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0116 ANSEL HOWLAND ROAD
� � �o�t�n� .�2 �. a= , . ��� e �...Y � ` i� '� � � o I.1 n � - L p e � - o n o .. .. � � ° ` � ,. e ' � .. � 4 J �. 'c p I,. .. .. e C ., .. o - o - c.. A .. �, V r i o a WE Application number........'.. ... . 5„ ,,,, 0�Z`��l DateIssued.......1...............�1...................................... " B"NSTAMX. e MAM h��`� ® i Building Inspectors Initials...... . ........................... FD MP'� OCT2 Map/Parcel...... .L.....fro.Q................................ FOWN O� BARNSTABLE TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: /Q�,, / e✓ �n✓ NUMBER STREET VILLAGE Owner's Name: . djt4 Phone Number Email Address: rnura r,Ac, 11 Z 6 rw/Gi 1 C 01--? Cell Phone Number Project cost$ 2 1 D(oq — Check one Residential ✓ Commercial OWNEWS AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: See A-N'ad,,,,:,C Date: TYPE OF WORK ❑ SidingU Windows no header change)# ❑ Insulation/Weatheriza ' ( g ) _ � tton ❑ Doors (no header change)# Commercial Doors require an inspector's review_ ❑ Roof(not applying more than 1 layer of shingles) Construction Debris will be.going to w a;sj CONTRACTOR'S INFORMATION Contractor's name_A,,,,/j'� - ors e l t/S Home Improvement Contractors Registration if applicable)# /IZ 7 (attach copy ) Construction Supervisor's License# /Q 5 (� _ (attach copy) Email of Contractor 4 ff Se lim a • C c3''n Phone number 4"o /- 7IV-6 3`! 9 ALL PROPERTIES THAT HAVE STRUCTURE OVER TS YEARS OLD OR IF THE SUBJECT PROPERTY 15 IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one:this event is a:for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached.Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a health Department approval between the hours of 8:00am-9:30 am or 3.30 pm-4:30pm. Commercial events may require Fire Department approval *WOOD/COAL/PELLET STOVES x Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles:front back left side right side HOMEOWNER'S LICENSE EX e`N TION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date /Ap LICA1V 19S L3gGl`VA flJF E Signature Date All permit applicatio are subject to a building official's approval prior to issuance. I . - Home Improvement Agreement: Pagel.. Home Depot License #'s - For the most current listing www.Homede'pot.com/LicenseNumbers MA: 107774, 112785 Janice Campbell Salesperson Name: Registration No. (if applicable): Home Depot U.S.A., 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. MARA RITA 1 New England South 1-MQ853QL• Customer Last Name Customer First Name ' Store #/ Branch Name Customer Lead/ PO# 116 Ansel Howland Road Centerville MA 02632 Customer Address City State Zip IM araritall2@gmail.com Home Phone# Work Phone# Cell Phone# Customer Email 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 61545 Address City State Zip Or Email: customercancellationnortheast@homedepot.com Service Provider Email Address 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,BYLAW 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 SERVICE PROVIDER, 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 HOME DEPOT 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 by: 09/25/2019 -Customer' ign re 'Date , Contract Price and Payment Schedule : Payment of the Contract Price is due upon signing•unless a 'different payment schedule.is required by law, specified below or in a payment addendum. Contract Price: $ 12069.90 Includes all applicable taxes. Excludes finance charges.* Sales Tax: $ 0.00 (If applicable) *Maximum deposit ONLY applicable in MD, MA, ME(33916), NJ, Wl(99916) Dep. 125.0 % Deposit Amount $ 1517.25 Remaining Balance $ 1551.75 The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1-800-466-3337 4601`I HIDE Customer Agreement(24 Jul.18) v 0.1.8 Home Improvement Agreement: Page2, ® ... as _ .t • ' 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: t. Installation of 1windows A more detailed description of the work to be performed is inclu ed in the section entitled Scope o Work which appears on page 0 of this Agreement.• , Anticipated Delivery Date/Installation Schedule ' Approximate Start Date: 11/20/2019 Approximate Finish Date: 12/18/2019 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. r By ' 'tialing this paragraph, I consent to receive only electronic records related to this transaction. Aft al 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 may be 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 1 09/25/20197The Home Depot Cus omer's Signature Date Service Provider Name , X 09/25/2019 1908 Boston Turnpike Unit 1 Co-Signer (if applicabl ) Date - Service Provider Address X 09/25/2019 Shrewsbury MA 01545 Sign toFro n a f Home Depot Date City State Zip R-1-073-13-00016 + Service rovider Phone Number s _ Service Provider License Number The Home Depot-2455 Paces Ferry Road, N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care: 1-800-466-3337 4601`I HIDE Customer Agreement(24 Jul.18) v 0.1.8 I Commonwealth of Massachusetts Division of Professional t_icensure Board of.Building Regulations and Standards ConsttuctipTI-S or Specialty CSSL-100648 ires: 0611W2020 ER{CSSON T�RR�S P.O.Box 673 SOUTH YARM ._4 - Commissioner Wi Otfitc®of Co su�rne �IK psi �®ssRegutatlon. HOME P.R, OUENIENT 1M CO RACTOR r .+ y �` M • C7V�' s'� ` z i yr�3 r�r,� � a 4 ��� .^ i ��y �a MIR {.w 2 �,,�v���r�.a' d' AlAk The Ca mWAa sif t 600 wasbawm met Barsiono MA 021ZF WnrkM' Catnpeas�Iasmnc$A,fridavib AmOk;mt f Please Prhit Yew Wam - -- tr w5.S.Scm orres tom.O73 _ Are,jmu an anplayvr7 C&eck the'appraFr1aft boar Type of projed fregnm miT- L❑ I=a emplyeruf5. 