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HomeMy WebLinkAbout0014 BUMPUS ROAD o�VE Application number. :._?. 1 ... ........ Date Issued.. ��.�.�.�.� .......... BARhS1'ABI:E. ° jf s ��'�ry .................. • 4 MASS. �a 2a39. �� tf`, Building Inspectors Initials.......... v ................... Map/Parcel.......I.�.....0 3 4............................ TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WF,ATHERIZATION PROPERTY INFORMA TON Address of Project: NUMBER STREET VILLAGE Owner's Name: to'f CJ./.s01 Phone Number 508- 77S 9 9 7 1 Email Address: r—nLn¢r'} ;.y c o'ic o N. Cell Phone.Number Project cost$_ qL,( _ Check one Residential ,/ -- Commercial OWNS.+W 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- ad,,-Q � ���- Date: TYPE OF WORK ❑ Siding Q/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 w CONTRACTOR'S INFORMATION Contractor's name A �� �,✓P o ,e ( L/S A Home Improvement Contractors Registration(if applicable)# 112-7 (attach copy) Construction Supervisor's License# 0170 o 7 7 (attach copy) Email of Contractor 5wel-1 ft S a 11 • C c3--^ Phone number 4�'o /- 7IV- 6'3'3 9 ALL PROPERTIES THAT HAVE STRUCTURE OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY 15 IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. I ' APPLICATION NUMBER............................................................ *For Tents Only* 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 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 Iffood is being served at your event lease 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/COA,CPELLET STOVES x Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles:front back left side right side HOMEOWNER'S LICENSE EXEN Y HJION 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 /APPLICANT9S SIGNATURE Signature lk,4� Date -7— 31-1 All permit applications are subject to a building official's approval prior to issuance. -isma COmmOmyealth of Massachusetts Division of professional Licensure Board of Building Regulations and Standards COnSt j Win'Supervisor CS-070OT7 ar } � f,plres: 1213012t12Q JOSEPH C RTE� LL Is.FA Sa ti -, ^'t NN COIL missioner f Office of Consurnei Affahi k Business Regulation 4 n HOME"IMPROVEME4fCONTRACTOR Reg�stiatfort valFdtoc indrv�dua{use only ehxpd Rrtem toTPE:P hm beor u en ' Reaistrabion Excxrefion Offiice'of ConsuinerAffarrs and 8usu�as5 S6gulabon t?21 t000 Washington Street Sutta 71Q 't32399 Oi/'{i)t2 Sosto�,NtA tY11't8 _ •; �` � JOSEPH C.DUAR� :;�, D/BIA J&J REIUtfJOEt.INfs { Y r f JOSEPH C ©UARTE -' 15 FALL ST - of vaf[d withoaE signature"{ WAREHAM,MA"02571, undersecretary The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' a I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information y Please Print Legibly Name(Business/Organization/Individual): Address: �� �i9LL- S T City/State/Zi A 016_71 Phone#: 77,1(- 74i(o'" o�c3CQ Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 4. I am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6. ❑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.comp.insurance p• required.] 5. We are a corporation and its ME]Electrical repairs or additions 3.❑ I am a homeowner doing'all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. Ian:an employer that isproviding workers'compensation insurance for my employees.Below is thepolicy 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 2!M 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 cer 'y unde the pain�gDnd penalties of perjury that the information provided above is true and correct. i nature• !� e: Phone#- Ofcial 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#: The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114 2017 www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Eleetrieians/Plumbers. TO BE FILED W=THE PEPlvffr ING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organizadon/individuai): NnM e- Z-:�,9n-�' Address: 9026 2� S-�nn City/State/Zip: S w MA. 01 TLA S` Phone#: -7-7 L4 -7 `5 - 2. 1 S S' Are You nu employer?Check the appropriate box: Type of project(required)' IQ i am a cmpleyer witlt`lemployecs(full and/or part time).* 7. []New construction 2.[]1 am a sole proprietor or partnership and have no employees working for me in 8. F1 Remodeling,- any capacity-[No workers'comp,insurance required.] 3.