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Home My WebLink About0109 MAPLE STREET /09 map/ f - 0i KMEA°r ► Town of Barnstable *Permit•.# Expires 6 monfhs jrorrr issrte dale • Regulatory Services Fee BARNS'r.OLF Cal - r«ta.� $ Thomas F. Geiler, Director (P ($Cf �P 16Jy- A1� Ifnr�� Building Division Tom Perry, CBO, Building Commissioner - 200 Main Street, Hyannis, MA 02601 www.town.barnstab le.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not VaIid without Red X-Press Imprint Map/parcel Number < 'Property Address an 1t Y c t Residential Value of Work Minimum fee of$25.00 for work under$6000.00 . ' Owner's Name&Address �� L -erg Tele hone Number `�� ' 7`JG Contractor's Name P Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance -PRESS PIT Check one: ❑ I am a sole proprietor S E P t ,AS�2009 K I am the Homeowner ❑ I have Worker's Compensation Insurance TOWN OF BARNSTAB3 E 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'I`/ 56 7 Replacement Windows.,U-Value (maximum .44) U/ W i-)do-('LlS *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. Home ImprovemlCo ractors License&Construct Supervisors License is required. .SIGNATURE: Q:\WPFILES\FORMS xpress\EXPRESSPERMIT.DOC Revise060409 'Y A The Commonwealth ofMassachctsetts Department of Industrial Accidents ., Office of Investigations 600 Washington Street f. Boston MA 02111 �s www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers licant Information Please Print Le ibl Name (Business/Organization/Individual); 7�) e Address: City/State/Zip: c A Phone #: Are you an employer?Chick the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. employees and have workers' Y P Y• 9. ❑ Building addition [No workers' comp. insurance comp. insurance.1 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 13:0 Other' comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have. employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and the pains and pen ties f perjury that the information provided ab ve is true and correct. Si nature: Date: R Phone M 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." 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: 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-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia A M, THE Town of Barnstable Regulatory Services 9� IE * Thomas F. Geiler,Director Fo;a. 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 Property Owner Must Complete and Sign This Section If Using A Builder I, , as er of the subject property hereby authorize to act on my,behalf; in all matters relative,to work au rized by this ding permit application for. (Addres of Job Signature of Owner Date Print Name . If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS D WNERPERMISSION t Town of Barnstable �FIHE Regulatory Services snxrtsmim ; Thomas F.Geiler,Director ` AW Building Division rED MA't 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: UC, num er rr street r� village "HOMEOWNER": Q�v� name home phone# work phone# CURRENT MAILING ADDRESS: a,,Vn M_ -e S city/town I 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 requireme s. �Z Sig a e 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. Q:\WPFILES\FORMS\homeexempt.DOC 0 Ot THE Tp� Town of Barnstable *Permit# 1 ` Expires 6 ionths rroMissue date Regulatory Services Fee ?