HomeMy WebLinkAbout0454 OLD TOWN ROAD i
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
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Map Parcel 1 ,57 Permit# t 6
Health Division _a 0 Date Issued 61 —2.1
1002
Conservation Division -' Application Fee f ®D
Tax Collector Q Permit Fee V i
Treasurer Ok - 10L
/� SEPTIC SYSTEM MUST BE
Planning Dept. INSTALLED IN CWUMCE
Date Definitive Plan Approved by Planning Board Ti TM 6
EWRONMWAL CODE AND
Historic-OKH Preservation/Hyannis TOWN REGULATIONS
Project Street Address L.
r' oA*nN ,,. .?66 .. ,
Village a AR e D`= -EC . b �� b
Owner ` � �WAd e� �/EIV T I nr,,,
EMCN[
---1 1 ��
Telephone 8 7 "' � � RADE ®r T .� WILL T.�r r,-, ��a
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Permit Request /''1 e W o� vto
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i�W 4alA'S IMA 9Z 9' 01t&*t9l J'�11-1h I
-iih f1, A1 8
Square feet: 1 st f oor: existirfgq� proposed S 2nd floor:existing _; proposed r Totahr ew -
Zoning Distric Flood Plain Groundwater Overlay
cf
Project Valuati Construction Type W06 :&Qmc � � -
� ^ �.J
Lot Size ft � �� Grandfathered: ❑Yes *o If yes, attach supporting umentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
ca
Age of Existing Structure Historic House: ❑Yes JiNo On Old King's High ay: ❑Ye"& -XNo
Basement Type:wFull ❑Crawl ❑Walkout ' ❑Other
Basement Finished Area(sq.ft.) - Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing 4 new 3 Half:existing new
Number of Bedrooms: existing new
Total Room Count(not including baths): existing 3 new L First Floor Room Count 3
Heat Type and Fuel: *Gas ❑Oil ❑ Electric ❑Other
Central Air: ❑Yes XNo Fireplaces: Existing /'. New �. Existing wood/coal stove: ❑Yes XNo
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size
Attached garage:❑existing"`"k new size 74 Shed:,V existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes No If yes, site plan review#
Current Use ho, e Proposed Use o4*7 _
BUILDER INFORMATION /
Name J0� Telephone Number 506'7 g0 4-t�(O
Address 6&a r 04 License#
v a/'I!7�✓� !�'2�, 0 `�6�� Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE t,"IN2
F,
FOR OFFICIAL USE ONLY
✓ C 7
PERMIT NO. .-• -
'f
` DATE ISSUED
MAP/PARCEL NO.
ADDRESS .VILLAGE
OWNER t
DATE OF INSPECTION:%
FOUNDATION "-
-
FRAME $ ' " 0`( ��� A � ,.,✓
INSULATION /VS ej r 'O'
r,_ 1 FIREPLACE
ELECTRICAL: ROUGH * FINAL t_
PLUMBING: ROUGHw IN FINAL
GAS: ROUGH- 0q €a" FINAL- J
FINAL BUILDING P 4 _
DATE CLOSEDiOUT
ASSOCIATION•PLAN NO. = ) i' '4 '• ,�
' n
The Commonwealth of Massachusetts
Department of Industrial Accidents
_= _ 0/ffee ol/nreseations .
600 Washington Street
Boston,Mass. 02111
Workers' Com ensation Insurance Affidavit
name: Whi r m Cr-5
location t®w n rk
ci
hone# J®!r' �"' J
I am a homeowner performing all work myself.
C-J'i am a sole r netor and have no one workin in any capacity
I am an employer roviding workers' compensation for my employees'worlang on this job.
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❑ I.am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who.
have
n olices:
the followin workers comp g p ?:.;?:.?:;-::.?:.;:.?:.;:.:.;?:.;:.;:.:;.?:::.?:.?:.?::::::-,:.::.::::::::::::::::::.:_:.:.::::.::::::::::::::.:::::::::::::::::::.
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Fafinre to secure coverage as re under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this.statement may be forwarded to the Office of Investigations of the DIA for coverage verification
I do hereby certify under the pains and p naldes of perjury that the information provided above is true and correct.
