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HomeMy WebLinkAbout0063 HOMEPORT DRIVE �me�po,� �,� J � -- - / � -- i �pfTHE Town of Barnstable *Permit,,flt G 37�. Etpires 6 months from issue 2, Regulatory Services Fee sARrts7Ast.E, � A39, ,�� Thomas F. Geiler,Director plfp Mp`l s Building Division A " Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis, MA 02601 _ www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY ,p ? Not Valid without Red X-Press Imprint Map/parcel Number 0 �J 3 ZZesidential rhAddress �J/t'i('. p & -S �'Q Value of Work Minimum fee of$35.00 for work under$6006.00 Owner's Name&Address Contractor's Name ,�i Q pf, =��� elephone Number E0b�/cg� 6/ ` ; Home Improvement Contractor License#(if applicable)^ f� - .� Zu ction Supervisor's License#(if applicable)man's Compensation Insurance Check one: ❑ 1 am a sole proprietor X-PRE PERMIT El am the Homeowner ❑ Ihave Worker's Compensation Insurance SUN 3 0 2njI Insurance Company NameNS7 ABLE / Workman's Comp. Policy# 6 d C 7 3�a 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) YRe -side #of doors placement Windows/doors/sliders. U-Value V (maximum .44)#of windows *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 requi SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 070110 The Commonwealth of Massachusetts � f Department of Industrial Accidents Office of Investigations 600 Washington Street - Boston, MA 02111- � ;rr www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): &714 Address: �15� pe,,e. City/State/Zip: �GL t7= -3 o 5 3 y Phone#: �� '6 5-7 5-!9-p- Are you an employer? Check the appropriate b Type of project(required): 1 I am a employer with 4. I am a general contractor and I 6. ❑N 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 8. [] Demolition workingfor me in an capacity. employees and have workers' Y P h' 9. ❑ Building addition [No workers' comp. insurance r, comp.insurance.$ required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 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. Insurance CompanyName: 5tv �C) Policy#or Self-ins.Lic. #: (0 6 Expiration Date: f J Job Site Address: Mome-POA City/State/Zip: *&I 4•4. V Attach a copy of the workers'compen ation policy declaration page (showing the policy nuiUer and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify unde he pains and penalties of perjury that the information provided above is true and c rrect. Signature• ��., Date: D Phone#: J�IJ, [ to 6 7 � Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: The Commonwealth of Massachusetts I I Department of Industrial Accidents Office of Investigations 1 Ei i`•� i , 41, i 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contactors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Q SZ7 ,/V4 Address: (ci ;4 City/S to/Zipal/eWbt?o1 ' AAl,. ' ��„7�� Phone. Are ou.an employer?.Check t e appropriate box: Type of project(required): 1. I am a er with employer 4. ❑ am a ge neral,eneral,contractor and I p y 6.- ❑New.construction employees(full and/or part-time):* have hired the subcontractors 2.❑ I am a sole proprietoror partner- listed on the attached sheet. t I Remodeling 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 LE] Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required:] t employees, [No workers' 13.❑ Other comp..insurance required.]_ *Any applicant that checks box#l 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below:is the policy and job site information. L. / Insurance Company Name: /V l 7 7Z .. ®'41 Policy#or Self-ins. Lic.#: (z/ Expiration Date:,. Job Site Address: ,� D In a City/State/Zip: A,2vv, Attach a copy of the workers'_compensation policy declaration page (showing the policy number an(Xpiration 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 impnsonment,,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day.against the violator. Be.advised that a copy of this statement may be forwarded to the Office.of Investigations of the DIA for insurance coverage verification. I do hereby certify d r the pains and pe !ties of jury that the 'nformation provided above is true and correct: . 