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L TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel: d 3� Application # Z� t , — A ?--
Health Division Date Issued a(a-4-1a 1 I
Conservation Division Application Fee i
57)
Planning Dept. = Permit Fee 15 c
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation/ Hyannis
Project Street Address /7�6 j y4 h y I S &rh S i e '---Re
Village arrxil£ e
Owner Yl Shn LI A r P5sy Address i3Y6o G'rdn' Tr. tv o )av -s it✓/k¢ cl
Telephone
Permit Request Ad (e /IuMe 1)Uwg - ,it 1 v45 )1u1 "7a A Tf)c R `3
is 7;lco ` Poor j /7hL Ai-sekhn , G1e47?.ers hrlepi.t 1 , ----P5T Evcy.t ,e we,./k
c,r 'TA J/kT,Y (ad a,5 8,514
Y
Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new
Zoning Districtst\ Flood Plain Groundwater Overlay
Project Valuation �, , o0 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 Historic House: ❑Yes ❑ No On Old King's Highway: _0 Yes9J No
Basement Type: ❑ Full ❑Crawl ❑Walkout ❑ Other -+
Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)
«3
Number of Baths: Full: existing new Half: existing new'a ="
Number of Bedrooms: existing _new I _ a�
ii ._„ �,
p. Total Room Count (not including baths): existing new First Floor Room Count "'
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
---iCentral Air: ❑Yes ❑ No Fireplaces: Existing New 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:
.2. Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
D Commercial ❑Yes ❑ No If yes, site plan review #
Current Use _ Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Mame/, S1e /A 4 L A -- Telephone Number SDi 6 `0 /5) 3
/
Address 14"4 c .te,4T P)jtas `-pti t-. License # o 7 7 l Z
/1/La.S k M. A- 0..?L /7 Home Improvement Contractor# / 2-0 1/3 7
Worker's Compensation # A WC II ( Q7
ALL CONSTRUCTION DEBRIS R SULTING FRO THIS PROJECT WILL BE TAKEN TO 16c4 ( 1 u
SIGNATURE r DATE -/1 --l l
3
i
FOR OFFICIAL USE ONLY
., 1
APPLICATION#
rr
3 -J DATE.ISSUED: J
'-'(:-
=MAP/PARCEL NO.. - .-
I
} ADDRESS VILLAGE
OWNER •
{
DATE OF INSPECTION: .
ti,FOUNDATION . ''= 4r .
FRAME
INSULATION..' -
FIREPLACE
i ELECTRICAL: ROUGH FINAL •
PLUMBING: ROUGH i FINAL
GAS ROUGH _t° .FINAL
, F
ti-F.INAL BUILDING:t'4.. WI:- ._
DATE CLOSED OUT
ASSOCIATION PLAN NO. •
,fit
t)
11. For breach of this Agreement by the Property Owner, the Property Owner shall reimburse
the Agency in an amount equal to the cost, as certified by y the Agency, of the
Weatherization materials installed and labor performed on the premises, as well as
attorney's fee and court costs. The Property.Owner may also be liable for damages to the
Tenant in accordance ith.applicable'law -in= uch'ihstance, the Property Owner shall
reimburse the Tenant for attorney's fees and court costs. Without limiting the foregoing, the
r a Agency may at its option terminate this-Agreemenk by providing written notice toe.the ,re
r t- .Property Owner,and Tenant, in the event,of breach by_;the Property Owner or Tenant.
12. Performance of the Weatherization work hereunder by the Agency is contingent upon the
availability of funds to the Agency from the commonwealth of Massachusetts and the
federal.government, as well as the eligibility of the Tenant under WAP program
requirements. The Agency may terminate this Agreement, by providing written notice to
the Property Owner and Tenant, if the Agency determines that the unavailability of funds or
,meli ibility of the Tenent,werrants termination. _ _
13. The Parties acknowledge that this Agreement is under seal. It is intended by the Parties
that the Tenant or any successor Tenant is the intended beneficiary of the Agreement and
shall have a right of enforcement.
Property Owner' /
-
Signature: Date_ _-p 2
Phone: Y 6o7 - 7o )O
Address: /3 J o g),EP-o rJ A 3.42_ .