> + BARNSTABLE, 9pO 1639. `�� Thomas F. Geiler, Director ,olFD MA'S A Building Division pf? Tom Perry,CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us 01'fice: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint -map/parcel Number I �� PrZ., Address dential Value of Wort, Minimum fee of$25.00 for work under$6000.00 Owner's Name &Address vsV `�' r'V rook lop 3� K'j / ii / p SQ9'�19 �1t� "\ Contractor's Name J a.md' t(IV)? � r 1� , ��f�!!"i. . Tele hone Number I'lome Improvement Contractor License# (if applicable) y� Ta ;�C 6�j C.'ons uction Supervisor's License #(if applicable) orkman's Compensation Insurance -PRESS PERMIT Check one: YElarn a sole proprietor JUN I the Homeowner ve Worker's Compensation Insurance . TOWN QF BARNSTABL Insurance Company Name 441 C� Workman's Comp: Policy#}_ Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers_of roof) ❑ Re-s eplacement Windows/doors/sliders. U-Value (maximum .44) - " "Where required: Issuance of,this permit does not exempt compliance with other town department regulations, i.e. Historic,Conservation,etc. 'Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. SIG'NATt1RE: PI-II.I.S\ 0l S\huilding permit forms\EXPRESS.doc Revised 100608. ' APR-24-3009 18:36 HOME DEPOT HYANNIS P.001 HOME LAPROVEMENT CONTRACT' 'PLEA$E READ"THIS ^�� Sold,Furnished andllnstalled byt ."t^ Branch Namc:'Boston, At-Hcmt•.Sjervices,Inc: J d/b/a The Iiotne Depot-At-jjC,mc Services Branch Number 34�A Greenwood Street Unrt,2,•Worcester,MA 0.1607. Toll•Free,(800)657-5182 ,Fax(5CI18)75,"823, ONorth 33 puth 31 Pedecal ID#75-?69ii460;M>r Uc ftC 024,9;Ri Cont.Ltak 16427 "CT Cis#565522;M,L ornc improvement Coitlractor']teg:"#126893 Installation Address: ity State : Zip. Purchaser(s)r Work Phone> Home phones- Cell T'heaM t . 'Home Address: (If different 1Yom L>ctallation Address): City.._. State:: Zip E-nruil`.Address(to receive project conimunications'a id Hoiiie.Dcpot•update.$):. •-- ❑1 DO NOT wish to receive any marketing ern ail lrvm'The'Home Depot Pro'eei Information: Undersigned('.Customer the owners oftbe property located at the�tioLe installation address agrucs'to buy, and THD At-Home Services,Inc.("The Home Depot")agree§io'fdnnsh;deliver and•arrange-for the.installation("installation")of all-materials described ou•the•below.and.on•tlie..rc(;=nced rSpee;Sheet(s),.all of.Which-,gq,jncorporated into;this,C.ontract.by.this reierencc,along_with.any.applical?le,St"ate,Supplement md,Payme'ILSumnvuy attached hereto,and.any CYiutge Ordelis..(col)vctrvely, "Contract!');, ,lobe#: (t.ie lRef—to)' P ducts $ ee Sheets #:. Pro'eceAmouut. „ RiSting Siding Windows' Insulation (�J � � []Gutters/Covers j]hntry;Duors ❑ O. ^3 .L�:.� $ y�l ... Roofing EISZZ, U.Windows Lj insulation, " $ QGuttcrs!Covers ❑Entry Doors Ell Ca Roofing. Sidu�¢•, W.indows..". Insulation $ QGlittcrs'/Covers�QEntty Doors - Roofmfi:' Siding= Windows •`lnsulafion, ' t : • 'OGuitcrs/Covers❑Entry.Doors ❑ � . Minimum25%DepositorfioutractAmountdueuponexecutionofthiseoo"ct TotaFCdntract'An]ount $ Maine Purchasers may.not deposit more-than one-third,of the Coutnctrlmount.„ G� Custi�tuer.a roes that,inimecliately..upon completion,Pf the*ork for eac),1_PlQduct�,Customer wi11 v�cefite a Compla`trori Certificate (onc.tpr each:l?oduet is defined by::ul:individil-1 Spec Sheet):utd:.pay*my balanee:due.':A,c:ipphea)ile;•c:ach,Custlamcr under this Contract:iigrees to tic.jointly aitd Sc.t�zrally oliligated,and liablc'hereutider_ ' I The Hume Depot reservc3:the rightto issue a Chatigq.