Signature Date
-
Prinf name Phone# ' �ti 7
official use only do not write in this area to be completed by city or town official
city or town: pennit%license# CIBuilding Department
ClUcensing Board
❑checkif immediate response is required ❑Selectmen's Office
_❑HealthDepartrnent
contact person: phone#; ❑Other
ONised 9/95 PJeu
Information and Instructions r
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the"law", 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 section 25 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 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 chapter have been presented to the contracting
authority. :..
Applicants
Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and
supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be
submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
permit or license is
e affidavit. The affidavit should be returned to the city or town that the application for the pe
date the license
being requested, not the Department of Industrial Accidents. Should you have any questions regarding the'law or if you
are required to obiain a workers' compensation policy,please ca11`the Department at the number listed below:.
City or Towns -
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom ottlie
affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please.,.
the be,sure
artinent br mail, dense number which will be used as a-reference number..The affidavits may be rebuned;t�+
P. _.
ep 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 questions. .
please do not hesitate to give us a call.
The Department's address,telephone and fax number:The Commonwealth Of Massachusetts
Department of Industrial Accidents
Olflce of Investigations
600 Washington Street
Boston,Ma. 02111
fax#: (617.)727-7749
phone#: (617) 727-4900 ext. 406, 409 or 375
• Table IS"b(eeasla 04
prod ipthe Paeks;es for daa aad Tws-F smir
Res"aadal BU WL V Ewmd t+�gO�Fella
AXIMUM
um
M
Charing . GL�ag Ceslial wall • Flow Hsaement �Wci=
Rrval� P
Area'(•/.) U-vial R-value� R-��� Rwabw.
Paten?r ST01 to 6500 H Dew 02W
19 1 D 6 Normal
Q 1Z!'. 0.40 31 13 6 Noma!
g 12% OS2 30 19 19 10 15 AFUE
19 t0 6
0.50 31 1] NIA NJt Nmmai
T' 15•/. 036 31 1] 6 Normal
U 1Sy. 0.46 31 19 19 10 WA
UAFUTE
13 21 WAA13 AFVE
V IS'/. 0.4.4 3E 10 6
w 15% OSZ 30 19 14 NI Normal
A N!A .
. 13 ZS •
X 18% 0.]Z 31 NIA Normal
y I E'/. 0.4Z 31 19 ZT 13 WA 10
40 AFUE
19 6
y 0.41 31 6 90 AFVE
AA Ism. 30 19 I9 10
SS OF PROPERTY:
T. ADDRE
2. SQUARE FOOTAGE OF ALL EMERIOR WALLS:
46
3. SQUARE FOOTAGE OF ALL GLAZING'.'
G AREA #3 DIVIDID BY#2):
4, %GLAZING � •
5:'SELECT PACKAGE(Q—AA-see chart above)::
• NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING
ENERGY'REQUIREMENTS
ARE AVAILABLE. ASK US FOR THIS IlIFORMP,TION.
BUILDING INSPECTOR APPROVAL:
YES: NO:
q.forms-f9&0303 a
Footnote's to Table J5.2.1b:
Glazing area zin
is the ratio of the area of the glag assemblies (including sliding-glass doors, skylights. and
basement windows if located in walls that enclose conditioned space,but excluditig opaque doors)to the gross wall
area. exp tr
ressed as a percentage. Up to 1%of the total glazing area ay be exeluded.from the U-value requirement.
For example;3 ft'of decorative glass may be excluded from a building design with.300 ill of glazing area.
Z After January 1, 1999, glazing U-values must be tested and documented by the manufacnuer in accordance with
the National Fenestration Rating Council (NFRC) test procedure, or taken'from Table J1.5.31. U-values are for
whole units: center-of-glass U-values cannot be used.
' The ceiling R-values do not assume a raised or oversized trios coastrctetion. If the insulation achieves the full
insulation thickness. over the exterior walls without compression, R 30 ittsulatioa may be substituted for R-38
insulation and R-38 insulation may be substituted for R=49 insulation. Ceiling R-values represent the sum of cavity
insulation plus insulating sheathing (if used). For.ventilated ceilings,.insulating sheathing must be placed between
the conditioned space and the ventilated portion of the roof.