[3 I am a homeowner doing all work myself(No workers'comp.insurance required.]t 1 El Demolition 10 Building addition 4.❑r an a homeowner and will be hiring contractors to conduct all work on my property. twill ensure that all contractors either have workers'compensation insurance or are solo 1 L[]Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.011'am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.QR0 f repairs These sub-cofactors have employees and have workers'comp.msumnce t A ' 6.❑We area corporation and its officers have exercised their right of m=ption per MGL c. 14. Other 15Z,§1(4),and we have no employees.[No workers'comp.insurance required.] ry1 ce,,.-e�1'Y '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 now affidavit indicating-oh. $Contractors that eheckthis 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 mrmber. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. ,�// _ Insurance Company Name: t1A;Q,1 r j1-e d�r ur,2,nr a aaal — Policy 4 of Self-ins.Lie.#: X G Jr S S (0 5 5 `��7 Expiration Date- 3 - � -2_O Job Site Address: ✓S City/State/Zip:�n,t.'s *ti Attach a copy of the workers'compensatlowpolicy declaration page(showing the policy number and exp' atioix date). Failure to secure coverage as required under MGL-c.152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonm as ell as civil penalties in the form of a STOP WORK ORDER and a fine of up to$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 empties o information provided above is true and correct Si atlue .. Date: Phone A--.40 317 Official use only. Do not write in this area,to be completed by city or tmpn 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#: Office of Consumer Affairs and Business Regulation . 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home improveme&Contractor 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 -- Update Address and Return Card. SCA t u 2OM-05/17 Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE;0upplement Card before the expiration date. If found return to: R2gWgBEian Expiration Office of Consumer Affairs and Business Regulation _. 04/22/2021 1000 Washington Street Su' 10 HOME DEPOT t:I Boston,MA 02118 ANDREW SWEEF.. -' 2455 PACES FERR°kfWC=Y1 HSC ATLANTA,GA 30339 Undersecretary No slid It ut SI nature i A`� CERTIFICATE OF LIABILITY INSURANCE D0A210Efi2C19DIYYYY) 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: PHONE FAX TWO ALLIANCE CENTER C. o AIC No 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA.GA 30326 ADDRESS: _ INSURERS AFFORDING COVERAGE NAIC N 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 ATLINTA.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; TYPE OF INSURANCE IAODLISUBRi j POLICY EFF POLICY EXP LIMITS LTR` POLICY NUMBER MMIDDIYYYY I MMIDDIYYYY I A X :COMMERCIAL GENERAL LIABILITY FMWZY 314574 i 03101/2019 03/01/2022 EACH OCCURRENCEIIA AGE RENTED To 3 1.000,000 CLAIMS-MADE X ;OCCUR 's PREMISES Ea occur ence 3 1.000.000 X SIR:$1,000.000 'MED EXP(Any one person) 3 EXCLUDED PERSONAL&ADV INJURY 3 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 1,000,000 X POLICY PRO- PRODUCTS 1,000.000 JECT PRODUCTS-COMP/OP AG 3 OTHER: S A :AUTOMOBILE LIABILITY MWT8314573 03/01/2019 03101r2022 COMBINED TINGLE LIMIT 3 1.000.000 _ (Ea accident) X i ANY AUTO i BODILY INJURY(Per person) ~a OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident)! 3 AUTOS ONLY '.AUTOS i HIRED NON-OWNED PROPERTY DAMAGE 3 AUTOS ONLY AUTOS ONLY i Per accident 3 UMBRELLA LIAR OCCUR EACH OCCURRENCE 3 —~EXCESS LIAR CLAIMS-MADE: AGGREGATE S DED RETENTION 3 3 8 i WORKERS COMPENSATION i INC 012717099(AK,NH.NJ,VT) I! i 03/01/2020 X Sr.4TUTE ! ERH B AND EMPLOYERS'LIABILITY YIN WC 012717100( ) S.000,OOO WI 03I0112019 03101I2020 'ANYPROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT 13 (OFFICER/MEMBEREXCLUDED7 N ;N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEES 5.000,000 If yes,describe under Continued on Additional Page 5.000,000 DESCRIPTION OF OPERATIONS below 9 E.L.DISEASE-POLICY LIMIT!3 C :Excess Auto 297110011002019 03/01/2019 03101/2020 Limit: 4,000,000 A Excess General Liability MWZX 314580 03I01I2019 0310112022 Limit: 8.000,000 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 �Cauao ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CNIO1642069 LOC#: Atlanta ACC)IIR o ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMEDINSURED MARSH USA.INC. THE HOME DEPOT.INC. HOME DEPOT U.S.A..INC. POLICY NUMBER 2455 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:'NLR C65890549(AL.AR.FL.ID.IA.KS.KY.LA,MS.MO.NE.NM,ND,OK,SC.SD.TN,WV.,NY) Effective Date:03/01/2019 Expiration Date:03101/2020 (EL)Umit 55.000,000 Camer:New Hampshire Insurance Company Policy Number:INC 012717098 (DC.DE.HI.IN,MD.MN.MT,NY.Rl) Effective Date:03101/2019 Expiration Dale:03101/2020 (EL)Limit:35.000.000 Carrier:ACE American Insurance Company Policy Number.'NCU C55890586(OSI) (AZ.CA.IL,NC.OR.