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0225 CAP'N LIJAH'S ROAD
` TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION '2 C� Map Parcel v Application�©/J Health Division Date Issued Conservation Division Application Fee i Planning Dept. Permit Fee "I Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address Village Owner ly/,d2T_2� Address Telephone�y'o Permit Request & e",4q Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation �-,O�A, D Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supportind-docu entation. CID Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) j Age of Existing Structure Historic House: ❑Yes ) No On Old King' Highway ❑des �'No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) - - Name� '��� Ufa 7 Telephone Number .5`0 � 3 7 1PI Address j �2�'�/��0�� �, License # Home Improvement Contractor# 45 Email Worker's Compensation ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE �44 FOR OFFICIAL USE ONLY C APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: �. FOUNDATION i' FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. f 1 Wpeaeror�M PARTICIPATING y . BONtt1ACfOR mass save MV M4s I�Id J't nMgy Y[3hICrzC: • - - V PERMIT AUTHORIZATION FORM 2)a I/J Q S LJ 2 , owner,of the'property located at (Owner's Name,printed) (Pro a Street A ess) (Cityrrown) p rtY hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor,listed below to act on my behalf and obtain a'building permit to perform insulation and/or weatherization work on my property. Owner's Sig ature Date FORCSG OFFICE USE.ONLY •'i Conservation Services Group has assigned the following Mass Save Home Energy Services Participating.Contractor to the above referenced project; Participating Contractor Date Rev.12132011 _"'�"", Masrtu llu5ttl`, tJlaE�tlrtmertt of F,ublic.Safety, Board of BUIldiny 109ulatlons and Stanelards' Cunsh'nt'tion•.Superl isnr License; CS-100988 HENRY E CASSI13Y 8 SHED ROW WEST YARMOUTH ' s ✓-•G.. �Gi` f. Expiration Commissioner 11/11/2015 a Office of Consurner.Affairs and Business Regulation- -10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Con4ktor Registration Registration: 153567 Type: Private Corporation . Tfl� Expiration: 12/15/2016 'Tr# 259188 CAPE COD INSULATION, INC., HENRY CASSIDY 18 REARDON CIRCLE ` SO. YARMOUTH, MA 02664 Update Address and return card, Mark reason for change. KA I .2� 20M•05/11 (� Address ❑ Renewal Employ ment �� Lost Card ❑ P Y �ce a/�i�raoouue«�C�a��/�lroJOrro�ctaeG� . \ Of(lee of Consumer Affairs& Business Regulntion License or registration valid for individul use only, i OME IMPROVEMENT CONTRACTOR before the expiration date, If found return to: . eglstratlon; 153567 Type: Office of Consumer Affairs and Business Regulation :y xpiratlon; 1;2/15/20;16 Private Corporation 10 Park Plaza, Suite 5170 :..•.. «ai Boston,MA 02116 CAPE COD INSULATLON HENRY CASSIDY 18 REARDON CIRCLE`: SO. YARMOUTH,MA 02664 Undersecretary N valid wi tit sign e The-Coni'monwealth,of Massachusetts Department of Industrial Accidents .. j Office of Investigations 600 Washington Street Boston, MA 02111 _ www.mass.gov/dia Workers' Compensatiori Insurance Affidavit; Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Bus iness/Organizat iongndividual); Lot .; ll ` �f /1, Address. Ella/� � ✓_1 city/state/zip: Phone #: Are you an employer? Check th appropriate box; Type of project (required):, �' 4. I am a general contractor and 1 YP p J l. ,1 am a employer with�i°;' _ � . ' employees(full and/or part-time).* have hired the sub-contractors 6; ❑;New construction 2.❑ 1 am a sole proprietor or partner listed on the attached sheet, 7, [] Remodeling ship and have no employees h - Tese sub-contractors have 8, (] Demolition working for me in any capacity. employees and have workers' comp, insurance.$ 9, ❑ Building addition [No workers' comp, insurance p , required,J 5. We are a corporation and its 10. Electrical repairs or additions officers have exercised their.