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HomeMy WebLinkAbout0011 CARLSON LANE / Ca-r SD1� LAn e UPC 12543 a �; No. 3LOR Hu$i�NGS. MN Application number,,✓....�. �(Y,- . . d '1, Date Issued........7) ........0 " ................................. 1ARiVsrAgLr, MAM JUL 24 2019 �Bp a6g9. `0� Building Inspectors Initials....... .......................... `�Fo►��° TOWN OEbARNS-FABLE Map/Parcel.........1:3.3....�:3 0........................... TOWN OF BARNSTABLE 3Jou EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: NUMBER STREET VILLAGE Owner's Name: K gl d 4 c.1/,l�d(o UX Phone Number 5 oft-?,C Z _!T k 7 Email Address: A�m(ela,,x 5 e 50,.A.cam-. Cell Phone Number Project cost$ ( ti 7 6 — Check one Residential ✓ Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: See A- a ka C& (-a, Date: TYPE OF WORK ❑ Siding [2 Windows (no header change)#' ( ❑ Insulation/weatherization ❑ Doors (no header change)# Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to %,J a-s4 e- t,�., CONTRACTOR'S INFORMATION Contractor's name Aa&4 ,1 US A Home Improvement Contractors Registration(if applicable)# 11 Z 7 S (attach copy) Construction Supervisor's License# (attach copy) Email of Contractor �2 S Cp 5L141 C CP''' Phone number 4"o/- 7 3`7,9 ALL PROPERTIES THAT HAVE STRUCTURE OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS 1N A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. i APPLICATION NUMBER............................................................ i *For Tents Orly* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides? Yes No (if yes please attach floor plan with exits marked) Dimensions of each Tent X X 3 X Additional tent dimensions can be attached on a separate piece of paper. Check one:this event is a:for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side. HOMEOWNER'S LICENSE EX M[PTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date /APPLICANT'S SIGNATURE Signature Date 7-Z N -! 1 All permit applicatio are subject to a building official's approval prior to issuance. i r' Home Improvement Agreement: Pagel Home Depot License #'s - For the most current listing www.Homedepot.com/LicenseNumbers MA: 107774, 112785 Janice Campbell Salesperson Name: Registration No. (if applicable): Home Depot U.S.A., Inc. ("Home Depot") or Service Provider named below will furnish, install and/ or service the equipment listed below at the price, terms and conditions as outlined on this form. Ledoux Kenneth New England South 1-M703UW9 Customer Last Name Customer First Name Store #/ Branch Name Customer Lead/ PO# 11 Carlson Lane West Barnstable I MA 7 02668 Customer Address City State Zip (508) 362-9874 kenledoux56@gmail.com Home Phone# Work Phone# Cell Phone# Customer Email Address NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 908 Boston Turnpike Unit 1 Shrewsbury MA 01545 Address City State Zip Or Email: customercancellationnortheast@homedepot.com Service Provider Email Address BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BEL.OW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE R RIGH CANCEL. Acknowledged by: 06/05/2019 Customer's Signature Date Contract Price and Payment Schedule : Payment of the Contract Price is due upon signing unless a different payment schedule is required by law, specified below or in a payment addendum. Contract Price: $ 11576.00 Includes all applicable taxes. Excludes finance charges.* Sales Tax: $ 10.00 (If applicable) *Maximum deposit ONLY applicable in MD, MA, ME(33%), NJ, Wl(99%) Dep. 125.0 7 % Deposit Amount $ 1394 Remaining Balance $ 11182.00 The Home Depot-2455 Paces Ferry Road, N.W. Bldg.B-3,Atlara,Georgia 30339-Customer Care: 1-800-466-3337 4601`I HDE Customer Agreement(24 Jul.18) v 0.1.8 Home Improvement Agreement: Page2 Finance Charges: *Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement, to which The Home Depot is NOT a party, and will be in addition to Customer's payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service Provider may collect Customer's payment(s) made payable to The Home Depot. Insurance proceeds will will not be used to pay some or all of the total amount of sale. Description of Work to be Performed: Installation of 1windows A more detailed description of the work to be performed is included In the section entitled Scope o Work which appears on page 0 of this Agreement. Anticipated Delivery Date/Installation Schedule Approximate Start Date: 07/31/2019 Approximate Finish Date: 08/28/2019 All dates are approximate and subject to change based on unforeseen events including inclement weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if applicable. Electronic Records Authorization: You are entitled to a paper copy of this Agreement if you choose. If you consent to an e-mailed copy, your consent applies to this Agreement and all subsequent documents and written communications related to this agreement. By contacting your Service Provider, you may update your email address, withdraw your consent, or obtain a paper copy of the Agreement or related documents at no charge. By providing your consent and verifying your email address above, you confirm that you have access to a computer that can receive and open emalls and PDF documents. B niti this paragraph, I consent to receive only electronic records related to this transaction. Initial Acceptance and Authorization: By signing below, you