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HomeMy WebLinkAbout0580 LUMBERT MILL ROAD ,k .� f � _ - ., �� - �: :. .. ,: .' .. ' .. �: �i y ;. c. ., '.. v £ � . . .. ,. 1 �:. .. < < _ u ,. . � - . . ., e - - _ p t it �- � ,. ., �. � .. 7 - I i .. .. i o g ,. �� u Town of Barnstable Blilldlil PostThisCa d SoThat rtis_Visible From the Street Approved;Plans Nlustbe Retained or+Job an'drtxthis Card Must be Kept ' Posted'Untal:Final lrispection Has Been Made z _ , WheaCertIficateof Oc'c nc is Re"aired such:Bciild�n' sHall Not be Occu ied ant�t a Finallns` ection has been made Permit Permit NO. B-19-1962 Applicant Name: SOUTHERN NEW ENGLAND WINDOWS LLC Approvals Date Issued: 06/18/2019 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 12/18/2019 Foundation: Location: 580 LUMBERT MILL ROAD,CENTERVILLE Map/Lot: 147-086 Zoning District: RC Sheathing: Contractor:,Name:: SOUTHERN NEW ENGLAND Framing: 1 Owner on Record: AMBROGIO,ANTHONY F&VLASOPOLOS, , S WINDOWS LLC - Address: 580 LUMBERT MILL ROAD ••Coritracto`r,License 173245 CENTERVILLE,MA 02632 Chimney: Description: window replacement(4) Est Protect Cost: $9,758.00 Permit Fee: $49.77 Insulation: Project Review Req: Fee Paid: $49.77 Final: ®ate. 6/18/2019 r4. Plumbing/Gas Rough Plumbing: x30 W h Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months afte issuance. Rough Gas: All work authorized by this permit shall conform to the approved application a'nd the;approved construction documents-for which this permit has been granted. All construction,alterations and changes of use of any building and steuctures`shall be in compliance with the local zoning by laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street orroad and shall be maintained open for public inspegi6n for the entire duration of the work until the completion of the same. Electrical . - •.i f fi , The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided othis permit. Service: Minimum of Five Call Inspections Required for All Construction Work:':: Rough: 1.Foundation or Footing 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department _S' Building plans are to be available on site Final: �`C All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT E �. p�, �^ W-1 _I 10 Application number BAXNsrnBis Date Issued..................... ...... .��...... ..... .. ........................ 039. 12 2019 BuildingInspectors Initials... I �� Map/Parcel................���. ... .. TOMW OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: �� NUMBER STREET VILLAGE Owner's N7e:_A1f/vo,,y ,��,(��o�;o Phone Number 7 7 L/- 2 2 S'-z Email Address: Cell Phone Number S off- 8"/ 72 6 Project cost$ R 7 S Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR -Owner Signature: S e� .4"f(Q P. a 06,4-c,4 Date: TYPE OF WORK ❑ Siding Windows (no header change)# ❑ Insulation/W g ) eathenzahon ❑ Doors (no header change)# Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to GJ k s4e-1*-�4�� o/r /� 1 v CONTRACTOWS INFORMATION Contractor's name i�r un `7R n�,'so✓� - So,��.��n ��l &, (cv4 Ji'n 6L)S Home Improvement Contractors Registration(if applicable)# 17 3 L.K (attach copy) Construction Supervisor's License# S 7 O' (attach copy) Email of Contractor Gk,JC �. C 6 M Phone number LlOI— Z Z R - R ALL PROPERTIES THAT HAVE STRUCTURES VER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. r APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one:this event is a: for profit non-profit event Check one:Food served Yes No Flame Spread Sheet of each tent must be attached.Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3.30 pm-4.30pm. Commercial events may require Fire Department approval *WOOD/COAL/PELLET STOVES x Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side TIOIVIEOWNERIS LICENSE EXEITTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date PLICANT'S SIGNATURE Signature Date -/2- All permit applications are subject to a building official's approval prior to issuance. r Renewal Agreement Document and Payment Terms Andersen. dba:Renewal By Andersen of Southern New England Anthony Ambrosio&Arica Vlasopolos Legal Name:Southern New England Windows;LLC 580 Lumbert Mill Rd . ISO, RI#36079,MA#173245,CT#0634555,Lead Firm#1237. Centerville,MA 02632. wIxoow pE ucerExr ,10 Reservoir Rd I Smithfield,.Rl 02917 H:(313)585-8276 Phone:866-563-2235 I Fax:'401-633-6602 1 