HomeMy WebLinkAbout0012 SAINT JOSEPH STREET Town of Barnstable *Permit#
Expires 6 months from issue ate
���' Regulatory Services Fee
Thomas F.Geiler,Director
Building Division
ARNS�AgL� Tom Perry,CBO, Building Commissioner
10\N ® g 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 ,
Property Address 4 1 Cl ✓ C
Residential Value of Work 64000 Minimum fee of$25.00 for work r$6000.00 '
Owner's Name&Address kk-.J4 C4 P/t o b 0 5 � �USpn h 7
Contractor's Namey4 e Nc a l'eipcT + �E 5'r, e r s' Telephone Number S^��''Q v 2
Home Improvement Contractor License#(if applicable) 1 d 6 8 Y ?
Construction Supervisor's License#(if applicable) `
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
(]v-I have Worker's Compensation Insurance
Insurance Company Name !U�W yg rn rr s kj r a fA 5,
Workman's Comp.Policy# 17a la o s
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 (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 Hom I rovement Contractors License is required.
SIGNATURE:
Q:Forms:expmtrg
Revise061306
The Commonwealth of Massachusetts
Department of Industrial Accidents _ . _. .. _.•
Office of Investigations
a 600 Washington Street
' Boston,.MA 02111
www.mass.gov/dia
Workers'. Compensation Insurance Affidavit: Builders/Contractors/Electriciais/Plumbers
Applicant Information - Please Print Legibly
Name(Business/Organization/Individual): e
Address.
City/State/Zip.rlB: •3 Phone#: ;^ 6 ?' y�l
Are you an employer?Check the appropriate box:.. Type of project(required):
1. Lam a employerwtth i d 4 '❑ I am a general contractor and I .6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
7. Remodehn
2.❑ I am a sole proprietor or'partner- listed on the attached sheet. $ : 0 g
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me m an capacity. workers' comp. insurance.
g. y9 ❑Building addition
[No workers'comp insurance 5 ❑ We are.a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.01 am a homeowner doing all work right of exemption per MGL- 11.❑ Plumbing repairs'or Additions
myself. [No workers' comp C. 152,:§1(4) and we have no 12❑ Roof repairs
insurance required.]t -'employees. [No workers'.
_ f3 ❑.Other
comp.insurance re aired.
*Any applicant that c6cks 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 anew affidavit indicating such: "
-.--tContractors_thAt check this box must attached an additional sheet showing the name of the sub-contractors and their workem'comp policy Information;�»�-- -----
I am an employer that is providing'workers'compensation insurance for my employees. Below is the poltcy and job slie
information.
Insurance Company Name;.' .. .SA,1
Policy#or Self-ins:Lic # -1 �.�®: Expiration Date:
Job Site Address a S r (/05 e S l Ci /State/Zt
ty P �f�rny �S �n-`Da6a�
Attach a.copy of the workers'.compensation.policy declaration page(showing the policy number and expiration daie):
Failure.to secure coverage as required under Section 25A of MGL c. i52 can lead to the imposition of criminali 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:fin.e'
of up to$250.00 a day against the:violator.:Be advised that a.copy of this.statement may be forwarded to the Office_of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains anddppenalties ofperjury that the information provided above is.true and.edrrecf.
Signature. A // Date:
Phone#: 5-0 42 l t0 �1 �_c
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Perm" it/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#:
6 I.._ w•,ir t4( E I.;�g4t{�tf c f,j: j ,
'FpA5M5�"rr, �fbE��"�t`{.YrMtrk!.'""` ..
Informat ion and : nstructions
,.
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."
Addition*illy'1MGI:.'chap"ter 152, §25C(7)states"Neither the commonwealth not 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
dt completely,b checking the boxes that apply to your situation and,if
affidavit g
• worke
rs'compensation P Y Y
out the
Please fill o p
necessary,supply sub=contractors)name(s),addresses)and phone numbers)alongwith their certificates)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 maybe submitted to the Department:of Industrial
Accidents:for conf rmation of insurance coverage Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or`tow.n 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'
comiien2ttiatiiolicy;'please call the Department atthe number listed below-•Self insured companies should enter their
self-insurance license humber on the appropriate line.
