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0017 CROOKED POND ROAD
Town of Barnstable Building Post;This.Card:So-That,ii,is UisibleFrom;the Street A_, rovedtPlansMust be33-Retained on Job and-this Ca ' rdMust be Ke" t M" " Posted Until F�nalal`pect�on Has Been Made3 3 ° er Where a�Certifica�teof Occupancy is Regaired,such Bum g shad Not bye Ocwp�eduntil a Final Inspection hates beenKmade A Permit No. B-18-672 Applicant Name: VAN DINE, DAVID L Ap provals Date Issued: 03/09/2018 Current Use: Structure Permit Type: Building-Shed-Residential-200 sf and under Expiration Date: 09/09/2018 Foundation: Location: 17 CROOKED POND ROAD, HYANNIS Map/Lot 291 121 Zoning District: RB Sheathing: ' Owner on Record: VAN DINE, DAVID L Contra`ctorName Framing: 1 Address: 17 CROOKED POND ROAD p ContractorLicense HYANNIS, MA 02601 roject Cost: $0.00 Chimney: Description: 8x6 shed rPermit Fee: $35.00 Insulation: y1, Fee Paid $35.00 Project Review Req: SHED TO INSTALLED GREATER THAN TWENTY FEET FROM Date ' Final: SKATING RINK ROAD PROPERTY LINE , f 3/9/2018 Plumbing/Gas 7 Rough Plumbing: Building Official r, Final Plumbing. This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months afterissuance. 5 Rough Gas: All work authorized by this permit shall conform to the approved applicationand the'approved construction documents four which this permit has been granted. All construction,alterations and changes of use of any building and strictures shall be in compliance with the local zonmg�by laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street o,r r"' d' nd shall be maintained open four public inspection for the entire duration of the work until the completion of the same. , f Electrical- The Certificate of Occupancy will not be issued until all applicable signatures by the Bwldmg and Fire Officials areiprovideAd on this'pe�mit. Service: Minimum of Five Call Inspections Required for All Construction Work 1.Foundation or footing to " Rough: r ' 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.final Inspection before Occupancy Low Voltage final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth.in MGL c.142A). Fire Department Building plans are to be available on site Final: N All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Town of Barnstable �SNE Tati Building Department Services 0�2 Q o � Brian Florence,CBO 0 � z�N I.E. Building Commissioner O,� 1639. ��� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us � Office: 508-862-4038 Fax: 508-790-6230 PERAMN FEE: $35.00 SHED REGISTRATION RESIDENTIAL ONLY 200 square feet or less 17 CRookg-D PdN.D f'W' H �/q IVNIS Location of shed(address) Village D 4 V t O VG A A16- 20 3 260 91/l0 Property owner's name Telephone number Ex 6. C 07 2 0D A41iljC zs-o oo I oov,S C Size of Shed Map/Parcel# P1 R R C H 6 2a 1 S Signature Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? You must file with Old King's Highway Conservation Commission(signature is required) Sign off hours for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:08/6/17 15/03/201.1•'* 04:22 50?4200055 1 PAGE 01/01 r,.° OR TG.A.G-E 1]V SPEC TION P-L.AI\T APPLICANT: VANDINE TOWN: HYANNIS C LOT 1 f O 4 129� 0 2 LOT 2 N/F o =_#17 =_ SHUMAN ��Ek A Or"AJASS e� L=38 . 46 44.74' ��. tit,15're'-4 Ica d P o r• L=38 . �� = STEPHEN ^� J. y P 4 DOE b.SKATING RINK ROAD4p��� oyoQ4�° P S OD PANEL: 250001 0005 C FLOOD ZONE: "C" DATE MAP REVISED: 8/19/1985 r CDnWY THAT 1W MORTGAGE NSPTtON PLAN HAS OEM PREPARED FOR; DATE:. 5/3/11 SCALE: 1" = 30' LGREN, KORETZ. SCARANO & MURPHY CERT RER 192181 PLAN REF: 14034 F ATION OF 1HE DNIDIJNG SHOWN DOW NOT FALL VMN A SPWAL FLOOD HAZARD ZONRL, ED INSPWTIDN THE DNMW^.APPEARS 7D CONR M In THE LOCAL ZO"C PYLAWS IN EFFECT M STMCIURES SHOW ON THIS WMTOAM K3PWnCW FLAN ARE LOCATED BY TAPE Supwy ONE OF CDMSf@UCTIOM"RESPECT 70 HORIZONTAL DUMSIONAL SMACK REOUOt-WENTS M0.Y. NO IWIRUMIT MM%Cf WAS PERFORM AM LOCATIONS 3140VM ARE APPRomATE UPT MOM VIOLAIIDN ENbRCEWENT ACRON WPM NA GENERAL LAPla CHAKER TWA AN INSIQUMENT SURVEY IS NEC MARY FOR PRECISE DEMMIAIM OF BUILDING LOCATIONS 7.R9EREMCE OEM SUBSCT TO AND WITH TA BDOI I OF ALL RWH7S.R 01479 OF WAY, AND EMCkOACHI47M IF ANY EIOST, E17MM WAY ACROSS PROPERTY LINM YA10n[MID M RWVAIWNS MD RESTRICTIONS OF RECORD,IF ANY THERE SHALL BE,AND AFAR e'Y1RVE1f COWANY M SHALL NOT BE HELD LIABLE FOR DAMAOM RESULTING FROM ANY USE SAME ARE OF UaoAl FORM AND UF=. OF THO PLAN FOR PURPO^=OTHER-MAN MMTDAW.IM.SpECrM :PHONE: 508-428-0055 YANIffE LAND SURVEY COMPANY. INC `AX: 508-420-5553 119 ROUTE 149, Marstons Mills, MA 02648 yankeesurvey@comcost.net www.yankeesurvey.com 81402 JM I Town of Barnstable ReWatory Seees Richard V.Sca%Interim iXrecWr BUMIDgMislon 10 v 1�► Tome Peace,CS®,jWft Commissioner - 200 Main ShVA Hyannis;MA 02601 wn.batastablemaus 508-862-4038 EXPRES S�1 �'���1�TlI® d � ONLY Fam 08 790-6230 RLUP/Parcel Number ok-9 Nor VaW s&ikoutRedX-PressIjuprint Property Address I C/'" lCe or /l'J o� T � Resideafiiit Value of Work oZ oZ ,3 10 to WUM fee of$35.00 for work under$6000.00 Ounter's Name&Address Contractoa's1�Iame SSe,p 1 uQ! �e Telephone .. Dome Iunprovement Contractor License I#(if applicable) Email- Construction Sapervisoes License#(if applicable)0 70 a 7 '7 - ( WoAman's Compensation bsuraace Check one. ❑ I am a sole proprietor L : ❑ I am the Homeowner I have Motirees Compensation Insurance It2ssutaaee CompanyName Co .' 4 r- ®!p p w0flM Sn'S COMP.PUlic,•W.V 5'S/ Copy of ee Conmp➢iance Certificate must accompattp eac_h peerin Peru it Request(check box) ❑ Ile-roof(hurricane imaged)(SWPPmg old shingles) All conshvction debriswM betaken to r ❑Re-roof(hunicane naled)(not stripping: Going over egg layers of roof) [��e-side �•'Replacement Windows/doors/sliders,.I7 Value 3 (3 (maximum 3 #of windows l #of doors: . .0 SmokdCarbon Monoxide detectors 4 floor plans marked with red Sand%VeMeus requke& Separate Electriml&Fim permits r.,W, d. ' 4VJb=fe4I*e&L% anseofthispem&dgmEMexemptcampnawewithoSiertocen deparmaent regnleitons,i.e. ,Conservation,eta Note Property er sign�p�y der Y.etter of Permyssiotr. r copy& I�rOvement Contradvs Lfeense&Construction Supervisors Disease is regBeired SIGNATURE; •r:TSM MuII&B fhaAgesme Ears doo Revised 061313 The Commonwealth of Massachusetts, 0 Department of Industrial Accidents is Office of Investigations Efl .1 Congress Street, Suite 100 r Boston,JVIA 02114-2017 www mass gov/din - Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lmibly -The Home Depot At-Home Services Name (Business/Organization/Individual): } Addre s a on k Cl St / bu ,MA 01545 Phone 9:111-962-6942` Ar employer?Check the appropria b x:.; Type of project(required): Woy 4. am a general contractor and I 6 �]Newconstruction ull dt/ rpnrt-time).* " have hired the sub-contractors ❑ listed on the attached sheet. 7. [ [remodeling 2_ I am a sole proprietor or partner- . ' These sub-contractors have ship and have no employees . g, []Demolition employees and have workers'` working for me in any capacity. 9. 0 Building addition [No workers' comp. insurance comp. insurance.• ` 10.❑Electrical repairs or additions required-] 5. � We are a corporation and its '3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No,workers' comp. right of exemption per MGL 12.❑Roof repairs ` . 152, §I(4),and we have no c. ' insurance required:] Ja t employees. [No workers' c P� `_t comp. insurance required.] 5 *Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities ha ve .i employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. T I am an employer that is providing workers'compensation insurance for my employees. Belmv is the policy and job site information... f Insurance Company Name: New Hampshire Insurance Company Policy#or Self-ins. Lic:#: WC 015519215 .Expiration Date:311/2017= Job Site Address: 7 Cr'oo keg o-I City/State/Zip: S M A— Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D r nsurance coverage verification. I do hereby certify u pains and penalties of perjury that the information provided above is true and correct Date:fl {�Z Signafire: ' Phone#: :.401-714-6 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# _ Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person:— Phone#• DATE(MMIDDIYYYY) Aco CERTIFICATE OF LIABILITY INSURANCE Eotitel2ots THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS ALTER TIGHTS UPON E CER RE COVERAGE AFFORD CATS THE POLICIES HOLDER IS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, 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. 