-Ordet;,or•terminate i1,iw Contractor any individual;Product(s)-inrsludedherein,at its discretion,if The Home Depot or its authorized service provider determines that,it cannot pertormiits,obliga ons dti',le.to a.strucWral . problem:with,the:home,.eavitonmental ba•,ards such.as.mold;asbestos or lead aint,Ether,safety,conccros,_pricing Errors,or.bccause work required to complete the job was.not included in.die Contract. ( ;, Pa meat Surnma . The Payment Summarf,#' :1'} - -b jTichtded'.as•partlof this.Contract„sct;k forth IUe total Contract amoitnt"urd a eats-re'cjuired;for tlic'de 'sits'.and'�fina'1' ,i Debt,, b•Product as a', licable. p Ym Po . P Yt Y ( ' Pp ) NOTICE TO;CUSTOMER You'are entitled'to•a courpletely`filled-itir copy of the'ContTact ntthe I' " you ugn: `Do'not sign a Gornplehori Gertiticatc(note: there is one Completion Certificate for each listed Prodoct•as dcffi1W=hrindividuai Spce.Sheki)'-before workonJOat Product is complete. In the event of temination of this-Contract,Customer agrees to pay The Horne Depot the costs of materials,;labor,expenses and services provided by The Floine Depot or Authorized Service Prodder through the date of termination,plus any.other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT NlAY�WITHHOLD iWOUNTS OWED TO THE HOME'DEPOT POT FROM TFE. DEPOSIT.PA_j7MF.NT'OR OT'FI'ER PAYMENTS lMMAl11E, WITHOUT LEVIITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acecutance and Authorization:...Customer agrees and underst ads that this Agreenierlt is the entire agreement between Customer and The Home Depot.with regard to the Products and Installation services and supersedes all Prior discussions and alp•ccments,either Oral or written,relating to said Products and Installation.This Agreement cannot be assigned or antendcdexcept by:a writing signed by Customer and 17nc Home Depot.Custorer ack-c ledg .rd agrees that.Customer hats read,understands.voluntarily accepts the tc.rn,s of and has rcotived acopy of this Agreement. c by; Submi by: Cus m 's.Signatur. Date Sales Con uhant•s S' nature Date . ., Y Telephone No. L�5 CustolDWS Signature Date Sales Consultant Liccnse No. CANCELLATION: CUSTOMER MAY CANCEL .THIS (.ts applicv.ble) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE TtIMD BUSINESS DAY AFTF R'SIGNING TffIS ACREEMENT- TffR STATE SUPPLEMENT ATTACI•IED HERETO CONTAINS A FORM TO USE IF ONE 1S SPECIFICALLY. PRESCRIBED BY LAW IN CUS CiMER'S STATE. I. NOTICE:ADDITIONAL TERnt$A!YD CONDITIONS ARE STATED ON r11E RF.VERSE,'S1UE AND ARE PART OF THIS G:pVTRACr ' nti,r0 ^ct:o��s:Fila•.:XellowwCUstoMerf'Pink Sales Consultant WINDOW SPECIFICATION SHEET - Spec. S ee4#: Q 6 0 Sh"t [ of / Customer: _ �� _Job9: ! Consukant: � J Date: 10-17 New Window 37 ExlslingWindow Labor 4wtaceuan. 10 ►Aeasurementa Grids Product Options. Optlona Frorn—tslk,Left to RiaF i C Bays,80'xa,CSmnts,' . .Color Rw gh Openloq F o}Darr i of bars t Pnl,use t-R or S r Localion. 1 _ O -- °m GIs,Hardwr,Screens, Misc hems Mull Code E � - For� .o.,-s-•wcmrr Wreps Style Series T¢ .. �. .y .. - e.