'Wall R-values represent the sum of the wall cavity.insuladon plus insulating sheathing (if used). Do not include
exterior siding, structural sheathing, and interior'drywall.For example,an R-19 r'equiternent could be met EITHER
by R-19 cavity insulation•OR R-13'eavity insulation plus R-5 insulating sheathing. Wall rsquuemenm apply to
wood-frame or mass(concrete,masonry,log)wall construetidns,but do not apply to metal-frame construction.
The floor'rcquirements apply to floors over unconditioned spaces(such as unconditioned crawlspaces, basements,
or garages).Floors over outside air must meet the ceiling requirtmeats-
•TFe entire opaque portion of any individual basement wall with an average depth Iess than 50%below grade must
runt; the same R-value requirement.as above-grade walls. Windows and sliding glass.doors of conditioned
br..,ements must-be included with the other glazing. Basement doors mint meet the door U-value requirement
d-scribed in Note b.
'The R-value requirements are for unheated slabs,Add an additional R-2 for heated slabs.
' If the building utilizes electric resistance heating use compliance approach 3;4, or 5. if you plan to install more
than one piece.of heating equipment or.more than one pie= of cooling equipment, the equipment with the lowest
efficiency must meet or exceed the efficiency required by the selected package.
'For Heating Degree Day requirements of the closest city ortown see Table JS.Z.Ia.
NOTES:
a) Glazing areas and U-values are maximum acceptable.levels.Insulation R-values are minimum acceptable levels.
R-value requirements arc for insulation only and do not include structural components.
b) Opaque doors in the building envelope must have a U-value no greater than 035.Door U-values must be tested
and documented by the manufacturer in.accordance with the NFRC test procedure or taken from the door U-value
in Table J1.5.3b. If a door contains glass and an aggregate U-value rang for that door is not available, include the
glass area of the door with your windows and use the opaque door U-value to determine compliance of the door.'
One door may be excluded from this requirement'(Le.,may have a U-value greater than 035).
c) if a ceiling,wall,floor,basement wall,slab-edga,or crawl space wall component includes two or more areas with
different insulation levels,the.component complies if the area-weighted average R value is greater than or equal to
the R-value requirement for that component. Glazing or door components comply if the area-weighted average U-
value of all windows or doors is less than or equal to the U-value requirement(6.35 for doors). .
•
- 43
f
RESIDENTIAL BUILDING PERMIT FEES
APPLICATION FEE
New Buildings,Additions $50.00
Alterations/Renovations ' ' $25.00
Building Permit Amendment $25.00
FEE VALUE WORF{SHEET
NEW LIVING•SPACE x 9 � p
96/s = 39 4 x. 31=00
T square feet x$ .foot q
plus from below(if applicable)
ALTERATIONS/RENOVATIONS OF EXISTING SPACE . .
square feet x$64/sq.foot
S o2 �x.0031=
plus from below(if applicable)
ACCESSORY STRUCTURE>120 sq.f'
>120 sf-500 sf S 35.00
>500 sf-750 sf 50.00
>750 sf- 1000 sf 75.00
>1000 sf-1500 sf 100.00
>1500 sf Same as new building Permit
x.00 ,_
Square feet x$961sq. foot= -
STAND ALONE PERMITS 00
Open Porch x$30.00=
(number)
Deck , ___ __x$30.00=
(number),
Fireplace/Chimney (number)
x$25.00=
Ingraund Swimming Pool $60.00
Above Ground Swimming Pool $25.00
Relocation/Moving $150.00
(plus above if applicable) permit Fe
U " D(o
propost
I
ZNE, � Town of Barnstable
Regulatory Services
v��SrABM
AASS. Thomas F.Geiler,Director
'OTE1639. Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
Permit no.
Date Ov_ n e-
1 1
l
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization, conversion,
improvement,removal,demolition, or construction of an addition to any pre-existing owner-occupied
building containing at least one but not more than four dwelling units or to structures which are adjacent to
such residence or building be done by registered contractors,with certain exceptions,along with other
requirements.Type of Work: a6/ , /24 Rem Did,,J
eL Estimated Cost ®,00
Address of Work: / 9 7a w /, ww S
Owner's Name: C Z_
Date of Application:
I hereby certify that:
Registration is not required for the following reason(s):
❑Work excluded by law
❑Job Under$1,000
❑ uilding not owner-occupied
Nzowner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner:
Date Contractor Name Registration No.
