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HomeMy WebLinkAbout0113 BLANTYRE AVENUE 4 a 4 �n„ I, y � t. 'n � .i[ .�. ,. •,r .. tY�. l � :I art , .�jin � ,. ',� ; � w �� ... _ I i i U o ° C �� ., i a P � �. 0 ., a° I � is h ,. u h - �� f Y APPlication number....................,.. � to Issued.. 7 Ji s .... .... ..................................... i3 MSTABM HAM a639� �®� JUN 2 2018 Building Inspectors Initials...To ...f, ,,__j�8A Map/Parcel......... Zq...v�.. .............................. TO O A ST LE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATIERIZATION PROPERTY INFORMATION' Address of Project: //3 Fla.,fvi-e Ayc (�IP�c4v�ry,-Gl'e-- NUMBER STREET VILLAGE Owner's Name:��/q p CO r S Phone Number 6 r 7- 7-3 7 Email Address: C D G Dti S @ C ao l-coM Cell Phone Number Project cost _5' <�r 2 — Check one Residential Commercial OWNER'S 1VER'S AUTHORIZATION HORIIILtl'ATIOl`7 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-Aac ,e k Cg-z- 'A-4 Date: TYPE OF WORK 0 Siding El Windows (no header change)# 0 Insulation/Weatherization Doors(no header change)# 2-_ Commercial boors require an inspector's review 711 Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S FORMATION Contractor's name Adee mn e l yc, zas Home Improvement Contractors Registration(if applicable)# //Z 7 8 S (attach copy) Construction Supervisor's License# 0 7o0 7 Z (attach copy) Email of Contractor Phone number -//o/- 7i,/- 6 3`1 9 ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF TIME SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. r APPLICATION NUMBER............................................................ *For Vents 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 df f ood 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 EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand nay 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 CI'V R and the Town of Barnstable. Signature Date /APPLICANT'S SIGNATURE Signature Date 6-2 -7-1 k All permit applicafi;�are subject to a building official's approval prior to issuance Home Improvement Agreement: Page 1 Home Depot License Number(s): Visit www.homedepot.com/c/SV_HS_Contractor_License_Numbers for latest license info MA: 107774, 112785 Salesperson Name: Janice Campbell Registration No. (if applicable): �— Home Depot U.S.A., Inc. ("Home Depot") or service provider named below ("Service Provider") will furnish, install or service the equipment listed below at the price, terms and conditions as outlined on this form. COCORIS I PAULA New England South 1-653TB0X Customer Last Name Customer First Name Store #/ Branch Name Lead/Customer Order# 113 BLANTYRE AVE Centerville MA 02632 Customer Address City State Zip (617) 797-5544 paulacocoris@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 HOME DEPOT USA INC., 2455 PACES FERRY ROAD, BLDG. B-3, ATLANTA, GEORGIA 30339 or EMAIL The Home Depot @ 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 PAYMENTS 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 THAT44PME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN W TO ACKNOWLEDgg THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF Y RIGHT TO C"CEje 0111 Acknowledged by: 06/11/2018 Custo s Signature ate Contract Price and Payment Schedule : Payment of oel ntract Price is due upon signing unless a different payment schedule is required by law, specifieor in a payment addendum. Contract Price: 5s12.00 -Includes all applicabl txcludes finance charges.