4 ❑I amp a gei=d caairsctasrandI * Irage Itited Eller-camdtn�s 6�. Q New(fail aadlor:gar�time�: . 2.ur I am a-sale pmpAetasr orgasfaer- Fined esithe aid sbeet. I- ❑RemodedfaB - aad hm no ernpkryees R. nDPM01ition Wa¢bnb f CW M 2UY emVIaZew amlbave w adame g � addi iaa- e gyp_i,. �—* nquire f�BLR Ga>�_invtra nr I� Wt a 2ai£ � and f+ 14-0 Etecllicd reirdirs,orad s I of-== rave cs-cised fiffi 3.❑ Iam.agaazea>�tSoinrgalFwoa:k _ 1L[]i'iu�dbfagrepaiss arsc�tiams ` mYsigE END '�= Zt�of sett per MGL Ifi. Roofs Plim Rwmmnc:&id-]i r`M,§1{4,aadwe have no emplasyem[No waitress` 13 �lffier camp.im mm ] °may�p€esed:�ac�'6as;lmast elsafi�an��c�oabdaar�ag�eawo�o�ppa5c�riaca • ��ara�st�r snia�rids sf�dae� g S�eg m�damg ag�3c s�dd�.7axe acoaa;>sca�a�sn2�fesn�ma�ada8tmdie�;sacs. . rCaatrsdoa'ffistcY�cYHgsba���ar�atadeiifims2s8eetd5ou�g13�ea�.eaf8�esnb-c �ndst�e �aatf6nsehage ' e�iayees,3Ef�esafi-resb�e emQTa�s,fhega�C�i�t� armP•gaT�m�btr. �curt are errip 'lliatisprcrur�n�rkers'e�osattiarr irFs�craara jar�ecrgvfapees B�Iory is�rapvrfiGy oral jab srf`e •. Fr1�OCma�Dlb- ' lnSIItaaEe CQ i M3= Jab Me Aiddr CitglSbt Vz Attach a.capyoffheworks'couspeasaiiaapolicydec1<amfm page(ALaXisgthepoFcyanmrIaer and e h-.dioada4 F'&=Ll to secure coverage as requirea uuderSwfwn 25A o€MCI.c.157 can lead to tine fmposilim of criminal peaalg of a floe np to$L5OD DG amVar one-yewimpasos=mmt,as w6u as tuna pamausia the fom of a SMp VKyKK OMERaad a ime - of up to MW a any agamsf fire vmbdat Be advised ibat a copy offitis statement mybe farww&d to the Office of IuVes*d ions ofVm DyA far;nsmm covemse ieaa.. Fcia ftergby rurdsr i3rs paans ratfi�s afF 'HuEtflae it farmu iaragrm d abar ig tnw grid coTect Siffiafar� PIMM �Dfr-962- � usa�ctrrF,�. �]a rtrrt eta frr�a�#cr be crrrnpfetc+d by r.,iip crr�iarart I - - Clt- `or'Iawn: Pease# Rn*Am l wity(cart€ome). L Beard of ReaIfh 2.BmTdiag Depmbne t S.CiVrown C=k 4 Ekcft=d Em� 5.P&addughtspmW d.Man i~aMf2atP==3:' phow9: 6 f - Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Horne Improvement_.Contractor Registration -- -= _ Type: Supplement Card _ Registration. 112785 HOME DEPOT USA INC Expiration: 04/22/2021 P O BOX 105451 ATTN: LICENSE MGMT TEAM ATLANTA,GA 30348 Update Address and Return Card. SCA 1 20M-05i17 Office of Consumer Affairs S Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE,,-.'Jpolement Card before the expiration date. If found return to: Renistration Expiration Office of Consumer Affairs and Business Regulation _ 04/22/2021 1000 Washington Street Su' 10 HOME DEPOT rl-ice Boston,MA 02118 ANDREW SWEE'. 2455 PACES FERRX:foG.f 1 HSC ATLANTA,GA 30339 Undersecretary No alld It ut sl nature I ` The Commonwealth of Nl'assaehuseffs Department of Industrud Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www nuwsxgovA a Workers'Compensation Insurance Affidavit:Builders/Contractors/Eledricians/rhmbers, TO BE Fmn WITH THE EERIN n-mG AUTBORM A"liicantInformation Please Print Legibly Name(Business(Organizstion/ladividual): H n rn 2 O n—� Address: 0i0q; n rr,p i K2-,, City/State/Zip: S 1 v,r M .. 015-4 Phone#: 7-7 L4 -Ig 5 - 2..1 Ts- Are youan employer?Check the appropriate box. Type Of project(required): LQ r am a employe'Vid . . employees(full and/or part time).# 7. ❑1�TeW Consh tICtLOu 2.❑I am a sole proprietor or paftcrship and here no employees woe,&g.forme in S. ❑Remodeling cons any capacity.iNo wodoas'comp.insurance nquired•]- 3.E]I am a homeoanerdo• aH wodt owodeers'a t 9.•❑Demolition ms mY�CN crop,iosatantxrognit�.] 4. ram a homeownermd vat betmtrig contractorsn w conduct all 10❑Building addition wodcon my properCy.I watt ensure that all contractors either hwevvorkere compensation i„smance or are'solo i L[]Electrical repairs or additions proprietors with no employees t s.�Iam ato a general conkarand I have hired the sub-eontraetom listed oathe attached sheet 12.[Plumbing repairs or additions These sub-contractors have o and have workers'0 13.❑RA repairs empl Pees crop.insmrraace.= 6. Wo am a orationand its offitsers have exercised their 14 thel l/1 ❑ °mP nght of exemption perMGL o. §1(4).and we have no employees.Wo wodmne camp.fim,,nce required] r P 1 of c 8..0,e-/l t *Any applieant1hat aheal®box#1 must also fill out the seetionbelow showing their workers'eompmsatioa policy i of rmaticn. 'tZMIeowaara who submit this afifdavk fadi'cating they are doing gg work and thenhire outside contractors mast submit anew affidavit indiaatng such. kCcntraotors that eheckthis boat must attached an additional sheet showing the name of the sub-contractors and state wherber or notihose entities have employees. If the sub-contractors have employees,they mustprovide their wodwre comp.policy number. ram an employer that is providing workers'compensation insurance for my employees. Belmv is the policy and jots site, information. Insurance Company Name- lU/ dwcyl �/� 11'e 1:�car A"'0 Policy or Self-ins.Lic.#: X fnJ(' &5 5 1`7 Expiration Date: 3 — F r Job Site Address:--- /_��o n �_' �D,��An G (�j• City/$tabemp. C 4y I✓; el.e— 1''A Attach a copy of the workers'eompensation•policy declaration page(showing.the policy number and expirsfi n slate). Failure to secure coverage as required un4er MGL c.152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonm as ell'a's civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator, py this statement may be.forwarded to the Office of Investigations of the DIA for ins iraace coverage verification. I do hereby certify an enalties o information provided above is true and correct Si ate• WAF Phone#: 3 Official use only. Do not write in this area,to be completed by city or town official ^s City or Town: rer�mitucense# Issuing Authority(circle one): . 