Tenant Signatur Date I Z• 11 • lO 1D
Agency Approved Weatherization Company: L_ 4-.So-PS
c
•
All Cape Energy Caliber Building&Remodeling Cape Cod Insulation
Cape Save
Creswell Construction Frontier Energy Solutions
Lohr& Son;_s„, Peter Smith Resolution Energy
Rock Solid Construction Sprinkle Home Improvement
•
This Agreement becomes Effective as of the Date of the Agency's Signature. The Agency will sign, and return
copies of the Agreement to all parties,upon completion of the proposed Weatherization work. The Agreement shall
remain in Effect for one_ ullll year from the Effective Date. •
NA Agency Signature AkiC � tivti t Date \ I S\ a G (
•
?oo (o
,, ,4A
oO V
00W Town of Barnstable *Permit#
X. ® . Expires 6 months from issue date
Regulatory Services Fee c Cpt
BARNssn . EIR,AIrr
r, J* .. Thomas F.Geiler,Director
tlati
,®���a OD6 Building Division k F� R.
"/�BA Tom Perry,CBO, Building Commissioner A S �� k N .
��STABLE 200 Main Street,Hyannis,MA 02601 5e e›. ;C:1(e), $9.-A' _
www.town.barnstable.ma.us 042$.c4'
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY ,g
Not Valid without Red X-Press Imprint
Map/parcel Number -Z' q.—o 3 7
Property Address 1 4 8 v 410.p s i3as-v,skcjote, R i Fuirrisvc Sot.e.
V.'.esidential Value of Work ` /0,4O.co Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address '- `,.jonA .,A S1%,a,ilci- vi56 c l
13 4io 6 e zo ICE- 0 . .3 C,►t- 1V Fe, e gi22,46
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
XRe-roof(stripping old shingles) All construction debris will be taken to Pv AA.?
❑Re-roof(not stripping. Going over existing layers of roof)
Re-side
❑ Replacement Windows. U-Value (maximum.44)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Pr e wner must sign Property Owner Letter of Permission.
! H e I rovement Contractors License is required.
SIGNATURE: ti
Q:Forms:expmtrg
Revise071405
4 a
%.011. ratio Town of Barnstable *Permit# 72 8 3
A' ,.1•T Expires 6 months from issue date
: SABLE, = Regulatory Services Fee c5 .00
1639. . Thomas F.Geiler,Director
'E°M Building Division X-PRESS PERMIT
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601 AUG 1 4 2003410
Office: 508-862-4038
Fax: 508-790-6230 TOWN OF BARNSTABLE
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number e:2 (gg Y 0-3 7
`--BQr-Bar W 1e d, •
Property Address /1/it Alga„/,/ /g �y—h sla�ip
[]Residential Value of Work
Owner's Name&Address /►►Q 744--A eui Mo tw P p,P y, at9 n ias
I4i1 A/cQ/2 S 6Q,ei7 A/P
Contractor's Name - Telephone Number
Home Improvement'Contractor-License#(if applicable) =
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance--
- _ Check one: .. a
Di am a sole proprietor
am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name -
Workman's Comp.Policy#
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)
0--
6
❑ Replacement Windows. U-Value (maximum.44)
*where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission. •
Home Improvement Contractors License is required.
Signature 2Z,it-fAd‘X.-
Q:Forms:expmtrg
Revise053003
t g "
`• TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION J fr
OD Q, Parcel Permit# 7 02 2
Health 0 Date Issued l
Conservation Division 6 ®G I" ~ ;t; { 1;;_` r': Application Fee
Tax Collector sia 0 D k — 112 f/e>/0 Permit Fee
Treasurer L ' a// c/d 3 `: !SION
Planning Dept. P2PLICANT MUST OBTAIN ASEWER
CONNECTION PERMIT FROM THE
Date Definitive Plan Approved by Planning Board ENGINEERING DIVISION PRIOR TO
CONSTRUCTION.
