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0020 CARL AVENUE
i ,,.: .�.. c it i �TME Town of Barnstable oExpires-;6 months from issue date: .Regulatory Services Fee nattxsTnsi� 1 � Richard V:Sca11,Director �Eos X-PRESS PERMIT Building`Division Tom Perry;CBO,Building Commissioner SEP $ 201� 200:Main Street,Hyannis,MA o260l TOWN OF BA H N STAB LE www.townbarnstable.:iria;us Offim 508-862-4038 Fax. $ o-t6230 EXPRESS PERNHT APPLICATION. - RESIDENTIAL ONLY Not`:Ya1id without Red X Pre s Imprint Map/*cel Number: .30b 1 7 1 Prppem Address 20 Cc -) %Ayc- 0 2.6 3 2- [Residential Value of Work$ .S-2 o Minimu.m fee of:$35 00 for work under$6000 00 Owner's.Naine&Address._ 2d Cv k Apt VAUW%. ,(1 01163z Contractor's Name Telephgne Number. 50 S —Q-!5 J _9�I Y g• Ho ne Improvement Contractor License#(if applicablc) Ogd $.y q Email: W l �.W F I Construction.:Supervisor'sb tense:#(if applicable); [}'VJ,orlmian-s Compensation Insurance: �. Cheek one::' ! ❑ ;Lama sole propletor I ❑ TAM the Homeowner j [�Ihave Workers;Compensation.Insurauce. Insurance C6bgp y=Name; A66tx £r►,��o y�r'3 Workman's Comp.-::Policy;#` ijGe. -oe 64>"7 q q 2015 Copy of insurance Compliance Ce.rtificate:must accompany eachpermit; Permit Request(cheek box) Re-roof.(hurricane nailed)(stripping old'shirigles) All:construction debris will:be taken to - he �_�t:.- ❑'Re roof(.hurricane nailed)(nof trapping Goug over:.. existing layers of`roofj Re side: 510heplacement Vi inw dos%doorslslders U-t7alue... .. b (maximum.32)`#of windows:-. ❑ Smoke/Carbon lvlonoxide detectors 4 floor'plansI.marked wit6:ired S and inspections'required: :Separate Electrical&;Fire Permits required.. *whererequired Issuance of this>pemiWdoes not:exempt compliance witfi,ottier town department;regu[ations ea His[one.Conservation;etc: ***Note.:, .- Pr, Owner must sigt,Property .Owner Letter of Permission. A.copy of the Home Ij) ovement Coptraetors-Lie ense>&Construction Supervisors License isr required; . SIGNr�TURE .... .�/` - . . .._. :. Q;\WPFILEs�FORMSIbuildmg'.peiniit forffii X M doii. Revised Mf5 ent of Public Safety Department Massachusetts -t)ep ulations and Standards �! Board of Building Reg Su errisor " Construction -077846 j License: CS ,t:r ` b 34� GA �CgAEL B '• 356 Bay Ln p'3632 = Cent'rAueMA ! �.. Expiration r 03123/2016 commissioner Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991rri3)of a enclosed space. Failure to possess a current edition of the Massachusetts w m State Building Code is cause for revocation of this license. r { For'DPS Licensing information visit: www.Mass.Gov/DPS t • t g,a 4; *a .�• � License or registration valid for 6drvidul'use only - Office f C n mer ffairs BuSine s egulahon rr 1 before the expiration date. If founet rn�to ,I s HOME IMPROVEMENT CONTRACTOR u + Registration: ;�,80849 Type: Office of Consumer Affairs,and�Business.RegalahCl, a 8�s� 10 Park Plaza-Suite 5170 *, A Expiration: I20[2017 LLC Boston,MA 02116s ` w MI EL GAS PARD LLC ;� - ht'ba Vs. • -- - • MICHAEL GASPARD==�x-<-t:=-=• "�• �,,.., � 356 BAY LANE .-v =a_ =' c o /� i .•= z = 'mow.=-�-.�--- , CENTERVILLE,MA 02632 _• Undersecretary Not valid without-s�gnat Ire W s anxttsresi.E. `*` 9� �� Town of Barnstable Regulatory Services Richard V<Scah,:Direcior: Building W."IsIon. Thomas Perry,G'BO Suild�ng Gommssoaer 20:0 Main Sheet, Hyannis;MA 02601, wwwaown 6- stable'.mams - - Office: 508-862-4038 Fax: 508 79..U-6230 IDro e : Owner Must A 17 Complete,'and Sign This ,,oq o :If Using A Builder c—.S qv FaLocG,.�, ,as Oivnet of the subject prof Y: hereby authorize: /G�G�� ( f'd• to:act oii mp behalfi is all matters relative.to'work�guthor zed b y this building pertnrt a hcat on.fox` PP 20 Card Ave- w6l S (Yl lq 02-63 2- (Address of job); S` t�re`of Owner Date Print:Name IfProperty-UwnerAs.applying for..;:permat,_please completE the Homeowners License Exempt ou'Form on,the reverse side J QAWPFII.ES\EORMSIb Iding permiIt fbnns\EWRESS:doc: -Revised 0402iS ?7r�Cr mnromveah*o, ,fkssacIi=etts: Die' �F' -t o, AGQl�t°�t� MORmtlSS Of fifl;r Mrorkers' 'ampensafz�nInsuFance f day B der CflrntractarsJElectr�c ns(P1umhers App lnfarn atiazE PPfease P'finf LeOW Name(s rgcho.�'.`.. L:L� ... Address: Gtylstatet nsi tole . m _0263o Pl ane . , 0 8 >h' 0 r 9 y yS Amycu an.:employer?deck# itpprdpnate l a=. Type of p eject(regmre am a.employes with Z 4 Q I ara a geneaal confractor and I employees.