1.Board of Stealth 2.BuildingDepartment 3.City/Town Clerk 4.Electrical Inspector 3.Plumbing Inspector , 6.Other Contact Person: Phone#: JATE IYY'('() CERTIFICATE OF LIABILITY INSURANCE 12ic6i2019/2c1� 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 have ADDITIONAL INSURED provisions or 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 andorsement(s). PRODUCER CONTACT MARSH USA,INC. NAME: TWO,ALLIANCE CENTER PHc°N o ° AAll C No 3560 LENOX ROAD,SUITE 2400 =-.MAIL ATLANTA,GA 30326 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC S CN101642069-HomeD-GAW-19-20 INSURER A:Old Republic Insurance Co 24147 INSURED THE HOME DEPOT,INC. INSURER a:New Hampshire Ins Co .23841 HOME DEPOT U.S.A.,INC. INSURER C:HomeRisk Captive Insurance Company 2455 PACES FERRY ROAD INSURER o: BUILDING C-20 ATLANTA.GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-004353439-28 REVISION NUMBER: 21 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. IN SR ADDCSUBR POLICY EFF POUCY EXPi LTR TYPE OF INSURANCE 1 POLICY NUMBER i MMIDD/YYYY MMIODIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY MWZY 314574 03/01019 :03/01/2022 ;EACH OCCURRENCE I S 1.300.000 i CLAIMS.MADE OCCUR DAMAGE[ORIENTED 1A00,000 PREMISES;Ea occurrence) i X SIR:81.000.000 MED ExP(Any one person) i EXCLUDED 1, PERSONAL 3.ADV INJURY ' S 300 000 GEN'L.AGGREGATELIMITAPPIIES?ER: GENERAL.AGGREGATE S I'M0,000 %< POLICY ',E� LOC PRODUCTS-COMP/OP AGG S 1;300.000 OTHER: 4 MINT831d 7 1 COMBINED 31NGLE LIMIT 53 3 /O1/ 09 Au7oMo91LE UA9IUT'r _ 3 2 03101i2022 ;,Ea accidenU � S 1.000.000 X :ANY AUTO BODILY INJURY(Per person) S OWNED _SCHEDULED SELF INSURED AUTO PHY DMG .AUTOS ONLY '..AUTOS - BODILY INJURY Per accident)� S HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIA9 OCCUR EACH OCCURRENCE S EXCESS LIAR —'CLAIMS-,YIADE 'AGGREGATE I S OED RETENTION S b B :WORKERS COMPENSATION !INC 012717099(AK,NHAJ,VT) 03/01019 03/01/2020 € X ;TRnJrF ORTH- B AND EMPLOYERS'LIABILITY YIN WC 012717100'WI 03I0112019 03101/2020 'ANYPROPRIETOR/PARTNERIEXECUTIVE 1 ) i E.L.EACH.ACCIDENT 1 S 5.000,000 '.OFFICER/MEMBEREXCLUDED? ' N N/A s(Mandatory in NH) 'E.L.DISEASE-EA EMPILOYEEI S 5,000,000 DESCRIPTION OF OPERATIONS below es.describe under E.L.On Additional Page E.L.DISEASE-POLICY LIMIT 3 5.000,000 . C Excess Auto 297110011002019 03/0112019 03101/2020 ':Limit: 4,000.000 A :Excess General Liability MWZX 314580 03101/2019 03/01/2022 Limit: 8,000,300 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 P4CES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING C-20 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Nlukherlee -Daua0" ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER 10: CtN 101042069 LOC#: Atlanta ALA D ADDITIONAL REMARKS SCHEDULE Page z Of 3_ AGENCY NAMED INSURED MARSH USA.INC. THE HCNIE DEPOT,INC. - ---__—_-- — HOME DEPOT U.S.A..INC. POLICY NUMBER 245E PACES FERRY ROAD BUILDING C-20 -- ---- ATLANTA,�A 30339 CARRIER NAIC CODE - EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Cartificate of Liability Insurance Workers Compensation Continued: Carrier:Indemnity Insurance Company of Nonh America Policy Number:'NLR C65890549lAL...ARFL,ID.IA.KS.X'!.LA.MS.MO,NE.NM,ND.OK,3C.30.TN,1NV.'NY) Effective Date:03101/2019 Expiration Dale:03101/2020 (EL)Limit:S5,000,000 Carrier:New Hampshire Insurance Company Palfcy Number'NC 012717098 (DC.DE.HI.IN.410.MN.MT;VY„RI) Effective Dale:93101019 Expiralion Date:03101/2020 (EL)Limit:S5.000A00 Carrier:ACE American Insurance Company Policy Vumber'NCU C65890586(OSI) (AZ.CAJL VC.OR.VA,WA) _ Effective Date:)31012019 Expiralion Dale.03101/2020 (EL)Gmd:34.000.000 SIR:S1.000.000 SIR for the agates of AZ,CA,ILNC.OR.vA.'NA Carrier:National Union=ire Insurance Company Policy Number.XWC 5565596(OSI)(C0.CT.GA,ME,:MI.W/.0H.PA.1JT) Effective Dale:+031012019 Expiration Date:03101/2020 (EL)emit:34,000,000 31.000,000 SIR!or the dates of CO.MEAV„MI.OH,P.A.UT 5750.000 31R for he slate of GA 3350,000 SIR for he;tale of CT 1 Carries National Union Fire Insurance Company Policy Number:XWC i565597(OSI)(MA) Effective Date:03101/2019 Expiration Dale:0310112020 (EL)Limit:34,500,000 SIR:3500.000 TX'employers XS Indemnity: Camierlllimos Union Insurance Company Policy Number.TNS C65221019 iTX) Effective Date:03101/2019 Expiration Date:031012020 (EL)limit:310.000.000 .. SIR:SIAK000 ACORD 101 (2008/01) Oc 2008 ACORD CORPORATION. All rights reserved: The ACORD name and logo are registered marks of ACORD r es 0 3)23)tiy Town of Barnstable *Permit# Regulatory Services gee 6 � � �ntsxareis, tom Richard V.Scali,Interim Director 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 Valid without Red X-Press Imprint Map/parcel Number / l�AAA Property Address 1 (� S�L � /� U - Lrl t= Residential Value of Work$ 6 3a Minimum fee of$35.00 for work under$6000.00 "-ROwner's Name&Address A PTA /i& ,4ti s-F-L i�w/, � Contractor's Name Telephone Number-jc)/-7jy A39/ Home Improvement Con for License#(if applicable) !Z6 Email: Construction Supervisor's License#(if applicable) 676077 „V)y� { _ ;kW1 orkman's Compensation Insurance Check one: ❑ I am a sole proprietor MAR 2 8 2014 ❑ I am the Homeowner �I have Worker's Compensation insurance /� Insurance Company Name �—C , ® N ® ANSTABLE Workman's Comp.Policy# Copy of Insurance Compliance Certific a 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 3� Z Replacement Windows/doors/sliders.U-Value r (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. 