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Home My WebLink About0134 BAXTER ROAD 13�13�X-I-� 2� - - - --- _ � Town of Barnstable *Permit# lEx�sisea 6 can ne a date Regulatory Services Fee MAM nerx Richard V.Scale,Interim Director. er►1s Biffiding DiviSiOB ' t Tom Perry,CB09 Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.maus Fax:508-790-6230 Office: 508-862-4038 ` EXPRESS PERMIT AppLICATIo1V a RESIDENT ®l��' Not Yaifd without Red X-Press Imprint Map/parcel Ntmiber. � Address 3 S - . esideatial .Value of Work$7 J Minimum fee of$35.00 for work sender$6000.00 Owner's Name&Address 3y Sd Telephone Number �&1'7/_�_10� �� Contractor's Name Home Improvement Contractor License#(if applicable)_LR_6__0'_f3 Construction Supervisor's License#(if applicable) a [ V�orkman's.Com 7sation insurance T v ®EC Q 1.2014 "� Check one:. ' ❑ 1amasoleproprieto> TOWN OF RARNSTABLE , ❑ lam the Homeowner I have Worker's Compensation insurance Insurance Company Name W orkman's Comp.Policy# v �I " Copy of insurance Compliance Certificate must accompany each permit. cJkOY�- ' Permit Rcquest )(check box Reroof box)cane.naned)I(stripping old shingles) A0 construction debris will betaken to�;Aw �4�f ®Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side . maximum.35)#of windows ❑ Replacement Windows/doors/sliders:U Value #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. on,etc. aWltere required: Issuance of this permit does not exempt compliance with other town department-gulatioits,i e historic;Conservation, ***Note: Property; Cr ign.Property®weer Letter of Permissitsn. t A copy of 13 a improvement Contractors License&Construction Supervisors License is required. SIGNATURE: TACFM P�Building Changes S RESS.doc . Revised 061313 The Commonwealth of Massachusetts Eb Department of IndustrialAccidents r Office of Investigations I Congress Street,Suite 106 Boston,IAA 021142017 www-mass.govldia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electrician�/Plu Albers iea>lnt Information Please Print ILeg1<�ly Name (Business/organization/Individual): HOME DEPOT AT HOME SERVICES Addiess:2455 PACES FERRY ROAD A G / tate/Zip:ATLANTA, GA 30339 Pho .774-265-2139 ;WMployees employe ?Chec the appropr' to ; Type of project(required): .employ �-. � am a general contractor , d I ( 1 part-time).* have hired the sub-contractors 6. ❑Ne,,v 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 capacihe. employees and have workers' [No workers' comp. insurance comp. insurance. 9. ❑Building addition' required.] We are a corporation I0.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work ised their 11.❑Plumbing repairs or additions myself. [No workers' comp right of exemption per MGL 12 g Roof repairs insurance required.] t c. 152, y 1(4),and we have no - ` employees_ [No workers' 13.0 Other comp. insurance required.] "Airy applicant that checks box T1 must also fill out the section below shoring their ieorkers compensation policy information. r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractor must submit a nen•afdavitindicating such. Con tractors that check this box must attached an additional sheet sho�xing the name of the sub-contractors and state whether or not those entities have employees, if the sub-contractors have employees,they must proxide 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:NEW HAMPSHIRE INS. CO. - Policy#or Self-ins. Lic.#:WC049101882 Expiration Date:3/1/2015 Job Site Address:_ /-1 dxj l"y City/State/Zip: Mian Attach a copy of the workers' compensation policy declaration page(showing the policy nu er and expiration date): Failure to secure coverage as required under Section 23A o£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 thelator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA foriquroce coverage verification. d do hereby certify under p a e the information provided above is true and correct. ' Signature: Date: �iUz- 17( Phone 4. 401-714-6399 Official use only. Do not tvrite in this area,to be completed bj city or town official. City or Town., ,Perirtit/Liceaise# Issuing.Authority(circle one): 1.Board of Health 2.Building Department,3.City/Town Clerk 4.Electrical lnspeetor 5.Plumbing Inspector 6.Other - Contact Pei-son: Phone#• ` . r Si tr�,�r��z�zr�ecr.�� sc�i .U��1 Lr�e Office of Consumer Affairs and Business Q•r.- ness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 . Home Improvement:Contractor Registration - _ Registration: 126893 - Type. Supplement Card THD AT HOME SERVICES, INC. Expiration: 8IV2016 ANDREW SWEET 2690 CUMBERLAND PARKWAY SUITE - ATLANTA, GA 30339 - - - - Update Address and return card.illark reason,for change. .sc 2oa1 osrn J.Address �i=1 Renewal ! Employment.f� Lost Card . �Y�P ((f•Ur qit+gn:ryl//�a,(%!