* Sales Tax: 0.00 (If applicable) *Maximum deposit ONLY applicable in MD, MA, ME(3396), NJ, Wl(99%) Dep. 125.0 % Deposit Amount 11403.00 Remaining Contract Balance 4209.00 The Home Depot-2455 Paces Ferry Road, N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1-800-466-3337 Customer Agreement(C,E,I)(31 Jan.18) v 50.1.2 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 1 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): Address: �J� J�i9LL sr City/State/Zi : d1�7 Phone#: 77Y 74 4 ' e?c3Qj Are-you an employer?Check the appropriate box: Type of project(required): I.❑ I am a employer with 4. ❑ I am a general contractor and I K employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. am a sole proprietor or partner- listed on the attached sheet. 7. ElRemodeling 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 i l.❑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#t must also fill out the section below showing their workers'compensation policy information., t Homeowners who submit this affidavit indicating they ate 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 fine of up to$250.00 a day against the violator.Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ceTXU__ ' thepaiMWndpenalties of perjury that the information provided above is true and correct. i n t l Date: phone#: Official use only.Do not write in this area,to be completed by city or town official, City or Town: Permit/License# Issuing Authority.(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: %� 'E$cd�►r�g ftr�esl:ra�aa�ac �r�"s{aut�t��rrei� 3' yp The Commonwealth of Massachusetts Department of Industrial Accidents ' 1 Office of Investigations 1 Congress Street,Suite 100 J r/ Boston,J1L4 02114-2017 �y www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders!Contractors/Electricians/Plumbers licant Information `� Please Print Le 'blv faIIIe (.Business/U•gartizationdzdividual): HO e< - Address: 90 l�0 S l URNtflt/ Citv'State/Zip: s� sb M o/syr Phone#: 7 '7L� 75- - a /S�5_ eyouu an employer?Check the propria b x: Type of project(required): am a lover with - _ 4 I am a general corm actor and I I emp 6. ❑New construction l 1-..:employees(full and/or part-time)- have hired the sub-contractors i r, listed on the attached sheet. 7. ❑Remodeling 2. I am a sole proprietor or parmer- ship and have no employees These sub-contractors have g• Demolition worlsmg for me in any capacity. rmoioyees and have workers' 9 ❑Building addition o workers' --om insurance c� n s'rar,ce.- p 5, ❑ We are a corporation and its I 10.❑Electrical repairs or additionsrequired- i ] officers have exercised their 11.7 Plumbing repairs or addi ons ;.[ I am a homeowner doing all work mysellr ;No workers' comp. right of exemption per i�1GL 12.❑Rpof-ep:its + c_ 152,§1(4),and we have no insurance required.] , 1=.i Other �ctf;.� coo empiovee4. [tiff wormers• comp. itisun•ance required.] I , e,,la c e,-.s-•-� •Ary applicant that c ecL box dl must also fill out the section below showing their workers'compensation policy mformatiop. rlomeowne s who submit this affidavit indicating they are doing aD work and thou hie outside contactors must submit anew affidavit indicating such. :Contactors that check this box must attached an addiboual sheet showing the name of the sub-contactors and state whathcr or not those entities have -=pioyees. s the sub-contractors have employees,they must provide their workers'comp.policy number. I a�I an employer rliat is providing workers'compensation insurance for my employees. Below is the policy and job site information. Lusi=ce Company?lame: �.FJt{r/Zr 2�biticf./ V N�o�✓ �//'t �it/S . �6 Pohcy#or Self-ins.Lic.