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Home My WebLink About1673 MAIN ST./RTE 6A(W.BARN.) it.73 Mai v\ S�. �i i k N VAT Pj . o rru a F o a Z)z a ,T 0 1 T fi �-- a t� '� ..lam �� --t a a� ® Y� Town of Barnstable *Permit# Emwes 6 months from Lme date Regulatory Services • eaaxar�. • MASS. Richard V.Scan,Interim Director Building Division XPRES PER Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 JUL 10 2014 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENT RNSTASLE �j 0 y Not Valid without Red X-Press Imprint Map/parcel Number I; ( (/ r„ _ Property Address /6 7,3 A'/A) .s �FST ,� �57GC (Residential Value of Work$ 3 Minimum fee of$35.00 for work under$6000.00 a Owner's Name&Address &RBg7eh ►mo o 173 I71A�av ST, 10, ?Z4fN s Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) ®aR Email: Construction Supervisor's License#(if applicable) 07 00 7 7 [�Workman's Compensation Insurance \\ Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name beg) #dVAS,*/RC- /s"/ -s . co . Workinan's Comp.Policy# W ®/Y Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)' ❑ Re-side Replacement Windows/doors/sliders.U-Value 3 y (maximum.35)#of windows #of doors: ❑ 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,Le-Historic,Conservation,etc. ***Note: Property er sign Property Owner Letter of Permission. A copy of H Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: T:�VIN D1Buildmg ChangesTEXP S RESS-doc Revised 061313 HOME L" ROV1rWATCONTRACT Pi.EASE READ THIS Branch Name_Boston North&South Date:_Jt191J_4, Sold.Furnished and inst<if[ed.by. THD At-Fiume Services,•1nd_ Branch Number:31 and 33 d/b18 Ttte H=C Depot At-home Seevives 908 Boston Ttttngt r-Unit 1.Shrewsbury,MA 01545 Toll Free 877-%M-4768 Federal ID*#75-26 WO-.ME Uc#C 07439;RI Cunt_limit l64'2 j Cr L.tC C RIG MA Home meat Contractor Reg.0 I26tl93 imstauation Addr�t: 1b tiles.t S ( �r City State zip wort Phome: Home Phoar- Cell rbone: I --d(-5-6 KI s/..2 6 [ ] ap/ �n�Address: '' • - . (1f dIiYereltt frum Installation Address) City State Zap E-nrA Address(to receive project communications and Home Deport updates): 0 I.DO N017 wish to receive any towketing e=ils from The Home Depot ftolee�Irlffoenmti�: Undcr agned��Customer"),the dwmerg of the property'located at the agave infaWladon address.agrees to buy,' . and THD At-Home Services.Inc.("the Home depot")agrees to fivaish,deliver and arrange Yor the liwallation("Installation')of all materials described an the below and on the referenced Spec Shcw(s),all of which are incorporated into this Cotnbuc4 by.this refiliy,ence,along W'A arty applicable State Supplem=and Payment Summary'attacbed hereto and any Change orders(collectively, 11 Cobtract.). __ Spec S.he s M. Project Amount QRool-mg Siding Wmdows Insulation tvesa ❑Qattw,/Glinvy D.❑ Ql �. . �� 3 Roofing Siding Windows 0 Insulation ❑Cutters/Coveis ❑Gttiry Doors ❑ $ Ruling Sidling . Windows Iasulatioin OQ"xs/Covrxs LIEntry Doris❑ Roofing ..aiding❑Windows Ll Insulation .... .. ❑GnttcrslCdtvets❑F.ntrylXidxx-� $- . D"iwi 254'o'nePodt of Cmteait Amauat due up m exeaman of the cwav t . Told Contract Amutml $ . .MalwPurdm smay net depwit moretham Qw-Wrd oftbe Cwts"CLAMOIBI& ' Cu�totn,cr'agrees tlkit,immediaicry upon•completion of the wokk for each-Producr'CtMomer VATi excCute,a Cbiitp1CdjM C-eRlflcafd.' . (one idi-eacfi'Pikuct as definid fiy an individual Spec Sheet)and pay any bounce due. As appticiwe,ea*Custw=uttder•thi3 Colitract*ext to 6e jointly and severally obligated'and liable hacunder. TFie Honnt llepot•te iervcs'the ilgbt tot iusue a Change Ordk r of te=.minale this Conttao:l or any milMduar Product(s)included hi rajn;sit. its disdxeuott,il'The Flonle repot or ifs authtm lice)service provider.determines.That it=nut.p&*rm its ublgati6na due to a'stxiceural problem with the home,environmental htusrds,such.mold,asbestos or lead paint,other safety eoncerri3,pricing err<�r.dA tiee tie work required to complete•the job was not included iri the Contract Payment Simrmil The Payment Snmmnry d included as part of this Ccgttrstet..sets litidt the h:ta! . Contract amqunt and payments required for the deposits