3a Signature: ova Date: Phone#: Official use only: Do not write in this area;to be completed by city or,town officia;! City or Town: 'Perminicense# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Information and 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 moire 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is-required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please'call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to.fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not.hesitate to give us a call. The Department's address,telephone*and fax number: 4 ;" 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-N ASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia Oa DATE(h5M1DDr1YYY) CERTIFICATE OF LIABILITY IN 02/21/2011 THI�RTIFICATE 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: ' Marsh USA, Inc. PHONE ;FAX homede Ot.Certre uest@marsh.COm E-MAIL p Q ADDRESS___ --- Two Alliance Center, 3560 Lenox Road, Suite 2400 - AFFORDING COVERAGE Atlanta, GA 30326 INSURER(Sj ------------ -------— --------- - ..... Fax (212) 948-0902 _ _ INSURER A: Steadfast Ins Co 26387 INSURED — INSURER 8: Zurich American Ins CO — 16535 The Home Depot, Inc. 23841 Home Depot U.S.A., Inc. INSURER C: New Hampshire ins Co— — 2455 Paces Ferry Road NW INSURER0: Illinois Natl Ins Co 23817 Building C-20 INSURER E: NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanta, GA 30339 INSURER F: Illinois Union Ins Co — 27960 COVERAGES CERTIFICATE NUMBER: 19834682 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TH7POLICYPERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECCERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY-THE POLICIES DESCRIBED HEREIN IS SUBJECT TOEXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITSSHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADUL SUER POLICYEFF POLICY EXP LIMIT L1 TYPE OF INSURANCE INSR WVD POLICY NUMBER — MMIDDIYYYY MMIDDIYYYY _ A GENERAL LIABILITY GL04887714-01 03/01/1 03/01/12 EACHOCCURRENCE $ 9,000,000 DAMAGE TO RENTED 1,000,000 " X COMMERCIAL GENERAL LIABILITY PREMISES tEa occurrence,_ $-.: _.._._._..-. j X 1 MED EXP(Any one person) e' S EXCLUDED CLAIMS-MADE u OCCUR — — ---- --- X LIMITS OF POLICY XS PERSONAL BADV INJURY $.9,000,000 X OF SIR: $1M PER OCC GENERAL AGGREGATE $9,000,000—- GEN'L AGGREGATE LIMIT APPLIES PER:. PRODUCTS-COMP/OP AGG $ 9,000,000 — -il POLICYEl PRO- LOC - $ 03 Dl 1 03 O1 12 COMBINED SINGLE LIMIT B NGLE BAP 2938663-081,000,DOD AUTOMOBILE LIABILITY Ea accident X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED - BODILY INJURY(Per accident) $ AUTOS AUTOS —.— —._�..__..__....._... ._.. PROPERTY DAMAGE $ 'NON-OWNED .. Peraccident —_ __.__..... HIRED AUTOS AUTOS � $ X SIR AUTO P Y UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAO HCLAIMS-MADE AGGREGATE_._ $ DEO I I RETENTION$ $ C WORKERS COMPENSATION WC061967352 (ADS) 03/O1/1 03/01/12 X WCSTIMITS ER_ ATU- OTH- ---u-__ AND EMPLOYERS'LIABILITY D ANY PROPRIETORIPARTNER/EXECUTIVE YIN NIA WC061967354 (FL) 03/01/1 03/O1/12 E.LEACHACCIDENT $ 1,000,000— OFFICERtMEMBEREXCLUDED? N - 03/O1 .LDISEASE-EA EMPLOYE $ 1,000,000 E (Mandatory in NH) WC061967353 (CA) 03/01/1 �.—._ If yes,describe under ISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below C Workers Compensation WCO61967355(KY,MO,NY,WI, )03/01/1 03/01/12 . F TX Employers XS Indemnity TNSC46244151 (TX) 03/01/ 03/01/12 Occ rrence/SIR 30M/1M E Workers Compensation WC1192378 (OSI) 03/01 1 _ 03/01/12 S 1M DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD101,Additional Remarks Schedule,if more spat s 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 ATLANTA, GA 3D339 USA ©1988-2010 ACORD CORPORATION. All rightsreserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD jfiero hd 19834682 .. �'.�ltR 'C C•rr+mt4nea.Elaf� ��� �ZlZwfLC3RU3� .. ()ffice of Cousumer Affairs 8 Sasisess�egatatiaaaa — 'HOME IMPROVEMENT CONTRACTOR _ Registratian: 126893 Tye" Expiration. &3=12 Suppiement; Tne Horne Depot At-Hwe Services DARR.EN DEMERS 2590 CUMBERIAND PAMMAY S 4 ' .GA 3A339 t'¢dersrcrctar}' License or registration valid for individul use only before the expiration date.