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HomeMy WebLinkAbout0029 REDWOOD LANE z �, z ___. I � � c coo ��}v � 9ARA;S T�9, a INSULATION 7617 V-D12 l j ®® -MOW5 St4u" SPpA►N" 395ra M cuum 1-800-696-6611 Rik,r Town of Barnstable Regulatory Services Building Division 200 Main St n / Hyannis, MA 02601 Date: Dear Building.Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc.performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal& State Requirements. Property Owner Property Address Village 1411j 25 )&,&& d lane, 4a'n4 ics Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings ( ) ( ( f ) ( ) ( ) Slopes ( ) ( ) ( ) ( ) ( ) Floors ( Walls ( ) ( ) ( 13 ) ('X ( ) Sincerely He E C Lidy r, President Ca a Cod ation, Inc. r• ,p " TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map p b Parcel \ Application4�96 )2/b-0 Health Division Date Issued D-:-) ( Z Conservation Division Application Fe Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address L;A,� Village Owner �7o e 11 Address _5 Telephone cli',z -.2 `3 7 Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation o :V Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family .9 " Two Family ❑ Multi-Family (# units) 25_ Age of Existing Structure Historic House: ❑Yes a'No On Old King's Highway: ❑'_�-Yes No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other ^4a Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) + =' Number of Baths: Full: existing new Half: existing new F i� Number of Bedrooms: existing —new 3 Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stover ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use l APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name C'D� J ��� �� Telephone Number Address Z g>,_a 4010.5 License # PI-7 !o 1 '�-,-__� Home Improvement Contractor# ./�� Worker's Compensation #4,1614D 3""2,t, / ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE V sx FOR OFFICIAL USE ONLY : t APPLICATION# l DATE ISSUED MAP PARCEL NO. ADDRESS VILLAGE OWNER it • { ` DATE OF INSPECTION: ; it FOUNDATION FRAME ' INSULATION t if FIREPLACE j= ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL 4 GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. Y{\ n jw,0;;k 1r, i ic 10 Park Plaza - Suite 5170 - Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 153567 Type: Private Corporation Expiration: 1 211 5/201 2 Tr# 206433 CAPE COD INSULATION, INC HENRY CASSIDY ------- -- --- __... -. ..-• - -- _ ___ 455 YARMOUTH RD. - - - HYANNIS, MA 02601 ;Update Address and return card. Mark reason for change. El Address C_:I Renewal I- I Employment i--I Lost Card 8-CA1 0 yom o4/04-G,oiri6 OfficrJ o�sumer Affairs taus ne f2egul�ation License or registration valid for in. ividu! ::se e^.!; �` fi�uJedGi before the expiration date. 1f found return to: HOMEP6�AE `fJ"(e��IVI` A Registration: 153567 Type: . Office of Consumer Affairs and Business Regulation ' Expiration: 12/15/2012 Private Corporation 10 Park Plaza-Suite 5170 _ 41 Boston,MA 02116 OD INSULATION;'INC HENRY CASSIDY 455 YARMOUTH RD. HYANNIS,MA 02601 --� Undersecretary t slid ith t si ture \lashachusetts-.JI)Cp trtincllt llf Pul)lll' Sal'eh Boar(l of Building„ Ro„ulations and Standards' 4onstructiort Supervisor License LicLnsa: CS- 100988 HENRY CASSIDY 8 SHED ROW WESaT YARMOUTH, MA 02673 Expiration: 11/11/2013 Tr#: 7620 Z. LV I Z rivi No. 1605 P, 1 Client#:4597 CCINSUL ACORD,,, CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER?THIS Z 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[$SUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT:If the certlNcate holder is an AbDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and Conditions of the pollcy,certain pOlICles tray ruquil u an endorsement.A statement on this certificate doer not Confer ri [its to the Csrtlflcate holder in lieu of such endursement(s). 