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0053 KILKORE DRIVE
�3 lii�re �� , / � ._ _� s ' ,�TM� TOWN OF BARNSTABLE Permit No. .3311�7. l BUILDING DEPARTMENT t •avn f .... I TOWN OFFICE BUILDING Cash '659• Y HYANNIS,MASS.02601 Bond X. . .1 " CE11TIFICATE OF USE AND OCCUPANCY f P Issued to Greenbrier Corp. Address Lot #27, 53 Kilkore Drive Hyannis, Massachusetts USE GROUP FIRE GRADING OCCUPANCY LOAD 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. September 14 r., 19....89.............. .................. Building Inspector �'�y ••'. TOWN OF BARNSTABLE BUILDING DEPARTMENT TOWN OFFICE BUILDING rua i6J9. �� ' HYANNIS, MASS. 02601 '�o rur�• MEMO TO: Town Clerk FROM: Building Department DATE: fll6le F An Occupancy Permit has been issued for the building pauthorized by Building Permit �'$�............3 . ... . :.:...+............................................................................... ................ _» .... .__ issued to .....1'?., ''.J,� it �.0�,�:�............` -� ..��� d•"G ?'_i' �. �_._ Please release the performance bond. r t - •. 1ri '�`�•�..f.. 'i..,ir.P p.- 'YiC ♦ 31q�+A P1 TOWN OF BARNSTABLE, MASSACHUSETTS BUILDING A-272-005.011 4uUa`.t j 89 TAD ` 3 - DATE ° + `�9 PERMIT NO. Owner APPLICANT ADDRESS INO.) (STREET) (CONTR'S LICENSE) Build dwelli.ns i PERMIT TO ( ` 5,17.t file f F1ll111y dtAie�.1iT1 NUMBER OF UNITS _) STORY (TYPE OF IMPROVEMENT) NO. (PROPOSED USE) AT (LOCATION) lot #21 J3 Ki kOre Drive, Hyannis ZONING RC 1 (NO.) (STREET) DISTRICT— BETWEEN` AND - (CROSS STREET) - (CROSS STREET) SUBDIVISION. LOT _ LOT BLOCK SIZE (t 9 k;. BUILDING IS TO BE FT. WIDE BY FT. LONG BY FT. IN HEIGHT'AND.SHALL CONFORN+ IN-CONSTRUCTIO TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION (TYPE) REMARKS: Town ,ewes #311;' ' AREAVR BOND OLUM 768 sq. is t. ' E 45 ESTIMATED COST $ ,000 PERMIT �61.50 (CUBIC/50 UARE FEET) FEE .-, td OWNER Greenbrier Corp. !, • l ! r\ ox .`i_,) (,c'�Ll.l_' 1:Li -a f 1`u�, l}i.5 2 . ADDRESS BUILDING DEPT l BY `TV•S""'VY"><'Ot3'C-TC-'ti�PIIRT('S'-`l`It-t5 'b'Yl"fIrC1="O'F`'"fYiTS'l''t'`Y21GifT"[7' ...:OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. � � T^� --Ap-P 7�f"1'FY'E''C'OTM T6 MINIMUM THREE CALL APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: CARD KEPT POSTED UNTIL FINAL INSPECTION, HAS BEEN PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING I. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- .MECHANICAL INSTALLATIONS. D 2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL . MEMBERS(READY TO LATFI). 3. FINAL INSPECTION BEFORE FINAL INSPECTION HAS BEEN MADE. OCCUPANCY. POST THIS CARD SO IT IS VISIBLE FROM STREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS 1 ELECTRICAL INSPECTION APPROVALS I� •v Cb rL 2 (1444 2 - -- F(•n � Z c h1 s HEATING INSPECTION APPROVALS ENGIN RING DEP TMENT . I c OTHER b, L.' _ U _ BOARD OF HEALTH WORK SHALL NOT PROCEED UNTIL THE INSPEC- PERMIT W!L L BECOME NULL AND VOID IF CONSTRUCTION INSPECTIONS INDICATED ON THIS CARD CAN TOR HAS APPROVED THE VARIODUS STAGES OF I WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE CONSTRUCTION. PERMIT IS ISSUED AS NOTED ABOVE. ARRANGED FOR BY TELEPHONE OR WRITT NOTIFICATION. i I \ �G7- 1 � 0 `, h r - `1 • M C THIS PLAN IS NEITHER INTENDED NO. oA�e �oescw lm By y FOR, NOR SHALL IT BE USED FOR AS—BUILT FOUNDATION PLAN—LOT MORTGAGE LOAN PURPOSES. L o r 27 Ki�,ro,eE �e�✓F M ' � •' Tf1e. G,e���v��E,e Ga,eP. PA U L A. \1 SCALE. / _lo l im N0. 13M 1 CERTIFY THAT THE FOUNDATION LEVY y 90 do SHOWN ON THIS PLAN IS LOCATED No. 10617 ON THE G S INDIC D. CIS 11<1 IBVY, ILDMM TiM GIs K bAlf RE I RED LAND SURVEYOR r PAUL A. ``,•�, s7R ! COITatv= !" 0E6Si i .a i ,r 4 t t ; i I i I 1 I I I I I APPRO% V,E,D ���`'"�'�:'y� �*p�`'NF ' �� p�r+, � sc.LLe/4t'<lo" �aveo ev: NIWi puww ar: .�.<i. Y V d 3 {d• a t i �� f� DATE. t_2 M ��� PENSED BlF f2 9i ��7'30�6i4iIi�Iil ���x p_�•.S�<. i i i li II . i II II iI i li I � I � � I � I I 8 g RUM I 1-4--- -- i jig Lo� 00 i fJ 003 N � es O i o � h _ L i r D p' I t-----� l r Vf" AL QL i� Gae'' GAY 6d 8%w' 6'-m• I 6Y 1 2.10 ti s 16^o.t. Im4f.M I I r �,� I n / L—J I I y .-.:�µMfR4 _OWIi Ir+CdN•� r-se.-IZ.:6w �'O( � �1 dRat I f---) _I1 µ�'yr�rM C IGYO,L./ -_'7Ysr-CaG• 4(/�ri.. .-- - -1� ._,�,.I. � 1— I I � � I � ____h-'4�-1'�-• _—err G..c-r.+lde.:- I ewo.�. ,t•,< IG k-big P � :_Gw+•(f�s.WLr f�I7..Y•r... .-yq�,�yl r�'.IxrCd.,�7O lGtiir. �,�t•1 ''^�T- 1 fr L?Anww 11 f 1 uM Avg '1 �t�t 167 I s4f-1� •_ 2_ 1 1 t Assessor's offioe"11st 4 Assessor's map and lot number ....v?��?....®..;..... / *} *1N¢TO�f ` Q Board'of Health (3rd floor):. Sewage Permit number �/ 2 BlHd9T s AD s" L , Engineering Department (3rd floor) } a rY. �Y..t MAD6 House number ................... .....: ....::. 