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HomeMy WebLinkAbout0023 DENVER STREET �3 �1 en ver `�-� t t ,��. oFt r own of 13a>rnstable, *Permit# E,rpires.6 ntonthsfrorrt issu are Regulatory Seryiees Fee . _ a ThomasIF Geiger,,Director'. Building Division - Tom Perry,:CBO, Building Co 'missioner 200 MatnStreet, Hyannis; MA 02601 F� wWw to.Wn'barn3t4b_le.ma;US`; Office: 508-862-4038 _ ' . fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL'.ONLY ` Not:Valid wilhoul Red X-Press_Jmprurl Map/parcel Number Pro AddressJtp M1. Residential Value of Work j IrTirnrnum fee'of$35.00 for work under$6000.00 Owner's Name & Address Contractor's Narne _ /1!t✓��l'��C�S 0�'G S '.Telephone Number.�� Home Improvement ContractorLicense #(if applicable) _ 4, , /n, uction Supervisor's License#(if.applicable)rkman's Compensation Insurance I .' " Check one: K . [] I'at a sole Proprietor am the Homeowner ( ii 011 I have Worker's Compensation Insurance t ®0IUN �F �AkN_S aL� Insurance Company Name tali(/ �� a r Workmen's comp.-Policy# ��J j — _ Copy of Insurance Compliance.Certificate"must accompany each permit Permit Request(check box) 31. )' .. Re-roof(hurricane,nailed) (stripping.old shingles) All construction deb is ill be taken to [] Re-roof(hurricane.-nailed)(not stripping Goring over extstrrig layersiof,roof) [] Re- ide #of doors , Replacement Windows/doors%sliders. U Value J4; �_(maxim urn'.35)`il of windows , ry"Where required: :Issuance of this permR does not erernpt 6ornpliance.with other town'depiirl regulations,i e. Historic;Conservanon`etc ***Note: ' -Property Owner must sign Property ivner Lefter of Permission, th.copy of he Home{Irnproveti�ent Contractors Lie' & Constractto.n Supervisors License is re. _ IGNATURC: , 1WPHLESTORiMSNii1ding permit formslEXPRESS.doc, evised 0721 10' h The 1✓ommonweakit of'Mt ss aehaasetts, e Department ojlnrftast,•irsl Accidents 0fjtce of'Investigralions r - w1V1V.?!7U 5 7f t%/tilit Workers' Compensation Insurance Ai'tadayst. $taildens/Cont-ractors/Electricians/Plu'9'cets Applicant Information ; Piease Print Lca blv Name(Business/Organization/individual). t 11 ++ Address: -� Phone#: � a City/State/Zip: +�'� - t Are you an employer?Check e a propriate b Type of pro' ct(required): I. I atn a employer with 4. 1 am a general contractor and I 6 ❑ construction have hired the sub-contractors Remodeling employees(full and/or part-time).* listed on the attached sheet. 2.❑ 1 am a sole proprietor or partner- These sub-contractors have L ition ship and have no employees employees and have workers Building addition working for;me in any capacity. , comp.insurance.* [No workers'comp.insurance cal repairs or additions required.] 5• ❑ We are a corporation and its 3.❑ 1 am a homeowner doing all work officers have exercised their ing repairs or additions myself.[No workers comp. right of exemption.per MGI: epairs insurance required.]tc. 152,§1(4),and we have no employees.[No workers' comp.insurance required.] `Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ':Contractors that check this box must attached 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. 0 ` 5 ' � ` Insurance Company Name: n �•yExpiration Date: `� Policy b or Self-ins.Lic.#: rJ'© "9- Job Site Address: a � j .�' City/State/Zip: �l/i/I/1 �v���/ 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 MGI,C. 152 can lead to the imposition of criminal penalties of a a tine 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 tine. of up to$250:00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify unde pains and penaltie perjury that the information provided above is true and correct. �,r� Date: v 1 Signature: 11 Phone b L FFO-ffficialuse 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 5LPIumbing 6.Other Phone#: - Contact Person: i �J �r»amwnurrct!ll<i c��I�lc�aoatft.udeClo ess Regulation Office of Consumer Affairs&c Basen License or registration valid for individail use onty before the expiration date. If found return to: (BIOME IMPROVEMENT CONTRACTOR a - Office of Consumer Affairs and Business Ilegul"ti+ire Registration 126893 Type: 10 Park Plaza-Suite 5170 i Expiration-. 