-If found return to: Office of Consumer Affairs and Business Reguiation_ 10 Park Plaza-Suite 5170 ;arts Boston, 02 116 Not valid without signature { CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYYY) 12128/2010 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Vieira Insurance Agency,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 65 Alden Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Fairhaven MA 02719 INSURERS AFFORDING COVERAGE NAIC# INSURED Douglas Szynal dba Szynal Property Services INSURERA: Essex Insurance Company 24 Logan Unit N504 INSURER B: Granite State Ins Co INSURER C. New Bedford MA 02740 INSURER 0. INSURER E'. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMEDABOVE 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 BYTHE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD'L POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION)ATE(MMIDDfYYYYi LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 E ToA COMMERCIAL GENERAL LIABILITY 3DE9446 11/22110 11I M111 PR�MRE G zS I a oNTEO $100,000 CLAIMS MADE Fx_]OCCUR MED EXP(Any oneperson) - 5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG 1,000,000 POLICY PRO• LOC - AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEOULEDAUTOS (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 $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ _ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- X OTI"- AND EMPLOYERS'LIABILITY t�,,. B ANY PROPRIETORMARTNER/EXECUTIVE Y/N WC 002-25-3582 11/2312010 1112i1:G 1 E.L.EACH ACCIDENT $100000 OFFICER/MEMBER EXCLUDED? N❑ (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $100000 If yes,describe under 500000 SPECtAL PROVISIONS below E.L.DISEASE-POLICY LIMIT .$ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS additional insured:THD At Home Services Inc and the Home Depot are included as Additional insured with respects to General Liability Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THD At-Home Services Inc DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL_DAYS WRITTEN dba The Home Depot at Home Services NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 2690 Cumberland Parkway IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR Suite 300 REPRESENTATIVES. " Atlanta GA 30339 - AUTHORIZED REPRESENTATIVE ACORD 25(2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and Iogo are registered marks of ACORD 1/fie ^a�n.rnon..kez�/� a 1�r sc/ru ell3 License or registration valid for individul use-only Office of Conautncr Affai Bi siness Regulation ti before the expiration date. If found return to:' HOME IMPROVEMENT TRACTOR t�' T e: Office of Consumer Affairs and Business Regulatiur y t Registra'on , .146142 YP `s` i >4F ' Exptratton: 312912013 DBA IQ Park Plaza-Suite SI70 Boston,MA 02116 S2ML PROPERTY SER { 4. i DOUGLAS SZ NAL 24 LOGON ST UNIT 802. NEW BEDFORD;MA'•0274d,..<, (lnderscci ct.iry N alid wtt ut stgnatu, _, .. fiifbii'Y 1f Atii{:. yY � I 2 L t�!�AN ST:ltivyT��..5G4 �. •,NEW St. ORD ;43 A'I:d�r�� 4 C.st,;ai r �pair HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold,Furnished and Installed by: Branch Name: Boston Date: �p , THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services 345A Greenwood Street,Unit 2,Worcester,MA 01607 Toll Free(800)657-5182;Fax(508)756-8823 Branch Number:31 Federal M#75-26984W;ME Ur-#C 02439;RI Cont,Lic#16427. Cr lac#HIC.0565522.MA Home improvement Contractor Reg.