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I _,",,�,,�� - , �, , ,��:.��I_ ,�, )_-""��_,,,,�� 1�1 �, I , � - #;;,",i�11' e,";, �,L� ,,� ,-, _...... __ _ � A ", A Way Is,;x W� w&V V W. 0106.10 - - _Lf_L�L�11" 'L �:_ __ _�__L�� r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma v71(� Parcel 01 A lication #4 1 P pp Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board 0J)9/I l AAL Historic - OKH _ Preservation / Hyannis Project Street A dress C(9 Th tG» r Village cc-'4')��L,`\L' Owner " I l 50Y7 ' MO Address Telephone �S`�- a�a- �vs rr n P-e-rmiit Request ; U cXSrSt�h �Sa b G f� Square feet: 1 st floor: existing proposed 7 2 U 2nd floor: existing proposed Total new _n -Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type� � Lot Size • 3 Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. s CD , # Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) -- Age of Existing St2LII re �� Historic House: ❑Yes ❑ No On Old Kings Highway:` ]Yet❑ No Basement Type: ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) 7y ? Number of Baths: Full: existing_ new Half: existing net,% - Number of Bedrooms: 02 existing" new Total Room Count (not including baths): existing y new -�' ` First Floor Room Count Heat Type and Fuel: ❑ Gas ®(Oil ❑ Electric ❑ Other Central Air: ❑Yes [/r No Fireplaces: Existing New -y- 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 Appeal Aut o rization ❑ A ppeal # Recorded ❑ Commercial ❑Yes s�� If es site Ian review# Current Use S l rn J Proposed Use APPLICANT INFORMATION g. (BUILDER OR HOMEOWNER) L G -7 72 Nari�e / 1 �V06,0 6. Telephone Number JDd- 7 tf;Qo'1--*' Address J d d�rze_�j License# SX 7 `I In NI"i V y �0 Home Improvement Contractor# 160�?7 Y Worker's Compensation # ALL CONSTRUCTION D BRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO IG `��- SIGNATURE DATE q--3 ` o FOR OFFICIAL USE ONLY i APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER t DATE OF INSPECTION: FOUNDATION FRAME a INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL t PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 4 The commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/din Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name (Business/Organization/Individind): Address: City/State/Zip: (t nv, 1 ��. � � Phone-# Are n an employer? Check the appropriate bog Type of project(required): 1.�I am a employer with 4: I am a gentor and I employees(full and/or part-time),* have hired tractors hew construction 2.❑ I am a sole proprietor or partner- listed on thheet. 7. Remodeling ship and have no employees; These sub- have g, [�Demolition working for me in any capacity:,- employees orkers'No workers' comp,insurance comp.insur . 9...0 Building addition required.] 5, Q We are a corporation and its ,10.11 Electrical repairs or additions 3,❑ I am a homeowner doing all work officers have exercised their 11. Plumbing myself. [No workers' comp, right of exemption per MGL g repairs or additions insurance required]t c. 152, §1(4), and we have no 12 0 Roof repairs employees. [No workers' 13:0 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 $Contractors that check this box must attached a then hire outside contractors mus ubmit a new affidavit indicating such. n 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:1 I Policy#or Self-ins. Lic.#: xe�- S- �� �_ 3 ( ?--- -�-- Expiration Date; o Job Site Address:_IV In q l4r IS' City/State/Zip lav, J40 Attach a copy of the workers' compensation policy III,-P p cY 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 and a fine STOP WORK ORDER a of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office a Investigations of the DIA for insurance coverage verification I do hereby ce and penalties of perjury that the information provided above istrue and correct Signature: 4� S /�Date: Phone Official use only. Do not write in this area to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3, City/Town Clerk 4 ElectrEWo5,Plumbing Inspector 6. Other Contact Person: Phone#: . 3f2'= _a7l1. 6:_8:16 PN PST (GMT-3) FROM: insurancevis ions.com-TO: 15081JSC770 Page: 2 of- ?_ ACOO 1' CERTIFICATE OF LIABILITY INSURANCE DATE Q4IN(DDIYYYY) 123/2011 THIO "MRTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS -tgRTIFICATE 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. PRODUCER FREDERICKS INSURANCE AGENCY INC - CONTACT NAME:: 1046 MAIN STREET PHONE 508'428-8999 FAX Arc No: 508 420-1637 OSTERVILLE: MA 026550427 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC S NSURERA: Liberty Mutual Group INSURED MARKWOOD CORPORATION NSURERB: 110 BREEDS HILL RD UNIT 10 HYANNIS MA 02601 NsuRERc: INSURER D: INSURER E NSURERF: COVERAGES CERTIFICATE NUMBER: 9780984 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 ISSUEQ_OR;MAY PERTAIN,THE,INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.L1MirS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADD SUBR-- - POUCY EFF POLICY EXP . _ LIMITS LTR POUCYNUMBER (MM)Dl MMIDDIYYYY GENERALLIABILITY -Al • EACH OCCURRENCE > l DAMAGE TO RENTED COMPAERCLAL GENERAL LIABILITY PREMISES Ea ocarrenc e D CLAIMS-MACE OCCUR- CCUR MED EXP(Anyone person) S PERSONAL&ACV INJURY j . GENERALAGGREGATE S GENLAGGREGATELIMRAPPL'i, 'FEgj � PRCDUCTS-COMP/OPAGG 3 POLICY PRO- F AUTOMOBILE LIABILITY- - - - COMBINED SINGLE LIMIT - - IEa aaident) > AN�AUTO �� "- - - SOCILY INJURY(Psr person)ALL S AUTOSNED SSC EDULED BOORMLYINJURY;Peraccident) S HIRED AUTOS8 AUTOS NON-OWNED PP racc entDAMAGE 3 v UMBRELLAUAB OCCUR " EACH OCCURRENCE S EXCESSUAB HICLA.QalSAACE $ AGGREGATE S DED RETENTION$ $ is A WORKERS COMPENSATION VVC2-31 S-319674-031 2il/2011 2/1 r2012 ✓ roRSrA,.TTs DW AND EMPLOYERS*LIABILITY Y/N ANY PROPRIETOMPARTNER/EYECUnVE - - :E.L'EACHACCIOENT - $ 100000 OFFICERIMEMBIREXCLUDED? F N/A (ly�ndatory in NH) E.L.DISEASE-EA EMPLOYEE S100000 If yes,describe under DESCRIPTION OF OPERATIONS beam E.L DISEASE-POLICY L MIT S 50110i70 IT[ I I I DESCRIPTION OF OPERATIONS ILOCATIONS 1 VEHICLES(Attach ACORD161,Additional Remarks Schedule;if more space Is required) - Workers Compensation Insurance:Part One of the policy applies only tAe Workers Compensation Law of the State of MA. - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF SANDWICH MA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING DEPARTMENT ACCORDANCE NTH THE POLICY PROVISIONS. 16 JAN SEBASTIAN WAY - SANDWICH MA 02563 AUTHORIZED REPRESENTATIVE �I f 'Jeff Eldridge ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks'of ACORD CE2T DO.: 978C984 CLiENr Com:-1319674 Arne Chandler 3/23/1011 6:14:19 AM Pace 1 of 1 . 7 Town of Barnstable Regulatory Services MAft g, Thomas F. Geiler,Director 1639. Enr��" Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508`-790-6230 'Property Owner Must Complete and Sign This Section If Using A Builder . I, `i,S(1''1 M .✓�� as Owner of the subject property, hereby authorizeecRr to ac t on my behalf, in all matters relative to work authorized by this building permit. Address of job) ) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled before fence is installed and pools are not to be utilized until all final inspections are performed and accepted. ,r-b�� Sign. e of Owner Signature of Applicant Print Name Print Name Date Q:FORMS:OWNERPEF MISSIONPOOLS � y THE Town of Barnstable Regulatory Services �* saxtvsrnar.e, : Thomas F.Geller,Director y MASS. q,A 16.19 Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings,of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see-Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt r • ' iVtussachusetts-Deparfinent of.Putlie Safety " Board.of)Building te�„�ulations�a Will- Standards i;, Cofi $IM ion.Supervisor License - ' License: CS 5867 Restricted to IZ i TIMOTHY pEARSON� -- - -r PO BOX 5.1 GENTERUILLE MA Q 632- . -- Expiration: 11/11JZU11 Tr#: 8599 ! J r Jlt,CCJO%77il11,fNLG1ClJll11• p�f✓�(.(ZiJcfCC(.Y(•CIdB�Co - - r r � License or registration valid for individul use only , • — � -before the expiration date. if found return to: . �m •� Ol'tice of Consumer Affau•s&Business Regulation • HOME IMPROVEMENT CONTRACTOR. �` t` Office of.Consumcr Affairs and Business.Regulation S Registration , ,100871• Type' \r .• 10 Paris Plaza-•Suite 5170 Expiration G124 012 Private Corporation ,N Boston,MA 02116 MARKWOOD - t TIMOTHY PE ARSON y. -\ te —�� \ v 110 l3REED'S HILL ROAD UNIT'10 _ r.. _ .� — — ------ ` HYANIS,MA 02601 UnJcrsccr�tary` _ Not valid without sigitsiturc N ` - Town of Barnstable `*Permit 0 ?00��� � Expires 6 onilisJrom issue date -ppq Regulatory-Services Fee Thomas F.Geiler,Director' OCT Building Division 7 200? Tom Perry,CBO, Building Commissioner t i 200 Main Street,Hyannis,MA 02601 www.town.barnstable.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 I y Property Address r1r_ (.�, %f'�;.� i C e� -1-e(-1'I I-L elCesidential 'Value of Work t 1, 000 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 2 alt_" ' `ann s sn Contractor's Name 6A1Glr /t'�C C G�f,'S '( Telephone Number Home Improvement Contractor License#(if applicable) 13 3-)q Construction Supervisor's License#(if applicable) pWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner [jAlave Worker's Compensation Insurance Insurance Company Name -row-e4e,'�S y��:ni►-�p, Workman's Comp.Policy#�o 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 roof) ❑ Re-side Lam'KePlacement Windows/doors/sliders. U-Value (maximum.44) �J C *Where required: Issuance of this permit does not exempt compliance with other town department regulations;i.e.Historic,.Conservation,etc. .