9 PRODUCER CONTACT Rogers&Gray his. -So. Dennis NAME: Margaret YoUn PHONE F --,--�_ 434 Route 134 Arc No Ekl:508 760 4602 Arc Ne. B17-816.2156 EMAIL South Dennis, MA 02660-1601 506 398-7980 INSURER(9)AFFORDINU COVERAGE NgIC H INSURER A:Peerless Insurance 18333 INSURED y -- Cape Cod Insulation(no INSURERS:Evanston Insurance Company 455 Yarmouth Road INSURER C:Atlantic Chatter Insutance Hyannis,MA 02601 INSURERD:Commerce Insurance Company 34754 INSURER E: INWRER F: COVERAGES CERTIFICATE NUMBER,' REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTI=D IJELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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. 9 TYPE OF INSURANCE ADDL SUER POLICY EFF pOLItV El( POLICY NUn+OER MMIDONYYY MMJDDNYYY LIMI7s A GENERAL LIABILITY CBP8263063 4/0112012 04/01 J201 FACH OCCURRENCE $ QQQ QQQ X COMMERCIAL GENERAL LIABILITY Ra�Cgj� ENTED $100 000 IS a occurrence CLAIMS-MADE OCCUR MEDEXP(Any one p9mon) $5000 PERS0NA49cAOVINJURY 11000000 GENERALAGGREGATF $2,000,000 GEN'L AGGREGATE LIMITAPPLICS PER: PRODUCTS--OMPIOP AGG 12 000 000 POLICY JPCT PRO LOC Q AUTOMOHILE LIABILITY 12MMBCKvMK A101 J2012 p4Jp1 J201 COMBINED SINGLE LIMIT 1000000 000 000 ANY AUTO BODILY INJURY(Per Person) ALL OWNED X SCHEDULED _ — AUTOS AUTOS - BODILY INJURY(Per A ddenl) 5 X HIR X NON-OWNED PROPERTYOAMATD S B X VMURI LLA LIAB OCCUR XONJ453512 041010012 0410112013 EACH OCCURRENCE $1 000 000 EXCESU L.IAB CLAIMS-MADE $1,000,UU0 AGGREGATE OEO X RETENTION 10000 C WORKER.COMPENSATION $ AND EMPLOYERS'LIABILITY WCA00525902 6/30/2012 MOJ201 X WCSTATU. OTH. ANY PROPRIE7O{�PgR7NE !''�CUTIVP YIN E,L,EACH ACCIOkN1" .1 OOO OOO OFFICERIM�M9ER ExCI UO R � N I A (MendeWry a It yen,daee6he uandnder E.L.DISEASE-EA Gk4PLOYEE $1 00O 000 DESCRIPTION OF OPERATIONS hein. _ E.L.DISEASE,POLICY LIMIT $1 000 000 OESCHIPTION OF OPERATIONS I LOCATIONS)VF141CLES(AL(aah ACORb 101,Addhfmr j A.m rks 8�h@dulp,It pI0P0 BppQ.16 rowAlrod) "Workers Comp Information.d Included Officers or Proprietors Certificate Holder is Included as an additional insured under General Liagility when required by Written contract or agreement. CERTIFICATE HOLDER CANCELLATION Cape Cod Insulation,lnc r SHOULD ANY OF THEABOVE DESCRIBED POLICIES 6E CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL 13E DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ®18B -2010 ACORD CORPORATION.All fights reseryed. ACORD 25(201U/05) 1 Ot 1 The ACORD name and logo arcs raglslared marks of ACORD #$83849/M83848 MEY The Cornrnolnic•rrlth vfMdssachusetts I' Departrnetit of bidustrial Accidents Office o/ (rt vestigations — - — a boa VV(-shington Street Bosr.ol,!, AAA 02111 wwl l .lilt lss.gov/dia Worker's corttpeusatioll Insurance Aftia.a,it: Builders/Contractors/El lectricians/Plt►tubers `pplicant Information Please Print Legibly Nantc (Liu�itiirss/Qr�,ani�ation/l.nclividu�ll): � r _.. Ct� --= �G' alr �_L'�] �� Phone#: ' —t_ Arc vtru an etployer? Check the appropriate box; Type of project(reyuired): I. l ant a cntployer vvith_._._ .._._ I am a;;rnc r:,l contractor and I have 6. ❑ New consttuctian r.ntpluyres (Fail and/or part-tirile). hired thee---contractors listed on 7. Rerncxlelutg the attachc:,.l�.heet.$ I aun a salt:proprietor or partnership These sut, c,.ouvactors have $• Demolition have;nt:r ctnployi es working For employc<s:aid have workers' comp. 9. building addition mr in any capacity. (No workers' insurance.': Cutup insurance rccluire(l.] 5. We are❑c ,iporation and its 10 Electricat repairs ur additions 1 officers Baer exercised their right of IL Plumbing ietrurs ur additions houleowuer doing all work exemplic,u twi. MGL c. 152 5(4),and 12. Roof repairs nly,srlF. INn workers' comp. we have ilk,employees.[No workers' nsurance rec uiri d._ 13. Outert comp. insur:uice required,] lC Anv apph aiu that checks box #1 roust also fill out the section below shown" llw�ir workers'compensation policy information. tt„nici,:vncis who submit this affidavit indicating they are doing all woilc and ibcu hire outside contractors must submit a new affidavit indicating such. puutiitu 5 that check this box must attach an additional sheet showing dw woi,of the sub-contactors and state whether or not those entities have empliryees.It tiic sub-lsmtracWrs have employees, they t"❑uSt provide then'workers,Couip pol,cY number. 