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0077 DELTA STREET
r� -` -� d 'L �. V -- -- - - ----- - -- -- --•-- - - - - �� '� t may To pfjrgt,, wn of Barnstable Permit# ti p� Expires 6 months rom issue date Regulatory Services Fee 5, BARNSresr.e MASS9cb , Thomas F. Geiler,Directors . -�AP R SS Building Division P� Ia�J� Vi Ttim Perry,CBO, Building Commissioner _ 200 Main Street,-Hyannis, MA 02601 www.town:Barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - .RESIDENTIAL ONLY Not Valid without Red X-Press Imprint. Map/parcel Number o;) 013 6 VRerstiy Address Cam �/,& . �: V 0dential Value of Work Minimum fee of$35.00 f r,work under$6000.00 Owner's Name &Address lv r 0le,6 V � 1 U/ /V Contractor's Name ® )O—w ov,4, Telephone Number Off;' t> —e�Y Home Improvement Contractor License#(if applicable) / 01 ' #D Vonsction Supervisor's License#(if applicable)man's Compensation Insurance. Check one: ❑ I m a sole proprietor am the Homeowner Lf I.have Worker's Compensation Insurance Insurance Company Name A&�/�/ �}✓►11�5�i�`f^� L/VS Workman's Comp. Policy# ,mob Copy of Insurance Compliance.Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ R tde of doors Replacement Wind ows/doors/sIid'ers. U-Value V, a (maximum .44)#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 must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License& Construction Supervisors License is require SIGNATURE: Q:\WPFILESTORMS\building permit forms\EXPRESS.doC ,Revised 070110 The Commonwealth af1Y1:ta.ssaehlasetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,t n, MA 02111 www,mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): l Address: j ec"6e_6 City/State/Zip: �(1,�.rt. - -3 Jg 3 9 Phone#: Are you an employer? Check the appropriate b Type o;;:w r 'ect(required): 1. I am a employer with p�l7 4• I am a general contractor and I 6 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. 7. Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition and have workers'a working :forme in any,capacity: employees9: ❑ Building addition comp.insurance: [No workers comp. insurance ,� 10.❑ Electrical repairs or additions required.] 5. ❑ We are a corporation and its p 3.❑ I am a homeowner doing all work officers have exercised their I L[I Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. / /re , Insurance Company Name: Policy#or Self-ins.Lic.#: Q I Expiration Date: ' i (;� City/State/Zip: /V/VrS, C Job Site Address:�7 d policy declaration page(showing the policy numbxp�n date). Attach a copy of the workers compensation p y p g ( g P i 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 forinsurance coverage verification. I do hereby certify unde ains and penalties of perjury that the information provided above is true and correct. Si ature: -- Date: Phone#: Zb 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/TownClerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person. Phone#: v The Commonwealth of Massachusetts Department of Industrial Accidents �C I- ,' a Office of Investigations �� 600 Washington Street �� a j Boston, MA 02.111 c- www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LelZibl Name (Business/Organization/Individual): Jase �U Address: City/State/Zip: k d�© ~ fk �Jg hone-#: jd� /f��'t�/ � Are you an employer?Check the appropriate box:" t` Type of project(required): 1./]a em to er with 4. ❑ I am a general contractor and 1 p y 6. _❑ Ne construction ees(full and/or part-time).* have hired the sub-contractors 2. ole proprietor-or partners-. ;.listed on the attached sheet #•, emodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its officers have exercised their 10;❑ Electrical repairs or additions required.] of 3.❑ I am a homeowner doing all work right of exemption per MGL I'I.❑ Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance re9 wired. 't. - ,_. employees.,[No workers' 13.❑ Other' ' comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'-compensition 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 their workers'comp.policy information. I am an employer that is providing workers'compensate n ins ance form. employees. Below is thepolicy and job site + information. ' . Insurance Company Name:` A, NS Policy#or Self-ins. Lic.#: - [J AN Expiration Date: ���` Job Site Address: .77- 1 City/State/Zip: &A, - go Attach a copy of the workers' compensation policy declaration page (showing the policy n64ber an 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 impt-isonnient,as well as civil penalties in the,form of a STOP WORK'ORDER and afine 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 certi under the pain nd penalties erjury that t information provided above is true_ 44 and correct, Signature: Date: Phone#:, .. Official use only. Do not write in this area;to be completed by city_or town offccia[ City or Town: Permit/License# Issuing Authority(circle one): ].'Board of Health 2. Building Department 3.Cityrrown;Clerk 4.Electrical Inspector.'S.Plumbing Inspector r. 6.Other Contact Person: Phone#: *� 1 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance;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." k' t 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 T printed legibly. e Department has provided a space at the bottom Please �e sure that the affidavit�s complete and rnn S Y The�. r r r of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations' 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia I 1 �, DATE(MMIDDIYYYY) A��R� CERTIFICATE ®F LIAEILITY INSURANCE D2/21/2011 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 1-404-995-3000 CONTACT NAME_:______ -- .T-FAX'------- ----- Marsh USA, Inc. PHONE � LAIC No_ homedepot.certrequest@rnarsh.com E-MAIL Two Alliance Center, 3560 Lenox Road, Suite 2400 INSURERS--- AFFORDING COVERAGE NAIC# Atlanta, GA 30326 __--- �.1---------'-------------...._..._.-_._......__... Fax (212) 948-0902 _ _ INSURER A: Steadfast Ins Cc --- _ — -26387- INSURED INSURERS: Zurich American Ins Co 16535 The Home Depot, Inc. New Hampshire Ins Co 23841 Home Depot U.S.A., Inc. INSURERC: P _ _____._....__.._......