11 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 endomement(s). ACT PRODUCER : FAX MARSH USA,INC. 71MA E AIC No TWO ALLIANCE CENTERIL 3560 LENOX ROAD,SUITE 2400ADDRESS- ATLANTA,GA 30326 INSURE S AFFORDING COVERAGE NAIC# Steadfast Insurance Company 26387 100492-HomeD-GAW-16-17ER A: 16535 RER e:Zurich American Insurance CoINSURED 23841 THD AT-HOME SERVICES,INC. RER C:New Hampshire Ins CoDBA THE HOME DEPOT AT-HOME SEIllinois National Insurance Company 23817 2690 CUMBERLAND PARKWAY,SUITRER oATLANTA,GA 30339RER E:RER F: ' COVERAGES CERTIFICATE NUMBER: ATL-003746646-14 REVISION NUMBER:B D TO THE INSURED NAMED THIS IS TO CERTIFY THAT THE ANYES OF REQUIREMENT,TERM OR CONDINCE LISTED TION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO FOR THE LIWHICH CY PERIOD INDICATED 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 PAID POLICYCLAIM . EXPS '• LIMITS I�TR ADDL BR POLICY NUMBER MMIDDIYYYY MWOD TYPE OF INSURANCE 9,000,000 A X COMMERCIAL GENERAL LIABILITY GL04867714 06 0310112016 03101/2017 DAMAGE TO RENTED EACH OCCURRENCE $ PREMISE a occurrence $ 1,000,000 CLAIMS-MADE OCCUR LIMITS OF POLICY XS - EXCLUDED MED EXP one person) $ OF SIR:$1M PER OCC PERSONAL&ADV INJURY $ 9,000,000 GENERAL AGGREGATE $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 9,000,000 X POLICY❑JECT LOC $ OTHER: 03/01/2016 03/01/2017 COMBINED SINGLE LIN $ 1 000 000 B AUTOMOBILE LIABILITY BAP 2938863 13 Ea accdent BODILY INJURY(Per person) $ X ANY AUTO - BODILY INJURY(Per accident) $ ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG PROPERTY DAMAGE AUTOS AUT $ NON-OWNED Per accident HIRED AUTOS AUTOS $ EACH OCCURRENCE $ UMBRELLA LIAB OCCUR AGGREGATE $ EXCESS LIAB CLAIMS-MADE $ DED RETENTION$ 03/0112016 0310112017 X TMPER OTH- C WORKERS COMPENSATION WC015519215(AOS) TATUT ER AND EMPLOYERS'LIABILITY Y/N WC015519217(AK,KY,NH,NJ,VT) 03101/2016 03/01/2017 E.L.EACH ACCIDENT $ 1,000,000 C ANY PROPRIETOR/PARTNER/EXECUTIVE NIA 1,000,000 D OF EXCLUDED? WC015519216(FL) 0310112016 0310112017 E.L.DISEASE-EA EMPLOYE $ (Mandatory in NH) 1,000,000 If yes,describe under Conitnued on Additional Page E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space.is required) EVIDENCE OF INSURANCE i CANCELLATION CERTIFICTE HOLDER A F2455 HD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PACES FERRY ROADACCORDANCE WITH THE POLICY PROVISIONS. TLANTA,GA 30339 , AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD' � rJ M. 17C? f�dd ?'l frJff 'hi d%[•fi'� C°�?/�ll!l(i � _ Office of Consumer Affairs and.Business Regulation' 10 Park Plaza Suite 5170 Boston, Massachusetts 02116 Home Improvement:Contractor Registration . t Registration: 126893 � k Type: Supplement Card f' Expiration: 8/3/2018 THD AT HOME SERVICES, INC —_=— ANDREW SWEET 2455 PACES FERRY ROAD, HSCn'C ATLANTA, GA 30339 ;k -- s U to Address and return card.Mark reason for change. (� Address Renewal I] Employment Lost Card - ":_, ffice of Consumer Affairs&Business Regulation License or registration valid for individual use only �.- OME IMPROVEMENT CONTRACTOR before the expiration dote. If fiiund return to: a Office of Consumer Affairs and Business Regulation Registration 126893 Type: 10 Park Plaza-Suite 5170 Expiration 8/3%20i8 Supplement Card Boston,MA 02116 THO AT HOME SERVICES INC THE-HOMED EPOT`AT HOME�SERVICES ANDREW SWEET 2455'PACES FERRY ROAD;HSC ATIANTA,GA 30339 Undersecretary Not v with utsignature I MA04achwAorts Depanmeot of Pubitc Safes 34ogrcd of 3uaiding Rcgw43t*n4 ar4 Standards `�rl, ° i •ti+;a tA�d9K,W 1N.i�+e C5 rN•r! + l can"- CS-070077 X)SMI t:DUARn t t FALL ST " WARULAUM u ; a Otlrcr�,tf'onesmerAft &0 � HOME IMPROVEMENT CON � Registration j3234W #" Expiration: 111� �,FGh ti 4 a }. �. funOdQdtt9 CC Fall St Ware1*m,ma 02571 � M°�t�� a•r� � a. A . , • ` 07 Home Depot Contractor License Numbers: MA Home Improvement Contractor Reg. # 126894 Salesperson Name and Registration Number: Janice Campbell : R-1-073-13-00016 Home Improvement Agreement THD AT- HOME SERVICES, 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. Customer Information: david vandine IF I W66879 First Name Last Name Branch Name Lead# 17 Crooked Pond Rd, Hyannis, MA HYANNIS MA 02601 Customer Address City State Zip (203) 260-9410 F 1 [ Home Phone# Work Phone# Cell Phone# davevandine@mac.com Customer E-mail 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 Shrewsbury MA 01545 Address City State Zip or Email CustomerCancellationNorthEast@homedepot.com 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 PROFESSIONAL, 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 CONTRACTOR GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN,GIVEN ORAL AND WRITTEN NOTICE OF YOUR RIG T TO CANCEL. Acknowledged fZ. / X 09/15/2016 Customer's Signature Date Distribution: White- Home Depot Yellow=Customer Copy • The Commwnwealth of Massachusetts _t Departrnent of Industrial Accidents Office of Investigations - �s 4�.-= - 1 Congress Stree4 Suite 100 . Boston,MA 02114-2017 www rnassgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: t 60 ti )7-3y4 Phone#: 7 7`I 764 Z3 2S Are you an employer?Check the appropriate bog: Type of project(required): I.❑ I atn 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' 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 1 I.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑.Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy'and job site' information. Insurance Company Name:- 60 iQ(� t� s Policy#or Self-int.Lic.•#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certiftAnder the paips and en 'es o er u that the in ormation provided above is true and correct Si ature: � l Date - Phone#: �77 r L. 9 Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitlLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector,,5.Plumbing Inspector 6.'Other Contact Person: Phone#: r st�b�e t ��ed To 6f Byrn Lau date moires 6 monthsfrm �► : Regulatory Services :gee liichard V.Scall,Interim I ector 'Biding DivisiOD Tom Percy,CRO,building Commissioner 200:Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Fax:508-790-6230 Office:. 508-862-4038 PR�ss�E 'r A��LICA°rioN S E Not YaUd without Red X I's'ess$mprant . a 'Map/parcel Number Property Address. O C� Residential Value of Work �q:.�OO minimum fee of$35.00 for work under�60fl0 4i0 VWV 1 Y W� r1f,VIP. Owner's Name&Address v 02(c I r Telephone Number bl 3 f Contractor's Name Home Intprodement Contractor License#(if applicable) aZ. �' Email: F Construction Supervisor's License#(if applicable) �� 0O, ' -P'ESS PERMIT mpeasation Insurance F Workmen's.Co - . Check one: : F ❑ rr ` Iamasolepropnetor ° oCC. 1� ����- I am the Homeowner ' I have Worker's Compensation Insurance -TOWN OF BARNSTABLE Insurance Company Name = � •&. lit d , lm .P 0 '.Workman s Comp. Y .� permit. Copy of ihsurance Compliance Certificate must accompany each p b permit Request(check box) , construction debris will be taken to lte roof(hurricane ataiied}(stripping old shingles) Re-roof(hutrricane nailed)(not stripping- Going over existing layers of roof} ❑ Re-side maximuta.3 #'of windows Ne. Replacement Windows/doors/sliders:IT Value •30 ( #of doors: I `" a ti n required. [] Smoke/Carbon Monoxide detectors"4 floor plans marked evlth red S and inspections � Separate El & 'ire Permits required. A regulations,a e Hisso c,Conservation, °Where required: Issuance of this permit does not exempt compliance with ot3�er todn department regale' t •er i Pro a er Letter of Permission: Note: Property > p ' A copy of H e Improvement.C c rs License sic Construction Supervisors lUcense is required. t SIGNATUM t.gaVlN WuUding Changes S RESS.doc �;. Revised 061313 The Commonwealth of Massachusetts ,- - Department of IndustrialAccidents Office of Investigations I Congress Street,Suite 100 Boston,MA 02114 2017 www.mass.govldia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/Individual): HOME DEPOT AT HOME SERVICES Address:2455 PACES FERRY ROAD City/State/Zip:ATLANTA, GA 30339 Phone#:?74-265-2139 Are you an employer?Check the appropriate Type of project(required): 1.(_- `I am a employer with 20 4. Z!111 a general contractor and I __'{employees (full and/or part-time).*=_ have hired the sub-contractors h• ❑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 8. ❑Demolition v working for me in any capacity. employees and have«corkers' [No workers' comp.-insurance comp. insurance.t � 9• ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑'Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.