Loading...
HomeMy WebLinkAbout0328 ARROWHEAD DRIVE �8 -r'1�'�ow�� fie. --- - — -- Town of Barnstable 1 �x. � _z _.� Bui ding c P,os#This Card So'That rt is Visible From.the'Street A roved Plans Must be Retained onCJob and this.6rd Must be Ke"t. �F :,mw a ,•,v �r7,,.�.g a-..,.'" `•T�:;.<'�- �:...w.�,qr gyp, r., �gi, '.l�ve+;"'w°+d.r'a,�V,,hum$6"w�k'v N4��d� 2A; ',.�am*�''�� b°�„+ ;U•s.�'< :�:' '"" Posted Unti)FinaF Inspection Has Been°Matle. _ :r x e` ��;w �.,��, _.. e�;• *,� �' r .,i. "�` a.r='�. �� : R� -•�«Sk r 'Gu'.i .A' • " '. -h ,ry tl•� „y ` „� .5+�...Y 31 , _ W Permit , ce' Where.a,Cectificate of Occupancy;is;Requred,such 6.uildmg sFiallrNo be Occupieduntil a Finalalnspection has.;been made _' Permit NO. B-18-2811 Applicant Name: Craig Bishop Approvals Date Issued: 08/27/2018 Current Use: Structure, Permit Type: Building-Insulation:Residential Expiration Date: 02/27/2019 Foundation: Location: 328 ARROWHEAD DRIVE,HYANNIS Map/Lot 270-098 Zoning District: RB Sheathing: ,, ' Owner on Record: VANKLEEF, H MICHAEL JR ,; Contractor Name Craig P Bishop Framing- 1 Address: 328 ARROWHEAD DR II ;Conteactor:License GCS 109777 2 HYANNIS, MA 02601 a EstProJct Cost: $614.00 Chimney: Description: Air Sealing&Weatherization = PermitFFee: $85.00 Insulation: Project Review Re Fee'Paid 5 85.00 J G Final: y} d Date 8/27/2018 t', a o Plumbing/Gas r 55 .. Rough Plumbing: it Building Official i g Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authonzed by this permit is commenced within six months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved applicatiorrand th_eiapproved construction documents forawhich this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in with the local zoning by laws and codes. final Gas This permit shall be displayed in a location clearly visible from access street or,road and shall be maintained open fonpublic inspection for the entire duration of the work until the completion of the same. " _ Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this'permit. Service: Minimum of Five Call Inspections Required for All Construction Work: „y . 1.Foundation or Footing *s ti g Rou h' 2.Sheathing Inspection " 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough`. 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. �Zif' �j�' � Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire,Department. Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Town of Barnstable Building �...,. , s - PostThis Card SoThat rt�s,Visible:From the,.Stret ;A ro�edPlans Must-sbe Retained on;Job and this Card Must be,Kept « BApEFtSYeStE. " , � • - 6 sd UntilFinal Po te lns ectionH„as Been�Made�s -� {{�� ��, fx ° Wh'ere a.Certificate�of Occu anc. is Re, ,aired,suchwBu�ldmg shall Not;be Oceapied antlla Final lnspectionahas been made" h �j l� Permit No. B-16-1813 Applicant Name: Michael VanKleefl Map/Lot: 270-098 Date Issued: 07/25/2016 Current Use: Zoning District: RB Permit Type: Alteration INTERIOR Work Only-Residential Expiration Date: 01/25/2017 Contractor Name: Location: 328ARROWHEAD DRIVE,HYANNIS Est Project Cost: $5,500.00f Contractor License: l Owner on Record: VANKLEEF H MICHAEL JR P,.errnit Fee $85.00 Address: 328 ARROWHEAD DR �. Fee Paid $85.00 J J. HYANNIS, MA 02601 7%25/2016 Description: Construct a bathroom on the second floor of the house,right above the existing bathroom _ x t Jl Project Review Req Construct a bathroom on the secondxfloor of the house, right above the existing bathroom. j, Building Official i, This permit shall be deemed abandoned and invalid unless the work authorized,�by, s permit s commencedtwith�n si mor the after issuance. All work authorized by this permit shall conform to the approved apphcatio and the approved constru""coon documents for which this permit has been granted: 0 . All construction,alterations and changes of use of any building and structures shall,be in compliance with the local zoningFby la s and codes.. a This permit shall be displayed in a location clearly visible from access street road and shall be maintained open for,p blic ni spection for the entire duration ofthe work until the completion of the same. The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on"th�permit. Minimum of Five Call Inspections Required for All Construction Work: ,, 1.Foundation or Footing € . 