(ful andlor par#= met.. have it to tlfe sab_on4 actoxs G_ Q New coniftu tioa 2;❑ I am a sale prolxxetas or gartn . I�sted ogtize aarhed skeet ❑Rrodeg These snb-conRac#ors}aae AV and Fire no eplolees Demof�frau: tv Q for nae In-a ' i effiplor and hale$tors`a 9.: Q B.ualdmg aittoa [No nrorl*'cflmp::uast ance comp snsuragce I S Q:wleare:acorpdat�smaIIdits 1DElecincalrepangor:ads refired j; , officers ixave ercrsedecr 3:.Q I a a bomeov�mer slaing ail_word .; 1 L Q FtuuzbsngZepaus Cw lidcbhons SE`S� 81vQL CLS' Qf PS[';Mp '0 per MGI my N 17`❑RDafrepasrs In i nWrecl ed.]:s c I�2 §I(4kandwefiaveno e fo ` Q cvo>jcess 13'_Q�tler: ,y ` .caatp='iasura�e required] - ��YaFlicsjT4hatcFiechosT;��t also fillaie secuoabeTaw — F _. .. .. .,, .;.. slrasaagt5e¢.,rro�ces'camp�saho-npoTicy,afvemsumL I nmeo�rnsswh0's¢bmrt[hisaf#iJda[[nFi Xatiag YeredBi cPmkaukt6ailineaumdeCOIIh9CLOts�st,`svltniitanewaffidaeattnrlirStlD�g1le i aawbg. f � fills bmt must attaches as addihans2 slsQet the name of the-sut>-ca�cdas snd state whe�hec:�natirhose enntres liar'' nacth[sIuve?mPIaf?zs,efieY�sCgzqu�de;t3teu':-srockess mmg.galugn�brvr es..Ifthesnb-cqa -CamtactDrstSsechedr Tam an errepioy`er'fha#is prmztii �vorkors'conrFeresr iril insrirat ce fvr i�*eurp7 y�ePs y$elo�v Ls"i7[e�ao7 cy rr�d job aztcr :- form ills anceConzpanyName l�SSaL �Mp�oye. nS Ga Policy�ar a f--ins:Lic 6< wec Sop' p7 9 9 9 Zo/<5.4. E�piaatzouDate 3/6/2ol b Job Site Address: ZO • Gcr• A v t CtiyJSkafel7 p I'�y w►r r� : /11!-, 02 6 3 Z r ftach a cppy of Elie iearlLem campensal onpol cF dec ara4aan:pAV(s uW the policy mfml?er and expiration date):: Fair to secure coverage as required ruder Section ZJA o€MGL c-152 car lead to`tfie sffipositian of crimsiial penalties of a fuse up to I SOU OQ and nor wen- 0i-- penalties rsi I.e fora of a:STOP WO- RS ORDF1R afld a.fime> of up to 5U_Qtf a day dc9sed tixaf a copy of tits statement ray laa forwarded td tine;flffice:of: IfiE�esEigatiAnsbfthe DIa4;€ar ansuraac�coverage:y�c�ian. , - , I duo here.&y comfy ander'the pains:aljd pert AAA o Ferlury'fhatfiie mfbrma€ran pimzded aboyns is base mid correct. 2o15 Pfiane �0�.® `3�5.0 — 9l/` O O, cial trsQ c nIf+; I3Q i[or asrite in tFaes::axea,tv_b carngfeted by cciy n n a ciat City or:Town:.. .. Wou_ nthoity[cil4n one): 1 ] oard:of$eaItli. .13uT g;I}eparfineent;: City-LTown Clerk Q:.lectricd Inspec#or 5P Fli�mti ng Inspctur 6 Otiier', .;. Contact.Person! Phone#. I MICHGAS-01 MVAUGHAN ACOROm CERTIFICATE OF LIABILITY INSURANCE FDAT1612/2 D/YYYY) 6/2/2015 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: Rogers&Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 A/c No Ert: A/C No): South Dennis,MA 02660 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:NATIONAL GRANGE-MAIN STREET AMERICA INSURED INSURER B:Associated Employers Insurance Co. 11104, Michael Gaspard LLC INSURERC: dba Renovation Specialists 356 Bay Lane INSURERD: Centerville,MA 02632-3308 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDD MMIDD A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE T OCCUR MPP6672B 05/17/2015 05/17/2016 DAMAGE REN ED SOO,000 PREMISES Ea Occurrence $ MED EXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 X POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea acc dent ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LABILITY STATUTE I ER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/Y❑N N/A WCC5005079992015A 03/06/2015 03/06/2016 E.L.EACH ACCIDENT $ 500,00 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) �e CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF BARNSTABLE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 MAIN ST. ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE �jWLrJ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD _ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION or r�AFUIF,-,�AAIE AWL Map 3 ()U Parcel 111 7M +d i t Application 0 o Health Division Date Issued Conservation Division AL Application Fee Planning Dept. Permit Fee 3 a Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address pVc- Village 5 Owner Re'dio, PCJA ti F41-YVelA\ Address 20 Cc44 Avc- 9,K n�%►s �601 Telephone 960 - 202 — "7`HBO Permit Request ►�c,�c�n Rtrw%v \ , ,nrwve- b A\cMru4- s rs _ i 5AT.,\0 E,,.) c�J�AL-AAJ uX\4L S1•r�cr� Square feet: 1 st floor: existing proposed O 2nd floor: existing proposed O Total new 0 .Zoning District Flood Plain No Groundwater Overlay Project Valuation -7 tM Construction Type WQod Lot Size • _% Grandfathered: ❑Yes 2rNo If yes, attach supporting documentation. Dwelling Type: Single Family Or Two Family ❑ Multi-Family (# units) Age of Existing Structure I Historic House: ❑Yes O No On Old King's Highway: ❑Yes YNo Basement Type: 0"Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) /Q'& Number of Baths: Full: existing Z. new Half: existing new Number of Bedrooms: °'r existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas Ybil ❑ 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 ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name lcollc e,\ &6.&an&, Telephone Number Address 3'6 .,, ,e__ License # 0'770416 �_V1 rCr AkC_ MPt 62.63 Z_ Home Improvement Contractor# /a6SZ?_ Worker's Compensation # UXc-_5M60?gMc1 Z01q A 1 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �crti,z O..cu.dL-�� 40 SIGNATURE DATE FOR OFFICIAL USE ONLY C r A4PLICATION# 4� DATEISSUED,v MAP/PARCEL NO. ADDRESS VILLAGE M OWNER e , " DATE OF INSPECTION: k FQUNDATIOIV` % ritji-4f)- ';,7-N-.