8/1/2012 Supplement Card Boston,MA 021I6 �.rs. _ The Home Depot:At Hoene Services i DARREN DEMERS ' 2690 CUMBERL.AND PARKWAY GA 30339 Undersecretary Not valid without signatuee 4. r ,t W Tile C0772111011)vealth of Massachusetts Department of 1ndustrial.Accidents 0ffice of InVestig ations ..W., Ia 600 Washington Street � Boston, MA 02II I wtivw.ntass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual) L S Address: 1jacittr UIAyMot4 City/State/Zip: 04.73 Phone#. Are you an employer? Check the appropriate box: Type of project(required): 1.El7npla a employer.with 4. E] I am a general contractor and I oyees (full and/orpart-time).* have hired the sub-contractors6. D N construction sole proprietor or partner- listed on the attached sheet. 7. Remodeling sub-contractors have ship and have no employees These 8. ❑Demolition workingfor me in an capacity. employees and have workers' Y p �'• $ 9. �Building addition [No workers' comp.insurance. comp.insurance. required.] 5. We are a corporation and its 10.7 Electrical repairs or additions 3.El 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_7 Roof repairs insurance required.]t c. 152,_§1(4),and we have no employees. [No workers' 13:7 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. xContractors that checkthis 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'compen.atinn In rance for my employees. Below is thepolicy and job site information. Insurance Company Name: i� VV e� '✓�/ VVG�l Policy#or Self-ins.Lic.#: + � �� Expiration Date: Job Site Address: V < —�V �- Pe,/ e� S� Ci /State/Zi-ty p 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance,coverage verification. I do hereby certify under the ains nd penalties of perjury that the inf- or ration providedf above is true/and correct. Signature: Date: 6 ��✓`t/ Phone Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit,/License r Issuing Authority(circle,one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone r: J. 1009 9 2UAM 0arIes' t. la .e Jr, No, 4/ II r. j a1•s anusiness e u�a ion ��fice o onsul�ler � � � 10 Park Plaza Suite 5170 Boston, Massachu etas 02116 Hone Improvement Contractor Registration Registration: 163528 Type: DBA Expiration: 7/7/2011 Tr# 285903 ERICSSON HOME IMPROVEMENT ERICSSON TORRES 16 HOOVER RD WEST YARMOUTH, MA 02673 return card.Mark reason for change, Update Address and Address [] Renewal (] Employment [] Lost Card 7PS•CAt Q 40M-0e/08•098LIFORMCA108212008 Of(i1A bY2U1ssWjjM-V`i�0rV.A40 A tlon License or rogistratlon valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation f Reglstrall'on: 163528 10 park plaza-Sulto 5170 Expiration: .7n/2011 Tr# 285903 Boston,MA.02116 ERICSSON HOME-IMPROVEMENT ERICSSON TORRES ...;: ...... 16 HOOVER RD WEST YARM06TH;.MA-02673 Undersecretary Not valid without signature Jul, 23. 2009 9: 20AM Charles C. Casef Jr: No, 4717 P. 6. i Restricted to: Nhiss,iebuscits- Delmrhnetit of Public,Safety IA.- Masonn','o.nly Board of Buildin;;.Regiihtions alai Stsindards RF- hoof Couching Construction Supervisor Specialty License 'WS•Windo4s aril Siding License: Cyst. 100548 SF- Solid Puel Burning:Devices Restricted to:. W.S DM-Demolition only ERICSSON; TORRES Failure to possess it current edition of the 16•HOOVEf�ROAD Massachusetts State Building Code is cause for revocation of this license. WEST IYARMOUTH, IVA 02673 Refer to: WVVW.Mass,Gov/DPS IL Expiration: i 2012 Y wm1,l+xl mir Tra: 100548 HOME IMPROVEMENT CONTRACT PLEASE READ THIS t Sold,Furnished and Installed by: Date: �D�� TtW At home Services,Inc. Branch Name: Boston d/bla The Horne Depot At-Home Services 345A Greenwood Street,Unit 2,Worcester.MA 01607.. Branch Number:31 Toll Free(800)657-5182, Fax(508)750-8MI Federal ID#75-269MW;ME Lic#C 02439,R1 Cont.L'"I6427 CI'Uc#56552221;MA HamImProvement Contractor Reg.