sales®renewalsne.com''. Buyer(s) Name: Anthony Ambrosio &Anea Vlasopolos Contract Date: 05/28/10 Buyer(s)Street Address: 580'1umbert Mill Rd ;_Centerville, MA 02632 Primary Telephone Number: Secondary Telephone Number: (313)585-8276 - . • Primary Email: anthonyambrogid@� bcglobal.net Secondary Email: Buyer(s)hereby jointly and.severally agrees to purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern'New England("Contractor'),in accordance with the terms and con ditions.describe d in.this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other.document attached to.ihis Agreement Document, the terms.of which are all agreed to b the parties and incorporated herein b reference,(collectively,this"Agreement')y pp y Buyer(s)hereby agrees to sign a completion certificate after Contractor has compleced.all work under.this Agreement. Total Job Amount: $9,758 By signing this Agreement;you acknowledge than the.Balance Due;and:.the Amount Financed must be made by personal check-,bank check,credit_card,or cash. Deposit Received: :." Balance Due: $6,506' Estimated Start: Estimated Completion:. Amount Financed: 6-8 Weeks $0 6-8 weeks. - Method of PaymentCash/.Check We schedule installations based'on the date.of the signed contract.and secondarily on the date in which we complete the technical:measurements.The installation date that: . we are providing at this time is.only an estimate.We will communicate an official date. and time at a later date..Rain.and eztreme.weather are the most common causes for:. d elay Notes: 113 deposit,1/3 at start,1/3 at.completion Buyer(s)agrees and understands that this Agree the ent►re understandings between the parties and thac.there'are no yet understandings changing:or modifying any of the:terms of this Agreement.No alterations to or deviations from this Agreement will:be `E valid without.the signed,-written consent of both the Buyer(s) and Contractor.-Buyer(s)hereby acknowledges that Buyer(s) I).has:read this , Agreement, understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreerttent,including the two attached Notices of Cancellation,on the date first written above'and 2)was orally informed of Buyer's right to cancel,this Agreement: NOTICE.TO BUYER Do:not sign th►s contract if blank.'You are ent►tled to a copy of the:contract at the time you sign YOU,.THE BUYER,MAY CANCEL,THIS TRANSACTION AT ANYTIME NOT:LATER THAN MIDNIGHT_. OF 05/31/2019.OR THE THIRD BUSINESS.DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER:SEETHE ATTACHED NOTICE OF CANCELLATION`FORM FOR AN EXPLANATION OF THIS RIGHT Legal Name:Southern New England Windows,LLC dba:Renewa A. erne of$outhern'New England Buyers) F. Signature of Sales Person Signature Signature Paul Sandrey Anthony Ambrosio _Arica Vlasopolos Print Name of Sales Person. Print Name Print Name UPDATED.- 05/28/19 Page 2 /.11 Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement-�Contractor Registration Type: Supplement Card Registration: 173245 SOUTHERN NEW ENGLAND WINDOWS LLG 10 RESERVOIR ROAD - Expiration: 09/18/2020 SMITHFIELD, RI 02917 SG1 7 is 20M-05/17 Update Address and Return Card. e �cvnirenirrcea,�l�e���m:-:¢cloclG1 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE,Supplement Card before the expiration date. If found return to: Reaisfiation Expiration Office of Consumer Affairs and Business Regulation 1;73245^_;_ 09/18/2020 1000 Washington Street-Suite 710 SOUTHERN NEW EN.GLAND WINDOWS,LLC Boston,MA 0211 BRIAN DENNISON �Q 10 RESERVOIR ROAD G SMITHFIELD,RI 02917 Undersecretary "v� without Signature Y r � Commonwealth of Massachusett-s Division of Professional Licensure - Board of Building Regulations and Standards k1o,nstrort�n $Sdpg,rvisor CS-095707 R- Epp i res : 09/08/2020 BRIAN D DENNISON 8 BLACKWELL-DRIVE � T CHARLTON IUI�4�015®? civ Commissioner r I The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114--2017 www mass gov/dia Norkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PEP—I*Lr TLYG AUTHORITY. Apoliciat Information Please Print Le 'blv Name(Business/Organization/Individual): G Q Address: I U ' tp r UDt r IZeC City/State/Zip: (-/IiAj tads 9 l] Phone#: Are you an employer'Check the appropriate box: Type of project(required): 1. 1 am a employer with ?t2temployces(fidl and/or part-time).' 7. 0 New construction 2 am a sole proprietor or partnership and stave no employees working for me in S: Remodeling s any capacity.