the subject property 4 hereby authorize to act on my behalf, in all matters relative to work authorized by Zsbuilding permit application for: (Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\ContentOutlook\DDV87AAZ\EXPRESS.doc Revised 072110 Assessor's map.and lot number ,,.,2 2.. !1. :... `' . �&THE l� i' � �� Sewage Permit' number ....., ..... ... d� 2 Bas , :. House number ............. :. ZQ?.............:............. ........: . 'oNA E TADL MABB' Oe 209• \00 TOWN OF BARN,STABLE BUILDING IHSPE�CT0R APPLICATION FOR PERMIT. TO ....G:° ?: !?.`.:. ......�...S.fv"�'.... f �/� Cav Sly TYPE OF CONSTRUCTION ..... !U j. ......? !'.'.'. ?.!s:.................................................I........ I ................................. / ................... ` / TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ... ..$ ....rx..( / i/YS......./ /-"4./... ....... . ........ TrR. {. L... W .....:........................................... Proposed Use �]. ,5................................... I .....,......................... ...... ..... ..... C, "—O Zoning District ...... /...................................................Fire District ........................................... Name of Owner ...:...( o.. 'r�.T.....5 �./..`...........Address Name of Builder N..�!�......5 1/�5 ... Address Aox.... ................ Name of Architect ...... ......................................:...Address ...................................................i......,......................... Number of Rooms ........ Foundation ... Qi!. .flat��....... Q��.G.. /rTie Exterior ........... ...............................................Roofing ...........A -L CA..A'0A ....Interior ...........5 Ir e av/ Floors ............ ............................................... ..'�.z�°.1.�...........K.......................................... ................: .PlumbFn ... fy� ... .. ... ...................... Fireplace ../.........: /Q!G.%�. ...Approximate Cost ................ ........ ..... Definitive Plan Approved 'by Planning Board ----_---------------------------19.__-� Area Diagram of Lot, and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the, above construction. Na .. .....^.......... A=252-118 Starr, Robert No 21101....... Permit for ...CRTIs.to...s3zlgle..... 4' .................I........................................ ` Locat6n3HuGkins..Ne�k..Rd................ ...............Center.ui ne........................................ Owner ....Robert..Starr.................................... Type of Construction ....Waod•.Frame................ ............................................................................... Plot ........................... Lot ...8a........................ Permit Granted .....March 19 ....19 79 Date of Inspection .. ................................19 Date Completed .....................................19 PERMIT REFUSED .. 19 C............ .. . ................................... ... .................. . ........... ...................................... .......... ................................. ........... Approved ................................................ 19 ............................................................... ......... I , • ! .................... ......................................................... { , yO�tM9 - - , TOWN OF�BARNSTABLE , Permit No Jl Building Inspector faurr.a Cash. 00CUPANCY PERMIT Bond - L t "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Robert Starr Address South Yarmouth lot 183 225 Hucki Neck oa t e ltexv??le Wiring Inspector Inspection date Plumbing Liver rA^ N Inspection date v V Gras Inspector Es` y��� �;� �f Inspection'date "'" i9 ' / Y Engineering Departmentf � , Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. �� r Building Inspector - o V EXIST/Ivc LO T .83 M 14 " 0�IYDA T/p P t SILL ZL-E✓.._____ FEET 4f30✓� POdD F-'L0T FLAN LOCAT/ON= Qf�f11�fS f .lQZF_ e SCAL 1� '_yU D.4 T,-- I PLAN of&4 GEC3P.Gz 11l612 0Y C, QE 7 7 7 1A T 7A Ex%57 -//V FOUNDAT/0" LOCAT/ON /SCORe4C s'~ As SHOWN gAvD_QQCa___COAiF00,If WirN Ts-IL 8UILD/N6 SETl3.