_- 2455 Paces Ferry Road NW INSURERC: Illinois Natl Ins Co 23817 ---- --- ----- ----- --..............._.._._.. Building C-20 INSURERE: NATIONAL UNION FIRE INS CO OF PITTS 19445 ...........--- Atlanta, GA 30339 ----- ----... ----....--------- -- - ----...__... .. . . _ INSURERF: Illinois Union Ins Co 27960 COVERAGES CERTIFICATE NUMBER: -19831682 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. TNSRAOUL SUER POLICY EFF POLICY EXP ILTR TYPE Or INSURANCE I POLICY NUMBER MMIDDIYYYY MMIDDIYYYY LIMITS A GENERAL LIABILITY GL04887714-01 03/0.1/1 03/01/12 EACHOCCURRENCE a9,000,000 - - X DAMAGE TO RENTED 1,000,000•. COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence._ $_--_-..-_-_. CLAIMS-MADE OCCUR MED_EXP(Any one person) $EXCLUDED X LIMITS OF POLICY'XS PERSONAL BA DV INJURY $ 9,000,000 X OF SIR: $lM PER OCC GENERAL AGGREGATE $ 9,000_000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 9,000,000 . - X POLICY PRO• LOC $ B AUTOMOBILE LIABILITY HAP 2938863-08 03 01 1 -03/01/12 COMBINED SINGLE LIMIT 1,000_.,000 Ea accident -._. _-- X ANY AUTO BODILY INJURY(Per person) 8 ALL OWNED F7 SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident X SIR AUTO P Y - r - $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DIED RETENTION$ -- - $ C WORKERS COMPENSATION WC061967352 (AOS) 03/01/1 03/01/12 X WCSTATU- OTH- -----_---AND EMPLOYERS'LIABILITY YIN 03/O1/12 _ D ANY PROPRIETORIPARTNERIEXECUTIVE❑ WC061967354 (FL) 03/01/1 E.L.EACH ACCIDENT $ 1,000,000—_-_ OFFICERIMEMBER EXCLUDED? N NIA E (Mandatory in NH) WC061967353 (CA) 03/01/1 03/01/12 E.L.DISEASE-EA EMPLOYE $ 1,000,000 II yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C Workers Compensation WC061967355(KY,M0,NY,WI, p3/O1/1 03/O1/12 F TX Employers XS Indemnity TNSC46244151 (TX) 03/01/1 03/01/12 Occurrence/SIR 30M/lM E Workers Compensation WC1192378 (QSI) 03/01/1 03/01/12 SIR 1M DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 701,Additional Remarks Schedule,if more space Is required) RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HOME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C-20 t- ATLANTA, GA 30339 w USA ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD jfiero_hd 19834682 ;� ��,e �Gr rV+.0 rccr.etz�c�✓c aJ�_'LLttddCccf?" �c' - ' Office of Consumer affairs&Business Regulation l i`,,,,—''HOME IMPROVEMENT CONTRAI-TOR Registration:, .126893 Type: Expiration ;8/3/2012 Supplement C . The Home Depot At-Home Services DARREN DEMERS 2690 CUMBERLAND PARKWAYS GA 30339 Undersecretary License or registration valid for individul use only before the expiration date. If found return-to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 ;ard Boston,MA 02116 , 5 Not valid without signature a )WORD IIT LIABILITY INSURANCE DATE(MMIDDIYYIYI 03/23/2011. PRODUCER 50S.Z95.4440 FAX 508.295.5864 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Paul B. Sullivan Insurance Agency Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 2870 CranberryHighway z HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 9 Y ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0. Box 551 East Wareham, MA €2538 INSURERS AFFORDING COVERAGE NAIC# INSURED 7 & 1 Remodeling INSURERA: Vermont Mutual Insurance Co. 26018 - 15 Wilson Way INSURER B: Middleborough, MA 02346 INSURERQ INSURER D: INSURER E; COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE \ POLICY NUMBER DATE MhVDD1YYYY DATE MMIDD'YYYY LIMITS GENERAL LIABILITY BP110205ZO 03/22/2011 03/22/2012 EACHOCCURRENCE S 11000100 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) S S010001 CLAIMS MADE OCCUR MED EXP(Any one person) S S,000 A - PERSONAL&AOV INJURY $ .1,000,000 GENERAL AGGREGATE S 2-,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 PDLICY F7EO- LOC AUTOMOBILE LABILITY .. COMBINED SINGLE LIMIT S ANC AUTO (Es accident; ALL OWNED AUTOS - - BODILY INJURY $ SZHEDULED AUTOS (Pei Persol) HIRED AUTOS BODILY INJURY NON-OWNEDAUTOS (Peracciden;) $ ' PROPERTY DAMAGE $ (Per acUden:) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ AN"AUTO OTHERTHAN EA ACC .$. AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR D CLAWS MADE AGGREGAT_ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION - ' AND EMPLOYERS'LIABILITY - -NV LIMIT YIN .ANY PROPRIETORIPARTNER/EXECUTIVE aN E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.E DISEASE•EA EMPLOYE $ y SPes,describe under ECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS HD At Home Services,. Inc and the Home Depot are included as additional insureds with respects to general liability linsurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUC19S BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN THD At Home Services, Inc. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TODOSOSHALL 3200 Cobb Gal l eri a Partway IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Suite 200 REPRESENTATIVES. Atlanta, GA 30339 ; AUTHORIZED REPRESENTATIVE Edward Sullivan/MARIE ACORD 25(2009101) FAX: S08.756.8823 ©1988.2009 ACORD CORPORATION. Ail.rights reserved. The ACORD name and logo are registered marks of ACORD - . AM office of Consumer Affairs and usiness Regulation f' 10 Park P1a/-v Suite 5170 y Boston, Massachusetts 02116 Nome Improvement Ct::tractor Registration Registration: 132349 Type: Partnership •: Expiration: 1/11/2013 Tr# 207392 J &J Remodeling Joseph Duarte -- 15 Fall St. ma 02571 Wareham, card.Mark reason for change Update Address and return . Address Renewal Employment (� 1,nsE Card )PS•GAt 0 60M•04/04-0101216 Otfice�lC°oum a rs�i9sincsI'KigulsCion License or registration valid for individul use only IMPROVEMENT CONTRACTgR_ before the expiration date. if found return to: HOME I THOMERegistration. •,•132349 Type: Office of Consumer Affairs and Business Regulation Partnership10 Park Plaza-Suite 5170 Expiration: :�lt1/2013 Boston,MA 02116 J emodeling,.: Joseph Duarte 15 Fall St. �. _ _ lam— Wareham,ma 02571 .•: Undersecretary of v d without signature 11:►.