(rtJ.itirylicir�/.i .. .. _ 1 Office of ConsumerAfLiirs llvsinessllegulation. ` License or registration valid for individul use only I, ( HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to* Office of Consumer Afrairsand Business Regulation •=�=1=� Registration: 126893. TIPu� . IO Park Plaza-Suite5l70 xpiraUon: 8iX2016 Supplzmen,Card Boston,;12;10? Su T un rr un%Ac ecawye_e jai. /1l rHE HOME DEPOT AT HOME SERVICES / ANDPEW SWEET 2690 CUMBERU016'PARKI1P/AY S i it 40m,kit, ors of € �aater cc� -.k °CSSL-1010ZT`: }x 16 i�€ort&.Street .. . r All te�ia�tiam MA#017�DZ` of 114111.:,SOLO firm Cfs "t. 1.2i0J/2015 H. .xcy-. .P.o. .....:h .... ,.A.. . • of �` ,. r Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, AM 02114:2017 www.massgov/dia ' Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le •bI Name (Business/Organization/Individual): Address: a oer City/State/Zip: AA 61?42. Phone#: Are you an employer?Chec the appropriate bog: Type of project(required): 1.❑ I am a employer with 4• ❑ I am a general contractor.and I 6: El New construction employees(full and/or part-time).* have hired the sub-contractors 2Al am a sole proprietor or partner- listed on the attached sheet, 7. ❑Remodeling ' shipand have no-em to These-sub-contractors have p 8. fl Demolition working for me in any.capacity.' employees and have workers' comp.insurance.* 9:.[]Building addition n [No workers' comp,insurance p• required.] 5•_❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ Lam a homeowner doing all work officers have exercised their I LEI Plumbing repairs or additions myself[No workers'comp. right of exemption per MGL 12 Roof repairs insurance required:]t F c. 152, §l(4);and we have no 13.❑Other • employees. [No workers' comp.insurance required:] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached en 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 Beloiu is the policy and job site information. Insurance Company Name: ° 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 insurancepocy,erage verification. 1 do hereby u e t e pains a44j&ahies!kf&Uuq that the information provided above is true and correct Si afore: Date: .,Phone#: Offu:ial use only.'Do not write in this area,to be completed by.etty or town official City or Town: Permit/License# S Issuing Authority{cjrcle one). 1.Board of Health 2.Buildin Department 3.Ci %''own Cie .El. g Pa rk 4 Electrical inspector 5.Pl um iumbin . , , P 6.Other g Contact Person: Phone#: F. HOME IMPROVEMENT CONTRACT Sold,Furnished and Installed by PLEASE READ THIS CONTRACT THD At-Home Services,Inc d/b/a The Home Depot At-Home Service- 908 Boston Turnpike Unit l,Shrewsb MA 1541 Branch Name: Boston South Date: 11/21/2014 Toll Free 8779033768- 800986361(ME Lic#C 0243W16 Cont.Lic#1.6427 CT Lic#HIC.0565522 MA Home Improvement Branch No: 31 Contractor Reg.# 126893 Federal ID 4 75-269846C Installation Address: 134 Baxter Rd HYANNIS 'MA 02601 City State zip Purchaser(s): Work Phone: F . .Home Phone: Cell Phone: M/M Betsy Hendricks (508)775-9018 Home Address: HYANNIS MA r 02601 (If different from Installation Address) City State zip E-mail Address (to receive project communications and Home Depot updates):homer(i,homedepot.com Marketing emails will not be sent from The Home Depot. Proiect Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to. buy,and THD At-Home Services,Inc. ("The Home Depot")agrees to furnish,deliver and arrange for the installation("Installati _. on")of all materials described on the below and on the referenced Spec Sheet(s),all of which are incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary(where applicable)attached hereto and any Change Orders(collectively, "Contract"): , Job#:(Internal Reference) Products: -Spec Sheet(s): Project Amount 7947488 Roofing 7947488 $7,567.00 Minimum 25% Deposit of Contract Amount Total Contract Amount $7,567.00 due upon execution of this contract Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion- Certificate (one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable, each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder., The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s) included herein,at its discretion, if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem with the home,environmental hazards such as mold,asbestos or lead paint,other safety concerns, pricing errors or.because work required to complete the job was not included in the Contract. Payment Summary: The Payment Summary'# '7947488, ,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). 9114SA Page,1 of 7 I u AFTER SIGNING THIS AGREEMENT.THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE t L• � aI a X �r �„IL�LC �'S e Betsy Hendricks (Nov 21, 2014, 12M P on Hendricks (Nov 21, 2014,.12:05 PM) r . Accepted by:Christopher Read(Nov 21, 2014: 07/09/14-SA Page 7 of 7'