authorize Home Depot to (a) arrange for Service Provider to perform Installation and/or (b) order and arrange for the delivery of special order merchandise, including special order merchandise that may be custom made, as specified in this Agreement. Do not sign.if blank or incomplete. (Service Provider's/permitting information may need to be provided to You later.) By signing, you acknowledge that you have read, understand, and accept this Agreement in its entirety, including the General Terms and Conditions and State Supplement, if any. You further acknowledge receiving a complete copy of ent. Keep it to protect your legal rights. X 06/05/2019 1 The Home Depot om Signat Date Service Provider Name xF 106/05/2019 908 Boston Turnpike Unit 1 Co-Signer (if tpVlicaVe Date Service Provider Address X 06/05/2019 Shrewsbury MA 01545 Signature On Be of H D of Date City State Zip R-1-073-13-00016 Service Pro­iM4 P lone Number x Service Provider License Number The Home Depot-2455 Paces Ferry Road, N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1-800-466-3337 460FI HDE Customer Agreement(24 Jul.18) v 01 8 r i e 'd6ninwoweatth of Massuhus2ets 00 Q' - bivision otprotP.$61OR8!LtSgnSUPQ Sfii��t�Ip &oars of Building 6teiiu1a4ions and stanc9ae}�s rOF s4ri;, ggc�isor 19 commissioner CA- e The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia '"Porkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PEPMT nNG AUTHORITY. Applicant Information Please Print Leeibly Name'(Btuiness/Orgmization/Individual): ��,�,,� (�/ ,n n e- Address: City/State/tip: to►l r� 7 6 Phone#: !2 - 5-3-7 3 Are you an employer?Check the appropriate box: Type of project(required): l.❑[ a employer with 'employees(full and/or part-time).* 7. ❑New construction In I am a sole proprietor or partnership and have no employees working'for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9: El Demolition 3.❑1 am a homeowner doing all work myself.(No workers'comp.insurance required.)' 4.❑I am a homeowner and will be hiringcontractors to conduct all work on 10 ❑Building addition my Property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13:❑Roof repairs These sub-contracto¢have employees and have workers'camp.insurance. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. T4.❑Other 157,§1(4),and we have no employees.[No workers'comp.insurance required.] °Arty 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 isproviding workers'compensation insurance for my employees. Below is the policy and job site information. ' Insurance Company Name: Policy#of Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiratijt-date). Failure to secure coverage as required udder MGL c_ 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penaltiesin the form of a STOP WORK ORDER and a fine of up"to$250.00 a day against the violator.A copy pf this'statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi rr er the pains and penalti of perjury t/ta[the information provided above is true turd correct. Sienature::- 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 S.Plumbing Inspector 6.Other Contact Person: Phone#: ` The Commonwealth ofMassachusetfs DepartmentoflndustrialAccidents 1 Congress Stree4 Suite 100 Boston,MA 02114-2017 www massgov/dia "Workers'Compensation Insurance Affidavit:Builders/Contractors!Electricians/Ptnmbers. TO BE FILED WITH nm EERMTT nNG AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Iadividaal): N rl rn e 1--4,p r,—�' Address: - 010,S Imo -`'ten Tr�r.,6?;K e, City/State/Zip M Ol S4 S— Phone#: -7-7 L4 -�1 `� - 2- t S S� Are yetLan employer?Check the appropriate boa Type of project(required): 1.Q i am a employer witlk . . . employees(full and/or part-time).* 7. [—]New conshvction 2.❑1 am a sole proprietor or Ownership and have no employee;viorldng.forme in $. F Remodeling any capacity.[No workers'comp.insurance required.]. . 3.[]1 am a homeowner doing all work myself:(No wodoers'comp.insu aoce required]t 9. ❑Demolition O4.Qlamahomrnavner and wrll bebiringcaahachsrsto conduct all auodconmYProP�Y• Iw�TI 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees 12. Blumbing repairs or additions 5.2I am a general contractor and Ihave hired the sub-contractors listed on the attached sheet 13.❑R f repairs These sub-contractors have employees and have worlmrs'comp.insurance.= 6.R We are a corporation and its officers have exercised their ri exemption p .14• Other Wy 11 6r.) rp ght of exem oa etMGL o. 152,§ RI and we have no employees.[No workers'comp.insurance required.] 14 c e,a *Any applicant that checks box#1 mast also fin out the section below showing their workers'compensation policy information- 1 Homeowners who submit this a$idev$indicating they are doing aft work and then hire outside contractors must submit a new affidavit indicating sualL tCoutractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Belmv is the policy and job site infor madom Insurance CompanyName� �I/dyliallyi� �niGY1 ��lt"e 1���re�1('P l„A.,, �/ Policy-9 or Self-ins.Lic.#: X JAjr S S Expiration Date: Job Site Address: �� L�ti�C,��1 �.�r City/StatelZip: l✓-l� 9 Attacb a copy of the workers'compeusation'policy declaration page(showing the policy number and eapirsti A,.date). Failure to secure coverage as r " ed under MGL•,e.152,§25A is a criminal violation punishable by a fine uP to$I,500.00 and/or one-year imprisonm as ell'as civil penalties in the form of a STOP WORK ORDER and a fine of up m$250.00 a day against the violator. py; this statement may be.forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un an enalties o '`iieri=the information provided above is true and correct Sianature:.