[]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no WINDOW REPLACEMENT employees. [No workers' 13.E Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below shonine their nvorkers'compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. !Contractors that check this box must attached an additional sheet shoti ine the name of the sub-contractors and state whether or not those entities have employees. Ifthe sub-contractors have employees;they must provide their workers'comp_policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:NEW HAMPSHIRE INS. CO. Policy#or Self-ins. Lic. #:WC049101882 Expiration Date:3/1/2015 Job Site Address: 01 r_rim Ked, Po haKt City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy nu er and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day agamst.th • lator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for in ur ce coverage verification. 1 do hereby certify under.t s a en -the information provided ab ve is 'fe and correct. Signature: Date: 17 / Phone#: 401-714-6399 - Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#:. i i r i . t ;:��• Office of Consume � r Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 _ Home Improvement:Contractor Registration - Registration: 126893 Type: Supplement Card THD AT HOME SERVICES,'INC. : Expiration: 82016 ANDREW SWEET 2690 CUMBERLAND PARKWAY SUITE 300 ATLANTA, GA 30339 - — Update Address and return card_ 'Mark reason for change. `c,i e_ xo,iosm i Address Renewal i_:; Cmployment Lost Card ' Y\ r%�e�ri�,uiai�nr7��/�o/�'•llul.iar�i��r//,i . _ _ Office of Consumer:lffurs&12usinessl2egulntion License or registration valid for individul use only w i ( HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: i26893 TYPe�' Office of Consumer Affairs and business Reguintion ; ' Cxpiraiion: ©�3j2016 supplement Card I0 Park Plaza-Suite 5170-run AT unane eco„yn_e Boston,MA 02I16 _c:��i.-_ ^> ' ME HOME DEPOT AT HOME SERVICES J ANDREW SWEET 2690 CUDABERLAND PARKitiIAY S .2..___ 111TC 9nn _ lJ.. 'I _ The Commonweahk of Massachusetts " "� Department of Industrial Accidents i= �...�. p 7� ' 43 Office of InVestig'adonsJL 1 Congress Street, Suite 100 ' Boston,.MA 02114 2017 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anaficant Information Please Print Legibly Dame(Business/Organization/Individual): Address: ! S W/1--so City/State/Zip: t 60 U Phone #: 7 7'� 76L-2-3 2S Are you an employer?Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. Q I am a general contractor and I . employees(full and/or part-time).* have hired the subcontractors 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. Q Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance.* ' 9. Q Building addition required.] ' 5. 0 We are a corporation and its 10.❑Electrical repairs or additions h d i h ffi ocers have exercised their 11.❑Plumbing repairs 3.El I am a homeowner doing all work g Pairs or additions myself.[No workers' comp. right of exemption per MGL 12.D.Roof repairs insurance required.]t . c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] •.Any.appticant that,checks box:#1 t wst.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. d am an employer that is providing workers'compensation insurance for my employeex Below is the policy-gird job site information. Insurance Company Name: �(} JA). , Policy#or Self=ins.Lic.•#: Expiration*Date: X 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 canlead to the imposition ofcrin inal-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. .1 do hereby cer140,4nder the paips and en 'es ofperjug that the in ormation provided above is true and correct. . l Signature: ' Phone#: 7 � 744—2- a2 5 Official use only. Do not write in this area,to be completed by city or town official, City or Town: "' Permit/Liceuse# 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#: t . • CCf"i�C�. . PLEASE READ THIS /� Sold,Furnished and Installed by: Branch Name:Boston North&South Datet°irJ J.� THD At-Home Services,Jnc. • &Wa The Home Depot At-Home Services Araiach Nunrbcit 31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free 877-903-3768: Federal TD#75-2698460;ME Lie#C 02439;RT Conk UC#16427•' CT Uc# 0565522;MA,fHoomc Improvement Contractor dreg.##1126893 Installation Address: City State Zip'.. Pnrchaser(s)'. Work Plane: Hone Phene: Ce>i Pi 4w. Home Address: (If.differeat from Installation Address) City State rip F-mail Address(to receive project communications and Home Depot updates): ❑1 DO NOT wish to receive any marketing emails from The Horne Depot Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, and THD At-Homo:Services,Inc.("The Home DepoY')agrees to furnish,deliver and arrange for the installation(``Installation')of all materials described on the below and on the referenced Spec Sheet(s), all of which are incorporated into this Contract by this reference;along with any applicable State Supplement and•Payment,Summary°artached•hereto ant!any Change Orders(Wllectively; .,contract"), Job#: (W,.W R*—.) Spec Sheet(s)(l Pr'o'ect Amount . hoofing LJSiding indows.0 Insulation y, $ ❑Gutrnra/Covers ❑Entry Doors ❑ �oZ `�3. 0" 5- 7- hoofing OSiding- Windows Ll Insulation ❑Gutters./Covers ❑Entry Doors ❑ $ hoofing Sidictg WIndaws.U'lasulation ❑Gutters/Covers []Entry IN)or,❑ �u. Roofdno USiding Ll Windows Insulation $ ❑Gutters/Covers ❑Entry 1Doors ❑ l 25%Deposit of C:antrad Ammmt due upun execudon of this contract. Maine Purc asers may not depodt more than one4bitd of the Conrad Amato Total Contract Amount $ Ct► Customer agrees that immediately upon completion of the work for each Product,Customer will exccutc a Completion Certificate (one'for each Product as defined by an individual Spec:Sheet)and pay any balance due. As`applicable,each Cuetomer'undei this Contract agrees to be jointly and severally obligated and liable hereunder- s The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)inchlded herein, it. its discretion,if The Horne Depot or its authorized service provider determines that it cannot perform its obligations due to a struetural problem with the home,environmental hazards such as mold,asbestos or lead paint,other safety concerns,Pricing errors or because work required to complete the job was not included in the Contract.p Payment Summary: 'The'Payment Summary# �Q T �. j included as part of this Contract, sets forth the total Contract amount and,payrnents 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 Tote sign. 00 not sign a Completion Certificate(note: 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 casts of materials,i6or,expenses' and services provided by The Home Depot or Authmized Service Provider thrrntgh the date of termination,plus any other amounts,Set forth In this Agreement or allowed udder applicable law. THE HOMF DFI*OT MAY.WITHHOLD AMOUNTS `OWED TO THE 110ME'DEPOT FROM THE DFPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT' LIF.MITM-1 G-T--BE.iloME.D1I:;POrS'OT cHE RFfe/>�'D&S--kX)I2 IZECOVF RY OF'slIC.H AMOUNTS. • Ac¢entance and Authorization:Customer agrees and understands.that this Agreement is the entire:agreement between Customea and The Home Depot with regard to the Prod"and Tn.c. llation services and supersedes all prior discussions and agreements,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,voluntarilyaccepts the terrns of and has received a copy of this Agreement. cce tad b)� v/ Serb by-. ; iv el Customer's Si ature Date �0'- lpt Sales C stdtant's Signature Dafe X Telephone No. J'G? �jfe7 Customer's Signature Date Sales Consultant License No. GANCFi.LA_TLON: CUSTOMER MAY CANCEL THIS (sa apPliudbtc) AGREEMENT WrMOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT.BY,MIIDNiGJrr OM THE.THIRD BUSINES5 IDA-1�'-:: AMR_ �a'+sAIZP+I r Itxr.�;•t *R li§FN I: THE" STATE SUPPLEMENT ATTACI313A HERETO CONTAINS A FORM TO USE IF ONE IS ' SPECIFICALLY PRESCRIBED BY LAW - IN CUSTOMER'S STATE. 1 , NOTICE:ADDITIONAL TERMS AND CONDMONS ARE STATED ON THE REVERIE SIDE AND ARE PART OF THIS CONTRA(,T. 11•t -1$ White--Branch'File Yellow—Customer Td .-,MJLZ!:L., ,TToz Sc ',U"r T4z Z9zKS::,=ON Xt d: p26u�(:::'lpdy� 0 rf t Town of Barnstable *P�# Regulatory Services �ee 6 months from issue date • g rY • sAxivsr�, • MASS.39. `0� Thomas F.Geiler,Director ED Mld� Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY p Not Vdid without Red X-Press Imprint Map/parcel Number O2—` 1 1a y . Property Address Q e� Re sidential Value of Work SW Mini um fee of$35.00 for work under$6000.00 Owner's Name&Address LY) - r90 C T 0(;C1 Contractor's Nam _ (Alzs, - "T_Telephone Number}•�•QQ-S Z Home Improvement Contractor License#(if applicable) 14 A-kJRESS PERMIT Construction Supervisor's License#(if applicable) �Workman's Comp J. ensation Insurance Check one: T ❑ I am a sole proprietor OWN OF BARNSTABL El I am the,Homeowner I have Worker's Compensation Insurance Insurance Company Name A C e A w E c I CQ ►'1 J " ,l M h Ce 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 Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side S4vr►� Dour- . 