City or Town Officials
Pleases be`sure-that the affidavit is complete and printed legibly. The.Departmenthas provided a space at the bottom
of the affidavit for youao fill out in the event:the Office of Investigaiibris has to contact you regarding the applicant.
Please be`§ure'to fll.in the permittlicense 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 co the affidavit thathas 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 5-26-05 www.mass.gov/dia .
`ro
$>) y� Rp §� a Y, I CERTIFICATE NUMBER x, f
�;� �.� �.� �-�•°��,��,� �� � ��, .ram.. ATL-00'1234410-01
PRODUCER THIS OERTIfICAT6IS ISSUED"A9 A MATTER OF INFORMATION ONLY AND CONFERS
MARSH USA,INC. NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE
hOmedepOt.Ce.rtreQUest@rrlafSkl.COm POLICY.THIS CERTIFICATE ODES NOT AMEND,EXTEND OR ALTER THE.COVERAGE
FAX(212)948-0902 — --- `- .• AFFORDED BY THE POLICIES DESCRIBED HEREIN... . .- _.. - .
3475 PIEDMONT ROAD,SUITE 1200 COMPANIES AFFORDING COVERAGE
ATLANTA,GA 30305 <
..:r .COMPANY - --
00492-THD-IPUSA-07-08 IPUSA A STEADFAST INSURANCE COMPANY
INSURED COMPANY
HOME DEPOT USA,INC. B ZURICH AMERICAN INSURANCE COMPANY
2455 PACES FERRY ROAD NW
BUILDING C-8 COMPANY '
ATLANTA,GA 30339 C , AMERICAN HOME ASSURANCE COMPANY
COMPANY
D NEW HAMPSHIRE INS COMPANY
COVERAGES O r .... a 4A tus certif aCe q ersedes 'ntl re [ac n evi usl :i su d ceit ficat f rtlte glie enod:n te`d;bekoow 2 ` z
w.., .... .. ...., - ,.,,. ... a..... P - -.Y t ,..:..4.. ..1!...., ,�_-_ __ P- ,aP.,...., Y P•, ..,-_..o .w...... .._, ,. .. ., .:..-
THIS IS TO CER7IFY THAT POLICIES OF INSURANCE DESCRIBED'HEREIN.HAVE BEEN'ISSUED',TO.THE INSURED NAMED HEREIN,FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR.OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAYBE ISSUED OR MAY
PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,CONDITIONS AND EXCLUSIONS OF SUCH POLICIES.AGGREGATE
LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE Of INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE(MMIDDIYY) DATE(MWDDIYY)
A GENERAL LIABILITY IPR 3757 608-02. 03/01/07 03/01/08
GENERAL AGGREGATE $ 4,000,000
X COMMERCIAL GENERAL LIABILITY 'LIMITS OF POLICY ARE EXCESS' PRODUCTS-COMP/OP AGG $ 4,000,000
R- CLAIMS MADE a OCCUR 'OF SIR.$1.000,000 PER OCC PERSONAL&ADV INJURY $ 4.000,000
OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 4,000,000
FIRE DAMAGE(Any one fire) $ 1,000,000
MED EXP(Any oneperson) $ EXCLUDED
B AUTOM013ILEUA131LITY BAP.2938863-04 03/01/07 03/01/08
COMBINED SINGLE LIMIT $ 1,000,000
X ANY AUTO
ALL OWNED AUTOS BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY INJURY $