•. ate: Poe . O,f dal rise only. Do not write in this area,to be completed by city or town officiai City or Town: PermitUcense# 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#: I /mil� Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home ImprovemehkContractor Registration Type: Supplement Card Registration: 112785 HOME DEPOT USA INC Expiration: 04/22/2021 P O BOX 105451 ATTN: LICENSE MGMT TEAM ATLANTA,GA 30348 turn Update Address and Re Card. SCA I u 20M•05/17 .��8 �/n/I'�il�n/1C<w,!/.��h�C�^.���1-vi!U/![GiP//i• Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPEoolement Card before the expiration date. If found return to: Resist Expiration Office of Consumer Affairs and Business Regulation -_04/22/2021 1000 Washington Street Sqjleylo HOME DEPOT 1 _ Boston,MA 02118 ANDREW SWEET,.., 2455 PACES FER14`E:FUC=11 HSC ATLANTA,GA 30339 _ Undersecretary NO slid It ut sl nature ATE A���� CERTIFICATE OF LIABILITY INSURANCE D0210612019DmvYl 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT MARSH USA,INC. NAME: TWO ALLIANCE CENTER pHCN o A/C No): 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA.GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIC tl CN101642069-HomeD-GAW-19-20 _ INSURER A:Old Republic Insurance Co 24147 INSURED THE HOME DEPOT,INC. INSURER B:New Hampshire Ins Co '23841 HOME DEPOT U.S.A.,INC. INSURER C:HomeRisk Captive Insurance Company 2455 PACES FERRY ROAD BUILDING C-20 INSURER D ATLANTA.GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-004353439-28 REVISION NUMBER: 21 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 i TYPE OF INSURANCE !ADOLISUBR; i POLICY EFF POLICY EXP i LIMITS LTR' POLICY NUMBER I MMIDD/YYYY l MMIDDIYYYY I - AI X :'COMMERCIAL GENERAL LIABILITY MWZY 314574 101010ig 03/0112022 EACH OCCURRENCE 3A AGE RENTED 1.000,000 CLAIMS-MADE FX OCCUR j !PREMISES(Ea occurrence) '3 1.000.000 X !SIR:31,000.000 i MED EXP(Any one person) 3 EXCLUDED _ PERSONAL 3 ADV INJURY 3 1.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 3 1,000,000 t X POLICY PRO- lOC 1 JECT PRODUCTS-COMP/OP AGG 3 1,000.000 I OTHER: 3 A AUTOMOBILE LIABILITY :MINT8314573 l03/0112019 €03i01/2022 IGOMeweDSINGLEUMIT 3 1.000.000 _ (Ea accident) X i ANY AUTO BODILY INJURY(Per oerson) ? a OWNED _SCHEDULED 'SELF INSURED AUTO PHY DMG AUTOS ONLY !AUTOS ;BODILY INJURY(Per accident),3 HIRED NON-OWNED PROPERTY DAMAGE 3 AUTOS ONLY AUTOS ONLY ! Per accZ 3 UMBRELLA IIAB OCCUR ! EACH OCCURRENCE 3 I EXCESS LIAR CLAIMS MADE; I i ':AGGREGATE 3 DED RETENTION 3 8 i WORKERS COMPENSATION WC 012717099(AK,NH.NJ /T) 03/01/2020 1 X PER OTH- 'AND EMPLOYERS'LIABILITY 1 I STATUTE i ER B IANYPROPRIETORIPARTNER/EXECUTIVE .Y/NN i 1 !INC 012717100(WI) 03/010019 0310112020 ! 5.000,000 OFFICEWMEMBER EXCLUDED? N I N/A' E.L.EACH ACCIDENT 3 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEEI 3 5.000.000 If yes,describe under a Continued on Additional Pa 5.000,000 :DESCRIPTION OF OPERATIONS below 9 !E.L.DISEASE-POLICY LIMIT 3 C f Excess Auto ! 297110011002019 0310112019 0310112020 ;Limit: 4,000,000 A `:Excess General Liability MWZX 314580 03/01/2019 103101/2022 Limit: i8.000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached if more space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING C-20 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee �CauJ�a•: ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD i AGENCY CUSTOMER ID: CN 101642069 LOC#: Atlanta ACOO o ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMEDINSUREO MARSH USA.INC. THE HOME DEPOT.INC. HOME DEPOT U.S.A..INC. POLICY NUMBER a2455 PACES FERRY ROAD BUILDING C-20 ATLANTA,GA 30339 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Compensation Continued: Carrier:Indemnity Insurance Company of North America Policy Number.WLR C65890549(AL.AR.FL.ID.IA.KS.KY.IA.MS.NO.NE.NM,ND.OK,SC.SD.TN Wl/.'NY) Effective Dale:03101019 Expiration Date:03101/2020 (EL)Limit:55.000.000 Cartier:New Hampshire Insurance Company Policy Number:WC 012717098 (OC.DE.HLINADANATAY,Rl) Effective Date:03101019 Expiration Date:03/01/2020 (EL)Limit:55.000.000 Carder:ACE American Insurance Company Policy Number:`NCU C65890586(OSI) (AZ.CA.IL.NC.OR.VA,'NA I Effective Date:03101/2019 Expiration Date:0310112020 (EL)limit:S4.000.000 SIR:31.000.000 SIR for the Mates of AZ,CA.IL.NC.0R.1/A.WA Cartier:National Union Fire Insurance Company Policy Number.XWC 5565596(OSI)(CO.CT.GA.ME.MI,NV.OH,PA.UT) Effective Date:03101/2019 Expiration Date:03/0112020 (EL)limit:$4,000.000 S1.000,000 SIR for the states of CO.ME,4V.MI.OH,P.4.UT 3750.000 SIR for the state of GA $350,000 SIR for the slate of CT - r Carrier:National Union Fire Insurance Company Policy Number.XWC 5565597(OSI)(MA) Effective Date:03/0112019 Expiration Date:0310112020 (EL)Limit:34,500.000 SIR:3500.000 TX Employers XS Indemnity: Carder:lllinios Union Insurance Company Policy Number.TNS C65221019 iTX) Effective Date:03101r2019 Expiration Date:0310112020 (EL)Limit:S10,000,000 SIR:S1.000,000 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD r • �� TOWN OF BARNSTABLE Permit No. ---Z8729 Building Inspector �263 Cash -�R OCCUPANCY PERMIT Bond Issued to Kennciih Ledoux Address Lot #1, 11 Carlson Lane, West Barnstable Wiring Inspector` Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date ' Board of Health Inspection date 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. .. .......... ........... 