#: X W e�l / J ! l Expiration Date: 3 j Job Site P ddress: ,Lf 1�f a"i-4x e' City/Slate/Zip: I✓r 1 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Faihire to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a Eme un to$1;500.00 and/or one-y imprisonment, as well as civil penalties infor the form of a STOP WORK ORDER and a e of up to V250.00 a day a ' stZqce lator. Be advised that a copy of this statement may be forwarded to the Office of r coverage verification. Ivestigations of thebLk I do hereby certify un e i at the information provided above is true and correct 011 Si attre: Date: - — i Phone T: Official use only. Do not write in this area,to be completed by city or town official. Citv 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#: 44 == = Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Supplement Card Registration: 112785 HOME DEPOT USA INC Expiration: 04122,12019 2455 PACES FERRY RD C-11 HSC ATi ANTA,GA 30339 Update Address and return card. Mark reason for change. D Address ❑ Renevm! D Employment ❑ Lost Card -_- Office of Consumer Affairs&Business Regulation --- HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Suonlement Card before the expiration date. B found return to: Registration Expiration , Office of Consumer Affairs and Business Regulation = 1127E5 04/22/2019 10 Park Plaza-Suite 5170 i 0ME DEPOT USA INC Boston;MA 02116 'J 1 ANDREW SWEET - 2455 PACES FERRY RD C-11 HSC (] iji1ouj signature ATLANTA,GA 30339 Undersecretary DATE IMWDDNYYY) ACORV CERTIFICATE OF LIABILITY INSURANCE F021222018 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 WANED,subject to the terns 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 PRODUCMARSH USA,INC. NAME: FAX TWO ALLIANCE CENTER we No 3560 LENOX ROAD.SUITE 2400 E-MAIL ATLANTA.GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE I NAIC X CN101642069-HaneD-GAIN-18-19 INSURER A:Oki Republic Insurance Co 24147 INSURED THE HOME DEPOT,INC. INSURER B:New HaIMstfire Ins Co 23841 HOME DEPOT U.S.A.,INC. INSURER c:HomeRisk Came Insurance Company 2455 PACES FERRY ROAD INSURER D BUILDING C-20 ATLANTA.GA 30339 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: ATL-00435343916 REVISION NUMBER:3 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I TYPE OF INSURANCE ADDL SUB POLICY NUMBER MWDD EFF MIWD OLIGY FYY LIMITS LTR A I X I coMMERCIAL GENERAL LIABILITY MWZY312717 031012018 lowoiam EACHOCCURRENCE S 9•�•000 DAM An R ED CLAIMS-MADE OCCUR LIMITS OF POLICY XS I )PREMISES Ea occurrence S 1.ODD,000 MED EXP(Any one person) :S EX..LUDE.. OF SIR:$1 M PER OCC PERSONAL a ADV INJURY S °000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - GENERAL AGGREGATE 5 9A00.0� X POLICY a PRO- ❑ LOC PRODUCTS-COMPIOP AGG S 9,OOC,OIY� - JEC7 S OTHER: P. l AUTOMOBILE LIABILITY MWTB312718 0310112018 03/0112019 COMBINED SINGLE LIMIT S 1.00G,000 Fa amdent X ANY AUTO BODILY INJURY(Par person) S OWNED SCHEDULED I SELF INSURED AUTO PHY DMG - BODILY INJURY(Per accident) 5 AUTOS ONLY AUTOS HIRED NON-OWNED I I PROPERTY DAMAGE 5 1 AUTOS ONLY AUTOS ONLY Per accident t 5 UMBRELLA LIAR HOCCUR EACH OCCURRENCE S EXCFW LIAR CLAIMS-MADE AGGREGATE 5 S DED RETENTION S B WORKERS COMPENSATION WC 014122577 (AK,NH,NJ VT) 031D1t 018 03I0U2D19—MELD OTH. STATUTE ER B AND EMPLOYERS'LIABILITY Y 1 N WC 014122578(WI) 03/012018 031012019 5.CDD,000 ANYPROPRIETORIPARTNERIEXECUTIVE ) E.L.EACH ACCIDENT S OFFICERrMEMBEREXCLUDED� NIA 5,000.0w (Mandatory in NH) EL.DISEASE-EA EMPLOVFJ: S n yes,describe under Continued on Adchonal Page EL-DISEASE-POLICY LIMIT S 5•�• DESCRIPTION OF OPERATIONS below C Excess Auto 297-1-10011-00-2018 03101201E 031012019 Urttit 4.000.000 DESCRIPTION OF OPERATIONS I LOCATIONS I 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 CANCFI I Fi]BEFORE 2455 PACES 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 