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HomeMy WebLinkAbout0094 LINDEN STREET qy u „e� s� Application number... WEE -� l3 o Date Issued................. ....i............................ YAMSUBLE. MAM �®o 16 ��� APR 24 2019 Building Inspectors Initials...... ._.. . ............... o�/�� 0"A 'u 3. 0...-Z. ...` ....................... .. �r!��LE M /Pare TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDINGAVINDOWS/DOORS/TENTS/STOVES/WEATIERIZATION PROPERTY INFORMATION Address of Project: NUMBER STREET VILLAG Owner's Name: to iYii A Gl v Phone Number Email Address:6,44,,.r1,,roci< 7&/4e Cell Phone Number ? Project cost$ /Z '77 Check one Residential ✓ Commercial O VVNEWS AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: See A4ad--L i ra� Date: TYPE OF WORK 1:1 Siding ❑ Windows (no header change)# ❑ Insulation/Weatherization Doors(no header change)# i Commerciai Doors require an inspector's review `--1 Roof(not applying more than 1 layer of shingles) Construction Debris will be going to a,s4 e- �, .,Q ram`-�--L, -,-1 mo.,fib, MA CONTRACTOR'S R40RMATION Contractor's name Aa �k✓' � oar e I N V� P� Home Improvement Contractors Registration Cif aP licable)-# (attach copy)Y) Construction Supervisor's License# 6,74 z y 7 (attach copy) Email of Contractor 4 Sp e,,,l ft S-cp Ina �� Phone number 4"o/-7IV-6 3"1 9 ALL PROPERTIES THAT HAVE STRUCTURE OVER 75 YEARS OLD OR 1F THE SUBJECT PROPERTY 1511V A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. i I APPLICATION NUMBER............................................................ *For Vents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one:this event is a:for profit non-profit event Check one:Food served Yes No Flame Spread Sheet of each tent must be attached.Provide a site plan with the location(s) of each tent If,food is being served at your event please obtain a Health Department approval between the hours of Se 00arn-930 am or 330 pm-4:30pm. Commercial events may require Fire(Department approva *WOODICOAL/PELLET STOVES " Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles:front back left side right side H®1gJEOW1'EWE LICENSE EX.IGN2TIO Homeowner's Name: Telephone Number Cell or Work number I understand nay responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature Date 2 q— 9 All permit applicatio are subject to a building officials approval prior to issuance SPECIAL SERVICES CUSTOMER INVOICE Page 1 of 5 NO. H2612-112722 -------------------------------------------- Store 2612 HYANNIS Phone: (508)778-8948 65 INDEPENDENCE DRIVE Salesperson: ACC1SC HYANNIS, MA 02601 Reviewer: VXG1123 Name Phone MCCARTHY KATELYN GO (774) 994-1639 REPRINT Address 94 LINDEN ST Phone �O©� Company Name • city HYANNIS Job Description exterior door install 2019-04-11 15:40 State MA Zip 02601 County BARNSTABLE INSTALLER DELIVERY #1 MERCHANDISE AND SERVICE SUMMARY ssooldrtoc stothe mes9httolimitthequantitiesofinerchandise REF# 101 STOCK MERCHANDISE TO BE DELIVERED: REF# SKU QTY UM' DESCRIPTION PI TAX P RIC#t!A EXTENSION R03 0000-254-466 2.00 EA 3/4"X7-1/4"X8' PVC BOARD/ A o $29.92 $59.84 R04 0000-690-012 1.00 EA 3/4"X1 1-1/4"X8' PVC CMPSTE BOARD/ $31.82 $31.82 R05 0000-213-502 20.00 LF 11/16 X2-1/2 PINE WM315 CASING/ Y $1.41 $28.20 R06 1002-961-477 1.00 EA 6"X50'WINDOW& DOOR SEALING TAPE/ A Y $17.97 $17.97 R07 0000-715-499 1.00 RL MULTI-PURP 16"X48" ROLL INSUL 5.3SF/ A Y $5.48 $5.48 R08 0000-734-834 2.00 EA PHENOSEAL ALL PURPOSE WHITE 10.1 OZ/ A Y $5.98 $11.96 R10 0000-934-127 1.00 EA 32X80 RH PREM 9 LT FG IS BM/ A Y $264.00 $264.00 R11 1001-817-591 1.00 EA 32"400 SS WHITE W/NICKEL HDW TRWPAW I A Y $269.001 $269.00 oM I e bg $688.27 DELIVERY INFORMATION: DELIVERY DATE: INSTALLER WILL_SCH INSTALLER WILL DELIVER MDSE TO: SITE OF INSTALLATIO #I IME OF INSTALLATION. INSTALLATION #1 0 01 D ESTIMATED INSTALL BEGIN DATE: 04/11/2019 ESTIMATED INSTALL END DATE: 05/11/2019 **"CONTINUED ON NEXT PAGE*** Check your current order status online at www.homedepot.com/orderstatus Page 1 of 5 NO. H2612-112722 Customer Copy SPECIAL SERVICES CUSTOMER INVOICE - Continued Name: MCCARTHY Page 5 of 5 NO. H2612-112722 TOTAL CHARGES OF ALL MERCHANDISE & SERVICES $1293.28 Policy Id (PI): SALES TAX $43.02 A: 90 DAYS DEFAULT POLICY; TOTAL $1 340.30 BALANCE DUE $0.00 'The Home Depot reserves the right to limit/deny returns. Please see the return policy sign in stores for details.' END OF ORDER No. H2612-112722 _ . Page 5 of 5 NO. H2612-112722 Customer Copy S IAL SERVICES CUSTOMER INVOICE - Continued Name: MCCARTHY Page 4 of 5 NO. H2612-1 12722 "INSTALLATION. #2 1 (Continued) ' REF#102 BASIC INSTALLATION LABOR: SKU y` DESCRIPTION Y QTY n "UM TAX PRICEEACH :EXTENSION $f 0000-114 1 BUILDING MATERIALS PERMIT FEE-NAT/ 1.00 EA N $0.01 $0.01 -442 OPTIONAL LABOR SELECTED INCLUDES: OPTION - `. ` -. DESCRIPTION.w` i. QTY,, UM :: TAX PRICE"EACH F EXTENSION 6 ADMINISTRATIVE FEE/ 1.00 EA N $50.00 $50.00 7 PERMIT FEE/ 35.00 EA N $1.00 $35.00 CUSTOM LABOR SELECTED INCLUDES: OPTION a -DESCRIPTION �`' ° QTY UM I TAX 1,,PRICE EACH > EXTENSION 1 IRURNNER 1.001 MRI N 1 $50.00 $50.00 INSTALLATION SITE NAME" MCCARTHY KATELYN INSTALL LABOR CHARGE: $135.01 ADDRESS: 94 LINDEN ST TRIP CHARGE: $0.00 CITY: HYANNIS STATE: MA ZIP: 02601 CREDIT FOR DEPOSIT/MEASURE:1 $0.00 COUNTY: BARNSTABLE SALES TAX RATE: 6.250 TAX: Merchandise- Y LABOR- N • $135.01 PHONE: 774 9941539 ALTERNATE PHONE: 774 9941539 BASIC INSTALLATION LABOR INCLUDES: ARRIVE AT JOBSITE ON DAY OF INSTALL AND LEAVE WITH CUSTOMER. POSTAGE AND ADMINISTRATIVE). OR INSTALLER.IF DELIVERED TO INSTALLER,THE INSTALLER WILL FEES,ENGINEERING,WIND LOAD CALCULATIONS,RECORDING, PICK UP FROM THAT MUNICIPALITY AND DELIVER TO EITHER JOBSITE *ALL FEES ASSOCIATED WITH OBTAINING PERMIT(MUNICIPALITY *DELIVER COMPLETED PERMIT PACKAGE TO PROPER MUNICIPALITY, SPECIAL NOTES: *CUSTOMER IS RESPONSIBLE FOR PAYMENT OF THE PERMIT.ONCE IN FULL.NO REFUNDS ON PERMIT FEES AFTER 72 HRS.OF PAYMENT. THE PERMIT IS PAID FOR,WORK ON THE PERMIT ASSEMBLY BEGINS IMMEDIATELY.CANCELLATIONS WITHIN 72 HRS.WILL BE REFUNDED END Page 4 of 5 NO. H2612-112722 Customer Copy Home Improvement Agreement: Page 1 Home Depot License Number(s): Home Depot license numbers are listed on page 3, and at www.Homedepot.com/LicenseNumbers DAVID WINSTANLEY Salesperson Name Registration No. (if applicable) Home Depot U.S.A., Inc. ("Home Depot")or Service Provider named below will furnish, install and/or service the equipment listed below at the price, terms and conditions as outlined on this form. Service Provider Contact Information TBD TBD Authorized Representative Name Service Provider Company Name TBD TBD TBD Phone# Service Provider Email Address Service Provider License#(s) Customer Information MCCARTHY KATELYN 2612 H2612-112722 Customer Last Name Customer First Name Store#/Branch Name Customer Lead/PO# 94 LINDEN ST I HYANNIS MA 1 02601 Customer Address City State Zip 7749941539 7749941539 7749941539 1 1 BUTTERFLYROCK7616(?�YAHOO.COM Home Phone# Work Phone# Cell Phone# Customer Email Address NOTICE OF RIGHT TO CANCEL YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY CONTACTING THE SERVICE PROVIDER OR STORE DIRECTLY; EMAILING SERVICE PROVIDER AT: Contact Store Directly ;OR DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 2455 PacesFerry Rd SE Atlanta 130339 Address City State Zip I BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES JA DIFFERENT CANCELLATION PERIOD.THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE.YOUR PAYMENT(S)WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR SERVICE PROVIDER,AT YOUR SERVICE ADDRESS,AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED,ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR RIGHT TO CANCEL. Acknowledged by: 04/11/2019 Customer's Signature Date Home Improvement Agreement: Page 2 Description of Work to be Performed !A detailed description of the work to be performed is included in the paragraph entitled Scope of Work or Specification which is included in this Agreement. V� I Anticipated Delivery Date / Installation Schedule (Approximate Start Date: TBD Approximate Finish Date: TBD All dates are approximate land subject to change based on