19... ._ ........... .... .. ...... Building Inspector TOWN OF BARNSTABLE Permit No. 28729_ a. = Building Inspector Cash _ 1619. — OCCUPANCY PERMIT Bond __xJ/� Issued to Kenneth Ledoux Address Lot #1, 11 Carlson Lane, West Barnstable Wiring Inspector Inspection date Plumbing Inspector Inspection date i i Gas Inspector Inspection date Engineering Department Inspection date i Board of Health Inspection date 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. . ....... .»... 19 � ...a ---------- or.. ... ry«�r . Y ,... ..»w.r».w. Buildin, Inspector ... - - ,.._ �,�t,,,,t_ ,.! � � _ ,, '-� � .-.- ., � ,. .r.a-c-•;. �.�"y.�vt��v..-...1r'�•,rri-�-r�^.+R-'.•.+-�r'�'Y-'^'^Nt` I ��..o�� O•�ew TOWN OF BARNSTABLE BUILDING DEPARTMENT »ST = TOWN OFFICE BUILDING 7 1#YL 9 i659. HYANNIS, MASS. 02601 �o rnY r. MEMO TO: Town Clerk FROM: Building Department DATE: 7—�— " An Occupancy Permit has been issued for the building authorized by BuildingPermit _ e ..........._...._ ..................................... .. _ .._ .............. issued to 1�—xe;W.64.0.0.0.0., ...................................._......... ._..._ Please release the performance bond. L DING .TOWN OF BARNSTABLE, MASS.ACHUSETTS! �y.< ,' PkER MIT.-.. A@ 133-30 JOB W E A T H C A.R 0= pr_yc.-� - 1 December 3. 85 ,�.28 f IG�fly half -Cape Construct�oi� ^��9,u -11 €RMIT�l��t i �.._ .-4� APPLICANT ADDRESS } • a _ IN0.) (STREET) (CONTR'S LICENSE) I Build dwelling. ' l} Single family dwelling NUMBER of 1 PERMIT TO (_) STORY DWELLING UNITS (TYPE OF IMPROVEMENT) NO. _ (PROPOSED USE) iUL -v.. J L'a -Lson I'clue, Wes b arna a )ie ZONING AT (LOCATION) DISTRICT IN0.) (STREET) BETWEEN AND (CROSS STREET) (CROSS STREET) LOT SUBDIVIS[614 - ° LOT' BLOCK SIZE ,,BUILDING IS TO.BE FT. WIESE BY _FT. LONG BY FT.'IN HEIGHT-AND SHALL CONFORM IN CONSTRUCTI ti TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION • ' !' (TYPE) Sewage #85-1057 ' REMARKS: BOND AREA OR 1456 sq. it. 135#000 PERMIT 84.00 VOLUME ESTIMATED COST $ FEE (CUBIC/SQUARE FEET) -Kenneth �eddux, OWNER BUILDING DEPT,.,---�---1 f,'� �r� "' ADDRESS BY THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY ► PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY_NOT'SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE ! PROVED BY THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAIN FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIC OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF THREE GALL APPROVED, 'PLANS MUST BE RETAINED ON JOW AND THIS WHERE APPLICABLE SEPARATE INSPECTIONS REQUIRED FOR CARD KEPT 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 QUIREO,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL MINAL INSPECTION TI TO BEFORE FINAL INSPECTION HAS BEEN MADE. 3. FINAL INSPECTION BEFORE OCCUPANCY. POST THIS CARD SO IT IS VISIBLE FROM STREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS y,ELLEJ_CTRICAL INSPECTION APPROVALS suiion'BARNSTABLE (�s,, ..�►-q �` • rr��,.:•• INSaroRi 0 2 2 / 2 I I _—_ _ � • � � � /gam • 3 _ HEATING IN EC ING APPR VALS R O E P VAL. Co`3o� I 0-HER 2 - _------- 2 - - NEE IIVG p. �L { 'NCRK SHALL NCT PROCEED UNT;L THE PERMIT W!LL BECOME NULL AND VOID IF CONSTRUCTION INSPECTIONS INDICATED ON THIS C, :NSPECTOR SAS APPROVED -tiE.w�i RICUS WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE CAN BE ARRANGED FOR BY TELEPH- '•' STAGES DF CONSTRUCTION. OR WRITTEN NOTIFICATION. f PERMIT IS ISSUED AS NOTED ABOVE. .s . . Assessor's ma and lot' Cie )-/ /7_ p • number r�tQ�:.�,, N ... f - THE --7 r Sewage Permit Gnumber ,�'7......`.. �c ry • 0 Z E SAIUSTOD House number .............. ....•.:::.... .��....................':........, , °� V� - 1� �Ef�`�croo "b a L��� t 39' TOWN OF . ' BARNSTABLE 1/1� /7"/li BUILDING INSPECTOR ;i APPLICATIOW FOR PERMIT TO .....C.. h S 1`ll.U� ........:Ci h.��r-�Q.......FCr ;/....... G ; ::...................... .. TYPE OF CONSTRUCTION ......i..I:!fi-. ................ ......... ..... .:3...........19. :ate UU/ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according•tg the following information: Location ...1A7...a. ......... ?'�:�� ~fi U. f:� ................. ... .................................. Proposed Use �G'.S,oteh �cc'l ���� ;�, Zoning District /g :.........................................................Fire District � �.,: G �J� ....'�� /,. '................ Name of Owner ../....C'v1hE?.Lt �P 4�dU k.......................Address .................................................................................... Name of Builder ....CGcDP. �2k4l.........Address ...?AR........ ......S:� ......A�/km.4 ... Name of Architect ..........0<.?A' Address CAA!S..tpHlm 1,c (Cgx....!1W S'69 17 Number of Rooms .............................................Foundation ... Exterior T r !` jw:...../c c/..c r /t.......:5!�e.4....�!.�.:..Roofing .....R�'.l-P...l.e�ci R......./7�a`F............................... � .................. Floors ....Npy?.,4G5:;�cd..,.... i2p.e .Interior 13/&C....�-'.e'ai2c/ ....... ....................5......`.................................. Heating ! .?_ ...C..L�rt .!?...��... !!..j.............................Plumbing ...........