�-1 -62 °
Date wner's Name
Q:fonns:homeaffidav
Town of Barnstable
THE Tp�
yP "0an Regulatory Services
sARNSTASLE Thomas F.Geiler,Director
MASS.
�639. Building Division
rBn �A Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
'f p�J Please Print
DATE:Tu �'/ A l.lh"
JOB LOCATION: ✓ �/ I✓7 �L(l rOW4 � ! �l ICI)
/nnu'�mber street % village
"HOMEOWNER l�": wti ZX; , �{ �U �✓I/°I S 5 Oe--�7:/�J/�p�—KQ 0 ✓�`f`,�/1 �7 G
na a home phone# work phone#
CURRENT MAILING ADDRESS: / 15 / GW✓� r .
11J4 2� xr7J
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 fo 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.
Si ature 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"'`
3� v. Luc
j eA�snNc I.�.
- DwE•cuNc � - .
Lo T -oz 3 .
47�t
.53;8/
aGa ?T tw•v
I certify that this property is _
located in Flood-.Hazard'Zone C (out-
side the 5.00 year flood) as identified
by the Department of Housing and Urban F
.Development (HUD) .
Date /-qua. io /�y,S o� M.� CERTIFIED PLOT PLAN
ED�vAFt�y LOCATION
G� / t7 10
SCALE . .... DATE
Reg Ad. r/ PLAN REFERENCE
STtR��J�
,. �Gty�1 ,gyp �, . �•�• . . ... . . . .
I certify to Sandwich Co-op, Bank and its title ins. Co.
that there are no visible encroachments I CERTIFY THAT THE .. ... .. . . . . . .
or easements except as shown and that this SHOWN ON THIS PLAN IS LOCATED ON THE GROUND
plan was prepared under my immediate AS SHOWN HEREON AND THAT IT CONFORMS TO THE
S TRACK REQUIREMENTS OF THE TOWN OF
supervision. !9L�LE, WHEN CONSTRUCTED,
DATE fILG �� /9qs
cyvr/�,s� .S�,y,�,�-,ems - •��nTov� . .,. G���•�f'
REGISTERED LAND SURVEY
J� Tom- .'
SNP �N
$0`
u
3g ,e
01STIM�
� DWE7,t.1�lG &, rq
Inv
Lor iQlZ 1¢'
TT WvAl
I certify that this property is
located in Flood Hazard Zone C (out-
side the 500 year flood) as identified
by the Department of Housing and Urban
Development (HUD) .
Date 0-- i8 Zoe zz CERTI FI ED PLOT PLAN
�✓�tN OF �ygssq�y LOCATION � i�!►!.S76IQlt�C�I�/A/1/N!5�
SCALE DATE.acr 18 Zvoz
rvL.c- r ,& 7 Z
�� -3c?!�!G
Reg. ndo-SuIrveyo,r PLAN REFERENCE
rstER�� /-�s .S WAl o�v, f�-B!L• /33
L•LA�® . . . .. . . . . . . . . .. . . . . . . . . . . . .. .
I certify to Sandwich Co-op. Bonk and its title ins. co.
that there are no visible encroachments I CERTIFY THAT THE •
or easements except as shown and that this SHOWN ON THIS PLAN IS LOCATED ON THE GROUND
plan was prepared under m immediate AS SHOWN HEREON AND THAT IT CONFORMS TO THE
p y S TBACK REQUIREMENTS OF THE TOWN OF
supervision. e � ?i!�S�AC�I .... . . . .WHEN CONSTRUCTED.