and final payments by Product(as applicable). NOTT(x TO CUSTOMER' _ there is Oneompletiu are entitled to a on Cell.efor Mh listed Product as of the Contract adefined by tjodt ideal spec W-ts)before woik:On thairrod�' is rnmplete. In the event of termination of this Contract,Customer agrees to pay The Horne Deport the t--asts of materW*labor,expeam otheror1 UNTS amounts set forth.in this Agreement or allowed)rode,Triable law. Tl3L HO1_ R DEPOT MAY W1'1IIHOLA O OWED TO THE ROME DEPOT FROM THE DFpOS1T PAYMENT OR OTHM PAYMENTS MADE, WffflOifY LIMIi1NG`CHE HOMIt DEi�T"S OT1t1ER Rrd►�IEDIUS I!OR RECOVERY OF SUCK AMOUNTS. p c an thorizall • custtotndx agrees and uuderstandS that this Agreement is the entree agreenienLbetwcent Custorlter nm a ome Depot with regard to the Products and Insutliativa services and supersedes all prior diseussinns and agreemduts,�dlher oral a.written,relafiog to said Ptdulucts and In:dailatinn.This Agreement cannot be assigned a Pumd'd except by a writing signed' by Customer and The Home .Customer acknowledges and agtecv that Customer ha&read,understandc,vniunt<inly accepts the t 's Agteemen- terms of and h&q received a o y 4Acby Submi by: - C Sales C sultant'S Signaturepate 's Signature tc 0 �� .. Telephone No. Customer's Sipatu[C DamSales Consultant IdCCOse 140.• (as applicable) CAN ELATION: CUSTOMER MAY CANCEL TM ACRE r WITHOUT nNALTY OR OBLIGATION AY'D&WERING•WRTTTEN NOTICE O 7 HE HOME' ......vo rFtTtRri BUSINESS '+e� t ; bf V.P lk •1- wli l�r" t�w �• i{'SF tX't� .4 The Commonwealth of Massachusetts -t Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 I.... 1 Y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly r Name (Business/Organization/Individual): Address:_ /-6� Wli_-60/J a 4v City/State/Zip: t kLot7 U d 7-3y4 Phone #: 7 7J/— 764 -23 2-1- Are you an employer?Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. ElI 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 g. ❑ Demolition working for me in any capacity. employees and have workers' insurance. 9. ❑ Building addition [No workers comp. insurancecomp. required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] "Any applicant that checks box##1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 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 thepolicy'andjob site information. Insurance Company Name: r' au S Policy#or Self-ins.Lic.* Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certifyAnder the gaips and gen ALes of perjur that the in ormation provided above is true and correct Si ature: Date •. _ - •. v _ Phone#: "�7? 744—2 3Z-5— 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#: ice o onsumer G��e�6 ailian�ess Re ulation 10 Park Plaza - Suite 5170 g Boston, Massachusetts 02116 Home Improvemen��ontractor Registration Registration: 126893 z x Type: Supplement Card The Home Depot At-Home Services — Expiration: 8/3/2014 ANDREW SWEET 2690 CUMBERLAND PARKWAY�S� ATLANTA, GA 30339 b �e 7,G'1Ar sl;1b Update Address and return card.Mark reason for change. DPS•CA1 0 SOM-04/04-GGIO'12166 ,,,,�� Address Renewal Employment Lost Card Office OF&.sYir�i r' a1rs us"fness egu ano License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:•6893 Office of Consumer Affairs and Business Regulation Expiration:, Type' 10 Park Plaza-Suite 5170 �8/3/2014 Supplement Card Boston,MA 02116 T e Home Depot,At-Home=Ser&es ANDREW SWEl —� 2690 CUMBERLAND PARK/ XYDAt'J`%,GA 30339 a Undersecretary al41t signature r f. t, The Commonwealth of.'Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street U9 Boston,IVA 02111 www.mass.gov/dia WorPleers' Com ensation Insurance Affidavit: Builders/Contractors/El please Print nLegibly A licant Information y,rzs Name(Business/Organ=bOntlndividual):. Address: S �1111City/State/Zip: Gt.+U`t�• O f�, �03 3 Phone `'�- °Z�3 Type of project(required): Are you an employer?Check the appropriate lyoa: eneral contractor and I 6 New construction 4. Iamag 1, I am a employer with — have hired the sub-contractors Remodeling employees(full and/or Part t>me)'` listed on the attached sheet. 2.