-�........w ...................:.................................... /..'. ..........................................................G Fireplace ........ ..... ......................................................Approximate. Cost ...<:. ... Definitive Plan Approved by Planning Board -------------------_-----------19_ . Area ........ .............. :. Diagram of Lot and Building with Dimensions Fee ................................... SUBJECT TO APPROVAL OF BOARD OF HEALTH If OCCUPANCY PERMITS REQUIRED FOR NEW.DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstoble,�eggrding the above construction. Name ..1 (........................................ / Construction Supervisor's License 9 77 :�f,5.......... LEDOUX, KENrZETH A=133-,10 o No ...2.8.7.29.-.-*. Permit for AA.Atou. .... ..... Single .................. . .............. .... Location ........L9t 1,......1.1...Ca.r.1s.. ....L Re....... . .... . .... West Barnstable ............................................................................... Owner ..........Kenn.e..t..h......L.e..dou.......x ........ ........................... Type of Construction ...Frame......... ................................................................ Plot ............................ Lot ................................... ....... Permit Granted ...... December 3, 19 85.................:.......... Date of Inspection ....................................19 Date Completed .......................................19 Assessor's map and lot number hlap r/. Aecsr Jahn �'J� THE 0/�: . /c = //= /y-ems ��✓�- v IfAll Ce't r.�Y o� Toy o JeelSewage Permit umber .R :.... f. G�:��...:..J;l.1�s:—yf ... r� �� �1£�q � EPTIC SYSTEM House •number ........ .. ,..........�L.!.........Ak :........`:. /v IN C NTH TITL 1639 0m w � APPROVED ENTALC a N ,U F B ARN S T REGULATIONS Bate 7.stable Conservation C So /� � — Signed Data 1811,LDING INSPECTOR I APPLICATION'FOR PERMIT TO .........S/.h` ....... 0.,P A, �y......� .f........................ TYPE OF CONSTRUCTION ..........I/ C�%�1...... � ri'h.Q..................................................................................... .....�......�j...........19.&i TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit acco ding to the following information: 0a,eLSON Location ... —?7...3.D......... . . ... . .... ......... ........................................................................................... Proposed Use ........ .'S�o�eh...........:........... E7iC��r.�tJC......................................................................:...................... C Zoning District .......... ..).....................................................Fire District ./.... /L. Nameof Owner ..XCkl ?.k]�l?..... .......................Address .................................................................................... Name of Builder k 6.....Cai?. ..........Colisl` .......Aclaress ... ...... .,.,�Iv.,L Ag47.......!5T.....P/y`t7P1. 4... Name of Architect s G (bi1.ax,.........PesIfM.................Address .C.6t/tl.S?4/7Li�....�R.�t'f�ti.... d.........5�/IVAw!CL Number of Rooms ......7...R!�a............................................Foundation ...c.8..K.99......411..,,1.AA.0..... �GL Exterior 7—..5A.......age' .q&,4..A........Skp&5..... Roofing .....12.C'd....cepl&......t2o.-P h.............................. Floors .... R./Lc G4 .. Glx .t?�:...............................Interior Qw /jcct2c� S/.. Caa 1. 2p E....................................................7.............. Heating ....:/��fi..... A4?f�(L./.fJl..�.............................Plumbing S 00 1 � Fireplace ........"2.......... ..........................................................Approximate. Cost ............. ..........:.............................. .. ... Definitive Plan Approved by Planning Board -----------_______-----------19_______. Area ...... I.. ................'s. ......... Diagram of Lot and Building with Dimensions Fee .............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH l� r6 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 .: ... ...................................... Construction Supervisor's License �0 .......... LhDOUX, RENNETH N0" .'2872?... Perri for 11�tory Sin.... ..... ....Family .ling, 0 ........................... "i 11 Carlson Lane Location ......L2t.vLO......... C, > 0 West, Marnstable ............................................................................... 0 t: Keff-neT-h Leioux Owner .... .................�,........ .. e Type of Construction.,........ ��ZaTje....................... .............................................. ................................ Plot ............................ Lot ................................ ...... . Permit Granted .............................December 3, . ... 19 85 Date of Inspection 1�1 �- ;.�7?*................19 Date Completed /— ...; ...... 0 ............19 Town of Barnstable *Permit# PERMIT. Regulatory Services e 6"'°nt Shg, Z MASS ,wxrrsrwBis L,r " 13 2012 Thomas F.Geiler,Director r-Mo-► Building Division -TOWN OF BARNSTABLIEm Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barmtable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY I Not Valid without Red X-Press Imprint Map/parcel Number Property.Address 1 0-RR.WAf 1AAJE 4 K/E5r �f Is �e.C- MA czp 6,9El/ r Residential Value of Work c$/Z o 000, Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Named�7 /�J` 7�y)7 y ��S Telephone Number_7 74 - Home Improvement Contractor License#(if applicable)- Construction Supervisor's License#(if applicable) CS 763 . 