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HomeMy WebLinkAbout0402 LAKE ELIZABETH DRIVE - . . &r1z-e-tz- 0 1 I W at .1 ,Y' �� �fiW t 1Y,R _K § l iY�Pi 3O� 11, 1--i'- i, f,1!' !T" !' 424 ,� .I'�. �Yr .1 u i�� e r et �Ss. 4! iJ N .._.__ r , m I I 11 �. % :, , 11 x: , ^ ,.. - �" ., 0 t a d u + , J' �, _ 1 .. t } 4 k, t1 1✓. li /1 C O ,_ } ' of a 'ti', 'R it: t tl ry 3 ,I 1, vP �' F WP1 p 1,e U n1�6 J, 'g i �U: > d. 1 t; 'fir• rK 'I e _ 1 f M q 1 ,. O: 1 t, t, n All 6�. 1.. „� 1r:i " a n, �. �� A, 0 c a r > 4 t ) �;. c C t 1 t 1 1. t A 1 .0 "' M ! t S P It, t ; r t r } .� �, d't :i t ' ;< .A, �'� t t �' I i r.. t t g t 4'• t i } 4 t 1 h d Sk 4' E i b 'k t J r }1 t .4 8r n 'P. 'N n, ! n A , P r • 1, a ,. t. 1. R n . Y E^ 'u s 1.r i ,d I a it r a ,t, �, '+t 4 . e �t4i s 1, '�'i a -1 a rf, r l4 „. ,...r. „� .,: t w k` e 11 pt„, 'I f rr , M1 'A •k '6i i Y z "i %W y e e^ ' 'Ib A .tM , , [11 ,1b a Ni1 �t a —e n p9n dv YI ,µ n %.c a e I, , 1 y n%, 1. b d "p, , N 'd p' R` Ii 1 1' i 1,ii,N u r+ iY r v � e I o,, e f :�m a ,z d 1 k t.. - •,A lay- °� Town of Barnstable *Permit# 01©/403��C Co Expires 6 n onths from issue date Regulatory Services Fee , • 1AItN9rABIE. + a MAW 1639. Richard V.Scah,Interim Director ��� �p RIIA'I Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY r� Not valid without Red X-Press Imprint Map/parcel Number a a / 0 �6 e#¢ele7// Property Address Y0 2. k 4k t 6:11-A t 6-em Dr9 ile. C&41/ 2j`//e_/ AU 6 2634 Q/Residential Value of Work$W Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address v 0114/ We,' Z 0 G l- Ya 9 141te elo 4 eerll Pilir/,, C�044tllll,:�`hi4 0263 4 Contractor's Name J'4,77Q.5 //6 l 't'14 c yt Telephone Number Home Improvement Contractor License#(if applicable) J 007 Y© Email: ?-e I/lsl l.4 8. C4od Z2:90igfe 001 01 e,5- /� Construction Supervisor's License#(if applicable) 0 y&Z 0/ Vorkman's Compensation Insurance X" PRESS Check one: ❑ I am a sole proprietor JUN - 4 2014 ❑ I am the Homeowner FYI have Worker's Compensation Insuranccee Insurance Company Name f�//�Pk' Z�6/- � IIN F�gRN3TABLE Workman's Comp.Policy# a CC, 3 00 J pigl a tw 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 ❑ e-roof(hu ricane nailed (not stripping. Going over existing layers of roof) YRe-side I /WVL r4�U(4�-or McSiJ 3.4 ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections 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 required. SIGNATURE: TACEVIN D\Buildi Changes RESS PERMIREXPRESS.doc Revised 061313 CAPIHOM-01 APELL CERTIFICATE OF LIABILITY INSURANCE °12 27 0 3 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WANED,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 CONTANAME: Ann Pell - Rogers&Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 (AIC,N Ext: A/C No):(877)816-2156 South Dennis,MA 02660 nn aM6:apell@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC iI INSURER A..Main Street America Assurance Co. INSURED INSURER B:Associated Employers Insurance Co. Capiai Home Improvement,Inc. INSURER C: Capin➢Enterprises,Inc 1645 Newtown Road IN��D' Cotuit,MA 02636 INSURER E: INSURER F: COVERAGES 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 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. INSR ADDL SU POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSRPOLICY NUMBER MIDDIYYYY) (MMIDDIYYM LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,0001 A X COMMERCIAL GENERAL LIABILITY MPB1075H 6/8/2013 6/8/2014 DAM (RENTED PREMMISESS a occunence) $ 500,00 CLAIMS-MADE 41 OCCUR. MED EXP(Any one person) $ 10,00 PERSONAL BADVINJURY $ 1,000,0 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,00 POLICY X I PRO- Fx1 LOC S AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT 500,00 a accident $ A ANY AUTO M1 M28044 6/8/2013 6/8/2014 BODILY INJURY(Per person) $ ALL OWNED Ix SCHEDULED BODILYINJURY(Peraccident) $ AUTOS AUTOSHIREDAUTOS NON-OWNED PROPER' DAMAGE $ AUTOS Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,00 A EXCESS LAB CLAIMS-MADE CUB1076H 6/8/2013 6/8/2014 AGGREGATE $ DELI I X I RETENTION$ 10,000 $ WORKERS COMPENSATION X WC STATIY OTL+ AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIETOR/PARTNERIEXECUTIVE YIN CC50050105472013A 12/26/2013 12/25/2014 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? ® NIA (Mandatory in NHI E.L.DISEASE-EA EMPLOYEd$ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 1,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101.Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601-0000 AUTHOR®REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD g ,Massachusetts -Department of:aublicafety 3L- Board of Building Regulations and Standards i Construction Supervisor , License: CS-076268 is 4 JAMES MCCORM CIC f 73 FEARING MOIL RD d, P West Warehngn RSA 01576 Expiratioo 1312015 Commissioner i ✓le-�am�r�rnzuea/,l< o�'✓Glaaeac�iueeka. Office of Consumer Affairs&Business Regulation License or registration valid for individul use only, _ OME IMPROVEMENT CONTRACTOR before the.expiration date. If found return to: R Office of Consumer Affairs and Business Regulation Registration V-1'00740 Type:.,.. YO Park Plaza-quite 5170 Expiration 6/ 3/ 01� Supplement Card Boston,MA 02116 CAPIZZI HOME I'MPROVEMERTANC. J A M E S MCCORMACK 1645 Newton Rd 2. . Cotuit,MA 02635 ..Undersecretary : N valid without signature y� Ali Z/ If 94 �t ille i i r Page 7 of 7 Capizzi Home Improvement Inc. Specifications and Estimates STATE OF MASSACHUSETTS LETTER:OF AUTHORIZATION TO APPLE'FOR A BUILDING PERMIT /12 I, Am'Gg f.// O���c , OWN THE PROPERTY LOCATED AT GEC �4/e IN ZG4i i71/1 6�� , MASSACHUSETTS. I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE. BUILDING CODE. I GIVE MY PERMISSION TO - LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING:CODE. SIGNATURE.OF OWNER: � ��T Q� �n ������;�l* OWNER'S ADDRESS: OWNER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS 1645 Newtown Rd., Cotuit,MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: f 1 C04gxess Street,Sulfe I©Q It WW. . 12C1,5s.9V fdia Workers' Compensation h1surance A davit:BuiIders/C�oiatractorsXlec ciansfPltmbers A-Rplzcant Informatiolt Please Print-egb y Nalne(Business/chganizat on/Individual}:Capizzi Home(mprovemem. Address: 1645 Newtown Road. — City/Mate/Zip:Gofuif, MA'02648 Phone#:508-428=9518 Are you an employer?Check the appropriate bog: T e of project(required): 40�- .4. I am a e yk p 3 ( q ): l:�.I am a employex with [ general contractor and I employees(full and/or pant time).* have hired the sub-contractors 6= ❑Newconstruction 2.[) I.am a sole proprietor or par er- ... Iisted on the attached sheet. .. 7. [l Remodeling ship and have.no employees These sub-contractors:have 8. Q Demolition: working for me in any capacity. employees and have have ce. :_.__...- - --- ---- - ._._..— required.] 5. Q We area corporation and its 10.[]Electrical repairs or additions .officers have exercised their. '3:[( I am:a homeowner doing all work 11.. n Pluznbmg repaus or additions myself [No workers' comp, right of exemption per MGL 12.[]Roofre airs:- insurancerequired we have no P_ einployses:LZ�l o workers' 13.LOther COMP.insurance required.] *Ariy.apF scantThat check§box#I must also fill out the section below hov.ing their workers'compensation po4R` infornmation.�" fi Homeownets who sabmit this affidavit indicating they are ding all work_a,.�'i ffien hire outside contradors must subunit a new affidavit indicating such, fContragtors that check this box must attached an addifign..al,sheet show.inalke name of the sub-contractors-and_Mate whether or not those entities have employees. If the sub-contractors have employees,they must:provide their workers'comp:poTioynumbet. _' F:nrrz•att employer that is providing workers'.coin per�satiorz insurance for my employees, .below is the policy and j-oh.site Tnsurance Company Name:Associated Employers Insurance Company_ Policy#or.Self in.s Lie.#:INCC5010 5470.1201.1... Dee: ate: / . Job Site Address:. 0 2' : '�/�/Le �!Z�A/atO7�!/ IO • VCtty/State%Zip: C� /�UO/f� A4 cla a.copy of the workers'.