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is nstalled� ' - y 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection ' ' 5.Prior to Covering Structural Members(Frame Inspection) ` 6.Insulation ,° ; 7.Final Inspection before Occupancy Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. ON4'ZrvE "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). S J-�- Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT a. • r -z2 ,s . hay Cape Save Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 508-398-0399 1/16/15 Thomas Perry CBO Town of Barnstable Building Division 200 Main St. Hyannis,MA 02601 RE: Insulation Permit 201404522 Dear Mr. Perry . This affidavit is to certify that all work completed for 328 Arrowhead Drive,Hyannis has been inspected by a third party Certified Building Performance'Institute(BPI)Inspector. All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey NOISIA1 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map a V Parcel T O Application # Health Division Date Issued Conservation Division Application Fee Via. 06' Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 3 Village t4polll15 Owner t'►16 e, An k e+ Address sSa,M t° Telephone s0 (�1�- ( ot R5 Permit Request pa R-14 Lon, t d teltYLIuse, '6 andMr seA snp, r s , Square feet: 1 st floor: existing proposed 2nd floor: existing propose T I neig Zoning District Flood Plain Groundwater Overlay lc_ e Ln o Project Valuation k K 0 0 Construction Type � _ Lot Size Grandfathered: ❑Yes ❑ No If yes, attach sul iporting docuniffitation. c» Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) S;! w Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's lighway.gi Yeg; ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor,Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No, Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing. ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes XNo If yes, site plan review# Current Use Proposed Use _APPLICANT_INFORMATION (BUILDER OR HOMEOWNER) Name ill Telephone Number �50$ �8 034P 7 Address D IC6 41 film"6ro Cif- License # C t�� �ou YarA01h ��'a.b�� Home Improvement Contractor# _1711380 Email Worker's Compensation # WC O 8 5 b 3 3 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO SIGNATURE DATE ­�/ a v FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE s OWNER DATE OF INSPECTION: - FOUNDATION 4 _ FRAME 3 INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL R FINAL BUILDING DATE°__CLOSED OUT ASSOCION PLAN NO. Building Permit Authorization, '. I, MichaeLwanK eef , as owner hereby give my permission to Cape Save, Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Office: 508-398-0398 , to take all necessary steps to obtain a building permit to perform work at my property located at 328 Arrowhead Drive Hyannis, MA 02601 Signed Date The 0mmonwealth of Massachusetts Department of Industrial Accidents Office of Investigations f 6 , 7 1 1I Congress Street, Suite 100` Boston,MA 02114-241 7 www.massgov/dig Workers'-Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legible Natne(Business/Organization/Itidividual): Cape Save Inc. Address: 7D Huntington Ave City/State/Zip: South Yarmouth,MA 02664 _ Phone#: 50:8-398-0398 Are you an employer?Check-the appropriate box: Type of project(required}: 1.0 1 Am a employer with l 4. Q I am a.general contractor and l p 6. ❑New construction employees(full and/or part-tithe):'` , have hired the sub-contractors listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have g. Q.Demolition workingfor in an ca aci employees and have workers' Y p. ty 9. Q Building addition: i No workers comp.insurance: comp.insurance.* required.]_ We are a corporation and its 10.Q Electrical repairs or additions:. 3.