•uchu:ett•- Dcp:u unectt of Puhlic tixfcq 1 Board of Buililimr Red.:uL•piuns acid S(andards Con&truction Supervisor License License: cs 70077 JOSEPH G DUARTE 15 FALL ST . WAREHAM,MA 02571 1 aw , Expiration, 12l3oj2012 Tr#: 704a TO 30dd Z9L6S6Z 69:TZ TTOZ/ZO/10 f HOME IMPROVEMENT CONTRACT PLEASE READ TMS Sold,Furnished and Installed by:. Branch Name: Boston Dale. THD At Home Services,Inc.. d/b/a The Horne Depot At-Home Services 345A Greenwood Street,Unit 2,Worcester,MA UIliU7 Toll Free(800)657-5182.;Fax(508).756-8823 Branch Number.31 Federal 1D#75.2698460;ME Lie#C 02439;RI Cont Lic#16427 CT Lie#HIC.0565522;NIA Homc Imp vcmcnt Contractor Reg.#i268t 5 Installation Address: �3i � �F�7 U1�n Y) i� Q , State Cify p Pu er(s): Work Phone: Home Phone: Cell Phone: Home Address, (If different from Installation Addres City State tp E-mail Address(to receive project communications and Home Depot updates): ❑I DO NOT wish to receive any marketing emails from The Home Depot Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, and THD At-Home Services,Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installation.("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 attached hereto and any Change Orders(collectively, "Contract"): Job#: rmwrnm Rdtmiw) ucts; S Sheet(s)#: Project Amount Roofing Siain� Windows ❑Insulation. / 5 ❑Gutters/Covers ❑Entry Doors ❑ ❑Roofing ❑Siding. Windows Insulation $ ❑C,utters I Covers ❑Entry Doors ❑ ❑Roofing ❑Siding ❑Windows ❑Insulation $ C�a ❑Guttors/Covers ❑Entry Doors❑ ❑Roofing 08iding ❑Windows ❑Insulation $ ❑Gutters/Covcrs QEatry Doors ❑ Minimum 25%Deposit of Contract Amount due upon etecation of this contract. Total Contract Amount $ Maitae Purchasers way out deposit mote than one-.bird of the Gmt AtIArnr aL Customer agrees.that,immediately upon completion of the work for each Product,Customer will execute a Completion Certificate (one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. The Home.Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem with the home,environmental!lizards 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 # included as part of this Contract, sets forth ate total Contract amount and payments required for the deposit%and final payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a completely Pilled-in copy of the Contract at the time you sign.Do not sign a Completion Certificate(note: there is one Completion Certificate for each listen Product as defined by individual Spec Sheets)before work-on that Product is complete. in the event of termination of this Contract,Customer agree to pay The Hume Depot the costs oi'materials,labor,expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus any other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY VOTHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DF.POSTI PAYMENT OR OTHER PAVMENI.'S MADE, WITHOUT LIMITING THE HOME DEPOTS OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Custurrtcr and The Home Depot with regard to the Products and installation services and supersedes all prior discussions and agreements,either oral or written,relating to said Products and Installation_This Agreement cannot be assigned or amended except by a writing sibned by Customer and The Home Depot Customer acknowledges and agrees that Customer has read,understands, oluntarily accepts the terms of and ct cived a copy of this Agreement, A . Sub tot by: t X , l X - r l� u omer's Signature Date Sales Co sultant's S'Pature X Telephone No._� �,(�� CuStomer's Signature Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL TFUS (as applicable). AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE TffiRD BUSINESS DAY AFTER SIGNING THLS AGREEMENT. THE STATE ' SUPPLEMENT ATTACHED HERETO . CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARF.PART OF TIM CONTRACT . "I-10 GSC White—Branch File Yellow-Customer. Td WdLO:S 800? t7Z 'UPE T22?7_9£80S: 'ON X1dJ pp6wef: W083 f 961(q Town of Barnstable Permit# 00 �oF� Tti Expires nionthsfr issue date . S PERMIT Regulatory Services F� BARNSCABLE. Thomas F. Geiler,Director MASS. � 1639- 17 2008 building Division Tom Perry,CBO, Building Commissioner . TOWN OF BARNSTABLE 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office:- 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY �J Not Valid valid without Red X-Press Imprint Map/parcel Number Property Address V, esidential Value of Work Minimum ee of$25.00 for work under$6000.00 �-. c, Owner's Name&AddresslL it h R 4 I Contractor's Name Telephone Number ? Home Improvement Contractor License#(if applicable) "oran's Compensation Insurance Check one: ❑ I am a sole proprietor 0 I the HomeQwner have Worker's Compensation Insurance Insurance Company Name - Workman's Comp.Policy# �/ L✓ �/� ` �j Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) e-roof(stripping old shingles) All construction debris will be taken to 0 Re-roof(not stripping. Going over existing layers of roof) Re-side F1 Replacement Windows/doors/sliders.U-Value- (maximum.44) *Where required: issuance of this permit does not exempt compliance_with other town department.regulations,i.e.Historic,Conservation,eta ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATURE: I -� Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revise020108 The Commonweatth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111' wrdw.mass.gov/da ' Workers'Compensation Insurance Affidavit:Builders/Contractors/Blectricians/Plumbers A licant Inforamation :Please Print"Le ` 1 Name(Businessmrganizationffndividual):: Address: -24 bi- AZE City/StateJZip: d/�U`'if /Zd/k Phone.#: Are you an employer?Check the appropriate boa: :Type of protect(required):; 1.[�I am e employer with 2y 4.'[] I am'a general contractor and I tiP y 6. []New construction . '•employees(full apolor part time).*• have hired the sub-contractors 2.0 I am a'sole,pioprietor or partner- listed on the'attached sheet. 7. [remodeling ship and have no employees These sub-contractors have 8. ❑Demolition 'working forme in an capacity. employees snd have workers.' y aP tY 9. �Building addition ` COlIlp menrance$' • [No work7s comp.insurance 5. We are a corporation and its 10.❑Electrical repairs or additions required.] d their i e h ffi ocers ave exercised , '3-n I as ahomeowner doing F.M.work . 11.[]Plumbing repairs or additions ' zgyselt:[No workers'comp. right t5f exemption per MGL 12.❑Roof repairs insurance.require • 152, 01(4);and w have no employees.