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0144 WOODLAND AVENUE
p ve, f �f Town of Barnstable -permit# Expires 6 months from issue date Regulatory Services Fee sARtvsresM 9�A t p`0g Richard V.Scali,Interim Director Building Division -R � 7 Tom Perry,CB®,Building Commissioner !' , 200 Main Street,Hyannis,MA 02601 r,�' 082016 8 2016 w Office: 508-862-4038, U j Fa x• 508-790-6230 EXPRESS PERMIT APPLICATION - �+ SIDENZ'UIL ®NEWE Not Valid without Red X-Press Imprint Map/parcel Number 2 70 3/ Pro e Address / lD n 'I✓e rlyQnn 5 [Residential Value of Work S /y 7C6 — Minimum fee of S35.00 for work under$6000.00 Owner's Name&Address kltA t9 2r �ly -u/00 d 14 y",s � 1,,4 Contractor's Name 1 2 o/ r 7 r �i+,Pn"fa Telephone Number C�01 7 �y -6 51 � Home Improvement Contractor License T(if applicable) /,2 F9 Email: Construction Supervisor's License#(if applicable) Q9-/ Jq(p ((Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner 71 have Worker's Compensation Insurance Insurance Company Name X�26"<-AiP-e 112 f CD Workman's Comp.Policy'& L410Q/S�� 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. Going over existing layers of roof) ["Re-side ❑ Replacement Windows/doors/sliders.U Value (maximum.35)r of windows of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *wheie required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. *`'Note: Prope er must sign Property Owner Letter of Permission. A cop of t e Home Improvement Contractors License&Construction Supervisors License is requ' ed. 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SValg ned%tby,CamScanner ti)glCk;�i'!1rf�f11lif,iFR;xtV,sf�lil57r1'4`Itf\;,al2h:`<'1'ti'fIt' f'4 i , � t!}.l�f•l5 bites+--9t;�rlpttFr;tf ±n€.fYx-f:::s�it?s _ F Massachusett, Depaitmeni of Public Safety ' Board of Suildin ' g Regulations and Standards License:CSSL-099196 Ccrsrruc.--n :'r iscr SPecialcv GIL S P)MENTAL 273.CLIFFORD STREET aq NEW BEDFORD MA L Commissioner Expiration: 1111712017 --- --..-,.__.._.-- _Of lee of Consu r°�('"rlrJ�rrr�r%c!T merAfrairs&BusincssRcgulntion ' 19iOME IMPROVEMENT CONTRACTOR ^j"gam Re istration: ax 9 = 77897 = 'Ex ;...2%2012018 T9Be. -' �` pirationc Corporation F&G HOME IMPROVEMENTS INC: GIL PIMENTAL 273 CLIFFORD S"f NEWBEDFORD,MA 02745' Undersecrelary " I -P- �r r'r'�•--��:�J_'�— �. may,. 'sir•` �r.t I The Commonwealth of Massachusetts _ Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):'I Address: a 13 �ree-1 City/State/Zip: 0e_� ,6_- Phone #: c5a�-Q(�2-r*l`vf Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. El I am a general contractor and I mppoyees(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 8.° 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 10.❑ Electrical repairs or additions 3.Q 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#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lie.#: 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,fne of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certi n er thep 'tas andpenalties ofperjury that the information provided above is true and correct. Si natur Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official ' City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: U RUNOffice of Consumer Affairs and Business Regulatio, - 10 Park Plaza Suite.5170 Boston, Massachusetts 021.16 Home Irnprovem�nt Contractor Registration; RepistraUon. 126893 ?. Type:: :Supplement Card F 2 Expiration: Z/3/2018 F F 'THD AT HOME SERVICE.$, INC. - ANDREW. SWEET ;• 2455.PACES FERRY ROAD, HSC C 1r1� � u i .,, ATLANTk GA 30339 Update Address and return card.Mark'reason for change. Ad dress R.Renewal -Employment Q LostCard ffice of Consumer Affairs.*Busiaess Regulndoa License or mistrahon valid for indwidual use only '•'. HOME 1MPROVEMEN7 CONTRACTOR: 'before the espiiation date.'If found return to: ` Office of consumer'Affairs and.Business Regulation . .Registration: 126893 Type: 10 Fark Plaza Suite 5170 l_xpirat�onc 8/312Qj8 Suppiemerit Card Boston, 02116 'NtA P. THO AT HOME SERVICES INC THE HOME DEPOT AT HOME SERVICES ANDREW SWEET` 2455 PACES FERRY ROAO HSC �' 1`i with ut signature ATtANTA,GA 30339. Undersecretary ot'.. f The Commonwealth of ttilassachusetts De artment of Industrial Accidents . ., P 1 �„Z Office of Investigations 1 Cor��'ess Street Suite 100 Boston,CIA 02114-2017 �7 wW1W.)nQSS.aOVldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Busness/organization/Individual): The Horne Depot At-Home Services . Address:908 Boston Tpk Shrewsbury.MA 01W Phone#:508-962-6942 City/State/Zip:S Are you an employer?Check the appropriate bog: 76Ne: oject(required): 1_© I am a employer with 2oo- 4. ❑ I am a general contractor and I construction employees(full and/or Part time)•* have hired the sub-contractorslisted on the attached sheet_ odeling 2❑ I am a sole proprietor or partner These sub-contractors have g, []Demolition ship and have no employees employees and have workers' working for me.in any capacity. 9. ❑Building addition insurance [No workers' comp.insurance comp. 10.0 Electrical repairs or.additions required.] 5• ❑ We area corporation and its 3_❑ I required-] a homeowner doing all work officers have exercised their 1 I U Plumbing repairs or additions myself..[No workers' comp. right of exemption per IVIGL 12.❑Roof repairs insurance required.] c. 152, §1(4),and we have no 13:[]�Otheri r1 employees..[No workers' comp.insurance required.] *Aay applicant that checks box 41 must also fill out the section below.shoring their workers'compensation policy information. t Homeowners who submit this affidavit milicating 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-coutactois and state whetheror not those entities have employees If the sub-contractors have employees,they must provide their worker'comp.policy number: ers,vokm nation insurance for my employees. Belmp is the policy:and job site , I am an employer that is providing cope information Insurance Company Name: New Hampshire Insurance Company Policy#or Self-ins.Lic.#: WC 015519215 Expiration Date:3112017 City/State/Zip: !f �/a401 Job.Site Address: f�y G✓otx� �Qna ✓e Attach a copy of the workers' compensation policy declaration:page(showing the policy number and expiration date)lead to the imposit. . ion of criminal penalties of a Failure to secure coverage as required under Section 25A of MGL . 