Historic-OKH Preservation/Hyannis
Project Street Address /I/W //yam/ S —130Jeh S 2t'i/e 'Q)
Village A0/2hSz�Cr.oIP
Owner m G f/-h Pu) ,-J 7Ouiieei 1 To hue Address
Telephone 3(9 a-t 34 9
Permit Request C oh 5-1/2 G/C-IIo A) o4' shed
Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Ao o.00 Construction Type SA ed
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure )Jppme (4,5-yp s Historic House: ❑Yes I3o On Old King's Highway: Comes ❑No
Basement Type: ❑Full ❑Crawl ❑Walkout 0-Other /4 A04•047/./9 C PA,J,L
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 C, 'Oil ❑ Electric ❑Other
•
Central Air: ❑Yes 1lo Fireplaces: Existing ,1 a New Existing wood/coal stove: ❑Yes ®-No IF
Detached garage:❑existing ❑new size JV f Pool:❑existing ❑new size Alf Barn:❑existing ❑new size ///tC1
Attached garage:❑existing ❑new size /V4 Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review#
Current Use Proposed Use
UILDER INFORMATION
Name p119.2. C,l r,I7 O D Telephone Number
Address , `i h e /d License#
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE kklaii,UD�L DATE jD—/ 0 j
r a,, FOR OFFICIAL USE ONLY
4
fi' g PERMIT NO.
C .r' DATE_ISSUED
41
MAP/PARCEL NO.
▪ ,
.• A
r r •
ADDRESS VILLAGE •
'r OWNER - - '
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
I
FIREPLACE
ELECTRICAL: ROUGH FINAL
• PLUMBING: ROUGH FINAL
•
GAS: ROUGH - FINAL •
I
• FINAL BUILDING
'. DATE CLOSED.OUT '
ti ASSOCIATION PLAN NO.
Town of Barnstable
op THE404
Regulatory Services
• Thomas F.Geiler,Director
SARNBTABIL s
9do_;9. 4b Building Division
do_
Tom Perry,Building Commissioner •
• 200 Main Street, Hyannis,MA 02601
•
•
)ffice: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: d /0-6t/"0 5
JOB LOCATION:. l U2S l /�Jl'G/2M?/S- n5 h% K d
number` / street village .
"HOMEOWNER": 'MO f) 4L eeg ��i1i'�s %�G�—7�m -&3 j
name home phone# work phone# •
CURRENT MAILING ADDRESS:
/47 G�2� 3d
city/town 5 4 4 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
gn
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
re.72jquirements.
Signature of Homeown
•
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.
r
Jul 28 03 09:09a Keller y Associates, P.C. 1 (8171983-3907 p. 1 1
G LO RAL ASSOCIATES
R isterd Land Surveyor Registered Professional Engineer
44/ ,0 9 (.3oad'.va Wakefield, MA 01880 T:(781)246-9345 Fax: (781)246-4333
G"
NOTE: iUILDING IS "GRANDFATHERED" WITH RESPECT TO SET BACKS AND
LOT DIMI NSIONS BUT MAY NOT MEET CURRENT REQUIREMENTS. BUILDING
LOCATIOIIS ARE APPROXIMATE. A PLAN, PREPARED BY AN INSTRUMENT
SURVEY, IS NECESSARY FOR THE BUILDING TO BE ACCURATELY LOCATED
RELATIVE TO THE PROERTY LINES.
p
• 4A) Tq6 y/no,
`�`c0"l£R�' s
'' Rpq
00" 0
F.
G tr �4 4s0 De,
Z CM x�,
0
+ d_
f.
In S no.,aso
0,
vi \H/+ 0
LD
ado ��8v1sN�d8-S�NNdI.
OF
;4.('
•
AL6ERT .
THIS IS A',“,E SURYE Y_;QED ON SURVEY MARKERS OF OTHERS AND THIS PLAN WAS //.�{�w ' K. 1
DRAWN F);7 MOR TO AGE P' / :.\ ^'� f v.PURPOSES ONLY.ixlS PLAN WAS NOT MADE FOR:. i
PURPOSE;,DEED Or ea;P?IONS CONSTRUCTION VERIFtCATiON OF PROPERTY LINE '�g� f
DiAIENSIC;:S.BUILDING OFFSETS,FENCES ORLOF CONFIGURATIONS.ONLYA PRECISE '
iA S IRUME NI SURVEY C,N DE TERMINE ALL OF THE ABOVE. . i
I
LDiE PRE,..ASE S SHC.','N Ut:THIS PLAN ARE NOT LOCATED WITHIN THE
FLOOD HAZARD 10t:E AS DELINEATE()ON THE MAPS OF THE Mortgage Inspection Plan
CO.MMUr:'lA 250001 0005 C In
HERiO',E?TI ;HA 1 THE SUILD:NDIS)SHOWN ON THIS PLAN ARE
APPROA;:,A EIY :GA:E7 CH THE GROUNDS AS SHOWN THEREON AND BBARNSTABLE, MA.
