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Home My WebLink About68 TANBARK ROAD f r .� NO. 152 113 BLU MADE N U.S.R. ESSELTE of Town of Barnstable *Permit# p�' Q Fapirw 6 months from line date Regulatory Services X. i AIANRTI_^.Tt i 'T 9� KAM.-*1�i Thomas F. Geiler,Director Building Division MAR 2 8 2012 Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis,MA 02601 TOWN OF BARNSTABLE www.town:barnstable.ma us Office: 508-8 62-403 8 Fax: 508-790-623 0 ENPRESS PERMIT APPLICATION - RESIDENTIAL ONLY n/ Not Valid without Red X-Press Imprint Map/parcel Number a cZ 1 Property Address o residential` Value of Work S�"--- Minimum fee of$35.00 for work under$6000.00 Owner'''s-Name&Address �) /► �-�� 0 Contractor's Name / ep :1 S f 0 I-)V l It-Telephone Number cJ 2�3 Home Improvement Contractor License#(if applicable) / / / 6 �93 ;Forkman's coon Supervisor's License#(if applicable) 7oQ,77 Compensation Insurance Check one: ❑ I Xrn a sole proprietor FI/arn the Homeowner EI I have Worker's Compensation Insurance Insurance Company Name ev') 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 t stripping. Going-over existing layers of roof) ❑ -side 9 #of doors Replacement Windows/doors/sliders. U-Value / (maximum.4-4)#of windows *Where required: Issuance of this permit does not exempt compliance with other Gown department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Ffermission. A copy of the Home Improvement Contractors License& Construction Supervisors License is requi :GNATURE: %WPMESTORMSUilding permit forms\EXPRESSAcc 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 Legibly Name(Business/Organization/ladividual): . n .( /�/� •Address: - �/aiV V� ' City/S to/Zip: !e t7 d 3 Phone.#: AV an employer? Check the appropriate box: Type of project(required):. 1. m a employer with 4. ❑ I am a general contractor and-I Y 6. ❑N construction . ployees(full and/or part-time).*. have hired the sub-contractors 2. m a sole proprietor or partner- listed on the-attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g. ❑Demolition workingfor me in an capacity. employees and have workers' Y P tY• $. 9. ❑Building addition [No workers' comp.insurance comp.insurance. 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.❑ 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. #Contactors 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-contactors 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. .9 Insurance Company Name: V �y I (/ /� ,y/VS Policy#or Self-ins.Lic.#: 1� P / �c J/^� Expiration Date: d - � Job Site Address: g Tu W-k !'l City/State/Zip: �/� a 0 9-�. 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cent" under the p ns-andpet(b7tks ofperjurl that the information provided above is true and cornett Signafore: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions 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 produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 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 compliance withthe 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 may be 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 to any business or commercial venture (i.e. a dog license or permit to burn 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 Commonwealth of M=xhusetts llepar�ment of lndusttiai Accidents office of Investigations 600 Washingtori Street . Boston,MA 02111 Teel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 11-22-06 Fax##617-727-7749 www.raass..gov/dia The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aaalicant Information Please Print Legibly, Name(Business/Organization/Individual); _.ij Address: G2 5 City/State/Zip: aL&4 �o - 3 0 3 Phone#: Are you an employer? Check the Appropriate b : Type of prof (required): 1.0 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. ❑N construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. emode ng ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp.insurance comp. insurance.t 9. Electrical repairs required.] 5. ❑ We are a corporation and its ❑ ep or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 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 13.0 Other employees. [No workers' 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. tContraetors 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 isproviding workers'compensation insurance for my employees. Below is thepolky and job site information. ' Insurance Company Name: at1 Policy#or Self-ins.Lic. #: C 01 J?6 J Expiration Date: 3 f/ ' -3 f 4 16 a Job Site Address: � City/State/Zip:MNJOWN Attach a copy of the workers'compensation policy declaration page(showing the policy number and eviration 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$i,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 hereby cerdijy un�der/thepams and penalties o erjury that the information provided above is true and corre& Signature: �`�� Date: V Phone#: Offlcial use only. Do not write in this area,to be completed by city or town of kiaL City or Town: Permit/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#: GERTIFiCATE OF LIABILITY INSURANCE 02/27/2012 i ' 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 1-866-966-4664 CONTACT Marsh USA Inc. NAME: PHONE IFAX (A/C,No Ezt): A/C Noj___._- homedepot.certrequest@marsh.com E-MAIL _ Two Alliance Center, 3560 Lenox Road, Suite 2400 ADDRESS: Atlanta, GA 30326 INSURERS AFFORDING COVERAGE NAIC# Fax (212) 948-0902 INSURER A: Steadfast Ins Co 26387 INSURED INSURERB: Zurich American Ins Co 16535 The Home Depot, Inc. Home Depot U.S.A., Inc. INS Home New Hampshire Ina Co 23841 2455 Paces Ferry Road NW INSURERD: Illinois Natl Ins Co 23817 Building GA 3 Atlanta, GA 0339 INSURER E: NATIONAL UNION FIRE INS CO OF PITTS 19445 — INSURERF: Illinois Union Ins Co 27960 COVERAGES CERTIFICATE NUMBER: 25776028 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 OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DDIYYYY MM/DDIYYYY A GENERAL LIABILITY GL04887714-02 03/01/1 03/01/13 EACH OCCURRENCE $ 9,000,000 DAMAGE TORENTED PREMISES Ea occurrence OM $MERCIAL GENERAL LIABILITY 1,000,000 CLAIMS-MADE �OCCUR MED EXP(Any one person) $ EXCLUDED 1Xi:C_L:11 MITS OF POLICY XS 9,000,000 PERSONAL 8 ADV INJURY $ X OF SIR: $1M PER OCC GENERAL AGGREGATE $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: _PRODUCTS-COMPIOP AGG $ 9,000,000 X POLICY PRO JECTLOC $ B AUTOMOBILE LIABILITY BAP 2938863-09 03 0 03/01/13 COMBINED SINGLE LIMIT 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident X SELF INSURHDPHY DMG $ UMBRELLA LIAB -OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ ATUC WORKERS COMPENSATION AND EMPLOYERS'LIABILITY WC019736915 (AOS) 03/01/1 03/01/13 X WCSTIMIT OTH- D ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WC019736917 (FL) 03/01/1 03/01/13 E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? N] N/A E (Mandatory In NH) WC019736916 (CA) 03/01/1 03/01/13 E.L.DISEASE-EA EMPLOYE $ 1,000,000 if yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 E Workers Compensation WC1192494 (QSI) 03/01/1 03/01/13 SIR (AOS)/SIR (GA) 1M/750,000 C Workers Compensation WC019736918 (WI) 03/01/1 03/01/13 F TX Employers XS Indemnity TNSC46566397 (TX) 03/01/1 03/01/13 Occurrence/SIR 30M/lM DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HOME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C-20 ATLANTA, GA 30339 USA ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Jthornton_hd ��ie T�oryrvm�aruuecz`C�i a�✓�/�aa:lau�,uael�s Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR Registration 1:26093 Type:. Expiration;= 20:12-, Supplement C The Home Dep6tlAfHom&S-entices .a �a -W DARREN DEMER p S� a _= ; 2690 CUMBERL 45—K111/IAY S A D XTDAM, GA 30339 ' =�,1 Undersecretary License or registration valid for individul use only before the expiration-date. If found return to: Office of Consumer Affairs"and Business Regulation 10 Park