% `'i�� ,F FRAME 'INSULATION;)� R FIREPLACE :> ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL k � GAS: ROUGH FINAL FINAL BUILDING' DATE CLOSED OUT ASSOCIATION PLAN NO. ' to Cori monnwalth of-Vlassachusefts Deparftnent of fidmskzal Accidents - O KWe Of investigations 600 Washiregto;Fa M eet Boston!,MA 02111E wnw.inass.gmMia Workers' Compensa.tiGn Insurance Affidavit:Builders/Con"ctors/ElectriciauslPlumbers Applicant Information Please Print Lef ibly Flame(BudaessIOxpui2a onlFndivid=I): � LSfi-S&�ch- Ll-c— ' i4ddress: 35 6 Y 1^cv%t' citylstateMp: 1•er4klle- 02632 Phone�k SOB- ys! v ?y y B Are you an employer:'Check the appropriate box: Type of project(�o' r uire�: 4. I am contractor and i � 1_VI am a employer with ❑ 6- ❑New construction, employees{fail and/or part-time).* have hued the sub=conbmctors 2_❑ I am a sole proprietor or partner- listed on the attached sheet 7_ ❑Remodelmg slug and h nre no employees These sub-oontractors have g. ❑Demolition w for me many capacity_ employees and have workers' or�.ng Y 1 g_ ❑Building addition [No workers' comp.insurance comp_insuranr required] 5_❑ 'We are a corporation and its 10-0 Electrical repairs or additions 3.❑ I am a homeowner doing all work- officers have exercised their 11_.❑Plumbing repairs or additions myself [No workers'coarp- right of exemptioa per MGL 12❑Roof repairs. insurance required.]l c.1.52,§1(4),and we have na employees-[No works' 13❑Other comp-insurance required]; "Any applicant that checks boa Wr1 taut also fill out the:section below shavrisg their workers'compensation polity information_ Homeowners who s this ubmit affid va indscsti¢g they ate doing in track and then hire outside coatractors mo st submit a new affidavit mdncsting smrh_ rC.aatmctors ihst check this book mint attached an additional sheet Ovowmg the name of the sub�conft3ctars and sts whether ocnot those enffi�Have amployees- If the sub-contractuts have employees,they must provide their workers'romp.policy number_ I am ari employer iliac is prm-idbirg tt orke-rs'compenmtion insarauce for err} employees. Beloit•is Ste poYi y arid job site information. Insurance Compauy.Name: /t6Sli-, (5�0 . PoliLy g or Self-ins.Lim;�: WC.r—-T SOS 4f t79 7-01 f#4 Expiration Date: -316 OZD(,5- robsip : 2O Ce.0 Ave City/State/Zip: Ny wn n)s " Attach a copy of the workers'compensation polic3, declaration page(showing the policy number And expiration date). Failure to secure coverage as required under Section?5A of MGL c- 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 andlor 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 render the pains avid penalties ofper,wy that the inforxtation provided above is,hue and correct Sienature- Bate.: Phone#_ Sin)8- A®s � 18 OjEciat rase only. Do,not write in this area,to he completed by civ or town offlciaL City or Town:. PtsrmitfLicense Issuing Authority,(circle one): 1.Board of Health 2.Building Department 3.City[rown Clerk 4.EIectrical Inspector 5:Plumbing.Inspector 6.Other Contact Person. " Phone 9- 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto 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 Iegal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer;or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the - owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the - dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or Iocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the com.monwc2lth or 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 peformance of public work until acceptable evidence of compliance vrith 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 numbers)along with their cf:ri:ficate(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_ De advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. AIso be sure to sign and date the affidavit '11e affidavit should be returned to the city or town that the application for the permit or license is being regLested, 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 pennitllicense 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 bum leaves etc.)said person is NTOT required to complete this affidavit. The Office of Investigations would lice 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 G mce ofJavesf gaticas 600 Washin an Street Boston 02111 Tel A 617-727-4900 w 406 or 1-m MASWE Revised 4-2"7 Fax# 617-727-7749 WWW mas�govjdia MICHGAS-01 LTADDIA CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 3/31/2014 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: Rogers&Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 (AIC,No Ext: A/C No):(877)816'2156 South Dennis,MA 02660 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:NATIONAL GRANGE-MAIN STREET AMERICA INSURED INSURER B:Associated Employers Insurance Co. 11104 Michael Gaspard LLC INSURERC: dba Renovation Specialists 356 Bay Lane INSURER D Centerville,MA 02632-3308 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE A DL UBR POLICY NUMBER MM/DDI EFF MMI POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY MPP6672B 05/17/2012 05/17/2013 PREMISES R occurrenceNTE $ 100,000 Ful (EaCLAIMS-MADE OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 