DATE OGT. /8 Zoo Z V
REGISTERED LAND SURVEY
Assessor's office(1st Floor):
Assessor's map and lot number 214 8—1 57 C r P��f THE>p``
Conservation(4th Floor):
Board of Health(3rd floor):
Sewage Permit number
0
Engineering Department(3rd floor):. a °''�i6}9.`���
House number ' 0 YtaY
Definitive Plan Approved by Planning Board 19
{
APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only
TOWN : OF BARNSTABLE
BUILDING - INSPECTOR
/j APPLICATION FOR PERMIT TO RE ROOF
TYPE OF CONSTRUCTION _SINGLE FAMILY-RESIDENTIAL WOOD FRAME
4-5-94 19
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the foll"ing information:
Location 454 OLD TOWN RD ' l CL" /2 s
Proposed Use S FR
Zoning District Fire District
Name of Owner C 1 y d P�y Address- SAME /
Name of Builder,JACK MAENRA 4 Address3 5 G PT STUDLEY BID M a MILLS
./ J�r Q i—zcv—z'i'LTLTI—a['t'lT—
�( Name of Architect N A Address
Number of Rooms Foundation
Exterior Riofing20 YR 3TAB ASPHALT W/felt pa er
Floors Interior
Heating Plumbing
Fireplace Approximate Cost $9 7 5 0g
Area Aid 14y'e4 C t-
41, o0
Diagram of Lot and Building with Dimensions Fee
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable egarding he above construction.
Nam
American States insurance Comm Policy 01-C 963946
Remodeler Reg 104683 Construction Supervisor's LicenseQ�2246
PERRY, CLYDE
1
No 3 6 618 Permit For Re-Roof - <
Single Family Dwelling
Location 454 Old town Road
Hyannis
Owner Clyde Perry -
Type of Construction " Frame
Plot Lot
Permit Granted April 15 , 19 . 94
Date of Inspection:
s
Frame 19
Insulation 19 Y -
Fireplace 19 ,J
Date Completed 19 c
Y
r t
's i
i
v.._.COMMONWF„ALT
-_QEPARTMENT OF_PUBUCSAFETY . IPa/intopcsscisaccrrent
OF . _.:,.IW }°" 1 .ONE ASHBORTON PLACE isiaQMsctbStitl6efldfRB
MASSACHUSETTS BOSTON,MA 02108Il�QaiBNotti110cat�®n
L I EN`;E CAUTION
EXPIRATION DATE CONSTR. SUPERVISOR
R �ICnON5995 EFFECTIVE DATE LIC-NO. FOR PROTECTION AGAINST
THEFT, PUT RIGHT THUMB
r NONE g }b/30/ 1973 Q28246 PRINT IN APPROPRIATE
� o BOX ON LICENSE.
JOHN W -1AFNPA.A JR
35 CAPTAIN STUDLEY RD � a BLASTING qf ERATORS
M.ARSTONS PALLS MA 0264 � , . M aINCLEDE PHOTO.
,pt+OTO(BLASTIN(i`OPRQNIVI FEE: //�� ((jj
• NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY
HEIGHT: STAMPED-OR-SIGNATURE OF THE COMMISSIONER r - ♦^n
,
(.
\ I { THIS DOCUMENT MUST BE SIGNTSAME IN FUL�ABOVE 1GN
THE HOLDER WHEN EN-
ATURE LINE
CARRIEDONTHE PERSONOF SIG RE OF I ENS
EE
��; •%�" f
-�-Q GAGED IN THISOCCUPATION. ER
^'t r !
1 � J1e�oo„:oieaseu °�✓ IdORC/u`°elta
HOME IMPROVEMENT CONTRACTOR ;
Registration 104683
INDIVIDUAL
Expiration 07/15/94
o'rin W. Maenpaa, it.
Join W. Maenpaa Jr .
35 Captain Studley Road
ADMINISTRATOR Marston K:1Is MA 0264S
1
�CC7DENT3'$
�a•*•cs- a ���c'. iO$3 O,�'. !��>_S$ACi j US3-I 3-$02113
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�eeeauocl�amictoc) - _ -
.Rich s nrinapal plUocofbnsir=fr mot:
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zp)
4�,,.2y dohcrcby ccrd6'.undcr the inssnd pazZlrc ofpajury;daa
() I :m.2n cmplovcr proviainZ the followinsv ork='compcn=rion<cvcrzZc formycmployccs uorkin on '
lnsur,2ncc Company
Policy Number
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