Mukherjee JVLaIA0,01 ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD r AGENCY CUSTOMER ID: CN 101642069 LOC#: Atlanta .4`oRo® ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY MARSH USA,INC. NAMED INSURED THE HOME DEPOT,INC. POLICY NUMBER HOME DEPOT U.S.A.,INC. 2455 PACES FERRY ROAD BUILDING C•20 'CARRIER �ATLANTA�.GA 3D339 NAIL CODE .EFFECTI ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Compensation Continued: Carrier:Indemnity Insurance Company of North America Policy Number.WLR C64763191(AL,AR,FL,ID,IA,KS.KY,LA,MS.MO:NE,NM,ND OK,SC,SD TN.WV.WY) Effective Date:03101/2018 Expiration Dale:03101/2019 (EL).Lirnit:S1,000,000 Carrier New Hampshire Insurance Company Policy Number.WC 014122576 (DC.DE,HI;IN,MD,MN.MT,NY;RI) Effective Dale:03101/2018 Expiration Date:03101/2019 (EL)Lirml:S1,000,000 Carrier:ACE American Insurance Company Policy Number.WCU C64783221(QSI)(AZ,CA,IL.NC,OR.VA,WA) Effective Dale:0310 12016 Expiration Dale:0310112019 (EL)Limit:S1,000.000 SIR.$1,DD0,000 SIR for the states of AZ,CA,IL,NC,OR,VA,WA Carrier.National Union Fire Insurance Company Policy Number.XWC459558D(QSI)(CO.CT,GA,ME,MI.NV,OH,PA,UT) Effective Date:OW0112018 Expiration Dale:0310112019 (EL)Urnil:$1,000,000 S1,000,000 SIR for the stales of CO.ME.'NV,MI,OH.PA,UT S750,000 SIR.for the state of GA S350,000 SIR for the state of CT Carrier:National Union fire Insurance Company Pdicy Number.XWC 4595581.(QSI)'IMA) Effective Dale:MID112D18 Expiration DateJ03ID112019 (EL)Limit:.S1,0DD,00D SIR:S500.00D TX Employers XS indemnity. Carrier61inios Union Insurance Company Policy Number TNS.C4916693A ITX) Effective Date:03/0112018 Expiration'Date:.031D1r2019 (EL)lintit:S10.000.000 SIR:S1,000,000 ►CORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 7.F-1 l P of r ti 'Town ®f Barnstable Permit 7 35�; O Expires 6 mmnlhs nt a at Regulatory ServicesNAM Fee4 aaursrast�, a 9cb , ,�� Richard V.Scaii, Director QED AAA's Building Division Tom,Perry,CBO,Building Commissioner 200 Plain Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax:508-790-6230 EXPRESS PERMIT APPLICATION - RESIDEl TUL ONLY Not Valid rvithaat Red X-Press Lnpr7nt Map/parcel Number 2-Z . 00q Property Address vt`tyA✓Z (Residential Value of Work$ cis — Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 4,)LA Loco., S 113 ?-Sr!ctn tyre -A ✓C rph- -e-e, l , m A t)L[9 s z_ Contractor's Name ALE Telephone Number f!L(o I q�O C7 Horne Improvement Contractor License#(if applicable) / 73 Z 14 S Email: Construction Supervisor's License#(if applicable) 7 O �Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ �m the Homeowner I have Worker's Compensation Insurance _ Insurance Company Name El re_ 2 Workman's Comp.Policy# � Copy of Insurance Compliance Certificate must 4ccompany 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) [R❑ e-side eplacement Windows/doors/sliders.U-Value . 3O (maximum.32)#ofwindows _ #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i_e-Historic,Conservation,etc. ***Note: Pro a caner must sign Property Owner Letter of Permission. m' -- A copy cftthe Home Improvement Contractors License&Construction Supervisors License is require c o - SIGNATURE: C:\Users\Decollik\AppData\Local\ijlicrosoft\WindowsUemporary Internet Files\Content.0ut1ook12P10I DHR\EXPRESS.doc Revised 040215 Renewal Agreement Document and. Payment Terms byAndersen. dba:Renewal By Andersen of Southern New England' Paula Cocoris Legal Name:Southern New England Windows,.LLC 113 Blantyre Ave RI#36079,MA#173245,CT#0634555, Lead Firm#1237: Centerville,MA 02532 w�xoow RE uCEMEMT 26 Albion Rd I Lincoln -RI 02865 '- _ ' H:(617)797=5544 - Phone:866-563-2235 I Fax:401-633-6602 1 sales®renewalsne.com . Buyer(s)Name: Paula Cocoris Contract Date: 07/13/17 Buyer(s)Street Address: 113 Blantyre Ave, Centerville , MA.02632 " Primary Telephone Numben.