�z-•or,rn;,�. C Room floor styte Code - (YIN) Code Code .Wi dth HOOKW r'- c°� ¢_. >` -' •a = - Q7 :J C- r x 0 C17 a 'h s 0 H s x • y z 6 - z r 6 . SPFt CONSIDERAT10 Wrap color - - - _ U Interior CasUg Type _ ` _ �J K Bay or Bow window; Seatboard Material:(vinyl only-Birch or ook) Say Projeeuon Angle(30'or45°] - Bay Flanker Typo(DH,Sff or Csrnirlj Top of window to soffit(Inches) - 1.1 _ If Tied to soffit,color of soffitnmaterfal !have revievred and agiee with all the fob specHlcations above and the' Construct Roof(Yes or No)t Sp I Terms and Condkio f on the track of the yellow(Customer)Copy.' - - Garden Window:. - - - - - SoaWoard 6taterlet:(vinyl only-White Picnka, Bi - �- Cualnrt�er S:g.anre Weil TMckrress,QnChas) O Additional Shelf(Yes.or Nod PJ 9.There is ro gic'ryrCe31ha1 n cr shir.�rs nil mairJt end siry cNo. SFGYi','Yi i-02-CC Write-the Hone Dc9ot Yslox-Cuvs r Pink-Salmi CorsUFri'S THD-tad f r --A _.. . The Common►+'ealth of.. :-- vachusetts Department of Industrial Accii ��!s Office of Investigations 600 ff'ashingfon Street Boston, ;i ! 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):_ 'i f Address: ' U . r Phone#: ;�; _ �_.(✓'�'Lf City/State/Zip: 1/tWztcL Are�u an employer?Check the appropriate box: Type of project(required): 1.L, 1 a a employer with S w ❑ I am a general contractor and I b ®Navy, nstnaction loyees(full and/or part-time).* have hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet. 7. modeling / These sub-contractors have g• ❑ Demolition , �/( ship and have no employeesemployees and have workers ,i working for me in any capacity. 9. ❑ Building addition comp.instirance.t [No workers' comp.insurance 10.❑Electrical repairs or additions required.] 5. ❑ We are a corporation and its . 3.❑ I required.] a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions right of exemption per MGL 12.❑ Roof repairs myself. [No workers' comp. c. 152, insurance required.]t workers' 13 ❑Other employeees.es. have no ([No woork and comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy infomlation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors neat 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 th provide their workers'corm•policy number. employees. If the sub-contractors have employees, ey must p - I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: / L Expiration Date: tv C Policy#or Self-ins. Lic. #: p �d� co Job Site Address:- CityfState/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 MGv I enhies i.n the form of a STOP WORK ORDER n lead to the imposition of crlm�inal penalties nd of fine fine up to SI,500.00 and/or one-year imprisonment,as well as ci t p �5 .00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of of u to$'2 0 Y g p - investigations of the DIA for insurance coverage verification. /do lterc'h1'c" • 't :der the ins art naltie.s of perjurl'that the is formation provided abort is trace and cor ,c f• ---- Phone : ------ ----- — — ----- Offccidl use only. Do not write in this area,to be completed by tit}or town official. Catty or i own: _._-----_..__.-._—�_._ -------___. PeritutlLicense# _—_.