`/A,'NA) Effective Date:03/01/2019 Expiration Dale:03/01/2020 (EL)Limit:$4.000.000 SIR:31.000.000 SIR for the slates of AZ,CA.IL,NC.ORJ/A,WA Cartier:National Union Fire Insurance Company Policy Number.XWC 5565596(DSI)(CO.CT,GA,,ME,MI,NV.OH,PA.UT) Effective Date:03/0112019 Expiration Dale:03/01/2020 (EL)limit:34,000,000 31.000.000 SIR for the states of CO.MEAVAI.OH,P.4.UT $750.000 SIR for the state of GA $350,000 SIR(whe state of CT Carder:National Union Fire Insurance Company Policy Number:XWC 5565597(GSI)(MA) Effective Date:03101/2019 Expiration Date:03/01/2020 (EL)Limit:34,500,000 SIR:3500,000 TX Employers XS Indemnity: Carderlllinios Union Insurance Company Policy Number.TNS C65221019 JX) Effective Dale:03101/2019 Expiration Data:03101020 (EL)Limit:310,000.000 SIR:31.000.000 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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 entit ed cope of Work which appears on page 0 of this Agreement. Anticipated Delivery Date/Installation Schedule Approximate Start Date: os/17/2019 Approximate Finish Date: 09/14/2019 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 receiv and open emalls and PDF documents. B •nit• ling this paragraph, I consent to receive only electronic records related to this transaction. Initial Ac eptance 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 compl cop of this Agreement. Keep it to protect your legal rights. XIZ( I A 106/22/2019 The Home Depot u ome s Sig atffrV Service Provider Name X 06/22/201 9 908 Boston Turnpike Unit 1 o- ig er (if a pli le) Date Service Provider Address X 06/22/2019 IShrewsbury MA 01545 Signature n B half of Hom De t Date City tate Zi R-I-073-13-00016 Service Provider hone Number Service Provider License Number L� The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care: 1-800-466-3337 460FI HOE Customer Agreement(24 Jul.18) v 0.1.8 Home Improvement Agreement: Pagel Home Depot License #'s - For the most current listing www.Homede.�ot 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. Wilson robert New England South 1-—MA 9Y2AF Customer Last Name Customer First Name Store #/ Branch Name Customer Lead/ PO# 14 Bumpus Road Hyannis MA 02601 Customer Address City State Zip (508) 775-9 1 - 1 irobertandrhonda@yahoo.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 1 Shrewsbury 101545 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 BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF Y R RIGH NCEL. Acknowledged by: AVIIIA111, 06/22/2019 Customer's Signaturb 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: $ 15044.00 Includes all applicable taxes. Excludes finance charges.* Sales Tax: $ 10.00 (If applicable) *Maximum deposit ONLY applicable in MLA, MA, ME(33%), Nil, Wl(99916) Dep. 125.0 % Deposit Amount $ 1261 Remaining Balance $ 3783.00 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 0.1.8 _ Y ► �r_- Town of BarnstablePermit D PERMITExpi s, niontlisfrom issue date Regulatory Services L ?_01.0 v MASS. �� Thorllas:F. Geiler,Director ARNSTABLE Building Division Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 : www:town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number t' 44 r' } Property Address /"-� `'`''�•'.J Residential Value of Work Minimum fee of$25.00 for work.under$6000.00 Owner's Name&Address PC Contractor's Name 6 c Az, � Telephone Number :5d Home Improvement Contractor License#(if applicable) �� L/ /yG Construction Supervisor's License#(if applicable),. IS 0, ❑Workman's Compensation Insurance Check one: EB/Iamasole proprietor ❑ 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 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 ' #of doors Replacement-Windows/doors/sliders. U-Value (maximum .44)#of windows f 0 *Where required: Issuance of this permit does not exempt compliance with other town pdepartment regulations,i.e.Historic,Conservation;etc. ***Not': Property Owner musty sign Property Owner Letter of�Permission. 