1 ara an employer that is providing workers'cornpensation irrsrc,a ice for my employees.Below is the policy and job site lu>urancrC'ornp1- nyNrU1"te: , .0 l.) MlAe•e Policy ti or.Sell-kas. Lic. #: AWCA 1�� C `' I �t= Expiration Date: 2j,:,-1 .lob>Itr..Address: ._ __--- City/State/Zip: Attach a copy of lire workers' compensation policy declaration page(slowing the policy numher and expiration date). I ailuic to securc covcrago as required under Section 25A of MGL c. 15':;,,i Icad to the imposition of criminal penalties of a fine up to$1,500.00 and/ur our-year imprtsunrnen[,as well as civil penalties in the form of a STOP W t tkK ORDER and a fine of up to$250.00 a day against the violator.Be advised h:,t a :spy of(his statement rna e forwarded to the Office of Investi :ui„ns ut the DIA for insurance cuverugeveril'ication. I do here c if under the ins and penalties 0j'perjury that the information provided above is true and correct. Si�nalurc: , Date: I'fu.me#: Official use urtly. Do riot write ire this area,to be completed bY city or town official City of-Town: — Perinit/License# Issuing Authority (circle one): I.Hoard of Health 2. Btidding Department 3.City/'loon Clerk 4,Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: _ Phone#: OWNER AUTHORIZATION FORM (Owner's Name) owner of the property located at Z 7 Redwood (Property Address) �/v �•+n:s, /Ll 2 6�/ (Property Address) hereby authorize QGt, , (Subcon or) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. Owner's Signatupd Date _t oF1�r� Town of Barnstable P� p Expires 6 mo hsfrom issue Ye } Regulatory Services Fee ■ tARNsrABLE, + 639 ��� Thomas F. Geiler,Director Building Division , Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid with ocrt Red X-Press Imprint Map/parcel Number l. Pro rty Address 9 W00 /j/ 11//Uts c ][Residential Value of Work - � Minimum fee of$25.00 for work under$6000.00 �,/ n Owner's Name&Address 14 P1 S�7/Ia e Contractor's Namee/Tr "I G�sp, 0 re'c'S T leplione Number,�0 X9 C, T Home Improvement Contractor License#(if applicable) T . Construction Supervisor's License#(if applicable) /00s-yVc clew"Orkman's Compensation Insurance -PRESS PERMIT Check one: t ❑ I am a sole proprietor AUG 2010 . ❑ Vm the Homeowner I have Worker's Compensation Insurance 'OWN OF BARNSTABLE Insurance Company Name New 7AI Workman's Comp.Policy Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of r000 ❑ Re- ' e .. #of doors Replacement Windows/doors/sliders.U-Value 01 3<__S (maximum .44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License& Construction Supervisors License is requir SIGNATURE: _ Q:IWPFILESTORMSlbuilding permit forms\EXPRESS.doc The Conrnzo.nw'eaRl,of-i<l:cssachuseas ➢eparimVit of Tnllustrial Aceide:tts Of �e of jlivestibatimis (61l! yl<`tiSiitliyatoli.Sirepi a of 1 -- n Y'?ti,til1lSS.h Lftiliiit! Please Print Leoibih �IecirioiarsiPlttn< ers ~v,` r§' Cosnpensat3ois li3surance .xMdai°it. BulltlersiConitastorsf Wort e a :, licant ltaf��liration , � �f dame (B1isine5si0rea11tzatt0,ir'ht?d Address: ? — Phone#-. e of project.(required); Type Cih $tateiZip: rate bo 'p Are you an employer?Check t t p��4. atr a gztzral contractor and 1 b construction l. 1 am a employer w ith —wa have hired the to ' 7 Remodeling 4 employees(Tull and:=or part-time).* listed on the attached sheet. 2. t am a sole p' Q These sub-contractors have 8. []Demolition to rietor or partner- 9 Building addition 1 ship and have no employees employees and have workers' � r working for me in any capacity. comp.insurance 1p 0 Electrical repairs or additions (.o workers' comp.insurance 5 �4'e are a corporation and its 1 I plumbing repairs or additions required.) officers have exercised their exemption er iviGL 12-0 Roof repairs 3,❑ 1 am a homeowner doing all work ,•;cht aT P myself.(1`o a orkers' co+rp �t52.t1(4),and we have no 13.0i. Other_____ 'i insurance required.}+ employees• [No workers' corn) :nsurance required.