5 .. .`. ...... ... .... '°�' y I,. $'' '°o s o�a R .0 Olt APPLICATIONS PROCESSED 8:30:=9:30•A.M. :and 1:00 2:00 P.M. only Y +. 'TO.WN �OF =BARN-S�'ABLE k: BUILDIH,G iNSsPE.CTOR y¢ APPLICATION FOR ,PERMIT TO C 6"V sr'0-uC, btucc c y-c TYPE OF CONSTRUCTION L✓�U1�........ i(nM� *, 19:.� ......... --•-•- .--... TO"THE INSPECTOR OF BUILDINGS: s •- The undersigned hereby applies for a .permit according; to the following information— Location 0=........... ...... KIcKo4:F Z NE f � ...v�.?j ... r....... ..... w ProposedUse....................................... ......... ....... ......... ....... ....... : .. ......... ......................... Zoning District .... ........................:.. _......:Fire.:District .. ... . .... Name of Owner Gs2c ,f�,z�t'� �o d; r/X 15/0 �F.vr6W.rat .............: n E p........... ....:...Address ......... ..... .../.......................................... Name of Builder ................................... ..:....Address Name of Architect ............. t..:.Address F f... ;.... .... .... ...... ... . .............. t 0 �7) O Nclt ......... Number of Rooms ...:.................. Foundation ... �'.... r L� S s/J k i�eotT Ex�er�o. '�.. . u ......... .Roofing .5� ..... ........ ...................................... Floors Interior SNt E r KAC................................... Heating ......A.1 ........CrP..�.................:. .Plumbing �.....('. .:. ... , k. FireplaceVo........../ ... .........Approximate.Cost ..... .....t................................ �.. .... �. Definitive Plan Approved by,Planning Board __ - _____________ A5: Area .. /� .+� ...'....-.... Diagram of Lot and Building with' Dimensions '' •. 'Fee ...:....� ............................�.. SUBJECT TO APPROVAL OF BOARD OF HEALTH` E 6 `q- r * ; V Y , OCCUPANCY PERMITS REQUIRED. FOR, NEW DWELLINGS:' . . I hereby agree to conform to oil the Rules.an'd' Regulations of the;Town of Barnstable+regarding tffe above construction. { - x .Name ,Q p OQl3`1 Construction Su ervisor's License ... .... :. ... GREENBRIER CORP. ;c' 3 No x 3311.�... Permit for ....1.'-...StorX........... ` . ..:Single rFamily.. Dwelling........... r p ;Lot #27, iore rive Location- 53 Klk D - - - HXannis ............ .......................................... Owner ...Greenbrier Corp...,,................... _ ~r r, Type of _Construction Frame ............................................... f Plot ............................. Lots.................. ' Permit Granted .....A 1 .gwq. ... .r..........:..19 8 9 _ Date of Inspection .... .. ................. .19 - Date Completed �" .. ....... 19. r ,+ c� q. . Assessor's offioe (1st floor): Assessor`% map and lot number .................... ......S..... .. C{ .,°F7�NEt°�` Board of Health (3rd floor): Sewage Permit number ©- ` �. Engineering Department (3rd floor): so rasa i, f` i639 House number .� ..... O • APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00'P.M: only TOWN_ OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ....... ;r� "........ ,- hzvrC.r r/.,G TYPE OF CONSTRUCTION .................G [rC ....... t. �.�.. fir / ......... � ................. f . = ...........19.: .cs. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location 07 a ) s zseow . 1 ProposedUse ........................r.... .,........;.. /................................................................................................................... �7 C Zoning District .......:.................................................................Fire District .:............................................................................ Name of Owner Gzc c`� r�,z.j(,)— ('�4 K%:....................Address / 6, �JX .. .� 1.........................�Atirrtz� ...-.............,............I................... .C .. ... .................. C J I l Nameof Builder ....................................................................Address .....Sf......... ....................:.......................................... Nameof Architect .................................................................Address ............ .......................................................... Number of Rooms ...........Foundation .,.. avrcrl) (zvs�teKe jC Exterior ........ . C..........:.......«.................................�..� ......:.Roofing ........:' t.4JP /yc�....................................................... Floors ......� /?!"..r.... }.:v V (i Interior .................... .................. . .... .......................................................... t rJ Plumbin f Heating . A...1......... :.. g �..... ....................................................... r � r ; Fireplace /vO ............................Approximate Cost ; yF f: r r .......................................... ......:..... . .................................................... } A � qq Definitive Plan Approved by Planning Board _____ _ __!