[No workers' 13.[] Other comp.insurance regivred.] *Any applicant test checks box#1 must also M out the section below showing theii workers'compensation policy information. t Hemeownera•wbo submit this affidavit indicating Trey ate doing all work and ttien hire outside contractors must submit anew affidavit indicating•such. tcnntraetors Ttat check thie box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have .mrployees, if the sub-conhrmtnrs have a¢iployees,1hey trust provide their woikas'comp,policy number. I ant an employer.that is provldtng workers'compensation insurance for my employees. Bdow.isAe policy and job site.' information. _ Insurance Company Nahie: Policy#or Self-ins..Lid.k- 41,7Y7-1 Expiration Date: _ f Tob Site Address" City/Sta-&Zip: =_ Attach a copy.of the.'brkers'compensation policy declarafionpage,(showing the policy nurnber and expiration date). Fa>7ure,to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,500.00 and/or one-year imprisonment;as well as civil penalties in the fors of a STOP WORK,ORDER and a fine of up to$250.00-a day against thg`violator. Be advised that a copy of this statement maybe forwarded to the;Office of Investi a ' of the bIA for' e c era a verification. I do here 'rti under the sin pe es of perjury that the information Provfded above Is true and correct Si ature: Date: Phone#• Official use only. Do not write m area, to be completed by;city or town,official City or Town: ' Termit/License# Issuing Authority(circle one): J.Board of Health 2.Buildiiii Department 3, City/Town Clerk 4,Electrical Inspector 5;Plumbing Inspector 6. Other Contact Person: Phone#: iy Ilo.uit,tf Building Rcguhfurns and Standards License or rcgishahon walitl for indrvrdf l use,ouly HOME IMPROVEMENT CONTRACTOR -bcfgrcYlic exliiration,date. If found return to: I� t hoard of Building Regnlalions.:ind Stand a tls i3\t�1i Registration. 100503 One Ashburton Place lim 1301 s . -Expiration: 6/19/2010 Boston;N1a:02708 - Type: Supplement Card CARE FREE HOMES INC. x' DANA PICKUP.JR.` J J X". 239 Huttlestop ave !/1��� ( /� ` f( _ Fairhaven,MA 027,19. Not v,ilid without 'gnattire Administrator Board of Building Regulations and Staudards i Construction Supervisor License u, License: CS *95228: Expiration 3/22%2010 Tr# 95228 = Restriction: 00 DANA.PICKUP 19 HAMLET STREET FAIRHAVEN,'MA 02719 Commissioner c , Man OFFICE: (508) 997-1111 Lug MA. Builder's Lic. #021330 FAX: (508)997-1297 IfCWA R E F R E E Home Improvement TOLL FREE: 1-800-407-1111 wes IIIC. Contractor's License WEBSITE: #100503 MA. www.carefreehomescompany.com 239 HUTTLESTON AVE. (RT 6)•FAIRHAVEN, MA 02719 // #15179 R.I. NAME -<Andfr,-_grid Cyr J DATE 11-13-D f ADDRESS��__$LO��v�►— " Ze-- i'A:�Ye - ZIP CODE ADDRESS OF JOB -2, c. TELU�J77��U�t/�� _ h JOB DESCRIPTION Scheduled Start _ -d W Scheduled Completion A. Replacement of missing or rotted lumber is not included unless specified. B.All start&completion dates are approximate and could change due to weather conditions. L, C. Stripping of roof includes removal of up to two (2)layers of shingles, each additional layer to be charged @ �y ft . D. Replacement of rotted roof boards/plywood to be charged @ `'j._J ftz. E. Existing chimney flashings will be reused; replacement, if necessary, is not included. F. Care Free Homes, Inca is not responsible fo r-mold/mi 1 dev,,conditions that are pre-existing or resu!t.from leaks.,noi.h.rought to the attention of C.F.H., Inc. promptly. The Company hereby proposes to furnish labor and material to complete the above work for the amount herein. Fulfillment of this order is contingent, however, upon the want of strikes, fires and any natural disasters, the ability to obtain materials, or any other conditions beyond the control of the Company. Cost of Project$ �'���� PAYMENT TERMS ©� Date 1. You,the Owner,may cancel this transaction at anytime prior to midnight of the third business day after the date of this transaction. 2. You,the Owners,agree to pay any and all expenses incurred by Care Free Homes, Inc.in collecting money due under this contract and enforcing the terms of this contract, including but not limited:to, reasonable attorney's fees, interest and court costs. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES CARE FR H ES 9 ACCEPTED: By: Buyer acknowledges 0.., er,r9�6 t✓r" i`�fj� £_9�1--- ----- ARE FREE HOMES,INC. receipt of fully completed copy of this Agreement Owner All contractors and subcontractors shall be registered by the director and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Director, Home Improvement Contractor Registration One Ashburton Place, Room 1301 Boston, MA 02108 Tel. (617)727-8598 i Cllent#:33723 CAREF DATE(MM/DDfYYYY) ACORD,. CERTIFICATE OF LIABILITY INSURANCE 09/04/08 PRODUCER .. •u. - _ THIS CERTIFICATE.IS ISSUED AS AmATTER OF INFORMATION Herlihy Insurance Agency,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 51 Pullman Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,°EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW; Worcester, MA 01606 508 756-5159 INSURERS AFFORDING COVERAGE NAIC# INSURED - - _ '.', 5. - - INSURER A-'ACadlatnSUranCeC Oinpany.' Care Free Homes Inc' INSURER B. Interguard Insurance Cornpany 239 Huttleston Avenue 3 INSURER C: Fairhaven,MA. 62719 INsuRERb: INSURER E: COVERAGES,THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDINGANY 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 1S SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH` POLICIES.AGGREGATE LIMITS SHOWN MAY,HAVE BEEN REDUCED BY PAID CLAIMS. LTR- NSR TYPE OF INSURANCE POLICY NUMBER DATEYMM/DDIYI E EFFECTIVEX MMlDDIYY OLICY N LIMITS + A GENERA%LLIABILITY COA0265674 09/01/08 09/01109 EACH OCCURRENCE $1 QOQ 000 ,. X' COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $300 000 - CLAIMS'MADE a OCCUR - - - MEDEXP(Any one person) A$15000 PERSONAL&ADV INJURY $1 000 000 •- - GENERALAGGREGATE $2 000 000 - GEN'L AGGREGATE LIMIT APPLIES PER:- - PRODUCTS-COMP/OPAGG s2,000,000 . POLICY PRO-.. :. JECT.. LOC , AUTOMOBILE LIABILITY - COMBINEDSINGLELIMIT $ t ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULEDAUTOS . (Per person) $ , HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ +, `• PROPERTY DAMAGE. } (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT- $ - -. ANY AUTO - - - - - OTHER THAN EA ACC $. AUTO ONLY: AGG' $ EXCESSAJMBRELLA LIABILITY EACH OCCURRENCE $' OCCUR, CLAIMS MADE - AGGREGATE - $ .. DEDUCTIBLE RETENTION B' WORKERS COMPENSATION AND CAWC017429'. - 09/01/08 09/01/09 WCSTATU- F- OTH- - - Y M S - % EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $1 000 0 00. ANY PROPRIETOR/PARTNER/EXECUTIVE r + - OFFICERWEMBER EXCLUDED? ' - E.L.DISEASE-EA EMPLOYEE $1 000,000,- er If yes,.describe und - - -.