- ***Note: Property Owner muss sign Property Owner Letter of Permission: A copy the Home Impr ement Contractors License is required. SIGNAT ` l Q:Forms:expmtrg Revise061306 4 10/17/2007 WED 16: 09 FAX 508 790 1677 FAIR INS 0001/002 ,M CERTIFICATE OF LIABILITY INSURANCE 10/17/2007 DUCER (508)775-3131 FAX- (508)790-1677 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION e Fair Insurance_ Agency, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. Box 430 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, 619 Main St. Centerville, MA 02632 INSURERS AFFORDING COVERAGE NAIC# INSURED Macallister Builders - INSURER A: Western World HTBO18 DBA: Mark Macallister INSURERS: Commerce Insurance Co. 34754 64 Ebenezer Road INSURERc: Travelers Ind. Co of IL-ARWC 13579 Osterville, MA 02655 INSURERD: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS - DATE fMMIDDNY) GENERAL LIABILITY NPP1114986 08/11/2007 08/11/2008 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY - _ DAMAGE TO RENTED $ 300,000 CLAIMS MADE OCCUR MED EXP(Any one person) $ S,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- JECT LOC AUTOMOBILE LIABILITY 04MMZX2082 09/07/2007 09/07/2008 COMBINED SINGLE LIMIT - ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ 100,000 B HIRED AUTOS BODILY INJURY r accident) $ (Pe NON-OWNED AUTOS �_ 300,000 PROPERTY DAMAGE $ (Per accident) 100,000 GARAGE LIABILITY .. AUTO ONLY-EA ACCIDENT $ ANY AUTO - OTHER THAN EA ACC $ AUTO ONLY: AGG S F1 EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ S DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND 0209680606 11/07/2006 11/07/2007 WC STATU- OER TH- EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 100,000 C ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEEI $ 100,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE-HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE . EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL Town Of Barnstable 15 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, building dept y BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY' South Street OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. rKathy THORIZED REPRESENTATIVE '` Hyannis, MA 02601 ,O �• Silvia/FAIKAI ACORD 25(2001/08) FAX: (508)790-6230 :©ACORD CORPORATION 1988 The Commonwealth of Massachusetts Deparfrnent oflndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 021II www.mass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):_ Mau, � '5 U•-,I k",to Address: U t✓b �. f City/State/Zip: D.S+,trv; IIt .PAS,. U�-1oSS Phone.#: SD -A&-GyU8 Are you�an employer? Check the appropriate box: 'Type of project(required):, t✓1 1. ,,I am a employer with_/ 4. [] I am a general contractor and I . employees (full and/orpart;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 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp,insurance comp.insurance. $• required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers' comp, right of exemption per MGL insurance required.] t c. 152, §1(4),and we have no 12.❑Roof repairs employees. [No workers' 6v,MkwS 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 anew affidavit indicating such. 1C6ntractors 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 providt their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and f ob site information. Insurance Company Name: %r-G S Policy#or Self-ins.Lic.#: [�, /e U Ca�04(j }0 (,,���'� Expiration Date:_ %J Ij Job Site Address: 2 4(� -r-n d i 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 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 DIA for insurance coverage verification Ido hereby certify;ender the ins-andpenal 'es ofperjury that the information provided above is true and correct: Simature: j 0. Date: _ Phone#: Official use only. Do not write in this area,'tb be completed by city or town ociaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: F c� .r °FVE 1, Town of Barnstable. Regulatory Services BnaNSTABLE, • mss $ Thomas F. Geller,Director .+a, Bundling Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 we w-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, ts(lh Q1T ,as Owner of the subject property hereby authorize G,k �r I'�5 � to act on my behalf, ,`� in all.matters relative to.work authorized bythis building permit application for: ., (Address of Job) / Signature of Owner Date Print Name Q TO RM S:OwNERP ERM IS S I ON ..� � ✓fie TOanvinareuiP� o�✓UGc�J3ac�tctde�4 Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 133744 Board of Building Regulations and Standards One Ashburton Place Rm 1301 Expiration: 8/3/2009 Tr/r 132899 Boston,Ma.02108 Type: DBA MACALLISTER BUILDING MARK MACALLISTER. 64 EBENEZER ROAD OSTERVILLE,MA 02655 Administrator Not valid without signature - _ ��Le .�OO7L17G09ZCl/C2LL/L 0 ✓ULdA;1QCf7.LCdE�6 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 079358 _ Birthdate: 08/12/1975 ' Expires: 08/12/2008 Tr.no' 1062.0 Restricted: 00 MARK A,MACALLISTER 64 EBENEZER RD G— OSTERVILLE, MA 02655 Commissioner