(617)797-5544: Secondary Telephone Number Primary Email: paulacogoris@gntail.co111 Secondary Email: - Buyer(s)hereby jointly and severally agrees to.purchase the'products and/or services of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern New England("Contractor'),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement' Document,the terms.of which are all agreed to by the parties and incorporated herein,by reference(collectively,this"Agreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed.all work under.this Agreement. Total Job Amount. $6,995. By signing this Agreement;you acknowledge that,the Balance Due,and:the Amount Financed must be made by personal check;bank check,credit card,or cash. Deposit Received: : $2,331 Balance Due: $4,664 . Estimated Start: Estimated Completion Amount Financed: $0 8-10 weeks" 8-10 weeks Method of Payment. Cash/Check We schedule"installations based on the date of the signed contract and secondarily on -the date in which we complete the technical measurements:The installation date that we are providing at this time is only an estimate.We will communicate an official date and time a later date..Rain and'extreme.weatherare.the most common causes for "delay. Notes: Deposit and final balance by check Buyer(s)agrees and understands that this Agreement constitutes.the entire-understandings between the parties and that.there'are no verbal. understandings changing or modifying any:of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without.the signed,written consent of both the Buyer(s) and Contractor:Buyers)hereby acknowledges that Buyer(s)1)has read this. . Agreement; understands the terms of this Agreement,and has received a'completed,signed,and dated copy of this•Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was:orally informed of Buyer's right to cancel this Agreement: . NOTICE TO BUYER:Do.'not sign this contract if blank.You are entided.to a copy.of the contract at the time you sign YOU,THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 07/17/2017 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT Legal Name:Southern New England Windows,LLC. dba:Rene v By Andersen of Southern New.England Buyer(s).' ...... ............. Signature of Sales Person Signature Signature Victor Anger .Paula Cocoris - Print Name of.Sales Person. Print Name Print Name. UPDATED:.07/13/17. Page 2:./,7. .. Massachusetts Department of Public .Safat f Board of Building Regulations and Standams _icense: CS-095707 BRIAN D DENNISON 7 LAMBS POND CIRCL E-." CHARLTON MA 01507 - ..M l� =x�irarcn: Commissioner 09i08f2018 C�r0. OCSlliIlZr,', a r51and BllSiT[ZjSRea-I1iaC 0^ 10 Iar':Plaza -SLite ; 70 ✓ Boston. i`itassacaLse�s '_' Home tTnprovement C-o^tractor Registration =- ReWstradon: 173245 -- -_ - - Type: Supplement Card = E:piraton: 91191201S SOUTHERN NEW ENGLAND VVINDOW8 LL BRIAN DENNISON ---- 2.5 ALBION RD -- LINCOLN, Ri Q28-15 Uedece.kddres5 and return'card.Ytarit:easun Pur range. --Andress —3eee:r31 -Employment Los-,ward ,.,.=-:ORce of(:3osamer.Urairs F 3osin�s RE oladao R istrarioe-+slid for indit'fduai ase nnh'Reline dfe �,91: espiratioo date 1f round mtam to: - -:=FIOME IMPROVEMENT;CNTRACTCR aosumer.A:Tair and 3nsiness.Re;znnn 9egistratlon:.t.73245 Type: 16 Pant Elwin-smte 51?0 c:.piration:..9155/2043 Supplement Card Ustan.,L-\E116 aOU-HERN NeN ENGLAND WINDOWS 1_LC. RENEV/AL 3Y ANDERSON_ BRIAN DENNISON .. 