152 in the form of a STOP WO ORDER and a fine fine up to$1,500.00 and/or one-year imprisonment, as well as civilpenalties 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 DJA r: nsurance coverage verification I do hereby certify-u pains and penalties of perjury that the information provided above is true and correct Dater /2 — Si afore: Phone#: 401-714-6 in this area,to be completed.by city or town offieial Official use only. Do not write 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 per or 6.Other Phone#• Contact Person: I ACO® DATE(MMIDD/YYYY) 6. CERTIFICATE OF LIABILITY INSURANCE 0211812016 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 poiicy(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). .CONTACT PRODUCER NAME: MARSH USA,INC. PHONE 1FAX TWO ALLIANCE CENTERIAIC- (A/C, IC No), E-MAIL 3560 LENOX ROAD,SUITE 2400 ADDRESS: ATLANTA,GA 30326 - INSURERS AFFORDING COVERAGE NAIC# 100492-HomeD-GAW-16-17 INSURER A c Steadfast Insurance Company 26387 INSURED - - INSURER_B Zurich American Insurance Co - - 16535 THD AT-HOME SERVICES,INC. hire Ins Co 23841 New Hams DBA THE HOME DEPOT AT-HOME SERVICES INSURER C: p 2690 CUMBERLAND PARKWAY,SUITE 300 INSURER D:Illinois National Insurance Company 23817 ATLANTA,GA 30339 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003746646.14 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED'BY THE POLICIES;DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR - POLICY EFF POLICY EXP _ LIMITS LTRTYPE OF INSURANCE POLICY NUMBER MWDDIYYYY MMIDDIYYYY A X COMMERCIAL GENERAL LIABILITY GLO4887714-06 03/01/2016 03101/2017 EACH OCCURRENCE $ 9;000,000 DAMAGE-TO RENTED - 1,000,000. CLAIMS-MADE M OCCUR - - - PREMISES Ea occurrence $ LIMITS OF POLICY.XS MED EXP(Anyone person) $ EXCLUDED OF SIR:$1M PER OCC PERSONAL e.ADV INJURY $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 9,000,000 X POLICY❑JECT LOC PRODUCTS-COMP/OP AGG $ 9,000,000 $ OTHER: BAP 2938863-13 0310112016 03/0112017 COMBINED SINGLE LIMIT $ 1,000,000 B AUTOMOBILE LIABILITY .. Ea accident X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY,INJURY(Per accident). $. AUTOS AUTOS PROPERTY DAMAGE NON-OWNED per acc dent $ HIREDAUTOS AUTOS Is UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ 03 10112016 03101I2017 SER OTH- C WORKERS COMPENSATION WC015519215(ADS) PTATUTE ER ' C AND EMPLOYERS'LIABILITY v I N WC015519217(AK,KY;NH,NJ,VT) 03/01/2016 03/01/2017 E.L.'EACH ACCIDENT $ 1,000,000 ANY PROPRIETORIPARTNERIEXECUTIVE NIA - D OFFICERIMEMBER EXCLUE N WC015519216(FL) 03/01/2016 03/01/2017 E.L.DISEASE-EA.EMPLOYE $ 1,000,000 (Mandatory In NH) 1,000,000 If yes,describe under Conitnued-on Additional Page E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached IT 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 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 1� ''2j! �ZME Tp� Town of Barnstable Permit# 1.0 Expires 6 monilrs from issrre date Regulatory Services Fee BAMSTABM MASS. $ Richard V.Scali,Interim Director i639 �0 to Building Divisions Tom Perry,CBO,Building Commissioner ' 200 Main Street,Hyannis,MA 02601 ®EC 08 2016 www.town.bamstable.ma.us K/N Office: 508-862-4038 L! � F508-790-6230 - EXPRESS PERMIT APPLICATION - RESIDEN'TIA]L ONLY, // Not valid without Red X-Press Imprint Map/parcel Number )-70 N(p �J tfn Property"Address ��7�f 6 c��11/ VIC— yCt'/1/II S [Residential Value of Work$ J 1. kk o — Minimum fee of S35.00 for work under$6000.00 Owner's Name&Address Auff lVel Il e r d✓oo�llQ^ilcl MA n i&a Contractor's Name 7 � / �P,o h I�Va C Telephone Number y 01 -] I y -6 Home Improvement Contractor License T(if applicable) /,2 Email: Construction Supervisor's License 4(if applicable) 0IL007 7 ((Workmen's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner 71 have Worker's Compensation Insurance Insurance Company Name AA�W 4/Bn90S'{ Lre_ Os, t"11) • - Workman's Comp.Policy 9 /S5r5"119 2- /S� 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. Going over existing layers of roof) ❑ Re-side ®replacement Windows/doors/sliders.U-Value .130 (maximum .35)4 of windows /q 4 of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Alhere' required: [ssuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation;etc. **'Note: Prope er must sign Property Owner Letter of Permission. A cop of t e Home Improvement Contractors License&Construction Supervisors License is requ' ed. SIGNATURE: Q:\WPFILESIFORMS\building permi rrri XPRESS.doe Revised 061313 Home Depot Contractor License Numbers: MA Home Improvement Contractor Reg. # 126893 Salesperson Name and Registration Number: Janice Campbell : R-1-073-13-00016 Home Improvement Agreement THD AT- HOME SERVICES, INC ("Home Depot") or Service Provider named below will furnish, install and/or service the equipment listed below at the price, terms and conditions as outlined on this form. Customer Information: Kurt Wegner [Boston North 9681157 First Name Last Name Branch Name Lead# 144 Woodland Avenue HYANNIS MA K2601 Customer Address city State Zip [(661) 607-7930 Home Phone# Work Phone# Cell Phone# kurt.wegner@gmail.com Customer E-mail Address NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 908 Boston Turnpike Unit 1 Shrewsbury MA 01545 Address city State Zip or Email CustomerCancellationNorthEast@homedepot.com BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A different CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR PROFESSIONAL, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT THE CONTRACTOR GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR RIGHT TO CANCEL. Acknowledged XC-A v0=117 11/01/2016 Customer's s ature Date 1 Distribution: White-Home Depot Yellow-Customer Copy Contract Price and Payment Schedule: Payment of the Contract Price is due upon completion unless a different payment schedule is specified in the State Supplement. 19880.00 Includes all applicable discounts, rebates, and , taxes. Contract Price $ Excludes finance charges." Minimum %q deposit$ Due Immediately Remaining balance $ Due upon completion ' Finance Charges *Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement, to which The Home Depot is NOT a party, and will be in addition to Customer's payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service Provider may collect Customer's.payment(s) made payable to The Home Depot. Insurance proceeds will ❑will not be used to pay some or all of the total amount of sale. Description of Work to be Performed: Installation of Windows A more detailed description of the work to be performed is included in the section entitled Scope of Work which appears on page 3 of this Agreement. Anticipated Delivery Date / Installation Schedule Approximate Start Date: 12/27/2016 Approximate Finish Date: 01/24/2017 All dates are approximate and subject to change based on unforeseen events including inclement Weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if applicable. Electronic Records Authorization: You are entitled to a paper copy of this Agreement if you choose. If you consent to an e-mailed copy, your consent