[No workers'comp.insurance required.] ' 3M I am a homeowner doing all work myself(No workers'comp.insurance required.]t 9. ❑Demolition 4.[]f am a homeowner and will be 10 D Building addition hiring contractors to conduct all work on my property. [will ensure that all contractors either have workers'compensation insurance or are sole I l.a Electrical repairs or additions proprietors with no employees. 12.[J Plumbing repairs or additions i. l am a general contractor and I have hired the sub-contractors listed on the attached sheet j 3.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.= 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14. 152,§10),and we have no employees.[No workers'comp.h urarce required.] 'Arty applicant that checks box#I must also fill out the section below showing their workers'compensation policy information - Homeowners Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-mamicmrs and mte whether or not dm entities have employees. If the subcontractors have employees,they must provide their workers'camp,policy number. lam an enrtrloyer that is protriding workers'compensation insurance for my employees: Below is the policy end job site informadolL Insurance Company Name: F1 MW5 fnS wa Ay— �p . oF MN U, e Policy#or Self-ins.Lic.#:_WCri-,31,!�= !a7 Expiration Date: Job Site Address: 5-en Gvrh 6er /`7:l( /'z� City/State2ip: �� n �-��,h/e ti-A Attach a cagy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to S 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 MOM a day against the violator*.A copy of this statement maybe forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby c under the p ' penalties of pery'ury that the information provided above is true=d correct S i re: Date: Phone#: Official use only. Do not write in dds 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 J.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i ACC CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/28/2018 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 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). PRODUCER CONTACT CoBiz Insurance, Inc.-CO NAME` 1401 Lawrence St., Ste. 1200 PHONE t. 303-988-0446 AIC No:303-988-0804 IL Denver CO 80202 ADDRESS: COMailincobizinsurance.com INSURE S AFFORDING COVERAGE NAIC# INSURER A:Acadia Insurance Company 31325 INSURED ESLERCO01 INSURERS:Firemens Insurance Company of WA,D.C. 21784 Southern New England en ofS u hernLLC INSURERC:Homeland Insurance Company of New York 34452 dba Renewal by Andersen of Southern New England 10 Reservior Rd INSURER D: Smithfield RI 02917 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:787175890 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 TYPE INSURANCE ADDL SU R . POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDD/YYYY MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CPA315872a 1/112019 1/112020 EACH OCCURRENCE $1,000,000 CLAIMS-MADEM OCCUR DAMAGE TO RERTE5—— PREMISES a occurrence $3D0,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,ow,00o GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY PRO- LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY CPA3158728 1/1/2019 1/1/2020 COMBINED SINGLE LIMIT a accident $1 000 0 0 X ANY AUTO BODILY INJURY(Per person) $ ALLOWNED AOSSCHEDULED AUTOS U T BODILY INJURY(Per accident) $ X HIREDAIlTOS M NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ A X UMBRELLA LIAR X OCCUR CPA315872a 1I1I2019 1l1/2020 EACH OCCURRENCE $15,000,0 0 EXCESS LIAB CLAIMS-MADE AGGREGATE $15,000,000 DED I X I RETENTION$ $ B WORKERS COMPENSATION WCA315872924 1/1/2019 1/1/2020 X S R— ER AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNERIEXEC OFFICERIMEMBER EXCLUDED? U ❑N N A TIVE E.L.EACH ACCIDENT $1,000,000 ! (Mandatory in NH)If E.L.DISEASE-EA EMPLOYEE.