26 AL310N RD LINCOLN.RI 02665 '-Undersecmutry Not va arum s a ` The Commonwealth of Massachusetts Department of Industrial Accidents a I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electriciaus/Plumbers- TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Name (Business/Organization/Individual): e Address: 24a ,C]u ao 'keJ- - City/State/Zip: LA&LP Phone#: 2>1= Q Are you an employer?Check the appropriate box: Type of project(required): 1 KI am a employer with Zo 1,employees(full and/or part-time).* 7. ❑New construction In I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 []Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I l.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.: ❑ / 14: they Gt/t✓►c(o+�•) 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. L 152,§1(4),and we have no employees.[No workers'comp.insurance required.] /e/--�,*neon e,t 7 S *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 far my employees. Below is the policy and job site information. //jj Insurance Company Name: Irk Ple $ l.p Policy#or Self-ins.Lic.#: W C 31s�7 Z•q — Z- Expiration Date: k Job Site Address: I1 3 3/,aea t yr e Ave- City/State/Zip: ( A e,,,,;/l e 14d Attach a copy of the workers'compensation policy declaration page(showing the policy number aiW expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the ains and penalties of perjury that the information provided above is true and correct _ o _ Si ature: Date: 7' - Phone#: 2- 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#: ESLERCO-01 SANDERSO CERTIFICATE OF LIABILITY INSURANCE D 0610712077I� 06/07/2017 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 endorsement(s). PRODUCER CON NAMTACT CoBiz Insurance,Inc.-CO PHONE 1401 Lawrence St,Ste.1200 wc,N4 Ed):(303)988-0446 IF c,No):(303)988-0804 Denver,CO 80202 Abm&1 s :COMail@cobrzinsurance.com INSURERS AFFORDING COVERAGE NAIC INSURERA:Acadia Insurance Company 31325 INSURED INSURER a:Firemen Insurance Company of WA D.C. 21784 Southern New England Windows,LLC.dba Renewal by INSURER c:Liberty Surplus Insurance 10725 Andersen of Southern New England 26 Albion Road,Suite 1 INSURER D Lincoln,RI 02865 INSURERE: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE INSD WVD POLICY NUMBER D MMIDD A X COMMERCIAL GENERAL uABILrry EACH OCCURRENCE S 1,000,000 CLAIMS-MADE 7X OCCUR CPA3158728 01101/2017 01/01/2018 oAMAGETORENTED 300,000 PREMI E Ea ocairrence S MED EXP(Any oneperson) S 5,000 PERSONAL 8 ADV INJURY S 1,000,000 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 5 X POLICY❑PEe7 LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER. EBL AGGREGATE S 2,000000 A AUTOMOBILE LIABILnY ED a.dBINEerDdSINGLE LIMIT S 1;OOQ�DDD X ANY AUTO CPA3158728 01/01/2017 01/01/2018 BODILY INJURY Perperson) S AO OSDONLY SCHEDULED BODILY INJURY Per accident S HIRED NON-OWNED PeOemdenDAMAGE S AUTOS ONLY AUTOS ONLY S A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 1,000,000 EXCESS UAB CLAIMS-MADE CPA3158728 01/01/2017 01/01/2018 AGGREGATE S DED X RETENTIONS 0 Aggregate - S- pE 1,000,OOD B WORKERS COMPENSATION X SrA ER AND EMPLOYERS'LIABILITY YIN WCA3158729-20 0110112017 01/01/2018 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EA ACCIDENT 5 gni'ER/MEMBER EXCLUDED? L_J N 1 A - 1,000,000 (Mandatory in NH) E.L DISEASE-EA EMPLOYE S tt yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT S B Forker's Compensatio WCA3158730-20 01/01/2017 01/01/2018 1,000,000 C ollution Liability TIEDE654299117 01101120170110112018 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 17-18 Workers Compesnation Includes-All states except ND,OH,WA,WV,WY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLWY PROVISIONS. A' AUTHORIZED REPRESENTATIVE