applies to this Agreement and all subsequent documents and written communications related to this agreement. By contacting your Service Provider, you may update your email address,withdraw your consent, or obtain a paper copy of the Agreement or related documents at no charge. By providing your consent and verifying your email address above, you confirm that you have access to a computer that can receive and open emails and PDF documents. is 'n this paragraph, I consent to receive only electronic records related to this transaction. Initial Acceptance and Authorization: By signing below, you authorize Home Depot to (a) arrange for Service Provider to perform Installation and/or(b)order and arrange for the delivery of special order merchandise, including special order merchandise that maybe custom made, as specified in this Agreement. Do not sign if blank or incomplete. (Service Provider's/permitting information may need to be provided to You later.) By signing, you acknowledge that you have read, understand, and accept this Agreement in its entirety, including the General Terms and Conditions and State Supplement, if any. You further acknowledge receiving a complete copy of this Agreement. Keep it to protect your legal rights. X 11/01/2016 Customer's Signature a, Date X Cosigner(if applicable) Date X 11/01/2016 Sales Cons s Si Date .f' 2 Distribution: White- Home Depot Yellow-Customer Copy �J i;oard of filusldlf,�g Rogs lattom,* ar4 Staftdafds C ,, �` ( �sisyTe IsriF�<pM 'tiuiu�,iMaal ;lN L w#n" CS-470M , t X)SEPH C OVARIt f' 15 VALL Sf WA.REHA.M MAW it /C et - Ofrott of C'oneanrer Affwita► HOME IMPROVEMENT CO M � Registration 134Q Expiration: 1140.0 T." ° J S J 'Remod king �~ / 1 ran ,a 7- 15 Fall SS Viareiarn,ma 02571 I The Comawnwealth of Massackusetts Department of Industrial Accidents �---j Office of Ini4sfigadons CEP` . ,- 1 Congress Stree4 Suite 100 P. Boston,AM 02114 2017 -" www nwss gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Nate(Business/Organization/Individual): ,T Address: 1: ' City/State/Zip: t 60 ti M' d Phone#: L3 2� Are you an employer?Check the appropriate bog: Type of project(required): 1.❑ I gun a employer with 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. []New construction V0 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 an capacity. employees and have workers' g y p �� Building additi� i [No workers' comp.insurance comp:insurance.t 9. [ on required.] ' S. F1 We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp. insurance required.] 'Any applicant that checks box 01 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit thi_c affidavit indicating they are domg all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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 arils an employer that is providing workers'cornpensadon insurance for any employees: Below is the policy and job site information. Insurance Company Name:- Policy#or Self-ins.Lic.-#: Expiration Date: . Job Site Address: City/State/Zip.` Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152-can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c- nder the pajVs and en 'es o er'u that the in ormation provided above is true and correct Si gn afore: ! Date t. w Phone#: Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: The Commonwealth of Massachusetts Department of Industrial Accidents 1= +1 Office of Investigations :~ I Congress Street; Suite 100 == Boston,MA 0211 4-2017 www mass aOV1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/El ectricians/Plumbers . Please Print 1-mi-b11 Applicant Information Name (Business/Or.-mizaaon/individual): The Home Depot At-Home Services Address-908 Boston Tpk City/State/Zip: Shrewsbury,MA 01545 Phone#:508-962-6942 Are you an employer?Check the appropriate bog: F6E of project(required). zoos 4. I am a general contractor and I 1.© I am a employer with El consttltction * have hired the sub-contractors [l emodeling employees(full and/or part-time).. listed on the attached sheet 7. 2.❑ I am a sole proprietor or partner-' These.sub-contractors have Demolition shipand have no employeesemployees and,have workers' Buildingon working for me in any capacity. comp.insurance.= Electrical repairs or additions o workers comp.insurance. 5 We area corporation and itsrequired.] officers have exercised their I .]Plumbing repairs or additions 3.❑ I am a homeowner'doing all work. right of exemption per A+IGL myself. No workers' comp. h p 12_[I Roof repairs c. 152, §1(4),.and we have no 13 [gOther �� �.�dot.✓ insurance required.]" . employees. [No workers' comp.insurance required] rE lucP/�P/i +pm applicant that checks boy 1 must also till out the do ing all o� their workers I and Ihea hire outside cmontcactois must submits pensation policy a new affidavit indicating such. t Homeonvers who submit this affidavit indicating they are'Contractors that check this bay must attached an additional sheet showing the name of the sub contractors and state whether or got those entities have employees. if the sub-contractors have employees,they must Provide their workers'comp.police number: . . workers com nsaiion insurance for mY employees. Below is the policy and job site 1 am an employer that is proviav pe information. Insurance Company Name: New Harnp shire Insurance Company Policy#or Self-ins.Lic:#: sinrzoi7 WC 015519215 Expiration Date: Job:Site Address: l y y l.�Do���►� ✓e— City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expire imposition Of criminal altr of a Failure to secure coverage as required under Section s ef NMGLll as t Pena211eans II�thde for to m of a STOP V►tORK RDER and a fine fine up to$1,500.00 and/or one-year .Impnsonment, as 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 A r: surance coverage verification. . I do hereby certify is pains and penalties of perjury that the information provided above is true and correct Date: /2 7 Si attire: Phone#: 401.-7:1:4-6 LEOther only. Do not write in this area,to be completed'by city or town official. Town: � Permit/I,icensehority(circle one):Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Phone#• son• _ - - ion Office of Consumer Affairs and Business Regulation 10`Park Plaza Suite 5170 Boston, Massachusetts '02116 Home Improvem�n�Conttactor Registration ReOisteaUun; 126893 ' Typ ;Supplement Card: Expiration: .8/3/2018 •THD:AT HOME SERVICES, INC ANDREW SWEET 1 ;-1 _ - - 2455 PACES FERRY ROAD, HSC C 11 ° - ATLANTA, GA 30339 , { 3, Update Address and return card.Mark reason for change._ Renewal (�-Empioymenf '0 Lost Card Address E] r SEA 1 , 2pM-US/ty; fi3ce of Consumer AffaLs.