#12 893 Installation Address: 0 -h rty tState Zip Pnmhascr(s): Work Phone: Home Phone: Ceti Phone. Home Address_ ' C rQ C7r 0 Q 5- (If different from installation Address) City Stare Zip E-mail Address(to receive project communications and home Depot updates): ❑I DO NOT wish to receive any marketing cmails 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 Depor')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#: UUNM+t aete.) Products: Spec 5tceet s)# Pro'eet Amount Roofing 0SIdingeWindows EjInsulation 0 oGuuerY;/CovcTs ❑Entry Doors El q RcWfing Siding El Windows ❑1nsuIation C�. EIGutters/Covers 0Entry Doors ❑ ❑Roofing []Siding ❑windows Insulation ❑Gnttars/Covers []Entry Doors n QRoofmg Siding Windows ❑insulation (]Gutters/Covers ❑Entry Doors ❑ Nrbuamrm 25`Yo Deposit of Contract Amount due upon occook r of this contr w - Maine Purrhaser s rimy rot mom than ene-durd of the Contract Atuount Total Contract Amount 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 agicc's to be jointly and severally obligated and liable hereunder. The Home Depott reserves the right to issue a Change Order or terminate this Contract or aay individual Prudw.;t(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 hazards such as mold,asbcstus or lead paint,other safety concerns,pricing errors or because work required to complete the job was not included in the Co r Payment Summary: The Payment Summary # _� —i eluded as part of this Contract, sets forth'the total Contract amount and payments acquired for the deposits and final payments by Product(as applicable). NOTICF.TO CUSTOMER You are entitled to a completely filed-in copy of the Contract at the time you sign: Du not sign a Completion Certificate(note: there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product is complete. In the event of termination of this Contract,Customer agrees to pay The Home Depot the 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 under applicable taw. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM TILE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT 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 agreement between Customer and The I-tome 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 signed by Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has received a copy of this Agreement. A ed by S fled by: ea�io/UOO c Al U-e Customer's Signature Date S es 's DX TeleptlisLinmt c No. Customer's Signature Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS (as applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE ff ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S.STATE. NOTICE;:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT 8-31-i0 GSC White,Branch File Yellow-Customer Id WUPS-01 80OZ S 'uRf IZZZZ4£SOS: 'ON XkJJ pe6wef: WpN-� Town of Barnstable *Permit# 67653;1­d Expires 6 months from issue date Regulatory Services Fee 610 Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 2-6,6 Property Address " v S Residential Value of Work 3 ZvU, Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name z y Telephone Num4r SO 0 77S" 376 a Home Improvement Contractor License#(if applicable) //Z 9 7 7 Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ® ®g��p ❑ I am a sole proprietor X-PRESS PERMIT MIT ❑ am the Homeowner ®I have Worker's Compensation Insurance AUG 2 4 2007 Insurance Company Name BARNSTABLE Workman's Comp.Policy#lV e IM-ZA 6 Z 35-VOV Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) �Re-roof(stripping old shingles) All construction debris will be taken to A'* A/A Agwl &q ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) =:n,Q *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 ome Improvement Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise061306 ` < The,Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 k www.mass.gov/dia Workers"Compensation Insurance_Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly N e(Busine s/ rganization/Individual):&0Yjj4ff ' Address: — 4e 6 44, City/State/Zip: rXL4 .0�;437kone*(�VV - 2 AFuan employer? Check the appropriate box: Type of project(required):, 1. am a employer with 4. ❑ I am a general contractor and T employees(full and/or part-time)-* have hired the sub-contractors 6. ❑New construction . 2.El am a•sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g• Demolition workingfor me in an capacity. employees and have workers' Y P tY• �. 9. []Building addition [No workers' comp. insurance comp.insurance.t' 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 11.El Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.[/Roof repairs insurance required.] t c. 152, §1(4),and we have no employees, [No workers' . •13.