11 #of doors 1 - Frl ,J001--. Replacement Windows/doors/sliders.U-Value l (maximum.35)#of windows y *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 Ho a Improvement Contractors License&Construction Supervisors License is r ired. SIGNAT s C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 UT www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Orgaruzation/Individual): Sears Home Improvement Products Incorporated Address: 1024 Florida Central Parkway City/State/Zip: Longwood, FL 32750 Phone #: 860-753-0452 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working forme in any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance 5. We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work ' right of exemption per MGL IL❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof m repai insurance required.] t employees. [No workers' ru_a comp. insurance required.] 132 Other I—f h' z *My 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 anew affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Ace American Insurance Company / Phone:866-283-7122 Policy#or Self-ins. Lic. #: WLRC46138211 Expiration Date: 08/01/2011 Job Site Address: City/State/Zip�'� t 1 /� _0Z60 / Attach.a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby kerb nde a pains and p hies of perjury that the information provi d above is true and correct. Si {Sears Auth.Agent} Date: Phone Home—Fax: 8604 68 / Cell: 860-753-0452 ronly. Do not write in this area, to be completed by city or town officialn: Permit/Licensehority(circle one): Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: 08/06/2010 08:14 4077678536 SHIP PERMITS&LICENSE PAGE 01/02 AC RL7�' DATE(MiN DD/YWY) CERTIFICATE OF LIABILITY INSURANCE Def04/2010 �O°D TFFIS CERq'MCATE IS JSSU.ED AS A MATTER OF INPORRIATION ONLY Aon Risk Services Central., Inc- Chi C8gO IL Office AND CONFERS YO RIGHTS 1;IPON THE CER17irICATE HOLDER T,WS 2M East Randolph CFRTIFTCATE DOES NOT AM@ND,EXTEND OR ALTER TW, Chi CAgo IL 60601 USA COVERAGE;AFFORDED BY THE POLICIES BELOW PHONB. 866 2$3-7122 Fes- 847 953-5390 (NSURERSAFTOMI NG COVERAGE NAIL 9 IPL�IREI1 - Tmft--RA: National union Fire ins co of Pittsburgh 19445 •• Sears moldings corporation D+Sime: ACE American insurance company 22667 dba sears Nome Imprgqvelnent rroducts, znc `i Attn: Risk Mana emeht,E3-219A. INSU mr_. Indemnity insurance Co of North America 4357S 3333 Beverly Rose — .. Hoffman Estates zL 0179 USA 1NSURftRO v INSUR1IRM o COVERAGES !� THFPDLTCMOFMURANCELlSRT3ORFAIMTiAVE BEEN ISSUEDTDPMLNSURT;DNAMEDABOVEFORTAU POLICY PMEODMbICA.TED.N0TWj-MS.rANOB4G ANY REQUIRSMFNr,TERM OR=DITION OF ANY CONTRACT OR OTH&OOCUMENC wrm RESPECT TO WEITCH THIS CERTI c-n MAY HE ISSUED OR MAY MKTADi.THE INSURANCE AIFORDFD BY THE FOLICIES DESC&MED HP..I YM 1S WUSIECT TO ALL THE TERMS,"CLUS7ONS AND C:ONDMONS OF SUCH POLICIes. AGCREZATL+TIMIIS SHOWN MAY HAVEBEEN'k=cED BY PAID c kUIS LWM SHOWN ARE AS REOUESTEA R114R DD' ' iTa NSRII TMOF]?M h= POLICYN(mmsR POLICYEMCn%%PWCV VKMAIM VMIR A fA)D nATR 1DWV o WALL1ADR.flY ' HDOCLSs7.9826 08/01/20111 08/01/2011 BACHOCCWRrNrE 55,000.000 X CONW16ROALOVIERALLMUILMY DAMAOR'(ORENTED SS,000,OOo CB OCCUR i'RBtDbB4 A a LAIMSMAD •1 rAno.DaRw -'kxclua PERSONALRADY INJURY Ss,000,040 n OENVIAL A0gRE0ATE ss.ouu,000 GENLAGORBOATE LTW APPIM PER FROMM-COMNOPACC s5.000,000 0 7 P(triCv © T414CT©I,OC o I�;1 IE r 0 AMMORTIALtAB1LM - ISAHOSGx5545 08/01/2010 08/01120U COMSMOSINGLBUMIT g ,vYhvm Z5AH08625499 08/01/2010 09/01/2011 CrAftad c) S5.000.000 Z A1J_OxT1E0 AU70S BODILY INJURY $LTIEOULED AU709 � <IbP�I X KMEDAUTOS }: BODILY INJURY U MON OWN-MAUTOS � (Pancddme. PROPERTY DAMAOG IT E'[AKiAi01) CAPA(7F LIABUM AUTO ONLY-EA AMMISP-M ANY,W-TO OTHFRTHAN EA ADC' AU'PO ONLY AOO A BXCW1UMFR.F'LI.ALIAB1LM BE2747I375 Oe/01/2009 '/ BAG]OCCURRENCE J( — El aATMADS AWRIMAM $2.000.000 ' BRUMMON g - W&RC461M.W. X STATU- OTN. WORKURS CONNEN9ATTON AND CA PTA . &NTLOYP.RS'LTABB.lIY I-I_YACHA=DEN'T 12.000,000 C fu N � SGC46238259 OS/Ol/201fI 08/Ol/2Q3,1 _,-,- ANY PROTRMTOR I PARTNER J tyECUW ,i Ey D1SPAS&EA sMKQYEG, S2.(100.000 C (w�[ REXCLVDEET WLRC46138211 09/01/2010 08/01/2011 It de=iw w)wSPSCTALPR(MUON9bdow All Other states R.L " roucy wArr S2,000.000 or= DESCRR PION ODODSRATIO!$$ACATTg2e9n+ENIT155IBXCGTSI6NS ADDSD pY ENOORSBhn�1JTPfiCfAL PROVf9TONS CERTIFICATE HOLDER CANCELLATION Sear$. home Improvement Products, Inc. SHOUIP ANY OF THE ABovBDES(RBM P01ME'S aECAHCMAM BEFORE THE exrMATION 1024 Florida Central Park%,ay OA-M-MMEOP,TI03 mwwn INSURER W LL BKDBAvORTO XwL Longwood FL 32754 USA 0okVSWMTPl7NOTiMTOTHECERT01CAn"PI.DERWAWSOTO TUB Luri. 9� OL°T FAILORE.TO DO SO SHALL IMF09ENO 08LTGATT(ON OR WORM OF ANY HIND UPON THE naUABR,TI8 AMM OR HTWESEh'TATIV$S ALHHOROZn REPRMVTATTV6 Qe— or— ACORD zs(2009101) 01988-2004 ACORD COMRAT101q.All rights ffflerve T& The ACORN)Dame Rad logo are regWaTod 019rkS Of ACORD Received on 8/6/2010 8:16:28 AM 7 a.!7P.Gt �..�[.fit✓i ,i� O flee ot �su�xa.er i•�aiXe;E�u ness emu anon 1 10 Park- Plaza - SLiite 5 170 y =' Boston, Massachusetts 02116 ° Home luiprovement Contractor Registration Registration: 148607 , Type: Supplement Card Expiration: /0/1112011 SEALS HOME IMPROVEMENT PRODUCT •LUBOS SVEC 1024 FLORIDA,CENTkAL PKWY LONGWOOD, FL 32750 Update Address and return card.Mark reason'foe change s"- Address Renewal "` Employment ;' lost Card 6P&•CM Ca 5Q41•LLE�4•C-1015)6 - _ - '•-•:, .•,.. a :,�; i Office of C'uncunlcr At'farrs C License or registrationVand.for ittdiridttl use only " HOME IMPROVEMENT CONTRACTOR before the expiration date. tl'found return to: Office of Consumer Affairs and Business Regulation Registration: 148607- = IU Park.Plana-Suite 5170 rY Expiration:_ 1o/1112o11 Huston,i11A 02116 Type: Supplement Card SEARS HOME IMPROVEMENT PRODUCTS INC. LL18OS SVEC 1024 FLORIDA CENTRAL.PKWY LONGWOOD.FL 32750 -" _ '{ndrrecretar�• Not-valid withnut eienature +�IasSachusett:N Dclt:u•tmcnt 41f Pillttic safet;v Board of Building Re_tilations irnd t.uulurtts Construction Supervisor License License: CS 97519 x LUBOS SVEC 827 THOMPSON F 'SAD THOMPSON, CT 06277 Expiration: 8/3112012; p< R"+nullissis/ncr .t Tr#' '2442'-. . r � �uuiu�nnm Proposal DateWIt Job d Sears Home Improvement Products,Inc. Customer me P.O.Box 1024 Floridaids Central Parkway Customer's Home Phone Customers work Phone Longwood,FL 32752 2290 o Home Improvement Products - 4 Phone 800)469-4663 Street Address ESTIMATE AND PROPOSAL ontractor License/Registration Number T HIC.0607669;DC 50006423• • Doors ( > ( )� Ciry State zip Code D(46542,87854);RI(27281); p��p Is installation within city limits? AfV(WV025882) I s I lon Add ss CouIty ❑Yes ❑No Billing Address(if different from shove) City State zip Code roject Consultant Name&License No (if applicable) Description of the and Description of the Significant Materials to be Used an d Equipment to be installed Entry Door 1 Location: Entry Door 2 Locatio : Style: Style: ull Jamb ❑L Frame ❑Double ❑Heritage ❑Patio ❑Full Jamb ❑L Framd ❑Double ❑Heritage ❑Patio ❑CC Grained ❑GC Smooth ❑VL Smooth ❑CC Grained ❑CC Smooth ❑VL Smooth Colors Ext „¢,fig�! , Int Colors . Ext ` Int Grid/Blind Colors GridiBlind Colors i Ext Int Ext Int ❑Glass Style []Glass Style Finish: ❑Bright Brass Antique Brass Satin Nickel ❑Aged Bronze Finish: ❑Bright Brass❑A itique Brass []Satin Nickel 0 Aged Bronze ❑Standard Hardware Package ❑Standard Hardware Pack ige Additional Options: Additional Options: ❑INSWING: ❑LH ❑RH ❑ OUTSWING: LH RH❑INSWING: LH RH ❑ OUTSWING: ❑LH ❑RH Casing: ❑2.5 Modern ❑2.5 Colonial [13.5 Colonial Casing: ❑2.5 Modern g ❑2.5 Colonial ❑3.5 Colonial Casing Color. Casing Color: _ ❑Door Cutdown Patio Door Screen Color ❑Door Cutdown Patio poor Screen Color []Standard Jamb ❑Extended Jamb El Standard Jamb ❑Es ended Jamb Jamb Cladding Color: Jamb Cladding Color: Door 1 SIDELITES STORM DOORS Local on: Model Number: Model Number: [I Full Jamb ❑L Frame []Double ❑Heritage ❑Patio Colors Ext e►-If , Int []CC Grained ❑CC Smooth ❑VL Smooth ❑Tinted Glass: 013rorte OGray ❑Green ❑Low'E' Colors Ext Int $Standard Hardware Package ❑Black ❑White Grid/Blind Colors ❑Specialty Hardware: Ext Int ❑Glass Style Door 1 TRANSOMS Finish: ❑Bright Brass❑Afl)ique Brass Alsatin Nickel ❑Aged Bronze Model Number: Grid Color Ext Int PLEASE NOTE: Contr#ctor is not liable for the condition or ❑Glass Style operationjof rehung storm doors. k Additional work to be done: Work NOT to be done: SPECIAL INSTRUCTIONS: All of the above check boxes and the"Work NOT to be done"section have been reviewed and explained tome. Customer(s)initials APPROXIMATE START DATE and APPROXIMATE COMPLETION DATE: The work will start approximately iib- 6� f (Approximate Start Date)and will be substantially completed by approximately f� Ole 5, (Approximate Completioh Date).These dates are subject to change at the time the contract is accepted by Sears Home Improvement Products,Inc.