#126893 Installation Address: �-��hvQ T t-(4-y\-A1. �? t"L�L Q -.�L_G D City State zap Pumhaser(s): work Phone: florme Phone: _ Cell Phone: Home Address: State zip (If different from Installation Address) City E mail Address(to receive project communications and Horne Depot updates). ❑1 DO NOT wish to receive any marketing emads from The Home Depot Protect iriforntation: Undersigned("Castom&,,),the owners of the property located at the above installation address,agrees to buy, and T1IU At Services,Inc.(`"Titre Home Depot")agrees to furnish,delver and arrange for the installation( Installation")of all materials described on the below and on the referenced Spec Shcet(s),all of which arc incorpnnte i into-this Contract by this . reference,along with any applicable State Supplement and Payment Summary attached hereto and any Ctiange Orders(collectively, "Contract"): Job#: aw..L Herein s oduMc: Spe c Sheet(s)# Pro Amawt4 Roofing❑Siding indows Tnsulation ` ` OQmrers/Covers [ Envy Doors ooting Siding Windows Tmulation $ ❑Gutters/Covers ❑Entry Doors ❑ Roofng Siding❑Windows tnsuladan $ ❑Gutters/Covers DEntry Doors n ❑RooSgB Siding[�Windows Insulation $ [ Gutters/Cove`s ❑Entry Doors 0 Mhdniumi 25%Deposit of Contrud Amount dueugan a we dion of this onnhad. Total Contract Amount $ Maine Pardo a may not deposit more than on&dd d of the Contra Amormt. I Customer agrees that,inuncdiately upon completion of the work for each Product,Customer will exmutc a-Cprnpietion Certificate (one for each product as defined by an individual Spec.Sheet)and pay any balance duo- As applicable,each Customer under this Contract agims 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,ai. it%discretion,if The liomc 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 concents,pricing errors or because s work required to complete the job was not included in the CgnUCgCL�. . Payment Summary' The Payment Summary# � —� ,included as part iif 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 ate entitled to a completely fdled4n copy of the Contract at the time you sign. Do 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,Cudomer agrees to pay The Home Depot the costs of 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 tinder applicable law. THE HOME DEPOT MAY yp1T�iOLD AwHUI u OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER (PAYMENTS MADE, i.IMTI'IlHG THE HOME DEPOT'S OTHER,REMEDIES FOR RECOVERY OF SUCH AMOUNTS• between Customer Ac�entance and Authorization: Customer agrees and understands that this Agreement is the rioer%�usre agreement s and agrecracnta,either. and Tlu Horne Depot with regard to the Products and Installation services and supersedes all prior signed oral or written,relating to said Products and Installation.This Agreement cannot he assigned or amended except by n �& by Customer and The Home Depot.Customer acknowlcxiges and agrees that Customer has read urrdexslt+nds,voluntarily accepts the 2 terms of s received u copy of this Agreement S5 by. 10 Date Gusto s Si Date Sales Consul Yq.�i X Telephone No. 7� Customer's Signature Date Sales Consultant License No., (err applicable) CANCELLATION: CUSTOMER MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION ' BY DELrVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE TH M BUSINESS DAY AI TER SIGNING THIS AGREEMENT- THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE I5 SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE:ADDITIONAL TERMS AND CONDMONS ARE S'T'ATt D ON THE REVERSE SIDE AND A"PRAT OF TEiGY CONTRACT 11,'t�GSC µnpte�BTaticttE'sle Yellow-Custtutier Pink-Sai�Consuttant '�£i? 