iNA I 11:C1 Cpr:.Drr,I i0 IhE ZONING AND BUILDING LAWS
iOIA+Err_: NAL A:.'-,AI::,::IENTS)OF THE TOWN OF BARNSTABLE Prepared For
IrhEN c r c D r,Ic? or,REcORo. MATTHEW a MAUREEN JONES
7-24-03 1 Scale 1"= 60' Date 7-24-03
SignE,wre Date
- ....;:- . , , .: , . . .
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 42 /t
Map o2 99637 Parcel Permit# 7// 0
Health Division - 44., 2.715 U d� 0��in Date Issued !// Ph
Conservation Division A n ►Ait Application Fee �J . a
Tax Collector c-0()c 0 lc —\' L_ gJ&? /03 Permit Fee �— C� —
: " Y3T-
Treasurer ® � A) L — �S �& D3 In��EPT LE. ��' � UST E
0� E s,Oa
Planning Dept. ret Ai TI 5 , onvo
ENV'C:\\ y`a,lT'1. etj :- �% ER p is
Date Definitive Plan Approved by Planni Board p � . p
Historic-OKH l)k i\reservation/Hyannis Ni , 0 •
,,g �0
Project Street Address /LJ Pif fX y/C!/2nic Ad
Village f3cYLn 9d4 1)le_ >> • /
Owner runt --hVO, I.-. j'Y)2ukeen \jDnPS Address /Uk�' f``-,c1/ ei), -AQ,i?sArA1e led
Telephone SO,?-3'2-4. 3 '",1 J
Permit Request d e o/0117`,'D{/ 6'€ d'c1c
Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family 0 Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No
Basement Type: O 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 0 Other
Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: 0 Yes ❑No
Detached garage:0 existing ❑new size Pool: 0 existing ❑new size Barn:❑existing ❑new size
Attached garage:0 existing 0 new size Shed:0 existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑ No If yes,site plan review# 1
Current Use Proposed Use
BUILDER INFORMATION i
Name 0/1//74/2 Telephone Number I
Address License#
6►
d '-,
Home Improvement Contractor# i� -"
a
Worker's Compensation#
u�
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO I `_' 5.1
al rn
SIGNATURE Q DATE O�/ .3
FOR OFFICIAL USE ONLY
PERMIT NO.
•
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME •
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH . : FINAL •
,
FINAL BUILDING
Ey t
/
a' t. _
DATE CLOSED OUT
ASSOCIATION PLAN NO. •
oFt�ra,,
Town of Barnstable
Regulatory Services
BARNSTABLE. . Thomas F.Geiler,Director
rKnss.
039. f Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: , / /
JOB LOCATION:. /L.�g0 /X /Q/-h/S feel �G)&1/S 7/-e l e
number street village
"HOMEOWNER": ;PO,j h-PP rr Tan f s 5-70 W- (0,2-G 3 5 9
name home phone# work phone#
CURRENT MAILING ADDRESS: 3 O YY)`Q.-•
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. 0 )
Signature of Homeown '
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
4
i l
SHED REGISTRATION
Li kaS Rc ®
location of shed(address)
CQC-!itON e \ cS
property owner's name
l*l tag
size of shed
signature I
date
Old King's Highway Historic District Commission jurisdiction? 1-2-0
THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN
shed
i i
Sheet of
1 ROD UCTS CORP
E SFile
CROSSLINKED POLYETHYLENE FOAM& RUBBER PRODUCTS Subject �0 Ne S
By
Date
...NOTES...
R
Owes.. ikt,NNS
•
WO?OS , S KQCII 0 _____. -
Q
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. afl
t V SOP.15_
,
___. __ . .____.
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•
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