unforeseen events including inclement weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if applicable. Electronic Records Authorization You are entitled to a paper copy of this Agreement if you choose. If you consent to an e-mailed copy, your consent applies to this Agreement and all subsequent documents and written communications related to this Agreement. By contacting your Service Provider, you may update your email address, withdraw your consent, or obtain a paper copy of the Agreement or ,related documents at no charge. By providing your consent and verifying your email address above, you confirm that you have access to a computer that can receive and open emails and PDF documents. 11 do❑do not❑consent to receive only electronic records related to this transaction. Contract Price and Payment Schedule Payment of the Contract Price is due upon signing unless a different payment schedule is required by law, specified below or in a payment addendum. Contract Price: $ 11297.28 Includes all applicable taxes. Excludes finance charges.* Sales Tax: $ 143.02 (If applicable, total amount of taxes included in Contract Price) I *Maximum deposit ONLY applicable in MD, MA, ME(33%), NJ, WI(99%) Deposit% Deposit Amount $ Remaining Balance $ Finance Charges !Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement, to }which Home Depot is NOT a party, and will be in addition to Customer's payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service Provider may collect Customer's payments made payable to Home Depot. I Insurance proceeds will❑will not❑be used to pay some or all of the total amount of sale. Acceptance and Authorization By signing below, you authorize Home Depot to: (a)arrange for Service Provider to perform any Services or(b)order and arrange for the delivery of special order merchandise, including special order merchandise that may be custom made, as specified in this Agreement.-Do not sign if blank or incomplete. (Service Provider's or permitting information may need to be provided to You later.) By signing, you acknowledge that: (i)You have read, understand, and accept this Agreement in Iits entirety, including the General Conditions and State Supplement, if any; (ii)You are receiving a complete copy of this (Agreement; (iii)all rights and interests under this Agreement are solely vested in the person listed as"Customer"above; and (iv) Electronic signatures will be deemed originals for all purposes. X 04/11/2019 Customer's Signature Date X /s/The Home Depot 04/11/2019 The Home Depot Digital Signature Date Call The Home Depot at 1-800-466-3337 for help. Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constrin ltogrvisor empires 0410412021 CS-074247 { PAUL M DOWNING 25 ALCOTT CIR TAUNTON MA 02180 Commissioner Clt- "i } ' The Commonwealth of Massachusetts Department of IndustrialAccidents : 1 Congress Street,Suite 100 Boston,MA 02114 2017 www mass:gov/dia Workers,Compensation.Insurance Affidavit:Builders/ContraetoraMedzieians/Plumbers. TO BE FILED WITS THE PERWMNG AUTHORITY. Applicant Information Please Print Lesibly Name(Business/Organhm ion/Iadivi&W): N Q fn e 12 c, Address: 9 0% `t kS-�nn Tu rli p i Ke, Citylstaw*: S w/' Nf ' OtS4 S' Phone#: -7-7 4 - _-1 5 - 2, Are You an employer?Check the appropriate boa: _ Type of project(required): LQ i am a employer vhtb`lemployees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees xvorking•forme in 8. Remodeling any capacity.(No workers'comp.insurance required.] 3.�I am a homeowner doing al(workmysa(No workers'comp.kwanee required.]t 1 Demolition ❑ Io p Building addition 4.❑r am a homeowner and writ he hang contractors to conduct all work on my property. Iwill ensure that all contractors either have workers'compensation insurance or are sole 1 I.Q Electrical repairs or additions proprietors wits'no employees. 12. Plumbing repairs or additions 5.9I am a general contractor and ihave hired the sub-contractors listed onthe attached sheet 13.nRoof repairs These sub-cofactors have employees and have worl=s'comp.insurance= 6.n We are a corporation and its officers have exercised their right of exemption perMGL a 14.utter r 152,§1(41 andwe have no employees.