'a Td WdSb:b LowT1.ZZZ9£80S: 'ON XCd pe6wef: W083 oEYKE t� Town of Bar nstable *Permit*# oc Expires 6 Is ronr issue dqt Regulatory Services Fee �l + BAANsrABLE, + y� MASS, $ Thomas F. Geiler, Director "6 39. A AIfD P't M �+ Building Division Tom Perry, CBO, Building Commissioner 200 Main'Street, Hyannis, MA 02601 www.town.barnstab le.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 ;zidential Address ,Y Y' �! A /V!V Value of Wort. �90� Minimum fee of$25.00 for work under$6000.00 C Owner's Name&Address �1 �' �/� Op F C'ontractor's NameTIM Kfl _ /Al C) T I phone Number �� o 'AG) �6, T I lome Improvement Contractor License#(if applicable) IT H4 t� M�� � � NO Constr ction Supervisor's License# (if applicable) 9 �� Workman's Compensation Insurance Check one: PERMIT ❑ 1 am a sole proprietor: a am the Homeowner have Worker's Compensation Insurance OCT. mm 200� Insurance Company Name �e s 4r' 7—Ar CO, BP►RNSTABLE Workman's Comp. Policy# / /S Copy of Insurance Compliance Certificate must be-on file. Permit Request(check box) r ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑Zeplacement e Windows/doors/sliders. U-Value 0,3S (maximum .44) 0/ 3 *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ; I ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATURE: ?.`N PI II.I:S\P(7RMS\huilding permit forms\EXPRESS.doc Revised 100608 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ` Please Print Legibly Name(Business/Organization/Individual): c .& - f �'-S Address: v City/State/Zip: tt, CA - 3 0 3 3 Phone 4. 1 5 , Are ou an employer?Check appropriate b Type of project(required): 1. am a employer with 4. I am a general contractor and I 6. ❑Ne construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. Remodeling 2.❑ 1 am a sole proprietor or partner- ship and have no employees . " " ' These sub=contractors have- .... "" g. Demolition working for me in any capacity. employees and have workers'comp. ❑ Building addition [No workers' comp.insurance comp. insurance.$ 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] 3.El 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 insuance required.]uired. t c. 152, §1(4),and we have no q ] employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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. CA-0 '. Insurance Company Name: C .5 S Policy#or Self-ins.Lie.#: J=J ) 6 l l Expiration Date: j l f Q Job Site Address: beAve�. J1 City/State/Zip: N)S 0? ��1 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 io the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify er the pains and a !ties of perjury that the information provided above is true and correct. a) Sicnature: Dater — Phone# CZ FIssui"n only. Do not write in this area, to be completed by cityor town officialn: Permit/Licensehority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: The ,— £Massachusetts y_ Departrrtei,;; �i nd�usteidtr idents ,I == ffce-of Inr r� ations 600 Washington St;e=ct i� 4! Boston, MA 02111 s. .: www.mass.gov/dia Compensation Insurance Aft /Contractors/El"idavit: Builders P Workers' omlease Print Legibly � C p A licant Information �. N �� Name (Business/organization/In dividual): Q ��� Address:_a) �` Q p �� � � Phone#: �Q�' /�� City/State/Zip: �/ mov (required): Check the appropriate box: Type of project(req ' )• Are you an employer., 4 I am a general contractor and I 6 New construction er with have hired the sub-contractors 1,❑ I am a employ 7 Remodeling ployees(full and/or part-tune).* listed on the attached sheet. 2.al am a sole proprietor or partner- These sub-contractors have g. [] Demolition ship and have no employees employees and have workers 9 Building addition working for me in any capacity. comp.insurance-t io.0 Electrical repairs or additions [No workers' comp.insurance 5 We are a corporation and its required.] officers have exercised their 11.