&Basiaess Regolatioo License or registration valid for individual use only arq" before the expiration date. If found return to: rHOME:IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation . �:` ;RegisVation. 128893 Type: 10 Park•Plaza-Suite 5170. Expiration g/3/2016 Supplement Card: Boston,MA 02116 " THD AT HOME SERVICES INC THE HOME DEPOT AT HOME SERVICES ANDREW SWEET` 2455 PACES FERRYAOA'Di. HSC ATVANTA,GA 30339 Ugdersecretary Not.v _ with nt signature ® DATE(MMIDDIYYYY) ACO CERTIFICATE OF LIABILITY INSURANCE F02/1812016 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 ER BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUR O, 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). CONTACT _ PRODUCER _ -NAME: MARSH USA,INC. PHONE FAX TWO ALLIANCE CENTER AIC No 3560 LENOX ROAD.SUITE 2400 EADD R-MAILES. S: ATLANTA,GA 30326 INSURERS AFFORDING COVERAGE423841 AIC# 100492-HomeD-GAW-16-17 INSURER A:Steadfast Insurance Company INSURED INSURER'S:Zurich American Insurance Co THD AT-HOME SERVICES,INC. INSURER C c New Hampshire Ins Co DBA THE HOME DEPOT AT-HOME SERVICES 2690 CUMBERLAND PARKWAY,SUITE 300 INSURER D:Illinois National Insurance Company ATLANTA,GA 30339 INSURER E INSURER F`. COVERAGES CERTIFICATE NUMBER: ATL-003746646-14, 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 CONTRACTOR OTHER DOCUMENT NTH 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. POLICY EFF POLICTEXP . ADDL SUER 'LIMITS INSR TYPE OF INSURANCE � � POLICYNUMBER � -MM/DDM(YY MM/DD/YYYY - LTR A X COMMERCIAL GENERAL LIABILITY GLO4887714-06 03/01/2016 03/01/2017 EACH OCCURRENCE $ 9;000,000 DAMAGE TO RENTED 1,000,000 CLAIMS-MADE a OCCUR -PREMISES Ea occurrence $ LIMITS OF POLICY XS. MED EXP(Anyone person) $ EXCLUDED OF SIR:$1 M PER OCC PERSONAL&ADV INJURY $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 9,000,000. X POLICY PRO- LOC PRODUCTS-COMP/OPAGG $ 9,000,000 JECT g OTHER: BAP 2938863-13 03/01/2016 03/01/2017 COMBINED SINGLE LIMIT $ 1,000,000 B AUTOMOBILE LIABILITY Ea accident BODILY INJURY(Per person) -$ X ANY AUTO - - - ALL OWNED. SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $. AUTOS AUTOS PROPERTY DAMAGE NON-OWNED Per PE dent $ HIRED AUTOS AUTOS $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS U18 CLAIMS-MADE AGGREGATE $ Is DIED - RETENTION$ PER OTH- C WORKERS COMPENSATION WC015519215(AOS) 03/01/2016 0310112017 X STATUTE ER C AND EMPLOYERS'LIABILITY Y1 W WC015519217(AK;KY;NH,NJ,VT) 03/01/2016 0310112017 E.L.EACH ACCIDENT $ 1,000,000. ANY PROPRIETOR/PARTNER/EXECUTIVE N I A D OFFICER/MEMBER EXCLUDED? N WC015519216(FL) 03/01/2016 03/01/2017 E.L.DISEASE-EA EMPLOYE $ 1,000,000 (Mandatory In NH) 1,000;000 If.yes,describe under Conitnued on Additional Page E.L.DISEASE-POLICY LIMIT $ DESCRIPTIONOF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,AddBonal Remarks Schedule,may be attached 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 DELIVERED IN 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. I Manashi Mukherjee _3ytbauoo :rb !� - ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD r 1SNw8 �o NN\01 Town ®f Barnstable *Permit ires 6 m nt mitLsftom Issue e I Regulatory Services Fee 900Z 6 Ndr R . Thomas F.Geiler,Director Building Division Torn Perry,CBO, Building Commissioner cq 1 200 ain Street,Hyannis,MA 02601 wttown.barnstable.ma us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not.Valid without Red X-Press Imprint Map/parcel Number / Property Address j/4/ esidential Value of Work 9 .7�© I Mini=4 fee of .00 for work under$6000.00 Owner's Name&Address !hr/b&4. Contractor's Name4 f ✓l�s �� Telephone Number 1y ys� o�yd. Home Improvement Contractor License#(if apQlicable) f ledti Construction Supervisor's License#(if applicable) 1647 Int orkman's Compensation Insurance Check one: - ❑ I am a sole proprietor ❑ I e Homeowner have Worker's Compensation Insurance Insurance Company Name 2`1rT w► h' s _ Workmen's Comp.Policy# ��12� / " a.S/ — Copy of Insurance Compliance Certificate must be on file. Permit Request Re-roof(stripping old shingles) All construction debris will be taken to SP ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side [] Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exerapt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. ome r C. tors License is required. SIGNATURE: Q:Forms:expmtrg Revise071405 COREY & COR-Ey T he -Rrooftrs Cart C % 4 ataitt k * 74 1694 FAL MOUTH RD #115, CENTERVILLE, MA 02632 CERTAINTEED WOODSCAPE AR30 RE -% R'OOFING PROPOSAL October 27, 2005 HELEN CHRISTIE HOUSE INSTALLATION ADDRESS: ATTN: .IOHNVIOLA - . HELEN CHRISTIE HOUSE P.O.BOX 653 144 WOODLAND AVE HYANNISPORT,MA 02647 HxANNIS,MA COREY & CO I' hereby proposes to perform the following sew cea'in a neat and professional manner and in accordaie with the manufacturers specftcations and local building codes. Remove and Haul Away All o ie.Old Asphalt Roofing Shingles: Re Nail All Plywood Sheathing&Fill.in Roof Vent Openings as needed. Supply and Install CERTAINTEED WOODSCAPE AR 30: 30 YEAR WARRANTY, 5 YEAR SURD START PROTECTION, CLASS A FIRE RATED, ALGAE RESISTANT, 245 POUND HEAVY WEIGHT, SELF-SEALING, 70 MPH WIND WARgANTy MULTL,LAYERED, LAMINATED ARC.I1ITECTITRAL STYLE,FIBERGLASS BASED ASPHALT SHINGLE with COPPER/CERAMIC STONES witha€FULL 10 YEAR WARRANTY AGAINST ALGAE CON�AM NEN1T COLOR:_2/1 F<'T . 00 l pv Supply and Install CERTAINTEED WINTER-GUARD (lee& Water Shield )WATERPROOF UNDERLAYMENT SYSTEM on Roof Eaves,Under the Step Flashing _ on the Skylight, Chimney and Gable Wafts. Supply and Install 8" WHITE ALUMINUM DRIP EDGE-on Ali of the Eaves. Supply and Install SMART SOFFIT VENT SYSTEM on the House Ventable Eaves. htto://www.dciomducts com/him]/smartveig htm Sup pl 'and`Install, SMART VENT RIDGE VENT SYSTEM on All ofthe Hp Midges. htto://www.dcinmducts.com/h�il/smart idee hi Supply and Install ALPHAPROTECTOR-SUL SYNTHETIC UNDERLAYMENT MEMBRANE httu.