1 A copy of the home Improvement Contractors License&Construction Supervisors License is . required. 1 SIGNATURE: C� , Q:\WPFILESTORMS\building permit forms\EXPRESS.doc , nnngnn, , i OF HARNSTABLEI ❑ 14y Poe Edit Tools Help En I A := D Year:Type:'Bill No. Customer account information _. uetail� ® i 'CROSS RICH^RCS P Propety information "� 5 T10EIF:C0 V E-UNIT 1-'r7, Ono Bill Panel 1G 1310JO34 ❑CASH VCHECK NA.PLE.S. FL 34113 r sh Parr [ eC.ie rJotc r TOM rr Lac 1 t Bul iPU OF BA �3TABLE� i Lien.Sale - ;(�Special Coridtions;Notes Scan Bill yT r+uickf Entr, Irt Lit Billed Pmt./Crd Interest. � Unpaid bal Lulit• -• 1� 1� ,cct _ 11,U2 v i lei 13 I� Custamer2; VuS, 511 7 1 52 n. Parcel Totals Prop Code Plo3CS :"JertS I u- r" 13.: C10, r Billinc Elates L J:"%N 1 0,, ner. L=t3ROSS,RICH='.RD P Per Diem _. .�.... ! Bill Awdit Irt Paid 11.13 Rec ' i Preferences j Diagnostics i . "rain he effective date. - .. . . -. My Fle Edit Tools Help .........._........_ _......_ ....._.__ __........... Year/Type/Bill No. _ _ Customer account information Histor} .�t�1C RE-R �. . . ; �s . ±. ® ! `C DetailROSS, RICH:ARD P Property information Mecx— C��91 TIGER COVE-UNIT 16:'.J Cria Bill Parcel ID 31 ?` i NAP LEB, =L 3'113 ................ ...... ".k Parc ' E`fecti.�e Date: :. ......... Prop Lrc 1A B U MPlU '. . Lien.--"Sale g9 heeT9R 917 TMES ( Special Conditions Notes Scan Bill i Quick Ern_rr int C. Billed PrTr.C d Interest Unpaid bal i fl.1 r Lfal' ;.cct 5-7 Customer 43:'C2'1C g � 72.1 i 1_ 2.JL 1 3 Namenswvw.uwewwmvmvnxawrS ..sa.exw.. ,.rx.rp ..,wwwx .n+xr+, wwwrnw.mw '-swra.r n. J:.-i Fees;Pen CC C ; L »� Jv .n.mn......._....r..r..+n..+n,...•. ..«..w_n..........w.ry-r....++..... .. r......r�..+«.t...........:« +.,.....e._ .,w..r_ { r el Totals _1 63 2 f' i Prop Code t1o?cs..�'Jerts Due 11 11 eC-IC Billinc Dates _ J:,`.N 1 Ov,ner: 'CRC+SS,(RICH.RD'P Per Diem 43 L: Bill:,'udit Int.'-aid Reprint "Oevv prior unpaid bills Preferences DiaGno,�tics ] _ I _ ..__...... - -- . _.. i Ir1a-i,stain t-•ie ef,ect;ve date. License or registration.valid for individul before the expiration d Office of ate. If found retur use only Consumer n to: 10 park P►aza_ Affairs and Business Suite 5170 Regulation i r Boston,DIA 02116 Not valid Wlth0ut signature i, 7i7i7i���ttt s, • �. - !e�o�rhna�zu�ea �p� aaaac�ivae - 'I Office of Consumer Affairs& Business Regulation I `� s IMPROVEMENT HOME I ``�� ENT � Registra i4- -64440 10/6/201 28 5 ExpirattEa��_ � � 1 Tr# 957 y Type IW-tnWV`dua r , I SHANE PACHELE SHANE PACHE`CO r s 143 HAYES RD. � I Y t CENTERVILLE,MA 02630' Undersecretary " s � G d <tchusetts- Department of Public Safeh Board of Building Regulations and St;lndards �. Construction Supervisor License License: CS 92958 Restricted to 00 s ; SHANE PACHECO ��.' �. • s .143 HAYES RD _ ENTERVILLE, MA 02632 `I ' . WIN Expiration: 10/17/2011 . ('ummissiuncr' Tr#: 4144 i O d — v v �� r a =r,E u. of� _B111-11011 Lr 111 r l Service's es :, :i tt:l.Rli S'T•A F11..E:, •i •i j MA.M `�� Thomas t . l,ei,c 11i.rr:tc,r t6]9• / f \FOJ,,i"r k;uildi:cq; Division ']���in i't rF-'�',atui.lr irts� C�i1rrJ.clsslcrner Aw t,-tt�w.trrtit'rr.i�t+rr;si:rblt=..ln: .us (. *01-1-11)I ate a1:id Sipi This fie cti0i 1ta lint t iIcle, I f }i.. SlibjCCZ_pJ-Uga'iy . I�.Cmby�t!1boiiz 7(i Al, �... _ ttJ <<GC QI] Ill��} �t 1.U1 i L� 1"U1:dUM AMN LO WOH! all(W1—iZC6 by-dli.M 'i1.1dd-i 't jJt1i111L appliC lGc".i'1 or: F (Ad dru,s.s �)fj crh; 3 i ! 7c a7urf C v,,rr:vr I„)at r... Phi a N;•i17 . 11' 1: 'irony OtAgIc:l-iS �,Ipply:iri�; 1i>► pear 'rt please corvipletc LIIC :for-i:reowil -s License Excrnl tioji ,l cai-r71 oil the iLverse Side. The Commonwealth of Massachusetts Department of Industrial Accidents• Office oflnvestigations 11 -ISSI, t500 Washington Street Boston,MA 02111 �� wfvm mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 5 6,- CU, � Address: J43 WtiJ �G City/State/Zip: rl�6*'Vi . M4 _6)&3) Phone #: Are you an employer? Check the appropriate box: Type of project(required): a a em ]o er with 4, ❑ I am a general contractor and I 1.El I m P Y 6. . New`construction mployees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. [✓ Remodeling 2,LJ I am a sole ro rietor orpartner-, P P ship and have no employees These sub-contractors have g, ❑ Demolition workin for me in an capacity. employees and have workers' g Y P Y• ' 9: ❑ Bui]ding addition [No workers' comp. insurance comp.insurance.