("Sears")or at any other time by mutual written agreement Customer understands that the Approximate Start Date is only an estimated date and the Customer will be contacted prior to this date to schedule the actual start date. , The TOTAL PRICE including all labor,material,taxes and any applicable discount is $ - I Contract Price $ Initial Payment(not to exceed 30%of Total Price unless Special Order) $ :State Sales Tax( %) $ Final Payment(balance payable upon completion of job) $ Local Sales Tax( o $ The Initial Payment is due prior to Sears ordering products. _ T at Amount Due $ The form and method by which the Customer(s)will pay is described in a separate Cash/Credit Card Payment Addendum made a part of and incorporated into this contract by reference. _- Customer(s)initials NOTICE TO BUYER:YOU,THE BUYER,MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY (FIFTH BUSINESS DAY IN ALASKA,FIFTEENTH BUSINESS DAY IN NORTH DAKOTA IF YOU ARE AGE 45 OR OLDER)AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THI RIGHT. Additional provisions of this contract are stated on the pages fallowing. Customer(s)initials /ppp```, SDI-CA,Rev 09/°9 mod/ 1`�l j � ',ir II IIIII I ll III111 ADDITIONAL PROVISIONS Proposal and Approve. Sears offers to furnish the materials and arrange for their delivery and installation as specified on the first page and/or the attached sketches and specification sheets for the TOTAL PRICE shown.This offer must be ap roved by the Installation Department.If this is a credit sale or a payment on completion sale,it must be approved by the Credit Sales Departr ient.If this proposal is not approved or the installation cannot be made in accordance with the law,this offer will be withdrawn and any paym nts you have made will be refunded to you. Any materials left over after the installation has been completed are Sears property and will be rei ioved by Sears. Installation. I understand that Sears will not install the materials but will arrange for the installati in.Sears is not responsible for materials or installation NOT furnished or arranged by Sears.Sears agrees to procure all permits required by I cal law. Authorization. I authorize Sears to:(1)arrange for a contractor(licensed where required by law)t make the installation of materials;(2)issue a work order for this installation to a contractor;(3)inspect the installation;and(4)pay the conitactor when the installation is complete if I have signed a certificate that the installation has been completed to my satisfaction. Delays]p Installation. I agree that Sears is not responsible for delays in delivery or installation d'a to weather,fire,strikes,war,government regulations or any causes beyond Sears'control. 41B1 Agreements aU Changes in]'on, tract. I understand that there are no oral agreements betty n Sears and me.Everything I expect Sears to do has been included in writing in this contract.Nothing can be changed in this contract unless it is in writing on a separate form accepted by me and Sears. flesnonsibility of Buyer. I agree that any information or measurements that I give to Sears are cortect and complete.I am responsible for any special work described in this contract. I Electrical A Plumbing Service. I will provide adequate electrical and/or plumbing service(s)to un any newly installed appliances or other furnishings.If the electrical and/or plumbing service(s)do not meet the standards of the utility company or electrical and/or plumbing codes, I will make the necessary changes at my expense unless Sears has agreed in this contract to mak the changes. as r Payment. I will pay Sears the cash price that covers the price of material and installation sho on the first page. Warranty Information. Appropriate product warranty documents will be given to me by Sears.Se#rs'Warranty on Installation is: SEARS'LIMITED WARRANTY ON INSTALLATION In addition to any manufacturer warranty extended to you on the product(s)used(which warranty becomes effective the date the merchandise is installed),if the workmanship(or application)of any Sears'arranged installation proves faulty within three years on Custom Craft products and one year on all other products,then upon notice from you Sears will cause such faults to be corre*d by repair at no additional cost to you.If Sears determines that repair is not commercially practicable or cannot be timely made,then,at Sears'sole discretion,Sears may elect to provide replacement or refund.Service under this Limited Warranty is available by calling Sears Home Improvement Products at 1-800-222-5030, Option 4.This warranty gives you specific legal rights,and you may also have other rights that vary tram State to State. NOTICE TO BUYER 1. DO NOT SIGN THE AGREEMENT IF ANY OF THE SPACES INTENDED FOR THE AGREED TEOMS TO THE EXTENT OF THE AVAILABLE INFORMATION ARE LEFT BLANK. 2. YOU ARE ENTITLED TO A COPY OF THIS AGREEMENT AT THE TIME YOU SIGN IT.KEEP IT TID PROTECT YOUR LEGAL RIGHTS. 3. YOU MAY PAY OFF THE FULL UNPAID BALANCE DUE UNDER THE AGREEMENT AT ANY pME,AND IN SO DOING YOU SHALL BE ENTITLED TO A FULL REBATE OF THE UNEARNED FINANCE AND INSURANCE CHARGES. 4. YOU MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY[FIFTH BUSINESS DAY IN ALASKA, FIFTEENTH BUSINESS DAY IN NORTH DAKOTA IF YOU ARE AGE 65 OR OLDER]AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT.FAILURE TO EXERCISE THIS OPTION, HOWEVER,WILL NOT INTERFERE WITH ANY OTHER REMEDIES AGAINST THE RETAIL SELLER YOU MAY POSSESS.IF YOU WISH,YOU MAY USE THIS PAGE AS NOTIFICATION BY WRITING"I HEREBY RESCIND"AND ADDING YOUR NAME AND ADDRESS.A DUPLICATE OF THIS RECEIPT IS PROVIDED BY THE SELLER FOR YOUR RECORDS. 5. IT SHALL NOT BE LEGAL FOR THE SELLER TO ENTER YOUR PREMISES UNLAWFULLY OR COMMIT ANY BREACH OF THE PEACE TO REPOSSESS GOODS PURCHASED UNDER THIS AGREEMENT. NOTICE TO MARYLAND RESIDENTS ONLY Notice:All home improvement contractors and subcontractors must be licensed by the Maryland Home Imp)ovement Commission.Inquiries regarding a contractor or subcontractor should be directed to the Home Improvement Commission,telephone:4104230-6309 or(in-state)1-888-218-5925. NOTICE TO NEW HAMPSHIRE CUSTOMERS NEW HAMPSHIRE LAW,RSA 359-G,CONTAINS IMPORTANT REQUIREMENTS YOU MUST FOLLOV4 BEFORE YOU MAY FILE A LAWSUIT OR OTHER ACTION FOR DEFECTIVE CONSTRUCTION AGAINST THE CONTRACTOR WHO CONSTRUCTED, REMODELED, OR REPAIRED YOUR HOME.SIXTY DAYS BEFORE YOU FILE A LAWSUIT OR OTHER ACTION,YOU MUST SERVE ON THE CONTRACTOR A WRITTEN NOTICE OF ANY CONSTRUCTION CONDITIONS YOU ALLEGE ARE DEFECTIVE.UNDER THE LAW,A CONTRACTOR HAS THE OPPORTUNITY TO REPAIR AND/OR PAY FOR THE DEFECTS.THERE ARE STRICT DEADLINES AND PROCEDURES UNDER STAT LAW,AND FAILURE TO FOLLOW THEM MAY AFFECT YOUR ABILITY TO FILE A LAWSUIT OR OTHER ACTION. Customer's signature Date Customers signi tu Gate Accepted by Sears Home Improvement Products,Inc.("Sean;)on i,' >: by.Date Management Representative .SDI-04-ftV 04 e s 4() _. �I os * iARN3TABLE, • ` 639. Town of Barnstable Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO s 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 I, via VanJI' V) ,as Owner cif the subject e�l prop hereby authoriz - nl-2�f�o act on my behalf, ` in all matters relative to work authorized by this building permit application for: 17 .,Crm6-d iDnyn)d Pd ./ (Address of Job) Signature of Owner Date On V 1/0 10 Y) e Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the i reverse side: C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 i Cape Cod Times 211 . MONDAY,JANUARY 24,2011 COURT REPORT more than$250,Jan.15 in Barnstable. Barnstable Pretrial hearing Feb.28. 1 IVERS,.Patrick,19,4 Wenfield Road, " DISTRICT COURT Forestdale; possession of Cymbalta, Jan..18 in Sandwich.Pretrial hearing k- In court Jan.18: Feb.2. ' ARRAIGNMENTS KELLY,Lisa,50,24 Spring St.;Hyan (The following pleaded not guilty.) nis;larceny from a person;Jan.16 in a BICKEL, Nicholas K., 25, 70 Cape )Barnstable."Pretrial hearing Feb.9. )r , Drive,Mashpee;oul and another traf- LIMA,Marcio F.,32,26 Sudbury Lane, L . t fic violation, Jan. 16 in Barnstable. Hyannis;indecent assault and battery F §Y3 y 9 Pretrial hearing Feb.7. of a person 14 years and older and 1 aq BRUMFIELD,Bart,48,367 Pitcher's aggravated assault and battery,Jan.18 q Way,Hyannis;assault and battery and in Barnstable.Pretrial hearing.Feb.9. " intimidating a witness,Jan.17 in Barn- MADIGAN, Robert, 29; 1365 Route i s stable.Pretrial hearing Feb.14. 