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0011 STETSON LANE
f Y�.� LL � .j:..: i� 5\ r" _ L (114 F*Z�4vw '�° No, ®16 NST�e ,X IN,';,"I I gal i b� 10 GD- jvdoso Pl"klr- \c� CZoak _ z c i r- z o r• E MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY : n//1/! F MA DATE l�/ /? /PERMIT# © i JOBSITE ADDRESS! c� �/T�///rOWNER'S NAME -2, P OWNERADDRE55 : -.v—�TELRP _ _FAX` TYPE OR OCCUPANCYTYPE COMMERCIAL;_' EDUCATIONAL _( RESIDENTI ` - PRINT CLEARLY NEW:, RENOVATION:J REPLACEMENT: PLANS SUBMITTED: YES 7— NOi_( APPLIANCES-1 FLOORS- BSM 1 2 3 4 5- 6 7 s s 10 11 12 13 14 BOILER I -j I.' i ► l——1—i—J_� BOOSTER —J—� ! ! CONVERSION BURNER Ii.. i COOK STOVE DIRECT VENT HEATER DRYER a FIREPLACE FRYOLATOR - FURNACE I GENERATOR. _..I . .. . I. t - t I —�_ I ! GRILLE — _1-1 ! ! ! I.,1 ! - — - -- INFRARED HEATER LABORATORY COCKS. -• f ----#.- _, _ . ; . _.... _..l . _ I_._ ....! r MAKEUP AIR UNIT OVEN POOL HEATER .,. !_..__...��� #,..�-.�:—..; !• i�_!—1 i #•--I J--1 ROOM/SPACE HEATER ROOF TOP UNIT I TEST UNIT HEATER ' UNVENTED ROOM HEATER WATER HEATER. ----=-- ---- - i.. 1... . . i l OTHER_ INSURANCE COVERAGE T I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.C4_,142 YES. (NO f I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW `- i �m LIABILITY INSURANCE POLICY-,:,54 OTHER TYPE INDEMNITY 1301��D I_i J = OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 df-:fhe ZZ Massachusetts General Laws,and that my signature on this permit application waives this requirement. a cam^ CHECK ONE ONLY: OWNER :X AGE -i SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the be 'f my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertine • 'sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMES. �� j>4LICENSE#c f ATU MP J MGF J $ JGF' f LPGI =f CORPORATION i# PARTNEP.SHIP !# LLC:i`#i• — _ . COMPANYNAME �� �,�15 �J.���/1i1�5!✓,/�iADDRESS �/ --- - - - ---- - (� CITY ,�/�/�/��, k STATE} ZIP TEL' ! FAX' i CELL IL ROUGH GAS INSPECTION NOTES TITIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ 6.r FEE: $ PERMIT ft is ����_ r(CA u-W PLAN REYIEI l NOTES ' tyZ C) I e._rl��,� :. S ro,•�� v n't s �- i_>, 4 DAn MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY `-'" ` MA DATE '�,I PERMIT# ? e6010 ' JOBSITE ADDRESS I� � � .r✓�.� L-N OWNER'S NAME OWNER ADDRESS TEL FAX P TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT PLANS SUBMITTED: YES 1-1NOD. CLEARLY NEW:C] RENOVATION:E1-- REPLACEMENT:0 FIXTURES I FLOOR- BSM 1 2 3 4 5 6 7 8 9 1ti 11 <. 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _-- DEDICATED WATER RECYCLE SYSTEM :. ��� DISHWASHER L. °i—�����. _ Is ..��-�-1 DRINKING FOUNTAIN a� - �- t s A= i � ., Tom_ FOOD DISPOSER �I-- FLOOR 1 AREA D RAIN INTERCEPTOR(INTERIOR) ED KITCHEN SINK ° LAVATORY �I a ROOF DRAIN - _ L ! SHOWER STALL ` SERVICE/MOP SINK Lg�- -�� TOILET :( ------ URINAL --- WASHING MACHINE CONNECTION - WATER HEATER ALL TYPES-L-�!- `_--=`I I I � �- `� - WATER PIPING ---h'A---- OTHER r�-�� —���e --��� ____�I .Y.LrL_..� �' "•�� INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YE N0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY, i OTHER TYPE OF INDEMNITY BOND [j OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. R` CHECK ONE ONLY OWNER AGENT [� SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accu a to t best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance w' a ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. . _ ' LICENSE# SIG TUBE PLUMBER'S NAME MP® CORPORATION# PARTNERSHIP Cj# LLCn# COMPANY NAME DDRESS � �/�//!/ STATE l� Z1P � 7� TEL CITY FAX s Cam. EMAIL l ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ _ _ S FEE: $ PERMIT# u i — i"J D PLAN RE,VIEW NOTES •6 .G1) 2e/�11. I ,IY r - Cape Save Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 508-398-0399 2/4/16 Thomas Perry CBO == Town of Barnstable " Crj C) . Building DivisionTau s 200 Main St. Hyannis,MA 02601 , RE: Insulation Permit 201508961 rn Dear Mr. Perry This affidavit is to certify that all work completed for 11 Stetson Lane,Hyannis has been inspected by a third party Certified Building Performance Institute(BPI)Inspector. All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey r C 28 0 TOWN OF BARNSTABLE BUT AR PERMMT A�R'�PIJ�hCc�TION Map �0 ( Parcel 6 0 Application'# 27o/& Health Division Date Issued Conservation Division Application Fee U Planning Dept. PermitTee .S J � Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address S+e+5 0 A "At Village y G.a n 15 Owner r Q, lan Address Telephone 5 o 2 8 5 R 7 0 Permit Request -Jvke_ Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project ValuationA 1 S U o Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sqA.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new r Number of Bedrooms: existing _new 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/coalistove:' ❑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 XNo If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) VVr 11 Name I AA1 n C. Telephone Number 5a 3 9 8 r0 39 Address J n ar License # 7' Q S )�4(Ifn 0tk-f 1 (� Home Improvement Contractor# 1 TI30 Email Worker's Compensation # � 3oj 6 a��4 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO )�nN,a►y�-I'►'1 SIGNATURE DATE f 7 r FOR OFFICIAL USE ONLY APPLICATION # P 1 DATE ISSUED MAP/ PARCEL NO. ADDRESS •VILLAGE OWNER 4 i DATE OF INSPECTION: FOUNDATION 1 FRAME c s INSULATION i FIREPLACE 7 ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ti GAS: ROUGH FINAL FINAL BUILDING - DATE CLOSED OUT ASSOCIATION PLAN NO. �.r MOV-16k-2015. 12:57 From: 1506T714947'" To:?W�5691933 Pate:2 , Town of Barnstable r :, rY Regulatory Services g v RicLard S. 1t a' it etess Director Building Uivisiun 'rum Ferry,building Cununissiuner 1G0 Nfaiu SUtOt,llya Ws,MA G2601 � . www.town.barnstubleina.us Ofiioo: $09-8624035 Fax: Mii-90-6230 ?,opetty l�rc7ler Must (:�n�plctr ant! Sign '. 'his 5cctic�rl x If Qsina. A Builder Y i, as Owner of the subject pro{x'tty licrY:hy attd�ari�x ((4 � tc, act on my behalf M ill Matteis r0ldvc to wo authorized by this b-uil&ng pern-rit applicaU011 for: kAddius of oG} •►"Pool fences and alarm are the trspo'usibility of the appbicaui. Poole *Ire not Co be filled orudLed before fence is ilutallyd and A final i ec ens ar+e erfo d acid accepted. 4Y t�Yl:t ;7'tt is of + ` 1'r4t4t ctilattt< rinks r Date Q:FORMS O%*NF.RMk'RAtC 'S WK)M cx.)j-, - ,• r¢" The Commonwealth of Massachusetts ' 'l' `Department of Indust al A ci ''`' 1 _ �, ri c 'dents '_, 1 Congress Street;.Suite'1:00 1' �, F t�+Boston,MA 02II4=2017- • r . — :" .; , b.,- -t _ www.mass. ovldia i, «'orkers'Compensation Insurance AfSdavit:Builders/Contractors/Electridans/Plumbees, - s •TO BE FILED WITH THE.PERMITTING AUTHORITY. Applicant Information Please Print Legibly r. ` ' Name(Business/Orgatuzaton/Individual) Ca Pa Save Inc 7,.0 Huntington.Avenue , 1. 1 Address: - " South Yarmouth, MA 02664 508-398-0398 City/State/Zip: -Thone#: Are you au employer'Check the appropriate box: ; Type of pro�ect(re gwred) : 1. ✓01 am a employer with.. t "employees(full an part-time)* '' , t r• f f. 7 - New construcrion jam a sole:propneto or partnershrp and have no employees working forme in w 1 0 8. Q Remodeling w j 1!any capacity.[No workers'comp.insurance required .? r ,: ;t rr, '�'- ". z - ;ty'r '* {r•l• •r ,,- �� ...11 3.a I.am a homeowner doing all work myself.[No workers comp..insurance required; t r _ _ 1 1 • 9. -' Demolition � � t r _ ._ , ' 0 Building addition.. f__ d, '�4.[I anti Homeowner and will be hiring contractors to:conduct all work on my property..I will ensure that all contractors either have workers'compensation insurance or are sole 11,0 Electrical repairs or additions e g proprietors with no employees.' ,'.. Plumbing repairs or additions 12. 5.❑I am a genera(contractor and Ihave hired the sub-contractors listed on the attached sheet. 13:❑ of re airs These sub-contractors have employees and have.workers comp,insurance.t ' - ., Insulation , 6.❑VJe are a corporation'and iti officers have exercised their right of exemption 14.Q✓ Other' p per MGL c: 4 15;§1(4),and we have no employees.[No workers'comp.insurance required:] - ,,*Any applicant that checks.box#1 must also.fill:out the section below showing their:workers'compensation policy information.. F t Homeowners who submit:this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicatiagsuch ..•-,, { *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.'lam an employer that is providing workers'compensation insurance for my employee& Below is'thepolicy and job site M ' infoiniatlon. .. - 3i +S k. '.. ',"Insurance Company Name:Wesco Insurance Company r d s Policy#or Self.-ins Lie:#: 93136274 �' t ' � ;,. ,�. . Expiration Date.04/09/2016 n,w�,- _ f _. . , - , =n : Job Site Address. T1f Stenson Lane: t Hyannis k j • i f +City/StatelZip: F -Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date)7.''. -_ _ . _ ._ , ,..N.. _ ._. Failure to secure coverage as required under.MGL c. 152,§25A is a criminal violation punishable by a fine up to.$1,500:0.0 e 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 4 . ...� day against the,violator:A copy,of this statement,may,be forwarded to the Office of.Invesrigarions of the DIA for insurance�- --- coverage verification. e �. , f ..1 do hereby certi . under th ains and:penalties o `er'u that the information provided above.is true and correct # y rY p p fP J +'y. f p s Si aturd: Date: 12/28/15 t Phone#: 508:-398 0398 Official use only. Do not write in this area,to be c'o►npleted by city or town of jicia ' n 1 t City orloWn; Permitl kense# '4. Issuing Authority(circle one) =.�s= • . r . ' .7 ,.. 1.Board of Health.n2.Building Department 3.City/Town Clerk 4.Electrical.inspector 5.Plumbing Inspector: F 6.Other Contact Person `" ' Phone#: �f':rvK..;'.''(ti.S,,.., .t i�4* ...,. s. •71 t- .'N=.:a`fit1 f t. r i',i. ;, 1_t� ,r�k> `,.��' ACORU� DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY,INSURANCE 10/14/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER: . , IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT ONT Colleen Crowley Risk Strategies Company ' PHCIN E (781)986-4400 FAC No: (781)963-4420 15 Pacella Park Drive " _ - E-MAIL :ccrowley@risk-strategies.comADDRESS ; Suite 240 INSURER(S)AFFORDING COVERAGE NAICi Randolph MA 02368 INSURERA:Selective Ins. of America INSURED INSURER Allmerica Financial!Alliance Ins Co 10212 Cape Save,_ Inc INSURERC.Wesco Insurance Company 7 D Huntington Ave INSURER D INSURER E South Yarmouth. MA 02664 INSURERF: COVERAGES CERTIFICATE NUMBER:CL15101402127. REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER POLICY MI ICY EFF MMOi�EXP LTR LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE Fx-1 OCCUR PREMISES Ea occurrence $ 100,000 B1994480 10/16/2016 10/16/2016 MEDEXP(Anyoneperson) $ 10,000 ' PERSONAL&ADVINJAJRY. $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: /- - GENERAL AGGREGATE $ 2,000,000 POLICY� � LOC PRODUCTS-COMPIOP AGG $ 2,000,000 OTHER: r $ AUTOMOBILE LIABILITY 1 NED SINGLE LIMIT I Eaacxdent) $ 1,000,000 ANY AUTO ' BODILY INJURY(Per person). $ B ALL OWNED SCHEDULED AUTOS X AUTOS A6BA96796600 11J6l2015 11/6/2016. BODILY INJURY(Per accident) $ 'NON-OWNED _ - _ P X HIREDAUTOS ROPERTYDAMAGE X., AUTOS PeracciTY $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $' 1,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED FTREfENiTION nil S1994480 10/16/2015 10/16/2016 $ WORKERS COMPENSATION officers Included for X PER OTH- AND EMPLOYERS'LIABILITY Y f N STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE NIA Coverage E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? N C (Mandatory in NH) e's VVC3136274 4/9/2015 4J9/2016. E.L.DISEASE-EA EMPLOYE $ 500 000 If yes,describe under ` DESCRIPTION OF OPERATIONS below °' E.L.DISEASE POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS t VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) National Grid Corporate_Services. LLC d/b/a National Grid, Action Inc, Colonial Gas .Company and NStar Electric are all included as Additional Insureds with respects to the .General,Liability coverage.of Named Insured as required by written contract. CERTIFICATE HOLDER 'CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Housing Assistance -Corporation THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 460 West Main Street ACCORDANCE WITH THE POLICY'PROVISIONS. Hyannis, MA. 02601 , a AUTHORIZED REPRESENTATIVE s Michael Christian/CLC f " _ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) �y2� ��Q'�?G?�Z1�I•?,tuea���• 01 CJ�����JJC�•C�t�/JPJ Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration ; - Registration: 171380 " :W Type: Corporation r $ Expiration: 3/14/2016 Tr# 249649 CAPE SAVE INC. WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE SOUTH YARMOUTH, MA 02664 r "� ---- — - --- - -- -- �4� 4 Update Address and return card.Mark reason for change. • Q Address Renewal IM Employment E] Lost Card SCA t C. 20M-0511 i �T c•�r riri�uruurFccl,/,�a`?�(t{.3:;rrn�rc�e//a _.......__ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: e istration: 5 Office of Consumer Affairs and Business Regulation 9 ` 71380 Type: g q,Expiration:gz-3X- 016. Corporation10 Park Plaza-Suite 5170 Boston,MA 02116 CAPE SAVE INC. <,r 3 WILLIAM MCCLUSKEY§ 7-D HUNTINGTON AVENUE SOUTH YARMOUTH,MA 02664 Undersecretary Not vali tthout signature j I . Massachusetts -Department of Public Safety , L� .Board of Building Regulations and Standards l..-/Illltl Ill'l11)ll Jt111Ct V1�111-J�CLI$Ity �pa�. License. CSSL 102776 • ```tiF Ql:ti ,err }- i �. ..- - WILLIAM J MC C' U 37 N.AUSET.ROAD ILW F West Yannout6 lVIA r - ✓�,G,.r,:%/�i -k"'A' ` Expiration Commissioner 06/2812017 y Town of Barnstable Regulatory Services c Richard V. Scali,Director Building Division BARNSTABLE + EAMSTABLE * __ 9 MA93. - "wumxsieus q, 1639. �� Thomas Perry, CBO " 1639_20,4 ArED1AP�� Building Commissioner 200 Main Street, Hyannis,MA 02601 www.t ow n.b a rn s to b l e.m a.u s Office: 508-862-4038 Fax: 508-790-6230 January 11, 2016 Octavio Cardosa 60 Dunns Pond Hyannis, MA 02601 RE: Massachusetts Public Records Request for the following address 11 Stetson Lane, Hyannis Dear Mr. Cardosa, For copies pertaining to the above address please pay the following. Copies 36 pages @ .20 7.20 fo Postage 2.30 Research Time 21.89 hr @ 2 43.78 53.28 Please make check payable to the Town of Barnstable Sincerely, Ltd',Imo• Debi Barrows Administrative Assistant ^ i January 8,2016 I Octavio Cardosa am requesting a copy of front and back of every file,permit,notes,pictures,emails on 11 Stetson Ln Barnstable.I am also requesting a copy of any correspondence or requests between the town and Gary Blank.Please provide this information promptly and in a timely manner. -Thank You, f/ Octavio Cardosa a • ���L�ING4C����`; , Y. 'JAN 0 8 2016 TOWN OF'BMAHST.Aak Jan. 11, 2016 9: 16AM Spencer Hallett No, 0156 P. 1/2 Phil Colvin From: Spencer Hallett Sent: Sunday,January 10,2016 7:47 AM To: MJ Carpenter, Phil Colvin Subject: FW:Gas Permit 290 Hinkley Hill I checked the permit folder in scans and it is correct there. I am assuming this is the second gas one that got sent in. I do not see a scan of it. Please get it sent in ASAP 1!!11111 Thank you Spencer Hallett Spencer Hallett Plumbing&Heating, Inc ' 381 Old Falmouth Rd. Suite 36 Marstons Mills MA 02648 T. 508.428,6080 F. 508.428.7991 EM..spencer(@hallettplu nbing.com From: Barrows, Debi [mailto:Debi.BarrowsWown.barnstable.ma.us] Sent: Friday,January 08, 2016 9:35 AM == To: Spencer Hallett Subject: Gas Permit 290 Hinkley Hill Good Morning, (was trying to process your gas permit for 290 Hinckley Hill. Th6t address does no exist, please sd a corrected permit. Thanks Debi , • r 1 I : :1�1 :.:.:�. .:,.. .p: : ::: - :.- :, p : .::.:�:��::::..�:-�;:.::::,:.:::.::::::::�::::::::::::::�::-:..,....::�::1`w�:wp:::p::p::;�q�::::;:..............---...............I. .11. . _ _. *; air �� __ : ... _ ,. � €S>� The mission of the Buildin -Zonin Division'is to fair) and'consistentl ro�ide g g Y Y p. � i mspectionaLservices throughout tlhe Town of Barnstable, including expert . plan review for proposed projects encompassing both residential a:n;d .. : . :: .commercial properties and zoning and code enforcement,while maintaining, •, and respecting the rights of the,individual citizens,visitors and business x operators ,4^ .:: c :: :i .. .. .. . _ .. ..... .. ..-.. .. I-:i TF ® r ......... .......: s. e:: a 0 . e p ® g .. .. s .:: ... ...y. � ... .... ... ... :. .. .. ... .... ... -... ..... . .,,.i. \,,§ p' .. .. ... _. 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",' .: K ® ... 0 o ® 0® o .:..�:....II..1.-I:.� d :-...:1.-1...:1:-.::....:.:I-I.:.I--:..-. _ .�...1.1I1..�...I-:�.:I....1 _.: :' ..: ::: e :��,,,111:;.�,:,.�:�:::.:.�:..:.I'�:...:�..-:�,:,!�.",..��!%,:�:...:--�.,,�.,.::.I..:-.-.::-..::..:.I..::-...::...!...:.......:.....:.I....:.I......I-...,�I..I... -.1�I .:,-1..':1--.- �..1.,..:..:1.�- ...�II1.:.-...:,I,�.w::..II�1.:..1,���-:I�. -...1.:�.I..�...�.I::�'-:I.�.I:.I...I..I.III.I II ::-':I:.I-....I��..I..I...—�-�-....I�.; I�.....- ��::1I-.1-1.....1.-...�- ... .. .... ... ... .... ... ... ... .. .. :: !: . ....... _._. __.._.:: .:...:..... .. ...... ............:....__.._-............. ..__... .. .......:._... .... ...: ... ._. r :: ... : .. :r n ... .. .. ... ... ..._.... .... ... ...: .... y: C� ,- ., Jnspectlon&P e n i ti tg;Pir M • i:.I FYI ._ .. ... t P',� Under mandated by Massachusetts General Laws, :the Building Zomng :Division ,� administers and enforces the Massachusetts State:Building Code; Plumbing/Gas .. Codes, Zoning Ordinance 6' d the Architectural Access Code Related life safety �! : . .: and construction codes: such :as the.;FEMA,;Coastal' Constructioniiand insurance guidelines are also enforced by,the Building Division These codes regulate all new residential and commercial construction, as well as all:additions, alterations; ;' < .. ry e renovations and accesso buildings and structures; The;;performance of thes, mandates necessitates.,the processing of all.;applications for permits, review of construction plans and specifications, the issuance of all related construction ; 4 .. . codes, local zoning ordiinances and all other local regulations Once permits have e . been issued, the inspector monitors code�a:nd safety com!phance of all;perm�ts `: issued with regular inspections of both residential a;nd commercial projects This ... _.::. _...... ... ....: .. process can be achieved, with!as little as one inspection for the simplest project; to.ias many as lift_ inspections for thelarger; more complex projects, such as the . Nyannis;Youth &:Com nun ty.Ce- o.:rCape:. Hospital.. "°`" _. -: .: The Massachusetts State Building Code also mandates periodic. nspections of ., certain public buildings such as hotels, motels, restaurants, churches, day care ._ ..: .:: .. : i L :: r."'..: -...I:.1��- ::q.::..:1.I.... :.,�.�.1I..--- :1:.1. -I .11 ��:.:I...I c :.::•• .:,l:::.1e.:...I"::1...--....-I....-- ..r -: .. 4:S :: e " ._.:. .,, . . . » : :: T r :: ". „. .:: ': : ... y :: .. ao p THE Tp� Town of Barnstable *Permit# Ecptres 6 nr, the front issue date eon; PERMIT Regulatory Services Fee STABLE.. 2010 MA''� �' Thomas F. Geiler,Director T rF. A BARNSTABLE Building Division Tom Perry, CBO,,Building Commissioner 200 Main Street,Hyannis,MA 02601 www,to wn.b arras table.m a.u s Office: 508-862-4038 Fax: 5,08-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY ( , Not Valid without Red X-Press-Imprint UCH Map/parcel Number; �1L Prop Address" �V G �C1�1 Nam' S Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Addresses' Contractor's Name I Telephone Number '/T� Home Improvement Contractor License,#-(if applicable) 1 f/1) J- IV ��� 61 Construction Supervisor's License#(if applicable) I cy 4orkman's Compensation Insurance Check one: ❑ I am a sole proprietor �am the Homeowner LJ I have Worker's Compensation Insurance Insurance Company Name l Workman's Comp.Policy# �� �_S 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 roof) ❑ Re,-'!!ride_ t #of doors Replacemen indow doors/sliders.U=Value (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 -required. : SIGNATURE: ���'��` "�- QAWPFILESWORMSUildi,ng permit forms\EXPRESS.doC Ppiii,eP,i nonQno DATE(MMIDDNYYY) AC"J?" CERTIFICATE OF LIABILITY INSURANCE 02/19/10 PRODUCER — 1-404-995-3000 T THIS CERTIFICATE IS ISSUED AS A MAl""fER OF INFORMATION Marsh USA, Inc. I ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NCT AMEND EXTEND OR homedepot.cerireclestCi ar.ccm �At ,E2 _ 1` C ERAGE A .-I DRDtI F" t c -L C;IES E3 Two Alliance Center, 3550 Lenox Road, Suite 2400 , j Atlanta, GA 3- GCIN lRCE Q r FhR� COVER' Fax 1212) 94r3-^902 _...-._.. . INSURED NSURERA St ins Ca 2153e The Home Denot, Inc. `-- - Hone Depot: U.S.A., Inc. In CF+ERB 'Gurich A;,eri.can n Co_ - _.-- »35 2455 Paces Ferry Road N`v1 IYSGRERC:New Hampshire Ins Co ___ � 23841 Building C-20 INSI RER D:NATIONAL UNICY FIRE—I_NS C_0_-_0_F P_ITTS 19945 Atlanta, GA 30339 r INSURER E:ill inois Union Ins Cc 27960 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. _ _ • -_ INSR NDYL — POLICY EFFECTIVE" POLICY EXPIRATION - LIMITS LTR NqRQ TYPE OF IN5URANCE POLICY NUMBER DATE fMM/ lY Y DATE M /D /YYYY A GENERAL LIABILITY GL04887714-00 03/01/10 03/01/11 EACH OCCURRENCE $ 4,000,000 DAMAGE TO RENTED $ 1,000 000 X COMMERCIAL GENERAL LIABILITY - . PREMISES(Ea occurrence) -_ _- CLAIMS MADE OCCUR - MED EXP(Any one person)'__ $EXCLUDED_, PERSONAL&ADV INJURY. $4,000 000 GENERAL AGGREGATE $4,-000 000_:__ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $4,000,000 - X POLICYPRO- LOC B AUTOMOBILELIABILITY SAP 2938863-07 03/01/10 03/01/11 COMBINED SINGLE LIMIT' $.1,000,000 (Ea accident) X ANY AUTO ALL OWNED AUTOS - f BODILY INJURY - $ (Per person) _ SCHEDULED AUTOSHIRED AUTOS AUTOS - v- - BODILY INJURY - : $ - (Per accident) NON-OWNED AUTOS - X SELF INSURED AUTO PROPERTY DAMAGE $ (Per accident) PHYSICAL DAMAGE AUTO ONLY-EA ACCIDENT $ GARAGE LIABILITY ANY AUTO OTHER THAN -EA ACC . AUTO ONLY: AGG $ - - A EXCESS I UMBRELLALIABILITY GL04887714-00 03/01/10 03/01/11 EACH OCCURRENCE S 5,000,000___ - X OCCUR F-ICLAIMS MADE AGGREGATE $5,0001000_ _ DEDUCTIBLE ---- ---- $ --- — ------ RETENTION $ WORKERS COMPENSATION 03/01/11 _X WCSTATU-' OTH- C WCO20342355 (ADS) 03/01/10 _ RVLI - --- -------- AND EMPLOYERS'LIABILITY YIN 1,000 000 " D ANY PROPRIETORIPARTNERIEXECUTIVE� WCO20342356 (CA) 03/01/10 03/01/11 E.L.EACH ACCIDENT $ --- OFFICERIMEMBER EXCLUDED? - E (Mandatory in NH) WCO20342357 ,(FL) 03/01/10 03/O1/11 E.L.DISEASE-EAEMPLOVEE $1,000,000 _ If yes,describe under E.L.DISEASE-POLICY LIMIT $11 000,000 _ SPECIAL PROVISIONS below - OTHER ' E TX Employers Excess TNSC46242373 (TX) 03/O1/10 03/01/11 Occurrence/SIR 30M/2M D Workers Compensation WC0910566 (QSI)' Q3/01/10 03/01/11 C Workers Compensation WCO20342358(XY,MO,NY,WI, ) 03/01/10 03/01/11 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES i EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS RE: EVIDENCE,OF COVERAGE " CERTIFICATE HOLDER CANCELLATION - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE IS INSURER WILL ENDEAVOR TO MAIL 3.0 •DAYS WRITTEN THE HOME DEPOT, INC. HOME. DEPOT U.S.A., INC. - - NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE 70 DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS.AGENTS OR 2455 PACES FERRY. ROAD NW REPRESENTATIVES. BUILDING C-20 UI' ATLANTA, GA 30339 - AHORIZEDREPRESENTATIVE USA ' ACORD 25(2009101).Jthornton-lid ©1988-2009 ACORD CORPORATION' All rights reserved 14481889 : ' The ACORD name and logo are registered marks of ACORD e4C[3e4D. CERTIFICATE OF LIABILITY INSURANCE OP ID DA'f£(MMIDD110 KEITHW2 02 12 10 PRODUCER THIS CERTIFICATE IS ISSUED AS 4 MATTER OF INFORMATION Mark T. Vokey Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Craig S. Vokey HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P.O. Box 1247 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, West Chatham MA 02669-12'47 Phone: 505-945-3535 INSURERS AFFORDING COVERAGE NAIL# INSURED ; iNSGRER A. Penn i%mer .Ca — INSURER o: Ula ri@ P, Fte19=:1 dha Soundview Construction 35 Soundview Avenue -- — -- -- Chatham MA 02633 INSURER E; COVERAGES THE POLICIES OF INSURANCE LISTED REL.OW HAVE BEEN ISSUED TO THE..INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY RCOUIREMENT,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.A(GRCGATF-LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _..�_ —--------- --- —---- — --..-----._..._._...._.�.P.00ICY EFFECTIVE I POLICY-EXPI'f0%VYA'r---.._._..-------_,..•......._..... LTR N$RD TYPE OF INSURANCE POLICY NUMBER I DATE MMIODIVY DATE MMIDD/YY LIMITS j GENERAL LIABILITY EACH OCCURRENCE__ __ S1,000,000 A :X 1COMMERCIALGENFRAL'LIABILITY PAC 6862315 I 02/23/10 02/23/11 I PREMSES(5 cr O�n«1 1$50,000 j ] CLAIMSMAOk X OCCUR I I•MGDEXP(Anyonepelso�) j$ 1,000 P[RSONAL 8 ADV INJURY i$ 1,0 0 0,0 0 0 -- .......__._._.._...__. j Ij—.—_...... .....- INJURY j ! I GENERALAGGREGATE j S 2,000,000 ` _ ,00 0-COMP/OPAGG 2/00OGEN'L AGGREGATE LIMIT APPLIES PER: PRO, — -- POLICY !JECT LOC ! I i AUTOMOBILELIABILITY ___ I COMBINED SINGLE LIMIT S j ANY AUTO i(Ea accidenj) ALL OWNED AUTOS I RODILY INJURY I(Per person) S SCHEDULED AUTOS I HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS .....---- . I I PROPERTY DAMAGE _—...I ....._..._. ..._ ... I I (Prracciden!) $ GARAGE LIABILITY AUTO ONLY•EA ACCIDENT S EA ACC S ANY AUTO ' OTHER THAN ----_ ... ..........---- AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY i I EACH OCCURRENCE $ i OCCUR `_� CLAIMS MADE ! AGGREGATE - $ _N ..._.... $ ....... ----— I WDUCTIBLC j WORKERS COMPENSATION AND I TORY LIMITS ER EMPLOYERS'LIABILITY i ..._—_-...__._...... . ----.._..------•--- E.L.EACH ACCIDENT S ANY PROPRIETOR/PAkTNER FXECUTNE ----...__.._...__.. ------------ OFFICER/MEMBER EXCLUDEf)? E.I..LIISEASE-EA EMPLOYEE S II yyes,describe under - ----...._._.. ..........___---_--__—_. 5 F.CIAI.PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER i J j DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS THD AT-HOME SERVICES< INC> AND THE HOME DEPOT ARE INCLUDED AS ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY INSURANCE CERTIFICATE HOLDER CANCELLATION THDATHI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL THD AT-HOME SERVICES., INC. IMPOSE NO OBLIGATION OR L14&UTY OF ANY KIND UPON THE INSURER,ITS AGENTS OR and The Home Depot 2690 Cumberland Pkwy, Ste 300 REPRESENTATIVES. -At1BSLta GA 30339 , AUTNORIZEDREPRESENT • 'OD. ACORD'25(2001/08) C AD CORPORATION 1988 Massachusetts- Department of Public Safett Board of Building Regulations and Standards s Construction Supervisor. License License: CS 94607 Restricted to: 00 :eT I� j k, WAYNE F :KEITH 35 SOUNDVIEW AVE �., CHATHAM, MA 0263.3„ Expiration: 1,0/62011 Commissioner Tr#: 4362 0/j6 Panvnaonufea �` dd License or registration valid for individul use only Office of consumer Affairs&Business Regulation before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR office of Consumer Affairs and Business Regulation Registration 157610 . 10 Park Plaza-Suite 5170 Expiration 10/2?12011 Trll 288775 Boston,MA 02116 _ - ,. ., Type :DBA SOUNDVIEW CONSTRUCTION Wayne KEITH 35 SOUNDVIEW AUE INo valid 'rthout signature W.CHATHAM,MA 02669. Undersecretary r ✓fre -in�o�rtmorausealtd o�'✓l�circ/zu<seC�,c \ Board of Building Regulations and Standards ' — W HOME IMPROVEMENT CONTRACTOR RegistrAtigR 126893 TYRe SUppiement Card The Home Depot:Atmeetwce DARREN _- 3200 COBS GALLERIA ATLANTA,GA 30339 ° Administrator License or registration valid for individul use only y"y before the expiration date. If found return to:. r Board of Building Regulations'and Standards One Ashburton Place Rm 1301 E` • Boston,Ma.02108 Not valid without Wgnature---`—_ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations w 600 Washington Street F Fe Boston, MA 02111 www.mass.gov/dia Worker's compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): AACW Address: City/State/Zip:L , Are you an employer?Check the appropriate box: Type of project(required): L ❑ I am a employer with 4.❑ I am a general contractor and I have 6. ❑ N construction mployees(full and/or part-time).* hired the sub-contractors listed on '7. Remodeling the attached sheet. 2. IZI am a sole proprietor or partnership These sub-contractors have g• ❑ Demolition and have no employees working for employees and have workers' comp. 9. ❑ Building addition mein any capacity. [No workers' insurance.$ 10. ❑ Electrical repairs or additions comp insurance required.] 5. ❑ We are a corporation and its officers have exercised their right of 11. ❑ Plumbing repairs or additions 3. ❑ I am a homeowner doing all work exemption per MGL c. 152§ (4),and 12. ❑ Roof repairs myself. [No workers' comp. we have no employees. [No workers' 13. ❑ Other insurance required.] t 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 attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees.If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site information. n Insurance Company �' /Name: ,/ V& 2 Policy#or Self-ins.Lic.#: Expiration Date- Job Site Address: % V City/State/Zip:A � 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 sweme may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do her c rtify under t �s a penalties of perjury that the information provi4ed ove is true and correct. Signature: Date: J��—/� Phone#. j 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) section 25 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, M.G.L. 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 applies to your situation and,if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy inform4tion (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 Revised 11-22-06 Fax# 617-727-7749 Revised 12-14-06 www.mass.gov/dia The C'oninaonwealth ofMassaachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street �''`"�'`• :�-_'. Boston,MA 192111 www.rn ass.gt7v/(tali Wor-leers' Compensation Insurance affidavit: Barilders/Contractors/Elect�ieians/Plumbers Applicant Inforrnataorr ; Please Print Legibly VL Na1112 (Business/Organization/hrdividual): t:%±%i - Address: S i G " F-ery-v L '� I be" .5 j r City/State/Zip: Irv_ Phone#: � ' Are you an employer?Check the a propriate b : d 1. Type of project(required): general con tractor r an larvae m to er with ,/A 4. I am a� 6, ❑N construction I• p Y have hired the sub-contractors employees(full and/or part-time). listed on the attached sheet. 7. Remodeling 2..❑ I am a sole proprietor or partner These sub-contractors have g. ❑Demolition ship and have no employees employees and have workers' 9. ❑Building addition ' an capacity. working for me m Yinsw•ance.* [No workers' comp.insurance comp. 10.❑ Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3.❑ I am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions myself. [No.workers' comp. right of exemption per MGL 12.❑ Roof repairs c. 152,§1(4),and we have no insurance required.]t I3.❑Other .employees. [No workers' 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 and job site information. Insurance Company Name: Lvl 9 Expiration Date: Policy#or Self-ins.Lie.#: P'0 3 �' I City/State/Zip: �ex Job Site Address:Attach a copy of the workers'compensation policy declaration page(showing the policy number andiration 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 tine 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 under4h ins and penalties rjury that the information provided above is true and correct. // Date: Si nature: 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): _.. s1.Board Auof thority i Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: - i ROMEMAPROWMENT'CONTRACT PRASE READ THIS Sold,Famished and J i�byr:. Branch Name Boston , ,Date: p , ,:>;HD At=Homc•Services,Inc:- .- F:.;.• _ ,, ,.dAva.ue�Home AepotAt-Home•3erviees 345A Cv=wood StrcetrUait 2„Worcestet:MA.U1607 Branch Number 31 - Tolle>-me(80U)657 5182"..Fax(508)7§6.8823 FcderillD i1.75-2G9&tb0:ids Lie 1t C 024391t1 Corrt T.icfF 16427' ' C 7 #56$522,MA Home im` vcmeoi CouAactoi Reg#126i193 Installation Address: Qr -�N j.:.. .. C' State H. (s)° Work Phone rHorite Phone Cell Phone: G> Home Address: t p (It different from Installation Address) ,, City c'. . Sate Zip, E-mail Addresb(to receiver rproject commurkauonsand lomcDepotupdate.) ❑I DO:NOTwish•to.r Eve any:markedng em.vls'from The.Home'Depoa Proiect informatirin:'Undersigned'("Customer");thc'owneis'ofitafvhc property located'acthe-above'i66nation address;agrees to buy, and THD At-Home Services,Inc.('"The Home Depot")afire a mish;"doiiver and atrtttgcfor'ilic iastalUtion-("Installation")of ail..materials-described yn-the.:below aud,on thc:rcferenced•Spec Sheet(s),.�11,of:Nhich aie:incorporstedAntoAhis Contract by,-this reference,along_.with aay;applicable Stale.Supplement and Eayment.Suruuoary attached het eto_and any Clitinge Oideis:(c011ectiveIy, "Contract")•.. Job4h (uwiws.a is) Pavtdurke' t:: .. •: Sheets"tkc` Pio'ect Amouint Roofing Siding' indoors' Iai�tlati'on: p! _ �S� "OC C]'G+iti�ry i Covers'pr-.u�q Doors'[1' ''` •=1�� `•d7 L'�=:. . .. �$' !///�;�c/ Roofing: Siding vt+ndows. Qc„ttcrs i CovM QEittry,Doors,r► ROOGng.oSijing, V✓indows' Insulation (] ' G=irs/:Covers.[3Entry boots . :" .Roofing ]Siding' ' Windows,0 Insulation QGutters'/Covets;.[]EntryDoors Nffiianmz2546DepadtotCAohsdAmOvntdueuponptop�tionaftl�isoon4ad.,:.„ ! , TotalCon�act AruitianC Maine purchasers may not deposit more than one third of the Contract Amok Customer aSireeS that,itttmedixtC y upon compltsti.oa of.tbc_w0.."for.eacl .Product;Customa wili ezecutg a�ComnTeti�oti 6crtificate (one_for each Product:as.dcfiiped`by:an indi�xdv' Spec;Sheet),:. 'pay.:any balance die;.:As,applieable;each'CtLstomer under this Contract agrees to bejoindy aud,severally obligated and liable hereupdei. . ' The Homc,Depot reservz.s,the right to:i.ssue a:Change„Order or,torrumate=this.Contract:or,any jndMOuallProduet(s)included,Iuaein;at its discretion,if The Home Depot or its authorized.service provider due to a,structural problem with the home,euytroam"tal.)tazacdx;uch;as.mold,asbestos or,lead paint,other safety,concerns pricing errors or.because work required to compiete,the job waa not included in Payment Sumrrlary 'The'P.aymen t Summary:# iocludod;as�pait of this:ContraCt:sets forth dio•:towl Contract amount'and<paymentc requirehdar.the-deposits iixd•finwPpayments by Product(as.apphcable).` NOTICE TO CUS'1 OME[t You are entitled'to a'cotnpletely MQ'-ln-copy of tlarContract at di'61ime you skvL-•Do no't sign*a Completion Ccrt,ts�'te(rioter there is one Completion Certificate for each listed.Produetas.de med.by'in&QludSpec Shects)'before:work-oiribW Product is complete In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of matcriW labor,expenses and services provided by The Home Depot or Authorized-Service Provider tbrough the date of terminatiion„plus any other. amounts set forth in this Agreement-or allowed under applicable law. THE'HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME.DEPOT FROM THE.DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTIMR REMEDIES FOIL RECOVERY OF SCICH AMOUNTS.. Acceptance and AuthOriration: .Customer agrees and understands that this Agreement is the entire agreement between Customer and The Home Depot with regard to the Products and Installation services and supersedes all prior,discussions and agreemcnts,7either oral or written,relating to said Products and Installation.This Agreement cannot be assigned or amended except by a writing signed by Customer and The Home Depot_Customer acknowledges and agrees that Customer has react,understands voluntarily aceTts the terms of and has received a copy of this Agreement.- SX y;ub c.'Ifiz 16'k 16) _.�.._ .. X. q Customer's Signature Date Sales Cta"anisalumm (Si�g,�-� -h-± X Telephone No'. Y( 7j V Customer's Signature Date Sales-Cousultant license No. CANCEMLATION: CUSTOMER MAY CANCEL THIS (m-Wieable) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE TtIIRD.BUSINESS t DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACKED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE:ADDIT1oNAL TERMS AND CONDTI'IONS ARE STA'T*:D ON THIS REVBRSF;SIDE AND ARE PART OF THIS CON RACE! 11-30-05 C-SC White-Branch File Yellow-Customeer Pink 100'd SINKYAH 10dSG SWOH 94 Z1' OIOZ-ZO-NRP