--_._.._------------ -- - --- - Issuing Authority(circle one): 1. Board of health 2. Building Department 3.City/Torun Clerk 4.Electrical inspector 5. Plumbing Inspector b. Other Phone Contact Person. — #: _ lgg sn0108 THIS CRATIPICATIS IS ISSUED ASA MATTER OF INIFORMATION ONLY PRODUCER AND CONFERS NO RIGHTS UPON THE CKRTI6[CATE HOLDER.THIS EARRELL BACKLUND INS AGCY CERTIFICATE DORS NOT AIMISND,EXTEND OR ALTER THE COVtUCR 128 DEAN"STREET/PO BOX 509 AFI70"ZD BY THE POLICIES BELOW. AUNTON,ILIA 02780 COMPANIES A.FFORDLNG COVIERAGE COMPANY IN-A 13?TTrR A ZURICH A ERICAN INSURANCE COMPANY CCMP,INY LETTFZ !NSURED COh+>aAt;y C R&R DELIVERY SERVICE INC LET= 740 GLEBE ST i�rTER Y IO TAUNTON,MA 02780 `° E mom T'd13 IS 1'0 CERTIFY TWAT THIE POLICIES OF INSUDANCC LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TIIC POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIRIiIMENT,TERM OR CONDITION Of ANY CONTRACT OR OTHER DOCUMENT WI'1')i RiimcT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,TIM INSURANCE AFPOIIDCD BY THE POLICIES DESCRIBRD H FRI;IN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONP-11—ION3 OF SUCH POLICIES.LIv11TS SHOWN MAY HAVE BEEN REDUCED BY PAID CI,A)MS co TYPE OF INSURANCE POLICY NUMBER POLICY POLICY LIMITS LTR rFFFA,nVE DATE EXPIRATION DATE MM/D MMNI7/YY) GENERALLIABILITY aRHffiALAGGRHOA.TB S 000MMFRCIALOEIIERALLIADI.ITY PRODUC'fSCOWIOPA00. S 0 MAW MADE, i OCCUR PERSONAL A ADV.D MMY s 0 OWNER'S&CON11ACTOR'SPVT, 9ACfj OCCUMLINCIS 3 (j — __ FIRSDAMACB(Any OeeFire) S M8D BXPBN56(Any odouroon S AUTOMOBILY.LIABILITY COMH!Nt:D SINOLb LlMlr 3 LI ANY AUTO 0 ALL OWNID AUTOS ROOILY INJURY g (PaPmoc} U scmuLtn autos U I4R8D AVtO3 BODILY no my S Gcr AcddoaO ' 0 NON-OWNED AUTOS U OARAC%LIABILITY PROPERTY DAMAGE S Q FXCRSS LIABILITY LI UMIDRPLLAFORM EACH OCCURRENCE i p OTH>RTHANUMUMLAFORM S 6ZZUB3237BS2 06/19/2008 06/19/2009 STA110 RY LIMITS -2-08 WORKERS'COMPENSATION PACp nCGIDSN7 "—`— 5100 000 A AND)sMPIAYER'S LIABILITY DISSASS-POLICY LWIT SS00 ODO 7hc SOIc Pnprietorftnoe6YEx9cu6vv Offices sync:INCLUD $100,000 OTHER 7-1 DESCRUMON OF OPE>IATIONhJLCCATIONSIVEDICLENPL'CUL ITu(v15 MIS REPLACLC ANY 18108 'RTIPI TII ISSUED TO THP CgMVWATE HOLDER AFFECTING WORKERR(:OMP C:OVRItkCE i Ell, .1 NAM TI DATHOMESERVICESINC SBOULD ANY OFTF4TIAI;OYgPBSCEIBED POLICIES BECANCELLIM6rtF`016ut;TIIE DBA THE HOM E DEI'pT AT I IOMB SEIZV ICES ISSPEIATION DATE TDESIEOP,Thk IMOVIKC COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WR117414 NOT105 x0 TIM CERTIFICATE]IOLDER NAMRb TO US LEFr, 3200 COBB CALLERIA PARKWAY SUITE200 BUT PAILVKK'rDNAIL SUCH NOTICE MAIL IMPOSE NO ObLiCATION OR ATLANTA,GA 30339 1AABILITY OFANY KIND UPON TNIt COMPANY,ITS ACBNTS OR REPRESEI,TATIVFS AVMOR=RCBRR5 MATH wn e . 4 YN I �1�ke,fASa ' The Commonwealth of Massachusetts' Department of Industrial Accidents Office of Investigations -600 Washington Street Boston,MA 02111 ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrician sip luinbers Applicant Information Please Print Legibly Name(Bus iness/Organization/Individual): 1�1? Address: ( U C% Lr�i'c-Z City/State/Zip: w5_� Are you an employer?Check the appropriatVI Type of project(required): �' 1.0 I am a employer with 4. m a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El N7 construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. emodeling ship and havee , _ _. . _no employees_. These su -_. ....... b=contractorsave h 8. ❑Demolition workingfor mein an capacity. employees and have workers', Y p ty� 9. ❑Building Laddition . [No workers' comp. insurance comp. insurance.$ required.] - 5. ❑ We are a corporation and its ME]Electrical repairs or additions 3.