_______________195 . Area Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH jJJeC inJ t�}/Jc?� V S F-.!h S �.f h. 7.i f'�" 1�,!°�'t ` � Let`v � k,a •' �' i..� << '1 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the,Town of Barnstable regarding the above construction. t, Name ............................................ Construction Supervisor's License ...�� r��. ................... GREENBRIER CORP. A=272-005. 011 No ..... Permit for ....12....Story........... 1 ' Sing.le.,Family...Dwel.liag........ location ...Lot #,27,......53 Kilkore Drive ..................Hyanni s............................. Owner .....Greenbrier. . . . ...Co. rp.................... .. . .. .. .. .. Type of Construction Frame ....................:........... ............................................................................... Plot ............................ Lot ................................ Permit Granted .....August...3..............19 89 Date of Inspection ....................................19 Date Completed .......................................19 146. F�,,�, Town of Barnstable *Permit� v 6`'�3� 1,0 d Expires 6 of orlthy fr 'fsuedate Regulatory Services Fee irnxxsras�; Thomas F. Geiler, Director n �b t639. .� Building Division pTEb�'t 6 Torn 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 - RESMENTIA.L ONLY Not Valid without Red X-Press Imprint Map/parcel Number ��� Oil Prop Address Residential Value of Work inimum fee of$25.00 r work under$6000.00. Owner's Name&Address Contractor's Name C � - 'Telephone Numb. 0171 Home Improvement Contractor License# (if applicable) ❑Workman's Compensation Insurance C ck one: , I M 1 m a sole proprietor EiA am the Homeowner 200� I have Worker's Co pensation Insurance AUG 2' 5 O Insurance Company Name . / TOWN'QF BARNSTASLE Workman's Comp. Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will > c taken to ❑ Re-roof(not stripping. Going over existing layers of roof) side Replacement Windows/doors/sliders, U-Value (maximum..44) *Where required: [ssuance of this permit does not exempt compliance with other town department regulatior�ri� w 3!bb Conservation,etc. ***Note: Property Owner.must sign Property.Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. i � . eat, SIGNATURE: Q:\WPFILES\F0R-MS\bui1ding permit forrns\EXPRESS.doc J The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AiDiDlicant Information Please Print Legibly Name(Business/Organization/Individual): , Address: City/State/Zip: Phone.#: Are you an employerf Check the appropriate box: Type of project(required):. 4. I am a general contractor and I 1.❑ m a employer with � 6. ❑New construction employees(full and/or part-time).*, have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition comp.insurance.$ [No workers' comp.insurance 5. 0 We are a corporation and its ME] Electrical repairs or additions required.] officers have exercised their 11.❑Plumbing re airs or additions 3.❑ I am a homeowner doing all work � myself. [No workers' comp. right of exemption per MGL 12.❑ of repairs insurance required.)t c. 152, §1(4),and we have no "� � employees. [No workers' 13. Other AolA !1i �_ 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 w rkers'compensation insurance r my employees. Below is.the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: , Expiration Date: Job Site Address: is City/State/Zip: j I Attach a copy of the workers' compensation policy declaration page(showing the policy num er and expiration date). Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK.ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the D1A for insurance coverage verification - I do hereby cer,ify under the pains d penalties of perjury that the information provided a4oe is tr a and orrect. Si ature. 111,0W Date: Phone#: Official use on y. Do not write in this area,to be completed by city or town official City or Town: Permit/License# I 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#: �l / • A .a ti 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 thantthree,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 r building appurtenant thereto shall not because of such employment be deemed to be an employer." or on the grounds o P b'r g P i MGL chap°ter 152; §25C(6)also states that"every state or lockrlicensing agency shalltwithhold'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 Departmenvha�provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations`has tb,contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a