$1,000,ODO DESCRIPTION OF O OF OPERATIONS below yes,describe E.L.DISEASE-POLICY LIMIT $1,000.000 D C Pollution Liability 7930073340MO 1/112019 1/1/2020 Each Occurrence $2,000,000 Claims-Made Policy Aggregate $2,000,000 Retroactive Data 0&20/2013 Deductible $25,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if 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. FOR INFORMATIONAL PURPOSES ONLY AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I ;.a TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application #a( Health Division Date Issued l Conservation'Division Mwyc c;�4ez(y- App fcation Fe • • Planning Dept. Permit Fee , _o b Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Project Street Address ® �-v Village- Owner VV\-eS 1�)4-C_ Address aTSG> MIA Telephone_ $ 0 -l©d 50% . "1.2; 0 Permit Request Square feet: 1 st floor: existing ' proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuati ��" Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure ` +^S Historic House: ❑Yes VNo 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 Number 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 stov..% ❑%s ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑existing ❑ new size _ Barn: LINxisting Q nevg size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size_ Other: Zoning Board.of Appeals Authorization ❑ Appeal # Recorded ❑ 01 Commercial ❑Yes ❑ No If yes, site plan review # Current Use5��`^ ��� Proposed Use — w _•� _ - -_ APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name � w� -�S Telephone Number Address WA QAicense# N L aA 016 S Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION nESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATU DATE 6 4 N FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. = t r ADDRESS - VILLAGE OWNER t DATE OF INSPECTION: 1 FRAME f INSULATION, FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ?°' ROUGH `'-- -''' FINAL ' FINAL BUILDINGt��z. '? ' k DATE CLOSED OUT =' - ASSOCIATION PLAN NO. 1 ' Tlie Commnwealth of Massachusetts Department oflndustrialAccidents 3 Office of Investigations 600 Washington Street Boston,MA 02111 k ,• wtvw.mass.gov/dia Workers" Compensationlusurance Affdavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organizadon/Individual): . •Address: ��--t �3. City/State/ZZA N L 1 Phone.#: lam' 01.C0 Are you an employer? Check the appropriate bog: . -Type of project(required):. 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction . 2.❑ I am a•sole proprietor or partner- These on the-attached sheet 7. Remodeling ship and have no employees These sub-contractors have g, Demolition vrorking for me in any capacity, employees and have workers' comp. insurance.;' 9. ❑Building addition [No workers comp,insurance P required.] 5• ❑ We are a corporation and its 10.❑•Electrical repairs or additions 3. I am a homeowner doing ill-work officers have exercised their 11.❑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 employees, [No workers' 13.❑ Other e��c¢r comp, insurance required:] *Any applicant that checks box#1 must also fill out the section below showing their'workers'compensation policy information. t Homeowners,who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors 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 she policy and job site' information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: 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$2.50.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA foLixLsurance covera e verification, I do he i and he pai sand penalties of perjury that the information provided above,is true and correct Signature: Date; Phone#: � -5� C)", Lf Official use only. Do not write in this area, to be completed by,city or town official City or ToTM ' Perinit/License# Issuing Authority(circle one): .1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in_the service of another under 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 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. 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 local 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 pro.duced,acceptable evidence of compliance with the insurance coverage required." Additionally,MGL ehaptez.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-compliariee with'die 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-conti•actor(s)name(s), address(es) and phone number(s) along with their certificate(s)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"the 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 maybe 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 bum leaves-etc.)said person is NOT required to complete this affidavit. The 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-and fax number:_ The Commonwl�'alith of Massa6WPtts '� � '` ►t t. . , Departmerzl of Ind-tst.6ai.A ceideiats 600 Washingt6 Street .