} ticy information. ensatiot,po •qny applicant that checks box#l must also flit out the section below showing th`n ire outside co tract r and state whether or not those entities have affidavit indicating they are doing all work anedna nehtre ontstde convact°rs must submit a new n€fi rhos indicating such. Homeo«.ners who submit this lit Lumber. Contractors that check this box must,nached an addaiona!sheet showtng t employees. Below is the policy and job site employees. If the sub-contractors have employees,they must provide their workers'comp.Po Y r oviding workers'compensation insurance for my I am an employer that is p' �'" O = information. N` Expiration Date: Insurance Company, Policy#or Self ins.Lic._: LA-1 ' _/ City,StateiZip: ®� — er and ex iration date). t lob Site.Address: page showing the policy nu Of the workers' compensation policy declaration p g .Attach a copy' �in the tone of a STOP WORK ORDER and a fine a required under Section 25A of 1v1CrL c- t52ttlan lead to the imposition of cnminal penalties o a Failure to secure cov.rage q well as civil pens :ine up to$1. 00.00 and/or one-year;mprisonment,as ofthis statement may be forwarded to the flt tc against the violator. Be advised that a copy v of up to$250.00 a day g investigations of the D1A for insurance coverage verifie,ury that the information provided above is true and correct- e sins and penalties of Perjury I do hereby certify u � Date: Si nature: f , 10 Phone : f uraL city or town a f t pf eial use only, Do not write in this area,to be completed 63' 0 4 i 'License" perm t; t ijCity or Tevvn: ` IssuinE �uthori:v (circle one): t 4. Electrical Inspector ;.Plumbing inspector 2,Building Department 3.C.itv;To��n C=e+l+ ; 1. Board of He.tith € i Phone* lj G.Other Mi Contact Person:' ; 4 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information h�! -T-- Please Print Legibly Name (Business/Organization/Individual): !'l e6�ow e (- Address: vt/8 4 City/State/Zip: c9V Phone#: v, 0'L 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 1 ployees(full and/or part-time).* have hired the sub-contractors 6. ❑N construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 2 Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. employees and have workers' y p ty• 9. ❑Building addition [No workers' comp.insurance comp.insurance.: required.] .5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. '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 y employees. Below is thepolicy and job site information. Insurance Company Name: l.(/�e� '�✓ Wl��� _ Policy#or Self-ins.Lic.#: �410C+ Expiration Date: Job Site Address: City/State/Zip: A 111,v,� q�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.-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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certif under the air ,penalties of perjury that the information provided above is true and correct. Si natur . Date: ���� Phone Official use only. Do not write in this area,to be completed by city or town official City or Town: _ Permit/License# Issuing Authority(circle one): 1.Board of Health 2." Building Department 3.City/Town Clerk 4. Electrical Inspeictor 5. Plumbing Inspector 6.Other Contact Person: Phone#: ,L ! J� �M7L71ZlN"EUM.I//AdE ��f�(.[Lddlbflll.LdBa6 \ Office of Consumer Affairs&Business Regulation License or registration valid for individut use only - before the expiration date. if found return to: OME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registrations 426t193 Type: 10 Park Plaza-Suite 5170 Expiration. 8/312012 Supplement Card Boston,MA 02116 The Home Depot At_Hume Services DARREN DEMERS 2690 CUMBERLAND PARKWAYS A�'LAt `A.GA 30339 Undersecretary Not valid without signature Ju1. 23. 2UU9 9:20AUI lharIe a .e Jr. IN0. 4t11 r, j "�,� ai anan usiness e u 4aff6jP& fice o Consumer A, g 10 Park Plaza e Suite 5170 r Boston, Massachusetts 02116 Hone I ' rovel-rent Contractor Registration Registration: 163528 Type: ©BA Expiration: 7/7/2011 Tr# 285903 ERICSSON HOME IMPROVEMENT ERICSSON TORRES 16 HOOVER RD F. WEST YARMOUTH, MA 02673 Update Address and return card.Mark reason for change. Address [] Renewal (] Employment n Trost Card 7PS-CAI n 40M-08/08.006LIFORMCA108212008 Ofdt$ 1.1ccnsc or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation c Registration: 163528 10 Park Plaza-Suite 5170 Expiration: .717/2011 Tr# 285903 Boston,MA 02116 Ty p.e: -08A. ERICSSON HO.ME'AMPROVEA/IENT ERICSSON TORRES 16 HOOVER RD' 1 WEST YARMOOTWIAA 02673 Undersecretary Not valid without signature Ju1. 