- - ' . .SPECIAL PROVISIONS below -- - - - E.L.DISEASE-POLICY LIMIT $1,000,000 - OTHER-'_ DESCRIPTION OF:OPERATIONS I LOCATIONS I VEHICLES!EXCLUSIONS ADDED'13Y ENDORSEMENT/SPECIAL PROVISIONS .' .• " ,: CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO,MAILr in ,DAYS WRITTEN Building Department NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT'FAILURE TO DO SO SHALL 367 Main Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Barnstable, MA-02601 REPRESENTATIVES, AUTHORIZED REPRESENTATIVE: ' ACORD 25(2001/08)1 Of 2 #M35563 M$g 0 ACORD CORPORATION 1988 Town *11erinit# 7 .I HE Tp� "own O Ba1 nS�tt��c F-Ypires 6 mouthsfro"n issue dare : Regulatory Services Fee 9 STABLE. E.g 'Thomas F.Geller,Director1639. X-PRESS PERMIT �pTf0MPtA Building DIv1s1o11 r Tom Perry, BuildingCoumlissioner JUL 2 $ 2003 200 Main Street, Hyatuvs,MA 02601 Office: 508-862-4038 A TOWN OF BARNSTABLE Fax: 508-790-6230 RL+'SIDLNTIA.L ONLY EYPRI';SS PERMIT t V'APPLICATION l otit Red -Press lmvrint avZ t'o2 Map/parcel Number --7 Q(� / Property Address O Value of Work Residential Owner's Name&Address ���/�` CniYl S� -� DykA' 1'1S'OEL S ZZ 1 (L Telephone Number Contractor's Name Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) 20�Orkman's Compensation Insurance Check one: ❑ I am a sole proprietor Vin the Homeowner ave Worker's Compensation Insurance° Insurance Company Name c ,jcc- Workman's Comp.Policy# Ot U Permit Request(check box) ❑ Re-roof(stripping old shingles) ❑Re-roof(not stripping. -Going over existing layers of roof) l r ❑ Re-side 3 1 S��l V i ' � �" '1"1 e i �� �ts� -Value aQ Replacement Windows. U (maximum.44) bk6rp-lif `❑ Other(specify) Vc� �- �dzAA_ W . *Where required: Issuance of this permit doe s not exempt Signature Willi other town department regulations,i.e. storic,Conservation,etc. Signature -t ` Q:Fomis:expmtrg - __„jinni The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations ` $00'Washington Street ' Boston,MA, 02111 Workers' Compensation Insurance:affidavit Applicant Information: PLEASE PRINK y' NAME LOCATION t q STATE ZIP CODE ` S--� PHONE j IT7 S--(91.4 CM' O I am a homeowner perforrning all work'myself.' , O 1 am a sole proprietor and have no one working in any capacity: O 1 am an employer providing workers' compensation for my employees working on this job,,' Company Name Address State w I P Zip Code ' )NO 3 5 Phone -y2 —9-5 City f _ . /n� /' I Insurance Co. UG1�C SV�0.b'1 Policy'T CSC C`1 U( O`� > Expiration Date O I am'a sole proprietor,general,contractor,or homeowner(circle one)and have hired the contractors listed bellow who have the , •: , following workers' compensation policies: Company Name Address State Zip Code Phone Cif, 7 Expiration Date Insurance Co. PolicyK' Company Name Address k State: ` Zip Code Phone 4 City Policy 4 Expiration Date Insurance Co. Failure to secure coverage as required under Section 25A of NMGL 152 can lead to the.imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of r cover a day against d/ I understand that copvof this statement may forwarded to the Office of Investigations of the DIA for coverage verification. W 1 do hereb certi under the pains and penalties of perjury that the information prov'ded�a�bove is true and correct. Date Signature , ` W -T,k � � 1ZZ1 V '.. Phone R.' CEO l- I Print name OtTicial use only-do not write in this area—to be completed by city or town official y PermitAicrnse x O Building Deparunent, O Licensing Board City or town O selectmen's Office O Health Depamnent O Other O check if itnmcd i iate response s required Phone M `e . Contact person -77 r ,b.. .. :nai,trMaFtds,h+�,mi+aAM,wY@try*..,v:n^•:r Mnw. ;.:.?n:<, r.d.b,..:: 'ri.tr.-b.i.: :.fa;,;i3 r ..i..c.-':..p.t,.,d;.w a. '- • - (ri\. al�I! (OOl1NlEOftIIM.?.I.IIL O��.Q�UTABQ� Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Reuistration: 100740 Expiration: 6/23/2004 Type: Private Corporation , CAPIZZI HOME IMPROVEMENT,1 I�fiomas Capizzi,jr. 1645 Newton Rd. Cotuil,MA 02635 Administrator �. lf> ` ✓ EP, (z,V"t'"I0 NllMQr�II O/ fO��CI1/dEl�d b 130ARD OF BUILDING REGULATIONS 'License: CONSTRUCTION SUPERVISOR !, < Nuinber: CS 057032 ' S � Expires: U9/26/20U3 Tr.no: 579U Reslrictod: OU THOMAS X CAPI711 JR 280 PERCIVAL DR w BARNSTAUL E,,MA 026638 — Administrator • T VAUL Ul AC ORD CERTIFICATE OF LIABILITY INSURANCEF pv DAYS " m0i'm "G)pIL i 03/26 03 PRODUCER THIS CERTIFICATIR IS ISTIUED As A MATTER OF INFORMATION Noraroms C Leighton Cape Loc. ONLY AND CONFERS NO WOHTS UPON THE CERTIFICATE! C.J.MoCarthy Ins.Agenoy,Inc. HOLDER.TI116 CERTIFICATE DOES NOT AMEND,EXTEND OR 437 Station Ave ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 9o.Yarmouth Kh 02664 phone: 508-394-0946 lax:508-760-1407 INSURERS AFFORDING COVERAGE INSURED INSURER A. }Rational Grange Mutual Ins. Ca INSURER B: Bafety Insurance Comany C iz i Homo glm�eprovvn nt Inc. INSURER C: Guard Insurance group Go ui O n INSURER D: INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INsuREo NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REC"REWENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSVED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1E SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN TYPE OF INSURANCE POLICY NUMBER T M Y LIMITS oz"mMUAIIIurY EACH OCCURRENCE 51000000 A X lCOMMERCMGENERALUANLIfY DMPS02733 04/01/03 04/02/04 FIRS DAMAGE IAoyeMfire) 1300000 CLAWS MADE FX OCCUR MED EAP(Agy9-4 pw"") 110000 PERSONAL t AOV INJURY 1 1000000 OENERAI.AGGREGATE 12000000 OENL AGGREGATE LIMIT APPLIES PER: PRODUCrB.COMPlDP AGG 1 2000000 