//www•permaroroduct&com/onrmeforms/alohanrotector ndf Supply and Install COPPER e& NEOPRENE SOIL PIPE FLASHINGS Clean and Remove Debris from work area after job is completed. J TOTAL, EWESTMENT $ 6500.00 Payable immediately upon completion. POSSIBLE EXTRA: After the Shingles are removed from the roof, we will lift one sheet of plywood make sure that the insulation is not up against the plywood sheathing so that Ventilation cannot occur from the Eaves to the Ridge. If it is, VENTILATION PANELS will be installed by Removing the Plywood Sheathing, Installing the Panels, Turning the Plywood over and then Re-installing the PI would be charged for as an Extra at the rate of$ 5.00 per panel including Materials and boaYw - If d 6 thi Panels per Sheet of Plywood. POSSIBLE EXTRA CARPENTRY: Any Rotted or Otherwise Deteriorated Trim Boards, Plywood Sheathing,Missing Metal Flashing, Side Walling or Any Other Carpentry Needing Replacement will be done and charged for as an Extra: Materials Plus 20% and Labor at the Rate of$ 50.00 per Hour. PAYMENT SCHEDULE: A Deposit of One Half is due at the Signing of this Roof Proposal and the Final Payment for the Balance is Due Immediately Upon Completion. WORD SCHEDULE: All Roof Work is Normally Scheduled for Completion Within 60 Days of Acceptance and Receipt of Deposit providing the Materials are Available. Please Make Checks Payable to: CHARLES CO.REY COREY & COREY Warranties the Shingles and Labor for 10 years. CERTAINTEED Warranties the shingles and labor 100% for the First 5 Years and then on a pro-rated basis for 30 Years Total if the shingles becomes defective. CERTAINTEED Warrants the Shingles up to a 70 MPH WIND WARRANTY. CERTAINTEED Warrants the Shingles to be Algae Resistant for a Full 10 Years. Any alteration or deviation from above __.. charge,over and above the estimate. All a specifications,will executed only upon written orders and will become an extra agreements contingent upon strikes,accidents or delays beyond our control. Owner to carry fire,tornado,and other necessary insurance upon the above work.. This proposal may be withdrawn by us if not accepted within thirty days. COREY & COREY carries Workman's Compensation and Public Liability Insurance on the above work DATE OF ACCEPTANCE: ///(a a ACCEPTED BY: SUBMITTED BY: AUTHORIZED SIGNATURE CHARLES HOMEOWNER COREY & COREY x p\,GRAG Rv�sp J OipRp'�SpRVG�\�N S 8 �pN ., p0288 . gn�e 18�g1 •� ' 6 \ C NRP FPx �E,M A 16aNIN00 -- --- ---- �, u Board of Building Regulations and Standards License or registration valid for individul use only" '' before the expiration date. If found return to: HOME IMP OVEMENT CONTRACTOR d Standar ds Board of Building Regulations an •... Registratt 'rw 136066 A§1 rtgai Place Rm 1301 PIN IV 61 / 06 oston, a. DdriO$ + . i ( J j COREY&CORE �: a r-y MENTS y' CHARLES CORE „ p i 16"FALMOUTH R 1 h!y7` C.G--�, r Not vale wit ature CENTERVILLE,MA 0261�. Administrator 7�a.4Department of bidustrial Accidents Office of Investigations* ' Su ' a 600 Washington Street Boston,MA 02111 5 a� www mass.gov/diar workers' Compensation prance Affidavit: Builders/Contractors/Electridahs/Pl hers A licant Infoa�ati®n Please Print Legibly Name (Business/Orga=ation/Indmdual): 1W ks 0J&4E1/_ Address: Ito 4916 )Lo lowaa'M /i r City/State/Zip: C „Aft/(ie Phone#: Are you an employer? Check the appropriate box: Type of project(required)-. 1.❑ i am a employer with 4. 21 am a general contractor and I ' 6. ❑New coristiuction employees(fall'and/or part time).* have hired the sub-contractors 7. Remodelin 2.❑ I am a sole proprietor or pminer- listed on the attached sheet $ ❑ g ship and have no employees These sub-contractors have 8. Demolition woriting for me in any capacity. workers' comp.insurance. g. Building addition (No workers' comp.insurance 5, ❑ we are a corporation and its i0.❑ Electrical repairs or.additions required.) officers have exercised their 3.❑ I am a homeowner doigg all work right of exemption per MGL I1.❑ Phimbm repairs or additions Myself.-[No workers' comp. c. 152, §1(4),and we have no 12. oof repairs insurance required.]t employees.[No workers'-- 13.❑ Other , comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: t Homeowners who submit this affidavit indicating they are doing all-work and then hire outside contractors must submit anew affidavit indicating such " tCor&actors that checkthis box must attached an additional sheet showing the name 6f the sub-contractors and their workers'comp,policy information, am an em information. ' Insurance.Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: I Yy QMJ� T,� City/State/Zip: b.__ Attach a copy of the workers' compensation policy declaration page(showing the policy number d piratfon date). Failure to,secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of 6iiminalpenalties of a fine up to$.1,500,.00 and/or one-year imprisonment, as well as,civil penalties in tfie 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 statemenf may be forwarded to the Office;of Investigations of the DIA for insurance coverage verification. I do hereby certify der the 'airs and penalties of perjury that the information provided a ove IS true and correct: Sf ature: Dater Phone#: ' Official use only. Do not write in this area,to be completed by city.or town official, City or Town: PermitUcense# Issuing Authority(circle ane)s 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Issuing Contact Person: Phone#: T Information . sachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees: Mas j t�� Statute, an employee is defined as"...every person in the service�of auotber under any contract of biue,� � Pursuan express or implied,dral or written." Au emiploy&is defined aS:.?4 vpdivi¢ual,;parinership association,o<uporation or other legal Mfity,or any two or.snore ged in a joint enterprise,and including the legal representatives of a deceased employer,a the of the foregoing enga " receiver or trustee of an individual,partnership,as, or other legal entity,employing employees. Howver:ttte owner of a dwelling house having not more than"three'apwinents and who resides therein,or.the occapant of the dwelling house of another who employs persons to do maintenance,construction or repair woiknn such dwelling house or on the grounds or bu37ding appurtenant thereto shall not because of such'empbyn!nt be deemed,%be an employer." MGL chapter 152, §25C(6)also states.that"every state or local licensing agency shall withhold the issuance or renewal of a license,or perm to operate a business or to construct buildings hi thetomnnonwealth for any applicant who has not produced acceptable evidence•of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its'political subdivisions shall enter into any contract for the performance of public work until acceptable.evidence of compliance with the insurance 1equirements of this chapter have been presented to the contracting authority. Applicants Please fill out the workers' condensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s).name(s),address(es) and phone numbers)along with their certifieate(s) of insurance. Limited Liability Companies(LLC).or Limited Liability Partnerships(LLP)with no employees other than the ' workers' compensation insurance. If an LLC or LLP does have members or partners; are not required to carry . employees,a policy is required. Be advised that this affidavit maybe submitted d e the dartment'f Ihe ndustrial should, Accidents for confirmation of insurance coverage. Also be sure to sign be Accidents to the city.or town that the application for the permit or license is being requested,not the Deparimeat of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' lease call the Department at the number listed below, Self-insured companies should enter their _.. ._compensatisznpohcY_�P._. . _. -_.h.