21 2009 9:204 Charles C. Case Jr. No. 4717' P. 6 i #= 111;Iss lchusetts- Dep:trtmelit of Public sdct� IA:- Masonry only 'Soord (if Brtildin� Regid-Ations and St.indards RF- Roof.Covet!ngIV ' Constructi.on Supervisor Specially License •WS-Windo4s Anil Siding License: CS SL 100546 SF- Solid Fuel Burn itg:Devices Restricted to:. W.S DM-Demolition only ERICS50N; TORRES Failure to possess a current edition of the Massachusetts State Building Code 16<HOOVEfF ROAD is cause for revocation of this license. W..ESTYARMOUTH, MA 02673 Refer to: WWW.Mass.Gov/DPS Expiration: 6/182012 t'„mmt+rl nor Tr;;: 100548. FROM :jamgad FAX NO. R:5083622271 Feb. 22 2007 6:49PM P1 HOME IT4I,'���D,�S TRACE' : Q�r/J Sold,Furnished and metalled by: j!/ Date; �-1J� —1_0 1'HD A of At- Services,Inc. dlb/a The Home Depot At-Home Services Branch Nam- Boston 345A tareehwmod Street,Unit 2,Worcester,MA 01607 To1TEtee(8W)657-$182; Fax(508)756-8823 ME Lie#C p2439;RI Cont.Lic#16427 p►� Branch Number:31 Federal ID#75.2698460: Co actor Reg.#126893 t CT I c#565522,M kTome Im➢rovemcnt of IristaBablon Address-, uy State Zip sr Work Phone. ome Phone: Cell Phone'. t ] c } - t � at Horne Address: City State tip (If different from Installation Address) E-mail Address(to receive project communications and Horne Depot updates)-- I DO N0T wish to receive any marketing cmails from The Home Depot es to bu ¢et i tion: Underslgrwd("Cu�wcT"%�owner'of the property located at the a or the iinstallave installationtion('Instal a, tion")of and'fFID Al-Home Servie cs,Inc (-Ile Horne Depot")agrees to furnisb,deliver and atrattg incorporated into this Contract by this all otaterials described on below State Supplement tipp reference P pecayitleS$ut(smrna ll of sach hete[which are�d any Change.Otders(collectively 4 reference,along Y .: •Contract"): .lob#: (cu~It ft 1 � nets: S Sheet(s #• Project Amount co Windows ❑Insulation Rtx>fing []Siding $ OC..Wrs I Covens []Uttry Door 0 — QRvuGng.[]Siding Windoas ©Insulatom $ rICautas I Covers QSniry Doors 0 — - QRtmfing QSiding ❑Windows ❑Insulation $ ]Gutters/Coven+ []Entry Doors O Roofing Eli ing D Windows insulation $ []Gutters I Coven []Entry I]oois [�� M dunum 25%t)�epasit of Cone ad Amn®t due upon exeadi-Oftbea-B&a& Total Contract Amount $ / Maine 1'uirhavery may not depostt mote than one4hird o[ihe ConlrJtctAr 6 Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion Certificate (o for each Product as deleted by an individual Spec:Sheet)and pay any balance due. As applicable,each Cusrpmer under this ne Coucract agrees to be jointly and severally obligated and liable hereunder. The Home Depot reserves tlx right to issue a Change Order or uxminate this Contract or any individual Product(s)included herein,at its discretion,if The Home Depot or its authorized service provides determines that it cannot perform its obligations due co a structural problem with the home,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because work required to complete the job was not included in the Contract. included as part of this Contract sets forth the total Payment Summary: The Payment Summary# Contract amount and payments required for the deposits and final payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a completely filled-in of the Contract at the time you sign. Do not sign a Completion Certificate(note: ' there is one Completion Certificate for each listed Product as defined by indivl:dual Spec Sheets)before work on that Product is complete. In the event of termination of this Contract,Customer,agrees to pay�dR me Depot the costs of ate of termination,materials, plus any other enses and services provided by The Home Depot or Authorized Service amounts set forth in this Agreement or allowed under applicable law. THE 90M1E DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OT$ER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEpOT,S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Airthtiricoation: Cu tourer agrees and understands that this Agreement is the entire agreement between Customer and'1'he Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,either oral or written,relating to said Products and installation.This Agreement