28, Bourne; possession of Adderall a F LEBEDEV,Alexey,24,27 Anchorage with intent to distribute and receiving Lane,Yarmouth;OUT, negligent driv- stolen property valued at more thanr ing and another traffic violation,Jan. $250, Jan.18 in Barnstable. Pretrial Y , r 16 in Yarmouth. Pretrial hearing Feb. hearing Feb.7. 8, u 15• ODOARDI,Katr'ine,26;.253 Route 28, t MEDINA,Felicia Y.,20,10 Billy Mitch- Dennis; three counts of violating a ell Drive,Falmouth;possession of oxy- protective order,Dec.19,Jan.13 and codone with intent to distribute and 18 in Yarmouth.Pretrial hearing Feb. being a minor in possession of alcohol, 28. May 15 in Barnstable.,Pretrial hearing PEARL,Derek,26,19 Jody Lane,For- CHRISTINEHOCHKEPPELICAPE COD TIME Jan.25. estdale;possession of heroin and pos- A a 2004 Toyota Prius was taken to Cape Cod hlospita READ, Kyle, 28, 17 Crooked Pond session of Suboxone,Jan.18 in Sand- Ir crashed on Route 6 in Brewster on Sunday. Road,.Hyannis; possession of oxy= with.Pretrial hearing Feb.14. codone with intent distribute and T Kelly N., 31, 31 Courtland resisting arrest,Jan.14 in Barnstable. Way,Yarmouth; ijured In Route 6 rollover in Brewster . two counts of shop-. Pretrial hearing Feb.8. lifting,Jan.18 in Barnstable.Pretrial SLADE, Richard J., 52, no known hearing Feb.28. TER - A Route 6 Brewster and Orleans rescu address; assault and battery with a VERA,Amanda,25,31 Courtland Way, one man to the hos- .crews responded to the scene. dangerous weapon (garden shears), Yarmouth;two counts of shoplifting,. ty afternoon and shut'- The male driver's injurie Aug.13 in Barnstable.Pretrial hearing Jan.18 in Barnstaple.Pretrial hearing " Feb.22. Feb.28. mstbound lane of the were'not considered serious _ TOSCHES, Allen, 57, 39 Frost Ave., WHALEN,Bridget,22,19 Jody Lane,: pr about 15 minutes, according tq an Orleans Fir Yarmouth;oUl and negligent driving, Sandwich; possession,of heroin and to state police. Department spokesman. Th Jan.16 in Barnstable.Pretrial hearing possession of a firearm without an, Feb.16. FID card,Jan.18 in Sandwich.Pretrial dent,reported at 1:43 highway was reopened aroun )PRESS YATES, Sabrina, 37, 52 Lake Drive hearing Feb.14. med in Brewster near 2 p.m.,state police said. wars west, Yarmouth; larceny of a motor is line.The driver of State police did not releas t his vehicle, Nov.1 in Barnstable..Pretrial : In court Jan.21: byota Prius involved the driver's name or a possibl hearing Feb.22. DISPOSITIONS ;to Cape Cod Hospital, cause of the crash as of Sunda BENTON,William L., tt Harwich Ito sae police.Both night. In court Jan.19: Road, Mashpee; admittedd ttt ht.sufficient P g DISPOSITIONS facts to breaking and entering a boat !' j CRUZ,Said Z.,30,49 Woodland Ave? or vehicle in the nighttime to commit Hyannis;guilty of operating a motor a felony,April 27 in Barnstable, and vehicle while under the influence of assault with a dangerous weapon, 01y yours- alcohol (01.11) and negligent driving, Aug.14 in Barnstable,continued with- 6 arch 7 i Barnstable, continued out a finding for one year,$ fees. . 9 i � .�� ® without a finding for one year,45-day CIMENO, Thomas, 69, 15 Oak Neck license loss,$1,847.22 costs and$50 Road,.Hyannis;open and gross lewd fee; not responsible for four other ness,July 4 in Barnstable;dismissed. traffic violations.' COFFIN, Chad, 31, 40 Anchorage for Special Reports, News Projects DAUPHINAIS,Kathleen,47,225 Main Lane,Yarmouth;not guilty of assault 990 St.,Hyannis;assault and battery;Nov, and battery with a dangerous weapon " ever 21 in Barnstable,dismissed. and threatening to commit a crime, HOLMES,Naomi,18,1 Jefferson Ave., Sept.10 in Yarmouth;guilty of vandal- D .00k Yarmouth; admitted sufficient fact s ism e year probation,$50 feeon . irns. to breaking and entering in the night= GRIFFITH,Alyssa R.,22,31 Forest Hills S I G x_than time to commit a felony,larceny from Road,Cotuit;admitted sufficient facts -hole a building and being a minor in pos- to two counts receiving stolen prop session alcohol, Nov. P2 in Barn- erty of a value less than $250, July D I stable, coo without without a finding 22 in Yarmouth,continued without a for- for two years,$1,200 costs and $90 finding for one year,$50 fee. S T -U nold fees;receiving stolen property valued MACKEIL,John C.,21,56 Davis Straits, ited at more than $250; same date,.dis- Falmouth;guilty plea to breaking and missed. entering in the nighttime to commit a rcise LOPEZ,Wilfred'T., 51,77 Winter St., felony and larceny from a building,Nov. North Street a Hyannis a 774-470-1363: into Hyannis;guilty of OUI.for the fourth 22 in Barnstable,18 months(suspended) time,Aug.31 in Barnstable,two years Barnstable County Correctional Facility, Monday - Friday 10-6; Satorday.10-3 k for in Barnstable County Correctional two years probation,$1,560 costs and Facility,eight-year license loss;guilty $90 fees;guilty plea to possession of , `IOPJII= FURNISHINGS ARRIVING DAILY! Pro' of negligent driving, same date, six marijuana with intent to distribute,one Your Complete Source For: )med months in county correctional facility year probation,$50 fee;receiving sto pro- . (concurrent). fen property,dismissed. Istery, Slipcovers, Custom Window Treatments' Inter LOUGHRAN,John G.,19,182 Sea St., WELDON, Vannica, 41, Binghamton, I Hyannis;admitted sufficient.f acts to N.Y.; carrying a dangerous weapon Fine Home Furnishings &Accessories i !neg breaking and entering in the night and deriving support from prostitu- time to commit a felony,larceny from tion,July 13 in Barnstable,dismissed his a building and being a•minor in pos- on payment of$300. Design Consultants and, session of alcohol, Nov. 22 in Barn- ARRAIGNMENTS I stable, continued without a finding (The following pleaded not guilty.) )avid Shinn o Sandy Tobins e Lisa Kinerson ed a for two years, $1,200 costs and $90 AMARAL,Evan,19,37 Discovery Hill that fees;receiving stolen property valued Road,Sandwich;assault and battery, ght- at more than $250, same date, dis- Jan.19 in Sandwich.Pretrial hearing )men missed. Feb.11. hose MARCELINE,Yolanda, 2,74 Danvers GLENN,Jessica,29,58 Carlotta 4 Way, Hyannis; being an accessory Hyannis; assault and battery with Ave,a nary .if ci nrRa a`a�chl(home invasion),June dangerous weapon (shod foot) and �;�, a"teae, j ^ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Zo Map Parcel'. D( Application # (O Health;Division '` Date Issued Conservation Division ;Application Fee Planning Dept. Permit Fee. Date Definitive Plan.Approved by Planning Board p /� Historic - OKH _ Preservation/ Hyannis o �a Project Street Address Village Owner "1� lc�. T( ce c I e5 rP. Address U, ' c .c � Telephone ash L L.. Permit Request R=LW -i �V Vi4n,�-y o C° fi Roayn / 0AAS Square feet: 1 st floor: existing proposed $00 2nd floor: existing proposed Total new C7— Zoning District Flood Plain Groundwater Overlay Project Valuation 410000!�- Construction Type ee7-Pockl 6Sek Lot Size i Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes 9No On Old King's Highway: ❑Yes Y, No Basement Type: 4 Full ❑Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new c Number of Bedrooms: 3 existing new � � Total Room Count (not including baths): existing new First Floor Rb§in Count? � CD -A Heat Type and Fuel: Gas ❑Oil ❑ Electric ❑ Other I., co Central Air: ❑Yes No Fireplaces: Existing New A- Existing wood/coal stove'�❑hes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑existing 0°newc*ize_ CD 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 t (BUILDER OR HOMEOWNER) Name (2� 0N._t1eSa0meA_ kfS " Telephone Number Address / �� S �C i/ License# 'h "A- Xa/ oaf 73 Home Improvement Contractor# / 1� ? �.2 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE A t° FOR OFFICIAL USE ONLY APPLICATION# w DATE ISSVEDJ ' MAR/PARCEL NO. i p ADDRESS VILLAGE . OWNER 1 ,t DATE OF INSPECTION: ti l f FOUNDATION FRAME t INSULATION'! x {. FIREPLACE ELECTRICAL: ROUGH FINAL w ' , y PLUMBING: ROUGH FINAL t-s GAS::, = ,>.- ROUGH o:' FINAL u,. JFINAL BUILDING .`> ;,. DATE CLOSED OUT _ F ASSOCIATION PLAN NO. Tfie CwtJ1110711veakh of±llassaclruseifts T Departrnew of Indrestlial Accidents D,f,fTceLj•Invesfl�lldlDllS F� z 600 Waslrin trip street eet . J Boston,±IIA 0?1II ivayrr.inass.e ov/dia WoArers' Compensation Iusurauce Affidavit: Builders/Contractoi•s/Etectraciaus/P'lumbL-rs Applicant Infarmation Please 1PAM Legufly Name(Sussveas o g-inkw t:nfludiridual> Ad&ess--'7C^ 91,�Nns 0—row elf IQ6ae� , Cit=j/State/7ip: 14 Vl�loUU-- Ma. Phone Are you an employer?Check the appropriate box: Type of project(required): 1-❑ I am a employer loath !