❑ I am a homeowner doing all work'- officers have exercised their I I.❑Plumbing repairs or additions myself o workers' com right of exemption per MGL y [N p. 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. rs I am an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site` information. . I . � . V - , . I I . Insurance Company Name 0S S Policy#or Self-ins.Ltc,y# ' .> 10 9l Expiration Date:` -j 1 j 1 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 may,be'forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thepains and penalties ofperjury that the information provided above is true and correct. G �-N-0 2 Signature• Date. — Phone Official use only. Do not write in this area, to be compleled.by city or town official t Y 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#: a License or registration valid for ind�idul use onl / (fi �ie �arr��u%xu�ea a�� aaa�cCZ`before the expiration date. If found return to: Y `3-\ Board of Building Regulations and Standards i Board of Building Regulations and Standards . HOME IMPROVEMENT CONTRACTOR 'I One Ashburton Place Rm 1361 ;t if Boston,Ma.02108 I� - Registr,ton 126893 E ation' 8%3/2010 f' TYpe :Supplement Card The: Home Depot At Home Service DARREN DEMERS x E h' 3200 COBB GALLERIA PKWY>#20 Not valid w ttl out signature ' ATLANTA,GA 30339 •,•.. -., _ Administrator 1 ' -• - „n•,. r�.u,�::::: ....,�_,a — �1,l..ailiu�i'!!• tflf l'ui)lic � !fi•f� Bnartl ullihln Ili ul rtlnn,-tnr1 �tantl lrtl of l3 L.cerise: CS 51899 Restricted t,Y 00 p.,. TIMOTHY M THOMAS .- 740 GLEBE ST TAUNTON, MA 02780 ' �y Expiration: 2121/2011 Tr-: 12144 ��e Fc.�n rna.:,uc wal crf i �a ar�i ccefQ ; y -`• IIoartl of ii•'•'d:id R`—ilstions r.:,. "ts License or regt iration valid for individul use only before the expiration date. if found return to: t; HO, E IMPROVENt Board of Building Regulations and Standards Registration:'152121 One Ashburton Place Rm 1301 j Expiration:. 8/112010 r 272597 Bosto'ii,ma•tr,"<1Q8 Private Cc.;.:r�• ,n Type: . R g R DEUVERY SERVICE, INC. TIMOTHY "!.HOMES 1009 POST ROR-D Not valid)without signature WARWICK,fl `L288 ...:..s: .. r_ - •. r' . ... a r. A. 6 0 3 �91 t, , T Town of Barnstable *Permit# 3� �P�pF �{•�� _ ,Expires 6 mondu front issue date b Re ulator Services Fee . • g Y v K'SS• Thomas F.Geiler,Director s6gq• �0 �ArFo►��A Building Division Tom Perry, Building Commissioner X.pRESS PERMIT 200 Main Street, Hyannis,.MA 02601 Office: 508-862-4038 JUN 6 = 2003 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENjA6kjQARNSTABLE Not Valid without Red X-Press Imprint _ n A Map/parcel Number 4 Property Address [Residential Value of Work Owner's Name&Address Contractor's Name / e G(/1 9:. Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance ' Check one: iQ, I am a sole proprietor a.i am the Homeowner have Wo rker's Com ensation Insurance Ih P „ s Insurance Company Name ' Workman's Comp.Policy# 7. permit Request(check box) i y C [/Re-roof(stripping old shingles). ❑Re-roof(not stripping• Going over existing layers of roof) ❑ Re-side r �❑ Replacement Windows. U-Value (maximum.44). El Other(specify) P. f' *Where re uned: Issuance of this,permit does not exem t compliance with other town department regulations,i.e.'Historic,Conservation,etc.:,- z Signature Q:Forms:expmtrg Revised121901 �'