❑ 1 am a homeowner doing all work officers have exercised their " 11.Q Plumbing repairs or additions myself. [No workers' comp. right;of exemption per MG 12.Q:Roofrepaits insurance required]t c. 152, §1(4),and we have no employees. [No workers' 13.Q✓':Other Insulation. comp.insurance required;]. "Any applicant that checks box#] must also Fill ouville section below showing their workers'compensation policy inlonnahon. t Homeowners who submit this affidavit indicating thev are doing all w{ork and then hire outside contractors must submit a new atTdavit indicating'suct: aCont actors that check this box must attached an additional skeet showing the'name o6he sub-contractors andstute whether or riot those entities it employees: If the sub-contractors have employees,they mustprovide their workers'comp:police nutitber. I ant an employer that is providing workers'contpensalinn insurance fvr nzyenzp/oyees. Below is the policy and job site information, Insurance Company Name: Wesco Insurance Company Policy#or Self-ins.Lic.# . WWC3085b33 Expiration Date.:, 04/09/2015 JobSite Address- 3 � A fo ka � Gity/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy numb rland expiration date)., Failure to secure coverage.as.required raider Section 215A of MGL c. 152 can lead to the imposition of criminal;penalties of a -fine up to S 1,500 00 and76r one-year imprison rnent,as well as civil penaltiesJn the form of.a STOP WORK ORDER and a fine, of up to$250.00;a day against the;violator. Be advised that a copy of this statement maybe forwarded to the Office of lnvestigafions of the DIA for insurance coverage verification. /do hereby certi under the dins and enalties of er` ,that the in orznatioit provided above is true and correct r_. S etiature: Phone'# 509-39$-0390 Official use os l}�., Do.rzot write iia"11z s area, o be cotrtpleted:8y e ty:6.totyn official. ' City or'Town .. _* Rermit/License. assume Authority(circie one): 1.Board of Health 2.:Build ng'Department-3.CitytTo .4 Clerk 4.Electrical inspector 5.Ptumbmg Inspector 6.Other Contact Person: ACURO® DATE IMMIDDJYYYYy CERTIFICATE OF LIABILITY INSURANCE 4/14/2014 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 INSIURER(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 oftthe policy,certain policies may require an endorsement. A statemen.t on this certificate does not confer rights to the certificate holder In lieu of such endorsement is). PRODUCER NAME:CONTACT ColleenCrowley Risk Strategies G`OItlpany PHONE (7$1j 986-4400 FAX (T81)963-9920 IC No 15 Pacella Park DriveADDRESS.Ccrowley@risk"strategies.com Suite 240 'INSURER(s)AFFORDING COVERAGE :NAIC# Randolph MA 02368, P INsuRERA:Selective Ins. , of America. INSURED iNsupERB-Safety Insurance C afty 33618 Cape Save, Inc INSURERic:Wesco Insurance CoMany. 7 D Huntington Ave INSURERO INSURER E South Yarmouth MA 02664 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1441475243 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'MAYHAVE`BEEN REDUCED BY PAID CLAIMS. .�TRR TYPE OF INSURANCE POLICY NUMBER SR MM DD:EFF (MPMI ICY E P LIMITS GENERAL LIABILITY _ EACH OCCURRENCE $_ 1,000,000 X COMMERCIAL GENERAL LABILITY DAMAGE �TE(5rc PREMISES Ea occurrence $ 100,000 A CLAIMSAIADE OCCUR 1999480 0y16/2013 0/16/2014 MED EXP(Any one person) $ lo,000 PERSONA LAADVINJURY $ 1,000,000 GENERAL AGGREGATE GEN'L AGGREGATE'UMIT APPLIES PER: PRODUCTS-COMP/OP AGG .$ 2,DOD,000 POLICY X PRCT X LOG $ AUTOMOBILE LIABILITY Fa accident)SINGLE,LIMIT. 1 000 000 ANYAUTO 86DILY INJURY(Per person), $ B ALL OWNED :U SCHEDULED 208200 1./6/2013 1/6/2014 AUTOS AUTOS BODILY WJURY(Per accident) $ NON-OHIREDAUTO.S X AUTOSwNED pe ecad DAMAGE .$ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAINIS-MADE. .AGGREGATE $.. 1,000,000 a1-- - 1994480 -0/16/2013 0/16/2019 -- - . GEt? RETENTION � C' WORKERS COMPENSATION - Officers Included For WC STATU- 6TH AND EMPLOYERS'LIABILITY YIN, $ R l ANY PROFRIEfORIPARTNER/EXECUTIVE Coverage E.L.EACH ACCIDENT $ 500. OAO OFFICERIMEME.EREXOLUDEM NIA 3085633 /9/2014 /9/2015 (Mandatory in NH). - E.L.DISEASE-:FA EMPLOYEE $ 500,000 IFy�a under D IV OPERATIONS'below describe nder • 'E.L.DISEASE:-.POLICY LNIT '$ 500 000 +' DESCRIPTION OF OPERATIONS FLOCATIONS I VEHICLES(Attach ACORD 161,Additional Remarks Schedule,it more space is required) Issued as evidence of insurance. Issued as evidence of insurance. Thielsch :Engineering; Inc. is listed as additional insured as respects General Liability as required by written contract.... CERTIFICATE HOLDER CANCELLATION msong@capelightColtpact.Org SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Cape Light. Compact ACCORDANCE WITH THE POLICY PROVISIONS.. Attn: Margaret Song PO Box 427fS.CH AUTHORIZED REPRESENTATIVE 3195 Main Street Barnstable, MP . 