Plaza—Suite 5110 ,ard Boston,MA 02.116 r. Not valid without signature Office of consumer Affairs and usiness Regulation Ind 10 Park Plaza - Stitite 5170 Easton, Massach>jsetts 02116 Home improvement qo-j 4or Registration Registration: 132349 Type: Partnership - 'Yw Expiration: 1/1112013 1 r# 207392 J &J Remodeling Joseph Duarte -- 15 Fall St. - -- Wareham, ma 02571 card.Mark reason for change. Update Address and return Address Renewal [] Employment Lost Card )PS-CAI 0 60M-04/04.0101216 T TA sines u a on License or registration valid for individul use only ptfice o aneum a r9 6tnes eg before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR office of Consumer Affairs and Business Regulation Registration: •132349 Type' Partnership 10 park Plaza-Suite 5170 Expiration: :f111/2013 p Boston,MA 02116 Joseph Duarte 15 Fall St. A - a � - �dwVkhu�tsignature Wareham,me 02571 .... Undersecretary 11:►:,achu:ctt�- DcpiU umnt of Puhlic Slice(% 1 Board of Buildim� Re4"ul:tliuns and;t:uulurd� Construction Supervisor License License: cs 70077 JOSEPH C DUARTE 15 FALL ST WAREHAM,MA 02571 Expiration: 12r30/2012 Tr#: 7048 I I TO 39tid Z9L656Z ES:ZZ ZZOZ/ZO/ZO H0ME'UAPR0VFMENr CONTRACT pz�sR�►n Laois - ,�� z / / Sold.Ftnnishnd and Installed hY' —^ Date: _J1_ THD At-Home Serviced Inc..• . Branch Name: Boston diWa,The Home Depul At-Hgme Scrvircb. 345A Gr"c ood Street,Unit 2,Wonceslm,.MA 01607, -Toll , Free(80.0)67-5182: Fax 508)7 823- Branch Number-3] lCV 16427jD p 75-2 : 3 ; o . . pCT Wg565=MA R me'ratPr'overireirf Cb.nuactaa Row— Q LustaHation Address: _>;7 r y "��J fin•� `_ .R°°_... Pttrchaser(s>- vQe.tc Phoa Iloine rb6na: Cell Phone: Home Address: - State zip (If different from Installation Address). City `-` F,mm7 Address(to receive project communications and Home Depot updates)' I•DO.NOT wish to receive any marketrng emails fmmTbr Hoare Depot at the above installation address.agrees to buy. Proiect Information: Undersigned("Customer 7,the owners of the property for the•insrallation("IDstallatxon')of and T14D At-Home Services,I_.(f°M Home Depon agrees w furnish,delver and arrangethis Contract by •m allatenals described on the below and on the refueumd Spa:Sheet(s).all of which are incorporated into a Orders(collectiv y, reference,along with any applicable State Supplement and Payment Summary attached hereto and any Chang /�� "Contract")- � I� Job#: �r�.,u Sw Shee s S: pro'ed Amount []NtoofiDg Sidi endows Insulation ! o�/C.ove:s []l-try o ��f Roofing []Siding Windows ❑Iffinlation $ OGaUrrs/Covets oEntry Doss 0 Roofing Siding[1 Wriadavrs btsalation $ []Gutters/cowo Many Doors rl Roofing []Siding Windows ❑ $ []e>htcers/Cores'Crinuy Door's n 1 2S%DepoWofCanradAmonaLdoeopm®ems-c'CO&-MDarL TOW C.AractAmoaat' $ MamePmcbmrs may not deposit Poore than o,0*d ote,e Co,61A,1 6 Customer,agrees that,immediately upon completion of the work for each Product,Customer will execute a Completiori Certfii ale (one for each Product as defined by an individual Spec Sheet)and pay any balance due- Ae applicable,each Cltstorncr under thii Contract agrees'to be jointly and severally obligated and liable bereandcr. The Home.Depot reserves the right i issue a Change Order or terminate this Contract or any individual Producl(s)included herein,at its discretion,if The Horne Depot or its authorized scrvitx Provider determines that it cannot perform its obligations due to a structural. problem with the home,enyironmc W hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because work required to complete the job was Dot included in the Conha/cc J s 'forthetsme total Pavmertt Sumrnarv: The payment Summary# Ll 5 included as part of this Conlrau+ .Contract amount and payments required for the deposits and final payments by produce(as applicable). NOTICE TO CUSTOMER Yon are entitled to a completely fitted-Nn coyy of the C;outract at tyre time you Sigma. Do-not sign a Completion Certificate(note: there is one Completion Certificate for each listed Pr'odaet as defined by»idivrdual Spec Sheets)before work on that Product Is complete. In the event of termination,of this Contrad,Customer agrees�NaY The Home Depot the costs of materials,labor,.expenses or Atrthor'bed Service Provider fhro'rgJz the date of tertninatioA,p1Ds any other and services provided by The Boma Depot law. THE HOME DEPOT MAY WITHHOLD AMOUNTS amounts set forth m Ores Agreement or allowed under I )SIT OWED TO THE HOME DRPUT FROM THE DE" 1?AY'OVE MEW OR OTHER PAYMENTS T'IADl;, WITHUUT LIMITING THE HOME DEPOT'S OTHER RE1V®iir.S FOR RECOY -RY OF SUCH A M O UN T S rs the entire agreement between Customer �cceutanee and AuthordlAtion: Customer agrees and tntderstands that this Agreement all Pine discussions and agreements,either acid The Ilon�e Uepot vnth regard to the Products and Installation services and supersed % or ended except by a writing signal . oral or written,relating to said products Customer Installation. andAgreement Customer usi�h��,understands,voluntarily accepts the by Customer and The Home Depot- Aandvul a copy of this Agreement Sub ' by:Saks uhant's 5(t' aetoye (3�`(D' a� Telepbone No. �5t�a` Customer's Signature Date Sales Consultant License No- CANCELLATION: C'UMMER MAY CANCEL TffiS es eppl"icabk) AGREEMENT WITHOUT PENALTY OR(OBLIGATION BY DELIVERING WRITTEN NOTICE TO TIE HOME DEPOT BY MIDNIGIiT ON TIME THIRD BUS94M DAY AFTER SIGNING 'TM AGREEMENT. THE STATE SUPPLEMENT ATTACKED MMBTO CONTAINS A FORM' TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE:ADDITIONAL TERMS ANDCONDrIIONSAR8 STA[1D7 ON TEIE Ri'VER48 SIDE AND ARE KART Of THIS CONTRACT 1130-09 C-Sc White-Branch File Yellow-Customer Pink-Sates.Cor> ftatd p126we f: W02Li Td W&M:T 8OW Z '1-00 TLZZZ9 ens: -ON XUA " w oF1HE Town of Barnstable *Permit# Expires 6 months from issue date Regulatory Services Fee =nxtvsTest.e, cc PERMIT 9cb , �� Thomas F. Geiler,Director X-PRCSJ MAy r. Building Division jUL Tom Perry,CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 TOWK OF BARNSTASI-, www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number A96 Q Prop rty Address r/� /g/V Prop Value of Work . S F�_ Minimum fee of$3 o work under$6000.00 Owner's Name&Address 01/�e1 J Ni 0 M Con c is Name1 /!7 S L'�S Se' �f/fid, Telephone Number _sog Home Impr vement Contractor icen a (if app 'cable) ,[� /p� 3) 3W 7Workman's ction S ervisor's Lice se#(if applicable) 700/,) Co pensatio Insurance Check one: ❑ I am a sole proprietor m the Homeowner I have Worker's Compensation I nsurance ! Insurance Company Name kif-1411 � 1f1C, 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) ❑X side #of doors Replacement Windows/doors/sliders. U-Value , (maximum .44)#of window_ *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i,e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License& Construction Supervisors License is require SIGNATURE: Q:IWPFILESTORMS\building permit formslEXPRESS.doc Revised 070110 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' L ! 600 Washington Street r t. {� Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I Please Print Legibly Name (Business/Organization/Individual): Cr)'►�t e, 7:> -f— Address: a��5� 'fCt,LeS ��P--� rCG�►� City/State/Zip: ((,L� = `3 v 3 3 9 Phone #: Are you an employer? Check the appropriate b Type of project(required): 13 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. ❑N construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. emodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.1 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.