❑Plumbing repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL i�,0 Roof repairs myself. [No workers' comp. c. 152,§1(4),and we have no 13 Other insurance required.]t employees.[No workers' comp.insurance required.] . *Any applicant that checks box#1 affidavit indicaatingtthey are doing the sec I tion tall work and then hire outside contract rs must submiow showing their woTkers'compensition policy information.new affidavit indicating such. t Homeowners who submit this aff must provide their workers'comp.policy number. (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 P m to er that is providing workers'compensation insurance for my emp information. 4AS Insurance Company Name: f3 lQ Opp `f Expiration Date: Policy#or Self-ins,Lic.#: l/ J �All G�60 City/State/Zip: Job Site Address: 3 l��Nti e�' S� T 1►/n/,� d expiration compensation policy declaration page(sho lead towinghtheoimpos t on of clicy number riiminal penalties of a Attach a copy of the workers' comp P can Failure to secure coverage as required under Section 25A of MGL c 00.00 and/or one-year imprisonment,as well as civil penalties in the may be forwarded d dOto the Office of ORDER d a fine fine up to$1,5 of this of up to$250.00 a day against the violator. Be advised that a copy Investigations of the DIA for insurance verage verification. sins nalties o perjury that the information provided above is true and correct. d I do hereby certr(, rder — Date: V Si nature: Phone # L[Otl only. Do not write in this area, to be completerl by city or town official + Permit/l,icense --- vt thority (circle one): f Health 2. Building Department 3. City/Town Clerk 4.Electrical InspectorS..PIu'nbing [nspec or Plioneerson: — 4 ^✓' Inform- tion aria Instructions Massachusetts General Lw": chapter 152 requires all cr._; :,yers to provide workc ,',compensation for their employees. Pursuant to this statute, an employe Aefined as"...every persu 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 (Le, a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Sheet Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.niass.gov/dia _ .. -ii,i irr.'.f <;.- �1. 'j .. - 4 13oard of Buillifng ReguIations and Standard's., N HOME IMPRO,1EMENT CONTRACTOR Registration: 153140 r Expiration .0l31/2010 Tr-4- 218191 i - ?ype: -DBA #. g' ?,iU'-VISION 1�1STAL''•_A T IONS' ST=PHct•1 RESTAIiNO 32 OVAL DRIVE.. WEST YARMOUTH, MA 02873 : :administrator . L ii:ense`or regi,tration valid for indivitlul use only before the expiration date. If found return-to: "Board of Building Regulations and Standards } • One Ashburton Place Rm 001 ' ` Boston, Nla.02108 a Not valid without signature. y ' Board of B liltl��� � �t��;�: �t���� ���c� �ta11 ���r I j �Iti t License: CS SL 99560 t Restricted to:_ .WS ' ' "p''rfg ti 9'"f,4 (Ytr a STEPHEN RESTAINO s r CL1_—Is..x3 32 OVAL DRIVE fi . WEST YARMOUTHi MA 02673 r Expirataon: . 1 /2212012 Tr::�� 99560 ' &5 HOME-iMPROVEMEdNTCONTRACr PLEASE READ,THIS �---'° Sold,Funs shed and Installed:by Branch Name: Boston Date . TF1D P t-Home.Services;Jne; .. :d/b/a;.The Home De?ot At-HomeServiccs 345A.Gmmwood Sweet,-Unit 2,:?�orceuer,.MA:O1b07 Branch Number,31 Toll Free(SM)657-5182; Fax(508)756-8823 FederaLM#75•2698460;ME lic'#C ON 19-,RT Cont.Lio#'16427 CT Lic#565522;14A HoweM?rvcment C iotractor.Reg.#126893 Installation Address: ' + G V ... ... City.• .State Purchaser($): .,.:Work Phone:• Home Phone f Ceti Phone Home-Address: (If different from installation Address). City. .Sta e.• T..tp: P,-mail Address(to receive.projectcommu»icatioass-and:Home Depot updates):.. ❑I DO NOT wish to receiva any madccting emails from.The Home-Depot. Proiect Inform"don: Undersigned("Camomer");the bwners'of the property located at the above'installatiot:address;agrees to buy, and THD At-Homc Services,Inc.