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 I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WCC5005079992014A 03/06/2014 03/0612015 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) "°Workers Comp Information-Proprietors/Partners/Executive Officers/Members Excluded:Michael Gaspard,Sole Proprietor"' Terry Kenyon,37 Jackson Ave.Centerville,MA 02632 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Dept ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD �ME Town of Barnstable. Regulatory Services • QARA'STAEM v mnas Richard V:Scaii,Director g ,s3¢..o Building:Division. Tom Perry;Building Commissioner 200Main Street,:Hyamnis;.MA 02601 WWW towo.barastable.ma.us Office: 508-862-4038 Fax: 508 790-6230 Properly Owner Must Complete and Sign Tliis Section If llsingABuilder 7> LiSLYre' `7 ,as Owner of the subject property herebyauthorn iI)A ,Zi6pa0& to.act on raybehai€ in all.matwrs relative to work:authorized.by:tbis building permit application for. ,Z a Gcfl Xc. 04 lc n'i S Wdk s of Job) -''Pool fences and alarms azt the r&,i ponsibility of the applicant.Pool; are not to be filled or utilized before.fence.is installed and.,A final inspections:are performed and accepted; c 04 A natvze of C?oyaer �. Sizruature of Applicant Pint Name I3nnt Name —'— Date. Q;:rQR:dS:Ql47v`£RPEe2ASISSIQT'PQOLS - Farrah kitchen remodel 51812014 r� 3'-5" 26'-9" Casement window group 8'slider door to patio �i 12'-4"— i' 11'-7" 9-7 New stairwell 1„6 X aZ� Sink M„Ok-,Z 11'-8" Peninsula Open to adjoining room do Stove KitchenINN I N N ' Dining area New door `O �- a; 3'-0" i Remove door Fridge 6,-0„ --------------- ------------ ----------------------- ------- -- ----------------------- --------- (--------- � w MMove opening Existing closet, Ne door Fireplace in living room will protrude 15"into new kitchen Enlarge opening 4'-2" 16'-2" 4'-9" 1'-101, 3'-5" 26'-9" 11L Y,6" 30'-0" ^` Town of Barnstable i 9 Expires 6 mon `� date n issue Regulatory Services _ e �, "� t snxxsrnst.e, MASS- $ Richard V.Scali,Director . ArFD MA't A 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 ®l Not Valid without Red X-Press Imprint Map/parcel Number Property Address residential. Value of Work$ `7W Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address t ot% �Q Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) ` Email: Construction Supervisor's License#(if applicable) CS lo[��LI�o 1 F�� 1Aa 10 r�O ❑Workman's Compensation Insurance Check one: am a sole 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(hurricane nailed)(stripping old shingles) All construction debris will be taken to � � �i um'? ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side Replacement Windows/doors/sliders.U-Value 0 o (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,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. t SIGNATURE: Q:\WPFILES\FORMS\buildi rmit fonns\EXPRESS.doC Revised 061313 o YTM Cttml`irorryv-ffa#i`a of mrzss-achus�ts Deparfinwt of huhutrid Accidents - Office Oflmwstka6ans 600 MsALugton Street Baston,,ALI 02111 wtt vs xnas&gow'dia workers' Compensatioulnsurance affidavit:S_uilders Contractors/BlectriciansTlumbers Applicant luf irmation- Please Priat Legibly Names�1t3anization/�ividualj:. � SNt��� Cityfstatejzip_ I 1 �S Phone Are you an employer?'check the appropriate bay: Type of r( ct d-_ ❑ I am a gener-al confractor and I �o'�eeq¢u�ed}: 1_❑ I am a c�ployer with 6- ❑New mns ru, _ou e %oyefs(fall and/or park ime * l�gyve-I the sub contractors. ?_�asn a sofe proprietor orpartner lisTed on the atiached shEei - ❑Rrmndeling h:tp assd have no employees TlaE-,e sub-contractors have g- ❑De aolitioa wcA ng ivrme in any c ev�plGS�es and have workers' ctr- 4_ ❑Building ad&tioh o UGrarkPSS' comp-istctsranre comp-nas rand. ]_❑ We are a corparatioaand its lGT_1 Metrical repairs or additions . 3.❑ I am a homeowner doing all work officers have exercised Their l t_.❑Plumbing repairs or additions myself [No tones'comp_ right of eimmptioaper MGL 12.0 Rnofrepairs §1 15?, and we have rto• it�c�xs�sicF.requu-ed-1 1 c_ {�' 13_.❑4.ther employees_[Na workess' comp_insurance,required.j any aggti asnt r3]SL ChPCkS bmt�l mvs#also fl10 tS secuan helaw cha cuea sroaices'Compe�saa�gohcy ssf�ms TIT -s hrno submit this affi a meat 3 wey ace Ming Riff ifmk and then hire omt ade contra tors psi skit a new a dsrit=n"' sryclL �ftrivacencs ttist cF+xk thi s gas mrast sttarlte3 azt addiiinnxI sheet shouiag t}Se hmL4e a+F 8ie snb- s�md stab.uhetie[nrnnt tLwsg esuties fi.