❑ 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. rr Insurance Company Name: cc) Policy#or Self-ins. Lic. #: C 3 s—--;t— Expiration Date: f I Job Site Address: City/State/Zip: 4._ vt' , (lanwoq D r 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 hereby certify under t. ains and penalties o, rjury that the information provided above is true and Corr ct j Si mature: C�r Date: Phone#: Official use only. Do not write in this area, to be completed by city or town ofciaL City or Town: Permit/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#: , a Oftiee of Consumer Af4ain 8 Ba�sess EteSalatioe i10h0E IMPROVEMENT CONTRACTOR Registration: 126893 Type; ExpifabOn: 8/3l2012 5uppit-ment C re —o-ne Depot At-HOm.e- -Ces DAP.REN DEMERS 259E CUMBERtAND PAf2}4WAY S GA-0339 1'aCersccretan License or registration valid for individui use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Piaui-Suite 5170 Boston—NIA 0211.6 i Not valid without signature r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street ' Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information n Please Print Le 'bl Name(Business/Organization/Individual): OSe I✓v e Address: ✓v City/Stat /Zip: i' /G r0 �U1, Phone#: 5o 8' 9r Any ou employer?Check the appropriate bog: Type of project(required): 1. I a employer with 4. ❑ I am a general contractor and I 6 ❑ construction loyees(full and/or part-time).' have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. emodeling These sub-contractors have g, ❑Demolition ship and have no employees employees and have workers'. working for me in any capacity. 9. ❑Building addition [No workers'comp.insurance comp•insurance x 10. Electrical airs or additions required.] 5. ❑ We are a corporation and its ❑ � 3.❑ I required.] a homeowner doing all work officers have exercised their 1 LEI Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL c. Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13.❑Other comp.insurance requited.] *Any applicant that checks box#1 must also fill out the section below showing their workers'convmation 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-0ontractors have employees,they must provide their workers'comp.policy number. . I am an employer that Is providing workers'compensation ins rance for my employees: Below Is the policy and Job site Information. Insurance Company Name V±r /17oN U /� P Policy#or Self-ins.Lic.#: af Ga�Jr� Expiration Date: 3- �J Job Site Address: O f N 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 hereby certO�u r the pains a enalties of ' ry that the inf mation provided above is true andvorrect. Sr afar e: Date: Phone M OJ�cial use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#' Information and:..-!Instructions Y . 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 notproduced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 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 compliance with the 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-contractors)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 permittlicense 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 may be 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.Wheie a home owner or citizen is obtaining a license or permit not related to 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111. Tel. #617-7274900 ext.406 or 1-877-MMSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia office of Consumer Affairs and 1 us'jig iness Regulation 10 Park Plaza: - Suite 5170 Boston, Massachusetts 02116 Nome Improvement Cbz?�tractor Registration Registration: 132349 Type: Partnership Expiration: 1/11/2013 Tr# 207392 J & J Remodeling Joseph Duarte - 15 Fall St. t.• - -- Wareham, ma 02571 .�' - - _ rn card.Mark reason for change. Update Address and retu Address Renewal ❑ Employment Lost Card )P6-CAI A 60M-0N04.0101216 Office of1Consump"alr9 asiness tccg�lat'°°° License or registration valid for individul use only before the expiration date. 1f found return to: HOME IMPROVEMENT CONTRACTOR, Type: Office of Consumer Affairs and Business Regulation Registration: • •132349 Partnership 10 park Plaza-Suite 5170 Expiration: :�/11/z013 p Boston,MA 02116 Tiomodeling , Joseph Duarte 15 Fall St. �s � •.*�5� _? a 'edwithout Wareham,ma 02571 . Undersecretary ofva Signature 11as�:►Chu:ctc•- Dep"I'llent u!'Puh"C�nfct• 1 Bu:uO of Buiidilrl Ret�ulatiuns:uit{!<1;uuhirds Construction Supervisor License, License: CS 70077 JOSEPH C DUARTE 15 FALL ST WAREHAM,MA 02571 �. • Expiration: 1713o/2012 Trir: 7048 TO 39dd Z9L656Z ES:TZ TTOZ/ZO/TO I FROM : DAN-MELLO FAX NO. : 7742020232 Jun. 27 2011 03:31PM P1 HOMEIM1'ROVP:MI;NT(;ONTRA(7f PLF,ASE twAD THIS Sold,furnished and installed by: Branch Name: Roston Date; THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services -J 345A Greenwood Street,Unit 2,Worcester,MA 01007 Toll tree(Ktgl)657-S 192;l+ax(508)756-8823 Pederal ID 0 75-2698460;ME Lic#C 02439;RI Cont.Lic#16427 Branch Number:31 CT i.ic it HIC.0i(x1522;MA home Impp]rovement Contractor Rcg.#126993 r Jrwiallation Address: �� I 4:22&4`9 t/ City State 7-iP / Purchaser(s): Work Phone: Home Phone: Cell Phone: etri� To 7 a20- Home Address: Lip (if different from installation Address) City State E-mait Addm,;s(to receive project communications and Home Depot updates): ❑I DO NOT wish to receive any marketing emails from The Home Depot Project Information: Undersigned("Customer'),the owners of the propt.rry located at the above installation address,agrees to buy, sod THD At-Horne Services,Inc.("The Home Depot")agrees to furnish,deliver and arrange fur the installation("Installation")of all materials described on the below and on the referenced Spec Sheet(s),all of which are incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively, "C;ontract"): Soh 9: O~_keft_) Pi ahtcts: Sec Shcet s #: Project Autount ❑Roofing Siding Windows ❑Insulation ,/ 4 $ L� 5ZQ t�g ❑Gutters/Covers ❑Entry boors ❑ �f ! �Q � `" ' [:]Roofing ❑Siding Windows ❑Insulation $ []Gutters/Covers ❑Entry Doors ❑_,_ - Rooting Siding ❑Windvws ❑Insulation $ ❑Gutters/Covers ❑Entry Doors❑ .— ,. ❑Roofing ❑Si<ling ❑Windows ❑insulation $ ❑Gutters/Covers ❑Entry Doors ❑_ Minimum 25%Deposit of Contrvet Amount due upon execution of this contract. Total Contract Amount $ Z-[// Maine Purchasers may not delxidt more than one third of the Contract Amount. 7(O Customer as ecs that,immediately upon completion of the work for each Product,Customer vvi l execute a Completion Certificate (one for each Product as defined by an individual.Spec Sheet)and pay any balance duc. As applicable,each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein.at its discretion,if The Home Depot or its authorized service provider dete mines that it cannon peiforol its obligations due to a structural problem with the home,environmental hazards such as mold,ashcStos or lead paint,other safely concerns,pricing errors or because work required to complete the job was not included in the_Contract. Pavment Strtnrnarv: The Payment Summary#, .. included as part Of this Contract, sets forth the total Cnntracl amount and payments required for the deposits and final pavnrcnlS by product(as applicable). NOTICE TO CUSTOMER You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note: there is one Completion Certificate for each listed Product as domed by individual Spec.Sheets)before work on that Product is complete. In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus any other amounts set forth in this Agreement or allowed under applicable law. THE IIOM£DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HUMP: DEPOT FROM THE DEPOSIT PAYMNNT OR OTHER PAYMENTS MADE, WITHOUT LIMITING TIIE HOME DEPOT'S OTHER REAJEWES FOR RECOVERY OF SUCH AMOUNTS. Acce lance and Authorization! Customer agrees and understands that.this Agreement.is the entire agreement between Customer and The Houle Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,either oral or written,relating to said Products and installation.This Agreement cannot be assigned or amended except by a writing signed by Customer and The Horne Depot,Customer acknowledges and agrees that Customer has mad,understands,voluntarily accepts the cans of rind has received'a coliy of 0ds Agreemcnt. n (� Xtt4by ' Subm' edby: X 1 M