[Nowodm&comp.insurance required.] rQ)0/4 G —L Q s-- *Any applicantthat oheoks 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 9p work and then hire outside contractors must submit a new affidavit indicating sue}y_ tContractors that cheektbis box must attached an additional sheet showing the name ofthe sub-contractors and state whether or not those entities bave employees. If the sub-contractors have employees,they must provide their workers'comp.policy comber. I am an employer that is providing workers compensation insurance for my employees. Below is the policy and job site .' information. // Insurance Company Name N�f alJGt (1AiQ/1 1,;&a I/1 Policy#or Self ins.Lic. GAI( Expiration Date: {. — (n lob Site Address: 9 Lih ct/en City/Statezip: Attack a copy of the workers'compensation:policy declaration page(showing the policy number and expwatip date). Failure to secure coverage as r d under MCL•o.152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonFpthis as ell as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. statement may be.forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certifji un an enalties o information provided above is true and correct Si tare - Date:OW A y / Phone#: 3 q Official use only. Do not write in this area,to be completed by city or town official City or Town: PermAUcense# 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#: ;Yak 77?e Commonwealth of Massachusetts Department of IndustrialAccidents Office flnvestigations '^' r= I Congress Street,Suite 100 ; v; Boston,MA 02114 20.17 www.mass gov/dia Worker--s' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):_? Address: JL �C- t City/State/Zip: ¢� �, . ��c- Phone#: L0 7- l�qy y�Z- Are you an employer?Check the appropriate box: El I am a employer with 4. El am a general contractor and I Type of project(required): l. ,� employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2.M 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' [No workers' comp. insurance comp.insurance.! 9. ❑Building addition required_] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 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.]! C. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box rl must also till out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all-work and then hire outside contractors must submit anew 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 atn an employer that is providing workers'compensation insurance for nzy employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: YJ Job Site Address: City/Staie/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 ituprisotunent,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 x LL, e I under the pains andpenalties of perjury that the information provided above is true and correct.._.Si>niature: j 8 - Date.!..__...- Phone#: , Offrcial use only. Do not write in this area,to be completed by city or town.offzciaL 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#: Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improveme tGontractor Registration Type: Supplement Card Registration: 112785 HOME DEPOT USA INC y,u Expiration: 04/22/2021 p P O BOX 105451 d `• ATTN: LICENSE MGMT TEAM ATLANTA,GA 30348 Update Address and Return Card. SCA 1 20M-05/17 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:-`S'fiPolement Card before the expiration date. If found return to: Reaislijiien Expiration Office of Consumer Affairs and Business Regulation 04/22/2021 1000 Washington Street Su' 10 HOME DEPOTS ' Boston,MA 02118 r ANDREW SW - 2455 PACES FERR`C—C'1 HSC ATLANTA,GA 30339 Undersecretary No alid it ut si nature f ® DATE(MMIDDIYYYY) A o 0 CERTIFICATE OF LIABILITY INSURANCE 0210612019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or 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). CONTACT PRODUCER NAME: ' MARSH USA,INC. PHONE FAX TWO ALLIANCE CENTER o t• AIC No 3560 LENOX ROAD,SUITE 2400 EMAIL ADDRESS: _ATLANTA.GA 30326 INSURER(S)AFFORDING