'Where required: Lssuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Prope must sign Property Owner Letter of Permission. A cop of ome Improvement.Contractors License&Construction Supervisors License is requi d. t___ SIGNATURE: T:IKEVIN D1Building Changes S P WE T RESS.doc Revised 061313 • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www rnas&gov1k a Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansfPlumbers Applicant Information Please Print Legibly Name (Business/Organization(tndiv i&d): Address: Z yS� �A•C.t S ��� �b . Ci /State/Zi : T 1 kAT,F 9A aO33 3 Phone#: 7 7`/-a75--a/-3 9 Are you an employer?Check the appropria box: Type of project(required): 1.❑ I am a employer with . , 4. I am a general contractor and I 6. ❑New construction employees(fnll and/or part-time).* have hired the sub-contractors listed on the attached sheet 7. a Remodeling 2.0 I am a sole proprietor or partner- ship and have no employees These sub-contractors have g. 0Demolition working for me in any capacity. employees and have workers' 9• ®Building addition [No workers'comp.insurance comp•insurance. required;l 5. We are a corporation and its 10.[:]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I Q:1 Pbimbing repairs or additions myself[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance -]t c. 152,§1(41 and we have no 13 Other"A) �a� 3a.❑ I am a homeowner acting as a employees-[No workers' general contractor(refer to#4) comp•insurance requh-C&) •Any applicant that chet3aox b #1 moat also fill out the section below showing th wod=e do dtolicyy inn. t Homeowners who submit this affidavit mi icating they are doing all work and then hire outside comractms most submit a new affidavit indcating such. tCon to ns that check this box must attached an additional sheet showing the came of the s and state whadw or not those eatm have employees. If the sub-conmusms have employees,they mho parade their wodrere comp.policy number. Ian an employer that is proviaUg workers'compensation insu once for my employees. Below is the poUcy mrd job site informal om (1_ Insurance Company Name: E11J AAAI 1RF- Policy#or Self-ins.Lie.* �d gg�. Expiration Date: Job Site Address: 4 AS� 1A)1 ACity/StatelZip:��El`U l l'e� 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 WORKORDER and a fine of up to S250.00 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' coverage verification. I do hertby ca*under the d p o er}lYry that the informadion provided is and correct i �7 � Plow ID1-7/4- 6-� OhIcial use only. Do not write in this area,to be completed by city or town off lciol City or Town: Permit Ucense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector #.Other Contact Person: Phone ft The Commonwealth of Massachusetts "- .f Department o De art Industrial Accidents P Office of Investigations C. 5'. I Congress Street, Suite 100. Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual). A1D�CL/moo _ Address:_ City/State/Zip: t kL6roo � `�+� Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4.'❑ I am a general'contractor and I 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' comp. insurance.: 9. � Building addition [No workers comp. insurance p required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions' 3.❑ I am a homeowner doing all work officers have exercised their 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.❑ 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. of the sub-contractors have employees,they must provide their workers'comp.policy number. I am an emplvper that h providing workers'compensation insurance for my employees Below is the policy and job site information. Insuran cf e Company Name: �) S S — 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 certify nder the pakis and p en . ies of pejurthat the information provided above is true and correct. Si' at re ___ . Date: _.......3, 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#: H(NM EVlM0VnMNT CONTRACT PLEASE READ THIS ' Sold,1~utnished and Installed by: Branch Name:Boston North&South DaUe: THD At-Home Services;li« . Branch Number.31 and 33 908 Boston Turn The home JShret,Shrewsbury, At-HoMA ei e . pike,Unit 1,Shrewsbury,MA 01545f Toll Free 877-903-3769- Federal ID it 75-2698460;ME Uc 4 C 02439;RI Coat,Lic#-16427`. CT Lie 4) 0,5 522;MA Home Improvement Comacu Reg.#i 26891' instaliation Address: l I� f�SCX�6[rJr#�LVC�{ H� r(/1 � Q G am, � �,'. City.. State Zip Purrb (5}' Work Phone: Homophone: -Cell Phone;. tic,.. ,r _ i' ] [ ] L -nn . Hatte:at�it�: - . (If different from Installation Address) City State Zip E-mail Addra� (to receive project communications and Home Depot updates): ❑I DO NOT wish to receive any marketing cmails horn The Home Depot Project Information: Undersigned("Customer"),the owners of the property located at the above installation addmss,agrees to buy, and THD At-Home Services,Inc.C lie He.Depafl agrees to furnish,deliver and arrange fen the installation("Installation")of all nweriala dp%cribed on the below and of the rcicrenced Spec Sheet(s), all of which are incorporated into this Contract by this referenc eI along with any applicable State Supplemerit and Payment Summary attached hereto and any Change Orden(coll6c:tively, "Contract"):- Job#: paeeeoatttetemm> Spec Shows) /#: Project Amount_ Roofing Siding endows insulaticm 9y«� ❑�;a�t./C.oven ❑fttryDoars ❑ Roofing LISIding L1 Windaves Insulation - ❑Gutters/C:overs❑EnwyDoors ❑ Roofing LjSicling LJ Windows LJ insulation ❑Gutters/Covers ©Entry Doors❑ $ Roilnp usiting❑Windows Insulation - []Gutters/Covers'❑Entry Doors El—,- $ iLlhnittrtim 25%Deposit of Contract Amoi nt due upore wcatiar orthis tOrrtr>,ti Total Contract Amount $ Maim Purchasers may not deposit tm*than enter of the Contract Amount. Customcx agrees that, itl m6diately upon completion of the weak for each PrMuct,Customer will execute a Completion Certificate (one for each Product as defined'by an