Customer i�nature Date Sales Consultant's SignatureQ Date// X _ Telephone No. C3 Customer's Signature Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS (as applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DFLIVERIN'G WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE. SUPPLEMENT ATTACHND HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW iN CUSTOMER'S STATE,. . NO'.nM-ADDITIONA L TERMti AND CONDITLONS ARE.STATED ON THE Rr:VERSE SIDE AN[)ARE PART OF THIS CUnTRAt:l e-31-10 GSc WNW-BranchFle Yelltwv-Customer oF� r Town of Barnstable 3 7b ' �y d. * erm i t# Regulatory Services E.rpires 6 months jronr issue Barr ,. a sFtvstABt a. S Fee - v ,1 Thomas F. Geiler, Director Building Division - 3 Tom Perry, CBO, ,Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.bamstable.ma.us Office: 5 08-862-403 8 EXPRESS PERIYIIT APPLICATION - RESIDENTIAL ONLY 508-790-6230 Not Va1id tP11hout Red X-Press Imprint Map/parcel Number, d eZJ a / /}� VResiydential rAddress C7 25 NR , (/� J'f, S41,2� )1foil �Value of Work Minimum fee of$35.00 for work under$6000.00 Owner's Name & Address � ^ �,� Contractor's Name nio 6Se /? Tele hone Nu . P tuber SD -' �, �� Home Improvement Contractor License#(if applicable) Construction Supervisor's'License#(if applicable) 0077 0 orkman's Compensation Insurance Check one: ❑❑ I ama sole propribior T'.-PRESS PERMIT the Homeowner, I have Worker's Compensation Insurance J;JN Insurance Company Name /Uz%i/lif�/� ��j ;`L ` TOWN OF BARNS►ABLE r� Workman's Comp.Policy# O t� - C Copy of Insurance Compliance Certificate must accompany eac i permit. 'ermit Request(check box) ❑ Re-roof(hurricanenailed) (stripping old shingles) All construction debris will be taken to ❑ Re-roof(hurricane nailed)(not stripping: Going over existing layers of root) ❑ R side Replacement Windows/doors/sliders. U-Value 1 #of doors (maximum .35)#of window *Where required: Issuance of this permit does not exempt compliance with other town dcpartment regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License& Construction Supervisors License is required. NATURE: PFILESTORMSIbuiidingpermit formsiEXPRESS.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Ini%estigations 600 Iflashington Street Boston, MA 02111 �:,. iii iiS.i.gv^i%i 41 cu Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organizattiion/in-dividual): J J e e -1/1 Address: t�s lNj l wU ' Aft City/State/Zip:A k 4 Phone #: S0 Are you n employer? Check the appropriate box: Type of project(required): I.❑ m a employer with 4. ❑ I am a general contractor and I 6. ❑ N construction have hued the sub-contractors employees(full and/or part-time). 2." I am a sole proprietor or partner listed on the attached sheet. 7. Remodeling p ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. insurance) required.] 5. ❑ We are a corporation and its 10.❑ 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.❑ Other comp. insurance required.] o___.__-•-_ _ - -. 'c nforrnahon. ant thatcheela . Homeowners who s�rmt t-his af'fiaavit m icatmg ey areZdmg O work arid-then fiire dutsifie coritracto—r§—M—U5MbTfiiTy new-affidavirin-dicating such.- tContractors that check this box must attached an additional sheet showing the name of the subcontractors 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: V-e/'/YI/��( UJ�' ,�N� Co — Policy#or Self-ins. Lic.#: I P Expiration Date: (� � Job Site Address: � 0 I A/1/ City/State/Zip: , Attach a copy of the workers' compensation policy declaration page(showing the policy number and expira ion date). Failure to secure coverage as required under Section 25A of MGL c. i 52 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 hereby certi nder the pal a/z'd penalties of perjury that the information provided bovve is truand correct. — Signature:_ ` Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: r Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for thew employees. Pursuant to [his statute, an employee is defined as "...every person in the service of another under any contract of lure, 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 foregouig engaged in a joint enterprise, and including tlieelegal.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 ol'another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or hudding appurten'ant thereto sliall not because of such employment be deemed to be an employer." MGL chan'.er 152, §25C(6)also states that"every state or local licensing agency shall wiflihold the issuance or ren--:ral of a license or permit to operate a business or to construct buildings in the commonwealth for any ,ippiicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 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 compliance with the insurance requirements of this chapter have been presented io 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-contractor(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 affrdavit.may be submitted to the Department of Industrial . Accidents-foL_confirmation.of_insurance-coverage.insurance-coverage—Also-be.-sure.-to sign-and-date-the--affd-avit:- The-a€fdavit-should-- --- a-re owa that the applisatien-fe�the-pern-ut or--l-icense-is-being-fequested-,-not<-the-Hepartment 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. I 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 you7to 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 may be provided to the applicant as proof that a vaiid affidavit is on file for future permits or licenses. A new affidavit must be fiCed out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn 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, 6. please do not hesitate to give us a call. _ o t The Department's address, telephone and fax number: The Connnonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 11-22-06 Fax # 617-727-7749 www.mass.gov/dia The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1� 600 Washington Street +�t Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): DePO4- Address: g q5�- OL"e-e 5 F _cn+b City/State/Zip: (a K k, )' `3 e)3 3 y Phone #: b 5-7Are you an employer? Check the appropriate�Iam Type of project(required): 1 I am a employer with, 4. a general contractor and I 6. ❑remodeling onstIllction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ship and have no employees These sub-contractors have g, ❑ Demolition N working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.x required.] 5. ❑ We are a corporation and its 10.❑ Electrical Tepaits 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.❑ 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. TContractors 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. ✓r— C, Insurance Company Name: 5 kit Policy#or Self-ins. Lic. #: 1 to 3 �- Expiration Date: 1 J Job Site Address: City/State/Zip: .oa 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 hereby certify unde�thhe ains and penalties of perjury that the information provided above iss true and correct Signature: Phone#: Official use only. Do not write in this area, to be completed by city or town of j�ciaL City or Town: Permit/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#: a GATE IIJ�iJ�IDDYY`.') ' CORa CERTIFICATE OF LIABILITY INSURANCE 1 02/21/2011 THI�RTIFICATE 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). 1-404-995-3000 CONTACT PRODUCER .NAME:.-- Marsh USA, Inc. PHONE FAX-----_—_'.'