("The Home Depot' agrees,to'furnish,-deliver and arrange for•the insbdl;don•("Installation-)o all materials described on the below and.on,the referenced Spec:Sheet(s), all oF,which are incorporated.in o this Contract by.,this reference,along with any applicable State Supplement and.Payment Summary attached.hereto and any Chan;e Orders(collectively, "Contract"): t� Job#: aM�ma a�r�,o ar uctx S Sheets #. i'Pio'ect Aiiounf _11Roofing Siding indows• Insulation'. 6 O0uiters rCoveis'OEni y Doors"p $ ` ,. Rooting $idirtg 0 Virmdows.. Insulation OGuttm/Covers pl ncry Door, C7. . . . $ Rool"mg C3MJInj,ZI.Windows;•_ tnsuiatiOtt. OGuttm/Covers`O$ntry Doors.❑- i Roofing Siding El Windows insulation OGutters/Coves OEntry Doors ❑ $ VImimtun 25%Deposit of ControMAmountdue upmexecutionofthis.cuatmoL 1 T7 ' aine Purchasers way not deposit rnorc than one-third of the Cozad Total Contract Arnount Atmtmt- $ �� •' ��V � �� �� Customer agrecS that;immedlately j, on corgpletion'of the,worKfor each Product;•Ctietomer wilUOXeeute-a;Completion-CcrtiftCate (one for t ach Product`as:defiried by an_individua!Spec Shcct)and,pay auy,balanrz dnz. _:As appticabte:.ea;�.'Castotncr under this Contract agrees tq be jointly and severally obligatO.and liable hixeundcr.,'"` The I{omc Depot reserves,the,right.to issuee-a Changc,Orderor term inate•this Contraet:or,any.,ipdividual Pr'odu ot(s)included herein,at it,discretion.if The Home Depot or its authorised service providerdetermincs-thatit eannotperform.its obliga ionsdue.to-a.structural problem with the home,environmental hazards.such as mold,,asbestos or. pd paint other Safety concerns,pi icing:errors of.because worksiquired to complete the job ova..not included m:ihe Contra. Payment Summan•: The Raymeiu:Summary# ;,included;a&T=of this-.ConEr,ict, sets fotth:the'total Contract amount-and payments required for.the deposits�and final.pa),meals by Product(as-applicable)` .._.. NOTICE TO CUSTOMER' You are entitled to a completely roved-in Copy of the Coniract'at-thrtimc you sign. Do not.s-igri a Complt tiou Certffidtc tiaote: there i.i one Completion Certificate for each listed Product as:de(-r'ned--by_indiiiduai'Spec•Sheet&)•before•wortc•on..that:Prodduct is complete. In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of.mat#2K labor,expenses and services provided by The home Depot or Authorized Service Provider through the date of termit ration,plus any other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WI'I)MOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYM)ENTS;MAD4 WITIJOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire-agreen ant between Customer yid The Home Depot with regard to the Products and Installation services and supersedes all prior diseuisiow"d agreements,either oral or written.relating to said Products and Installation.This Agreement cannot be assigned or.amended exe pt by a•writing signed by Customer and The Home Depot.Customer acknowledges and agrees that Customer ha;read,understands,voluntarily accepts the terms of and has received a copy of this Agreement. $ubm y: i o �09 Cust s S• ate Sale3 Cons tint igrlature ea Telephone No. Customer's Signature Date Sales Consultant License No. i CANCELLATION: CUSTOMER. MAY CANCEL TIHS (�apt'ticabtc�> AGRF,EMF,NT WITHOUT PENALTY OR OBLIGATION BY DELTVERLNC WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT:- THE ' STATE SUPPLEMENT ATTACHED HERETO CON'rA1NS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW Nt CUSTOMER'S STATE. NOTICE:ADDITIONAL TER.YIS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF'.WS CONTRACT 100'd SIKNVEII .LOdflQ HWOH 69:Zi 600Z-EZ-d3S 1 ' %�Y ,p� ✓fie �amirrioouue� ���2�aa�ac`iudeC -\ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR a Registrations 126893 Expiration -8%3/2010 ' I —vl - E .{ i/ _ Tifr ype _Supplement Card The.Home Depot,At Home Servi � ce 6ARREN DEMERS f� ,i 3200 COBS GALLERI�A�',P�KW�Y,#20 I' ATLANTA,GA 30339 Administrator ' . .. "CaBx2: 1.'