cannot be assigned or amended except by a writing signed by Customer and 1 lle Horne I)epot.Cwtomer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has ived a copy of this Agreement. SubuyNed by: Cu i u DatC Sales ultant's Si Date J Telephone No. Custo r s ignature ate Sales Consultant License No. (aaappticablo) -. CANCELLATION: CUSTO R MAY CANCEL THIS AGREEMENT WITHOUT; ALTY OR OBLIGATION BY AF%VF,RTNG WRITTEN NOTICE TO THE HOME DypOT BY MTDNIGHT ON THE THIRD BUSINESS DAY AFTRR SIGNING THIS AGRRh'MRNT. THE STATE MJPPLEMi NT ATTACH VD . HERRTO CONTAINS A FORM TO USE IF ONE IS Sl'F,C[FICALLY pRFSCRTBED BY LAW 1N CUSTOMER'S STATE NOTIC]&-AbOrMNAL ANp CplIp phg pgg STAISA Udi TH612EVERSE SIDE AND ARE PART OF TM CONTRACT Li 1 °FIRE rOwa Town of Barnstable *Permit t,,-,-'?` d3�tel Expires 6 m s f sue ]regulatory Services Fee �� BARNSTABLE, : Thomas F.Geiler,Director Mass fo.39. a.�� Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - R:ESIDENTIAL ONLY I Not Valid without Red X-Press Imprint Map/parcel Number �" l Property Address . Residential Value of Wor q, 6 U Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Kv I/ '1® Contractor's Name yOt,_kvl( gt,�re "t`+ie�S Telephone Number Home Improvement Contractor License#(if applicable) ❑Workman's Compensation Insurance X-P ESS PERMIT Check one: ❑ I am a sole proprietor JUN 2 4:2008 ❑ 1,am the Homeowner I have Worker's Compensation Insurance TOWN 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 6, �' r� (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 4�ii SIGNATURE: C �uGG t; Q:\WPFILES\F0RMS\building permit forms\EXPP\ESS.doc Revise020108 The Commonwealth.of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 w =�°��� www.mass.gov/dig .Workers'.Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organization/Individual): S Address: City/State/Zip:` 7 �r1 b33 Phone.#: �� 7 . Are you an employer?.Check the appropriate box: _ ,6Typ e of project(required): 1.( I am a employer-with ': 0 4. D.I am a general contractor and I employees"(full and/orpart time).* have hired the sub-contractors ❑Ne construe w tton 2.ElI am a sole proprietor or partner- listed on the attached sheet. 7 ;0 Remodeling, ship and have no employees .,.employees . : _ 8 ;.� Demolition a, These sub contractors have working for me in any capacity. and have workers' co msurance.t 9. [�Building addition '. [No-.workers' comp.insurance comp. required.]. 5. We are a corporation and its. 10. Electrical.,repaus or additions q ] �. .. -officers have exercised their 3.0 1 am a homeowner domg all work 11 0 Plumbing repairs or additions m self o workers' co right of exemption per MGL Y mp• 12.0 Roof re irs insurance required.1,t c. 152, §1(4),and we have.no . 13 `employees. [No:workers 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 cheek'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 sue information. Insurance Company Name` CO . Policy#or Self uis:'1 •� �, � Expiration Date. S Job Site Address. �'A�''/� City/State/Zip. �- Attach a copy of the workers'compensation policy declaration page(showing the policy numbel and expiration date). Failure to.secure covera a as S. wired under Section 25A of Iv1OL c. 152 can lead to the,tmposition of cnminal 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 fie of up to$250.00 a day against the violator. Be advised that a copy of this statement may forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce .ify, der a pains n-. naltie of,-er' 1h th nfo ration provided above is true and correct., Si afore: Date: ' Phone#: Official use only. Do not write in this area,to be completed by city or town official I 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#: InformatRion and Instructions p 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 th the insurance ce table evidence of compliance with.enter into an contract for.the performance of public work until acceptable mP .. Y requirements of this chapter have been presented to the contracting authority." n, Applicants Please fill out=the workers' compens ation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),addresses)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/Iic