_' EMAIL homedepot.certreques t@marsh.com ADDRESS._—_ ------- "'-' Two Alliance Center, 3560 Lenox Road, Suite 2400 INSURER� VER AFFORDINGCOAGE ----- Atlanta, GA 30326 --'-- -- �26387 Fax (212) 948-0902 INSURER A: Steadfast Ins Cc INSURED — — INSURERB: Zurich American Ins Co 16535 The Home Depot, Inc. New Ham shire Ins Co 23841 INSURERC: P — �^^----- Home Depot U.S.A., Inc. — 23817 2455 Paces Ferry Road NW INSURERO: Illinois Natl Ins Cc _— __— Building C-20 INSURERS: NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanta, GA 30339 _ INSURERF: Illinois Union Ins Co 279 — b0 COVERAGES CERTIFICATE NUMBER: 19834682 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 ADUL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MMIDDNYYY A GENERAL LIABILITY GL04887714-01 03/01/1 03/01/12 EACH OCCURRENCE S 9,000,000 X DAMAGE OR NTED S-1,000,OOD COMMERCIAL GENERAL LIABILITY PREMISES fEa occurrence CLAIMS-MADE El OCCUR MED_EXP(An one person) $EXCLUDED X LIMITS OF POLICY XS PERSONAL 8 ADV INJURY S 9,000,000 X OF SIR: $lM PER OCC GENERAL AGGREGATE S 9,000,000-- GEN'L AGGREGATE LIMIT APPLIES PER: , PRODUCTS.COMPIOPAGG S 9,000,000 X POLICY PRO. LOCJECT S B AUTOMOBILE LIABILITY BAP 2938863-08 3 O1 1 03 O1 12 COaBINeDISINGLELIMIT 1,000,000 X ANY AUTO- BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) S - AUTOS AUTOS PROPERTY DAMAGE S NON-OWNED Peraccident) HIRED AUTOS AUTOS — S X SIR AUTO P Y UMBRELLA LIAR OCCUR EACH OCCURRENCE H J EXCESS LIAR CLAIMS-MADE AGGREGATE S DED I I RETENTIONS I WC STATU- OTH- C WORKERS COMPENSATION WC06 03101/12 1967352 (AOS) 03/01/1 03/01/12 X AND EMPLOYERS'LIABILITY YIN D ANY PROPRIETORIPARTNERIEXECUTIVED WC061967354 (FL) 03/01/1 EL EACHACGDENT $ 1,000,000� OFFICER/MEMBER EXCLUDED? N NIA 0 EL DISEASE-EA EMPLOYE S 1,000,000 E (Mandatory in NH) WC061967353 (CA) 03/O1/1 —.-- If yes,describe under E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below C Workers Compensation WC061957355(KY,14 0 ,NY,WI, p3/O1/ 03/O1/1 F TX Employers XS Indemnity TNSC46244151 (TX) 03/01 1 03/01/l2 ccurrence/SIR 30M/1M E Workers Compensation WC1192378 (QSI) 03/01 03/01/12 IR 1M DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schadule,if more apace Is �irad) RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HOME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C-20 �— ATLANTA, GA 30339 USA ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD jfiero hd 19634682 office of Consumer.Affairs S t3asit►�(�eSatatios iiOfllE IMPROVE ONTRACTOR. T Registiatio 1 '. �� Expira &312012 S�AP�"1ert C ,h;e -.0me Depot -flame Sefv: DARREN DEMERS 2590 CUMBERtAND PARKWAY S ��—•�"� a?"��..;:�,.ut+�Cj333 t:aderxcremn' License or registration valid for individui use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza•Suite 5170 ;ard Boston—NIA 02116 i i Not valid without signature ERN Office of Consumer Affairs and usiness Regulation 10 Park Plaza- Suite 5170 Boston, Massachpsetts 02116 Home Improvement (;�j r:•actor Registration Reaishatio 3349 PTy Prt artnership hip 1/11/ 01Expira Tr# 207392 J &J Remodeling Joseph Duarte -"- 15 Fall St. -- Wareham, ma 02571 - Update Address and return card.Mark reason for change. Address Renewal ❑ Employment Lost Card )P"Al Q SOM-04104-0101210 Office of l mm s rs iaee RegulaFion License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration- .,.132349 Type: Office of Consumer Affairs and Business Regulation Explratlon: .f/t1/2013 Partnership 10 Park Plaza-Suite 5170 - Boston,MA 02116 filemodelingi: Joseph Duarte - 15 Fall St. : :. °•• 4� — Wareham,ma 0257f.. Undersecretary of without signature Massachusetts- Departn►cat or Public�Sarct% Board of Buildim-1 Rcl.;ulatiuns and Construction Supervisor License License: CS 70077 JOSEPH C DUARTE 15 FALL ST , WAREHAM,MA 02571 Expira j2rM/2012 —�^ T 7M (,an,fd.eiuncl. TO 3DVd Z9LGSGZ ES:tiZ IZOZ/ZO/tO ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(NWMDIYYYYI 03/23/2011 'PRODUCER 508.295.4440 FAX 508.295.S864 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Paul B. Sullivan Insurance Agency Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 2870 Cranberry Highway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0. Box 551 East Wareham, MA OZ538 INSURERS AFFORDING COVERAGE NAIL 8 INSURED ) & 7 Remo de !ng INSURtRA: Vermont Mutual Insurance Co. 26018 15 Wilson Way INSURER B: Middleborough, MA 02346 INSURERC: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH. POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF UJSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE MhVDDIYYYY DATE MIDDD. LIMITS GENERALLIA81LM BP11020SZO 03/22/2011 03/22/2012 EACH OCCURRENCE $ 1,000,0001 X COMMERCIAL GENERAL LIABILITY PREMISES(Eeoccurrence) $ S0100 CLAIMS MADE rXj OCCUR MED EXP(Anyone parson) $ S 100 01 A � PERSONAL 6 ADV INJURY S .1,000,00 GENERAL AGGREGATE S 2' 000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S 2 0001000 POLICY jEa LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANC AUTO (Ea acGdentj $ ALL OWNED AUTOS BODILY INJURY SZHEDULEDAUTOS (Pe,Pawl $ HIRED AUTOS BODILY INJURY NONOWNEDAUTOS (Perec°den') $ PROPERTY DAMAGE $ (Per accident.) GARAGE UAWUITY AUTO ONLY-EA ACCIDENT S ANC AUTO OTHER THAN EA ACC $' li AUTO ONLY: AGG $ EXCESS/UMBRELLA LMILRY EACH OCCURRENCE S OCCUR ❑CLAIMS MADE AGGREGAT_ $ S DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILn'Y TORV IN LIMITS ER ANY PROPRIETOR/PARTNEPJEXECUTIVEY tL EACH ACCIDENT S OFFICER/NEMBER EXCLUDED? (Mandatory in NMI E.L.DISEASE-EA EMPLOYE S _ 9;as,describe under SPECIAL PROVfS10NS below E.L.DISEASE-POLICY LIMIT '$ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS HD At Home Services, Inc and the Hoare Depot are included as additional insureds ith respects to general liability linsurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN THD At Home Services, Inc. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURETODO90SHALL 3200 Cobb Gal l eri a Parkway IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR Suite 200 REPRESENTATIVES. Atlanta, GA 30339 AUTHORIZED REPRESENTATIVE ,o Edward Sullivan/MARIE ACORD 25(2009I01) FAX: S08.7S6.8823 01988.2009 ACORD CORPORATION. All.rights reserved.'' The ACORD name and logo are registered marks of ACORD Jun 29 11 07: 46p Michael Bedard 1 -401-246-2868 p. l FROM : DAN-MELLO FAX NO. : 7742020232 Jun. 27 2811 03:32PM rl � ,r lIOMF.INIYROVENIEN9'CONTRACT' r1 PLI-ASE Rl AD THIS i Sold,Furti l and Installed by: Branch Nanie: /3nstnn Date; THU At-Home Services,Inc. dlbra The biome Depot At-Fiume Services 345A Grcunwood Street,Unit 2,WOI'Cesler,MA 01607 Tull Free(900)697-5192;flax(508)756-8823 Branch Number:31 Federal ID 4 75-2698460;ME lie It C 02439:RI Cons Lie#16427 CT uc U mcwr�5522;1v1.4 Mine Improvement Contractor Reg.4 t2tiR93 JnstalEtltlon Address: ,J,fj�yryK'� frJ�Q City 'Slate Zip Purelinsrr(s): Work Phone r Home Yhorte Cell Phone: Hume Address: (If different from Inst dlnion mil s) City L E-mull Addresic(to receive project communications and Home i3epo,updates): State dip_ ❑I DO Myl'wish to receive any markering emails from The Home Depot Proieci Information: Undersigned("Customer"),the owners of the property lectttetl at due above installation address,agrees to buy, and THD At-Home Services,Inc.{"The Home Depot")agrees to fu aN mate rnish,deliver and arrange for the inswittLion('Installation 1)o° rials described on the below and on the referenced Spee Sheet(s),all of which are incorporated into this Contract by this reference,along with any applicable State Supplement a-td Payment Summary attached hereto and any Change Orders fcolleetively, "C ontrc ): Job It: narenao x<rtr.ni Yr ens: Sec Shect s 8: Project Amount �/ ORuoGng Siding Windows p Insulation S (j a y9 1]Guttcn!Covers Qpntn flours ❑ RoafinS Siding Windows rnsctation (p cop ❑Cutters/Covers)]EntryDoors ❑ V R x I l is Siding ❑WJndow" ❑Insulation — v []Cutters/Covers 0Emry Doors❑ 5 RZf-1q Siding ❑Windows ❑InsuLnion ❑tuners/Covers []Entry Doors p_ $ Miniototu 2590 Deport of Contract Ainoant doe upon execution of this eontmc=r-t-I fablePurdtasersnrry not tlgrnilmotle than one-third ulCAutrtct ctAmouut $Amutrn 7 7(p Ta Cuslotnet 1-9mcs that,immediately upon completion of the work fur each Product,Customer Brill execute a Cnmplciion Certificate (one for each Product as derined by an individual Spec Sheet)and pay any balance due. As applicable,each Cusrotner tinder this Contract agiCes to be jointly and