• 3.❑ I am a homeowner doing all work 1'1,7'Plumbing repairs or additions myself, [No workers' comp,` :right of ekemption per MGL 12,[] Roof repairs A insurance required,] t c. 152, §1(4),and we have no employees. [No workers' 1`3.N'L 1 Other ' comp, insurance required,] *Any applicant that checks box NI must also fill out the section below showing their workers'compensation`poIicy 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 attaFhed 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: 0V Policy # or Self ins. Lic, #; 0�l Expiration Date: 1 All Job Site Address: 2 4� ,Zf.1 /•�� City/State/Zip3� 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/ one-year itiprisonment, 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 insurai-4'coveraize verification, 1 do hereby certify d the pai an penalties of perjury that the information provided-above is true and correct. Signature: ° Date • Phone#: it 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 - l'nntart Per.cnn: Phnno f!. r - CAPECOD-27 BDELAWRENCE CERTIFICATE OF LIABILITY INSURANCE 76/3 (MMIDDrVYYY) ' 0I2015 _ THIS CERTIFICATE Il 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 pollcy(les)must be endorsed, If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement, A statement on this certificate does not confer rights•to the certificate holder In lieu of such endorsement(s),' PRODUCER CONTACT Rogers&Gray Insurance Agency,Inc. PHONE 434 RIB 134 AlExit; F South Dennis,MA 02660 E•MAa AIc No, (877) 816.2156 _ ADDRESS; INSURERS AFFORDING COVERAGE NAIC n INSURER A:Peerless Insurance Company•see LIBERTY MUTUAL INSURED INSURERB,ATLANTIC CHARTER INSURANCE GROUP Cape Cod Insulation,Inc, INSURER c; 16 Reardon .Circle INsuReRo; South Yarmouth,MA 02664: INSURER E; < INSURER F I 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 PERIO INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THE 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, IITR TYPE OF INSURANCE - PO C FF PO EXP MMIOD MMIDDIYI YY LIMITS: A X COMMERCIAL GENERAL LIABILITY POLICY NUMBER CLAIMS-MADE a OCCUR CBP6263063 EACH OCCURRENCE s" 1,000,00C 041011201E O4101/2016 PREMISE Eeoccurrencee) 100100_C MED EXP(Any one person) s S,OOC PERSONAL'&AOVINJURY s 11000,000 GENT AGGREGATE LIMIT APPLIES P.ER:POLICY PRO. LOc GENERAL AGGREGATE $ - 2,000,OOC X a - JECT OTHER: _ PRODUCTS•COMP/OP AGO '$ 2,000,000 AUTOMOBILE LIABILITYCOM s p t $ r• - EO eocldeDl Sl LE LIMI s ANY AUTO ' BODILY INJURY(Per person) 3 ALL OWNED 'SCHEDULED, AUTOS NO OWNED BODILY INJURY(Per accident) $ HIRED AUTOS AUTOS ROPER7YOA AGE (Per accident s F UMBRELLA LIAR $ -- H,CLAIMS-MADE OCCUR, EACH OCCURRENCE EXCESS LIAR AGGREGATE s DEC) RETENTION$ _ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY PER O7H• El ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WCE00431901 STATUTE ER OFFICERIMEMBER EXCLUDED? a NIA O6I3OI2O1 S 06I30I2016' E.L.EACH ACCIDENT g 1,000,000 If(Mandatory E.L.DISEASE•EA EMPLOYEE s 1,000,000 yes,describe under und DESCRIPTION OF OPERATIONS below r ` E.L.DISEASE•POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLESI CORD101,Additional Remarks Schedule,may attached it more space Is required) Workers Compensation Includes Officers or Proprietors, Addltlonai Insured status is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. CERTIFICATE HOLDER „ CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE e Cape Cod Insulation,Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 18 Reardon Circle ACCORDANCE WITH THE POLICY PROVISIONS, South Yarmouth,MA 02664 . AUTHORIZED REPRESENTATIVE ©1988.2014 ACORD CORPORATION, All rights reserved, ACORD 2$(2014/01) The ACORD name and logo are registered marks of ACORD WEEKLY TIME SHEET (Must be submitted on Thursday) Employee Name (pit) Division Week Ending: Regular Overtime Comp. Day/Week Date Hours Hours Time Earned Comments Friday Saturday Sunda Monday Tuesday Wednesday Thursday Total Note: Use codes.in Regular hour column: S=Sick V=Vacation H=Holiday P=Personal CT=Comp.Time B=Death in Family J=Jury Duty r Signature Date timsheet q TOWN OF B ARNSTA73LE Permit No. 1 VA"STua = Building Inspector Cash ----_ -- - •�""�� OCCUPANCY PERMIT Bond ........................