IFOR InformationalP ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 1141E, Town of Barnstable *r2L?6q7 5 ~p Expires 6 months jron issueva /_� # Regulatory Services Fee_ a& # BAMSrABLE. # y�PrtKnss. �N i639. Thomas F. Geiler,Director ♦ �1�c1 CIO U— ED MA A Building Division Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable,:ma.us Office: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Net Valid without Red X-Press Imprint Map/parcel Number Property Address ` \ LA C z*J7,C12-v ) L IF DR_Residential Value of Wor d Minimum fee'of$25.00 for work under$6000.00 , Owner's Name& Address A V L Z R F FZFJZ 9.5 Contractor's Name S Oty Jq' —14 A, ►kJ T`f L F—R— Telephone Number 5 )g-3 6Lf-_7 5 5-? Home Improvement Contractor.License.#(if applicable) �@L Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: S PERMIT ❑ I am a sole proprietor ❑ I am the.Homeowner OCTm 2 2009 I have Worker's Compensation Insurance Insurance Company Name j J� wL / t TOWN OF SARNSTASLE Workman's Comp.Policy# P-T Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) r `j4_Re-roof(stripping old shingles) All construction debris will betaken to 70 lrvN .p q� 3 yt_NS�TAR L E !Pt-ST, CT*Z ❑Re-roof(not stripping. Going over existing layers of roof). 1 ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum .44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property ner us tgn Property Owner Letter of Permission. A copy he o Improvement Contractors License is required. SIGNATURE: Q:\WPFILESTORM \b 'ding permit forms\EXPRESS.doC Revised 100608 The Commonwealth of Massach usetts Department of Industrial Accidents f r.: Office of Investigations 600 Washington Street Boston, MA 02111 www.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le;?ibly Name (Business/Organization/Individual):, �/� Z.J��r ��S'e�f�� Address: City/State/Zip: YApty I _S 14, ' Phone #: 5­0 _ -7 '7 ? S 1 Are you an employer? Check the apprbpriate box: Type of project(required): 1.❑ 1 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 workingfor me in an capacity. employees and have workers' Y9. ❑Building addition [No workers' comp. insurance AZ. comp. insurance.$ required.] 5 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their ME]Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 1 VZRoof 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees;they must provide their workers'comp,policy number. 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. 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-ye imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day agafor t he i W B advised that a copy of this statement may be forwarded to the Office of Investigatio e DIAi s ra ce cover ge verification. I do hereb certify i niter the s an p {ties of perjury that the information provided above is true and correct. Si nature: Date. /a/ � Phone#: / � � Y— 71 !) 7 Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority (circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: _._...-. -- _.- _ ! I, , By rt�a 3e t'Fiig�r'grr rtti is nri- fat t ni(l� ' Constftirfth 6'irp6NI9 yr.4icsn5e OU-35;000 cf enclosed space I 1A-Miisoary only Lio®nse: CS 72579 ` 1 Z Crrittily. Domes t; >Fpir tton T 4/2010 Tr# 14112 I i 4a's i, Failure to possess a ctn-rent edition of the S 'Im i �_ I; I\4nssneltusetts State Biiilding Code _ a �,+ is cause for revocntidn of this license. JON1�:iFl/ N M fi 2 LYNXWO.LM CT"<\ HYANNIS; MA 0260f L._:7 -` Gtsij misslofiet /re Tooyrrn�eoauoeaGlla o�'✓4ZaenachccaeCZd Office of Consumer Affnirs&Business Regulation License or registration valid for individui use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration'a