referericelnumber'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:. TN,Commonwealth of Ma'saphusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. ##617--727-4900 ext 406 or 1-977-MASSAFE Revised Fax 4 617-72777749 11-22-06 vrww.mass.govldia y hr ' t , °FmE'°�ti Town of Barnstable Regulatory Services M s�t.E,� Thomas F.Geller,Director Building Division. Tom Perry, Building Commissioner 200 Main Street, Hyazmis,MA 02601 www.town.b arnstabl a paxs Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section. If Using A Builder I, GJ G1�o e R. Pei r u e d Sr ,as Owner of the subject property hereby authorize R a are r 114 can,, to act on my behalf, in all matters relative to work authorized by this building permit application for. s. S 3 k; Ikon DC; ve , Nw�. �tj%s , rna (Address of Job) �— o 2 (0 o Signature of Owner Date �a�,�e R • 'P�-�rvcci Sc� Print Name Q:FORMS:0 W NMU ER1VZS S 1DN ,,pper� �1t6 "�70�iivri+u�� o�✓li�l�cfube� ---- ' <Z-\ Board of Building Regulations and Standards License'or registration valid for individul use only HOME IMPROVEM ENT'CONTRACTOR before the expiration date. If found return to: Registration; 132560 Board of Building Regulations and Standards Ez Iration: One Ashburton Place Rm 1301 � p 2�27/2009 Tr# 126482 Boston,Ma.02108 Type Individual ROGER E. BYAM ROGER BYAM 504 PITCHERS WAY HYANNIS, MA 02601 Administrator Not valid without ignature r, o _ .1 P Town of Barnstable *Peru# ;�06 -763-71(to Expires 6 months from issue date Regulatory Services Fee . 06 Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red.X--Press Imprint Map/parcel Number �D a 005 0 11 Property Address �l �r� I r�-r`' S esidential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address�1 % 1� CGI 3 1 Contractor's Name "/ r'l Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance X-PRESS PERMIT Check one: ❑ j_pz<sole proprietor. JUN 15 2007 am the Homeowner ❑ I have Worker's Compensation Insurance TOWS! OF BARNSTABLE Insurance Company Name Workman's Comp.Policy# - 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 ❑Re-roof(not stripping. Going over existing layers of roof) Re-side Replacement Windows/doors/sliders. U-Value (1V (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town d ,,tmm treg�712&Mji-i.Historic,Conservation,etc. _.._.... ***Note: Property Owner must sign Property Owner Letteref Permission. fi�.r A copy of the Home Improvement Contractors License mere ' SIGNATURE: Q:Forms:expmtrg Revise061306 The Commonwealth of Massachusetts f Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'blv Name(Business/Organization(Individual): . ✓1 IE5 tll �v CCU_ Address: C � IC�t 'k�J0, City/State/Zip: t 1 6-''""tS Phone.#: Are you an employer? Check the appropriate box: Type of project(required):. 1.❑ I am a employer with 4. I am a general contractor and I 6. ❑New construction . . employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the-attached sheet. 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. F�Building addition workers' comp.insurance comp.insurance. q�ed.] 5. We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 11. Plumbing repairs or additions 3. I am a homeowner doing all work ❑ g P myself. [No workers' comp. right of exemption per MGL c. Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' . 13.0 Other comp. insurance required.] . *Any applicant that checks box#1 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. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: — - City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains-andpenalties ofperjury that the information provided above is true and correct: Simature: 1K• Date: Phone#: Official use only. Do not write in this area,to be completed by city or town o jicial, City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and 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 hiie, 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 t6operate 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 ins .nce 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-contiactor(s)name(s), address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. 'The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to 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 Departrnenfs address,telephone-and fax number:. The Commonwealth of Massachusetts Department of lrifttrial A roidonts Office of Investigations 600 Washington Street Boston, ILIA 02111 Tel.#617-727-4900 ext 406 or 1-877 MASSAFE Revised 11-22-06 Fax 4 617-727-7749 ---' www.mass.gQ-v/dia '6 Town of Barnstable OF THE 1p� Regulatory Services BARNSTABLE, ; Thomas F. Geiler,Director 9Q, MASS.9 .