--� .Envh yer5_ Ii t snb co-nto dais h,�e em�Io s,[h�3•must provide th�-r wok s'comp.policy avmhrr lam an s rt r that is pr ddiit tt arl e-rs'c-a tunlivn irmzrartce f`or cry err�ees. Heivtr is die p aEcy and job site - lnSEtfaIlCe�iG�1paTIT€l�3IIIf:: - • .... Policy T or Self-ins-Lrc-4: ExptrationDate: Soh Sites ddress': CitvistawZip: Attack a copy of the-zs-arkers'compeusafmx policy-dedarstioin page(showing the policy number and Expiration date). Failure to sezme coverage as iequireduuder Sectioa 25 A of MGL c. 152 can lead to the imposition ofcnnlival penalties of a fine up to$1,50D_oa andror eve-year imprisonment,as well.as civil penalties in the fowl of a STOP WORK ODDERand a fine of up.to$254_0-0 a.day against the violator_•Be advised that a copy of tbis statement maybe fhrwnded to The Office'of lnvegt potions of ffie DIA for rnaarnmce coverage vezification .Ida hereby crtlif�7� t- .ns andpenaL Hs Df`perjuy thatthe.irnformcdian prmided abfine u.bfa a-nd correct Sianatum- Bate: — l Phone 9_ `i L1 `)a - G 1\1l ck, O,Tciot use only. Der nat write in tl s area,,•to bs campfeted by city or town officiaL City or Town:,,} Pa-mitTacense# _ ll-ls Authar`�. (Qrcle oue): I.Baaxd f I3ealth Budding Departme*st 3-CityTrGwu Qerk 4-Electrical Inspector S.Plumbing Inspector .6.biter Con- tact Peron.: Phone#: 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto 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" Au 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 Iegal representatives of a deceased employer;or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the - dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appur tenant thereto shall not because of sues employment be deemed to be an employer." MGL chapter 152, §25C(6)also st@xs 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 commonrve2lth for alay applicant who has not produced acceptable evidence of compliance-itch the insurance.coverage required." Additionally,MGL chapter 152, §25C(7)sues"Neither tie con,nmonwea b nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of comphFnce v iu'u the ire-=,,nc.e requirements of this chapter have been presented to the contracting authority_" Applicants — — — Please fill out the workers' compensation a hdavit completely,by checki_pg the boxes that apply'to;run sitLatien and if necessary,supply sub-contractor(s)name(s), addresses)and phone n•�r h ber(s) along w then ce-11-ficate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability P?,-tner,} ps(Z.LP)w,,, no employes other han the members or partners, are not rf-,qOured to carry workers' compensation=L ante. if an LL.0 or LL a does have employees, a policy is required Be advised oaf this affidavit may be s,:bmiited to the Department of induslcritI Accidents for confirmation of m auce coverage. Also be sure to sign and date the affldav t "111e a idavit sho>>ld be returned to the city or town that the application for the permit or license is being requested,not the Depafrtment of Industrial Accidents_ Should you have any questions regarding the law or if you are required to ob�_in a workers' compensation policy,please ca..11 he Department at the number listed below. Jell insured companies slmuld enter. *.heir self-insurance license number on the appropriate line. City or Town Officials Please be sure that the a-uffidavit is complete and printed legibly. The Department has pro-,ided a space at the bo'dom of the affidavit for you to ill out ia the event the Office of Inv.s-tigations has to contact you reg�rdirg he applicant Please be sure to fill in the permit/license number which will be useid as a reference number. In addition,an appLcaat inat must submit multiple pe-Init/license applications in any given year,need only submit one afl-davit indicating cu.�ent policy information (if necessary)and under"lob Sift Address"the applicant should vmite all Iocatio3s in (ciy 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 license$_ A new of fida•,Tit m,.rst be tilled 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 NTOT required to complete t] s of-adw it- 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: T �Commaawean of Massachusetts Depai meat cif Indust dal Acrid(-mot Offim of Iavestigatans 6-00 Washington Sit Bastion_MA 02111 TtL A 61 7 727-49-QO ext 406 or fax f 6I 7-`�27-T I t c F evised 4-2�07 - - r' THE t Town of Barnstable Regulatory Services IIAMST� MASS.AB Richard V.Scali,Director �'DTFpMpIA`0 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601' , www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder' r CC � �� as Owner of the subject property hereby authorize � ����eH F—I\ to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Pool fences and alarms are the responsibility of the applicant. Pools. are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. ignature of Owner S ture of Applicant SJ�� V)V G)b\ Print Name Print Name N Date , Q:FORMS:O WNERPERMISSIONPOOLS Town of Barnstable Regulatory Services P�oY TOtyy Richard V.Scali,Director Building Division snxxsTnsr> Tom Perry,Building Commissioner MASS. 200 Main Street; Hyannis,MA 02601 www.town.barnstablema.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER': name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,orris intended to be,a one or two- family dwelling, attached or detached structures accessory to such use and/or farm structures.. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. _ The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. '\ ' HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.11-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,RuIes &Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems, particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a formlcertification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313 ' 1 - �e�omv»ca�ccoecclC�o�C�/�ceaczc�ecJeGt . a Office of Consumer Affairs&Business Regulation - OME IMPROVEMENT CONTRACTOR egistration 142108 Type:, Expiration: 3/1512018,• DBA JIM TWITCHELL ALUMINUM&VYNYL JAMES TWITCHELL.'°:' 16 MANSFIELD AVE i MARSTONS MILLS, MA 02648 Undersecretary. Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen�isor License: CS402646 ` ' JAMES D TWITC)ELL•; '%.. E .,r 139 CAPTAIN CAMLTQNS RD! ' COTUIT MA 02613 s i63 - _XI)iration Commissioner 08/30/20f4 Mass. Corporations, external master page Page 1 of 1 c,��.ss►.S/C William Francis Galvin Secretary of the Commonwealth of Massachusetts Corporations Division Business Entity Summary ID Number: 000561784 Request certificate News J Summary for: CAPITAL LEASING OF CAPE COD, INC. The exact name of the Domestic Profit Corporation: CAPITAL LEASING OF CAPE COD, INC. Entity type: Domestic Profit Corporation Identification Number: 000561784 Old ID Number: 000000000 Date of Organization in Massachusetts: 01-08-1997 Last date certain: Current Fiscal Month/Day: 12/31 Previous Fiscal Month/Day: 00/00 The location of the Principal Office: Address: 1141 OLD STAGE RD. City or town, State, Zip code, CENTERVILLE, MA 02632 USA Country: The name and address of the Registered Agent: Name: CHARLES KIPNES Address: 1141 OLD STAGE ROAD City or town, State, Zip code, CENTERVILLE, MA 02632 USA Country: The Officers and Directors of the Corporation: Title Individual Name Address PRESIDENT ROBERT BELANGER 1141 OLD STAGE RD., CENTERVILLE, MA 02632 USA PRESIDENT ROBERT BELANGER 1141 OLD STAGE RD., CENTERVILLE, MA 02632 USA TREASURER ROBERT BELANGER 1141 OLD STAGE RD., CENTERVILLE, MA 02632 USA SECRETARY ROBERT BELANGER 1141 OLD STAGE RD., CENTERVILLE, MA 02632 USA DIRECTOR ROBERT BELANGER 1141 OLD STAGE RD., CENTERVILLE, MA. 02632 USA http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN=000561784&... 8/20/2014 h:? 9 Massachusetts Department of Public Safety Board of Building Regulations and Starrraarc:s License: CS-102646 JAMS D TWITC#E `j' i�✓ ray 161Msinfield Avedue Marston Mills M9LOZ648 _Expiration- Commissioner OW- 0/2016 is C F ti.e a / �.n{,nFivCx. JAWS-1D TWITC11BLI, 139 CAPTAIN CA`RLT01�5 R1D COTUIT MA 02635 a- t i ,ay 0813012014 To Oftiee of Consumer Affairs&'Business Regulation OME IMPROVEMENT CONTRACTOR egistration Type%�'_;a7Expiration:._ 3/15/2016:. DBA . JIM TWITCHELL ALUMINUM&WNYL JAMES 7WITCHELL 16'MANSFIELD AVE MARSTONS MILLS,MA 02 6 -Undersecretary Unrestricted-Buildings of any,use group which contain less than 35,000 cubic feet(991M )of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: www.Mass.Gov/DPS License or registration valid for individul use-only before the expiration date. If found return to: Office of Consumer Affairs and.. usiness Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116: Not valid without signature .X-PRESS PERMIT JUL 112012 4u0ca 0c� �.{ `owxz Ofara le. `I'prl:rtit gulatory e Services r F. Gcller, Building Division i ern Perry, CBG, BarlCing C crrcnisSioner J\<I�in �_r.et: =lyaina, 1vlr", 02 f11 rww.iov/n.bi-T1 ble,ma.us 0lfli0e. 5Vd-862-4038 Fax: 508-790-6230 vor Yn.[it!, 11,4 :rt Red.t-P;-ess lrr:or!zl r'•' Gir�elCGl u,7..,bc xs;:d. r:.y A.ddr,ss 5d-A v� /�/V/J/f � � coe..tia:` va ' ork Y'i:li,I7urr, iee ofS35.00 Tor ..:00/y� work ut.der t }.m OvmCr:s '�ana e to � Coritractor`S Name_rYO Oj. m'eSeWces . ..s.�O-c-e— eiep^oP e fir`-url,bt,, Improvem,en[COiiiiuGiCr iJ 1Cens:. r�!?a''DCat7l%) _ ✓ / i _/-1L1� . . rr �_ - — / - llO;i 5L`�)c1"YISOi' I iC i!3G i( � �i'C CiZ1- 7®o77 C7Gck tOBP.: :^� ;il�SOIP t;.rGriCiC:.Ci _i , air,I1 F Horincowr!er j I havp, V/or'.e. 's Cor,pArsaac 1 lr.sura,; e ✓vs �i .a ce Carr;any`lame ���/(� .��}/Yj 5/;9�'•e - s comp. Policy 4, ,C.F)"cf rlSurSrlce Compliance Certificate M111SL 1ICCOMP—Illyeach :?ennit. R-caiucst kvx) J '.-roof(h31rric-me nailed) (sir!apirilg o� si inzjes) A!l cor)struction debris will be takeii i0_ ,,RB-roc hurricaaa naiiedy ,i0t slr ir'rn'Pl. GOrn; CYe c:x!St:no aycrs `Jf roo _ •j �J Site ' r'of doof_ r IPr%2CBrn 1C tNtP,CI'1.YsFCpLIJi.SIiG rS. v-` r !%e O: 3.O 7 ,2(4'Tl iT, .3J) ` 3?.}';r2dOv'S r e jj!F CG: 15 R,..,01T JC... " VY:6 O'bc ;'r �('C•iF; J;Oj:.'.rCy h}`f 7.'•r ;:i�si-�t it PI)pei i—y OwnerLetter of I'erntisSiEJlI. - cop,y Of t12 Horne I.m.pi'U'r'c 1e1 C n7iriCi^r5 T 1Cel.Se ce COnstruction Supervisors License!S 'equired,. h`o�,e �Po�- Ui,^JI �e U5�✓1G c�OSeP�i p J �CQNsl��fa� S���r�^Sot� 1 The 5J'�.��'�X3 slachfs�zet-.