ense number which will be used as a reference number. In addition,an applicant that must submitp p multiple errnit/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 licensee or permit not related to any business or commercial venture (i.e.'a do g 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 11-22-06 www.mass.govfdia AQ®RE� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 02/261 8 PRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR homedepot.certrequest@marsh.com ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 3475 Piedmont Rd NE, Suite 1200 Atlanta, GA 30305 Fax (212) 948-0902 INSURERS AFFORDING COVERAGE I NAIC# INSURED INSURERA:Steadfast Ins Co 26387 Home Depot U.S.A., Inc. The Home Depot, Inc. INSURERB:Zurich American Ins Co 16535 2455 Paces Ferry Road Building C-8 INSURER C:Illinois Natl Ins Co 23817 _ Atlanta, GA 30339 INSURER D:American Home Assur Co 19380 INSURERE:New Hampshire Ins Cc 23841 COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IT, SR L POLICY EFFECTIVE POLICY EXPIRATION - - LT, NSRD PE OF INSURANCE POLICYNUMBER DATE MMIDDYY DATE fMM/DD1YYli LIMITS A GENERAL LIABILITY IPR 3757 608-02 03/01/08 03/01/09 EACH OCCURRENCE $4,000,000 X COMMERCIAL GENERAL LIABILITY LIMITS OF POLICY ARE EXCESS DAMAGE TO RENTED 1,000,000 PREMISES Eaoccurence $ CLAIMS MADE Fx-1 OCCUR "OF SIR: $1,000,000 PER CC" MED EXP(Any one person) $EXCLUDED PERSONAL BADVINJURY $4,000,000 - GENERALAGGREGATE $4+,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OPAGG- $4,000,000 - XLOCPOLICY PRO- JECT B AUTOMOBILE LIABILITY BAP 2938863-05 03/01/08 03/01/09 X COMBINED SINGLE LIMIT $1,000,000 ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY _ SCHEDULEOAUTOS (Per person) - $ HIRED AUTOS - .. BODILY INJURY _ $. NON-OWNEDAUTOS (Per accident) - - X SELF INSURED AUTO PROPERTYDAMAGE ,$ PHYSICAL DAMAGE (Per accident) GARAGE LIABILITY ' AUTO ONLY-EA ACCIDENT $ OTHERTHAN EA�ACC $ AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY IPR 3757 608-02 03/01/08 03/01/09 EACH OCCURRENCE $5,000,000 X OCCUR CLAIMSMADE AGGREGATE $5,000,000 $ DEDUCTIBLE $ RETENTION $ $ C WORKERS COMPENSATION AND 19287.57 (FL) 03/01/08 03/01/09 X TO ! IMTS O R .D EMPLOYERS'LIABILITY 1928756 (CA) ANY PROPRIETOR/PARTNER/EXECUTIVE 03/01/08 03/01/09 E.L.EACH ACCIDENT $1,000,000 E OFFICERIMEMBEREXCLUDED? 1928755(AOS) 03/01/08 03/01/09 E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 OTHER F TX Employers Excess TNS-C45197967 (TX) 03/01/08 03/01/09 Occurrence/SIR 25M/2M D Workers Compensation 1928759 (QSI) 03/01/08 03/01/09 E Workers Compensation 1928758 (KY, MCI, NY, WI) 03/01/08 03/01/09 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS *FOR EVIDENCE ONLY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THE HOME DEPOT, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 2455 PACES FERRY RD., N.W. BUILDING C-8 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE USA Lr+J O �Itr ACORD 25(2001/08)datkinson 8213215 ©ACORD CORPORATION 1988 r r s ,f•: r ✓� eow� 0/'/'// Board of Building Regulations and Standards License or registration valid for individul use only ifHOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ` Registra tion Board of Building Regulations and Standards ---- �26893 One Ashburton Place Rm 1301 Expiration 8/3/2008 Boston,Ma.02108 Type Supplement Card THE Home Depo-t.At Home Sen%c 'w FACHAEL BED AR. � 3200 COBB GALLERtA 0 AtIANTA, GA 30339 Administrator a Not valid ithout signature f JUN-23-2008 12:53 HOME DEPOT HYANNIS P.006i007 rc%a:A•BIOr . , ' - H011•kE,II�iPROVEMENT'CON'TRACT -, . Sold,.Furnisbed and Installed by: 'THD At-dome Services,Inc. 1;rancliNanoe:�_ ri. Date: �� /a -he HomeDOOVAI-Home'Service% 345A Greenwood Street;Worcester,MA 01607 :657-5.1.82;.Fax:508 756 2859 Branch Number::-'T1\Q-•3\.. :. Job#�• i y. Toll-Free(800) Fedeml TD#75-2698460 ME lac iJ;C 02439:1tT,Cont..Lic#16427 Cr Lic 8 565522; MA.Home Improvement Cannsctor Reg tl126893 b0' t-A N InstuAation Address: ' _ �--i . . .. ;State- O Zip Yh Lxst:4Alglts of Driycr's .. ;• ;,' Mo/Xr. Work Phones.'.:. . Home Phone:.. • ti.9`l qr,,Z�- �t1�.)'7-1t- o (fiu,�:8r.