2 ❑Workman's Compensation Insurance Ch�one: 9 I am a sWof Fopgotw 6&-AEjEJW- Gm%4 �e�R ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name ' Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. - Permit Requ t(check box) l�U LcIQ �t [� Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. . Separate Electrical&Fire Permits required.- "Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of'Permission. copy of the Home Improvement Contractors License&'Construction Supervisors License is required. SIGNATURE: �AWPMESTORM building permit forms RESS.doe Revised 053012 i s * SARNSr"LE, • 9� ,0 Town of Barnstable Regulatory Services Thomas F. Geiler,Director Building:Division M1 Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 ' www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, �flRlff GtJX ' , as.Owner of the subject property hereby authorize Z�gD a)6q YY) bll/W& , INC to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) . 916 �z Signature of 0,;nel Date 1��ViVEzY L E 9ay 3 es Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. QAWHHILESVORWbuilding permit fonns\EXPRESS.doc Revised 051811 �t► > Town of Barnstable ][regulatory Services 9 MAW- Thomas F. Geiler,Director 1659. Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION. Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be,a one or two- family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, j 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. Signature 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 nay>care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 051811 I i ?Ire Commonwealth of Massachusetts Department of Industrial Accidenis Office of Iniwfigations ` ' 600 Washington Street Boston,MA 02111 t ' wmv.mamgov/dia Workers' Compensation Insurance Affidavit Biers/ContractorslEkctric ans/Plumbers Applicant Information Please Print Lembly Naive 73 2 D COS 171M A V 1 LO egf l•tI�. Address: PO k z/ City/StateLZip: ,B&A)5�r&E 4q- %OM#: 5D&,9 33-&/e F Are you an employer?Check the appropriate b T of project r 4. Firm a contractor and I Type P ] ( ��= 1.❑ I am a employes with general 6_ ❑New construction employees(full andlorpact-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7- ❑Remodeling ship and have no employees. These sub-contractors have g_ ❑Demolition wcd=g for me in any capacity- employees and have worms' 9. Building addition, [No workers'comp_insurance comp.insurance,1 ❑ g 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 11. Plumbing airs or additions 3.❑ I am a homeowner doing all wad ❑ g rep myseM o wcrk=s' _ right of exemption per MGL Roof repairs Ce Vie-)t c.152,§1(4),and we have no 13. Other employees-[No workers' 13. Other �� comp.insurance requued.] 'Any applicant cat checks boas#1 Est also fill out the section below showing they workers'canipensatimpolicy infarmzin_ SOF BACK OF I HGMWWners who submit this affidasit W&catmz they are doing all work and then hue outside coutactors— submit anew of davit mdicaung such- ICounwtors that checlk this boar mast attached as additional sheet showing the name of the sub-comuycmcs and,svte whether ornot those entities bay employees. Ifthe.sub{oatnctors have employees,they mist pmv+ide their workers'comp.policy number. I am an employer that is provideng worhen'conrpwrsation.insurance for eery ompinyee& Below is the policy and job site information Iitisurance,Company Name: NLA Policy#or Self-ins.Le.#: Expiration Date: Job Site Address: l/ C.69L,< rn 0 /11711 City/State/Zip: k/- U)XA)5M( , Attach a copy of the workers'compensationpalky declaration page(showing the policy number and expiration date). O 2(ob 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 carte a thepains andpenatfies ofpetjury that the i►rformatcon prmvid d above is bue and correct Si Date: & .Z Phone#: 6�B Official use only. Do not write in this area,to be completed by city or town of'iC&I City or Town: Permit/I.icense# Issuing Andwrity(tarcle one):: 1.Board of Health 2.Building Department 3.City/rown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 9: 6 c SuBC�t 1.�5T' ��s5 35R4 N i LzS e7U Ccp4s Q u C9'lom COn�1flGT: ZESSF- tw►va-DStw e � w � ,{ Massachusetts- Department of Public Safet Board of Building Regulations and Standards 1 Construction Supervisor License ' License: CS 76332 -- KEVIN BOYAR• '= r PO BOX 716 _ W BARNSTABLE, MA 02668 i Expiration`. 9/5/2013 ('nnnnissiunir Tr0#: 4529 -\" Office of Consumer Affairs&Bu"si ss Reg HOME IMPROVEMENT CONTRACTOR Igg9 _ Registrations,,162150 Type: 9= a Expiration: AY26F2013 Private Corporal B&D CUSTOM Put ED L2S NC 1 KEVIN BOYAR'l 1050 MAIN STREE� '-' ;�,:I • WEST 13ARNSTABLE�MA� 2668 Undersecretary e � 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 5170 ' i I Boston,MA 02116 Not valid withouts' ature W crn-K ca i 1 c ¢t-sd�t a, I. 3Af A.-. MOE C6-M%P a K - ROOF) is cM4 34 �.�D¢�Tr�2. � 5u8coaaTRPr�-TAR. 43tsa- . INC. 4 ►31�Z- 1 ' 'Al Se,6 1� Town of Barnstable *Permit# oFs Expire n onthsf�+r+-issue date 9 ZUUB Regulatory Services F e >ARN Thomas F. Geiler, Director 9 MASS !j t639- Building Division PrfD f�At t` U Tom Perry, CBO, Building Commissioner `f Q 200 Main Street, Hyannis, MA 02601 v ww.town.banistoble.ma.us Office: 508-862-4038 Fax: 5087790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY `2 (, Not Valid svirhout Red X-Press Imprint Map/parcel Number Prop rty Address �O�r' 1 J�c,:\ �- IN �rL� IJ�„-,� Residential Value of Work �, 3e�r' Minimum fee of$25.00 for work under$6000.00 Owner'.s Name&Address t�J"�''��1 .