17 POLICYD El LOC AUTOMOB66 LIA6IUTY H ANY AUTO 1601064 04/01/03 04/01/04 (Em BI�s NGD SINGLEUMff 1 ALL OWNED AUTOS SODILYMJURY 11000000 X SCNEDIAED AUTOS - (PW PMO^) X HIREDAVTOS BODILY INJURY X NON•oWNEDAUTOS (Pw.eew�ep 11000000 PROPERTYDAMAGE 1500000 (rr swidwo 0ARA09 UAUItITY AUTO ONLY.rA ACCIDENT 1 ANY AUTO 9 R THAN 6A ACC 1 UT�V11T�ONLY: AGO 1 EXCESS LIABILITY EACH OCCURRENCE i 00" CLAIM,MADE AOOREOATE 1 DEDUCTIBLE i RETENTION 1 f WORKLRO COMPENMTION AND - X 1 C EMPLOYERS'LIABILITY GUPC401043 01/01/03 01/01/04 E.L.EACHACCIDSMT $100000 S,L.DwrAm•EA mmmoyet 1 I00000 LL•Dior-Ass POLICY LIMIT $500000 OTHER r DESCRIPTION OF T-fbR-&OCATIONSYMICLIESfgXCPLUSION&ADOEO BY ENDORSEMENTISPECIAL►ft"*Hs CERTIFICATE HOLDER p ADDITIONAL INSURED;INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED F'OLIOIES BE CANCELLED BEFORE THE lLxPl%ATION DATE THEREOF,T'646 ISSUING INSUR[R WILL ENDEAVOR TO MAIL .1.2_DAYS*MITTEN NOTICE TO THR CYATIPICATE HOLMR NAMED TO THE LEFT,BUT FAILURE TO DO 90 SMALL IMPOSE NO OBLIGATION OR LA1111ILITY OF ANY XRTD UPON THE INSURER,ITS AGENTS OR RNarRE.rEnTArnes. AUTHORED SENTAT - ACORD 25-5(7ro7) OACORD CO TION 1NI - i CAPIZZI HOME ` IMPROVEMENT INC . SPECIFICATIONS AND ESTIMATES PAGE 6 OF 6 STATE OF 14ASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT OWN THE PROPERTY LOCATED AT 1 yi IN &MYGS MASSACHUSETTS. I HAVE AUTHORIZED TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSTTS STATE BUILDING CODE. I GIVE MY PREMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT. IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: OWNER'S ADDRESS: OWNER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS: - LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1649 NEWTOWN RD., GOTTTTT, MA 0126-15 i APPLICANT'S TELEPHONE: 508/428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: I RESPONSIBLE OFFICER TELEPHONE: ACCEPTED BY DATE THIS PAGE IS PART OF AND IN CONFORMANCE WITH PROPOSAL # En'ineering Dept. (3rd floor) Map,, Parcel . Permit# V House# r7 Date Issued Board of Health 3r4 floor)(8:15 -9:30/1:00-4:30) Ka I Feend V -Conservation Office(4th floor)(8:30-- 9:30/1:00 2:00)n 1 pl chool Admin. Bldg.) ed,by ing Board 19 TOWN OF BARNSTABLE Building Permit Application Project Street Address :R :Z b e r Ta S f- Cha / 1--0 l Village 14 .11A h n; 5 / Owner 'A iew w Address 7 b�a Telephone Permit Request � „„�,;,� a ®, -- ,Z,.� a f ofT d U. First Floor 6 o square feet Second Floor �~ square feet Construction Type (,U Fg A,,,g Estimated Project Cost $ pQ c,—Z) Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: (Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)�/ 6 Number of Baths: Full: Existing_� New Half: Existing New No. of Bedrooms: Existing 2_New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil M/Electric ❑Other Central Air ❑Yes [�(No Fireplaces: Existing -8 � New Existing wood/coal stove ❑Yes p-1 0 Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑A ached(size) ❑Barn(size) None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes [2No If yes, site plan review# Current Use _V,�� r ��,� ; a Proposed Use 5A sh . Builder Information dame 1 .2 7 >A ,Q4' per,;,,, Telephone Number 5 d G 3 6 ddress __ __License# C S 6 Nome Improvement Contractor# 1194 93 c;V orker's Compensation# Q/ NEW CONSTRUCTION OR ADDITIONS RKQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO . SIGNATURE DATE B FO E FOLLOWING REASON(S) i , l FOR OFFICIAL USE ONLY ` PERMIT NO. DATE ISSUED' MAP/PARCEL NO' ADDRESS VILLAGE OWNER _.. DATE OF INSPECTION: FOUNDATION FRAME _ i INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL, FINAL BUILDING-' O /oDDATE CLOSED OUT ASSOCIATION PLAN NO y The Town of Barnstable Department of Health Safety and Environmental Services � • Building Division 367 Main Street,Hyannis MA 02601 Ralph Crosser Office: 508-*-6227 Building Commissior Fax: 508-190-6230 For office use only Permit no.__ Date AFFIDAVIT ' HOME MIPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation; repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. C/Type of Work: Est.Cost_ 21;>60 Address of Work: 0.¢-1fia 21 �wner's Name SA J r/I �te of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. Building not owner-occupied Owner pulling own permit Y • f Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL a 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. w CS 11 y4 3 3 Date Contractor Name Registration No. I� OR •• � .�,. ..-.. x aw.�&e. '"W.i13ue�Tu�lal3ll�'"e. �MNC.v> .e4-.�e ,�..�iYci�.;,.s.:�..cy::i9;mCx'�a+dJc�1r""W3i''>v •,-^tiiE.yad�'r«+±�A-7z:irr.r ...,+•.:.vsr, ..�tb's..:.1Eei%i..:fi..:rS:.','. HOME IMPROVEMENT CONTRACTORS REGISTRATION + Board of Building Regulations and Standards { J One Ashburton Place - Room 1301 'i Boston, Massachusetts 02108 HOME IMPROVEMENT CONTRACTOR Registration 119633 Expiration 08/08/97OL Type —. DBA s HOME IMPROVEMENT CONTRACTOR; Registration 119633 AMERICAN HERITAGE BUILDERS & REMOD Type - DBA BERTRAND N. ST . PIERRE Expiration 08/08/97 7 CHARBONNEAU ST GARDNER MA 01440 AMERICAN HERITAGE BUILDERS S- G� �o BERTRAND N. ST. PIERRE 7 CHARBONNEAU ST Ar""ISTRATOR GARDNER MA 01440 Restricted To: 00 BE ARTMENT OF PUBLIC SAFETY CONST66TION SUPERVISOR LICENSE 00 - None Nuober Expires 1G 1 R 2 Family Homes I Rest to `AI :00 } -°l-CiIRRBONNERU S1 � ��n rARONER, MA 01440 r �� Deck. UC � 5 SfiAirf 4Ra'lit Ir 16 ETTA III III r. Ll 0 k a D , 5 _J MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) TOWN OF BARNSTABLE Date 19 Building Permit# AT. Location Owner's Name Type of Occupancy: New ❑ Renovation ❑ Replacement ❑ Plans FIXTURES' Submitted: Yes❑ No ❑ = to t z s w to N N O Z ~ > W Y .J+ tti > u s N Z v s N Z N s a C = a N a z Z ze `Car H CI Z a to a N W a < W O < N z a • L a J W W S 1•' �' W >; O 3 J N a 1- < t< a tr a W 1L M Mo O N ►' Z 0 p N z z W O V Z _ ~ .4 < i N < < o < J J < a a G < O < 1' it i< -AO ze O O J 31 Z f w 1L v a 0 < ; a • O s s sue—es�T. � OAiEYENT teT FLOOR 2NOFLOOR ]RO FLOOR 4TN FLOOR STN FLOOR GTN FLOOR TTN FLOOR •TM FLOOR (Print or Type) Installing Company Name Check One: Certificate ❑ Corp. Address ❑ Partnership ❑ firm/Company Business.Telephone Name of Licensed Plumber I hereby aruh that all of the details and information 1 have abmilted for tnteredl In abme spplieation are trtw strd aceurele to the best of rift/ knowledge and that all plumbing wort and installations pertnrmcd under Permit Cloned for this applieatap will be in compliance with all cent=pia visions of Cho Massachusetts Slate Plumbing Code and Chapter 142 of the General LJwL I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. l Signature of Owner/Agent 1 have a current liability insurance policy to include completed operations coverage. By Title Signature of Licensed Plumber Type of Plumbing License ' City/Town: I License Number ❑ Master ❑ Journeyman APPROVED (OFFICE USE ONLY) w • _ -file (/l1It71011 1t'Ca astac 1 as`t/.7 Dcpartz"CrIt of lttdustrial Accidents :: Oflfc�a>'lm�estl9atlons ; ��?