(Pereccidenl)
NON-OWNED AUTOS
X ELF-INSURED AUTO PROPERTY DAMAGE $
PHYSICAL DAMAGE
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY: NO
EACH ACCIDENT $
AGGREGATE $
A EXCESS LIABILITY IPR 3757 608-02 03/01/07 03/01/08 EACH OCCURRENCE $ 5,000,000
X UMBRELLA FORM AGGREGATE $ 5,000,000
OTHER THAN UMBRELLA FORM $
C. WORKERS COMPENSATION AND 2921209(CA) 03101/07 03101108 X To
LIMITS ER , z:g-
EMPLOYERS'LIABILITY
E. 2921210(FL) 03/01/07 03101/08 EL EACH ACCIDENT $ 1,000,000
F THE PROPRIETOR/ X INCL 29212.11 (AZ,ID,.MD,VA) 03/01/07 .03/01/08 EL DISEASE-POLICY LIMIT Is 1,000,000
D PARTNERSIEXECUTIVE 2921208 AOS
OFFICERS ARE: EXCL ( ) 03/01/07 03/01/08 EL DISEASE-EACH EMPLOYEE $ 1.000,000
C OTHER 2921213(QSI) 03/01/07 03/01/08
E WORKERS'COMPENSATION 2921212(KY,MO,NY,WI) 03/01/07 03/01/08
G TEXAS EMPLOYERS TNS-C44642086.(TX) 03/01/07 03/01/08 EACH OCCURENCE 25,000,000
EXCESS LIABILITY SIR 2,000,000
DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESISPECIAL ITEMS
CERTkFIGATE HOLDERS , r Cr'Ea.NCELkATl4N a a � ,, c zR .,
-t ✓. ..� e >v ,,�.a,.�. -:Eax ea' " " '- t fart',x` S` 9 •,., x', ,'3g,v�:TrY',�F�
:&'.w.. u:.c'5:.•„.:.maz.;i sw.,kiw�s:>,.+ ,.ev a7.. ;..' ,s,«.,s,.�•w`s.-iSF d:x.-..% .iu d;.a. ,:o'.L:,...:.,.aF. .. Lek d>w....<....,.>.,s..s... :..r>wn>...«m 3..ve,....,a,�+,.
SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.
THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL in,DAYS WRITTEN NOTICE TO THE
FOR EVIDENCE ONLY - CERTIFICATE HOLDER NAMED HEREIN,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE,ITS AGENTS OR REPRESENTATIVES,OR THE
ISSUER OF THIS CERTIFICATE.
MARSH USA INC,
BY: Mary Radaszewskii�
ry I v a4 nr� c n {sa* `ia
MM1(31Q2k * VALID AS OF 02l28/07
1 Y x
"
.�
C �t �afr,z»w^ `s*-�..a .—^e--7 r°y5.a G •? I - 1
:. r`. .....,`i,`. yes',.,..`'r�s�r K: `f"•;. ,ra-,sue,:;a_ s `` _ +... ik J+K'✓.-4 �#- .n"-R .tx�
-$:a- DATE(MMIOOIYY) ...
� 4,..,vk4 � 02/28/07
� Nil
�� �
�'�'. -wauz�'gr:.,a..t5ak;,s7"'uak�:.:` 7: ;. ,:i ......,....,. .
PRaoucER COMPANIES AFFORDING COVERAGE
MARSH USA,INC. coMPANY
homedepot.certrequest@marsh.com - E ILLINOIS NATIONAL INSURANCE COMPANY
FAX(212)948-0902
3475 PIEDMONT ROAD,SUITE 1200
ATLANTA,GA 30305 COMPANY
F NATIONAL UNION FIRE INS CO
100492-TH O-I P U SA-07-08 IP U SA
INSURED — --COMPANY
HOME DEPOT USA,INC. G ILLINOIS UNION INSURANCE CO
2455 PACES FERRY ROAD NW
BUILDING C-8
ATLANTA,GA 30339° COMPANY
ice•
TIc d ps v t} s:r i Yr s r- wt wt 7x i r 3 {y .usss kr}IwS X:
MENa3�uA.. �-»'.. '£su �,�''' «.x: �nsis`�`S«. :3i
C.w`'+�+.`as.31`�
FOR EVIDENCE ONLY
--MARSH USA INCJlY ! L ...