- t ... Boaton,.MA 021.11` = Tel. #617-727-4. 500 ext 406 or 1-377-MASSAFE Revised 11-22-06 Fax# 617-727-7749 www.mass.gov/dia l` IHE Town of Barnstable o Regulatory Services Thomas F. Geiler,Director 16 P. .a� Building Division �Eoy Tom Perry,Building Commissioner 200 Main-Slreet,_HYannis,MA._02601 urWv.town.b arnstable.ma.us Office: 509-962-4038 Fax: 509-790-5230 EIMMOVNM LIC INSE EXE><=ON fy Pleare Print DATE JOB LOCATION: 'J l V number street �y village "HOMWWNER": L7 `e V \ V • l 0A name Q home phone# work phone# CURRENT),Ck TG ADDRESS: 7� � ® - cityhown state zip code Tbc current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to ragage an individual for hire who does not possess a license,provided that the owner acts as Sn1ACI73SOI. DEFII1 OX OF HONMOV" ER Persons)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intm&d to- be, a one or two-family dwelling, attached or detached it mctrires 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 bomeowmr, Such "homeowner"shall submit to the Building Of5cial 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"assumies responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"h cowne certifies that.he/she understands the Town of Barnstable Building Department inspection ocedare and requirements and that he/she will comply with said procedures and z creme ts. Signatizre of H eowner 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. HO1rMvvNER,s Exy-m bx The Code states that "Amy bomcowncr pcforrning work far which a building permit is required shall be exempt from the provisions of thin section.(Section 1 D9.1.1-Licensing of wnshvctian S-upcnzsors);.provided that if the homeowner engages a persons)for biro to do such warlc,that s�uCch Homowncr shall act as supe-visor. lrl'any homeowners who use this exemption are unaware that they are assurrung the responsibilities of a srip s:Dr(see Appendix Q. Rules&Regulations for Licer)sing Construction Supervisors,Section 2.15) This lack of awarrncss bftar results in serious problems,particularly when the homeowner hues unlicensed persons In.this case,our Board cannot proceed against the unlicensed person as it wrould with a liccnsod Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the hamwwnar is fuRy zwm=of his/hcrrespo=bilitim,many communities require,as part of the permit application, that the homcownor rar*that hdshe understands the mspammbtlities of a Supervisor. On the last page of this issue is a farm currently used by several towns. You may care t amend and adopt such a forrrJcerpfrr ztion for use in your ronanunity. Q:forrns:hom=xcrrrpt Town of Barnstable • Regulatory Services t • u1QqSrAVtP- MAM $ Thomas F. Geiler Direr-tor Building Division' Tom Perry, Building Commissioner 200 Main Street,Hyammis,MA 02'601 www.town.barnstable tna.us Office: 508-862-403 8 Fax: 508-790-6230. A.. Property Owner Must � y Complete and Sign 'T,l`us Section =g A Budder I � ' g , as Owner of the subject.property hereby authorize to act on my beha}f, La all matters relative to work authorized by this b ding permit application for. (Address of Job) Signature of Owner Data Pant N2j= i If Property Owner is aPP Yr for 1 'n - era-lit please complete the g P P Homeowners License Exemption Form on the reverse side. Q:FORM5:0WN RPEWL33IDN Jj r ---- L U V A�6 gEjXr. t � t •,i I /7 f TDUIJD ;� C7): t , um 1 B. . v BAXTER . . A . a I No 24U#8` .- .p� �p r �ST'E GE,eT1,c'/EC� �GO7' T.U,4T LOGQT/0iC/ /'0o x/,cif ANO SE TBA Cf< .�E'QU/.2E�'JENTS: Off' THE':7`owWaF ,C4CAT2sU jy/Ty/it,/ zo71 G THY � .�,GoaaPL,4/y /NST.2U/�lit/T�$'U.2YEY T� 0�,45'E'TS Syo�/y S. vLa 0(,,p77 8 7Q OE7jE, Ael41, Deck for 580 Lumbert Mill Road Centerville MA Constructed by homeowner Jim Preston 508 916 0400 cell phone ` Construction Specs Footers will be 4 feet deep 10 inch sonotube concrete filled with jbolts Posts will be 6x6 PT lumber Beams will be three 2x10 PT Lumber bolted together with'/2 inch carriage bolts as well as nailed. Header will be 2x10 PT lumber fastened to frame with either '/2 inch carriage bolts or 6 in lag bolts spaced 16 inch staggered high and low with 4 1/2 inch washers between header and siding for spacing. Joists are 2x10 PT connected to header with 10"joist hangers spaced 16 inches on center Decking is 5/4 bull nosed cedar decking screwed to joists 36"Railing will be installed according to code on all deck