I64032 10 Park Plaza-Suite 5110 Expirat101i= 81.44 11 Tr# 287856 Boston,MA 021 TypeCliv ter "ration REMODELING� 1I; JONATHAN TYL 2 LYNXHOLM CC�t� i HYANNIS, MA 026 LlndersecrefarY ---- Not valid witlwut signature -- - P� +t `"ET° �. Town of Barnstable ` Regulatory Services ►� MAM esr E$« ,Thomas F.Geiler,Director 1639. Building Division Tom Perry,Building Commissioner 200 Main,Street,Hyannis,MA 02601 www.town.barnstable.ma.us. Office: 508-862-4038 Fax: 5-08-790-6230 Property Owner Must Complete and Sign This Section If us inn ABuilder I, ;'as Owner of the subject property a � hereby authorize ONO i / tu A 5 C6� A to act on-my behalf, m all matters relative to work authorized by this building permit application for: (Address Job) Signature of Ow Uer : Date A 1� C= ' Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. 1 . Q:FORMS:OWNERPERMISSION ,i Town of Barnstable Regulatory Services RARNS.,BLF- ; Thomas F.Geiler,Director russ. 03¢ .�� Building Division PjED MA{A Tom Perry,Building Commissioner 200 Maui Street, Hyannis,MA 02.601 "W".town.barnstable.ma.us Office: 508-862-4038 Fax: 509-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name . home phone# work phone# CURRENT MAILING ADDRESS: city/town statz zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as- superyisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to- be, a one or two-family dwelling,attached or detached structures accessory to such use and/or fans structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that.he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that "Anyhomeowner performing work for which a building permit is required shall be exempt from the provisions of this section_(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix-Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly When the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed . Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a.form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forrmbomeexempt vDAC A W TRA { L WORKERS COM.PERSA T ION EMPLOYERS LIABILITY POLICY T YPE AR INFORMATION PAGE WC Do Do v ( A) POLICY NUMBER: (7PJUE-043I98-G-08.) RESEWAL OF INSURER: TPAVEL=RS PROPERTY CASUALTY COMPANY OF AMERICA MCC) CO CODE: 1'-579 i. INSURED: PRODUCEi-t-: REMODELING ASSOCIAitS INC . BRYDEN & SULLIV-AN ENS AC 2 LYt�CCHOLM COURT S8 F.ALMOUT!-; RD HYANNI S MA 02G0i -fYANht+_S MA 02601 Insurad is A CORPORA TI DN Other work places:and.identTrication number are shown in the scheduie(s) attached. . 2. The policy pe*iod is from 05-02-09 t 05-Q2-i 0 :D1 A-M. at me irsured's mailing address. g, A. WORKERS COMPENSA T lCvN INSURANCE:. Part One of the policy applies to the Worker Compensation I aw of the siate(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE- Par_Two of the policy applies to work in each s`�ate listed in item 3 A. The limits of our liability under Part ;we are: Bodily Injury by Ac=iderz: S• i 00000 Each.A=c dent Bodily Injury by Disease: S 500000 Policy Limit Bodily injury by Disease: S i 00000 Each Empioyee C. GTj-TER STATES INSURANCE-. Par Three or the policy applies TO the states; if any, listed her': COVERAGE REPLACED aY ENDORSEMENT WC 20 03 06A D.. This policy in -dudes these endorsements.and schedule: r SEE LIS -ING 'OF ENDORSEMENTS - =i`tSIOf+1. OF I.11rO PACE . The premium for this policy v✓iI! be determined by our.Manuals of Pules, Classmcations; Hates and Rating �. Pians. All required irriormation is subject to verification and.change by audit to be.made ANNUAL'_Y: 57 ASSIGN.: MA DATE OF ISSUE: 04724-0-0 SKI OFFICE: DIRECT ASS-G WENT 701 2_2-MY open(I('=R- RRYDEN & SULLIVAN I N5 A