��p Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE:�p l S )U� JOB LOCATION: S 3 4 6(V-" t-t-) number ��� �,strtr�eet �^ village z .HOMEOWNER": I Y�Q_ �� 1 r ( JZ'J) r' J name // home phone# "work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signa ure of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. :f Q orms:homeexempt a Town of Barnstable *Permit it Ex Tres 6 montks rom issue date Regulatory-Services e X-PRESS PE MIT Thomas F.Geiler,Director J Building Division P JUL 1 200I Tom Perry,CBO, Building Commissioner ASL F BARNST �00 Main Street,Hyannis,MA 02601 TOWN O www.town.bamstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address � te,1,4 r s ✓j- Residential Value of Work [ (7 yr Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address w a�.f tl[C 3 /.)1- A/ b� �✓l Contractor's Name j4 e Y©.Me ��� S e.�La�i _Telephone Number' 9 q 6 9 Y B Home Improvement Contractor License#(if applicable) 9?-? Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name New �a rn rr s���r �n �• G o Workman's Comp.Policy# 17a l ,3 U 8 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 ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side 9�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,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise061306 The Commonwealth of Massachusetts —- ---- Department of Industrial Accidents Office of Investigations # 5 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. Applicant Information Please Print Legibly . Name(Business/Organization/Individual): �i ? Address: �-L� �� �� - City/State/Zip T zu �o • .1002. . Phone.# Are you an employers Check the appropriate box. Type of project(require. 1. Lam a employer with d 4.❑ Lam a general contractor and I 6: El New construction employees(full and/or part have hired the sub-contractors .. . 2.❑.I am a sole proprietor or partner- listed onahe attached sheet. . 7• ❑ Remodeling. ship and have no employees These sub-contractors have 8.. ❑Demolition working for me,in any capacity. workers' comp. insurance. 9. ❑ Budding addition [No workers'comp. insurance S ❑ we are a corporation and its ;. required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑3 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself. [No workers' comp. c:152,'§1(4) and we have no 120 Roof repairs insurance requited.]t employees. [No workers'. comp.'.insurance required - 13.❑Other. 'Any applicant that cfiecks 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 outside contractors must submit anew affidavit indicating such: _;Contractors that check this box must:attached an additional sheet showing the naive 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 andlob slte. information. Insurance Company Name:. ...� ,$ 1 rGS' - Co. . Policy'#or Self-ins Lic #: da aL l�-®. Expiration Date: j O Job Site Address ` �<< vie C City/State/Zip. ,4 G 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. 162 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 STOPMORK.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 under the pains and penalties of perjury that the information provided above is true and.correct:' Signature Date: -11 :O-' .; ...� Phone#: �� to y� Ojjicial use only. Do not write in this area,to be completed by.city or town o�ciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instruction's A� employers.to provide workers' compensation for their emp Massachusetts.General Laws chapter 152 requires allloyees. 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:hm 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 situationand,if nece11 ssary,supplysube-contractors)name(s),address(es)and phone number(s)along with their certificates)of insurance: :I:imted Liabi ty.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 submitted to the Department of Industtial . 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' compen ttiori p6hcy;`please;ca11 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 surIe 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 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 erson is NOT required to complete this affidavit.. i e do` license or permit to burn leaves etc:)said p q a p ( g , The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not.hesitate:to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office.of Investigations . 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-05 www.mass.gov/dia ma+ _..K a ,s> ` •fiw R✓ .. � > _ TI Gn� � . ' 61 CERFICATE NUMBER x � s � �u w 11 max_ §t, a� ." ATL-001234410-01 PRODUCER THIS CERTIFICATE IS ISSUED"AS A MATTER OF INFORMATION ONLY AND CONFERS MARSH USA,INC. NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE hOmedepOt.ce-rtreQUest@fnarsh.COR1 POLICY.