❑ Other comp. insurance required.] . 'Any applicant that checks box#1 must also fin 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 providb their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below isihe policy and job site information. Insurance Company Name: 111!�t Policy#f or Self-ins.Lic.#: 1416 M'7 f,7_3S�6z Expiration Date: l g Job Site Address: �!3 �d?/��- City/State/Zip: t Attach a copy of the workers' compensation policy declaration page(showing the poucynuraVer 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$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coveraze verification, I do hereby certify tinder the pal1-andpenalties ofperjury that the information provided above is true and correct: Sienature: d]v6- Date: Phone#: 3 D g Official use only. Do not write in this area,Yd be completed by city or town ofj71ciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: FAPI of T Town of Barnstable. Regulatory Services "RWAS ,$ Thomas F. Geiler,Director Building Division Tom Perry, Building commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-62.30 Property Owner Must Complete,.atd Sign This Section f If Using A Builder as Owner of the subject property hereby authorize ,' to act on my behalf, in all matters relative to work authorized bythis bi Rdiag permit application for: . (Address of Jo ) Signature�ofCC)wner Date 1226L L Print Name QFOPMS:OwNERPERMISSION . •• ••,•� yr INSURANCE ;R LDATE(MWDDry- LIAUILITYAng (3'I+leilInsurance /13/07 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ?gericy ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR L-:1 West Main St.PO Box 1990 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. nis,MA 02601D INSURERS AFFORDING COVERAGEchael J. Dangelo Building INSURERA: Travelers Insurance CompanyNAIC# Remodeling,Inc. INSURER B: American Intl Companies Horseshoe Lane INSURERnterville,MA 0 6632 INSURER D: COVERAGES INSURER E: 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 HEREN IS 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 POLICY EFFECTIVE POLICY EXPIRATION A GENERAL LIABILITY 16HOH433HI75TCT07 D TE MM DD A E D 01/04/07 LIMITS X COMMERCIAL GENERAL LIABILITY 01/04/08 EACH OCCURRENCE $1 000 OOO CLAIMS MADE DAMAGE TO RENTED X occuR $300 000 X PD Ded:500 MED EXP(Any one person) $5 000 PERSONAL&ADV INJURY $1 0OO 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2 0Q0 000 POLICY PRO E T LOC PRODUCTS-COMP/OP AGG $2 000 0OO AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT ALL OWNED AUTOS (Ea accident) $ SCHEDULED AUTOS BODILY INJURY I HIRED AUTOS (Per person) $ I NON-OWNED AUTOS BODILY INJURY (Per accident) - $ PROPERTY DAMAGE GARAGE LIABILITY (Per accident) $ ANY AUTO AUTO ONLY-EA ACCIDENT $ OTHER THAN EA ACC $ EXCESS/UMBRELLA LIABILITY AUTO ONLY: AGG $ OCCUR ❑CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION AND WC1766359 EMPLOYERS'LIABILITY 02/19/07 02/19/08 X WC STATU- OTH $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.EACH ACCIDENT $1 OO OOO If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-FJ1 EMPLOYEE $100 QOO OTHER E.L.DISEASE-POLICY LIMIT $500 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Operations performed by the named insured subject to policy conditions and exclusions. CERTIFICATE HOLDER CANCELLAT=REPRESENTATnIVES. ON a r Y OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATI( itt I z . EOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL i �I, l n DAYS WRITTEN HE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITSAGENTS OR ATIVES.p F�EPRESENTATIVE�e ACID ea tzUUT/uts G of 2 _ #47256 LS1 ©ACORD CORPORATION 1, I � � , ✓lam -Pom�a.� ��, a�/ �- 4 Bgard'uf Budding Regulations and Standards . r HOME IMPROVEMENT CONTRACTOR Licen c or rctstrZtion vaLd for mdi�idol use only befot cNration,elate lf'found return to: Registration: 1512977 Boar ttfiiing Regulations and Standards Expirat : } 5/7/2009 Tr# 128790 One ion Rm",� orlon Place 1301 Type ry Individual Bosto IVIa.02108 MICHAEL J pANGELO�J` p{ MICHAEL,UANGELOQ fJ - 105 HORSESHOE LN " GENTERVti:LE MA.02632 " = Administrator Not valid hout signature