individual Spec Sheet)and pay any balance due- As applicable,each Customer under this Contract agrees to be jointly'and severally obligated and liable hereunder. The Home Depot reserves the.right to issue a Charge Order or ternrtinatc this Contract or any individual Pro ducts)included herein,at its discretion,if The Horne 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 ead paint,other safety ccncems,pricing errors or ba-dusc work required to'complew the job was loot included in the Contract. / Wmeat Srmmarv: The Payment Summary#,# 5�� CCC�I`All 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). NOTICF.TO CUSTOMER You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a CongAe_ m 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 pot and services provided by The Hfum De or Authorized Service Provider through the date of termination,plus a"other amounts set forth in this Agreement or allowed under a�,ppplicable law, THE HOME DEPOT MAY WII'A' HOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEP'USIT PAYMENT OR OTHER PAYMENTS MADE, VV11110UT LTMITMG THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. AcceuNance and Authorization: Customer aerates and understands that this Agreement is the entire agreement bctwee n Customer and The Borne Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,either oral or written,relating to said Products and Installation-This Agreement cannot be assigned or amended except by a writing signed by Customer and 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 Accepted 5ub t by: X � us is Si a Date Sales msultant's Si ahtre D Customer's S t Date -&4- Telcphcme No. 1 D Sales Consultant License No. CANCELLATION: MS1`0MRR MAy CANCEL THLS (Is 9pplicabtc) AGREEMENT WITHOUT PENAi.TY OR OBLIGATION BY DRLIVERiNG WRITTEN NOTICE TO TIIE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERET0 CONTAINS A NORM TO USE IF ONE IS SPECMCALLX PRESCRIBED By LAW IN CUSTOMER'S STATE. NOTICE:ADDrnONAL TERNLS AND CONDITIONIS ARE STATED ON Tin E REVERSE SIDE AND ARK PART OF TfilS CONTRACT 1t-0S'i3 White-Branch File Yellow-Customer Td WdOb:£ OTOZ 9Z 'daS TLZZZ9£80S: 'ON XdJ pL6wier; WOad ��� �_ b . a of Owl%, rd 0 - r aK � I- License C59"I-UO"'7 0 0 7 7 Jos - 1 T)U A lw,T� WAR"T. H .A..N-1 M—A .--02,57 5 A Ex on 71 office of c ' timer Affajr4, & Her �. ME IMPROVEMENT CONTRACTOR egiStration: 132:349 T •L ' Expiration : i & J Remodeling Duarte 15 Fall St. Wareham , u r cre U License or registration valid for individul use orilv kefore the ,expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston,, MA 02116 Vs' J Not v .A lid without signature .47 r a n�ce�i���onsumer an us�n4sefg4ue o 10 Park Plaza - Suite 5170 Boston, N*sachusetts 02116 14ome Improvetij�ati' ontractor Registration- ' ' `f Reolstrption: 126893 Type: Supplement Card 1.n ' F' � ,•• ; 12.*ration: 8/3/2014 The Home Depot�At-Home Serftoa ANDREW SWEET f,: n t t 2690 CUMBERLAND PAR'KWAAIjiT6..'w ' ' --- ----- ATLANTA, GA 30339 Update Address and return card Mark reason for change. n Address ❑ Renewal [l Employment E] Lost Card DPS-C.A1 Q WM44044101218 oitice e � �s� License or registration valid for lndividul use only OME IMPROVEMENT COWMCTOR before the expiration date. If found return to: Office of Consumer Affairs and Buslnem Regulation some 'wB93 Type- 10 Park plaza-Suite 5170 Expir , ( 1# Supplement Card Boston,MA 02116 ANDREW ME 2SW CUMBERLANI � LAI1,CAA 30339 Undersecretary aIRMS on ignature May 11, 2013 Barnstable Building Dept. The following is a list of our approved sub-contractors for The Home Depot: Ericsson Torres—CSSL# 100546 HIC # 163528 ' Michael Viola — CSSL#099403 HIC # 140993 Vincent Smith - CS# 106837 HIC# 165927 Timothy Thomas—CS# 51899 HIC# 152121 i Ronaldo Solano— CSSL# 101027 HIC# 152206 Joseph Duarte - CS # 70077 HIC# 132349 Douglas Szynal—,CSSL# 103950 HIC# 146142 , Brian Laroche—CSSL# 100478 HIC# 152612 Joseph McKeon —CSSL# 98863 HIC# 132614 If you have any questions please contact Mike Bedard our permit coordinator at 508-962-6942 or myself at 617-438-9017. S' erel uss ne Bra Installation Manager M AMome Sande w Inc. 9W Baton Tumpkke- Unk 19 Shrewsbury,MA 01545 Plane:774-275-2139*Far.5094M6ffim•Tnu oma-Ann.aa,7-ni as oFtMME r Town of Barnstable *Permit# �p Expires 6 m nth f o n issue dates Regulatory Services Fee BwxwsTABLE n6 i63� �� Thomas F.Geiler,Director ♦ , . ArFO jp coig nlLg�tO , ei Building Division rry,CBO,` Building Commissioner 22 Main Street, Hyannis,MA 02601 7*0 VV z010 www.town.barnstable.ma.us . Office: 508-862- 6?FQ,q(� Fax: 508-790-6230 EXPRESMT APPLICATION RESIDENTIAL-ONLY Not Valid without Red X-Press Imprint Map/parcel Number. Property Address ( \ ( t, K• A 8 ,?VA 1,1 C t?bi+, Y Residential Value of Work Minimum fee of$35.00 for work under$6000.60 /' Owner's Name&Address Contractor's Name Is t �r 1�S�, Telephone Number `i cI D 4" IQ I l0 Home Improvement Contractor License#(if applicable)' Construction Supervisor's License#(if applicable) j []Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner 2- have Worker's Compensation Insurance ; Insurance Company Name 14- 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. 