$ required.] t 5. We area corporation and its. ., 10.n Electrical repairs or addition 3,❑ 1 am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or addition myself. o workers' com right of exemption per MGL y [N p. 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 41 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: 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 fin of up to$250.00 a day against the violator. Be advised that a copy'of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification: I do hereby certify under the pains and penalties ofperjury that the information provided above is True and correct. Signature ,� �y.. ��hez� Date: �/7/j 6 Phone#: 'U -3&q sal ksG 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#: Information and. Instructions. M1 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,constriction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a.reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicant should write"all locations in (city or town). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business.or commercial venture (i,e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of 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 4-24-07 www.mass.gov/dia w s, Town of Ba&nstable Barnstable pgSHE.Tpk A iut mca II{••� - . _ '. _ CipRe Regulatory Services De artment RARINSTABLE, 9 9 MA39.SS. Public Health Division ArEti Mai a' W .200 Main Street, Hyannis:MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL 7008 3230 0002 5178.0905 December 9;2009 a Richard Lacross �r Y 8065 Tiger Cove-Unit 1607 Naples Fl 34113 , 3 EMERGENCY CONDEMNATION M f n ? �o Finding of Unfitness for Human Habitation and �x Determination of Immediate Danger .9 9 In accordance with M.G.L. c.l 1.1, sec.`127A and 127B, 105.CMR 400.000: State Sanitary Code, Chapter L• General Administrative Procedures and 105 CMR 410.000: State Sanitary Code, Chapter II: Minimum Standards of Fitness for Human Habitation,Jaime A. Cabot, R.S., Health Inspector for the Town of Barnstable, on December 8, 2009 conducted an investigation of a dwelling located at 14 Bumpus Road, Hyannis. The owner of this dwelling is Richard Lacross. Based on the results of that investigation, the Barnstable Health Department finds that' the dwelling is.unfit for human habitation.' Pursuant to M.G.L. c. 127B and 105 CMR 410.831 (D), the Health Department further finds that the conditions within the dwelling are such that the danger to the life or health of the occupants.of the subject dwelling is so immediate that`no delay may be permitted in making this finding. ` Conditions found within the dwelling, which give rise to the emergency finding of unfitness and determination of immediate danger;include: 410. 750: Conditions Deemed to Endan er or Impair Health or Safety . . ¢ 410.750 (A) Failure to provide potable_water in accordance with 410:T80. 410.75.0.: B Failure to provide de heat in acco rdance w'rt r 10 5 CMR 410.200. Based upon these findingsk any and all occupants are hereby ordered to vacate and the landlord/owner.is ordered to secure the subject dwelling within 48 hours of receipt of - g this order. If any person refuses to leave a dwelling or portion thereof, which was, ordered vacated she may be forcibly removed by the local Board of Health (Massachusetts General Laws C. 127B), or by local police authorities at request of the Board of Health. Furthermore, anyone who fails to comply with any order of the board of health may be subject to fines ranging from $10-$500. Each day's failure to comply with-an order shall constitute a separate violation. . Once vacated this unit may not be occupied without the.written approval of the Board of Health. Any person needing access to the inside of the dwelling must get permission from the Board of Health prior to entry. Note: This is an important legal document. It may affect your rights. PER ORDER Of Tr T' BOARD OF HEALTH T omas A. McKean, CHO\RS Director of Public Health Town of Barnstable Cc: Tom Perry, Building Commissioner