severally obligated and lii!ble her,,undcr. The Home Depot reservcs the right to issue a Change Order oi'terminnre this Contract ar any individual Product(s)includedi herein,at its disererinn,if The Home Depot or its authorized servirx provider deteamincs that it.cannot perfernt its obligations due to a structural prublcin with the Koine,eltvironmcntal hazards such as mold,ashestos or lean paint,other safety Concerts,pricing errors or because work required to complete the job was not Included in the Contract/ Payment Summary:and The Payment d for d,ry It ,�m�Cp included its part of this Contntct, seeS ford, the tuwl Contract amount and payments reyuircd for the deposit,and final payments by Product(as applicable). NOTICE You are entitled to a completely oiled-in copy of the Cnnh't!1 at the time yo u si;;n, Un matt sign a Cumpletion Certificate('note: there is nne Completion COITifl6nte For each listed Product as derined by individual Spec.Sheets)before work on that P:n a t, is complete. In the event or termination of this Contract,Customer agrees to pay The Home Dic" epot the costs of materials labor,expenses al ounts l provided n this Agreement orll Depot,ed unde r applicable lawrtt7ider HE IIpryI,F tKPO'Y'NL4Y�i'tTHHOI.e date of ter.ciiinaLion.D AC\IOUV'I'S OS4ED TO TI E >IOhiM DEPOT FROM THE DEPOSIT FAI'MFNT OR OTHER PA"IENTS MADCS, INITIJOU'r t.fNHTJNG TILE HOME DEPOT'S OTHER RENIF I ES FOR RECOVERY OF SUCH AMOUNTS, At ceotnnee and Antltoriirt ! Customer agr^,.es and understands that this Agreement.is the entire agreement hctween Customer and The Hume flepot with rt+pard to the ProduCrs and Ins(allation services and superscdos all prior discussions,nd agreements,cilh r oral or written,relating to said Products and Installation.This Agreement cannot be as&F.-ted or amcndW except by a writing signed by Customer and'The Horne,Depot.Custorril acknowledges and ao ees that Customer terms of and has rel.cived a uiliy Oftlu5 Agreetncnt. h.-Li read,nndctst nods,vuluulnrily neeeptc the d by: Sub ed by: Customer' -nature Sales Consultant's Signature D;tie" Telephone No... Customer's Signature Doi- Sales Consultant License No. CANCELLATION: CUSTOMER MAY CA)\CF,J. THIS ;'es applicnh[c} AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DEi.IVERING WRiTTEN NOTICE TO THE HOMN; DEPOT BY MIDNIGHT ON THE THIRD) BUSINESS DAY AFTER SIGNING TI3IS A.GREMliIENT. THE STATE. SUPPLEMENT ATTACHED HERETO CONTAiN'S A FORM TO USE ff ONE IS SPECIFICALLY PRESCRIBED BY LAW iN CUSTOMER'S STATE NOTTt:S:AOUTTIONAt,TERIM AND CONDITIONS ARt:STA I ON TRY ReVRPM SIDE AND A RE PART OF THIS CONTRACT "Mo CSC Whito-Branch File Yellow-Customer Town of Barnstable *Permit# �060 Expires 6 mo the fron,!Js date Regulatory Services Fee 01D Pel?tWirrhomas F.Geiler,Director APR(Y 4 2008 Building Division TOWN OF 13 Tom Perry,CBO, Building Commissioner A )tV pCE 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-79.0-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number n o o oP Property Address - J �Oj *-esidential Value of Work Q U Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Y LJ) w Contractor's Name -L� CQYt Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) [�Workman's Compensation Insurance Ched one: ❑ I am a sole proprietor ❑ I am the Homeowner have Worker's Compensation Insurance n Insurance Company Name 6— C) / Workman's Comp.Policy# 0 5 J O L 3 5 6 o Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) aRe-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders: 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. A copy of the Home Improvement Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise061306 i The Commonwealth of Massachusetts Department of Industrial Accidents F Office of Investigations ' 600 Washington Street 0 Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): RF}set (��-(I0/l)�T IZ.t.(_G' C''A) Address: _PQ 26)5� / Q y- City/State/Zip: �°y- _ PM7 OZ L3_�Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1.0I 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. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. employees and have workers' Y P h'• 9. ❑ Building addition [No workers' comp. insurance comp. insurance. 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.KRoof 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. tContractors 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. 1 ll Insurance Company Name: I7 F_ 7-7'�� y / p Policy#or Self-ins. Lic.#. D g� (�L S 550� Expiration Date: � "C� ' Q O/ Job Site Address: City/State/Zip: R0•(-4 tc� 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 hereby certi er the ains and (ties of perjury that the information provided above istrue and correct Si ature: Date: Phone#: 5 Z a `o� �oZ Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ..:................ .::... l>s ® fry%r•F..,il.:::>::or:;':t�:::::::::.r:•r:-r:�:�;::;.;:::: .... �.. ....� .. .:.............:•:.::.:.�:::::::•::•::.:�::::;:�r:�>:-;:;t;•::;•:•rr:';:�:-:-:>:�:>r:;;:::�: DATE r:- PRODUCER TFIIS CERTIFICATE IS ISSUED AS A MATTOR OF INFORMATION WISE & pUINN INS AGCY HOLDER�DTHISNCERTIFIC4TEIDOES MOT NO 9 PLEASANT ST OR 44 ALTER THE COVERAGE AFFORDED BY TPIE POLICIE BELOW. BROCKTON MA 02301 COMPANIES AFFORDING COVERAGE 24WCB COMPANY ' INSURED A HARTFORD UNDERWRITERS COMPANY INSURANCE COMPANY FRASER CONSTRUCTION LLC B PO BOX 1845 COTUIT MA 02635 COMPANY C COMPANY THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LI r.,.,...,.......:.::.«,...N"_:.:r:•rx.:r;:;<;: INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONT RACT OR OTHEFlSSUED TO THE RED DOCUMENT WITH RESPECT FOR T TO WHICH THIS +l 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. Co E OF INSURANCE LTR TYP POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION GENERAL LIaBIury DATE(MMWIAYV) DATE(MMIDDIVV) LIMITS • COMMERCIAL GENERAL LIABILITY GENERAL AGGREGATE $ CLAIMS MADE a OCCUR. PRODUCTS-COMP/OP AGG. OWNER'S&CONTRACTOR'S PROT. PERSONAL 8}ADV.INJURY $ EACH OCCURRENCE $ FIRE DAMAGE(Any one Nre) $ AUTOMOBILE LIABILITY MED.EXPENSE(Any one person) $ ANY AUTO COMBINED SINGLE ALL OWNED AUTOS LIMIT $ SCHEDULED AUTOS BODILY INJURY HIRED AUTOS (Per Person) $ NON-OWNED AUTOS BODILY INJURY (Per Accident) $ GARAGE LIABILITYPROPERTY DAMAGE $ ANY AUTO AUTO ONLY-EA,OCCIDENT $ OTHER THAN AUTO ONLY: EACH ACCIDENT $ EXCESS LIABILITY AGGREGATE $ UMBRELLA FORM EACH OCCURRENCE $ OTHER THAN UMBRELLA FORM AGGREGATE $ WORKER'S COMPENSATION AND A EMPLOYER'S LUUIIUITV (6S60UB-085OL35-5-07) 09-26-07 09-26-08 STATUTORY LIMITS THE PROPRIE oR1 ... PARTNERS/EXECUTIVE INCL EACH ACCIDENT $ OFFICERS ARE: X EXCL DISEASE-POUCY UMIT' OTHER DISEASE-EACH EMPLOYEE $ 500 000 I DESCRIPTION OF OPERATIONS/LOCATIONSNENICLES/RESTRICTIONS/SPECIAL ITEMS � I THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE H I ..: :,..:.....:::r�:::.>z:;:::-:-:::::r;:.:::.:•:-;:-;r:.:.�::.�:.�.::.:::.�:::::::.::..:.::.�.::::::.�:.�:........... OLD zr>:..:8 #br`.�I. �'� !8�1=�:::s::>:<::<z:::;:>:.r:<:>::r:<.;:.r;:.r:�:<:»::>:rr:.rr:.;r:.r;:;.:�::::::.�:::...............::::::......:.:.:.:........... ER AFFECTING .....:.:....:.:,............... TING WORKERS _...:::.:::::::::::::;;:-;rr;:.r-:::::,.�::.r:.:.:�:.r:.:::::::.:�:::r•::.::�:r:.rr:.;:.�:::::.�:::.r>:.:::.�::::;:::.;-:::::::::.r:.:.rrr:.r:.r:;.::.�.�::::.:.:;;:::::.�:.;.:.:;.r:.�..... ... MP CO COVERAGE I. .............:::::::..:::.�:.;:•:;•rr:.r:•;1��. '.U'.Q� r:.r:.:.rrr:.:.:::r;:.r:.:�s:.r:.r:.;:.r>rr:.r::.:.:.rrr:.r:::.:�:.r:.>:.:.::.;:�r•rr:;.r:�:.:.;:.r:.rr::.:.rrrr>:.:.:.r;:.:::r:r:.:;.:.:.:.:.r>;:.r; SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE.CANCELLED BEFORE THE I EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ERA EN®FAVOR TO MAIL SER ENTERPRISES LLC 10 DAYS WRITTEN RIO�CETOTHECEpIIFICATEHOLDERNAMEDTOTHE PO BOX 1845 LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR !COTU I T MA 02635 LIABILITV OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTA i ® 0""U It One Ashburton at1®� �d Standards r. 130stoll � a ® 13®1 B&sachusetts 02108 a°a,tor Aegigtratt®ll FRA`9ER CONS Regis�tton: 112536 1 DEAN FRASER I�[1CT1ON Co. Type: DBA P.