- y D:epazet ent pf Tadustrfdl rci eyglf Po f Office of Invests gador' 600 Washington Bisset Boston, .tom 02111 ivww. aass.gov/dia 'or.kers' Compensation Insurance Affidavit: Ball �r�P o �ctorsd lac °i�°lan�/Plat bars ADDlica nt Information Please Print Legibly w l Name (Business/Organization/Individuai): 0 R e, 1 Address: CZ 5 C2rry Q City/State/Zip: Phone#: Are you an employer? Check the Appropriate b : Type of project(required): 1. I am a employer with a�`= 4. I am a general contractor and i 001, - 6. ❑N construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. EYRemodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have g. Demolition workingfor me 'many capacity. employees and have workers' Y P h'• $ 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.D PIumbing 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.�] Other comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homedwners 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 thepollcy and job site information. Insurance Company Name: ew S o Policy#or Self-ins.Lic.#: WX O 1 q 7 J?' 6 Expiration Date: Job Site Address: a 0 1✓ City/State/Zip: O XO t Attacha copy of the workers'compensation policy declaration page(showing the policy nurYber 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 file of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and/correct. Sign ature• �� Date: Phone#• Offlcial use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# r 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 M •,`` '.T �tltaCci� Office of Consumer Affairs& Business Regulation ; HOME IMPROVEME14T COfl4TRAC3C}R Type: Registration: .:126893 s Fxpiratitt+t 'V3/2012 Su meni t ... . , Services The 'HOme Depot At Noms_.-: . 17 DARREN DEMER5 .--. 2690 CUMBERLAND PA_RKVVAY 3 AJP�LJA,Rn, GA 30333 Undersecretary License or registration valid for indididif found u� onty M before the expiration ffairs and Bus Regulation Office of Consumer 10 Park Plaza-suite-9170 ,arc Boston,MA 02116 Not valid without signature �/W21312 8:39:17 A24 PST ;GMT-8 FROM: 100005-`O: 15087302086 Gage: 2 of �'��� ODAMA e�ewurtiYYi CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIOM ONLY AND CODERS NO RIGHTS UPON THE.CERTIFICATE BOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEIN, EXTEND OR ALTER THE COVERAGE AFFORDED 13Y THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING MURER(S),AUTHORIZED RraPRESENTATIVE OR PROOUCER,AND THE CER71FICAT'Er HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the polieyp"I Imat be endorsed. N SUBROGATION IS WAIVED,ri rights to tct he i the terms and conditions of the policy,certain policies way requim an endorsement• A statement on this certificate does trot cattferrightE 10 dIe j cartiflcate holder in lieo of such endoreeme e. PRODUCER PAUL®SULLIVAN INS AGCY INC r 1$67 S MAIN SS PHONE FALL RIVER, MA 02724 WMA AIF RDING COVERAGE RAMS NSURER A INSURER e I JOS J 8t D REMODELING DALEY NSURERC: 15 WILSON WAY NBu o: MIDDLEBOROUGHMA 02346 NSURERE: COVERAGES CERTIFICATE NUMBER: 12 jj22 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 ISSIiED OR MAY PERTAIN.THE INSURANCE AFFORDED t3Y THE POLICIES DESCRIBED HEREIN IS SUB CT TO ALL THE TERMS, EXCLUSIONS ANO CONDITIONS OF SUCH POLICIES.LIMITS SHOWN-MAY HAVE BEEN REDUCED BY PAID CLAIMS. ` WS 1NSR TYPE OF INSURANCE POLICY RIME LTR t9MOCCIURRENCIFS CENERALLIAMiTY IS a otp rtgEca f COMMERCIAL G84ERAL LUtBILITV I LED ESQ' one person) E CLAMS-MADE ED OCCUR PERSONAL✓l ACV INJURY S GENERpLAGOREGATf S PRDDUCTS.Cq!ES CIP AGG S . GENT.AGGREGATE LIMIT APPLIES PER: S POLICY PRO LOC aact S AUTOWOSLLE UAaltTY 9ODILV,IN Uw(Pa person) ANY AUTO i SCOILY INJURY(Per acc+d ' ALL L rEO C"ECCULE0 GE AUTOS NON AUTOSWI� HIRED AUTOS HAUTOS t S EA/x/OCCURPENCE' S UWeRELLA LUte G[tiUR I - AGGREGATE S -. exce aLIA9 CLAus-MAsw S pE0 REfEM10NS j S f ! I1 S 212/2012 2r29 3 � M 1"M A woRlaERs conwENSArIav WC5 3IS384800-012 1t3000 AND 6W%OYEIfe'UA0fl fY YIN E.L.eAcri ACGIDf1iT i ANY7,- l�pR1PAATNERI6XEIZUTNE NIA �M:=!E EA EMPLOYEE S 1 O OFF h19ER FJrct1IDEOT Q 50000 (miin NH) •POLIGV LILpT S 11 0under pE IPT[ONOFOPERATWNSIsebw OESCRPTIONOf ERA no,ILOCATIONSIVEI6C1E3(AltwhAccao141,Add itionalReraarlratelredaM,i(AOfe�aaabrequircdi Workers compensation insurance coverage applies only to the workers compensation laws of the state of MIA. NO PARTNERS ARE COVERED BY THE WORKERS\COMPENSATION POLICY. ------------- -CERTIFICAT ON SHOULD ANY OF THEASOVE DESCRIBED POLKMS BE CAHMLI-ED BEFORE TOWN OF BARNSTABLE A CORD E NIITT DATE TmEReOF. NOTICE ITHE POLICY iMtOViSipNS. iMLL BE OELNEItED .W 200 MAIN STREET HYANNIS MA 02601 AUTNDRUE9ReMeSENTATnrt Jeff Eli' a ®tggti-2010 ACORC CORPORATION. All Tlgpts mgerved. ACORD 25(20AOM5) Ttle ACORD name and logo am TegWerod marks of ACORD Aadithis CLUNT andr 51APeagedesr ALL pzevLousl/s o3vea ceztitita[as}; Aft Page t or t "�1 7' FROM :jam9ad FAX NO. :5083622271 San. 7 2009 5:17PM P1 HOME J.MPROVENJFNT CONTRACT PLEASE READ THIS Sold,Furnished and Installed by: Branch Name: Boston Date: G `1 - THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 y Toll Free(900)657-5182;Fax(508)845-6017 Branch Number:31 Fcdrral ID#75-2698460;ME Cic#C 02439.RT Cont.)