(-�s�Tsg. ' Rome.Address! (If different.tiom.lustallation'Ad ) City St ate a Zip E-mai Address(tgreceive tipdtlfes and promotionsfroin'The HomcDcpot): ProjectInformatiom 1/We/You•(`,`Ptttohnser"),'tho.owners'ofthc property located at the above installation address,offer to contract with THD At-Home Services,Inc.("Home Depof):to furnish,deliver and arrange for the installation of all materials as described on the attached Spec Sheet. incorporated hcrcin..byTeifcrence'and•made.a part hereof. Homc•Aepot:rescrves the right to cancel this coniract,U,'upoa:re-Inspection of the job;HOmC Depot,detcrrnines that it cannot:pcdorm its-obligations due to a:structural-problem with the home,pricingerrors'or:bccaase-work required to complete.the job: Sheet or Contraet was;notancluded in.the Spcc DEFUSLT°PAYMENT'OFTIONS (S*cct to fundvari6eation tmd/or eredit'approval-) / CONTRACT AmoUNT $ J check•,Cashiers Check or.US PoidnLServico Moncy ade payable to The Home DepOU• , j•LESS,DEFOSrr $ 'Ao%llp' z; Crel erd•'.iad/or.othcrpvmeet•optioua—C' •cone Below BAI ANCE DUE' Visa ercw.d Dincovor can Express ON'COMPLETION the Home llepot A Improvement Tho some Depot Credit Gad 'QNew'Aawunt (9.g Gng Ac' (MIL&WWC ONT Y) fN inimum 25%-of Coph•act Amount doe upon :': /. G'Gc�ention.ofthts contract nvaitable.CredltcS _ .=.(1133�&ttnCC ONLY) Indicate Payment Method For noctlf: �' ' : BALANCE''DUE ON:COMPLETION:,. ":.Name ax it appears: - te13y my/o ww'.below,VWe"agt'cctnatilow Home Depot to Gh�G charge ove.referenced'eredit card for the deposit indicated:' 'When yow spaymcnt you providc.n:checka 'auUarizevs:eithor:. ,otder'aSi C . •` — . to Use'infoni,atiodfronl your heckto makc i orio-tinw elOcmnic. 1 ._ timd.htrnsfet'fioia.your:account or io�yr6cess the pgyment:a3'S' . cbCCk vuaauctioo:'when"we LAN intotmatim from your check to' •. >tI1I.or TMCC.:Autborikation Codes . ..make,'ao;clochmilicfundvsnafer,Swtds-may be­withdrawn from. ':':• ...De sit 'Final Pa ment yowaccouatassoon;aathepaymcntiaieceived and youwillaot . receive yow cheele tiaek.. P y Certificate and-pay any Purchases.agre�that,immediately,u oD complenoD'of•the:woik Purchaser will execute aCompletion balance:due:'•Pirrchaseratso-agrees to be Jolntly'and•severall obligated and:iiable herciutder. Entire A tnent This,agreement.and'ris attachment ins,incltidint any financing agreement contain:the complete agreement between tho parties•and.can not.bc amended or modified unless'in writing in a seperate.agree?ncnt signed by both parties, NOTICE TO.PURCIIASER Do,tot sign;,his.contra'ct:bcfore you read it..You-arc entitled to w4complctely fBled-ln copy of the-contract at the time . you.sign.-Jt cep It to,protect your rights.-Do-.not•sign;a'Complcdon Certificate before this:project is•completc. Law prohibits lromarepsir.:contractors.from re .aeecptingquestitigor. 2,C6mpletion Cer#Ifteat¢.sfgned:by.tbeowner prior to the aEtaal'-eomplction'of the work to beperformcd tinder the contract. YOU may.0 ncel •tr this ansaction any time prior to midnight ofthe,third bminess:day'after the-date ofothis contract See- .,of Cancellation for as explanation of this right There will be a.service charge equal to lo%of the contract amoWA if•itib is-cancc]]W by:Ptirehaser AFTER the third business AY,'but BEFORE.materials are ordered.There will bc:aaer.�ice charge'equalto 25%of the contractamountif job•is caneclled'by Purchaser AFTER materials are ordered. BY MY/OiI.R SIGNATU'RE.BEI:OW,llWE UNDERSTAND THAT'THE AGREEMENT MAY BE'SUBJECT TO REVIEW OF MY/O[JR:CREDIT HISTORY AND.VWE AUII1ORIZE HOME REPOT TO VERIFY AND REVIEW MY/OUR CREDIT RECORD WITH AN INDEPENDENT CREDIT REPORTING'AGENCY AND RELEASE THEM FROM ALL LIABtLITY,'INCURRED FROM INADVERTENT OMISSIONS OR ERRORS. . :BY MY/OUR SIGNATURE BELOW,IIW:E•AGREE TO.B'E'BOUND BY TIM TERMS-OF THIS CONTRACT. UW.E ACKN0WI.EDGERECEIPT OF A-COPY'OF THIS CONTRACT AND''TWO COMPLETED COPIES OF T14E NOTICE OF CANCELLATION. 'SUBMJTTSD BY: - Date: ie-23-G ut Date: ACCEPTED BY:. Purch - 'Date: Pmthaser NOTICE:-ADDITIONAL TERMS AND CONDMONS ARE STATED.ON THE REVERSE SH)F AND AOE PARTUT TIfIS CONTRACT. Customer 'Pink-$alas Coristiltant 9-21:07 rev 4.2'67'C-SC Whlte=Branch File.•Yollow;�' '