-�.� ...�:._•:k.r...�:Y"3• �L':3a�w�. -.�".2]'.$&'_ _'."'i.'.YhS�JM1ICTA.. c a I .I License or;'egistration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards f One Ashburton Place Rm 1301 fBoston,Ma.02108 Not valid ttout'signature r � t s Zo7-39 3 4- 1 c� I 7 b 46-0 h o a Q0 M I. rq o t Q � W ZZ QcNL9 � © � (2 x of I'L AJV �fl0w/.ver //D US-e L O CH T'/a A/ r s ^ �SC',7LE=/"= 3o' DE'C• /977 z u. /YDRIVAIV CiROSSMAN. )e L.S. Gu Nifk= CEnAR ACRa rW 7Y �4 1%� 11 ii ' Assessor's map and lot,number .... .� �.!l...J ... � l �{� /�� /4 —l — 7 7 SEPTIC SYSTEM MUST SE INSTALLED IN CO MPLIANC ESewa a Permit number . ......................... WITH ARTICLE:11 STATE-a I SANITARY CO �QyOF TH E Tp�O == TOWN OF B A 1N' n i ,_ .fi/t "` °W Cry 89HH3TABL • �•' § o pYa BUILDING. , INSPECTOR H < ,G APPLICATIONf FOR'PERMIT=TO ... x�lG .. ..................... ......... .. .. . TYPE OF CO;.�ISTRUCTION ................... '��, .. ..tt./... . /.SYI../...Y...'.. .. .1 .� 4.1 :. ` .......19........ 1 � TO THE INSPECTOR OF BUILDINGS: The undersigned hereby ap lies„for a permit according to the following information: Location ...... .... .h-. . .G� ..L ���.. �� . .�L..�� ......... . ................ ................................... ProposedUse ...... .! "�r�,/ .,' �. !�, .� ....................................................................................... ZoningDistrict ........................................................................Fire District .............................................................................. .... .r .r Name of Owner _:r�.... ��..f'1.�:��..�Address .......................... ....Czar:''Z:!3P.{�.r%. °.C'.e%�;:�......... Name of Builder ..� :,...,e .... ...1 1 12 �?. kddress Name of Architect ............ :.......................................Address Number of Rooms ................ .................................Foundation ...... Exterior ....... . .,- ... Roofing .. � -�-� Floors 4 ..L �. Interior' .......:. � ��ejjj� ............................ `' ��....Plumbin Heating ..... L�....:`. ...��. ...2..�..._.. .... .1.. ...,. g .................. .(�...�.. ., . ..::. .,��. .................. I Fireplace ....................... ......... ....... ........................ Approximate Cost ..G.. Definitive Plan Approved by Planning Board -----------_------_-----------19________ . Area ........ 0 Fol.................. Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH `,V 121 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. ,-7 Name !.�''.�-�..d'�tLf..... '' .�1�'�2� ..G:g,..... • . Cedar J&crmm Reeltr/ � ` � ~ �?�--. permit for ----..'�z:g�---- ` . , --------- -------- � - ~ - ^ Location .�].. ..���__^_�___---- � ' . ' ^ .........................UYA is------------- Owner .......................q@!Ut:K. '.. K� -���� ' ' Type of Construction --.--]�O.%. ........ _-.---..-�-----.-.-.-.---.~---- - 94 Plot .................�1......... Lot ................................ Permit Granted -..�8..�.]P �� ------. -- 4 Date | -'� --...1Q - . ` ' ^ ' � ^ .-Date Completedj�-----lA w � ' l� . 1E ^ PERMIT REFUSED , , ~ ]�,.---..---,/-.-.~-..,~----- ^ . . ^'.~'~-^`^--^'�^^—'-----------^'^^'- .......................................... ' .-.---..-.-..- -~-.-......-,_..~.^.^�...-~..~.-..-^-. -''^'-^~--'-^'r~---'-^^-^-----^'^^^' . ' Approved ................................................ lg ' - ' ' r ... .. ......., � ^ ' --.. .. --------..... -..-. .-.- ' -'-^-----.-~.-...-------~..-..... . | ' | Assessor's riiop and lot number .... L9 Sewage Permit number ......................................... ................ TOWN OF BARNSTABLE BARNSTABLE, MU& 1639- IWO BUIPING INSPECTOR APPLICATION'F'OR PERMIT 7 1 0 ............