Mary Radaszewskl
..•rm ''9e4.Wa2;l,,. :.wRa, F�.s.r�x�3 NT
; 1 ax
, .
, p
,
.,._,.....::xe. ...t.,,
I
✓!e -f°ianvywau�sea� o�../�ac`cuQe�a - .
Board of Building Regulations and Standards License or registration valid for individul use only
HOME IM3PROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
Registration 126893 One Ashburton Place Rm 1301 .
Ezp�ration 8/3/2008 Boston,Ma.02108
_ Type Supplement Card
iw sx 1 ;
THE Home Depot.r0.t�Icme SeNic
®'ANIEL PELOQUIN
3200 COBB GAL 20 _
AdministratorNot valid without signature
Atlantic,GA 30339
_ . ._ .._r- - - -- --- - --
a
pp
rututuaettar. Lie.#&tx .Mo/Yr: Work Phone: Home Phone:
Home Address: N�
(If different from Installation Address) City State Zip
E-mail Address(to receive updates and promotions from The Home Depot): NI A
Project Information: I/Wc/You("Purchaser"),the owners of the property located at the above installation address,offer to
contract with THD At-Home Services,Inc. " gme Depot")to furnish,deliver and arrange for the installation of all materials
as described on the attached Spec Sheet# S ,incorporated herein by reference and made a part hereof.
Home Depot reserves the right to cancel this contract if,upon re-inspection of the job,Home Depot determines that it
cannot perform its obligations due to a structural problem with the home,pricing errors or because work required to
complete the job was not included in the Spec Sheet or Contract.
DEPOSIT PAYMENT OPTIONS
(Subject to fund verification and/or credit approval.)
CONTRACT AMOUNT $J_ 1 Cheek*, hiers Check or US Postal Service Money Order
yable to The Home Depot).
tLESS DEPOSIT $ � 2. Credit Card"*and/or other payment options-Circle One Below
BALANCE DUE 10 Visa MasterCard Discover American Express
ON COMPLETION $ �I SAD The Home Depot Home Improvement Loan The Home Depot Credit Gard
tMinimum 25%of Contract Amount due upon O New Account ❑Existing Account (HIL&HDCC ONLY)
execution of this contract. Available Credit:$ (HIL&HDCC ONLY)
Indicate Payment Method For Acct#: Exp.Dale:
BALANCE DUE ON COMPLETION:
Name as it appears on card:
C' .b **By my/our signature below,I/We agree to allow Home Depot to
("A .R 1 charge the above referenced credit card for the deposit indicated.
"When you provide a check as pa authorize us either
to use information from you check to make a one-time electronic Cardholder's Signature Date
fund transfer from.your account or to process the payment as a
check transaction.When we use information from your check to HIL or HDCC Authorization Codes
make an electronic fund transfer,funds may be withdrawn from
you account as soon as the payment is received,and you will not Deposit Final Payment
receive your check back. # #
Purchaser agrees that,immediately upon compiction of the work,Purchaser will execute a Completion Certificate and pay any
balance due. Purchaser also agrees to be jointly and severally obligated and liable hereunder.
Entire Agreement: This agreement and its attachments, including any financing agreement,contain the complete agreement
between the parties and can not be amended or modified unless in writing in a separate agreement signed by both parties.
NOTICE TO PURCHASER
Do not sign this contract before you read it. You are entitled to a completely filled-in copy of the contract at the time
you sign. Keep it to protect your rights. Do not sign a Completion Certificate before this project is complete. Law
prohibits home repair contractors from requesting or accepting a Completion Certificate signed by the owner prior to
the actual completion of the work to be performed under the contract.
You may cancel this transaction any time prior to midnight of the third business day after the date of this contract. See
Notice of Cancellation for an explanation of this right. There will be a service charge equal to 10% of the contract
amount if job is cancelled by Purchaser AFTER the third business day,but BEFORE materials are ordered.There will
be a service charge equal to 25%of the contract amount if job is cancelled by Purchaser AFTER materials are ordered.