®, E30Xfl�1A845 Siration: 3/23/2009 � 12T92, C®TU'T, AL4 02835 DP8-Cqy d8 60A't'0.5/Ofi-PCgggU •- - l UpdateAddress -guard®1?� — —_-- - —.— Addr� CI ew�p�a cam,Alark s�®n$br cy� g HOME 9ildp ��18latf®ns and Emplos'�t � ]Lost Card Eh/IENg CONTRACTOR �MBe or agjefttlan: 72538 bell®a� �� for Ja� �ro�ttain: 09 =Pfmtfoffi date. $f f® use onlgr Ta# ®�o��g sand a�etmm to; ` Ibe: DES t b latfons aatd FRASER 12i�p Boston, 1Rg81�1��g�e$�F.$dBg D� CONSTRUC710 GO.� ja ^®�1®� 4556 RT 28 COTUIT,MA o2635 - N®t Wkhoat if�t� I Y ORLM022 Fraser Construction, LL CONSTRUCTION ROOFING � � � P.O. Box 1845, Cotuit MA. 02635 ' ING Email: fraser construction cr,yerizon.net SPECIALISTS -o- -A www.fraserroofing.com 508-428-2292 FAX 1-508-428-0123 RE-ROOFING PROPOSAL DATE: March 17, 2008 NAME: Vincent Longto PHONE: 508-420-4381 MAIL ADDRESS: same JOB ADDRESS: 68 Tabibark Rd. Marstons Mills, MA 02648 Th)i ,s ank FRASER CONSTRUCTION hereby proposes to perform the following services in a neat and professional like manner and in accordance with the manufacturer's specifications and local building code. -Remove and Haul away all of the old roofing material -Re-nail all plywood sheathing as needed. Supply and Install - CERTAINTEED LANDMARK /WOODSCAPE AR 30: 30 - Year Warranty, 5 year Sure Start Protection, CLASS A FIRE RATED, ALGAE Resistant, Extra Heavy Weight, Self Sealing, Multi- Layered, Architectural Style, Fiberglass Based Asphalt Shingle with New England's Exclusive COPPER/CERAMIC Stones with a Full 10 Year Warranty against ALGAE Containment. 5 year 70 mph wind- resistance warranty or 5 year 80 mph wind-resistance warranty available with six nails in common bond area, for an additional cost. See actual warranty for specific details and limitations. I � Color: �t1 CG.n-A ► C�j"\�1 J e-, PRICE- $3,800 Initial' OPTION: Vent panels in knee wall roof if needed PRICE- $200 Initial\ Supply & Install- CertainTeed Winter - Guard: (ice & water shield) Waterproof Underlayment System (3ft. on eves and valleys, 18" on rakes, walls, and skylights) Supply & Install- Roofer's Select Underlayment Paper (as recommended by CertainTeed) Supply & Install - Hick's Ventilated Drip Edge or 8" Aluminum Drip Edge Supply & Install -Aluminum & Neoprene Soil Pipe Flashing Supply & Install-Air Vent Ridge Vent (as recommended by CertainTeed) -1 Clean & Remove - Debris from work area daily. X4 Star Warranty Upgrade will be applied if proposal is signed and returned within 10 days. (see enclosed brochure) 2% Discount if paid by check immediately upon completion NO MONEY DOWN-NO Payment at the start or part way thru Payments accepted are: CASH- CHECK- MASTERCARD -VISA-AMERICAN EXPRESS *Any payments not made within 30 days of completion will be charged 1.5%for every 30 days the payment is late. Possible Extra-After the shingles are removed from the roof, we will lift one sheet of plywood to make sure that the insulation is not up against the plywood sheathing preventing ventilation from the eaves to the ridge. If it is, ventilation panels will be installed by; removing the plywood sheathing, installing the panels, turning the plywood over and then re-installing the plywood. If needed, this would be charged for as an extra at the rate of$4.00 per panel including Materials 8v Labor. There are 6 Panels per sheet of plywood. Possible Extra -Any rotted or otherwise deteriorated trim boards, plywood sheathing, lead flashing, or other carpentry needing replacement will be done and charged for as an extra at the rate of$50.00 per hour, plus materials, plus 20% overhead mark-up on total extras. FRASER CONSTRUCTION Warranties the labor for 12 years FRASER CONSTRUCTION Warranties the shingles against Blow-Offs for 10 years. CERTAINTEED Warranties the shingles and labor 100% through the Sure Start Warranty duration. CERTAINTEED Warranties the shingles to be ALGAE resistant for the duration of the Sure Start Warranty depending on the shingle that was purchased. Any deviation or alteration from above specification will be executed upon written orders and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays are beyond our control. Owner should carry fire, tornado and other necessary insurance upon the above work. We, if not accepted within thirty days may withdraw this proposal. FRASER CONSTRUCTION, LLC: Carries Workman's Compensation and Public Liability Insurance on the above work, certificate available upon request. DATE OF ACCEPTANCE: b 10 0 Homeowner Fraser C uc ion, LLC TOWN OF BARNSTABLE 33178 Permit No. . BUILDING DEPARTMENT TOWN OFFICE BUILDING Cash .Y� �9 ,679• N/A HYANNIS,MASS.02601 Bond LY CERTIFICATE OF USE AND OCCUPANCY Issued to Greenbrier Corp. Address Lot #14 4, 68 Tanbark Road Marstons Mills, Mass. USE GROUP FIRE GRADING OCCUPANCY LOAD THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND.IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. August 30, 19 89 Buildin nspector � a WN OF.....[• .' BUILDING ��F�E`R�11�111�T TC!WN OF BARNSTABLE, MASSACHUSETTS A=100-021 t DATE All[ ]G '10 , 19 R9 PERMIT NOM #13178 APPLICANT ChJf1E3Y - ADDRESS_ Rplow Q()1 397 (NO.) (STREET) (CONTR'S LICENSE) PERMIT T0. R1,1 l r� 1� p NUMBER OF w lung_(�_� STORY .Ciro FBnlj.1 � T��>•pl l i nR DWELLING UNITS ,CTYPE OF IMPROVEMENT) N0. (PROPOSED SE) AT (LOCATION) T.Ai- j144, FiR Tanhark Rnad , AQaref•nne Mi 1 1 ZONING 8(STREET) DISTRICT_ '' BETWEEN AND (CROSS STREET) (CROSS STREET) SUBDIVISION LOT . LOT BLOCK SIZE BUILDING IS TO BE FT. WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IJJ CONSTRUCTION TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION (TYPE) REMARKS: _- Sewage 'AREA OR VOLUME - 768 SU ft. $ 1igt5gs 45,000.QOrEEMIT 61.50 aESTIMATED COST (CUBIC/SQUARE FEET) OWNER Grppnhri pr C'nr ADDRESS D_ n_ RnY I,l 0� BUILDING DEPT. BY 1 '�.f:•,:t 71z.'TF'�� '' eYtl�r;:}��!,3 ;, r .,t, , , , FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSVANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF THREE CALL APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE INSPECTIONS REQUIRED FOR CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR ALL CONSTRUCTION WORK: ELECTRICAL, PLUMBING AND I. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS. 2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL MEMBERS(READY TO 3. FINAL INSPECTION BEEFOREFORE FINAL INSPECTION HAS BEEN MADE. OCCUPANCY. , POST THIS CARD SO IT IS VISIBLE FROM STREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 •_ 1 A�� d �J � 1 3 HEATING INSPECTION APPROVALS ENGIN ERING DEP RTMENT J a 1 1 OTHER BOARD OF HEALTH Al v/f WORK SHALL NOT PROCEED UNTIL THE INSPEC- PERMIT W!L L BECOME NULL AND VOID IF CONSTRUCTION INSPECTIONS INDICATED ON THIS CARD CAN BE TOR HAS APPROVED THE VARIODUS STAGES OF WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE I ARRANGED FOR BY TELEPHONE OR WRITTEN CONSTRUCTION. PERMIT iS ISSUED AS NOTED ABOVE. NOTIFICATION. � l - f • , o P o�v.^"�^�` l l�Oc -AI(e((ov Assessor's office (1st floor): _ �h c�—•: :tea V THE L;� .SYSTI�fc `.. �` Assessor's map and lot number . .... .. . ...... .... ........... , Board of Health (3rd floor): �. �'dALLEO IN COM Sewage Permit number .... ....df/!.-.......... / 9 �NITH 11TLE Z B�9?ADLL, Engineering Department (3rd floor): O� �J� , / ENVIRONMENTAL CO House number .............................................................�a... � TOWN REGULATIO ,,• 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 APPLICATION FOR PERMIT TO ......(7,0W.5TKUC.T .................................................................. . .......................... TYPE OF CONSTRUCTION ....... R 6z 6 ................................................19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ........!L�.............../`! �/✓/S/S7KlL. ,L.