-�h t ,ee-lo)v •,,�n IJ ;(` Nam,e S. �v c�?S , Contractor's Name_ 1p Telephone Number Home Improvement Contractor License#.(if applicable) fI1? ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor �❑ I am the Homeowner t�­I have Worker's Colenssatton Insurance i Insurance Company Name_ t1 "'� R- VM QS t1 t rc f_ C. Workman's Comp..Policy# / Copy of Insurance Comptiance Certificate must be on file. Permit Request(check.box) . ❑ Re-roof(stripping old shingles) All construction debris will be taken to �) ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side dReplacrneent DWindows/ ors/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. ***Mote: Property Owner must sign.Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. ✓1;=�[ y SIGNATURE: Q'\\x/PFILES\FORMS\building permit forms\EXPRESS.doc 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/Individual): S Address: 2 `� City/State/Zip:' d33 Phone.#:. Ls -y /0 Are you an,employer?Check the appropriate box: Type of project(required):. .I.. 1.( I am a'employer with 4. ❑ I am a general contractor and 1 have hired the sub-contractors 6. ❑New construction employees(full and/or part-time). , 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling 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 " required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions officers have exercised their 3.El am a homeowner doing all work 11.❑Plumbin9 repairs or additions myself.'[No.workeis'comp. right of exemption per MGL 12.❑ oof repairs insurance required.]t c. 152, §1(4),and we have no 13. Other employees. [No.workers' . comp.insurance required.] *Any applicarir that cheeks 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 thatcheck 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 thepolicy and job site information. ,... .... .;. Insurance Company Name: 'Paw.. Waolp5ktL J�tj-s CO Policy#or Self-ins. Lic.#: .�,, Expiration Date: f> Job Site Address: `I ,� c�►� L>�.' 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 tip 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 the pains and penalties ot'p r'u thMetion provided above is true and correct Sip-nature:. /` Date: Phone#: ! �' 6 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 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 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 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 IndustrialAccidents. 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 pernut/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 io 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. # 617-727-4900 ext 406 or 1-877-MASSAFE . Fax#617-727-7749 Revised 11-22-06 www.mass.gov/dia Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration.` 126893 Board of Building Regulations and Standards One Ashburton Place Rm 1301 ExpFato'n 873/2010 Boston,Ma. 02108 } Ty .::==;S.upp pe lement Card ` �._ � The Home Depot=AGFIUneWS.ervide MICHAEL BEDARD 3200 COBB GALLERdA`R:KSIVY 420 ATLANTA, GA 30339 Administrator Not va id without signature a r 08-29-2008 15:07 FROM-THO AT HOME SERVICES +508 756 8823 T-123 P.001 F-585 HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold,Furnished and Installed by: Branch Name: ?baton (Date: �/�/� THD At-Home Services,Inc. d/b/a The Home Depot At-Homc Services Branch Number: 345A Greenwood Street,Unit 2,Worcester,MA 01607 ❑North 33 South-31 'Toll Free(800)657-5182: Pax(508)756-8823 federal IDif 75-2698460;ME Licit C 02439;RI Cant.Lic#[6427 CT Lic#56SS22; Home Improvement Contractor Reg.d 126893 Installation Address: ��' c'py a 0.tJ Lt4 City Stara zip Parchnser(s): Work r nee. Rome Pbone: Cell Phone: etlrla �e 1 0 LL Y [ ] ] .4S2 [ ] Home Address: (Ifdtf£aent from lnatallalion Addrem) City (state Zip E-mall Address(to receive project communications and Home Depot updates):���1.�� "r='�►�+—C:�f1�'I Cf' ❑T DO NOT wiab to receive any marketing emails from The Home Depot li act oforma • Undersigned("Customer"),the owners of the Property located at the above installation address,agrees to buy, and THD At-Home Services,Inc,("The Rome Depot")agrees to filmish,deliver and arrange for the installation("Installntiow)of III materials described on the below and on the referenced Spec Sheet(s),all of which are incorporated into this Contract by this rarereacc,along with any applienbic State Supplement and Payment Summary attached hereto and any.Change Orders(col ti Y. Job#: nns.m.trc.u..a..t P doch: S cc She b 7I: PhD e[4 Dolt ) r. hoofing Siding Windows LJ Insulation (/ 9g 4 o 0G113crs 1 Ctwrra ❑Entry poets Q 1 O W7 $ i aj 2 Doting Siding Wmdows L3 Insulation ❑Gutters/Covets ❑Entry Doors ❑ $ Rooting Siding 0 Windows U Insulation 1 ❑Goners/Cavern ❑Entry noon❑ $ 1 Rcofmg USiding U Windows Insulaton — UI [Jetutt m/Covers UlFurry Doors I] $ Mlnlmnm 251A Dcpmtt ofContraetAmount due upon execution ortith coa"a Maine Purchasers Play m*depash more than one-third of the Cnntrnct Amount Total Contract Amount S `J Customer agrees that,immediamly upon completion of the work for each Product,Customer will execute a Corhpleticn Certitcate (one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each C uttumer trader.this Contract agrees to be jointly and severally obligated and liable hereunder. The Horne Depot reserves the right to isaue a Change Order or terminate this Contract or any individual Products(s)included heron;,at is discretion,If The Home Depot or Its authorized service provider determines that it cannot perform imobligacons duc ro a structural problem with the home,environmental hazards such as mold,asbestos or lead paia�other safety concerns,pricing cn'ors rn becoast: work required to complete the job was not included in the Contract. ftZnent SummQrv: The Payment Summary# included as part of this Conntect !:ctw funh ehc torsi Contract arn6nt and payments required for the deposits and imal payments by Product(as applicable). completely NOTICE TO CUSTOMER YOU are entitled to a o. there Is one Completion Certiticatt¢frir eaccopy [rated P oduct s defined by of the Contract a,the time lndiviou dun Spec ShDO not eets)before-work on a Completion n that Prficate oduct Is complete. .. , In the event orterminotion of thls Contract,Customer agrees to pay The home]Depot the Coats of materials,labor.expenses and services provided by The Home Depot or Authorized Service Provider throupb the date of termination,plus any other amounts set OWED Td forth rn this HOME Agreement EPOT F ROM THEder DEPOSIT PAYMEilrob1c law. NT OR OTHDER PAYEPOT MENTS ,yXA E. W7TK OUT LIMITING THE HOME DEPOT-S OTHER REMEDILS FOR RECOVERY OF SUCH AMOUNTS, A�cr tan an tier Customer agrees and talla'i ands that this Agrcemeat is the enfjro agreemcn[be�tvtxn Cststomor and a Home nepot with regard to the Producla end Iaseallatian services and supersedes all prior discttasions and agtc rneDts,either met oral or written,retatinR to said Products and Iasrallation.'Thia cement cannot he assigned or atneaded except by s vvrioog signed by Cuo f ad and The Hame Depot Costomcr eel M",lcdges an igrecs that Customer has read,undtaatauds,vollmtarily accepts the tcrtna of and has tncrived a copy ofthia i�gtcement. Accepratyh / Submitted by: �•�tB�rr��re.:�.��C_y��w x ns� fomcr'9�i�paturc Cam Sn1eE Consul t'a Signe Date Telephone No. Cus[ttmcr'S SigoatUre Date Sales Consultant License No, _ CANCEI,LA.TION; CUSTOMER MAY CANCEL THIS ens apph mbte) AGREEMENT WITHOUT PLNALTI,OR caLIGATION By DELIVERING s/t••RITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON Tn:E THIRD BUSINESS DAY ASTER SIGNING THIS AGREEMENT. TFU+, STATE SUPPLEM$NT ATTACHED FMPJETO CONTAINS A FORM TO USE IF ONE FS Frtpers<rt:�r_zv rrarscr+rxr�o gy L-AW _ rv+or.crc,nnen•nvHwc rna.xs,vm corooMONS ART STATED ON 1 . .b-hltnry�y,Piro Yolrm.. .. Z ' RF1r yx ISM a rn.._ . F �ACORDTM CERTIFICATE OF LIABILITY INSURANCE 02/z/0B"Y"'' PRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR homedepot.certrequest®marsh.com ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 3475 Piedmont Rd NE, Suite 1200 Atlanta, GA 30305 Pax (212) 948-0902 _ INSURERS AFFORDING COVERAGE ______ NAIC# _ INSURED _ INSURERA Steadfast Ins Co 26387 Home Depot U.S.A., Inc. The Home Depot, Inc. INSURERB:Zurich American in Co 16535 2455 Paces Ferry Road INSURERC:Illinois Natl Ins Co 23817 Building C-8 Atlanta, GA 30339 INSURER D:American Home Assur Co 19380 INSURERE:N— Hampshire Ins Co 23841 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. �6-ADD' POLICYEFFECTIVE POLICY EXPIRATION LTR 1 POLICYNUMBER DATE E LIMITS A GENERALUABILITY IPR 3757 608-02 03/01/08 03/01/09 EACH OCCURRENCE $4,000,000 X COMMERCIAL GENERAL LIABILITY LIMITS OF POLICY ARE EXC SS PR M PREMISES Eaoccuren� $1,000,000 CLAIMS MADE Fx-1 OCCUR "OF SIR: $1,000,000 PER )CC" MED EXP(Anyone person) $EXCLUDED PERSONAL BADVINJURY $4,000,000 GENERAL AGGREGATE $4,000,000 GEN'L AGGREGATE LIMITAPPLIESPER PRODUCTS-COMP/OPAGG $4,000,000 X POLICY PER,() E 4 LOC B AVTOMOBILELIABIUTY BAP 2938863-05 03/01/08 03/01/09 COMBINED SINGLE LIMIT $1,000,000 X ANY AUTO (Eaaccident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Perperson) $ HIRED AUTOS BODILY INJURY NON•OWNED AUTOS (Per accident) $ X SELF INSURED AUTO PROPERTY DAMAGE $ PHYSICAL DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EAACC_ S AUTO ONLY: AGG S A EXCESSIUMBRELLALIABWTY IPR 3757 608-02 03/01/08 03/01/09 EACH OCCURRENCE $5,000,000 OCCUR CLAIMSMADE AGGREGATE S 5,000,000 S DEDUCTIBLE $ RETENTION $ $ C WORKERS COMPENSATION AND 1928757 (FL) 03/01/08 03/01/019 X WCSTATU OTH- 70RYLIMITS I I ER D EMPLOYERS'LIABIUTY 1928756 (CA) 03/01/08 03/01/09 E.L.EACH ACCIDENT $1,000,000 ANY PROPRIETORPARTNERIEXECUTIVE E OFFICER/MEMBEREXCLUDED'1 192875S(AOS) 03/01/08 03/01/09 E.L.DISEASE-EA EMPLOYEE S1,000,000 I(yyes.describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 OTHER F TX Employers Excess TNS-C45197967 (TX) 03/01/08 03/01/09 ccurrence/SIR 25M/2M D Workers Compensation 1928759 (QSI) 03/01/08 03/01/09 E Workers Compensation 1928758 (KY, MO, NY, WI) 03/01/08 03/01/09 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES)EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS *FOR EVIDENCE ONLY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THE HOME DEPOT, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 2455 PACES FERRY RD., N.W. BUILDING C-8 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE USA ACORD 25(2001108)datkinson ©ACORD CORPORATION 1988 8207866 e b -XI 1 r. 4 & OLD J 2320 -HO VJ -