BY MY/OUR SIGNATURE BELOW,I/WE UNDERSTAND THAT THE AGREEMENT MAY BE SUBJECT TO REVIEW
OF MY/OUR CREDIT HISTORY AND I/WE AUTHORIZE HOME DEPOT TO VERIFY AND REVIEW MY/OUR
CREDIT RECORD WITH AN INDEPENDENT CREDIT REPORTING AGENCY AND RELEASE THEM FROM ALL
LIABILITY INCURRED FROM INADVERTLNT OMISSIONS OR ERRORS.
BY MY/OUR SIGNATURE BELOW, I/WE AGREE TO BE BOUND BY THE TERMS OF THIS CONTRACT. UWE _
ACKNOWLEDGE REC PT F COPY OF THIS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE
OF CANCELLATI N.
SUBMITTED BY: Date: - d/ .-
ales t
ACCEPTED BA,, bt C Date: -I- q -0 1
Purchaser
Date:
Purchaser
NOTICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE
AND ARE PART OF THIS CONTRACT
L b4-07 rev 4-2-07 C-SC b E 0 0 62 DAIAd—Branch File Yellow—Custom&0 PIW4 SO&Mr>;uttant
Danya Mahot 7743230034 P.6
HOME IMPROVEMENT CONTRACT
—7 Sold,Furnished and Installed by:
: Avjol
Branch Name Date: THD At-Home Services,Inc.
d/b/a The Home Depot At-Home Services
345A Greenwood Street,Worcester,MA 01607
Branch Number: }) Job#: R) Toll Free(800)657-5182; Fax:508-756-2859
Federal ID#75-2698460 ME Lic#C 02439 RI Coot.Lic#16427
CT Lic#565522; MA Home Improvement Contractor Reg.4126893
InstallationAddress: �� Stm Jci'c� S� gyAtomc, t aI Gy
City State Zip
Last 4 Digits of Driver's
Purchaser(s): I Lic.#&F.x .MoIYr: Work Phone: Home Phone:
Ar •� lv I (5b8)'775=1 (5og)-77g-7 ,
Home Address: N f A
(If different from Installation Address) City State Zip
E-mail Address(to receive updates and promotions from The Home Depot): NIA
Project Information: I/We/You ("Purchaser"),the owners of the property located at the above installation address,offer to
contract with THD At-Home Services,Inc,(' Qme Depot")to furnish,deliver and arrange for the installation of all materials
as described on the attached Spec Sheet# Abs ,incorporated herein by reference and made a part hereof.
Home Depot reserves the right to cancel this contract if,upon re-inspection of the job,Home Depot determines that it
cannot perform its obligations due to a structural problem with the home,pricing errors or because work required to .
complete the job;was not included in the Spec Sheet or Contract.
DEPOSIT PAYMENT OPTIONS
' (Subject to fund verification and/or credit approval.)
CONTRACT AMOUNT $ C
heck*, shiers Check or US Postal Service Money Order
to The Home Depot).
tLESS DEPOSIT $ } 2_ Credit Card"and/or other payment options-Circle One Below
BALANCE DUE visa MasterCard Discover American Express
ON COMPLETION $ q )Op The Home Depot Home Improvement Loan The Home Depot Credit Card
f Minimum 25%of Contract Amount due upon 0 New Account U Existing Account (HIL&HDCC ONLY)
execution of this contract.
Available Credit S (HIL&HDCC ONLY)
��- Indicate Payment Method For AccW: Exp.Date:
BALANCE DUE ON COMPLETION:
Name as it appears on card:
G t ""By my/our signature below,I/We agree to allow Home Depot to
(,vy >flt` charge the above referenced credit card for the deposit indicated.
c C 1;L
*When you provide a check as pa authorize us either
to use information from your check to make a one-time.clectronic Cardholder's Signature Date
fund transfer from your account or to process the payment as a
check transaction.When we use information from your check to HIL or HDCC Authorization Codes
make an electronic fund transfer, funds may be withdrawn from
your account as soon as the payment is received,and you will not Deposit Final Payment
receive your check back. # #
Purchaser agrees that,immediately upon completion of the work,Purchaser will execute a Completion Certificate and pay any
balance due. Purchaser also agrees to be jointly and severally obligated and liable hereunder.