- ❑ I am a general contractor and I 6- ❑Nelar con tructiou to ees full and/or part-time)- have hired the sub-coutracitus � Y ( lam- ) 2-x,I am a sole proprietor orparinm- ILted on the aitached sheet. 7. ❑Remodeling ship and have uo employees Thy a sub-contractors have 3. ❑Demolition evoz Q for me in any ca aci employees and have workers' � l p iY- T 9. ❑ Building addition [No rierleis'comp-insurance comp-insurance- required-] 5-❑ We are a corporation and its 10-❑ Electrical repairs or additimu 3-❑ I am a homeovrttei doiug all work officers have exercised their 11-0 Plumbing repairs or additions myself_ o.varkers'c right of exemption per_- � [N gyp- 12-❑ Roofrepaizs insurance required-]I c-152,§1(4),and we have no employees-[kio vroikers' 13.❑Other comp-insurance required-] 'Any appirwz th3i che&—box�'I mist also fill our the secs!oa below sltorriz g rsel vroikers'co-tpeusatioapolicj itlnst»eiou T,Ionieovsess rtLo sub-et rbis affidavit indicating they are doing M wDri and fun Lie outade ccettacmrs lust submh a MW afl±dr r_t iadicatiag suds =ConGacmiz rs.t chtc::this box must attachEd=3ddisio3A_feet showing the anz a of the sub-coaue lams and state rihethr as not those etweiRS&-ve estployet3-I.the sub-contractor have esaployc--s;fhey-nut provide their tvarkets'coup-policy rtu,er- 1 uni an employer•flub irprovirliijo evo4ars'competuadon hum-ance for my employees. Below i;Me policy mid job ails hifarilul oll- �f It>>tuance Company Name: ��t L /G L Policy-9 ar Self-iris-Lic--9: [O Z LA, `Q, f EFpiraiiou Date: Job Sife Address: I/ l-ooXed f W k. City/State/�ip: ✓ rpb� Attach is copy of the workers'compensation policy declaration pnge(xhowiug the policy number and espintion daic). Failure to secure coverage as required raider Seciian 25A of MGL c-152 can lead io the imposition of criminal penalties of a 3iue up to 31,500.00 audler one-year imprisonmeut,as.veil as ciTnl penalties in the form of a STOP`DORY ORDER.and a fine of up io$250-00 a day aoaimt the violator. Be advised That a copy of IL-statemeni may be ffiv2Larded to ilia Office of Investigations,of the DIA for imurance coverage verrification- 1 rL:liereb�r�f4=wc� oi •es of perjury iliutiho hijarinatiouprovided above is tAte and co,�rect Simatnra: G /'�/�J Date: PT:lcue i;: . J C.+a � /%•� '7�(?to O leial use only- Do not itAte in this area,to be conipleted by city or i•WJi officiaL t City or Towu: PermidUc�ense ig Issuing Authority(circle one): 1.Board of Health 1.Building Department 3.Ci y/Tonrn Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Odder Coniact Person: Phone 4: 6 ti NOTICE N NOTICE TO a TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152,Sections 21, 22&30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: ZURICH-AMERICAN INSURANCE GROUP NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY (GZZUB-9891 M33-7-10) 08-26-10 TO 08-26-11 POLICY NUMBER EFFECTIVE DATES BENSON YOUNG & DOWNS INS PO BOX 158 HARWICH PORT MA 02646 NAME OF INSURANCE AGENT ADDRESS PHONE# CEDAR CREST PROPERTIES LLC 72 HIGGINS CROWELL ROAD WEST YARMOUTH MA 02673 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS md-% "r, nd_%r►rr" Di7 uilk4nT 11t7L'n Commonwealth,of Massachusetts _ Division of Occupational Safety yn Heather Rowe,Acting Commissioner - Deleader-Contractor ' JOHN P. LYONS ��dd Eff.Date 06/18/10 Exp_Date 06/17/11 x<' DC001912 Manberof CA-N.ES.T. BO y. 1111111111111111111111111 BOSTONRENEW c Massachusetts- Department of Public Safet} Board(if Building Regulations and Standards Construction Supervisor License License: CS 76126 Restricted to: OR .ice P LYONS �4 72 HIGGINS CROWELL R!2 ; W YARMOUTK MA=73 Expiration: 1/6/2012 ('unnnisrioncr Tr#: 17179 Gf/� i�iw„wow.e�i g�✓ idu6elta Oft'tce of COBsomer Affairs&B t►�[dt gge� HOME IMPROVEMENT CONTRACTOR = _ w�ttt Registration: 1166189 TYPW- _ Bmrder =NdshudwNft y Expiration: 5!T/2012 LLC Gm ll?l e2=1�01 yj Baa>H= ltr> .U1288 Cedar Crest Properties LLC " ti 1' f> John Lyons 72 ins Crowell West Yarmouth.MA O2ti73:...:':= Undersecretary navallid Jack Lyons ®Q. '6 4 7 t � Cedar Crest Properties,LLC Has successfully completed the US.Dmartioenf of-labor National.Fiber Cellulose Application Training COursE G=v�anw HeaR-Ad atiarl B 22a°day/of March Zait} - hL�:�rx tllft�+iomP]eted a 104IM r Emotional Safety and H2211h Train3gg Gdtrse in t"�' � _ NATIONAL FIBER vadw zembw 'ed fraUfO5i1N:tl7f.7�r: fix: .. . ..- ',_.. --- -'- ' -- .'--_•._• __._:�:.--:_.. ., ..-.",.: I , oFt"e rqk, sawvs!r"M 3 Town of Barnstable �EDMArp Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO 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 2GdT.LT�,/ �"as Owner of the subject property hereby authorize��d�.� V- n-w-(�" (PS L l C,to act on my behalf, in all matters relative to work authorized by this building permit application for: Tor>cQ 4pcai S l�C'- (Address of Job) Signature of Owner Dat Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\A Data\Local\Microsoft\Windows\Tem ora Intemet Files\Content.outlook\DDV87AAZ\EXPRESS.doc PP P rY Revised 072110 aFtt+rtoy� 7. oWll ,6 f Barnstable *Permit# T p Expires 6 monrlrsfrom issue date R' Regulatory Expires Fee /\ �" BARV5IABLE, • , Thomas F. Geiier' Director Building,Divisio:n Torn Perry;CBO, Building Co>:..i issioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: '508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Nor V'alitl 011roal Red X-Press Imprirr/. Map/parcel Number �j� 1 _ 2A. /.V.p44ddressSidentia l Value of,Work Minimum fee of$35.00 for work under$6000.00 Owner's Name & Address4N )/u/— Contractor's Narne l \ erg Tel phone Number Home improvement Contractor License#(if applicable)� :�a��g Construction Supervisor's License.#-(if applicable) ' . 76077 ❑Workman's Compensation Insurance �. PERMIT Check one: ❑ I am a sole proprietor O C T ❑ J, m the Homeowner COIF I have Worker's Compensation Insurance TOWN OF BARNST ABLE Insurance Company Name p< -P 1A4, C d . Workman's Comp, Pof icy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check.box) ❑ Re-roof(h,orricane nailed) (stripping o'ldshingles) All construction debris will be taken to Re-roof(hu 'cane nailed)(not stripping: Going over existing layers of root) ;+ Re- ' e #;of doors Replacement Windows/doors/sliders. U-Value 0 (maximurm .35)# of window *Where required: Issuance of this permit does not exempt,compliance with other'town department regulations,i.e.Historic,Conservation;etc, —Note: Property Owner most sign Property Owner Letter of Permission: A copy of the Home Improvement Contractors License & Construction Supervisors License is req u SIGNATURE: ?AWPFILESIFORMSIhuildmg permit,forms\EXPRESS doc revised 072110 4 The COMMOnwea t#: of €ttssachitsetts - =-' DeprzrtMertt of lnt=ustriaLI[ccidents $ _ t'^j.ftce OJ P&B'�'sdt,�t[IlCit:S - �•t,,�,r.-� ::37n 6rit3-rtti?�tt7 � `%��'=i ' Flu r G _ M 0rIb rS, Compensation Insi r1inL': _�tti�113fiT" dJ� a1j�i'3 s,i.UT111i?.CLi43�;�• p-je`3`eFTrint Le7;bl- i .,ic:anT Irtfot• t v - ?' �_ r r 4 Na111' -- y i t Phone ` City State.71p: — t Ar you an employer'?Check a peopriate b Type of pro' ct(required): 4. f l.atn a general c onu actor and I 6_ 1 w consavction !_ € am a empiayer with have hired the sub-Cotracrors employees(full and/or part-time).* Reiriode€ing t l listed on the attached sheet. (1 2.❑ I am a sole proprietor or partner These sub-contractors have 8. ❑Demolition ship and have no employees employees and have workers 9_ ❑Buitdinz addition 4 j working for me in anv capacity. � � 1 o wormers' comp.insurance comp: insurance.' 1Q Elect;cal repairs or additiot:s {?v j, (� We are a corpora ion and its required.j officers have exercised their 1 1.❑Plumbing repairs or additions ;.❑ 1 am a homeowner doing all work right of exemption per ti4GL 12.❑ Roof repairs 1 . myself [tio workers' camp. c, 1 2.�1(4).and we have no 13.❑Other; —- i insurance required. # employees. [No workers' comp.insurance required.} i 'Any applicant that checks boxi must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit dic an additional sheep how all ong he name ofk and then �n�sub•conttside ractoi sr an state whether or n��hos must su se entries have such. Contractors that check this box m emplo}ees. If the sub-contractors have emplovees,they Rust provide their workers'corip.polic}numb eeS Below Is the policy and job site I am an employer that is providing workers'compensation insurance for my emp y information. ", 1 3 . 