areas 30" above grade All bolts,nails,post supports,joist hangers are galvanized I �IKE Town of Barnstable . *Permit# a D3 ,,3 Expires 6 months from issue date Regulatory Services Fee • BARNSTABM � 16 9. `0� Thomas F.Geiler,Director ATED MA'I Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis, MA 02601 ��1 ` 1pe- 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 y 9 086 Property Address S'S 0L V►^�� �T �� ��+'� V� Residential Value of Wo 15,Cs 0 O Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name J 1� — NoA�UJV\Q A` Telephone Number_�J®� cj��j (7 d� Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) S❑Workman's Compensation Insurance X-H E PERMIT Check one: JUL � 7 El 'I am a sole proprietor ! rl i I am the Homeowner TOWN �� I have Worker's Compensation Insurance BARNSTABLE Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. 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 #of doors V Replacement Windows/doors/sliders, U-Value 2.9 (maximum .44)#of windows ''L-0 *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Pro must sign Property Owner Letter of Permission. A co of the H e Improvement Contractors License & Construction Supervisors License is requir SIGNATURE: O✓`— Q:\WPFILES\FORMS\building p it forms\EXPRESS.doc Revised 070110 The Commonwealth of Massachusetts Department of Industrial Accidents ' Office of Investigations a 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl N1TTle (Business/Or ganization/Individual): V"re-'s� Address: L.LJNA-,�eA� � 1� � City/State/Zip: ��2iLiJ 1`�.Q, �OZ6s LPhone #: SCA 16 OLIOD Are you an employer?Check the appropriate box: :Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7.WRemodeling ship and have no employees These sub-contractors have g, ❑Demolition . working for me in any capacity. employees and have'workers' comp. insurance.$ 9.'.❑ [No workers' comp. insurance Building addition P• 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.❑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 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 then hire outside contractors must submit a new affidavit indicating such. $Contractors 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 Address: 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. I do he certify un r the p 'ns and penalties of perjury that the information provided above is true and correct Signature. G...�.— �. Date: Phone#: S08 9117 0400 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/T6wn Clerk _4.Electrical Inspector 5..Plumbing Inspector 6.Other Contact Person: Phone#: - 1 1HErati Town of Barnstable Regulatory Services * BARNSTABLE, y MASS. Thomas F.Geiler,Director 16.19. rFo ww�" 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 t t Complete and Sign''Thi' 'Section �4' �• If Using A Builder , ; - l _ I, as Owner of the subject property hereby authorize to act on my behalf, _. in all matters relative to k authorized by this building permit application for: (Add s of Job). Signature of Owner Date jf. Print Name f Pr Pr operty Owner is applying for permit 1 . ease P p p complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:OWNERPERMISSION w FTHe r Town of Barnstable y�P Regulatory Services 4 * BARNSfABLE, Thomas F.Geiler,Director S, MASS. g 161g. Building Division Tfoy Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 w•ww.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 t HOMEOWNER LICENSE EXEMPTION Please Print DATE: 2-- JOB LOCATION: Jr C) �^V�M L� sL���`��V number C street q /�� village l / "HOMEOWNER": ��1�V��7 �V�S� l�O K l � 6 y�®® C�i�\ SC�g �! � �LC�9D 1+1 name �1l iihome phone# A i work phone# CURRENT MAILING ADDRESS: v C>V \A\z vV\# ol-6 7­7 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 inspe cedures and requirements and that he/she will comply with said procedures and quir ents. Signature o 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, \V Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serous 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 i l� s /`a7- 0 Assessor's map and lot number ............................................ HE uF toy Sewage Permit number- . ' Z BARESTADLE, i House number .. .......................... t 9 rasa ........................ t �O i&39• MAI a TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ....... .� ..........