_ic#16427 ^ II``. CT Lie#HIC.0565522;MA Horner I)nprovement Contractor Rog.#J 26893 Installaticxr.Address: uSl LJ Q C'6 f"7t1�. C/Qn YLI- ) � G�� City State Zip Porchaser(s): Work Phone: Home Phone: Cell Phone: Hume Addre`w: (If different from Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot,updates): []I DO NOT wish to receive any marketing ernails from The Horne Depot Project information: Undersigned("Customer"),the owners of the property located at the abovcinstallation address,agrees to buy, and THD At-Horne Services,Inc-("The Home Depot")agrees to furnish,deliver and arrange for the installation("Installatiot")of all materials described.on the below-and on the referenced Spec Shcct(s), all of which are.incorporated into this Contract by.thi:s reference,along with any applicable.State Supplement and Payment Summary attached hereto and any Change Orders(collectively, "Contract"): Job#: (lilW-1 ka J1CC) P ucis: 5 ro Sheet(s)#: P ' Amount R(K)Fng Siding windows Insulation El Gutters I Covers El Entry Doors ❑ C� $ q JZcw>Fng Siding Windows Insulation Y6 ❑(;utters/Covers� /ntry Doors ❑ 6 6 Roiling Siding Windows Insulation ❑Outiers I Cove ❑Entry Doors❑._.__._ _ $ Roofing E3&jingLl Windows LJ Insulation i ❑Gutters/Covers ❑Envy TX)ors ❑ $ Minimum 25%Depodt of contract Amount doe upon e)mcu ion of thic.camraeL' Total Coritr.Ict Amount $ `� Nbirte Parehaaers may not deposit mote than one-third of the C ontimd.Amount l Customer. agrees that, immediately upon completion of the work for each Product,.Customer will execute a Completion Certificate (yn.e for.each Product as defined by an individual Spec Sheet) and.pay any balance due. As applicable,each Customer under.this Contract.iigi°ees 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.discreti(m,if The Home Depot or its authorized service provider determines that it Cannot perform its obligations due to a structural problem with the home,euvirownental hazards such as mold,asbestos or lead paint,other.safety concerns,pricing errors or because work required to complete oho job was not included in the Contract. Pavtuent Summary: The Payment.Summary#_ b e_!� b included as part of this Contract, sets forth the total Contract ntnount and payinents 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(node: there is one Completion Certificate 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 corks of materials,labor,expenses and services provided by The home Depot or Authorized Service Provider through the date of termination,phis any other amounts set forth in this Agreement or allowed under applicable law. TBE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DF.POSTT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT i,IMI'I'fNG THE HOME DFPOT'S O`fHER RFMEDIIS FOR RECOVERY OF SUCH AMOUNTS. Acce lance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer md'!he Home Depot with regard Lu the Products and installation services and supersedes all prior discussions and agreemenu,either oral or written,relating to said Products and installation.This Agreement cannot be assigned or amended except by a writing signed by Customer and The Home Depot_Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terns of and has received a copy of this Agreement. Accepted by: / SubMfillfed by: r ?( Custom Si natu bate Sales .u tant's Signature y�Date elephone No. � Custorrrer7 s Sr m Luc Date Sales Consultant license No. CANCELLATION; CUSTOMER MAY CANCEL THIS ias appl cartel AGRF.FMENT WITT401JT PENALTY OR OBLIGATION BY DELIVERINC, WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINRSS DAY AFTFR SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS .A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY . LAW IN CUSTOMER'S STATE. NOTICE::ADD1TIONAr.TFRa9S AND 400?TM IONS AVE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT - �! �YlFi v Pr`CT� aL1Q1� office ofConsumer!�ffairs � us�ntrss x` gig '�..� 10 Park P?azza - Suite B(Ist n,?`;/ assaC i? sel. s 02 116 Hoge improvement factor P eOstratiar, Registration: 132349 Type: Partnership Tf. 207392 Expiration: 1/11/2Q13 J ti &J Remodeling Joseph Duarte J _ -------- 15 Fall St. u Wareham, ma 02571 'I)pdate Address and,return card.Mark reason for Card Q Address [� gtenetival IEmployruent 7Ps�nt A 5oaa-oWoaosot2te License or registration valid for individul use ontY �F $►n amine"sfogu s on LNIN• Offiee o oneum before she eYplretioai date. if found returffi to:WOMB IMPRUVE�IENT CO NTRACTOR Type, Office of Consumer Affairs and Business Regulation Registration, 132349 10 park Plaza:Suitt 5170 err Expiration: Partnership Boston,MA 02116 Josaph Duarte 15 Fall St. ` . (((////� of v d without signature Wareham,me 02571 Unders¢eretarY ila<.:►chu:Mt�-DcpA+��ncut ul•Puhlic Sara) 9 Batac(t of Suildin'd ReoulaHuttx and St.1mlard• . Construttion Supefvisor License License: CS 70077 ,}OSEpH C DUARTE 15 FALL ST WARE,MA 02571 Expiration: 12W/2012 (..nvt�{.ciapcl' ZSL696Z ES:TZ TT0Z/Z0/T0 TO 39dd �CONS�!'U�fa,� Su��rc�^sor� S