0 . insurance Company Name: 3 �y Expiration Date: Policy A or Self-ins.Lic.#:_ ��d, CityiStatelZip: Job Site Address:17j: _ - .attach a copy of the workers' compensation policy e 25A of radonAGL Sag 2 Showing to e policy 4, r of and final penalties of a Failure to secure coverage as required under Section tine up to €,�GQ.QO and/or one-year imprisonment;as what ell a coy,[pf this'statem nt may be fowarded�Rth Office Of nd a line of up to S2:0.00 a day against the viota1or. Be adv.sed t p} lnvestigaticn.11 s of the Dl,� for insurance coverage verification. sins andnalties of per pe •ury that the information pr©vigil soave is true and correct I do hereby certify u n P r 7 — ale: Signature: -- —,__ Phone; n this area,to be completed by city or town official. Official use only. Do not write i l PermitlLicense# 9 CitybrTown:_ Issuing Authority(circle one): 1.Board of Health 2:Building Department 3.C►tyrTown Clerk 4.Electrical In S.Plumbing inspector 6.other Phone : Contact Person: The Commonwealth of Massachusetts Department of Industrial Accidents Offlee of Investigations 600 Washington Street Boston, AM 02111 www.mass gov/dia Workers' Compensa_ don Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AvyUcant Information Please Print LeLdbly Name(Business/Organization/Individual): G-(..e ; Address:- City/State,/Zip: cI(A/r Phone#: Aremiployees n employer?Check the appropriate box: Type of prof (required): 1. a employer with 4. I am a general contractor and I (full and/or part-time). • have hired the sub-contractors 6. ❑N construction 2. 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. insurance comp. required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp.insurance required.] •Any applicant that checks box#1 waist 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 subcontractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. 1 I am an employer that Is providing workers'compensado insur ce fo►my employees. Below is the policy and fob site information. Insurance Company Name: of ® Policy#or.Self-ins. Lic.`#: i Expiration Date: Job Site Address: / City/State/Zip: /WV, Attach a copy of the workers'compensation policy declaration page(showing the pone y nu err and piration ate). 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,SQ0.00 and/or erne-fear 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 Investi anions of the DIA for insurance coverage verification 1 do hereby certify err the pain,Van pen of perJury t the information provided above is true and correct Signafore: Date / _ Phone#: �� b — LU Of leial use only. Do not write In this area,to be comp eted y city or town ofJiciaL 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#: Information and I nstructions Massachusetts General Laws chapter 152 requires all employdrs 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,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 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-contractor(s)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 bum 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. # 617-7274900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 11-22-06 wwwmass.gov/dia r�/xLC LGf/L (I�.!(/(l.7ddfC!' •floe . . tJffrce of€`.unsuener titTairs Bc Business 1Legulation t.icensc or registration valid for individut use Daily before the expiration date. 1f found return to: I} r OME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regut ttiun Registration'-1261393 Type: 10 Park Plaza=Suite 5170 02116� supplement Expiration $1312092 t Card Boston,M ' The Home Depot`At-k a he Services DARREN DEMERS- -2690 CUMBERtAND PARKWAYS GA 30339 Undersecretary Not valid without signature r �l:I?P:IC!�il?Ctt? - ,Te'!rsr'int�t;t +i! !�U!i!IC b:iiCf� � —"3i5si•t!'nt•�e.i!alat2� !?a•satl;al�alr:. and `t:aaial:►t•tl. __--..- __ Construction Supervise( License License: CS 70077 Restvicted to: 00 JOSEPH C DUARTE 15 FALL ST WAREHAM, MA 02571 Expiration: 12/3012610 t mwi•.i n,r Tra: 7662 i 6 11Te >sadSts®Jarl• �.ictrsse-art aejisl:btieR valid P®er in®io•idualusifu3)° Rr W ` n1 IG��r �4oe of � "WiE WROVEMEW COMMACTak i.e•toov tote e� dote. !f round mieen ta: i9nArt$oC�teihDi^SC;1qui otinm avd gtaedaeds gegistratiota� 132�t9 flue•:�shbiaotn�Plaa+r�1_{I!i Eupantl01V 1/1 il20il Tst ??d91 44�stuR.�4a;WIN Tree: palinersbip J 6 J Remode" .los"h Duarte 15 t:a!1 St !`. '�-- . _ vatid wimaas sipatwn Vywo om. ma0267t trrmiei+v;r� + - HOME IMPROVEMENT CONTRACT PLEASE READ THIS $old Furnished and Installed by. 'fHD At-Home Scrvicc:s,Inc. Branch Name: Boston Date: -Home Services dWa The Home Depot At 345A Greenwood Street,Unit 2,Worcester,MA q 1607 Toll Free(800)657-5182; Fax(509)756-8823 Branch Number:31 Petlend M#75-2698460;ME Lia#(.,02439;RI Cont.]_ic#16427 CT Lic#0565522;MA Flome Improvement Contxacrar Reg:4 126893 . Installation Address: L \ i�►[LLV�-�—f-t1 „ City State -zip purchaser(s): Work Phone• Home Phone: Cell Phone: Home Address:. __.. City State 71p (If different from installation Address) . E-mail Address(to receive project communications and Home Depot updates): ❑I DO NOT wish to receive any marketing.email's from The Ilome Depot 1'roieet Information: Undersigned("(customer"),the owners of the property looted at the above installation address,agrees to buy, and T11D At Home Services,Inc.("The home Depot')agrees to furnish,deliver and arrange for the installation(Installitttop')of all materials described on the below and on the referenced Spec Sheet(s), all attachedof ic haretre ina d any Change d into this Contract nt ac by ly reference,along with any applicable State Supplement and Payment Summary "Contract"): Spec Sheet(s)#: Project Ammint Joh#: tt�,�rnnu a�r�re"oe) U. i . ❑Roofing ❑Siding Windows ❑Insulation S ��'' titm /Cnve+s ❑i ntry Doors ❑ []Roofing $td;r,g Windows ❑insulation ❑Gutter~l Covers ❑Entry Doors ❑ - ❑Roofing ❑Siding Windows ❑Insulation ❑Gutters/Covers ❑Entry Doors[]: ❑Roofing ❑Siding LjWindows ❑insulation $ co ❑Gutters/Covers❑Enuy Doors ❑ Almimtun 2,9%Deposit or Contract Amount due upon execution or this.contract- Total Contract Amount $ Maine purchasers may not deposit more than one-third or the Contract Amount V Customer agrees that,immediately upon completion of the work for each Product Customer will execute a Completion Certificate (one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder_ The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Products)included herein;at its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem_with the home,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because work required to complete the job was not included in the Contract. Payment Summary• The payment.Summary#_ 30 b _, included as part of this Contract, sets forth the total Contract amount and payments required for the.deposits and final payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a completely tilled-in copy of the Contract at the time you sight- Do not sign a Completion Certificate(note: there is one Completion Certificate for each listed Product as defined by individual Spec Streets)before work on that Product is complete. In the event or termination of this(contract,Customer agrees to pay The Home Deport the costs of materials,labor,expenses and services provided by The Horne DeQpuort or Authorized Service Provider through the date of termination,pins any outer amounts set forth in this Agreement or allowed,under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE; W1T130U7' LIMITING THE HOME DEPOT'$OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS' Accentance and Authorization: Customcr`agrecs and understands that this Agreement is the entire agreement between Customer and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and ag=.r vents,either oral or written,relating to said Products and Installation.This Agreement cannot he assigned or amended except by a writing signed by Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,undetstands,voluntarily accepts.the terms of and has received a copy of this Agreement. Ae epted by: + ` Sub 'tted by: ^ O XW X `f Customer's Signature Date Sales nsultant's Si lure q Date X Telephone No. 4� v $� Customer's Signature Date Sales Consultant License No. CANCELLATION; CUSTOMER MAY CANCEL THIS (as applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED By LAW : IN CUSTOMER'S STATE- NOTICE:ADDiTIONA�I.T£RMS AND CONDITIONS ARE SPATIM ON THF.RFVFRS7 "IDF.AND ARE PART OF THIS CONTl2ACr 7.7-10 C-SC White-Branch File'Yellow—Customer -Ld TL�9£t3@G: 'ON XHd pp6wef: W021d Td Wti�b:TT L@0Z i?T d ,