— -- - — --_-..__..-- ._...u...— — .—• — — .........— — .. —.....— — self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Departrnent 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'tthe permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any giveri,year,need-only'submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"'tlie applicant should write"all locations in (city or tom)."A copy of the.-affidavit that has been officially stamped or narked 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 or citizen is obtaining a license or permit not related to any business or commercial venture year.Where a home owner (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit lm Ike to thank you in advance for your cooperation and should you have any questions, The Office of Investigations would please do not hesitate to give us a call. The Department's address,telephone and.fax number: The Commonwealth of Massachusetts . . .T .. ' Department of Industrial•Accidents 0 nvestigaffi��ce of Iti®ns r. 400 Washington Street. . Boston,MA 02111. Tel.#617-727-4900 ext 406 or 1-�877-MASSAFE Fax#617-7274749 Revised 5-2645 www.mass.gov/c is FROM ':GLASSOWORKSHOP FAX NO. :5083520175 Jan. 19 2006 04:30PP1 P2 & s 2' Y ` �• 'f:.NY '3�Csat< t��'hx�e' 3 i�{ � �'•`', i�":{i �ti„ ' • a �_ � .'„•' r���,`c o•`T. 'e' '��`t Ykrw'•`� �-I Y 31FA`4 * (� .M:n,.n... .... n::r...... ..d .i t ......a • :a..ei:,:, ,�5�8.y.�'"''N K:.,xM.,i^s Puoo 1 THIS CERTIFICATE 05 ISSUE( ASxA WTTER OF INIFORMATION vOLDMAN ® ASSOC INS FIN ONLY AND CONIFEFW NO RIGHTS UPON THE CERTIFICATE lIeLDER, THIS C4INTIFICAlM DOES NOT AMEND EXTEND OR ALTER FALMOUTH RD ALTER Tim 4OVIEAR iE AtFORDEO Ry-rmIE t'OLiC�BELOW. RTE 28 HYANNIS MA 026012319 COMPANIES AFFORDING COVERAOE COAAPA9IY - 28HAP A THE TRAVELERS INDEMNITY COMPANY 'M9UfeED - CObLPAP1Y COREY, C4ARLES DBA f $ COREY & COREY COMPANY FALMOUTH ROAD OiIS CENTERVILL.E MA 02632 I C -- CORAPAIyY D }x THIS IS TO CEFTIFY THAT THE POLICII s x. OF iNSUF1ANCE 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 OTHEP DOCUMENT WITH PE$PEOT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE IN$URANOE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONpfTIaNS OF SLCH pOLIC1E8-tIMffE SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. co TAPE OF IIURAMCE PQ 9bm IIIIIIIIIINIMIR PATE MNY., IOATE 1Y� ; LI�tITB Golift"LM.l1iI G6NEFAL p¢QREOATE COMMERCIAL GENERAL LIARU rY �-{--- -- r PRODuCS$•CONP/OP AGG. (g <s:w CLAIMS MAN OCCUR PkR80NAl S AaV,NVJURY S pYRB€R'S&CCIMRAC fOA$PRAT. EACH OGCURIIENM L MAE DAMAGE 4"one III JAW,DWEAIBE Wv one ge am) S AAROYORIL,E L.lA81UTY COMBINED SML.6 � ANY AUTO um r ALL OWNED AL TO$ BODILY NJU14Y BCHEDULFD AUTOS (Per Peman) 8 HIRED ALIT08 9013I6Y JNJUAY NON-OWNEDAME ' (PerAwd*nt) { I e PiOPEF N allMOC Is lam GE u4mmy AUTO ONLY-EA ACCIDENT S ANY OTHER THAN AUTO ONLY: A< ''; `' ''�;<''r•,�' r EACH ACCIDENT g<+ i A2611I ATE FA6W OCCURflENOM i . UMSREL'.A FORM AACIIiECiAT! s OTHER THAN UI FOPM i A WORICtire COMnEdIiATIOR AMP r EMpLpym UABBIW (U8-O&ti8C$1-i�05) 09-14-05 09-14-08 STATUTDFY UMrrB 7116 PRCPHIETORr - - LAW A=DENT _ i too . O PAKINSRefF7(ECUTNE INCL lN9EA3M-POLICY UMR $ OFFICERS ARE: X pUQL SOD ORP T OTHER DfSE48E—E,ACN 661P.OYEE s 100.000 DEBL7MPTION OF 6C+8DiA Tlpb OeISIBtiECIAL ITI?p1$ THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE, -- SHOULD ANY OF THE ABOVE,MeemM!N GE aAMOEIJID■M1'OIE TIC 00"RILTM DATE TH®110Fr TILE Is1Z M Q COMPANY WILL ERDMAVDIR TO MAIL SAMUEL DAY C,ALLERY 10 DAYS "mm NOTI"To THE Cp,RTIFIf:ATl Ham wim yo Tm 4039 MAIN ST LE".WT FAVAN& TO MAIL SUC" P07M @TALL WOW Bo OWG IpN OR CUMMABU I D MA 026317 L1A>aI111Y�AMYL 1IP011 THE COMPAMY ITS AI1Wn Oft RUFREBENYATI IEO. c::.aw:.,:,<or,.:.;.,:,:<,;x,•..Y....,,.:::::.,.:.:...,.,...::::...................................... 'J + f ��1 ��cl ,rnitl��2 Sib C�YL CIS, 0s CG' FRAM ':(5LRSSOWORKSH P FA ' NO. :5083620175 Jan. 19. 20 04:29PM P1 ACMD „ C:E1 IMIC ATE OF 1.�"!,f RMCE 05��dr�wrn miw aftymom x1moomm A1tD O0 PtlIM8i0 ma 70 7118mom CMt Aim fay I"M ffiR169NY twin �1t d vossm t>Idt is wa retgrrit< is MOM" or it�Rllltit 1W O�iOS iiNA>er� two atuIll W►w l i *� Im e 1 A lrst P rltnlliP#ItlI�AA/tof19 AM► fly. wo = OF AMY OR tM{}4 I{ W YsflCM iris IDI►li! ta1lY N Sb1TiO aR MAY tl4i1l^ 1IE NQtA A 8� PCBJOMi !>16DItIJOtb r 'a84RA�6R 1O Ail ri1R 7�Y& + mP mN011 Mg1t',i�AdtlbM1; A9Y►YkIYYs:1 �kIQ1�BtlMKD6'tA� -- -- ..r....--•--��.-•—.� iat°trte�srrr °'�' vixub&AWAM • 0 0� � enlwwlarL - �� �3Sl �/'ili/ b 00e C two MDelPaur�r�ierl aewvwunao i ti®0.0 • it,0®Oe000 ..�.-�-....w..�-.._...,. pgbf+sggrk•qis/�FAt� b 1 r 4®0 r�Id _.. 7 illlrL AO�l�pd66lR Alice r'it is�Ix am fMit�eAi1t101M /110<suw �. Awffift Ars�r�enauroa i01�DA17Ai •�.,... _.__.,_ a�sOM�AYPAr ftod" ° A1199s1LV• i ORM�ItNlilrr 9AAW t AMIAIIId AI�ARaLM AM i s1y11�Wii1r1A0! I p Ago b a 77 °75 Oi`'aZ IZO�ffi !f tse+ aAeratenr �.�d-. a1,00 606 y 3.001 000 rrrbryltrMMdrr� Elt •POl�riif OI�o000 doo ptlL Zf Zit �If9tP1E117M NORt90JQ 71®� . m a►ram� Ate/�i� au�Mf.a�r°rrsw is r�� an morm „a I ITO wa attwewloz rlmlt ve err aar w.N" I& won mom Ns i zm i its it. fm wrorl *6 ram, w Arelli aII I sessp'rs mop..and ,lot .... .. s THE Sewage Permit"number,5 .�.................�... ..... $ House number .... ...................... .. a f Iy`+r AS& LE. • .. - -N SAL CO' wear a� TOWN OF -B'AR.NSTABII'�Eu �I b�� - BUILDIN�G . INSPECTOR APPLICATION `FOR -PERMIT TO Cans ri c ..S�X1gJ.. ... �m 1y....Dwell.ing..................................` TYPE'"OF CONSTRUCTION: ..:..........Wood Frame :............:............................................... �t ...................... 5. ...............19......84 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby.•applies for a permit `according to the following information: k Location Zo t...�S3.. WoQA1A*na,.AV.e...,....Fx. ...,...H�raran i ,...Maser..:............... Proposed Use ....... ... .�. �. ... i2.�L,�l.... .C.Y.� .�.4�'....... ................. .................. ........................... Zoning District R.'....8.•..........:................................Fire District Hyann S. ............................... - Name of Owner- Capr co,rn•, •eat, y,•„�' �5, ••,,,•Address ..�:6..,Falmouth Road. Hyann ,•„�vja,Ss. Name,of r`Builder Branco Real., Est.,Dev Q.Q. Icess ... Saille..................... ••• ........................ . , . Name of Architect ........:.................. ..............................Address ... Number of Rooms .....S1X......'