'Going over existing layers of roof) [�J Re-side #of doors'. ❑ Replacement Windows/doors/sliders. U-Value (maximum .35)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must si .,,Property Owner Letter of Permission. A copy of the Homes pr e t Contractors License& Construction Supervisors License is r ired. SIGNATURE: > Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 072110 - . NOTICE NOTICE TO TO EMPLOYEES EMPLOYEES The Common wealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS - 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22& 30, this will give you notice that I(we)have provided for payment to our injured employees under the above mentioned chapter by insuring with: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY NAME OF INSURANCE COMPANY 54 THIRD AVENUE, P.O. BOX 4070, BURLINGTON, MA 01803-0970 - ADDRESS OF INSURANCE COMPANY AWC 7016215012010 01/10/2010 - 01/10/2011 POLICY NUMBER EFFECTIVE DATES, P O Box 494 Leonard Insurance Agency Inc Ostenrille,MA 02655 (508)428-6921 NAME OF INSURANCE AGENT ADDRESS PHONE Mark Herbst 35 Peep Toad Road Centerville, MA 02632 EMPLOYER ADDRESS 01/11/2010 EMPLOYER'S WORKERS:COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in uses of personal injuries arising out.of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers'Compe�ation Act. ' A copy of the First Report of Injury.must be given to the injured employee. The.employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer,N the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention,employees are hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY NAME OF HOSPITAL ADDRESS L. ?6 TO BE POSTED BY EMPLOYER Q yi„ y` j t :n%!fit r, z`.z,'"t• r�' `a�v s t.. r ,;.- rG` 'tq+`a _ _ }x sy�. 04t, £ y�v` r�Y f <; � A l�" 4�-"tI" �C ��f'�� ^�1 ,a `f; ''s r :' a_y,, x`'�9•++`-"� �. �5�:.�°� �.,q .� ti � Y'r i.a,_'>• jr �r x,..' `�'r� s� •,jq' _ , dh•G,r'r are4 �+ t�v w1`r t� er i'' tFd xrx 4,gk ,sl. a-tr r cw" �7q� '4_i+, ."a �y'-10%y"' t :i ;� F 4..s�$ti r'Y.r. i 335• a .`' 'l Tt'd�{-''Atf a hex. ' k, .t f`" 4 l < i L? }s 0 so '"� ^soy. 1 ;$j. �' a, '3@,s'} Y�u r'4 ; -- �� �<c* xY r�^t� �' -�"� CENTERVILL r 44y= ak 508 420 6216/774-238 Ef'f WWW.rnarkherbst.com° .� } azk YF PROPOSAL SUB T0: - WORK PERFORMED AT: R 's y t x` Mrs.Mara LL , r y 116Ansell Howland Road r"� V ,' SAME igtCenterville MA 02632 x We herby propose to furnish the materials and perform:the labor necessary for the completion of � � 4 New siding p' h 4 Remove white cedar shingles from rear of house J` £; r Y Install house wrap 4 Install vinyl siding to match existing �+ t y a Cut back 3 rake boards Replace 1 comer board on sunroom- { Repair 1 facia end #; , Replace 1 side of window trim s f All wood replaced will be pre primed pine H zy p All debris cleaned daily z ,* -Price includes material,labor&dump fees so ' 4 Great care is taken not to crush plantings:*Please remove any hanpmg plants on house and remove around pots►VI f any Thank YYou� ,>s L_ a .§`f,�',- .�s§rn'�j' -e r t•,tiS r U rt.:. q"q�F,S` ..3 - , �i�p .• ,": t �,r ..-. �, i"t 2 v ! r...,�.y -T �.`s All material is guaranteed to be as specified The above work will be performed m accordance with the:rspecifications submiftedr 3 and co leted in a substantial workman like manner for the sum. Three-Thousand Seven Hundred � Jry,'n''� 3, I)oIlars($3, 4M)with.payments as follows FULL AMOUNT DUE UPON COMPLETION: * *Any alterations from aboverproposal involvmgextra costs will:be added under,a separate written agreement and become an .......... charge over and above said pr posal. f J �y RESPECTFU SUB T t r.5 'f#•k j `3gr, Y g4.l- �'' 05/25110' Mark Herbst r r � P11, `� AC'CEPTANCE OF PROPOSAL' The above price,specifications and conditions are satisfactory.`I herby accept.this proposal You are authorized to do the an' payments will be as specified above. FR Al SIGNATURE: � •p - 3 *This proposal may be withdrawn by said company if not accepted within 30 days , j v w e, r. t r l�rr w R^'� 5 1G � a ` "}'°' ��• �',»,aa�,� 'K' t R >, ..�r 'v f a .y. ✓ r ,+'� . �sr- t � Ys k r q y .1-s,�Y_��' �. -T � w s � ��M 3 Nti fir {'Z'r � rs �`�'�d t'•Y^t � at c r b> ". 3 w r`E r'S� �.�.. �,r"v'k y,�.i#' � c+1 . � -` ) � .h..;t 4�.,� f"nx tF ra yr'r aket a, t � jN'c1; �a}+;� .3<e f'•n L}>. r. -•�i. v! k 4 t A 3.a- .y t�' t ^'� r .�r'• y t=G2'a�*'Wa}�' 4`` ,+5,;.n s, r '�'7^ '" F'�. a5'."t. •X'`., 's+'e `r-�?r � _?x��e'i> T-`x�`A,�'x i� Syr "ttix ..� 7 {,} �f� �,xy _�. ,Yw - . �' t, ',>w�,• � FYx�`r` �� r.s",`t',�s. .3y-' k".'��—u � N{1r' %� y,�¢y ,x .w�,v,'u� F itr?{t S`'��' � ..� �+n �z '�q1�r r .. �'� v`"�'s F" ,� - �.. �'n'`'� - u ��' 't�`'�� •Q���',�.f�'�'. ,y��' .�,,rr t� �� s-. The Coinmoniv'e alth of Alassachusetts �K - --- Da �rrrrtnrerat oflnrlrrstrical ccidewts Office of Investigations 600 W ashin: tort Street Boston, AL4 02111 _. . »yogi v.rrrcass.govIdia "Yorkers' Compensation Insnranr -Affidavit: Builders/Conti:tctae-s/Electazc--.tnslPlumbers Applicant Inform,atiGn 1 s Please Print Legibly i alne(Bus r css Qr,w=atian/lndividual): Address: CYt'y/statP.:��r.7: �t '\ 1/ Phone#i. ab 011y 1 0 Are you an employer?Cheek the appropriate box Type of project(required).: 1_ a employer with_ 134. ❑ I ani a general contractor and I employees(full and/or pa :time). liar e hired the sub-contractors .6. ❑New constnwfion 2..ElI 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 a capacity. employees and have workers' any ty• 9.`❑Building addition .. [No workers' comp-insurance comp.insurance,: required..] 5. ❑ We are.a corporation.and its .10.❑Electrical repairs or additions 3.❑ I am a homeowner doisrg all work offcers have exercised their 11.❑Plumbing repairs or additions self. No workers'co right:of exemption per 1VIGL �' [ �• 12.❑Roof repairs . insuuance required.j' c. 152, §1(4),and we have no,. , employees.[No workers' comp.insurance:riegi ired.] 