❑ I am a sole proprietor or partner- These sub-contractors have g. Demolition ship and have no employees employees and have workers' 9 Building addition working for me in any capacity. ; o workers' comp.insurance comp.insurance• 10,[]Electrical repairs or additions [N g, � We are a corporation and tts repairs or additions required.] officers have exercised their 11.❑Plumbing ep 3 El am a homeowner doing work right of exemption per MGL 12.[]Roof repairs myself.[No workers' comp. c. 152,§1(4),and we have no 11ROdw /N 0 insurance required.]t employees.[No workers' comp.insurance required] *Any applicant that checks box#t must also fin out the section below showing their workers'compensation policy info lion• t Homeowners who submit this affidavit indicating they are doing all work owin Caned�hmhe sub-conts � and state whether or not,those entities have such. tContractors that check this box must attached an additional sheet sh thug workers'comp.policy number. employees. if the subcontractors have employees, �' p Below is the policy and job site I am an employer that is providing workers'compensation insurance for my employees. information. /� #am Insurance Company Name: / v Le�A-L G D lotg g aZ _ Expiration Date: 3 Policy#or Self-ins.Lic.#•_W City/State/Zip: Job Site Address: Attach a copy of the workers'compensation policy declaration page(showing the policy.number and expiration a Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal p risottment,as well as civil penalties in the form of a STOP WORK ORDER and a fine fine up to$1,500.00 and/or one-year imp be forwarded to the Office of of up to$250.00 a day against vi tor. Be advised that a copy of this statement may Investi atio is of the DIA for coverage verification. I do hereby certify under the 'n n pe ties perjury that the information provided abov is tr and correct Date: 7 r —' Si afore: Phone#: Official use only. Do not write in this area,to be completed by city or town official. Permit/License City or Town: # Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#• Contact Person• o DATE(MMIDDNYYY) /�`�o . CERTIFICATE ®F LIABILITY INSURANCE 02/19/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: MARSH USA,INC. PHONE FAX TWO ALLIANCE CENTER A/c o Ext: A/C No): _ 3560 LENOX ROAD,SUITE 2400 E-MAIL ADDRESS: ATLANTA,GA 30326 INSURER(S)AFFORDING COVERAGE NAIC S 100492-HomeD-GAW-14-15 _ INSURER A:Steadfast Insurance Company 26387 INSURED INSURER B:Zurich American Insurance Cc 16535 THD AT-HOME SERVICES,INC. — —— DBA THE HOME DEPOT AT-HOME SERVICES INSURER C:New Hampshire Ins Cc 23841 2455 PACES FERRY ROAD INSURER D:Illinois National Insurance Company 23817 ATLANTA,GA 30339 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003242685-01 REVISION NUMBER:3 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 D UBRJ POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVDPOLICY NUMBER MM1DD/YYYY MM/DD/YYYY LIMITS A GENERAL LIABILITY GL04887714-04 03/01/2014 03101/2015 EACH OCCURRENCE $ 9.000,000 X DAMAGE ORENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrenceL_ $ 1,000,000 CLAIMS-MADE M OCCUR LIMITS OF POLICY XS MED EXP(Anyone person) $ EXCLUDED OF SIR:$1M PER OCC 9,000,000 PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ 9.000,000 [G�EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 9.0w,000POLICY i ET -- LOC - $ B AUTOMOBILE LIABILrTY BAP 2938863-11 03/01/2014 03/01/2015 COMBINED SINGLE LIMIT 1,000,000 Ea accident S _ X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED.. RETENTIONS .. .. .. _. . $ C WORKERS COMPENSATION WC049101882(AOS) 03/01/2014 03/01/2015 X I WCSTATU- OTH- AND EMPLOYERS'LIABILITY TO I TS PQ C ANY PROPRIETOR/PARTNER/EXECUTIVEY YIN Wt;049101884(AK,AZ,VA) 03101/2014 03/01/2015 E.L.EACH ACCIDENT $ D OFFICERIMEMBER EXCLUDED? F`N] NIA WC049101883(FL)' 03/01/2014 03/01/2015 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under 1.000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C WORKERS COMPENSATION WC049101885(KY,NC,NH,VT) 03/01/2014 03/01/2015 (EL)LIMIT 1,000.000 C WC049101886(NJ) 03/01/2014 03/01/2015 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjeer>Luao►.► 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD