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0039 WOODLAND AVENUE
3 9 lo-s r�1�w�.( � - - -- _ __ 7IZLII(o �00 ® of Barnstablet# RegWatory ServicesFftNAM 9 f rdch d V•ScA Interim KNOWN 1135.0-0 BuRd-gMision 2016 �Id3ag Commissioner - 2011 Main .to baastanbltt:. N'I 2601F BARNS yTASLE Office: 508-862-4038 011PRIF-M PVDwn7 APPI��ATION d + �08 790-6Z30 Not VaW Wit ra utRed x-P ress lmprin t IV�apiparcel Number���� Property Address [!(Residential Value of Mork$ 3,0� — Mmilnum fee of 535A0 for work under 36000.00 Owners Name&Addressl�?'ii'f 3 L wCJocc tQ�.�l A ✓t j4ya�,�l S /Ali A Contractors Name ® 0✓� - TelephoneNmnber��—�,"��ln.� Home Improvement CoBlracto/r License#(if applicable)�o'Z(o �"�,3 EmaiL• Construction Supervisor's License#(if applicable) W01im n's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance h manceCompanyName_ 6� � / �� Co Workman's Comp.Polk,,' G ®/ Copy of Insurance Compliance Certificate must accompany each p�eimff Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old s*0es) All construction debris will be taken to r ❑Re-roof(hurricane nailed)(not stripping. Going aver existing layers of roof) ❑ side L-IlReplacementWindows/doors/sliders,.0 Value 30 (maximum35)#ofwindows #of doors: .:❑ Smolt a/Carbon Monmxide detectors 4 floor plans marked with red S and inVeMans required. Separate ElectijeW do Fim Permits required. - Wherereq rmmnceof*'pe mitdmnot=mPtmmPhawewi&otbertunn d nplarioos,i-e. ,Conse<vatiaa,etc. "Note: Prolietiy9RM&SMS sign Propertp Owner Letter of Permission. A copy Improvement ConUrscturs License&Construction supervisors Incense is �ui�SIIGNAT T:IREVIN MuRding Chi\EXP doe Revised 061313 a ROME IMPROVEMENT CONTRACT PLEASE READ THIS SOid,furnished and installed by: Branch Name:New England D-te:61 _ad THD At-Home Scrvic s,Inc. d/b/a The Home Depot At-Home Services Brandt Number:31 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free 877-903,-3768 iwla- M#75-2698460;ME Lic#C 02439;RI Coat.Lich 16427 /� Cr Uc#HiC.0565522;MA Home Improvement Contractor Rcg.#126893 Installation Address: 3 T�T� AQ,, elff_n n m /"/eI a e`?Q k D l y State Zip Purchaser(s): Work Phone: Home Phone: Cell Phone: I J r -1 Atlml � Home Address: (If different from installation Address) City State Zip E-rail Address(to receive project communications and Home Depot updates). ❑L DO NOT wish to receive any marketing emails from The Home Depot 1'ro'ect ormati n: Undersigned("Customer").the owners of the property located at the above installation address,agree%to buy, sn Tf D A_t ome Services,Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installation("LoWation')of all materials described on the below and on the referenced Spec Sheet(s),all of which are incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(cwllee:tively,' "Contract"): Job#: Products: Y Spec sireet(s)#: Pon' Amount qy ❑Roofing❑Siding Windows lnsuladon $ .lam.._.. ❑Gums/Covets ❑butry Doors[Ia,6( $ ❑Roofing[]Siding ❑Windows ❑insulation 0Gun=/Covets ❑Entry Doors❑ $ ❑Roofing (7St S 0 Windows ❑insulin []Gutters/Covers ❑lrntry Doors❑ $ ❑Roofing[]Siding Windows ❑Insulation ❑Cturms/Covers ❑Gmry loots f 7 $ M nimur ?S%Depedt of Cozad Amount due upuue wcadanafthty oont a& Total Contract Amount $_ MainePardtasersamty not deposit mere lhanooe4l"ofdoCaatnadAmmut p�� Customer agrees that immediately upon completion of the work for each Product,Customer will cxcx:ute a Completion Certificate (one for each Product as defined by an individual Spec'She ct)and pay any balance due. As applicable,each Customer undef this Contract agrees to be jointly and severalty obligated and liable hereunder. The:Home Depot,reserves the tight to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a Structural problem with the home,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors Or becawse work required to complete they job was not included in the Contract. Payment Summary: The Payment Summary# included as part of this Contract,sets forth the total 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 copy 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 individual Spec Sheets)before work on that Product is complete. In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses. and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus any other amounts set forth in this Agreement or allowed tinder applicable law, THE HOME DEP(YT MAY WITHHOLD AMOt1NTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHFM PAYMENTS MADE., WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. —Acceptance and Aut grin[ on: Custorer agrees and understanch that this Agreement is the entire agreement between Customer and Inc:Home Depot wi th regard to the Products and Installation services and supersedes all prior discussions and agreements,Lither oral or written,relating to said Produc-d and Lnstallation_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 read,understands,voluntarily accepts the terms of and has received a copy of this Agreement AffFpted by: Submi by: Customer's 5igna ar_,ol Date Sales Co Itant's Si azure /Date Telephone No. b Customer's Signature Date Saiet Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS (as applicable:) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE,TO,THE HOME DEPOT BY MIDNIGIiT ON THE THIRD BUSINESS �^� DAY AFTER SIGNING THIS AGREEMENT. THE (i /+C o . STATE SUPPLEMENT, ATTACHED HERETO S2 c{r� �(^ r►1�fQr� CONTAINS A FORM TO USE IF, ONE IS SPECIFICALLY PRESCRMED BY LAW IN H"bGG CUSTOMER'S STATE. NOTICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE.RF.VF.RSF 8lDF.AND ARV PART OF THis CONTRACT 10-0rr15 while—BianchFile Yellow—Customer Td Wd80:£ ZTOZ Se 'oaQ TLZZZ9£80S: 'ON XUJ p26aet: WON-1 03724%201:6 10:.2'9 5083783776 EDSON :INSURANCE AG N PAGE 01/.02 r E P P + Massachus+etts-Department of Public Safety toard,of Buiidi.ng Regulations and;Standards s �nns4rtitTinn Superi•isnr SnCcia3;•' i Ixense CSSI-0 162 119tX.k if " { Wa�ara'MA�'n. y�l IF F�tpiTstipin.. COmrnlssioner MM01=7' ' ' - J/nQ r(.�O+�ntnsni�i�+a��adatrrl�Ne�� ; Ofiiee:of CossRmer Affiirs;&Bupa�t Regal�rlon _ i OMMMOROVEMENT COW. MCfOR ratimr 1`112001..7 Irnlfi 4ull j 11MOTw HANSCOM P TIMOTHY HANSCOMA, ) LFOR A, waREFu+M,ruu►'o?s7� L►adt►mrobiry. i s i I r i 3 F The Commonwealth of Massachusetts Department of Industrial Accidents O.f�e of Investigations 600 Washington Street Boston,MA 02111 www mass gov/dla Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AvyUcant Information Please Print Leeibly, L Name(Businesslorgat&ation/individual): %// 6 1 iV P Address: a l TGe__ b t't ve- City/State/Zi : L e-h aP\, M 0,_ Od- 7/ Phone#: S-0 K— C/"— (y �<f Are you an employer?Check the appropriate box: 1.❑ j am a employer with 4. ❑ I am a general contractor and I Type of project(required): employees (full and/or part time).# have hired the sub-contractors . 6• ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.incnranCe comp.insurance.; 4• ❑Building addition required:] 5. ❑ We area corporation and its I011 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their . l I.❑Plumbing repairs or additions myself. [No workers' co,mp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no 3a.❑ I am a homeowner acting as a employees.[No workers' 13.❑Other general contractor(refer to#4) comp.insurance required.]. Any aPPHcant that chec m boa Kl must also fill out the section below showing their wod=e compeasatio4ahcy,infonmahon. Homeownem who submit this affidavit indicating they are doing all work and then hire outside connectors must submit a new affidavit indicating such. T,Contractms that check this box must attached as additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractMs have employees,they must provide their workers'co policy member. camp.P cY 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: C c>rA(`11 r&e_ 1 an Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment;as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under th pains and enalties of perjury that the information provided ab Ls a and correct Si a 7.ve '3 Phone#: OfflCial use only. Do not write in this area, to be completed by city or town offrciaL City or Town: PermittUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town CIerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person- Phone#• -� The Cointnonwealth of Massachusetts Depdrtinent of Industrial Accidents Office of Investigations 1 Congress.street; Suite 100 Boston, i L4 02114-2017 ytt;yy4V.tfddaSS g!?v1dla Workers' Compensation Insurance Affidavit;Builders/Contractors/Electricians/Plumbers Ap2meant Information 'lease Print Lmibly Name (Business/organization/Individual)-- The Home Depot At-dome Services Address:908 Boston Tpk City/State/Zip. Shrewsburl,MA 01545 Phone#:508-962 942 Are you an employer? Check the appropriate box: Type of project(required): 1.Fill I am a employer with zca+ 4. ❑ I am a general contractor and I 6 Q New construction employees(full and/or part-time).* have hired the sub-contractors Remodeling Z.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ These sub-contractors have g_ ❑'Demolition ship and have no employees working for me in any capacity. employees and have workers'comp.insurance. 9 Q Building addition No workers' comp.insurance 5. 10. Electrical repairs or additions Q We are a corporation and its required.] ;.Q I required.] a homeowner doing all work officers have exercised their 11_Q Plumbing repairs or additions right of exemption per MGL 12.Q Roof repairs.__ -_ myself. iNo worker comp. c. 152, §1(4),and we have no insurance required.] ' 13.Ev Other Gt�l/Ial 0W employees. [�io workers' comp. insurance required.] �e ��cNe,y e.,f--S #Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy intbrmation. .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:nia•boxmust atfached.an additional;hertsho�virg:the.,name of the sub-contractors and Mate whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.,policy number. - — -- I air an employer that-is providing ivorkers' compensatron iiisiii arice for my employees. Below is the pokey and job site - information. Insurance Company Name: New Hampshire Insurance Company Policy#or Self-ins. Lie.#: WC 015519215 Expiration Date:3112017 1 Job Site Address: 32 Wood lan ✓� City/State/Zip: l�yiaa S �.,� 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 in ce coverage verification. I do hereby certify under t p andpenalties of perjury that the information provided above is true and correct Si ature: Date: -/ Phone#: 401-714-6 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.CityPT6wn Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• i Offi6e of ro zs z-n�� A f�a�rs andus��ss Regulation MEN 10 Par1L Plaza - Suite 5170 Boson, MassachuseUs 02116 Home Lanprovem' end Contactor Registration Registration: 126893 Type: Supplement Cant - Expiration: 8/312016 THD AT HOME SERVICES. INC. -- ANDREW SWEET - - 2690 CUIl BERLAN© PARKWAY ATLANTA, GA 30339 _- -- ------ -- Update address and return card-hark reason for change. Address ;r� l3ene�va[ Empioy�ncnt � Lr�s!Car 1 %j7c '(%n.iro�r!=r<tcz:�c�f�.r�•'=,GCrc;:;ac�ti::rtf, , Office of Consumer Affairs&Business Regulation License or registration valid for individul use only -NOIOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation s Registratia 126893:.. Type: t� 10 Park Plaza-Suite 5170 Expiration--8/3G20E6 Supplement Card Boston,MA 02116 THD AT HOME SEW(GES 4G THE HOME DEPOT F%f,F{C kifE ERVICES ANDREW SWEET 2690 CUMBERLAND PARKWAY S � - AfL`A&`A,GA 30339 Undersecretary 41witut gnature DATE(MMIDOIYYYY) Aco CERTIFICATE OF LIABILITY INSURANCE 02JIN2016 Lam = 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. Ies must be endorsed. If SUBROGATION IS WANED,subject to IMPORTANT: ff the certificate holder is an ADDITIONAL INSURED,the policy(' the terms and conditions is the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT NAM! FAX PRODUCER - ' MARSH USA INC. PHONE AIC Not TWO ALLIANCE CENTER ADDRESS: 3560 LENOX ROAD,SUITE 2400 ATLANTA,GA.30326 - INSURER(S)AFFORDING.COVERAGE NAIC p 100492-HaneD-GAW-16-17 INSURER A fast Stead insurance Company 26387 INSURER B ZuridtAmericanlnsurance Co 16535 THDINSU�AT-HOME SERVICES,INC. New Hampshire Ins Col INSURER C DBA THE HOME DEPOT AT-HOME SERVICES Minds Na6onat Insurance Company 3817 2690 CUMBE WM PARKWAY,SUITE 300 INSURER D ATLANTA.GA 30339 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-00374W6-14 REVISION NUMBER:8 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.ANO CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REPDOULCEO YE" PAID omYMi�s. LIMITS -NSRR - DL SUB POLICY NUMBER TYPE OF INSURANCE A X COMMERCIAL GENERAL LIABILITY GLO46B7714 06 o3lovzols o310112017 EACH OCCURRENCE 9.000,000 I s X -PREMISES ocanence D TO $ 1,000,000 CLAIMS MADE ❑OCCUR EXCLUDED LIMITS OF POLICY XS MED EXP(Any one person) $ ( OF SIR:$1M PER OCC PERSONAL a ADV INJURY $ 9,000,000 GENERAL AGGREGATE $ g' '�0 GEN'L AGGREGATE UMITAPPUESPER: 9,000,000 PRODUCTS-COMPIOP AGG 1$ X POLICY❑JE O- ❑LOC i I is OTHER: 0310112016 03N112017 CCbtHBI�eD SINGLE LIMIT $ 1,000,000 B AUTOMOBILE Luurn.rrY iBAP 293986313 BODILY INJURY(Per Pelson) is X ANY AUTO I BODILY INJURY(Per accident)'$ �OyyNEp SCHEDULED SELF INSURED AUTO PHY DMG _ III AUTOS PROPERTY DAMAGE $ =NON.OWNED.. _er.aa ide -- -- - HIREDAUTOS � AUTOS ` "' '"--`- ____.�C._.�_�.._a._ _ UMBRELLALIAB OCCUR i - EACH.OCCURRENCE $ EXCESS LIAO CLAIMS-MADE l• AGGREGATE $ $ OW RETENTION$ WC0 1 5 51 921 5(AOS) 0310112016 0310112017 X I STATUTE I ER C WoWjM.COMPENSATION AND EMPLOYERS'LWBnJTY YIN WC015519217(AK,KY,fd)I,NJ,VT) 03101/2016 0310112017 E.L.EACH ACCIDENT $ 1,000,000 C ANY PROPRIETORFARTNF_RfEXECUTIVE N N rA 1q310112017 1,000.000 DOFRCE"ENBER EXCLUDED? WC015519216 FL) 03101/2016 E.L.pISEASE-EA EMPLOYE $ (Mandatory in NH) 1,000,000 If Yes,desrnbe under I Carutnued on Additional Page E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORDm 101,Additional Remarks Schedule,may be attached d more space Is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc Manashi Mukherjee � 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The.ACORD name and logo are registered marks of ACORD lk Town of Barnstable *Permit(dvt SD Expires 6 months issyedate Regulatory Services Fee sntsNWASM SLAM Richard V.Scali,Interim Director 63A ��0 - "� 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 - RESIDENTIAL ONLY Not VaUd without RedX-Press Imprint a.(Map/parcel Number O _6 Property Address—INDod�a n �� wyantil S Residential Value of Work$ 02 5 g Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address &iCKAnj(&JZ /&C'he' Zjh Dtt. C) .� e L o Contractor's Name / Sao^ Telephone Number 7/�(`6 3 Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) Workman's Compensation Insurance ®PRESS T Check one: ❑ I am a sole proprietor J U L 02 2015 ❑ I am the Homeowner I have Worker's Compensation Insurance TOWN OF B A R N STA B L E Insurance Company Name 4QC—k) Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) , ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. G6ing'over existing layers of roof) ❑ Re-side ['Replacement Windows/doors/sliders.U-Value 13 (maximum.35)#of Ldows #of doo ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red Sand inspections required. Separate Electrical&Fire Permits required. *Where required_ Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property er sign Property Owner Letter of Permission. A copy of H Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: TAKEVIN D\Building Changes\EXP S RESS.doc Revised 061313 r HOME 11WIMOVEM ENT.CONTRACT . PLEASE READ TERS Sold,Furnished and Installed by: Branch Name:Boston North&Sowb Date:6 j/0 I THD At-Humc Services,Inc, d/b/a The Home Depot At-Home Services Branch Number:31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545- Toll Free 877-903-3768. Federal ID#75-2698460;ME Lic#C 02439;RI.Coo.Iaep 16427 CT Lic#HICA565522;MA Home Improvement Contractor Reg.#126893 I mnati�.Aadrt _3q W o� U�-� ff—_a �L�/� . I Ct'4y State zap PurCh�sea{s)e Work Fbme: Home Phoue: Ceti Phertw Home Address: -of different rrom Installation Address) City State Zip mail Address(to receive project communications and Home Depot updates): DO NOT wish to receive any marketing cmails from The Home Depot Project Information., Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, and THD At-Home Services,inc_("Pie Home Depot")agrees to furnish,deliver and arrange for the installation("Installation")of all materials described on the below and on the referenced Spec Sheet(s), all of which are incurpmalcd into this Cuntr-acl by this 'refererim,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively, "Contract"): Job#: am-a w—) acts S Sheets # Project Amount Roofing USid1n8 indows U Insulation // $ d ❑Gttttcts/Covers ❑Entry Doors❑ /l -..- Rooting USiding U Windows U Insulation` ❑Outten/Coven ❑Retry Doors ❑ Roofing Siding 0 Windows insulation ❑Gutters/Covers ❑Entry Doors❑ $ Rooting Siding U Windows U Insulation $ ❑Gutters/Covers ❑Entry Doors ❑ , NHF durum 25%Deposit or Cottttad Amman due ttpm ewonion ottbts-nh"ad Total Contract Amount $ Maine Pumbaserr may n t depnd[more than art&third orthe Contract Anwunt Customer agrees that, immediately upon completion of the work for each Product,Cus turner wig execute a Completion Ccrlilicate (one for each Product as defined by an individual Spec Short)and pay any balance due. As applicable,each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. The Home Deport reserves the right to issue a Change Girder or terminate this Contract or any individual Product(s)included herein,at its discretion,if The Home Depot or its authorized service provider deterrWries that it cannot perform its obligations due to a structural problem with the bonne,environmental hazards such as mold,asbestos Ea lead paint,other safety concerns,pricing errors or boxause work required to complete the job was not included in the Ct tr c.t. Payment Summary: The Payment Summary# �S . included as part of this Contract, sets forth the total 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-iu copy of the Contract at the time you sign. Do not sign a Completion CertMeate(note'. there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product is complete. In.the event of termination of this Contract,Customer agrees to pay The Home Depot the mats of materials,,labor,expenses and services provided by The Home Depot or Authorized Service Provider throughthe date of termination,plus any.other amounts set forth in this Agreement or allowed under applicable.law. THE RODEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LRMTiING THE HOME DEpOT,S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acre and Authorization: Customer agrees and understands that thin Agreement is the entire:agreement between Customer and The'ence me Depot with regard to the Products and installation Services and supoxsedeS.all prior discussions and agreements,either oral oar 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 acknowledgcs and agrees that Customer dtas read,understands.voluntarily accepts the terms of and has received a copy of this Agreement. Ac by: Submi by: t Gbtn stoer's Signatture ate Sales Co ultant's Sigma e / /a �' � X Telephone No._ e� customer's Signature Date Sales Consultant License No. CANCELLATION! CUSTOMER MAY CANCEL THIS (as applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION .BY DEuvERING WRITTEN NOTICE TO THE HOME DEPOT BY. MMNI(*HT ON THE THIRD BUSINESS DAY AF`fER SIGNING THIS AGREEMENT. THE STA'17E SUPPLEMENT ATTACHED 1HERI?TO CONTAINS A FORM TO USE IF ONE Is SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. N#YL'1(7,-.ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE.REVERSE SIDE AND ARr.PART OT THI5 CONTRACT 10.23.14 White-Branch File Yellow-Customer s tit Wd00:L TTOZ T£ 'oaQ TLZZZ9£80S: 'ON Xtij pe6wief; WOdJ Massachusetts -Department of Public Safety Board of Building Regulations and Standards �Onstuctifin 'Sun rvi'sor SI-Mcialty ,,F License: CSSL-099162 :. TIMDIM P r�r• 4 CIRCLE DRIV1` 1 Wareham MA 0271 .�l a �.+f:... ,1Jc•.���4�:1� Expiration Commissioner 06/(t412017 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/Contractars/Electricians/Plumbers A130cant Information Please Print Le bly Name (Business/organization4ndividual): 1,56 Address: C l/�C�P_— be- City/State/Zi : areh QM Da,S"7/ Phone#: 6r0,1r Are you an employer?Check the appropriate boxy I.❑ I am a employer with 4. I am a general contractor and I Type of project(required): /employees(full and/or part-time).*. have hired the sub-contractors . 6. ❑New construction 2.® I am a sole proprietor or partner- listed on the attached sheet. .7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any.capacity. employees and have workers' [No workers' comp. insuranCe comp.insurance.: 9. Building addition required:] 5. [] We are a corporation and its 1011 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11 n❑Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL l2 ❑Roof repairs 3a.❑ insurance required]t c. 152, §1(4),and we have no I am a homeowner acting as a employees.[No workers' 13.❑Other general contractor(refer to#4) comp.insurance required,] -Any applicant that checks box#1 must also fill out the section below showing their workers°compensaticdj�olicy infonaation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidivit 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site, information n Insurance Company Name: 0-0m mt,fr&Q— g Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip. Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby eerd' under,th pains and enaldes of perjury that the information 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 ofciaL City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person. Phone#: Tke C'oa aotaweakk of Hassachaaseft 07 a earl of lfiadustrid Accidents Orke Of inves*atio'as 600 W askington Street Boston,MA 02111 wwry mass:gov/diea Workers' Compensation Imalmimee Affidavit:BuilderdContracton/Eiectriciang/Plumbers Atnaa:cant Information Please Print I.esibly Name(Business/Organization/individusl): 0) , o we-me, V/leas Address: log 6o,5-49P �yt'1�1A/>� pity/State/Zip: s9S v ®/5"K Phone#: J, e ou an employer?Check the appropriate box: Type'of project(regnireft 1. 1 am a employer with 4. 0—I am a general contractor acid 1 ��� have hired the sub-contractors 6. ❑New construction employees(full and/or part-time). Y 7. [:].Remodeling 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet ship and have no employees "these sub-contractors have 8_ ❑Demolition working for mein any capacity. workers'comp.insurance. 9. ❑wilding addition [No workers'comp.insurance 5. ❑ We are a corporation and its ME]Electrical repairs or additions required.] officers have exercised their 3.[] I 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 repa insurance required.]t employees.[No workers' 13. ir;Ao Otber L0l comp.insurance required.] 'Any applicant that checks box g l must also fill out the section below showing their workers'compensation policy' t Homeowners who submit this affidavit milkating-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 workers'gyp.policy informadDii. I am are employer rhat is provi ft worrlem'comperasadois w6wrancefor m'evrloyem Below is the policy aped job site Inf,ormadom e : / Insurance Company Name 4� � l 5 41ri!., 5 Policy#or Self-ins.Lie.#:_ `i O / 3 , 3 Expiration Date: 3 Job Site Address:e�q 00vc��Q ✓e City/State/Zip: yyT"s Attach a copy of the workers'compensation policy declaration page(showing the policy numher and expiration date). Failure to secure coverage as required tinder 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 D for' ce coverage verification. I do hewhy cer y pates Pewaky o,f perjury that the infmmodon provided above is one and cairn Si afore: / Date: '.30—o2 0-1 S Phone#: ��— ' aal use onok Do not wdie in area,to he coarkted by city or town official City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: f 2 {�G�lllt'7rsLr'iZ1-ereAf1`airsa/Q f� G{�//,/�JZ �j./� //y/a�/�.��,(/�/�/,Officeor Con business Regulation 10 Parr Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 126393 Type: Supplement Card THD AT HOME SERVICES, INC. --_ Expiration: 8IW2016 ANDREW SWEET —_ 2690 CUMBERLAND PARKWAY SUITE-3D0. ATLANTA, CA 30339 - �. Update Address and return card"Hark reason for chancre- SC:., J address i-1 Renewal i:' Employment ['I Lost Card T111e e0wZM09zu96C61Mb o�� a a ccaeGTi (Office of Consumer Affairs&Business Regulation License or registration valid for individul use only BIOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Re istratign,;f- a' Office of Consumer Affairs and Business Regulation 9 12 Type: 10 Park Plaza-Suite 5170 Expira#{ �g/3/2D16�4 Supplement Card Boston,MA 02116 THD AT HOME SERVI6S�INC3Lw} THE HOME DEPOTrA3=k10MfSERVICES ANDREW SWEET r', yr 2690 CUMBERLAND P PARKWAY S A'tM,GA 30339 Undersecretary Nov r with ut signature Aco CERTIFICATE OF LIABILITY INSURANCE °ATE`20115 YY' 02124/2o1s 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 endorsement(s). PRODUCER CONTACT MARSH USA,INC. \ NAME: TWO ALLIANCE CENTER PHONE � No 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC 100492-HomeD-GAW-15-16 INSURER A:Steadfast Insurance Company 26387 INSURED INSURER B:Zurich American Insurance Cc 16535 THD AT-HOME SERVICES,INC. ' DBA THE HOME DEPOT AT-HOME SERVICES INSURER C New Hampshire Ins Co 23841 2690 CUMBERLAND PARKWAY,SURE 300 INSURER D:Illinois National Insurance Company 23817 ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003242685.09 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. INTR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP AM POLICY NUMBER D MMIDD LIMITS A GENERAL LIABILITY GLO4887714-05 03/01/2015 03/01/2016 EACH OCCURRENCE $ 9,000,000 X COMMERCIAL GENERAL LIABILITY DAMAG E TO RENTED 1,000,000 PREMISES Ea occurrence $ CLAIMS-MADE ❑X OCCUR LIMITS OF POLICY XS MED EXP(Any one person) $ EXCLUDED OF SIR:$1M PER OCC PERSONAL&ADV INJURY $ 9,000,000 GENERAL AGGREGATE $ 9,000,000 GE XN,L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 9,000,0070 POLICY PRO-JECT LOC $ B AUTOMOBILE LIABILITY BAP 2938863-12 03/01/2015 03/01/2016 COMBINED SINGLE LIMIT 1000 000 Ea accident $ X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $ AUTOS. AUTOS NON-OWNED PROPERTYDAMAGE HIRED AUTOS AUTOS Per. dent $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DIED RETENTION S $ C WORKERS COMPENSATION WC017731493 (ADS) 03/01/2015 03/01/2016 X WCSTATu- oTH- AND EMPLOYERS'LIABILITY TORY LI TS R C ANY PROPRIETORIPARTNERIEXECUTIVE YIN WC017731495(AK,KY,NH,NJ,VT) 03/01/2015 03/01/2016 1,000.000 D OFFICERIMEMBER EXCLUDED? a NIA WC017731494 F E.L.EACH ACCIDENT $ (Mandatory in NH) ( L) 03/01/2015 03/01/2016 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 ff yes,describe under Conitihued on Additional P e 1,000,000 DESCRIPTION OF OPERATIONS below a9 E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD t. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma Parcel O u� Application # 0o Parcel, O Health Division . ' Date Issued l Conservation Division Application Fee �v Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board PV Historic - OKH _ Preservation / Hyannis Project Street Address I 00 y 44 ND h✓!p Village ElY&Jn/i S Owner l f g L. i 0_J&R6tE Address Sd r4Df Telephone Permit Request 4TI IC �i2 S�,ad�,�t;� r'nlS�il ►n✓ - Ate, I nrs t�T10{/ ", *1-I C Qek/ t V"I- R S r 2(PA k/0 I A/5A A—( tf/� GfN4 l✓4o., l -T C 14 INS 74-M So PA�[:: AW 8 fZl y(VT V is 4/f S 1 VS_rA-0_ 1 w/9 Ut_A- I oiy TO 4JZ&✓t-Se,.&Cd-� L✓# 1 S A/D Pd LV r O Pt oo Square feet: 1 st floor: existing&6proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 3 64 . v Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family U/ Two Family ❑ Multi-Family (# units) Age of Existing Structure O Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area�sq.ft) --1 Number of Baths: Full: existing new Half: existing -riew Number of Bedrooms: existing _new i w w Total Room Count (not including ba s): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing woo /coal stae: GYes ❑ 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 APPLICANT INFORMATION (BUILDER OR HOMEOWNER) N4.me P�I S(� EV���0,1�(Nt< Telephone Number aC l 7��/'�, D Address/ 3 cr�)p ;4 t-� License # O®t 5 0(� Home Improvement Contractor# oZC� 7 7!Y Worker's Compensation #WclfJ—Z// ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 1� R �� P v�v �t� ��,�� �o� G� SIGNATURE DATE /0 ,t FOR OFFICIAL USE ONLY �• APPLICATION# f DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL i FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. ► i 5 The Commonwealth o ,Massachusetts Department of Industrial Accidents _ Office of Investigations 4� 600 Washington Street Boston, MA 02111 yr www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):. 5� Address: L( &e Gj000 4a City/State/Zip: _ 2WS( ©./✓ IIK Od-q 16 Phone #: O/) 7?�(, 37.00 Are y6u an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑��eonstruction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. deling ship and have no employees These sub-contractors have" g• ❑ Demolition workingfor me in an capacity. employees and have workers' y [No workers' comp. insurance comp, insurance.$ 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.n Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself: [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 1 OA/ NC,-/A_ ���!'�/ ,P'lJ—ro�( Policy#or Self-ins. Lic.#: Lxc7 z 11- a-591 Y7 Y—01 `� Expiration Date: �" U /0 Job Site Address:_ (.JoD01_dn/l7 .�l/eT City/State/Zip:���//gA/Nls� A:�66 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. 1 do hereby certi find�, �ena,ties of perjury that the information provided above is ue and correct. Signature: Date: �0 O Phone#: G. 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#: tt` - Page 1 of 1 )fficial Website of the Executive Office of Public Safetyand'Security(FOPS) Mass.Gov Home Public Safety Department of Pubiie Safety Licensee Cofnp nts License Type Construction Supervisor License# 100459 1 t Restriction WS,IC Name Erik Nerstheimer City,State,Zip North Scituate, RI,02857 , Expiration Date 3/28/2012 Status Current • No complaints found for this Licensee. Back To Search w r ; Board of Building Regulations and Standards a. I Li.a ense or registration.valid for individul use only HOME IMPROVEMENT CONTRACTOR i. before the expiration date. If found return to: Registration- 120979 Board of Building Regulations and Standards - Ettptration 3/25/2010 One Ashburton dace Rm 1301 T e_Su "lement Card' =''s?sttlu'l��la. 021.0.8 Yp PP ' H I E L S C H ENGINEERING { =RIK NERSTHEIMER= 341 ELMWOOD AVE` ;RANSTON,RI 02910 �� - f i.i.. — --`Y— Admmisti ito r f Not valid without signm,r re http://db.state.ma.us/dps/liedetails.asp?txtSearchLN=CSL100459- 9/24/2009 J _ 100463 ��i'ftri' STEPHEN HINFS e 222 NARRAG k ETT AVENUE 'k�w JAMESTOWN, r..02835 6/23/2012 f =n;ni��iarrr' T" 100463 ro _ 102935 00 p STEPHEN HINESy X�Hx^1 222 NARRAGANSETT AVENUE �.. JAMESTOWN, RI 02835 6/23/2013 102935 k. QC'ORD CERTIFICATE OF LIABILITY INSURANCE . w OP ID 27 DATE(MMIDD/YYYY) THIEL-1 08/07/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Preston Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1350 Division Rd Suite 303. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR PO Box 810 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. East Greenwich RI 02818-0810 Phone: 401-886-8000 Fax:401-885-1700 - 'INSURERS`AFFORDING COVERAGE NAIC# INSURED • E y INSURER A: Hartford Underwriters Ins: Co .f T. INSURER B: Hartford Casualty Insurance Co Thielsch Engineering, Inc INSURER Liberty Mutual Insurance Group 195 Frances Avenue INSURERD: North American Capacity Cranston RI 02910 INSURER E: 4 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. OLICY EXPIRATION LTR NSR E TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY CTIV E DATE MM/DD/YY LIMITSS GENERAL LIABILITY - 7 EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY. 02UUNTD5678 04/01/09, ' 04/01/lo PREMISES(Eaoccurence) $ 300,000 CLAIMS MADE ®OCCUR .- MED EXP(Any one person) $ 1(),000 PERSONAL&ADV INJURY $l,OOO,OOO . - - GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY X PRO El LOO _. i Emp Ben. 1,000,000 AUTOMOBILE LIABILITY , B X ANY AUTO 02UENTD4850 04/01/09 04/01/1.0 CaaccidDswGLEUMIT. $ 1 OOO OOO CO accident) r r ALL OWNED AUTOS ` v. - - - BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS '�, � � F BODILY INJURY $ .. NON-OWNED AUTOS - (Per accident), PROPERTY DAMAGE $ - - (Per accident) , GARAGE LIABILITY - AUTO ONLY-EA ACCIDENT $ ANY AUTO ^" R ' OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY. - EACH OCCURRENCE $ 10,000,000 ❑ B X OCCUR CLAIMSMADE 02XHUUF6573 i 04/01'/09` 04/01/10_ AGGREGATE $ 10,000,000 W $ RDEDUCTIBLE • - a " $ , X RETENTION -$10,00O WORKERS COMPENSATION AND . f X TWu LIMITS ER EMPLOYERS'LIABILITY C ANY PROPRIETOR/PARTNER/EXECUTIVE WC2=Zll-259874-019 `'04'/01/09 04�01/1Oi E.G:EACHACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ SOO,000 If yes,describe under. SPECIAL PROVISIONS below '* E.L.-DISEASE-POLICY LIMIT Is 500,000 OTHER t D .Professional Liab µ DVL000025902 04/13/09 04%01%10; Prof tiab 2,000,000 A Leased/Rented E '02UU14TD5678 ,t ` 04/01/09 1 04/01/10 -Equipment . 100,000. • DESCRIPTION OF OPERATIONS i LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS *Except 10 days for non payment of premium. Certificate Holder -is included as an additional insured asrequired by a written-,contract with respect to the General Liability•coverage: " • CERTIFICATE HOLDER CANCELLATION TWNBARN SHOULD ANY OF,THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION `Town of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL *30 DAYS WRITTEN t Building Division NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Attn: Tom Perry IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR ,r 200 Main Street Hyannis MA 02601 REPRESENTATIVES. AUTHORIZED EPRES ACORD 25(2001/08) ©ACORD CORPORATION 1988 TE.�"/� THIEL-1 PAGE 2 INSUREVS NAME Thielsch Engineering; Inc OPI® 27 ®ATE 08/07/09 Also for RISE Engineering, a division of Thielsch Engineering, Inc. Gaskell Associates, a division of Thielsch Engineering, Inc. BAL Laboratory, a division of Thielsch Engineering, Inc. ESS Laboratory, a division of Thielsch Engineering, Inc. ALCO Engineering, a division of Thielsch Engineering, Inc. Water Management Services, a division of Thielsch Engineering, Inc. I � ENERGY CONSERVATION APPLICATION FORM FOR ENERGY EFFICICIENCY FOR ONE- AND TWO-FAMILY DETACHED RESIDENTIAL CONSTRUCTION (780 CMR 61.00) Applicant Name: L�12( � i�t i�S�1 (� Site Address: 3( w✓o w6tid o 1,j print Town: ly�✓til Applicant Phone: 6&,I) n - 7 0 Applicant Signature: Date of Application: /0. NEW CONSTRUCTION: choose ONE of the following two options) 780 CMR TABLE 6107.1 PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA FOR NEW ONE-AND TWO-FAMILY BUILDINGS MAXIMUM MINIMUM Ceiling or Slab Option 1: Basement P Fenestration exposed Wall Floor Perimeter U-factor floors R-Value R-Value Wall R-Value AFUE HSPF SEER R-Value R-Value and Depth National Appliance•Energy R-10, Conservation Act(NAECA)of 35 R-38 R-19 R=19 R-1O 4 ft. 1987 as amended,minimums or eater as a_pplicable k Note: This form is not required if you choose either of the two versions of REScheck as listed below. ❑ Option 2: RES check Version 4.1.2 or later variant software analysis must be completed 780 CMR 6107.3.2) REScheck—Web which can be accessed at http://www.ener c�gov/rescheck/ ADDITIONS OR ALTERATIONS,TO EXISTING BUILDINGS.OVER.5 YEARS OLD* *Buildings under 5 years old must use option#1 or#2 in New Construction section above. Complete the following formula to determine the % of glazing: (a) Gross Wall & Ceiling Area equals Formula: (100 x b _ a) SF 100 x — _ % of glazing (b) Glazing area equals SF b a If glazing is:5 40%.use the chart below. If glazing is>40 % roceed to "SUNROOM" section 780 CMR TABLE 6101.3 PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA ADDITIONS TO EXISTING LOW-RISE RESIDENTIAL BUILDINGS MAXIMUM MINIMUM Fenestration .Ceiling and .Wall Floor. Basement Wall Slab Perimeter U-factor Exposed floors R-Value R-value R-Value R-Value R-Value and Depth .39 R-3 7 a R-13 R-19 R-10 R-10, 4 feet a R-30 ceiling insulation may be used in place of R-37 if the insulation achieves the full R-value over the entire ceiling area(i.e.not compressed over exterior walls, and including any access openings). SUNROOM—An addition or alteration to an existing building/dwelling unit where the total glazing area of said addition exceeds 40% of the combined gross wall and ceiling area of the addition. Note: Owner to fill out Consumer Information Form (found in Appendix 120.P) RISE ENGINEERING - Federal ID#0"405629 RI Contractor Registration No 8186 A division of Thielsch Engineering' k ` MA Contractor Registration No 120979 R CT Contractor Registration No 620120 1341 Elmwood Avenue,Cranston,R102910 " S P 1 7 . Q09 COdVT'0 A ' (401)784-3700X j�� FAX(401)784 3710 . , MCT 8! I S it THIS CONTRACT IS ENTERED INTO BETWEEN RISE - ENGINEERING AND THE CUSTOMER FOR WORK AS ENGINEERING DESCRIBED BELOW CUSTOMER `. _'' -" "PHONE - DATE - Client S Rachel Todoroff (774)810-9066 09/14/2009. 104209 SERVICE STREET BILLING STREET - 39 Woodland Avenue - 39.Woodland Ave �. SERVICE CITY,STATE,LP - - BILLING CITY,STATE,ZIP Hyannis,MA 02601 Hyannis,MA 0260JOB DESCRIPTION RISE Engineering will provide labor and materials to seal areas of your home against wasteful,excess air leakage. This work will be ' performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can nclude caulks,foams,weatherstripping and other products. Primary areas for sealing include air leakage to attics,basements and other unheated areas(windows are not generally addressed.) This work will be performed at the rate of$66 per man per hour,which includes materials and testing. 8 man hours. ,. $528.00 RISE Engineering will provide labor and materials to install 2.25"R-10 semi-rigid fiberglass board insulation to III square feet of kneewall area , $299.70 RISE Engineering will provide labor and materials to install a 8"layer of R-30 Class 1 Cellulose added to 585 square feet of open attic space. $643.50 RISE Engineering will provide labor and materials to insulate the back of 1 existing lmeewall access hatch(es)with 1"rigid foam board , insulation,and seal the edge of the hatch with weatherstripping. $85.00 RISE Engineering will provide labor and materials to install(28)lineal feet of continuous aluminum ridge venting at the top ridge of your roof. The vent will be be supplied in(circle color)black,brown,mill finish. $476.00 RISE Engineering will provide labor and materials to install 6/4" X 16"rectangular aluminum soffit vents to increase ventilation in attic areas. : x $102.00 RISE Engineering will provide labor and materials to install 106 square feet of R-19 faced fiberglass insulation to the perimeter of the basement ceiling at the house sill. fi t $116.60 A RISE Engineering will provide labor and materials to install 41 square feet of R-19 faced fiberglass insulation to the crawlspace perimeter sill. r $53.30 ,. - I. Lei r - � { t;. � -.�:t. - _ _, • RISE ENGINEERING Federal ID#05-0405629 RI Contractor Registration No 8186 A division of Thielsch Engineering'. AAA Contractor Registration No 120979 CT Contractor Registration No 620120 1341 Elmwood Avenue;Cranston,R102910 ` (401)784-3700 FAX(401)784-3710 - -d,r®NTRd'�9CT I 7 E � .. _ Page _2 .THIS CONTRACT IS ENTERED INTO BETWEEN RISE ENGINEERING AND THE CUSTOMER FOR WORK AS _ E NC I N E E R I Nr- y DESCRIBED BELOW CUSTOMER - - - _ n ;PHONE •. .. -DATE Client# . Rachel Todoroff (774)810-9066 09/14/2009 . 104209 SERVICE STREET ,.:' - BILLING STREET - -' 39 Woodland Avenue 39 Woodland Ave SERVICE CITY,STATE,LP _ BILLING CITY,STATE,LP Hyannis,MA 02601 Hyannis,MA 02601 . t JOB DESCRIPTION - RISE Engineering will provide labor and materials to install 200 square feet of 6 ml polyethylene over open ground in designated _ crawlspace/earthen basement areas. F $60.00 RISE Engineering will apply all applicable,eligible incentives to this contract."You will be billed only the Net amount. Currently,for households where total income is less than or equal to 801/o of median income, the Cape Light Compact offers 100%incentive toward eligible measures(not to exceed$2,000 total incentive.). 4 . -$2,000.00 - ♦.. .✓ - a • Y. ' . . Y .. WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WRH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Three Hindresl Sixty-Fodr&10/100 Dollars $364.10 UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING.CUSTOMER AGREES TO REMIT AMOUNT.DUE IN FULL.NTEREST OF 1%VALL BE CHARGED MONTHLY ON ANY - - UNPAID BALANCE AFTER 30.DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AUTHORIZED SIG TURE RISE ENGINEERING - - ;- CUSTOMER ACCEPT _ NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE ACCEPTANCE OF CONTRACT�THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE �Ll SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK DAYS. AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE - r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Jnz GcJfos Map Parcel ® S� Permit# / l Health Division ( 01 b s Ab Me.1� Date Issued .G 6 Conservation Division �8 r bi/ Application Fee Tax Collector Permit Fee -3 S o O Treasurer 10 Planning Dept. EXISTING SEPTIC SYSTEM Date Definitive Plan Approved by Planning Board LIMITED TO_�P OF SEDROOMS Historic-OKH Preservation/Hyannis Project Street Address 39 U)o0 (a Ave - Village G1.1'll'1I -„ - Owner pQ.1 f Ck ac 0 OY OT� Address Telephone I_ Permit Request �� ► 1 �'�"'rn I % t Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 0 00 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(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new 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/coal stove: ❑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 - Y— � -A _ -Proposed Use BUILDER INFORMATION 7� Name � r Telephone Number 50 375 r lLa tg Address h License# 92L r P `��— Home Improvement Contractor# 3 k 7 Worker's Compensation# ALL CONSTRUCTION DEQB,115 RESULTING FROM THIS PROJECT WILL BE TAKEN TO CW 11r1(�t,�7 SIGNATURE DATE 10 ' I O Y FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER l DATE OF INSPECTION: y , FOUNDATION 0 f0 i9 /t /L /y - FRAME '07 n f�4L, INSULATION S v // G A9 ,�/'� �✓ �` � ��� �s;' FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ` GAS: ROUGH co FINAL `•-= �3 FINAL BUILDING DATE-CLOSED OUT co rr ttx - < ASSOCIATION PLAN NO. _" J _k T . � �, y - ',. .. -- . _.. _ ,,� k � f ` �L i 4 ` L.J t i f r � � � 1 t � - �.� �. � � F I i i _Y r � � i �y 1 7 r � � t } .,-J .�' � t i - � + I }ft � ~ � l 1 �"','� _ - � _ _ f _: _ I� i ' � , l•,1 _ .. r a ro o ti � R RoN`TT iy alo All- _ - 1 i i i 1 c� S 5KY Oki t e � i is 1.00 t � I o � I `x a k � �J I ! 1 r_ , I ASS. LOT 55 i- S60 113 �0 0 � ASS LOT 56 �' � ►�� ISS a \ � f80Z9 Ilia, 63�`_ A3L5. LOT 57 y — 1 , 'NOTE. PRE—EXISTING• NON—CONFORMING. WE.- 'RB" This MORTGAGE INSPECTIONPlan is For r00D WA% rin�tisTglltF, . 1�1.'.G(�`I'P1 OWNIER ;1�\i�i,'i,tl riioi IS ✓ 21I' 7.13E Ji; !i1. 1'�;IZ: Cr444-r1Fj I_'OQfI�(JI''I•' Y CERTIFY TO 1'�X�OU�[ �Z7G 9� ' r' - - - -SCALE:I" ___THAT THE BUILDING ��� of 'Q4.r IN THIS PLAN IS LOCATED ON THE GROUND AS t� y YANKED S U},1-I;l WD THAT ITS POSITION DOES _-_.__ CDNI'oP PAAUL CUNSI:];,TAN`)' ZONING LAW SE 8.,\CK REQUIREMENT 01 'I'1IE FAF�iITYIf:W __�Flrl(��1!�'_%'4 rll r' - A I�:D 't L•� c. _ '}, :� . -�,,• ''. •I013 Ii\Dl!sTRI' I"O:11) LIE WITHIN TIIE SPECIAL F1,00D IIr\::Af�l:. � �" �I:U2�'I'ONS �Ili..l �i:� it26-ltt :: :`•' ;SHOWN ON 'fHE H.U.D. btAP ll;1TEll_fI i9__fi7__. 1'EL- 428--00,�5 iit —Panel 250001 0005 �' FAX: 420-5553 IYFIGW PI THIS PLAN NOT MADE FROM AN INSTRUMENT SURVEY, NOT '1'O DE USED FOR FLN('1?.S ["PC'. 18745 J/)l' r a • _ of•ME rOEt- ` To of Barnstable • �'�� Regulatory Servides $ $ Thomas F.Geiler,Director s65s, Building Division FD A1A • Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 . Office: 508.862.4038 Fax; 508-790-6230 Permit ao, 1�ate AFMAVIT ' ErOME noROVEMENT CONTRACTOR LAW SWPIXhHM TO PERMIT ATTLICATION MQI,c,142A requi'es that the"reconstruction,alterations,renovation,repair,modernization,conversion •J aproyemeUt,removal,demolition,or construction of an additionto any pie-existing owj;er-occupied biding containing at least one but not more than four dwelling units or to structures which are adjacent to •• suoh residence or build pg be done by registere4 contractors,with certain exceptions,along with other requirements, • Type of Work: C� ' Estimated Cost 0 b 0, Address of Work: W 00 C� 1�-�V -• owner'sNeme;� �'I•e.9C .S " � C�C�® � Date of Application• \o— —0 . I hereby certify that: Itegi.stration is not required for the following reason(s); []Work excluded bylaw []Job Under S 11000 {]Building not owner-occupied [:]ev�ner pulling own permit Notice is hereby given that: OWt PULLING THEIR OWN PLE IT OR]jEAIMG WITH UNRYG•ISTMM CONTRACTORS FOR AYPLIC4,31 HOME IMpROYEMENT W OPX3)0 NOT JIM ACCESS TO THE AMITRATION PROGRAM OR.GUARANTY FUND UNDER MGL c,142A. SIGNED UNDERPBNALTIES OF PERJURY Ihereby apply foi a permit as the agept of the owner; Date Contractor Name Aegisfratioahlo, OR Owner's Name The Commonwealth of Massachusetts • — Department of Industrial Accidents' 660'Washington Street Boston,Mass. 02111. Workers' compensation.-Insurance Affidavit-General Businesses �!xy b ?Y�tea.• .YJ;°r„•F3•r"yw. •. � • :Y- , �'•jY �, tiA�i16-bl name: �'� _ - L, M1x .. } ;; :•r•- address; Uel 14 state: 5�s�ama ��ppro�ne 1 address tor and have no one $usiness Type: ❑Retail❑RestaurantlBaa,•/Aatiiag Establishment working in any capacity. ❑Office❑ Wei(mcludin.g•Real Estate,Autos etc.) ❑I am an em toyer with em Io ees(full& art time ❑ Other ' // %//%/% I am an cployer providing Yorkers' compensation for my employees working on this gob. :,, .-i.•ta+t'••,:.1'1:}% .'a; •t ��`,P'. ,t:•..••t• .r,3,.•(. ,, —'••::1•'!{ra ry y;r: •�. COIIl an -Xlam�- +•a'p'• •�: �,.r•;4.,- .•J,•, ,•i+ .:i.'.l a ,;• '!r- .'('••. i:; '.'%: 'h:` .?•' ' '!. ...:t > 'a7f•SyM1. •S''r:.+:i.:r�� .i•1.:. _ .i:;- J:. :i:)r r:•L t: wti. address7. :' t' . ;:,°; •;r .1:;,.:;: ,i:':.'-�'{:; tt+ .J� .;fir_ ::r... :1•. :ti:• '�. •ki•rt'r�+s.'r 4i•' � .:�.•,':.. :;�::.;. ,J� '•1 ,c.• �j' '•t' •l •:+ j •• :r ".,:'`` hone..#.::.�:•': :�. .':••;: `•:N'•'• �•' -%r• •:..fr+ JL���+.a.' :.y.::4".:y .•,i'Sn:p•.:k,':. Ul{C.'.#';:..,• ins'urance.00's :.: �.: . /;.. ... . 1.::: . :.•:.:,:• + .: :.•:�• ::.:_ .; 22 I am a sole proprietor and have hired the independent contractors listed below who have the following workers' .compensation polices: ^ ctim an 'n'anhe; y' ?r, 1, L. ;t.�':sYj :i - F•��}a:: nt'',..'i3. r••i'',�: '+• •,r` •ti,• •,9',•1:7:1 .t ,: '�( eddressi. 7 .,a. a •1 •Si;�.'••e;•Is.•.;.'e:i ';. .���. .i.+sa •;'i :�•a•r� frt, .r,`:'L ^a: .,r :'K •: - :i":�'r�:'•r.^.i,{;Y. i,��1.;i;: •.^;:. t.• �:J ,;::' s .;Z.�rr..'�C�' • ''r. . . ci �:.{•. '+, .I.r ,/t. .rr� •'• 'i r� iia•; :y:r.•t:'. ! f( ,e5 ':Y'ti. ,'•l'.i•• a:+: ` °t.,s�. •••f':T:•i'Y 4�. Y.Pn .i'�'• N lr r• •4' •O�iC :1F I" •.•`: fnsurance'co. - 'f'. 4' •}.;, 'r.'::• t�'•:..•• '�+,�•1•t• Yl.+ fir..:i'•t•:'r`'": •'• :ai••:r• com'any 319nte:•s-2 ' . . ! ' 'i;'• �hOnt:•ir:'. J•}, '� :i;•:i r .4M i;. .. Cl _ r� :L•i• :'4: '4. i.lj `, :..A'•. ;S,::o: :Y.:+• t.•ir • ;�• :i•Sy•, ;'i.•I:a,t .i,• .�:... :s� .:I. y: ,'}. ,7:,' .i+ ,,.'.fs�.� .i:�.•.. r_ i. si "• .. •1a c �: a.. :+�.. •`oil fns"urence'coP102 G Failure to secure coed under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a Pint up to 51,500.00 and/or !!!!rage as requir one years'impr{sonment as well as civil penalties In the foam of a STOP WORK OPMER and a fine of$100.00 a day against me. I understand that v. t may be forwarded to the Office of Investigations of the DIA.for coverage verifi copy of this statemen cation. I do here Acertz under the pains enalties of perjury that the information provided above is Prue and orrect Sign tur! Date. �. a c�Zzb Phone# SC���L716777,40 print name vJ official use only do not write in this area to be completed by city or town official city or town; permit/license it ❑Building DepartmeJ. ,❑Licensing Board 0•checkif immediate response is required ❑Selectmen's Office ❑HealthDepartmencontact person• phone#; ❑Other (zev�ed Sept 2003) Inforniation and Instructions. yiassachusetts General Laws ch4 pter�152 section 25•requires all employers to provide workers' compensation for their. loyees: As quoted from the Iaw' an employee is.defined as every person in the service'of another under any contract � li oral or written. of hire; express or imp .e An em f oyer is defined as an individual,partnership, association, corporation or other legal entity, or any two or mare of p ' oint enf rise, and including the legal representatives of a deceased,mVloyer, or the receiver or the foregoing engaged in a'� legal � to 'However the owner of a trustee of an iridivid�l,Partnership,.association or other le 1 entity, employing g employees.y dwelling house bay-mg :Lot morethan three apartments and-who resides therein, or fhe.occupant of the dwelling house of - another who employs,persbris to do.maintenance, construction or repair work on such dwelling house or on the grounds or b g appurtenant thereto shall not be of such eaployment.be deemed to bean employer. MGL chapter 152 section 25 also'states that every state'or local licensing agency shall vdthhold 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, neither the- not 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 in .the workers' compensation affidavit completely,by checking the box that applies to your,situation.:Please supply company Warne, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents-for confi=tion 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'"Iaw"or if you are _ obtain a;workers.'•compensation policy,please call the required to Department at the number'listed below. City or T owns . Please be sure that the affidavit is complete andprinted legrMy. The Department has provided a space at the bottorn 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.in.in the pe1rrnt/license number.which will be used as a reference number. The.affidavits,may:be.retumed to the sure, b mail or FAX unless other arrangements have been made. The Office of Investigations would like to than please in advance for you 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 - gtftce of tevesti�stiens 600 Washington Street Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 7274900 ext:406 Town of Barnstable p4�xrt rok� y� o� Regdatoxy S ery'ices ` Thomas F.Gefler,pirector Say- piyisiou rFD tN+ Tpmper* Budd"-Commissioner 200 Maw Stceet, $ya 'S'NIA 02601 wn,barnstable,ma,us -- Fax: 508-790-6230 office: 508:862-403 8 -� - vrop.erty p-w,nex Must _. complete and Sign:TMS section .... •' . . if using A$uilder owner of the subject property - Y' to o act n mybealf, -.. hereby authorize . hers relative to work lutlaoz=a by this bun&ng permit application f or - wood \Ck (Addxeso of Job} - - - .ate. Print Name r Town of Barnstable Regulatory Services Geiler,Thomas F. Director snnxsT,�s, * � gE 3 p.0� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstable.ma.'us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: 1 1 tIO'I JOB LOCATION: 3 C number street village "HOMEOWNER i l-at ttl4. 1�r 4 v V W cSoo ����a4�__ -`25.5 ?7,T name Borne phone# work phone# CURRENT MAILING ADDRESS: S:.aX41C AS vL/e_� O&KO L city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a.one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such. "homeowner"shall submit to the Building Official.on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building-permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of H er Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the' State Building Code Section 127.0 Construction Control HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section i09.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the respons bilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:hornmempt T"ET°�y TOWN OF BARNSTABLE r LE,BABB9TAB i 039. , BUILDING INSPECTOR APPLICATION FOR PERMIT TO ( SG� D *- �. TYPEOF CONSTRUCTION ......� 0. ................................................................................................................ ............. ....L �t......19..�� TO THE INSPECTOR OF BUILDINGS; _ The undersigned hereby applies four a permit according`. to the following information: Location —2 / 1,00.0-4 I-N....AkE.......1.! z.J.-!!.(.!IS........&4-, --�....................................................................... ProposedUse ... . .('.. !'...i..�.�.t +''...... ......D�.. .................................. ............ ........................................... Zoning District A... ...!...................... ..........................Fire District ... '` ` .............................................. Name of Owner : Yv i%i 4ee.... ... .....Address .................................................................................... a Nameof Builder ........ ..t .''?..P... .............................Address .................................................................................... Name of Architect "`""" ........Address .......................................................... .................................................................................... Number of Rooms .......4�./.Y..`.:............................................Foundation .. f,.. t /. Exterior '�r 11 Roofing �! � ��' � �?� /A-- — ................................................................................. FloorsW Op! ...................................................................Interior ...../.!!..��. ..L.......................................:................. HeatingG ....L..............................................................Plumbing ............ ........................................................... Fire lace Approximate Cost Difinitive Plan Approved by Planning Board ________________________________19________ . /40 Diagram of Lot and Building with Dimensions Fe e 40 rI a I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Jp / NameW.ti� ............. ......... Williams, �IIi W. /� D�ua�e � a�o, � �o E. ' [ x � ' �� | ! | en cIoaa deck 1 No Pennit {ur ----.---.----. ° ................... .----.- Location ......�9_�ondland..Avero�e,_____, o .-..----.�yuzuz�---.----.-.------ | Owner ' ����� ~`^ `^ Maude E. ' Type of Construction -.----..fr ............. ` -----~'-'--------^---------- � Plot ............................ Lot ................................ � Permit Granted October 14 19 71 - Date of Inspection "°'=| �""pe="~~ � � PERMIT REFUSED .----'-.--_-.......--.--.-. lV � � ---....-~.,...--.......---.-----~ � -''~-^^^^^'~'^^^'-^^--^---^-^--^---^ -.-.--..--.----...'.---,..-.-.---., ` _- .-...-...-.,_'.....,......,.-.,....~--~..- � . ' Approved ................................................. 19 � � -------.—.-------------...--. « ------`----------^~^--^--^^^ f ^ } ,