'Any applicant that checks boa o1 mist also fillout the section below showing their workers'compensation policy information- Homeowner's who submit this afhdauit indicating they are doing all work and then hire autsma contractors must submit a new affidavit indicating such_, rCantractors that check this bout mu-t attached an additional.street showing the rune of the sub-contractors and sum whether or not those entities have' . employers. Ifthe sub-contractors have employees,theyrraw provide their workers'comp.policy number. I arin are employer that is proiVing workers`contpe e.salion irnsanrance for my entployee.&`Below is the polio'aid Jab site information. Insurance Company Name. \ Policy#or:self--ins.Lic.#: Expiration Date: 7, Job Site Address: Virj l ( U3 I.4�J City,St.aterZep: Attach a copy of the war ers'compensation policy declaration page(showing the policy number and expiration date),. Failure to secure coverage as required under Section 25A of MGL c. 1.52 can.lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year impnsonmeiil,as well.as civil penalties in the form of a STOP W,ORR ORDER and a fine of up to$25.0-00 a day against the violator: Be a vised that a copy of this statement may be f0mrarded to the Office of Investigations of the DIA€'or insurance cover,alge yeti ti I do hereby certify it the S. a3 alties .ry thatthe irnformation prodded aboveis time and correct, Signature: i Dater (! ' Phone#: Official use.only'. Do not write in this area;to be mn!pleted bye ciiJr or tt twlt officiaL City or Town: Permit/License 9- Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityfl'o,"m Clerk: 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: �pF THE Tp� + BARNMBLE, MASS. 1639. Town of Barnstable 1� � prED MP't A Regulatory Services Thomas F. Geiler, Director ' Building Division Thomas Perry, CBO Building.Commissioner 200 Main Street, Hyannis, MA 02601 �'www.town.barnstable.ma.uS Office: 508-862-4038' 'Fax: 508-740-6230 Property Owner Must $. Complete and Sign This Section If Using A Builder I, as Owner of the subject property. " hereby authorize to act on my behalf, <; in all matters relative to work authorized by this_buildingpermit application for: (Address.of Job) Signature of Owner'" Date Print Name . a If Property Owner is applying for permit, please complete the Homeowners License Exemption Form on.the J reverse side. , Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 070110 OfliceorCo� - HOME IIVIpROV er Affairs&Business g�� Registratio gulation n rE2648p CONTRACTOR License or re o before registration valid for' Expiration: 6/8/ T the a mdivid 012 Type: expiration da MA K HERBS T Individual Office of Consu ate- If found returnut only e MAR air • 10 Park Plaza-Suite gfa►rs and Business Re o. - Boston 170 Regulation K HERBS I{i, ,. � a g MA 021Suite 35 PEEP TOAD Rp..� 16. i CENTERVILLE MA 02632 L j der secretary A. Jlikm �'` Not valid wi tssachuset oft signature Board 01' Depart 'License-nstrpct ofn SRC`�'mN0nv ttpUhltc Sa1�.1`: Restricted - CS 48� Pervisor nU Stanvar' i. d to; license U�' MARK D HE ENT ET C TOAD RD ERVIL, MA E. 02632E , tuner. i - • ExArrafion; , 11271 12 Tr#: 13g99 TOWN OF BARNSTABLE Permit No. ---------------------- 1 Building Inspector Cash C -OCCUPANCY PERMIT Bond ---— _-_------ C --- No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date 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. ...................................................... 19......„„ ....................................................................._........................_........_ Building Inspector �1►.IGI_C- FAMILY - 3 B1=DQooM 1..10 GA213AGE 62lWDEGz oP.tLy FI-OW = Ito x 3 = SEPTIC, TAIJK = 330x15C>% =A956.P. V, 'I U5c- 1000 �- lie , v15Po5�i PIT V51^ 1000 GAL. 0) ' 5 D6vJAl.t_ AeEa = t5os.F / IS 000 lG+ BOTTOM AREA= rj o S,F, 0 N 50 $.P X 1• O �• \{ h•. tt pMlNt tS ` ' (��, / 'TcTAL. DA I L\( F1-UV4 - 330 6.90. c�3Co � fo vN.DA r�o�.1. �• I PI~IZGOLATIOW RATE 1 `IN 2MlN rap MCHARD N ', - r ApQAXTERNa 2-NO J 1! L VW�PfVLtit TEST P-<Q4q � = St TOP FWD'{�Z HOLE 8�//,(1� �,(z s' .ram--r vr�• r�r/�y 17 LoaN�1 toav INv. i StJP1iAL . ... MST. INS. S£PTtC 48S j 2�L : 1000 INS 0UX 48,E TANK GAL. -.. /d- �• 'SAkto%/ LEAGu D tNV. 4$ 4 WASN6D GtiA�d. ., {,TONE• EL' � .. �. � -. . . ;. .. ; .' : . . 42•o I C,EQTIFISD PI-c, PLAN P R.a 1=I Lr.: AS LoC4�torJT /1 NO GA L E SCALE 1 7.. I S 1�=...�.... j7AT� k/aT> �E GE CEP-T%F•Y THAT THE Povat>ATIOW SKoµlN. . PL-At•a REFE NER60t�! C•OMPL`�6 WITP"T1-tIr S 1 C>V-_U -I r_— ' AWP -SsiVa CG < 26QvIR.�Mt=t�1T5 ot= -c4-I�- � bra"' ; c.,W ICI a� -e,P.IJS W' r-- ANC I s OT LOGp.TED WITEIIW THE G%_000 PLAIN -r b AT E 6 113 82 aAXTav- WYE: INC. �Z.EG 1 S'T rc.QEU't,A1.t D 5'.0 f�Y EYo>z'S T6.t;�j PLAN I �j ►�jU"T �.l��jEb bld AN OSTE2VILLI✓ MASS• (lJSTRuME.NT SVQVEY ,�'T4�f� OFFSETS 'SLIOuI� No'1' [3E Vet^-OTC) APPLICA►J"r �C,A L SMAU' I61G i Assessor's map and lot number .... .7..../......................... i ` TH E r SEPTIC SYSTEM MUS w Sewage Permit number ...... ..�.-�.....�-.�.1A. �...:..................... INSTALLED �. LL.ED ��6 , ! g ST4D�� ����"'® LE, i Houma number TITLE 5 rase 1639 ENWRONMENTAL CEDE .a`0� ' TOWN._ 'OF BARNSf,fi`t DURDIHG INSPECTOR APPLICATION FOR PERMIT TO ........ ..................:.......:....................................................................................... TYPE OF CONSTRUCTION ..... "z Cf:.. :....................................:............................ ................. !... .,/.. ....... .19. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit acSording to the following information: Location ..." Y3.:5... ,� '� .... -`r .. .......................... � .��G .............Proposed Use � Zoning District ................................./.'...................................Fire District ........ 