/ill," ................................................................................................................. TYPE OF CONSTRUCTION' ................... o /v//�=— Iq ..................................... ............................................................................ ................................................19........ TO THE INSPECTOR OF BUILDINGS: The,-undersigned hereby applies for a permit according to the following information: Location ....... .................... .......................................... ...............:......................................................................................... ProposedUse ...............I............................................................................................................................................................... ZoningDistrict ........................................................................Fire District .............................................................................. . Nameof Owner .....................:YAddress .................................................................................... f Name of Builder ........................................... (r .............................................!.................................. Nameof Architect ............ ......................................................Address .................................................................................... Number of Rooms .......................... ......................Foundation ........ Exierior ......... :t— ­01�' .Roofing ...... ..................... z............... .. ............... ............ .......................... ...................................... Floors ............................................!.........................................Interior ...................... .......................................... ................ f,-) . �r_:j,1 7-1 Heoting............. .......... ............ ......................Plumbing ..........................................................!.................... Fireplace ........................ ..........................................................Approximate Cost ..................................................................... Definitive Plan Approved by Planning Board -----------—-------------------19--------- Area ......................0�.................. Diagram of Lot and Building with Dimensions Fee .................. ... ...... .... . . .... *SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Wes and Regulations of the Town of Barnstable regarding the above construction. Name ... ....... ............................................................... Cedar Acres Realty low No !M�5..... Permit for ....Dwelling................ .................. ......Single..Family....................... Location .......2.3..Deaver-St................. .......... .......Hyannis............................................. .. ......./ Owner .....Cedar-..Acx.e-s,?r&ea1t-Y..................... Type of Construction .....Wa��Fr-aame............... ................................................................ ... ...... Plot ............................ Lot ... ....94.......... .......... F Permit Granted� ...... 6.......19 77 Date of I nspection (......... ........................19 Date Completed ... ........................19 Ce FERMI. REFUSE - ................i........................ ...................... 9 ... ....................... ... .............................. .....41-00 . . ... .... 1. ..f ........................ ................. ...... ........................... ............................................................................... Approved ................................................ 19 ............................................................................... ...............................................................................