��✓ic s'O�✓S (,(1CLS............................ ............../..................................... .�. ......................... .. .................. ProposedUse � 51 n(�L� ............. ......................................................... ........................................................ Zoning District ................. .. ...!....I..:.............................................il, ..Fire District ........��..1. .. . �................................................... (t�FE�I3 z1 E� e01Z a�C 51 0 Name of Owner Address A,<� Name of Builder .....5�..................'.............:........................Address S� f Nameof Architect ...................................................................Address .................................................................................... Number of Rooms i Foundation .. .........................................E......................... C io�s /S�u1NCrC crS— C !45 cuP CT !; Exierior ........... ..... ............................................................:.....Roofing FloorsS ��'dc C/9 b�4 N y C ...Interior ...... r HeatingW-4....... y ........... .!Q:S...................................Plumbing ...................�:9zN................................................... Fireplace ....../ .................................::...................:.............Approximate Cost ................................................ . ................. Area .v........................ agram of Lot and Building with Dimensions Fee ... >.. .4 ................... ' v n/ OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the ,own of Barnstable regarding the above construction. Name ... ............................ .............................................. Construction Supervisor's License .................�.............. GREENBRIER CORP. , No :33178... Permit for Az...Story Single„Fam,ily„Dwel,ling,,,,,,,,,,. Location ...Lot...#14.4.........6$...T4xjb.a r:k...Road ..................... ...................... ; Owner. ... reenbrier... Qr,p,*,,,,,,,,,,,,,,,,,,,,,, Type of Construction .....k'.Xame........................ . h ... . .... ................... ....................................... Plot ........................ Lot .......... .................. m L Permit Granted .,,,August 30, 19 89 Date'of Inspection .....:.............//.................19 Date Completed .... .. ........... .19 s 4 r= S• 7 i a,�.. `� ;.� y s ,.^�. ..� r yi �' �,`�'z:cn.�'tc�v ; e�/��• , Assessor's office .(lst floor): Assessor's map and lot number -��a........'. .. °~.d ', poi THE Toy . /........... Board of Health (3rd floor): 11 G fO�Q ♦� Sewage Permit number .....If .:..dl.:...... .//. k.'.�-....J �/ f i Baaa9?sDLE, Engineering Department (3rd° floor): % moo N 9 ♦0 �- 6 s Housenumber ................................................................. ...... `�o raY a. 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 OUILDING . INSPECTOR APPLICATION FOR PERMIT TO ..,...(,6^`•] rfeUC1 /)Wt-ccfn•(G ........................................................................................................ TYPE OF CONSTRUCTION ........S:cti G C c. ............616. �/z'/�•KC :...a. ..... .. ..........6o........................................................ is $9 ...................... .................... ....19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies- for a permit according to the following information: Location 4j/ r %�,J�i4�r-C �oAi� �Cl�.c s9(lws MF� .... (s.......... . ...................�. . ....................... ............ .. ................................. Proposed Use .:........... ZoningDistrict ........................................................................Fire District .............................................................................. Name of Owner ........!` �O.. G, ri''��t •�/G ..............Address ..:............................. I ' Name of Builder ......5�.... .[ ..........................................Address ............... .................................................................... Nameof Architect ..........................................................:.......Address ................................................,. Number of Rooms Foundation �.L.'.�Z. ........0 4-v ( k-(;rC .................................................................. .................. i Exterior C/ s r�/�° A G-[ C C t ))A>l �S N,�c r ..........�....C.:.. ..........................................................Roofing .................................................................................... Floors C .!z. .':.....A.!!-1 & -,L ...............................Interior .................................:.................................................. Heof n i lrrl - g q:::..... :...:..�l.A:�... Plumbing / $r9 5 C d'd ¢(} . Fireplace .......... ....�4...................................................................Approximate Cost ...................:.! t° ....................................... Area .......................................... Diagram of Lot and Building with Dimensions Fee C i i i 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. Name ... ............................:............................................... 17 1, r Construction Supervisor's License .................................... GREENBRIER CORP. - A=100-021 No 33178 Permit for .A1 StorX............. Single Family..Dwellin� Location .Lot ....... 8...Tanbark Road Marston. Mills Owner Greenbrier...Corp.,........................ Type of Construction Frame......... ............................................................................... Plot ............................ Lot ................................ Permit Granted ........August 30� „ 19 89 Date of Inspection .....................................19 Date Completed ......................................19 J The Town of Barnstable �t�+e Permit Massachusetts Date JFMABM � -,�%�7-9� BAKAM SOLID FUEL STOVE PERMIT � Fee d This constitutes an official stove permit after inspection and approval by the buil ' g insp 1 39 �30� //" 0. Owner `� J l Telephone no. U 3� Address of Property- Village tM c,,, d�-� Location and Stove Type I-ADO0d— _ �� ` n� ��Uhl Date: %0'3`%�'5?E —� Building Inspector The solid fuel burning stove at the above locatior, pass inspection ►,It,,,,,.,�,. t SHEET 7 OF 7 10M a , MARSTONS MILLS LOT 130 +un s a ,OT 1' �t`9 LOCATION MAP f 1' lot lil fit \\ LOT 12a OT 2 eta I tM IF db \ �•1 / ` Tom` i \ •�{�.1_—toTi2.7. LOT 31 IF VIM I�I LOT 137 . �y\� r LOT 124-''-' 8 LOT 106 ' 101 y~� At� '--1 P / " '�► j 1 LOT 123 I- LOT 128 I a4e \ t0.fN s ' I X/ I W I y ' ��' /1. / X 1�- t' ►•b `i I �' LOT 13 / \\ LOT 149 *•' I�1M - t \ Well III, i �a LOT 136lei sr 4-0 11 LOT 134 1 yf t l y �1 - ��/ S LOT 12z ` 1 1 LOrr 1: Y , �_ \� LOT 1 *Ala21 a�rA I ea LOT 107 {' LOT 14e \ ,roe er }' ° I �. r A• T 410 +�R� ` •y a X01" J .GkOT 1447% ` 1\�� .. y i1 � � i'�� .� �� LOT 119 F / >. hs 1r r. lei V`r- .''\ toeto s I \� . 1klOo ` a 34 ,oew s Y' LOT 117 LOTA43\\ It '�•�` tr�+me.er / \V' x!a 1tz s V, r I.Sic 60NW-T 7A or-l "K- Sc,t. up&* A%4b .l1'43 � \� ,i• LOT 11S �• r : �_ -Tleeso,.wTwa 1 1 LOT LOT A'' ',(aa/e I "`�� '" to700! �° e L,us fftiG T 7A oI 7 �� •Ll6iNID i 1 �^ � •' � `j �� ? /�IAt �� r 15,E y \`� t0.� 1�1 ,� \. \ •' r LOT 116 i 6 LOT 11b �� \• "4l , v asee fop I i t Ir 7) LOT 111 �qis 'L 4' LO 114 a I a t4 3 111 29 88 FINAL BLDG. AND SEPTIC C LOCATIONS PAL ' Ir �Yp I t 1I/s/sa BUILDING LOCATION PLAN DON 1 10 2 88 INITIAL IS ELK NO. DATE DESCRIPTI0 BY \\\ I•I °�� `�1 �, BUILDING LOCATION PLAN �- MARSTONS MILLS WOODLANDS LOT tog +°: °•'_ I BARNSTABLE, MASS CHUSETTS WOODLANDS ASSOCIATES US , \ \ SCALE: 1" = 50' JOB NO. 1338/wo-+O ✓• �4r� °o o so too t A. 1 LM, EIDMI do WAGNER Mocufb INC. ol® ulsa��s� norm um u 88Y HEST Mm 37xw CENTERV= KA 02632 '