COVERAGE NAIC 0 CN101642069-HomeD-GAW-19-20 INSURER A:Old Republic Insurance Co 24147 INSURED INSURER 8:New Hampshire Ins Cc 23841 THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. INSURER C:HomeRisk Ca live Insurance Company 2455 PACES FERRY ROAD INSURER D: BUILDING C-20 ATLANTA.GA 30339 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-004353439-28 REVISION NUMBER: 21 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR'. iADDL'SUR i POLICY EFF i POLICY EXP LIMITS LTR' TYPE OF INSURANCE POLICY NUMBERB MMIDDIYYYY i MMIDDIYYYY A X i COMMERCIAL GENERAL LIABILITY MWZY314574 03101i2019 0310112022 EACH OCCURRENCE S 1,000,000 L DAMAG R N D 1.000,000 CLAIMS-MADE `�OCCUR PREMISES(Ea occurrence) s EXCLUDED X SIR:$1,000.000 i MED EXP(Any one person) 3 PERSONAL ADV INJURY 3 1.000,000 [GENERAL AGGR i S 1,000.000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC PRODUCTS•COMPIOP AGG j S 1,000.000 X JECT J %s i OTHER: A i AUTOMOBILE LIABILITY MWTB314573 0310112019 03/0U2022 iE0�Bi=ISINGLE L T S 1.000.000 X ANY AUTO BODILY INJURY(Per person) j S OWNED ^SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident)'s _. AUTOS ONLY iAUTOS PROPERTY DAMAGE HIRED NON-OWNED i Per accident ` AUTOS ONLY i AUTOS ONLY tg I €UMBRELLA LIAR ;OCCUR EACH OCCURRENCE `~EXCESS LIAR !CLAIMS-MADE; (.AGGREGATE I S S DED RETENTIONS I 1 0310112020 X PER :OTH- 8 i WORKERS COMPENSATION l NC 012717099(AK,NH.NJ,/T) STATUTE i ER .:AND EMPLOYERS LIABILITY YI 03/0/209 0310112020 5.000,000 B E.L.EACH ACCIDENT 'ANYPROPRIETOR/PARTNERIEXECUTIVE OFFICERIMEMBEREXCLUDED? N �NIA E.L.DISEASE•EA EMPLOYEES 3 5.000,000 (Mandatory in NH) 5.000,000 11f yes.describe under Continued on Additional Page E.L.DISEASE-POLICY LIMIT S i DESCRIPTION OF OPERATIONS below C Excess Auto 297110011002019 0310112019 03/01/2020 Limit: 4,000,000 A '.Excess General Liability MWZX 314580 03101/2019 0310112022 Limit: 8,000.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional.Remarks Schedule,may be attached if more space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING C-20 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi MukherjeeauJao'� ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: C_N10_1_6_42_0_69 LOC fl`: Atlanta A�® ADDITIONAL REMARKS SCHEDULE Page z of 3 AGENCY 'NAMED INSURED THE HOME DEPOT.INC. MARSH USA.INC. HOME DEPOT U.S.A..INC. POLICY NUMBER2455 PACES FERRY ROAD BUILDING C-20 ATLANTA.GA 30339 CARRIER NAIC CODE _ — EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Compensation Continued: Carrier:Indemnity Insurance Company of North America Policy Number WLR C65890549(AL.AR.""rL.ID.IA.KS.KY.LA.MS.MO.NE,NM.ND.OK,SC.SD.TN!M/.WY) Effective Date:0310112019 Expiration Date:0310112020 (EL)Limit:55,000,000 Cartier.New Hampshire Insurance Company Policy Number:WC 012717098 (DC.DE.HI.IN.MD,tAN.MT.NY,RI) Effective Dale:0310V2019 Expiration Date:03101/2020 (EL)Limit:$5.000,000 Carrier:ACE American Insurance Company Policy Number'NCU C65890586(QSI) (AL CA.IL.NC.OR%/A,'NA) Effective Date:03101/2019 Expiration Date:03101/2020 (EL)Limit$4,000.000 SIR:31.000.00D SIR for the slates of AZ.CA,IL,NC.DR.VAJNA Cartier:National Union Fire Insurance Company Policy Number:XWC 5565596(QSI)(CO.CT.GA,ME,MI.NV.OH.PA,UT) Effective Date:0310112019 Expiration Date:0 310 1120 20 (EL)Limit:'$4,000,000 31,000,000 SIR for the states of CO.ME,NV.MI.OH,P.A.UT $750.000 SIR for the stale of GA $350,000 SIR for!he state of CT t Cartier:National Union Fire Insurance Company i Policy Number:XWC 5565597(QSI)(MA) Effective Date:03/01/2019 Expiration Date:03/0112020 (EL)Limit:34.500,000 SIR:$500,000 TX Employers XS Indemnity: Carfierlllinios Union Insurance Company Policy Number.TNS C65221019 iTX) Effective Date:0310112019 Expiration Date:0310112020 (EL)Limit:$10,000,000 �. SIR:31.000.000 ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD i Town of Barnstable *Permit#i OCR 7 0&7 ? Expires 6 oaths from issue date Regulatory Services Fee �a Thomas F.Geiler,Director NOV0 -20'07 Building Division ��— Tom Perry,CBO, Building Commissioner TOWN Of--'- BS'A NaTMA 't 