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE FAX(212)948-0902 AFFORDED BY THE POLICIES DESCRIBED HEREIN 3475 PIEDMONT ROAD,SUITE`1200 COMPANIES AFFORDING COVERAGE ATLANTA,GA 30305 COMPANY 00492-THD-IPUSA-07-08 IPUSA A STEADFAST INSURANCE COMPANY INSURED COMPANY HOME DEPOT USA,INC. B ZURICH AMERICAN INSURANCE COMPANY 2455 PACES FERRY ROAD NW BUILDING C-8 COMPANY ATLANTA,GA 30339 C .` AMERICAN HOME ASSURANCE COMPANY COMPANY D NEW HAMPSHIRE INS COMPANY .•..,<:<. l "^�'�.. .`• .., -ate..e...Yi; .e:..' _ur.. rr� x. '. -.,,. :,.�.,. wx.;.a t �', �u Ps..r•.:. ..W; .>,la-;.s ^.;3.✓ _COVERAG.ESx,-r n _ Thls certtfica# xs ersedesand re )ace an cevlousl Issued cert(ficaC f F they Dhe a ID notedx.belDw 2 � THIS IS TO,CERTIFY THAT PCUCIES.OF:INSURANCE DESCRIBED HEREIN..HAVE BEEN ISSUED:TO..THE INSURED.NAMED.HEREIN.FOR,THE POLICY PERIOD IN NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH.THE CERTIFICATE MAY ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED 8Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,CONDITIONS AND EXCLUSIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS: CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MMIDDIYY) DATE(MMIDDIYY) A GENERAL LIABILITY IPR 3767 608-02 03101/07 03/01/08 GENERAL AGGREGATE $ 4.000,000 X COMMERCIAL GENERAL LIABILITY 'LIMITS OF POLICY ARE EXCESS' PRODUCTS-COMP/OPAGG $ 4.060.000 CLAIMS MADE a OCCUR 'OF SIR:$1,000,000 PER OCC PERSONAL&ADV INJURY $ 4.000,000 OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 4.000,000 FIRE DAMAGE Any one fire) $ 1.000,000 MED EXP(Any one erson) $ EXCLUDED B AUTOMOBILE LIABILITY BAP•2938863-04 03/01/07 03/61/08 COMBINED SINGLE LIMIT $ 1.000,000 X ANY AUTO ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ (Per acddent) NON-OWNED AUTOS X ELF-INSURED AUTO PROPERTY DAMAGE $ PHYSICAL DAMAGE GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: p �xe '- 5 EACH ACCIDENT $ AGGREGATE $ A EXCESS LIABILITY IPR 3757 608-02 03/01/07 03/01/08 EACH OCCURRENCE $ 5,000,000 X UMBRELLAFORM AGGREGATE $ 5,000,000 OTHER THAN UMBRELLA FORM $ C WORKERS COMPENSATION AND 2921209(CA) 03/01/07 03/01/08 X TORY LIMITS ER A d::'70, EMPLOYERS'UABIUTY E 2921210(FL) 03/01/07 03/01/08 EL EACH ACCIDENT. $ 1,000,000 F THE PROPRIETOR/ X INCL 29212.11 (AZ,ID;MD,VA) 03/01/07 .03/01108 EL DISEASE-POLICY LIMIT' $ 1,000,000 PARTNERS/EXED OFFICERS ARE: E Exct 2921208(AOS) 03/01/07 03/01/08 EL DISEASE-EACH EMPLOYEE $ 1,000,000 C OTHER 2921213(QSI) 03/01/07 03/01/08 E . WORKERS'COMPENSATION 2921212(KY,MO,NY,WI) 03/01/07 03/01/08 G TEXAS EMPLOYERS TNS-C44642086(TX) 03/01/07 . 03/01/08 EACH OCCUR.ENCE 25,000,000 EXCESS LIABILITY SIR 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLESISPECIAL ITEMS •. .. .N`.3':;r f' P h ,.v _q 'tr ^s -. ➢ t[e -'.l6Xti'.°. R.C. ERTIFCG/TE t#QDEt x y , ; fie L� �y w"cv. aisii �? ..iv^ ,es•a .,a..•_ M.,.',,,.�„•k.2`z:'1.+`i ,iwst ir.. ?r. l.<�w3�£..-a'r .ax .+s,.x' ._: SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL__ a.DAYS WRITTEN NOTICE TO THE FOR EVIDENCE ONLY CERTIFICATE HOLDER NAMED HEREIN,BUT FAILURE TO MAIL SUCH NOTICE-SMALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE,ITS AGENTS OR REPRESENTATIVES-OR THE ISSUER OF THIS CERTIFICATE. MARSH USA INC. Bv: Mary Radaszewskl OF IDf`wII�M1 3t02 Y � VAL AS a02128/07 3� ^� .� - ` *a ,G1.1et f s'.r - ,,,,a ' zXv, - ,, ..;:4A �°-^?s.a'?`S< "`"^,,:. .., ,`�F�--#l_u„•r�nK � .->c'- s_,Sw�.:R',-�n�'.Z'Z'.;r�. 7T�.,��.�,..�,�'.. 'S+n��.v::;R ....r� „k-a`Y� �,L..can,°"`,..�.zw„r �. n'„�a.:..n�`",..:A�:::�} :C�'��..:��.y�;y'�''s ,��',�;_-��,,����,, �,, • �1�n,����� x�y.,;�`�'� p.:.,,to � �._ '� :�v� �-� �� "�y:.' ��� ��g£k DATE.(MMIOOIYYI .� '�¢ �� .✓ ��* „• ���x. � ����.Y � v;�-�.'���'� ��s�.a�h'��' G �'��M ��° ��� �"f� G2�28�Q/ u PRooucER ;;,,-�. ..'er�N�a ,.,;� , a� � `"COMPANIES AFFORDING COVERAGE . MARSHUSA,INC COMPANY homedepot.certrequestQmarsh.com �• - -• - FAX(212)948-.0902 - E . ILLINOIS NATIONAL INSURANCE COMPANY 3475 PIEDMONT ROAD,SUITE 1200 ATLANTA,GA 30305 COMPANY F NATIONAL UNION FIRE INS CO 100492-TH D-IPUSA-07-08 IPUSA _ _....INSURED.. ._COMPANY_ HOME DEPOT USA,INC.2455 PACES FERRY ROAD NW G ILLINOIS UNION INSURANCE CO .BUILDING C-8 . ATLANTA,GA 30339 COMPANY H ,.r .x.::s^- fi;: ` 'x# rr." " a ,s C r4 �• ,e .as _TEI� 7 N s 5>,5 dal �7a::�d �r� 5^:a m, a, & cv� �a. ' _:..,. m ,. � � r�.sz� .?etnss:fifsm �a� rsz4�� r ,. ,.. .. ...., ...;_�., .c... ._4 f^R,.a --?:<a. r.��,:,:�..a�`fig..�, .,�,.'w:?^x �.�r���'sr. �.-.1•Y-�;5"�2`ks"�ssx,,"�e� a�: �^'$cif k� �'Y'"�.�•%^"'Y..}�„.,;�h•'Yr., �.„e.�oa�a, ..�✓'h.���'.'� ��i•: :,CERT;IFICATE NQI�hER,� s,��., •� ,�r JS��d k� �+��,�' :S xsa,*.��'� .� ���` �'� '`�� � w� � ��� ,�•�.;���:�`�',r FOR EVIDENCE ONLY _. .... .... ...._.. ._ -.. ._ ._.....".. ....__._... . . . ..,-,.._. _.....MARSHUSA.INC..BY Mary RadaszewsklNAME M- �:. .