&�/( IC4... .:`:�`.4....... /# 6�s ..................................... TYPEOF CONSTRUCTION .......... .......................v.........r....................................................................... �� ......... 7................19 .... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the,allowing information: Location 4'a.a., l .'........ �A� . � � ��—"�. ' �t......7L1%I//LLB .............. .. ......... �. ..... ProposedUse ............................................................................................................................................... ZoningDistrict ............ ......................:......................Fire District ......................(,.,.,.:. <.��....................................... Name of Owner .. [71d .`... ...Address . Q.... C_�r:.....;;> C.�;'.�� , .............. Name of Builder . � ... ..Address ............. "�' ...................... C ...... ..........................P ................. �. Nameof Architect ..................................................................Address .................................................................................... Number of Rooms .......... ................................................Foundation ........ {. l,cve t� ........................................................... 1 �1', , Exterior ............... ................................................................Roofing ............... h....................... ..... Floors ........�......JJ.........).........`...........................Interior vM SUS// ..... ........................................................... Heating ..... ......Plumbing .. .......................0( v o ) Fireplace ............QAP.............................................................Approximate. Cost ........ c ............. ..:........ .. .......:. Definitive Plan Approved by Planning Board ________________________________19________. Area .......................................... Diagram of.Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH} E 7 �' - . OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. . L Name ..... ...................... . ............... ......................... Construction Supervisor's License ....................................©Z '. CERESKA, JONAS A=147-086 28049 No ................. Permit for ............. ............Single j).W .. .......... ...... . .ejjjMg.................. Location ......5B.0..Lunber.t.O.Mi.11.-Road .................. .................................... Owner ........JOncls..Ce;M_ ika............................. Type of Construction .......1±ame....................... ............................................................................... Plot ............................ Lot ................................ Permit Granted ...... .................19 85 Date of Inspection ....................................19 Date Completed ......................................19 H7- OF6 10, SYSTEM MUST Be L WITH TITLE 15 � BUILDING @0NN D0NG INSPECTOR � ^ . . APPLICATION ��� PERMIT --.�������.--..�����/�—.~<�����--. ,.—.---.--.---. TYPE OF CONSTRUCTION ---- ------------------.----.-----..------- --.�.. ---��----.]��.��� ' {/ � TO THE INSPECTOR OF BUILDINGS: ' The undersigned ,,f3liowing information: Location ---'����--.�—�--444�m�Uee��/--'�'�.�.�f.� --.r��������'''�'z:—'����'�'�����.�.���^ | Proposed Use ....... --------------________________________-________ qQ �Zoning District ----. ='--------------Rne District -------.1~�-����.------------.. � �� / �J �� Name of Owner ' ��c���J.--'����������------..A66eso ----��!����.!°��—.��f����h.�../,-/���--- Nome of Builder —' .......—' —.����- /" A66nss ----. .. ./..-�L--.y~�� �y......`�/ �-___--_- Name of Architect ------------ ............................Address ---------------------------- ~ �~- -1�f��� Number of Roomo ---'��-----------------Fuundohon --'^���'^��-'������/�.----------. ln ~~J Ex/erior "°6��� Roofing --' — -- ...................................... � -------' ------------------ � — ---' --��� � �� F|oo� ----'/y»~�'/ --�----------------..|n�hor ---- y�`^ �Uz�'.�---_-----------_ . � ` �j /.,J_ �" . i Heating --����������—.������������—(e.�fq���--Plumbing ------..�------.—.^--------,___ [/ " � Fireplace ............0.4 --------------__:__..App,oximote Coo ................ . x�/� ��. ..e40..................... � Definitive Plan Approved by Planning Board --------------------------------lg--------. Area C:2'Qw��� Diagram of Lot and Building with Dimensions Fee ...... ECT TO APPROVAL Of BOARD OF HEALTH Go \Y . ~ . . _- ' . . . � | � |~��n.�nr'y' ^ � . OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS . | hereby agree to conform no all the Rube and Regulations of the Town of Barnstable regorJi' the above construction. Name --»=���.x.—���.��--./�� ------.. | � ^ � \ C)�� Construction Supervisor's License --.�'.�.c--........... | . . CERFSKA, JONAS 28049 -No ................. Permit for ... �:!Pqr-v............. Single Family Dwelling ..................... Location .....580 LuTryberts.Mill Road......................... .......... ...............Penterville......................................... ................... .. Owner ..Johas...Cere..s.ka.............................................. ........ .... Type of Construction ....Fr xne............. ................................................................................ Plot ... ....................... Lot ................................ Permit 'Granted ....June..19............... .........1985 Date of Inspectio 9� .............7. Date Completecf� ....................... ..............19 CIL ALGER & SCHILLING ATTORNEYS AT LAW f 886 MAIN STREET P. O. BOX 449 OSTERVILLE, MASS. 02655-0063 JOHN R. ALGER TELEPHONE 428-8594 THEODORE A. SCHILLING AREA CODE 617 May 6 , 1985 Mr. Joseph Daluz Building Commissioner Town of Barnstable 367 Main Street Hyannis , MA 02601 Re: Jonas P. Cereska - Application for Building Permit Lot 6 , Lumbert Mill Road, Centerville , Massachusetts Dear Mr. Daluz: I have been requested by the builder, on behalf of the owner set forth above, to render an opinion concerning the status of Lot 6 shown on Land Court Plan 37432A which is less than an acre. This property, prior to February 1985 , was located in a Resident C district and complied with the zoning then existing. Jonas P. Cereska and Alexandra Cereska purchased this land on January 21 , 1983. At the time they. purchased this land, the Lot complied with existing zoning. Based on my examination of title, it is my opinion that since the Lot is in separate ownership and to the best- of my a.: knowledge and belief the owner owns no adjoining land, the Lot is buildable and remains buildable under the grandfather provisions of our. By-Laws and4Massachusetts General Laws . Very truly yours , - -v a • � Theodore A. Schilling TAS/dsd t TOWN OF BARNSTABLE BUILDING DEPARTMENT f �eaasr : TOWN OFFICE BUILDING rua i639' �� HYANNIS, MASS. 02601 MEMO TO: Town Clerk r FROM: Building De artment DATE: 4. An yOccupancy Permit has been issued for the building authorized by Building Permit 0,.. � .... ..V..................... ....................._............ issued to ...... ... ... .......... ....: .. .... ...._...........-----------_................. ................................. ............... _ .. .. __._..................._..._.... v � . I Please release the performance bond. J .., y3;:_; -. .�. ;\ ' i; �:j;,L '.wig .�d`. i .':? 'E .� . . - � •�;�, ? �',�,,�,.s h .; X. _ '� • L '` �`gy�` ••'. TOWN OF BARNSTABLE BUILDING DEPARTMENT = s►��T TOWN OFFICE BUILDING rua a MAY HYANNIS, MASS. 02601 t MEMO TO: Town Clerk FROM: Building Department DATE: 'v'0 v An Occupancy Permit has been issued for the building authorized by BuildingPermit .._.............................................................................................................................. . .w...» issued .to Please release the performance bond. a a TOWN OF BARNSTABLE 28049 Permit No. ------------------------------- sin = Building Inspector Cash ° sa OCCUPANCY PERMIT Bond ----- -------- Issued to Jbnas Ceresk.a Address,.1- ' r lot #6 580 Lumbert Mill Road, Cente vil1g,- Wiring Inspector � Inspection date, Plumbing Inspect6r�/e� Inspection date Gas Inspector � Inspection date Engineering Deparimenty �,• � Inspection date' e -- Board of Health ~1 �irv�Qrj � i s(c9t� Inaction date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON'4SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. ...................................................... 19......_... ..........................`Building..Inspeetor.....�.�...�� r r -H , r , r , J`.. r I t ! , : : j .... .:.. �._._ 1. � ... .. 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