Entire Asrreement: This agreement and its attachments, including any financing agreement,contain the complete agreement
between the parties and can not be amended or modified unless in writing in a separate agreement signed by both parties.
NOTICE TO PURCHASER
Do not sign this contract before you read it. You are entitled to a completely filled-in copy of the contract at the time
you sign. Keep it to protect your rights. Do not sign a Completion Certificate before this project is complete. Law
prohibits home repair contractors from requesting or accepting a Completion Certificate signed by the owner prior to
the actual completion of the work to be performed under the contract.
You may cancel this transaction any time prior to midnight of the third business day after the date of this contract. See
Notice of Cancellation for an explanation of this right. There will be a service charge equal to 10% of the contract
amount if job is cancelled by Purchaser AFTER the third business day,but BEFORE materials are ordered.There will
be a service charge equal to 25%of the contract amount if job is cancelled by Purchaser AFTER materials are ordered.
BY MY/OUR SIGNATURE BELOW,I/WE UNDERSTAND THAT THE AGREEMENT MAY BE SUBJECT TO REVIEW
OF MY/OUR CREDIT HISTORY AND I/WE AUTHORIZE HOME DEPOT TO VERIFY AND REVIEW MY/OUR
CREDIT RECORD WITH AN INDEPENDENT CREDIT REPORTING AGENCY AND RELEASE THEM FROM ALL
LIABILITY INCURRED FROM TNADVFRTFNT OMISSIONS OR ERRORS.
i
Town of Barnstable *Permit# $No I o�
Expires 6 months from issue date
Regulatory Services Fe� O
Thomas F.Geiler,Director
Building Division X-PRESS PERMIT
c Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601 OCT 2 8 2005 0
�.., www.town.barnstable.ma.us t�S
Office: 508-862-4038 - TOWN OF B 'g'�ET
��=�230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address
Residential Value of Work '2 i 6 U 6 Minimum fee of$25/w for work under$6000.00
Owner's Name&Address
/ A 6 it/P,r <5 Se10h S7 .
Contractor's Name / 1 U W N06f 0-t Sef VlLeS Telephone Numbe
Home Improvement Contractor License#(if applicable) /.7-6 f�/ 3
Construction Supervisor's License#(if applicable)
Workman's Compensation Insurance 1�
Check one:
❑ I am a sole proprietor
e.�
❑ I am the Homeowner
MI have Worker's Compensation Insurance
G p
Insurance Company Name {1
Workman's Comp.Policy# 5 G qf r
Copy of Insurance Compliance Certificate must be on file. --
c`
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to (,A gsTe ✓ '�` I
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side.
��`'�f vse
lacement Windows. tJ-Value3_(maximum.44)
KTo' j fr vav�,� c er
*Where required: Issuance of this pemutdoeinot exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
II ***Note:. Property Owner must sign Property Owner Letter of Permission.
Home Improvement Contractors License is required.
SIGNATURE:
Q:Forms:expmtrg
Revise071405
oFtHE r Town of Barnstable
Regulatory Services
" B^ MASS. ` Thomas F.Geilere Director
9 MASS. g
039..�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, {+- DCr as Owner of the subject property
hereby authorize 1"la n c to act on my behalf,
in all matters relative to work authorized by this building permit application for:
f <Sc-c rk �T
(Address of Job)
Signature of Owner Date
1 � Qac�v (saw
Print Name
Q TORMS:OWNERPERMISSION
. f✓II6 �PV�INI�V �<II<i�OOFa1�0�P��
. !!OwlE�0lPR(��EI�T OOiNtf�7�01t ..
126M
ampkaftm aw2me
"W. SUPpkwmdcwd
am xLmEnE
3200CM220 _
RLTANTA.GA MM
s
irCM�
ear '" fog"
one
f
.ata
plot
t