•-rs:•;fir. sxa,- ^�4M e�,y ,,,,�° '-"s '.}++w�r ,e '" s+mRx`x7" e .s..-a: ' `S _'.`. `..b, "4' n'k, '.: `'^" l�„5 063-A-03.$ 40-45 D CM NFRC 610.0 Renovations Argon/Low E SC t�iahel SS . With Grids 1-800-746-6686 NFRC 2001 ENERGY PERFORMANCE RATINGS U-Factor(U.S,/I-P) Solar Heat Gain Coefficient 0 . 36 0 . 27 ADDITIONAL PERFORMANCE RATINGS fiaitle-Trarlsrmittance- 0 . 44 mamftctuter tes that th i sflptd8 ese ratngs rnMom►to appl cable ttFAC procedures for determhting whole prod!performance.NFRC ratings are determined for a fixed set of erMmmental caodltions and a edit product site.Consult marurlacbtws literature for other product performance information. www.nfrcorg Unit qualifies for snotgp Star Ragion(s) : North Central, •.� South Central, Southern . P �� : 3 G . 3 naD. TRSIN est 8izta��4 X eeo-P.30 �uraer #".3 144 r4.tfU.3rjUU.L 413260 i •�le �an .uealll o�,/�aaaaclucaelta .' Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registratr_o Board of Building Regulations and Standards 126893 Expiraton 8/3/2008 One Ashburton Place Rm 1301 �-Type Supplement Card Boston,Ma.02108 THE Home Depot At Home Servic MNIEL PELOQUI � PLt--..--_- 3200 COBS GALLERIA PKWY#20 , / Atlaniantic,GA 30339 Administrator Not valid without signature ALTANTA.GA 30339 adminiorn;.w Danya Mahat •7743230034 p. 4 HOME IMPROVEMENT CONTRACT pQ Sold,Furnished and Installed by: Branch Name: I7� 40,! Date: -THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services pp 345A Greenwood Street,Worcester,MA 01607 Branch Number: �4}Ci�J Job#: '7 P-79)t Toll Free(800)657-5182; Fax: 508-756-2859 Federal ID#75-2698460 ME Lic#C 02439 RI Cont.Lic#16427 CT Lic#565522; MA Home Improvement Contractor Reg.#126893 Installation Address: ` AN .sJ hA A� C&Y� State Zip Last 4 Digits of Driver's Purchaser(s): Lic.#&Exp.Mo/Yr: Work Phone: Home Phone: he nxc.; `7gg7 3 6 AT (SA)_'l j-y431 (sb()77/-k Home Address: <iAYIL' (If different from Installation Address) City State Zip E-mail Address(to receive updates and promotions from The Home Depot): 1V A f Project Information: I/Wc/You("Purchaser"), the owners of the property located at the above installation address,offer to contract with THD At-Home Services, Inc.("Home epot")to furnish,deliver and arrange for the installation of all materials as described on the attached Spec Sheet# w�MV ___,incorporated herein by reference and made a part hereof. Home Depot reserves the right to cancel this contract if,upon re-inspection of the job, Home Depot determines that it cannot perform its obligations due to a structural problem with the home, pricing errors or because work required to 0 complete the job was not included in the Spec Sheet or Contract. o DEPOSIT PAYMENT OPTIONS o (Subject to fund verification and/or credit approval.) p `9 CONTRACT AMOUNT $ 1 1. Check*,Cashiers Check or US Postal Service Money Order (Made payable to The Home Depot). n tLESS DEPOSIT $ 2. Credit Card"and/or other payment options-Circle One Below BALANCE DUE ']Q Visa MasterCard Discover. American Express ON COMPLETION $ / V The Home Depot Home Improvement Loan The Hom.�DepotC-�dAC-d� tMinimum 25%of Contract Amount due upon d New Account Existing 1A�ccount (HIL&HDCC ONLY) 9, V execution of this contract. Available Credit:s (HIL&HDCC ONLY) Indicate Payment Method For Aect#:IMF!=d Exp.Date: BALANCE DUE ON COMPLETION: , 1 Name as it appears on card: W tyylt. 1 Lyry/ **By m lour signature below,I/We agree to allow Horne Depot to char a above referenced credit card for the deposit indicated. *When you provide a check as payment,you authorize us either �—~ 0 '7 to use information from your check to make a one-time electronic hole s Signature Date fund transfer from your account or to process the payment as a check transaction.When we use information from your check to make an electronic fund transfer, funds may be withdrawn from HiL or HDCC Authorization Codes your account as soon as the payment is received,and you will not Deposit Final Payment receive your check back. # # Purchaser agrees that,immediately upon completion of the work,Purchaser will execute a Completion Certificate and pay any balance due. Purchaser also agrees to be jointly and severally obligated and liable hereunder. Entire Agreement: This agreement and its attachments, including any financing agreement, contain the complete agreement between the parties and can not be amended or-modified unless in writing in a separate agreement signed by both parties. NOTICE TO PURCHASER Do not sign this contract before you read it. You are entitled to a completely filled-in copy of the contract at the time you sign. Keep it to protect your rights. Do not sign a Completion Certificate before this project is complete. Law prohibits home repair contractors from requesting or accepting.a Completion Certificate signed by the owner prior to the actual completion of the work to be performed under the contract. You may cancel this transaction anv time prior to midnitht of the third hnsinm t day nftpr the da+P nf this rnno- i c..,, Last 4 Ulg►tS of 1)rlver,s Purchaser(s): Lie.#&Ex .M /Yr: Work Phone: Home Phone: he ,c Neu q K7 3 6 (SA )7_7 —145/ (got}771_ Home Address: �Afl (If different from Installation Address) City State Zip E-mail Address(to receive updates and promotions from The Home Depot): ►y A Project Information: I/Wc/You("Purchaser"),the owners of the property located at the above installation address,offer to contract with THD At-Home Services,Inc.("HomeDepot")to furnish,deliver and arrange for the installation of all materials as described on the attached Spec Sheet# 6 JW incorporated herein by reference and made a part hereof. Home Depot reserves the right to cancel this contract if,upon re-inspection of the job,Home Depot determines that it cannot perform its obligations due to a structural problem with the home,pricing errors or because work required to complete the job was not included in the Spec Sheet or Contract DEPOSIT PAYMENT OPTIONS (Subject to fund verification and/or credit approval.) CONTRACT AMOUNTS 1. Check*,Cashiers Check or US Postal Service Money Order (Made payable to The Home Depot). tLESS DEPOSIT $ 2. Credit Card**and/or other payment options-Circle One Below BALANCE DUE 1479 Visa MasterCard Discover American Express ON COMPLETION $ The Home Depot Home Improvement Loan The Homc Depot Credit Card tMinimum M%of Contract Amount due upon O hew•Account XExisting Account (HIL&HDCC ONLY) execution of this contract. Available Credit:$ 9.dPQ_ (HIL&HDCC ONLY) Indicate Payment Method For AcctN: xp.Date: BALANCE DUE ON COMPLETION: tOh�c eP�nycl Name as it appears on cud: _ 1 Ley **By m /our signature below,I/We agree to allow Home Depot to (: ('�hC-s� char a above referenced credit card for the deposit indicated. ) X , a- 2, *When you provide a check as payment,you authorize us either to use information from your check to make a one-time electronic bol c s Signature Date fund transfer from your account or to process the payment as a check transaction.When we use information from your check-to HIL or HDCC Authorization Codes make an electronic fund transfer, funds may be withdrawn from your account as soon as the payment is received,and you will not Deposit Final Payment receive your check back. # # Purchaser agrees that,immediately upon completion of the work,Purchaser will execute a Completion Certificate and pay any balance due. Purchaser also agrees to be jointly and severally obligated and liable hereunder. Entire Al!reement: This agreement and its attachments, including any financing agreement, contain the complete agreement between the parties and can not be amended or modified unless in writing in a separate agreement signed by both parties. NOTICE TO PURCHASER Do not sign this contract before you read it. You are entitled to a completely filled-in copy of the contract at the time you sign. Keep it to protect your rights. Do not sign a Completion Certificate before this project is complete. Law prohibits home repair contractors from requesting or accepting a Completion Certificate signed by the owner prior to the actual completion of the work to be performed under the contract. You may cancel this transaction any time prior to midnight of the third business day after the date of this contract. See Notice of Cancellation for an explanation of this right. There will be a service charge equal to 10% of the contract amount if job is cancelled by Purchaser AFTER the third business day,but BEFORE materials are ordered.There will be a service charge equal to 25%of the contract amount if job is cancelled by Purchaser AFTER materials are ordered. BY MY/OUR SIGNATURE BELOW,IIWE UNDERSTAND THAT THE AGREEMENT MAY BE SUBJECT TO REVIEW OF MY/OUR CREDIT HISTORY AND I/WE AUTHORIZE HOME DEPOT TO VERIFY AND REVIEW MY/OUR CREDIT RECORD WITH AN INDEPENDENT CREDIT REPORTING AGENCY AND RELEASE THEM FROM ALL LIABILITY INCURRED FROM INADVERTENT OMISSIONS OR ERRORS. BY MY/OUR SIGNATURE BELOW, I/WE AGREE TO BE BOUND BY THE TERMS OF THIS CONTRACT. IIWE ACKNOWLEDGE RECE F A OPY OF THIS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE OF CANCELLATI SUBMITTED BY: Date: b �P., LAQ-7 onsultantACCEPTED BYDate: er Date: Purchaser NOTICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE ' AND ARE PART OF THIS CONTRACT 4-2-07 C-SC White—Branch File Yellow—Customer Pink—Sales Consultant S 'd FEOOEZEifLL 14oyeW eRuea