�JG�L�EQU�e�MFiv7 OF THE TOWN OF 7"A.�L SMH ( l' i :� � C,00 G[/ELL 4 7.a YGOlz CO�s7 8 W11-e-CW S . YAIP"or✓77/-,Z:;'oo07;MA. ssor's map and lot number 1./........ -'"-' 6 i°f, *THESEPTIC T� Sewage Permit number ... .... IP�� ,.LL ED FP, 4WITH .�t '� �ti_ d•.t'. Z BAHB9TAIILE. i House number .............. ... A�df?" t_ Id w 900 , . A RY .ems"b I4 I�EIa(�P n ►/y GDE A!qL) � Ar faGNSa TOWN OF,,^ BARNSTABLE a BUILDINt- INSPECTOR. - APPLICATION FOR PERMIT TO Cagy f/2 i` S ��'` R.1,4zt� Uv j){ j TYPE OF CONSTRUCTION .... o Uri �Z!�w?!E `..:... .......: ...... .........19...7...E TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .. 0 .. ..../1. G�J1ys........ / 4. ....... ........C/ ! TP !�l................................................... L Proposed Use .... .�.11..ej................................................................................... .... ....................................................... . ....... ........ Zoning District ......R.t, 7/...................................................Fire District ....0 0............................................... Name of Owner ......je.Q./ '8............. „ly. ' ..........Address O.C.&...t! Name of Builder ..... IA.p ...... 5 ...GpAddress .1/, �1 .... L U(.....aSd.. J................. jr- Name of Architect ..... U� ..........................................................Address .................................................................................... Number of Rooms L b y��� ......................................................Foundation .../' �1.....1.... ... . VV ^ 9�, ��� Exterior ...........c �! ,5................................................Roofing ..........,�1:7W •�:/...................................................... Interior .........Floors ...........��:^^�.� .�.............................. 1�4v/.P.7—.��..��........................................... Heating V� / � ..Plumbing �. 454��� Fireplace ./.........1�1..1,e, ..................................................Approximate Cost ................... (C?o .................. Definitive Plan Approved by Planning Board ---------------_---------------19__ Area ...���^.Q. Diagram of Lot and Building with Dimensions Fee ��`.../..� SUBJECT TO APPROVAL OF BOARD OF HEALTH f 1 C I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Noe . ........ .....:............ 7Z-252-118 Starr, Robert .... Permit for ... ......dwallivig....................................................... Location .....Lot 8.3...Hu.c.kins...Neck...Rd........... . .... .. . .... .Huck ins ........ e Centrvil .......................................1e................................... Owner ................................................................... Robert Starr Type of Construction .....WQQ.(J..Frmp................ F .............................................................................. Plot�........;..................... ........................ Permit Granted .............Mar.c.h....1. ..........1979 Date of Inspection /";.... .. ...............19 citt� completed PERMIT REFUSED ................................................................ 19 ............. ......... ............... .. ...................... ....... .. . .... ...... ... .. . ..... ........... r .... .......... .... ... . ...... ....... . ............... . . ........... Approved ................................................ 19 ............................................................................... f�1 oFIKE, Town of Barnstable *Permit# Expires 6 I the from a date �7 Regulatory Services Fee 163 PER-0,� Richard V.Scali,Director D MA MAY 29 Building Division 7 a� Tom Perry,CBO,Building Commissioner TOWN OF BA ��- 200 Main Street,Hyannis,MA 02601 IV ,LE www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number U Property Address �— l��J ��� &uke--6 jl .( �^ "residential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ��� r � ��l� l R Contractor's Name 1 � �� Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ;3,'I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name P,5,— 0-M 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 ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows ll 11 #of doors: � �I �01,11�,Lj© 2t.