&Oxdpensmion policy declarations page(showing the policy number and exp ratio7�date). Faxltiie.to'secuxe coverage as required under Section.25A of MGL c. 152 taxi lead to the imposition of criminal penalties of.a •Rine tip to$1,500.00 and/or one-year imprisoninent,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. y ^ -�' p P .fP J f •�clo hereb, cer�ti• zcrzder the ,air��and penalties enalties o er'zz t the irz or•matiorz provided above zs true and correct La�t : Gf a G 20 C v Phone#: 508-428-9518 '4 Offz_al ruse:yr Iy. :Do.rzct wife ah this area, to be corrzpleted by city or owrz officzat o City,or Towns _ . Permit/License# . Issiiing Autl ority.(circle one): : . - 7i:Board of l�eaItiZ 2:Btrildingl3epartnient 3.CitylTown Clerk 4.Electrical Inspector.5.Plumbing Tnspector - .. . '6. Other -------------- contact Person; Phor`e#: . - . t / Engineering Dept.(3rd floor) Map �27 Parcel 2 Permit# ,House# �� �� Date Issued Board of Health(3rd floor)(8:15^-9:30/1:00-4:30)aA2`4-RP Fee 3 Conservation Office(4th floor)(8:30- 9:30/1:00-2:00) .) a.iNE fp;_ 19 �q 1 �4 �A�/ , J� pphppl Ads'3� b®®d pR�7�g3 nn• �A_R,M I E •. J S _s6 TOWN OF BARNSTABLE WITH Building;PermitApplication lol��� ® '� � �� �� Project Street Address y Z. 4U 4 L , Village Owner - O p.-1c (to 0 LICV-I0 C A • Address L/O L zo/;'~E`i eloe P4 Telephone 71 Permit Request 4 d���`��c, ,; rem- .2 4 i-✓svz� —IF-i"r'st Floor square feet Second Floor square feet Construction Type tA.;*c�6cp._ ' 'Estimated Project Cost S;Chi n ' Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family pr Two Family ❑ Multi-Family(#units) Age of Existing Structure '3© Historic House ❑Yes Z N'o On Old King's Highway ❑Yes u10 Basement Type: dFull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) J(� Basement Unfinished Area(sq.ft) cx-) Number of Baths: Full: Existing / New r` Half: Existing New No.of Bedrooms: Existing New Total Room Count(not including baths): Existing New :—First Floor Room Count 2� Heat Type and Fuel: dGas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New — Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) U]rAttached(size) 6 L 12 a wo J% 11-?-,J AZ ❑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 er Information Name c-e- bevy -e Telephone Number y ') Address Z ;�.`,� �r.L% License# CU S`�/ O5 llt4z✓S ,A Al Home Improvement Contractor# 426 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 (�SM s, ti'lD 4 e. SIGNATURE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) l C . f FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO ADDRESS a r VILLAGE } F OWNER DATE OF INSPECTION: r FOUNDATION FRAME INSULATION r FIREPLACE , ELECTRICAL: ROUGH FINAL ' PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. r • Tile connummeaun a massarwaseRx _ Deparonent of IndusVialA. ccideffis . A i. , 1� Ofllcrollat�lgallo�rs - ' �',,.� ' .' --•��� 6110 IfWtinnian Street Buxton.Muss 02111 Workers' Compensation Insurance•Aitdavit •AR iicnnt nfot•trtation• _"•.. - .. Please pR11V`i'1e�•� ,�„ - - In on! /v lc; Win, YZ9 ❑ am a homeowner performing all.work myself. t am a sole proprietor and have no on-e working in any capacity, ❑ ,t Am an employer viding workers' compensation for my employees working on this job. Ann eiih- • ' S • S ❑ 1 am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contract listed below who . the following workers' compensation polices: add r. • �`v�'G� r y. h a n e o. 12-.b 7 S --�..tu...:a:�' «,- sr.�,+�: aa•..-Q.�+- r'R"fn. t*srr_ - -Ravt�l,er49!•'�;....;rs _ .e„s*r.� crimp Inv nnme! �:�.•��•� cihr phone d -sump- o nosiera Atiach addidi"I'sheet if tieees�at ;•vs -�►r•�-�,• +'''+'a ar+ar r•: a.�•w..;:,_ _:•era_-_—*--------- — - :� failure to secure coverage as required under Section 3A of AIGL 152 can lead to the imposition of criminal peaaidu of a floe up to 61,500.00 SO& one years,imprisonment as well as civil penalties in the farm of a S'MP WORK ORDER and a line of SI00.00 a day against me. I understand that copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage Verification. I do herebr cod, n the pains and perjttr}•that the information provided above is mte ttttd avrr,aht Signature Print name Phone# Fd only do not write in ibis area to be completed by�or town official permiNltem:e It neuiiding Department city : GU�Og Board mmedlate response is requitedOtQaDtlesith Department on• phonelh, nOtber. • Inforation and Instructions m ' wires all employers to mvidc+varkers' compensation for Massachusetts General Laws chapter 15-' section 25 requires p P "taw".an empint+ee is defined as every person in the acrvicc of another under an3 employees. As quoted from the contract of hire.