�Oqa Issued to r. P. gt-anley Ads?Ness (:en erV].ZIe, MA Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date Board of Health Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. , ....................................................... 19......_... :..'....::':...... �y..:. =: .... Building Inspector t}1k 0;y,,,, 1• r8 i}s1}11} _x , , 1`k Y V 0 0 f Lo7A e� I 7 Or 7 17 ;E as ALF u f . �OUjY��T/dam ix THOMAS E.KELLEY 00. . ENGINEERS-SURVEYORS. 346,LONO POND DaaV$. SOUTH:YARMOUTH,MASK. 026" CERTIFIED. :: PLOT , PLAN UWATiON (-4: wxY/4'. s$ f. SCALE,.�•�-. o� DATE PLAN REFERENCE 78 21, LCERTIF1r THAT THE r ,Ql��lD, �o el, .e SHOWN ON THIS PLAN iS LOCATED ON THEGROUND A$ SHOWN HEREON , t "DATE �� •�� •1..f�. (+1 4� 0 i5, V PETITIONM RKME , : ��' - •..• •._ .. .. ..u..,... `�,..� ... .Wyrai aWc•J, .f'+'n+•,1ero.•:(w:ww ..wm+o,.w.w..+auCunoaauaeC.�zOgtu�ww,axVwwv.wr.an Assessors map and lot number SEPTIC SV�STEM MUST BE Sewage Permit number .. ��Jr-...n. .,.. x •.... s INSTALLED IN C0 ¢IPLIANCE N OF BARS� IV � �g ANDTHE �,T T®W Z ,BAHBSTADLE • ,'y', + r "6 9 BUILDING• INSPECTOR k ,titer 0�0 MPY�'• •.'Jr,� k 3 v 4r ( A f /wC✓�! > APPLICATION FOR PERMIT TO .. TYPE OF CONSTRUCTION ........:` . . C�,Cr�...............................19 i TO THE INSPECTOR OF BUILDINGS: The undersigned hereby, applies for a p4rmit accor4ing to the following information: s Location ............d. ...... .....T 5 `"` ?f!x/ !' ................� . ........... /✓.... ..........//�... ............ ............. ProposedUse ............... o.................. I J+t...................................................................................1 ............ ' e. ......Fire District ........ N-� ^ 4! .C.c,... ' Zoning District .............................................. ................ Name of Qviner C..f.....`...`�. d .`:e ..... .....AddressJr 1......1 , 66.. . �.ti?/ , ��5..!.� .(f/V�{. 1 r � � . ` ...........................� /Name of Builde . ....... ............ ... ....Address .................... .. . ............ Nnc of Architect .......................................... .. ...Address ......................... _....... I .............. IN (m ...Foundation ... !.......... � .. eNu Exterior e.................�: Roofng ......... .......... . .............................................. .'Interio}r�.r...a........'br Y'.:,Ce l L. V-.,tdc?Lis r{eating s..Plumbin`g .... :`. , 'p;r W. ................... .5. ............ bra td 3 - Fireplace .. .... ...... ........................... . ..................... .,Approximate. Cost .................. .�..................... .......... .. Difi>al`hJe- Plan ArjproQd bye--,$6'rn5j P:cr ------ --- ---------------19 ---- --. Area ... ..... ...... t/'� ... _ D ' S F pjetrp ►,4af�Lod and Builcla�►g n1 �; Fee ...... _ ,�ecrtLi Qi. ens oras x. ...�.?' � ........... .' •.ram ' � t B'JE�C'T ,TO� APOROVAL. OF BO f�D,OF ,H �TH; i' -. • . ylf4' '".9� AAA �•` ��9t�SV r f;,,�i � ,• :.� �a '�l�.;tl ;8.,wok._ �'� Irt�.J�'3 a (''� .:� vf�� � _;c,,�.`',�.54 t`r~..• ;"', , ?.,., },r' Aiµ. ._.�t �¢�'t)iS: ..fit i ��tYtia,. �.,. -;a,• ., a 1 F "24f yJ�J+,�t � t.+. ., y.e...I� /':+11t en ... we.n ...�C�"ytjTs.,•1,1•�si t . I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regardi the.above construction. Name ....................................... . .................... z C. F. STANLEY No 23403 Permit for One StorX A e,. : Sin91e Fami1X:.Dwelling . . ...... Location ...Lot.. 45, 22 i„Captain E.ijan Rd. Centerville r" t ................................................................. C Owner .'F.....Stanley.............................. F s Type of%.Ccnstruction ...Frame . ; YJ ............... .... ....................................................... Plot ............................. Lot ................................ ust Permit Granted g................ 19 81 s Date of Inspection ��..:�.J.'��....:'..........19��ii s _ . � • .Date Completed` / .. ......." a 10 a��v f PERMIT REFUSED f r ' ......................1......................................... 19 rF ...... .. ...... ................... .................. ` iA •.,,,.,., .. .... ................. +. ,'� Y• ` M1 �. !r� v "f - ,. _- 1* .. r.. .............. e ..• •............ ..... • `'� "'•1 ♦� ./ram • - . • V ,. ", 1 v .Approved .............................................. 19 � ........ . . . .....................................................*... ............ 't.'d! i ..........................................-........ .. - f 1 ' f - - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION , ApplicaMap 3 P rceI tion # 13 625 Health Division Date Issued 1 l . 112 Conservation Division Application Fee S Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board �K t1ihi d146 Historic - OKH _ Preservation / Hyannis r Project Street Address t;er- 2 4-/ 69 Qir/1 Village Owner Z, f2Z �,®/�q ,�6 Address Telephone 0-Or f 2O !!�)Z,_?3 Permit Request �.� C'`�v�✓� / `'e��y/�1� ��� ,��G �j'/�'G� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain /Groundwater Overlay Project Valuation .� � l Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) _ Age of Existing Structure Historic House: ❑Yes Flo On Old King's Highway: ❑Yes ANo Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing ne, Number of Bedrooms: existing _new Total Room Count (not including bathf>): existing new First Floor Rolisting Count ' o Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other 7v Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing woodal stove:"❑hey ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ knew.-size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size — Other: ;Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # .Current Use Proposed Use w - APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name �� Telephone Number ^_a(f Address 4,4 License # Home Improvement Contractor# /5 �� 7 "nj a I� ° 'Worker s Compensation #�/�,',9,G' ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE Z// FOR OFFICIAL USE ONLY } APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE a OWNER ,sa t DATE OF INSPECTION: ••FOUNDATION. ' FRAME INSULATION � FIREPLACE ELECTRICAL: ROUGH FINAL t PLUMBING: ROUGH FINAL t - GAS: ROUGH FINAL FINAL BUILDING F DATE CLOSED OUT ASSOCIATION PLAN NO. ,l s10/15/2013 M M 5087759974 PACE 05 OWNER AUTHORIZATION FORM I, 1 5: W - 0-r0\,�n-s 1(} (Owner's Name) owner of the property located at Y/ (Property Address) Le-? 7e,, v GZI37— (Pro rty Address) C s° Ca I hereby authorize (Subcontractor) , an authortwd subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. v O(Nners slgn re t Mul.ss;w ILIwtcS - I.)l pal-tlltcnt ul" I'tllllic 1,ticl� Iiu;lrcl ill larlililin, ltc�ul.ltuul> Mid �It:iurl:lrlls Qonstrulction Suprwrvisor License a _ "C'S. 'I00988 — r HENRY CASSIUY d SHED ROW WE3if \iARMOUTH, MA 02673 %._ ..._:a .. fFxptrauon: 11(11/_U13 .• t ,.Ilull;.ni lucr Ti H: 7620 yo 4 4� Office of Consumer Affairs and Business regulation 10 Park Plaza - Suite 5170 Boston, MassachWettS 02116. 1-1.ome Irnprovement Contractor Registrattoll Registration: '`153567 Type: Private Corporation Expi-btion'. '12115/,?b'm rrN 2J;tt�'J1 i'A1:1F_ COD INSULATION, INC HENRY CASSIDY -18 REARDON CIRCLE Sl). YARMOUTH, MA 02664 Update Address illid return card. 111larlt Icilsuu till.change. �] address L I kteuctv.11 _� VIlllaluyulant .I bust turd r rrrrR r!lC�L r/S FT.rr,l.lUi'frU�lril�J - � - uilln ill t uu,unter lvf luil'ti J liusullss lilgulntioll License.ur registratiun valid tut' iudividul use only r l;lUMt IMNKCIVEM'EN1 CC�NTKACI-OR befure the expiratipn slate. If lutind rel'lllll to s{ r uyi9lrutllin: 153567 Type; Ofliwe of eonsumer.Attairs and Business Reg ItIa6uu 3f�ullauon: 12115/2014 Private Corporation 1U I'at k'laza-Suite 5170 ` bustuu,MA 02116_ ;'dvSi.!I-,ti I IiJN,aNCi �" i '�I i;t a.l I l l 11Ar'\U2liEi4 - tlullcrseerelnrl' 0IY71I WltlI0 t Ilat lC The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Ao.