10 Name of Owner ...,.K.6...x ....... Address L - ... . .............. ...... ...... Nameof Builder ................................. ................................Address ..................... .............................................................. ' Nameof Architect ..................................................................Address ................ ..................... .......................................... Number of Rooms ........j .......................................................Foundation ...... . ... ....... ......................................... . ........... ..... Exterior �................................................Roofing ..... .............................................................. Floors ...............................................Interior ... .... .. .. .... ...... .._ ............... Heating .. ... ......................:........:.....Plumbing ....... ... €. Fireplace .. ...............................................Approximate Cost ....... r�/.. ........... `F .... Definitive Plan Approved b Planning Board ----_____----------------------_19________. Area . ..................�--.. ® Diagram of Lot and Building with Dimensions Fee . ..G ....... SUBJECT TO APPROVAL OF BOARD OF HEALTH fJ ' q I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regardi g the above construction. j Name .......................�.. ................................. SMALL, ALAN ",No 2...4...0..5...7, Permit for One Sto ry . .......... Single Family Dwelling ............................................................................... Location ...u.ot...'.jf.3.5......1.16...Ansel. ...H.owl.and Rd. .. .... ..... .... .. .. ....... . Centerville ............................................................................... J Owner ....'Alan Small ............................................................... . Frame Type of C6nstruction .......................................... .................................................................. ............. Plot ............................. Lot ................ ............... May 17, 82 Permit Granted ........................................19 Date of Inspection ....................................19 Date Completed ............ �747.R:9.19 PERMIT REFUSED ................................................................ 19 _4 .............. ................................................................ ....................................................................... V-**, . ................................................................................. Approved................................................. 19 ....................................................................... .............. �j Assessor's map and lot number, ... /.,f.. ..1.�?.6. ....... ... FT er Sewage Permit number ...D....... . . .Jrr T i. .� HASBSTI�DLE, • House number 1� ��.w...: '.. 90o r639 •� 01 TOWN' ',OF BARNSTABLE BUILDING- INSPECTOR c APPLICATION FOR PERMIT TO ...................................................:.......... ®�.. TYPE OF CONSTRUCTION ....,...IN.. ..'a.............E /.: .......�.�...�.r...... y ..19..3. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information:%� Location ..:/.1.t?........ ..5 :.........Tl.. .... ....... ..� ...�.............�./......................................... `. . G/ Proposed Use ......SU!! .........!!... Q.!..:.1..........................................................:....:............. Zoning District .......... :. :............. Fire District ..4...el./�'.l/L•l .:..�..U� �Uf��� Name of Owner q /./A .......... . .. ...................Address ...... !C /V1 10 ks, X5 Name of Builder ...................................... .....................Add 1.........ress ..... .............................. .... ,/.......... .... Name of Architect ....Address ........................................:.................. Number of Rooms ............... ...........................................:......Foundation .................................... .. ........................ Exterior /.:.... �Il/CC �/ .S ... oofing ... /�„ L...l.............................................. Floors �. hf'. .........................................Interior ��.1................................................:.............. /V,B.ff..-.e. .......Plumbin ....../..,r ... � Fireplace ......../V AW JC........... .......:....... ......................Approximate. Cost ... �®.:. ....................... ..... Definitive Plan Approved by Planning Board -----------____—_---------19________, /// Area .......o D :......:...... Diagram of Lot and Building with Dimensions Fee �Q'................ ........... SUBJECT TO APPROVAL OF BOARD OF HEALTH ' r S u IV q-j- �X ST t r' � W,e fv G as � 7 .b OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS r p' I hereby agree to conform to all the Rules and Regulations of the Town f Barnstable re rding th bove construction. Nam ......... ........................... C nstruction Supervisor's License 41MARA, JOHN . 256 80, ADDITION No ................. Permit for .................................... Single- Family Dwelling ................................................................................ % Location .11,6 Ansel Howland Rdad ............................................................... Centerville ..................... ......................................................... r J6hn* Mara Owner ................. I................... j....................... Frame Type�o4 Construction. .......................................... ............................................................. ................... . .............. Lot ................................. Permit Granted 'Pct bgr...2A....... 19 83 Q.19 D spectiog Date . ............at,�Of 11 Date Completed ..... ...19j r