=press or implied.oral or written• association.corporation or atltcr ::ga! entity. or any ttvo or i An emplm�er is defined as an individual, partnership, rp the foregoing engaged in a 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. Howeve owner of a dwelling house having not more than three apartments and who resides therein, or the accupatrt of the d+vclJing house of another who employs to do maintenance,construction or repair work on such dwelling or on the garounds or building appurtenant thereto shall not because of such employment be deemed to bean empl( MGL chapter r53 section 25 also states that cvery.state.or local licensing agency sball withhold the issuance o: mnewal 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,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 chaps been presented to the contracting authority. Yia: .•.._. ,1I^.•M•... p Vl•I:li::' i►�t•+N�7�`...'1•�::Y'i.•••y - (: ..:.. P. ri.'�=�' ...�1 L'':. :QMt�•t'''.�R; '�: �•.t�...'r `Y :�Y .. w•L...�^r+:.u� ��•.: wa:-•ter __. ,r Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation a: supplying-company names.address and phone numbers as-ail affidavits may be submitted-to the Department of Industrial Accident s for confirmation of insurance coverage. Also be sure to sign and date the ai3idm iL 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 requ. to obtain a workers' compensation policy,please call the Department at the number listed below. • �,w�w.�'�w...r•wen..srs�� a ..;,...w:�^' -:i' �5.°�'i.�Y«•:.:.� La�S''lAi7!!4!�-�J�r;r`"'Fi•s�.•r.4atiil �L• ... . City or To%rns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the�L i . tee of Investigations has to contact you regarding the applt the Off Sa the affiidavtt for you to fitI out in the event a be return . The affidavits may e number. be sort to fill in the permtt/Itcense number which will be used as a referenc • 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 quest please do not hesitate to give us a=11. •---;,,,;��.._:..:::��%•...::•ram++,::: `:�:`*•,, ..��•-i-.. - :.`;:..' ...'�_�..�.::r u..� M.,,_./r:""r :t-:iir�t!�"•=aos�. .• .r '.w,a.- ter►.: The Department's address.telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Office of inadgadons 600 Washington Street .. _. Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 7274900 cat. 406, 409 or 375 I ( ti 1 I , ' 1' 1 ii I - S/ P,&OF Pl-YW°OD lZX�6 2�S `1R 69ADe ,4SpAIALT nil ATE X�7`i3 F in•G- 09EN To tXrSTItJ�r `� cr e COLLRQ E �S ►d fj• Tc R s r'v6' �cA-Mc* � , � ��p�� SOfE�.'1 o r .17Q tp vF.vT ����� SI�,}Jo 1 Pou aff b Ir �� o• 5 5' ������rroN P• s5 �Psv�u�v�?c�2 GA,��. rye BSc. �� The Town of Barnstable . • = entaI Services • M' �' Department of He alth Safety and Envlronm Building Division 367 Main Street+Hyannis MA 02601 Ralph Crossen office: 508-790-6227 Building Commissioner Fax: 508-790-6230 For office use only Permit no.------ Date AFFIDAVIT _ HOME IIVIPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMLT APPLICATION that the "reconstruction, alterations, renovation, repair, modernization, MGL c. 142A requiresy re-existing conversion, improvement, removal, demolition, or construction of an addition to an p owner occupied building containing at least one but not more than four dwelling units or to p y registered contractors, with structures which are adjacent to such residence or buildingbe done b regis certain exceptions,along with other requirements. _ Est.Cost L�S vim• vim' Type of Work• oL� ^�� Address of Work: Z. �.�a . _ ..�zr : ���• k . Owner's Name Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: PERMIT OR DEALING WTTH UNREGISTERED OWNERS PULLING THEIROWNCTORS FOR APPLICABLE HOME WROVEMENT CONTRA ITRATION PROGRAM OR GUARANTY UNDER MGL c.14ZA ACCESS TO THE ARB SIGNED UNDER PENALTIES OF PERJURY 1 for a permit as the agent of t e owner. I hereby apply - C(9 - Registration No. Contractor Name Date OR. 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