�C� 'l cS�in•�,��C_- o fn.� Smoke/Carbon onoxide detectors 4 floor plans marked with red S and inspectiWns 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 r d. equire SIGNATURE: Q:MPFILESTO �Ibuildin / in xP oc ` Revised 040215 77te Conimomaerlth 5f� azssackusetft rtinait 0r,f 7`i�riUUSJ ia�t'Accidaws Office oflnvesfigafiow 600 Wasldnglon S&eet Boston,MA 02111 wmw.mas&gvv1dira Workers' Compensation Insurance Affidavit:BadersJConti-ctordE2echiciana1Phmbers A pnUmut InfinMnation Please Pint Leaey NArYSPatCime ��iaraiarui�aftioR➢�pa�?: dmss- Lk Cityrstartelzip—S l�-� �.�� 3 � �C J:�z j G , Are you an empiger?Checkthe appropriate.box: Type of project(required): I.❑ Lama em lfl erwitty 4- ❑ I am a gemff al contractor and I p � 6_ ❑New oanstxaw€iam employees(full=Uor part-time)-* have hired the sub-conhaetars I am a,sole psaprietor orpartner- listed on the attached sheet. 7. ❑Remodeling and have no embp ayees. Tbesesub-contractors have 8. ❑Demolition wurfring fmr sme in any capacity- eruployees and have wodcers' 9_ ❑Building addition [No workers'comp.insurance comp_insurance 1 required.] 5. ❑ We are a corporation and its Electrical repairs or additions 3.❑ I am a homaeuu mer doing all work officers have emercised gi-eir. 1 I.❑Plumbing repairs or additions myself [Nor worlmn'commp. right of Mmmly ion.per MGL 12.❑Roof repairs insurance required.]R c.152, §1(4},and we hwe no ` 13.[�Othet employees.[No workers' comp_insurance restored.] t Piny sgp�tsurt t c>becks box#I amst also fal vot the&Kdon helm,sbowialltheir woeseB'compensation poluy iufarMatian. FBamueoaim ,who submit this dEdavit i��g they a dent aID vat a®d lie outside too nacinrs mmst 5mbm41t anew affida4lt inctieating 5nC1L +Conuxcaus that check this box mmst attached am addifwnv]sheet dhowieg the memo of the sob-rantesc m and state whether or mat tTwse eu ies have enVlayem Ifthe snb<a tsactars1mve employees they mmprovide their workers'comp.policy number. I am an emplo3,atr that is praWaiing nvrlkars'cosrTmsatfaas.insuraR a for my�enzptoyses. ,$dlow is die panicky and fain site infor�vr a'On. . Insurance CompariyName: S Policy#or Self-ins.Lic.#: l Expiration Irate:/ Job SiteAddress: ),e),� t'I,t$ J��c%� CitylStatedzip: Alttaclb a 1copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as regWred under Section 25A of MGL c-152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 andtor one-year i sm=ezd,as well as civil penalties in the forms of a STOP WORK ORDEEastd a time of up to MOM a day against the L iolator. Be.advised that a copy of this statement may be faawarded to the Office of Iuvestigatioms of the DIA fur insurance coverage verification. I do hereby cergfify under the pains an rpea Dies ta+fFerjur}fi'aat the in forrnafion.protiiied above fs b are and correct Si tyre: r �' / Date: Phone#: Official use onlyy. Do not write in oars area,,10 be completed by city or tmvn a fxciaL City or Town: PerndtfLkense if Issuing Authority(cube aue): 1.Board of Heafth r.Building Deprariment 3.Cityffown Clerk 4.Electrical Hnspector 5.Plumbing Inspector 6.O.ther Contact Person: Phone g: 6 MAY/21/2015/THU 01 : 46 PM Today RE M 14 FAX No, 5087901388 P, 004 May. 21. 201510-35AM No. 0459 P. 2/2 04 , VA" -of BarmTfable, own SFdBC;3 Regulatory Services Wtihard V.scali,Mortar �CL��7lg AJC�5xOX1 ',: i Thomaskarty,CB BuMine Commissioner i 20 Main SZeet, Eymt%MA02601 • warortowa.�atasm6le,ma.us Office; 508-862.438 �®c 508-790-6230 • 111Topexty Owner Must Coinpltte ax d Sign This Section Using A•Bnflcler as Owner of the subJectpzopetCp hereby au&oxize. � � I �C� to act as my.behalf c-i in aU=tctn z8adve to work 2utlhoriztd by this bullding p e=mit application f'or• _ (Address ofjob) • ..,jam si ulfatc of0c nec Date V e v iQrL/ P.xwt Name If>?roperty Owner is applyPug for peru%please completetha ]Form on the re,sere side. 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