\J"' 61111 11'a-dibig;run Street A. .: ' Bustun„1litrx 03111 Workers' Compensation Insurance Atridavit Pfcnse PR NTIe:• jv _ I !—��'�ilic:lntinforntatitin• — , �c�tion• � �•-�7.hr�o /1r/YISiA�` S•� n. ifLA17 krohnned I am a homeowner performing all work mvself. I am a sole proprietor and have no one working in any capacity G am an empio a providing workers*� compensation for my employees working on this job. cnrnnnm• nnmt- address• sin' nhnnc•lf• incnrance cn. nniiev It .�_.. .•.• ..ten. .�«�.�.��.w..•w.-�-w�...wa-�.r. ..�-._�...�. . G 1 am a sole proprietor. general contractor, or homeowner(circle one)and have hired the contractors listed below who hzvl� the following workers compensation polices: cnmminA, nntne- arm tees• cirn•• nhnnc f+• in-mr-inrr rn nniiry 0 cmmnanv namr- addrecc- -itv- nhnnc#' nsurancc cn nniicvtl lttachadditi tonal sheet if nee cs_iarv_ ;�,r --�i '•��•�r - -_ ••+• �n r^ - �.....��+: '.�• �w�M1 aiiurc to secure cin-ernac:is required under Section 3A of 111GL 152 can lead to the imposition of criminal penalties of a line up to S1.500.00 andiur ne 1 cars' imprisonment as it-ell:is civil penalties in the form of a STOP%YORK ORDER and a fine of 5100.00 a day against me. I understand that a op} of this statement ma}' be funrarded to the Olrce of Investigations of the DIA for coverage verification. do hercht•crrrift•undor the pains and penalties ojpedurr that the inforntarion prosided above is�d Err= r ^amm Date 'rint name Phone# olricial use univ do not Write in this area to be completed by city or toAm ollicial cit}•or town: IN it/11MISE141 rItluiiding Department ❑Licensing!Board L. cheek if immediate response is required 05eleetmen's Olfice C311ealth Department F phone tY• flOther :contact Pcrsrin: �: Information and Instructions Massacitusetts General Laws chapter IS'_section 2-{ requires all employers to provide workers compensation f e»tployces. As quoted from the "faw". an emplitree is defined as every person in the service of -iinother under:; contract of hire. express or implied. oral or written. An empinrer is defined as an individual. partnership. association. corporation or other legal entity. or any two o the foregoing anuaged in a joint enterprise,and including the legal representatives of a deceased employer, or d recci%•er or tntstee of an individual . pannership. association or other legal entity, employing employees. Hostile owncr of a dweIlitt_: house having not more than three apartments and who resides therein. or the occupant of th dwelling house of another who employs Persons to do maintenance , construction or repair work on such dwellii or on the _grounds or building appurtenant thereto shall not because of such employment be deemed to be an em MGL chapter 1�_' section =5 also states that eti•cry state or local licensing agency shall withhold the issuance rencival of a license or permit to operate a business or to construct buildings in the commontrealth for an, applicant who itas not produced acceptable evidence of compliance with the insurance eovernge required. Additionally. ncithcr the comtnomvealth 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 cha: been presented to the contracting authority. I �...�..��«_._—..« ..«_�+�r_.��' . ._. !!:.. , — .-. .. .,...... :a.. ,..+'ice:%•i .:tl�: W..-=i~ �`-,-'•'�':.._. • .. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation as all affidavits may be submitted to the Department of supplying company names. address and phone numbers raze. Also be sure to align and date the affidavit. The Industrial Accidents for confirmation of insurance cove 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 rec to obtain a workers* compensation policy. please call the Department at the number listed below. Ci ry or Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottc the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be recur the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any que please do not liesitate to _=ive us a c:11. 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 fax#: (617) 727-7749 "Assessor's map and lot number - < _ ... TM E � E Sewage Permit number ........9...........9....r ............................. , - Z 33ASd9TADLL i House number 'J ............................... ��O VAS ................................... Rr a YI►y TOWN OF BARNSTABLE BUILDING INSPECTOR - . APPLICATION FOR PERMIT TO 1p:.MMr�t�N/. .� ....o���a.�� r'�.. ... �/�?f ' .................................... TYPE OF CONSTRUCTION .. 87.11 ...En, M,,..d ... ftU4, / 8............. iw ..���........................�9. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .I-AT&. ..............,A 52L-rA............�. .4... .................l , 41YNIX........................................ Proposed Use ....N./�:... �� � .......Se!.P! 64A� IN-6............................................................................... Zoning District . ....................................................Fire District ...)Y. Y-. ...1*Zr............................................ Name of Owner A!✓�,4� !? / a..Address A..43...gA.D.inn;w. Name of Builde,"r"� N%.��Qa .� Ra/� 1� �l�s...Address 44..Bq ...5(e�... �/ !��F .... Name of Architect (. r11.Yf'.:?Yj/A.LHPi K,5........Address .!.X. 404PLg....8-1.�l..... ................................. Number of Rooms ............ ................................. ............Foundation ..�G�.��.L" �� ., ... ! r ............. Exterior ....Wd.o.D.........ItAt:/Y.?...................................... Roofing ..1 y e ............................................ ".:' Floors ....... .� /!.. ..��.......;p/lr) .................................Interior ......$ftt r 1. r .A�....................................... Heating .r. � .. .��.........................................Plumbing .... ./ .... :� -.5a...................................... Fireplace ............................................................APProximate Cost I ..................... r Definitive Plan Approved-by Planning Board/-V!4lf'�1 _1Q____19 Area ...../f`� ..... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH /O� d4 ! ,� 4?OD Roam b Rg4chi OCCIUP?gNCY-PER/iAITS--REGUTR'ED-FOR-N'EW-DWEECI'NGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. �,e i Y 5ow .3*414- l Name . .. _ !�"r* ..�,-;f' . !�?'�... . Construction Supervisor's License .04. .. ...... J PETRONI & SON BUILDERS, INC. A=292-003-002 a 9�-oo3-ao 2. 26531 One Story No ................. Permit for .................................... Single Family DwellinJ................................ ....................... Location ...jet..2A.....77.. ...Delta Street,,,,,,,,,, .... ........... ............. ...............Hy ................................................ . Owner .....Pe.tron.i...&..Son..Bu.i.lders,........ . .. ....... .... . .. Type of Construction .............................. ................................................................................ Plot ........................ Lot ................................ Permit Granted .......Tune••.], 1.9 84 Date of Inspection ....................................19 Date Completed ......................................19 FROM - ... OF BARNSTABLE: Mr.. Francis Lahteine BUILDING DEPARTMENT r Town Clerk 367 MAIN STREET HYANNIS,,MA 028#3`I' ,. Phone.. "75-412o SUBJECT: r FOLD MERE ... 2.. - DATE December 6, 1964 M ES S A G E F .. Worts has been completed under Building Permit #26531 (Petroni�& Son Builders, ins.) . Please release Bond. ' • SIGNED DATE REPLY . SIGNED . Nei-RMi 1 RP-CIPIENT:.RETAIN WHITE COPY.:RETURN<PINK'COPY w - - PRINTED IN U.S.A. , % SENDER: SNAP OUT-YELLOW COPY ONLY.SEND WHITE AND PINK COPIES WITH CARBON INTACT. ., �•"'"*. TOWN OF BARNSTABLE Permit No. ___`6531 Building Inspector l s.Unu, i Cash — ---- -- 'o° 7e°• �i OCCUPANCY PERMIT* Bond ____ Issued to letIoni & ',30._� T?t1i.isiP Address Lot 2, 77 Delta Sit.. NvBmig Wiring Inspector i� fir , . Inspection date Plumbing Inspector Cr�p � �� Inspection date Gas Inspector f{�/ Inspection date xEngineering Department `- f!� ✓.�' rrf1/'// f/f s Inspection date. Board of Health_;,c✓ ; Inspection date / THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. Ix ......................................................� 1J............ ..................................................a......................................................... . Building* Inspector G -'Assessor'1 map and lot number .. ./c :r..Go3...DcJ.a...r� �� 1�L S/7 $y 3 %TNEr Sewage Permit number ....... :�... .. ............................ fS!:P l IC gV!3TEF0 MUST 8,6 House number— .... ......� �'7.. ........................ . � TITLE 5 :o nea2639 � F TOWN OF BARNSTABLt"' BUILDING INSPECTOR . APPLICATION FOR PERMIT TO P. L .� �. ..S. rV..1 .. Q, f�.... C. .................................... TYPE OF CONSTRUCTION .. ,tl►.1� ..rAM.ily..D.V9 .44td?. xo.a..•..... 1/.? • - ' ...:jer../j.......................19.1.3. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a pyerrmit according to the following information: Location .. r� . ..............0.C1.r,./...A 5.1297: 6.1........a. ., .................17y1fM%1/.YIX. ................................... Proposed Use ....OWL ova .... .. .......... ......................•....................................................... Zoning District ....13..... ...................................................Fire District, ... dC 4 Name of Owned ���rC l��/ �L�6�!.���tJr1. 15+ IYe--i•.Address 1. d�•P•D® ' .. l ..:. k.... .lj�il// .... Name of Build/'3'D /..a � .�' 79%� -i! G.�...Address � .. t �. .1 .. �/ .... d!P..j / 1't .... Name of Architect ddl+,i.;ro.hA.1-72 1 /J4!.!'1C.5........Address .' / P!'. ..../..1.ek......................................... Number of Rooms .............V.................................................Foundation ..�t�.�6. �F'll�i ... /.�1� ���. Exterior ....WAOD..........1I.P.I.N.7......................................Roofing ..14.5 4,09.4. -.1................................................. Floors ......./0../j... tr.. ......�r�� ................................Interior ...... I7 ae-f ................................... Heating ..Cl—P) .LC LC.......................................... .... ./.A& ...��r�����".J�................................... �/ tea• Fireplace .............y1a............................................................Approximate Cost ...........7�?.. P... ......................�. Definitive Plan Approved by Planning Board/I-1+A0/�_j6-___19 � Area J. .. .... St . Diagram of. Lot and Building with Dimensions ' Fee ................./.••�.i........... .... SUBJECT TO APPROVAL OF .BOARD OF HEALTH 3 IYA.0 j�.4ty o� I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ... �A. . ..< ..:.. . .r� .... sG :. Construction Supervisor's License .e� . .�...... PFTRD4NI & SON-BUILDERS-, -INC- '26531 One Story No,................. Permit for .................................... -4 Singl6-, Family Dwelling ............................................................................... Location ....77...Delta...Street............ . .... .......... ........ .... Hyannis . ........... ...................................................... ........... Owner ...Petroni & Son Builaers, 'Inc; ............................................................... Type* ' Frarre of Construction. .......................................... ............................................................17................... �, �F f �'/ ' Plot ..... .. .......... 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