...................................:...•.....Foundation ....... .. j Exterior „UPaP., Q.4.xd...al� Ar•..Shin .es..............'..Roofln .sphalt Shingles t°� g .............. .................•... Carpet Shee•trocl Floors .•...........................................................Interior .........,.......................................................................... Heating Y Plumbing TWO Copper Gas........'.......F.,11V... A....:................................ ......... . ................. .......... Fireplace None.... ` �4O,,000 .00 '............ Approximate Cost .............. ... Definitive Plan Approved by Planning Board ___---------------------19________ . ,Area ................59�.Bf t r... ....' Diagram of Lot and Building with Dimension's Fee ,r........... SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY`PERMITS REQUIRED FOR NEW DWELLINGS I .hereby agee'e 'to conform to all the Rules and Regulations of the Town of Barnstabl regarding the above construction. c Nam .... ...................... ... /� res _ - 000g89 - y - Construction Supervisor's License ............ 8. ................. r'?RICORN REALTY TRUST ' rl No `27133 Permit for ..............One Story............. s I Single Family Dwelling ` ................... ............., ........................ ................ j Location Lot 53, 144 Woodland Avenue„ • Ownery..CaPricorn.. �], y.. Dust. r ,r TYOe of, Construction .k'x'aMe............................. .. ..... ..... ......... .... _ Plot- ......... ......... Lot ................................ == ' Permit Granted ..`:...,.. ....19 84 - Date 6f Inspecti ................. ! 19 Aj, ` ~' Date Completed ..o20 .T� .........19 'P✓ T " J I - �h V F 12 .49 n 2 �i an 2g 3 1z 00 00 a A la, bUv /-e c �tt7 U4.1 CERTIFIED PLOT PLAN s 11 vim ROB BRUGE q MORE y, IN I CERTIFY" THAT THE403 �o� �o,��-�u.✓ rt .. SHOWN ON THIS PLAN IS LOCATED _ iS°iRE� REOISTE42i¢�- �I@9}I" . ,AND NO a .....�, ON:; THE GROUND A3 INDICATED A14.0 ENGINEER SURVEYOR ., Y6 �=�,�� CONFORMS TO THE ZONIN® LAWS OF ID R NSTAB A- m a C sTa 712` I�A 9 N S T RE -ET ' T F H YA N R I S, MASS. SNEE9' .0 IDATE RES. LAND SURVEYOR • N TOWN OF BARNSTABLE permit No. __._Z7133________ Building Inspector s�nx�n Cash uua v---------- ---- �` OCCUPANCY PERMIT Bond __A_----__----__ _ t�, . Issued to Capricorn l aG t:L' Tnst Address = Wiring Inspector 1 Inspection date Plumbing Inspector/// Inspection date t,r Gas Inspector s l' j �.�way Inspection date X,n C,ap,9� :iEngineering Department 4 Inspection date• -^6 Board of Health-- J f Inspection date ,7, , r� THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. (,� / ✓. .. . _.,.. _.... 17 Building Inspector TOWN OF BARNSTABLE BUILDING DEPARTMENT seasSTAU = TOWN OFFICE BUILDING HYANNIS, MASS. 02601 MEMO TO: Town Clerk FROM: Building Department DATE: An Occupancy Permit has been issued for the building authorized by Building Permit #.............�Z-2--.2Z33..................... ....... ...................... .......................... issuedto ............................... .................. Please release the performance bond. Assessor's map•and lot number,:. .lJ ?HE ............ ay SewageA-Permit: number,:6 .�,,-.. .7.5...}........::............ ry, , #. Z EAR399TADLE, i House' number ............../ ✓.•. ...1? .�...:....................`,....... 9° MbS Ba ��� �'• 9- MPY a' y TOWN OF BARNSTABLE { r ' r BUILDING INSPECTOR APPLICATION FOR PERMIT TO I �+ .. „+ 1 v �n al 1 r+n .�.,.�®w�,.� ....� .� .,. ...F.,m�.l .�?..r.....,... i. ..... ...................... • TYPE OF CONSTRUC�TION. ............!Wood...F.ra e..................................................:..... ..................................... .. ....m I September 25.,...............19......§4 ............................... . TO THE INSPECTOR OF BUILDINGS: } )The undersigned hereby applies for a permit according to the following information: Location .............Lot... ....... . .�.�....H ranc.a.. .a.. tq . a ............. ................................... .�f C. !%ff2.i� +�•e �• .fir..... .................................... ............ ... . Proposed Use ......:...............rv.............��...........�/............... ....... ...... � ...... .. .. .. .. Zoning District ................R.....................................................Fire DistrictY.......:...HVa;Y1711:................................................. Capricornear"u t 7��5 Falmouth Road H�; � s; VT�� Name of Owner .........: .................. u. ........Address .. ... ..... ...... . a... ... ..S. Name of Builder ..RtaT1C©,Real Est. �eVQ..a. ZA"d:dress ..........S�.TT1e................................................................ ................... .... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ........ .............................Foundation ......p" Exterior C1ax�bAaxc . �xtd��r,•5h•,• p1.Ac Roofing Asphalt Shin�;les >........... . .. g ................... Floors Carpet .Interior Sheetrock................................................ ..................................................................................... ............... Heating Uas F. V . . Two - Coper . ................................ .................................:... Plumbing ............................... .. ........................................ Fireplace 1 pne........................................................................Approximate Cost ......4oy 000 .o0..... .......`....... Definitive Plan Approved by Planning Board ---------------_---------------19________. Area .. ......... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH . s b� 3 1 4 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all .the Rules and Regulations of the Town of Barnstable regarding the above construction. Pres 000989 Construction Supervisor's License .................................... CT,PRICORV REALTY TRUST A=270-316 - 27133: - No Permit for ..One..Story,,,,,,,,,,,,,, .....5:?•?z Jle Family..Dwell ?fig........................ - � � •:t. Location ......],44. WQWland..Avenue—Ext. 4' HY ........................... f ................. ; Ca ri o Owner ........P.....�.. .. a1. ..Txus ............. Type of Construction ..Fre me.............................. Plot Lot................................. t October 23 , 84 Permit Gran�ed ....t............19 I , Date of Inspection .....19 Date Completed ......................................19 ka G 1 • Y { Y T Assessor's office (1st floor): A ' f/ OF THE TO Assessors map and lot number ............................................ Board of HealtR-(3rd•Aoor): w� o� Sewage Permit number ........................................................ Z BASHSTaDLE, ! Engineering Department (3rd floor): 900 "639 ewe Housenumber ........................................................................ APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .. 4;;.,!if f.........................................................6, t n ...................................................... TYPE OF CONSTRUCTION ..:............................................................................................. ................................................19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ....1..Z`:. .......0..........:.....� /7r1.....1 l,`tl?,v11�f ............................................................................................................ ProposedUse .l f-�trlp....,:r::,1.`,: .r't.....................................................:................................................................................. Zoning District Fire District .............................................................................. Name of Owner -.. )., ,P).l�}C�_d .......... _ r�„(;_;f?`7I; 1*Address ........................ Name of Builder .....: M/L(?.4a...............................................Address ...................................................... 1 {" Name of Architect ... :':'.J�... �+ ' . ..�� �' Address /-C 1 .� ...`.� C-l..... f xk7�+}.�In)'} �� i�l./.. 77 ...............Y.,.e�.•„ ?.r! .......... Number of (Roomms .:.....:....._..(.,.:........::........ �'.....�'-.1�...............Foundationj� / Exterior AiJ..t+: ?.,... ? D ?1. r....................... ...Roofing .t j� s 'h G?5............................... .i d Floors 111 ' 1�:...... "f ��... ... It/ ,Interior ... 1 �:.. / — ld 1. ....�C .'Je....f7,� ..... N-eatin-g —........................................................Plumbing co Fireplace ... ........................................................................Approximate Cost ....:.............................................................. Definitive Plan Approved by Planning Board --------------------------------19-------- . Area .......................................... Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of a nstable regarding the above construction. Name ....................................... ....... ............................ Construction Supervisor's License ..........................:......... CHRISTIE, KENNETH & HELEN A=270-316 1 I No ..29504... Permit for .....Addition .............Single„Family...Dwelling,,................ Location.' .....144 Woodland Avenue .....9 ................. ............ ........Hyannis.......................................... Owner .......Kenneth & Helen Christie .................................................... Type of Construction ...EXAM9............................ ................................................................................ Plot ............................ Lot ................................ Permit Granted ....June. 3,.....................19 86 Date of Inspection ....................................19 Date Completed ......................................19 e4A\ Igo bapliC SYSTEM MUST BE Assessor's" office (and,lotr)number. '.. f..1..Q.�... .. ........K./✓ INSTALLED IN COMPLI ? ��NE l0 Assessor's m WITH THE 5 Board- of Health (3rd floor): Sewage Permit number ..... �.�T..�: ..�:.... ENVIRONMENTAL COD T��E, Engineering Department (3rd floor): , TOWN REGULATIO C 039, e�0 0 A"S Housenumber ........'..................................:............................, " a Jul a� APPLICATIONS PROCESSED '8:30-9:30 A.M. and 1:00-2:00 P.M. only' ., TOWN OF BARNSTABLE BUILDING INSjPECTOR APPLICATION 4FOR PERMIT TO 1? ...rho. ® :. ........f.�.. . ............................................................. TYPEOF CONSTRUCTION ..I �............................................................................................... ................................................19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: � N a ......................................Location .... nJ)dnd.... .1;4. ProposedUse D.1.17w*. .....jqh�..................................................................................................................................... Zoning District .............................tl/� .................... ................Fire District ......... ..._...-..-.............. f......�...................................... Name of Owner •. 1�17L1TI...........1..ti.�L1�..1„/7F1/ <,:Address .�d.: .. I�[1X2G1.....�I.CJl:1.?el.! Nameof Bui _r ..... .......K. 1. ... .� C4.F.-�Address ............................:....................................................... Name of Architect ... C ......................Address .....enl7a— ....UJALk ....:-. Number of Rooms fX �?: lt�l�: r�.. ./../.�. :.).:...............Foundation ..L . .¢. ..... ,*- �..����......................... Exterior ..N!I G .... CA[ e ..� :�.........,..r............. ...................Roofing .! l..e-/�...................... fir)/ .... ............................... � • v I Floors l...l vaci(..../ �d.1:7....41frv. ...` '� �i.' ...Interior ^Healing J7,011..................................................:..................Plumbing ...1.7�f?110 ................................................................ . -je co Fireplace J.10.....:...................................................................Approximate Cost .01>9................................ ..... Definitive Plan Approved by Planning Board --------------------------------19--------. Area .�`.�......o.... ............... Diagram of Lot and Building with Dimensions Fee .......... . .............. .. SUBJECT TO APPROVAL OF BOARD OF HEALTH M 1 1 • OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of B rnstable regarding the above" construction. Name .. .................................. .... ............................. ,�? C e� Construction Supervisor's License a �1.... .. .......... — CHRISTIE, KENNETH 6, HELEN No .... Addition ... ..... Pernit for .... ! ......................... ng .......... ..................... Location ....1.4.4..W.o.o.dlan.d..Av.e.nue.................... -D . . .. .. ... ........ .. .... . ...... Hyannis ................................... Owner .....Kenneth & .Helen Christie ....... ... .................................. Type of Construction ................ ......... kW ............... .................................................... Plot ............................ Cot ................................. , Permit Granted ......June......I.......3..............-....19, 86 7 Date of flrispection ....... 7 9, it Date `Completed .......................................19 L 01 M 5 FU 0 112;