02630ares' C" -lam chael Christian/CLC ACORD 25 2010/05 { ) O T988-2010 ACORD CORPORATION. All rights reserved. INS02512010%)..01 The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 10 Park Plaza Suite 5170 Boston,Massac tts 02116 Home Improvement Contractor Registration . , FE Registration 171380 Type Corporation Expiration ;3/14/2016 Tr# 249649 CAPE SAVE INC. WILLIAM MCCLUSKEY 7-D HUNTINGTON AVENUE " ` w SOUTH:YARMOUTH; MA 02664 1 pdate Address and return card:Mark reason for change.', Address Renewal Employment "Lost Card SCA 1 Co 20M-05/11 - . V1Le CPCY/7YY/7�I2LlI6ClGLiL Q�C/(GCLJtCGCJZlG1PLt3 Office of Consumer Affairs&Business Regulation ; I License or registration valid for indrvidul use only OME.IMPROVEMENT CONTRACTOR " before the expiration date. If found returp to j egistration A7t380 Type ;` Office°of Consumer Affairs and Business Regulation Expiration-3-12016 Corporatan 10 Park Plaza,-Suite 5170 Boston,MA 02116 CAPE SAVE INC: lI Q F q WILLIAM MCCLUSKEYM I r % 7-D MUNTINGTON AVENUE`r g•r�N�__o `t SOUTH YARMOUTH MA 02664 Uodersecietary Not vali rthout signature Massachusetts -Department of.Pubtic Safety Board of Building Regulations and Standards Construction Supenisor Spccialty License CSSL-102776 WILLIAM J MC GLIMIU, 37 NAUSET ROAD i ' West Yarmouth IRA 0267r3 Expiration Commissioner 06/28/2015 ; S Town of Barnstable �tHE h�-� Regulatory Services Thomas F.Geiler,Director MAft 144 Building Division 1639' Tom Perry,Building Commissioner Y� 1; 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 PERMIT#, ad/3 0�_3 2S� FEE: $ 35 - .. SHED REGISTRATION RESIDENTIAL ONLY 200 square feet or less 3aS- Afro,,Aectd &Ive- at)n Location of shed(address) Villag H. m tc lad U��,Ko s-9�7 a7s Property owner's name Telephone number Size of Shed Map/Parcel# Aill_=Xow Signature Date � � O Hyannis Main Street Waterfront Historic District? Al C Old King's Highway Historic District Commission jurisdiction? If over 120 square feet,you must file with Old King's Highway cm M Conservation Commission(signature is required) Sign off hours forZonservation 800-9:30&3:3 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. .THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:052813 Town of Barnstable Geographic Information System June 7,2013 ` 270187 { 10 #312 270160 270065 #33 319 e�i k ti O Q 270097 { Q #320 270159 Nt c #25 ti t Z a:: t 270063 '` Lv 270158 ' " � v O e a ? ~.9 ti' tirti i5' ii 270170 270064 � #18 270099 #9 6 r 269179 0 20 Feet 289178 #3 Y° DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:270 Parcel:098 boundary determination or regulatory interpretation. Enlargements beyond a scale of Selected Parcel 1"=100'may not meet established map accuracy standards. The parcel lines on this map Owner:VANKLEEF,H MICHAEL JR Total Assessed Value:$205300 are only graphic representations of Assessoes tax parcels. They are not true property Co-owner: Acreage:0.19 acres Abutters boundaries and do not represent accurate relationships to physical features on the map . such as building locations. Location:328 ARROWHEAD DRIVE Buffer i^ ofYKKEr Town of Barnstable *Permit# Expires 6 months jrorn issue rint Regulatory Services Fee � STtiB � v� N & 1�$ Thomas F. Geiler, Director °lto) Building Division Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstab le.ma.us Office: 508-862-4038 Fax: 508-740-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY ^-� Not Valid without Red X-Press Imprint u Map/parcel Nmber_ -/O � Z Address 1)r -ep-V r. g�, yil✓t ential Value of Wor 000 Minimurn fee of S25.00 for work under$6000.00' Owner's Name& Address �(�� ap ) U4/) 1,lee� Contractor's Name �� _Telephone Number . E Horne Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ©27 — ❑Workman's Compensation Insurance -PRESS PERMIT Check one: e�i ❑ I am a sole proprietor NOV 2 4 2009 7am the Homeowner have Worker's Compensation Insurance TOWN OF BARIVSTABLE Insurance Company Name /Ve W rr%,�.s/ 'l'e / Workman's Comp. Policy Copy of Insurance Compliance Certificate must be on tile. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to b ❑Re-roof(not stripping. Going over existing layers of roof) /Re- Idle Replacement Windows. U-Value �, S (maximum .44) �} *Where required: issuance of this permit does not exempt compliance with other town department regulations;i.e.hiistoric;£onservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. �.Ho15-te provement tractors License& Construct Supervisors License is required, SIGNATURE: � Q:\WPFILESTOPN-[S\Express\EXPRESSPERMIT.DOC rt I? The Commonwealth of Massachttsetts Department of Industrial Accidents Off ee of Investigations 600 Washington Street Boston, 314 02111 www,mass.gov/dia "Wrri 1pensation Insurance Affidavit: Builders/Contractors[Electricians/Plumbers Please Print Legibly Applicant Information D Name(Business/Organization/Individual): �l'v (CJE't Address: City/State/Zip: 30 S 3 Phone #: FEDI anmployer? Check a appropriate bo Type of project(required): employer with d� 4• I am a general contractor and I 6 7. Q N construction ees(full and/or part time).* have hired the sub-contractors Remodeling " sole proprietor or partner- listed on the attached sheet.___ These sub-contractors have g. Q Demolition ship and have no employees employees and have workers 9 Q Building addition working for me in any capacity. comp. insurance-T [No workers' comp.insurance 10.❑Electrical repairs or additions required.] ' S• ❑ We are a corporation and its officers have exercised their 1 1.❑Plumbing repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL myself.[No workers' comp." g p p 12.❑Roof repairs c. 152,§1(4),and we have no 13.❑Other . insurance required.]t employees. [No workers' comp.insurance required.] *Any applicant that checks box#11 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. Insurance Company Name: Expiration Date: 3 / U Policy#or Self-ins.Lic.#: �} City/State/Zip: /T' /I//'✓;15 /V�7 UdGO, Job Site Address: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ies of a Failure to secure coverage as required under Section 25A$1 of MGL c. 15alties in the form of.a STOP WORK ORDER2 can lead to the imposition of criminal and t,as well as civil penalties a ftne fine up.to ,500.00 and/or one-year imprisonment, of up too$1 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 cover a e verification. I do hereby certify u the pains and penalties of perjury that the information provided above is true and correct. Date: Signature: 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 Phone Contact Person: #: The Commonwealth of Massach usetts Department of Industrial Accidents k Office of Investigations 60 Washing ton on Street. .. gt Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: W I ti q City/State/Zip: ;` 1 vtj AAPhone#: s 0_ ' � Are you an employer? Check the appropfi a box: Type of project(required): 1.VI roam a employer with 4. I am a general contractor and I 6. ❑Ne construction mployees(full and/or part-time).* have hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet. 7. � emodeling p p p These sub-contractors have ship and have no employees 1. ❑ 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.[D 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. Insurance Company Name: veftlJ !'►f40 1, r"r/ Policy#or Self-ins.Lie. P1 Expiration Date: `1® OX Job Site Address: Lnojaj City/State/Zip: ; .` . . 0� 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 zmder thepains and penalties ofperjury that the information provided above is true and correct. Si ature: Date: Phone#: Offccial 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#: vJ/ LJ/ LVVJ VV• VJ LJ..IJIVL _ 1 '•IVL U1 �1u>�achu�ctr�,- Drh:u•tm�m Ilf 1'uFtlir �;(fr1� Board jrr'BuildiI12 Ri"atilatiolis and Construction Supervisor. License License: CS 70077 Restricted to: 00 JOSEPH C DUARTE 15 FALL ST WAREHAM, MA 02571 Expiration: 12/30/2010 ( Imuni..illnl r Tra: 7662 .� 6,o4srinanuwoa//� r /•. '`lau<u�wa�dd �.\ Board or Building liegul►tio,u NnU 51a►►darUs ugNOME IMPROVEMENT CONTRACTOR Registration: 132349 Expiration: 1/11/2011 Tra 278918 Type: Partnership J&J Remodeling Joseph Duarte �.. 