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 V � Property AddressE24 " Y� esidential Value of Work /w ` Minimum fee of$25.00 for work under$6000.00 G "(j l ��i A.Vu T(`fQ"5 Owner's Name&Address � y� � '�` 9q Z W� E, Contractor's Name �1M i�6k Telephone Number d _ 36 2 " 3 Home Improvement Contractor License#(if applicable) :ff [ 6 '76-0 Construction Supervisor's License#(if applicable) Workman's Compensation Insurance Che one: Iaam a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Vic "t 3 ! S 3 2 g 6 2 d01")" 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 g e)e LU oio b l e to . ❑Re-roof(not stripping. Going over existing layers of roof) Re-side ❑ 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: P9-/i,70�p operty Owner must sign Property Owner Letter of Permission. y of the Home�Improvement Contractors License is required. SIGNATURE: Q.For n s:expmtrg oa _ rd o rl _ C/z HOME drub 12egu1atiops ��2ax� IMpROyE and Standar l _ Regrstrat. G MENT CONTj=ACT ds O EXprratro' 15p950 R. License or ' n 5/8/2008 hef�re the t egrsha4on v PETER 3 S Type: OgA .., Board of a Ail? atio�,d slid for indivr '. PETER SM/MH Fi HpME 1 MpROV & one AshbBrtoni119 Regglation --Ound re urn to..use only 3925 EMENT r Boston Place and St . MgIN ST. ,11�a,p21 1zm 1301 andards `�- CUMMAQUI 08. MA 02637 I i Deputy4droinistr ` ,tor .�,• Notva t d who utgnature C f ' The Comnionwealth of Massachusetts Department of Industrial Accidents Office of Investigations a ' 600 Washington Street Boston,MA 02111' wrdw.mass.gov/dia ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Le 'bl Name(Business/Orgmn ntion/Individual): r W1 r •Address: �ga s �I � S� sJdN gh(M ( )r p 63 City/State/Zip: C���ufM vl o. "37Phone.#: Sd d 36 Z- 3 sgoF Are you an employer?Check the appropriate bog: :Type of project(required):, 1.El I am a e to er with 4. [] I am a general contractor and I mp y 6. ❑New construction . loyees(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 employees and have workers' working for me in any capacity. $, 9. ❑Building addition [No workers' comp.insurance comp.insurance.t, Electdcalr airs or additions required.] 5. � We are a corporation and its � , 3.❑ I am a homeowner doing ill-work . officers have exercised their 11.[]Pl bing repairs or additions myself.[No workers' comp. right 6f exemption per MGL 12• oof 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 mutt submit a new affidavit indicating'such. tContmotors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have employees. Ythe sub-contnetms have employees,they must providb their workers'comp,polio number. I am an employer that is providing workers'compensation insurance for my employees. Below isthe policy and job site information. Insurance Company Name: ��w� 'J Policy#or Self-ins.Lic.#: C A 31 S 2�_ Expiration Date: 12- d2 lob Site Address: L`t j City/State/Zip: !9 ca/_ !V t S. 04& 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 WA for insurance coverage verification. I do hereby c under the pains•and p4,nalties of perjury that the information provided a ove is true and correct. Si afore Date .Z •6 _ Phone#: Offccial 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#: f tV. , 1HEr Town of Barnstable Regulatory Services a g y yBA MAaSBM . Thomas F.Geiler,Director �p i639• TFo 59+' Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, �dloll ke8ir, as Owner of the subject property hereby authorize L� �'. �� to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address offob) Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. QTORMS:O WNERPERM ISSION I5 ram, Town of Barnstable 01* " Regulatory Services Thomas F.Geiler,Director BARNSfABLE, 9 MASS. g �A 1 39. .0 Building Division rFD �A 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: JOB LOCATION: number street village "HOMEOWNER': 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 su erp visor. 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. Signature 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 persons)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. Q:forms:homeexempt