15 Fall St. � Wareham.ma 02571 ,1Uministratur • ' es* g - - - -swmmem 4a - UW &.,do6& mat iml11 80sMm Rm 1301 ; ecn.•�a. 02t ' Not g T HOME IM PROVEMENT CON'IT9ACT PLEASE READ THIS �F / Sold,Furnished arid Installed by: branch Name: Boston Date: /i 0, THD At-Home Services,Inc. d/b/a 'rhe Home Depot At-Home Services 345A Greenwood Strect;Unit 2,Worcester,MA 01607 Branch Number:31 Toll Free(800).657-5182; Fax(508)756-8823 Federal ID#75-2699460;ME Lic#C 02439;Ri Cent Lid#16427 fCT Li0i 5655[222;MJAA Home Improvement Contractor Reg.0 126893 Installation Address: $(�J� Vi 4V� nnls �_aa b City State Zip Purchasers) - - Work Phone: Home Phone: Cell_Phonc: q61 Y, Roane Address:_ (i.f different ftom Installation Address) city State = Yip F-mail Address(to receive project communications and Home Depot updates) - ❑I DO NOT wish to receive any-marketing emails from The Horne Depot Plroiect Information: Undersigned("Customer'),the owners of the property located at the above installation address,agrees to buy, and THD At-Hume Services,Inc.("The Flume Depot")agrtxs to furnish,deliver and arrange for the installatiun("Installation")of all•materials described on Ole below and on the referenced Spec Sheet(s), all of which ate incorporated into this Contract by„this reference,along with.any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively, "Contract"): Job#: a h_aita..ar i ducts: S shex s #: PM[Le Amount ❑Rating ❑Siding Wint1. lnsulatiem / f L0 ❑Gutters/Covers' ❑Entry Doors ❑ Roufmg LjSldmg U Windows ❑Insulation $ r []Gutters/Covers DEntry Doors [I Roofing LjSiding wlndowr;.❑Insulation $ /` ❑Gum-r8/Covers ❑E=y Doors❑ ....._ _..,.�._ / ►►/n/�/ (((/JJAAp�t, ❑Koofing ❑Siding ❑Windows ❑Insulation $ 1✓ ❑Gutters I Covets ❑Entry Doors ❑ V wanimum 25%Deposit of Contract Amount ape upon""cation of this contract. 'Dotal Contract Amount $ Maine Purchasers may not deposit more than one-third of the Contract Amount d Customer agrees that, immediately upon completion of the work for each Product,!Customer will executea Completion Certificate (one for each Product as defined by an individual Spec Shcc:t)and pay any balance due..As applicable,each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. The Home.Dcpot reserves the right to issue a C:hangc Order or terminate this Contract or any individual Product(s)included herein,at its discretion,if The Hoene Depot or its audiorizW service provider determines that it cannot perfortwits obligations due to a.structural problem with the home,environmental hazards such as mold,asbestos or fetal paint,otter salcty concerns,pricing errors or bet ausc work rcttuircd to complete the job was not included in the C Payment Stimmaiy: The Payment Summary 4 R -0 ; included as part of this Contract, sets forth the total Contract amount and payments required for the deposits and final payments 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(hole-. there is one Completion CertifIeate for each listed Product as defined 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 HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOMI; DEPOT FROM Tilt': DEPOSIT PAYMENT OR OTH>rlx .PAYMENTS MADE, WiTF(OU'1' LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization:.Customer agrees and understands unit this Agreement is the entire agreement bcrivccu Customer and The Home 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 cannut be a.Ysigmcd or amended except by a writing Signed by Customer and The Home Depot.Customer acknowledges and agrees that Customer Iles rend,understands,voluntarily accepts the terms of and has received a copy of this Agreement ArCRpte Sgbmi bys Customer's Signature VDate / Sales Co Itant's Si atdate X Telephone Customer's Signature Date Sales Consultant License Nu: CANCELLATION- CUSTOMER MAY CANCEL TMS (as; plicablc) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE'TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING TWS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO "USE iF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE:ADDITIONAL.TERMS AND CONDITIONS ARE STATED ON THE REVERSE qME AND ARE PART OF THIS C.ON'I'RAcr `1-15-09 CSC white—Branch File Yellow—Customer Pink=Safes Consuftant Id WdM:? 900Z 8F FIeW ON Xui W021A