�, �c� Information Please Priat L Name (Business/Organization/Individual): 6�/�? Address.1� 44 Phone#: Are you an employer? Check t�appropriate box: l.PI am a employer with,��_ 4. I am a general contractor and I Type of project(required): employees (full and/or part-time).' have hired the sub-contractors ti. [] 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 $. Demolition i working'for me in any capacity. employees and have workers' [No workers' comp.-insurance comp. insurances 9• ❑ Building addition required:] 5. [] We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L0 Plumbing repairs.or additions I, myself. [No workers' comp, right of exemption per MGL insurance required.] t c. 152, §1(4),and we have no 12.❑ Roof repairs 3a.❑ I am a homeowner acting as a employees. [No workers' . 13•ff Other f�����. general contractor(refer to#4) comp.insurance required-) Any aPP6cant that checks box#1 muse also fill out the section below showing their workers'compensatiod�olicy information. ner t Homeows who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have Cenpioyees. If the SUb-CQA41lCtOr$have CrIIplOyCC1,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 jab site informadon. � 4 Insurance Company Name: �' G Policy#or Self-ins. Lic.#:�iG/�/,11� �J / • l Expiration Date: l�,�a Job Site Addressa7 / ity/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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ' I do hereby certify nder the nd penalties of perjury that the informadon provided above is true and correct i L�` Phone#: c `�,� 2l, -• OAW use only; Do not write in this area, to be completed b p y city or town o rein[ City or Town: Permit/LIcense# Issuing Authority(circle one): L Board of Health 2. Building Department 3. CityLTown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: CAPECOD-27 MYOUNG CERTIFICATE OF LIABILITY INSURANCE F DATE(MMIDD/YYYY) ,ATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS _ 7/812013� c DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES E CERTIFICATE HOLDER,THIS THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS),AUTHORIZED SENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. JRTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to .,le terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to tile certificate holder in Ileu_of such e.ndorsement(s). PRouucER _License#PC-514062 CONTACT Rogers&Gray Insurance Agency,Inc. NAME: Margaret Young 434 Rte 134 PHONE - FAX South Dennis,MA 02660 'E-MAIL — ADDRESS:Myoullg@rogersgray.com IN$URER(SI AFFORDING COVERAGE NAIC a INsuHED INSURER A:PEERLESS INSURANCE COMPANY INSURERS:COMMERCE INSURANCE COMPANY _ Cape Cod insulation,Inc. INSURERC:Evanston insurance Company _ 18 Reardon Circle wsuRERD:ATLANTIC CHARTER INSURANCE GROUP i South Yarmouth, A 02664 — M. INSURER E COVERAGES - -- INSURERF: _ _CERTIFICATE NUMBER: REVISION NUMBER - THIS IS TO CkF(1'IFY THATT HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICAIkD. 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 DESCRIBE[) HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN LT SR_.__.._.. -.— - ADDC SUB _'TYPE OF INSURANCE POLICY EFF POLICY EXP' POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY - -'EACH OCCURRENCE $ 1,000,000 A X coMMERCwLGENERAL LIABILITY CBP8263063 4/1l2013 4/1/2014 p� �g�En nmQanca ffi -__10.0,000 J CLAIMS-MADE -J OCCUR MED EXP Anyone parson) $ 5,000 —---- PERSONAL a ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ---- POLICYT n LOC PRODUCTS•COMP/OP AGG $ 2,000,000 AU 10MO81LE LIABILITY C SINE D SIN LE LIMIT $ - B ANY AU I O Ea acddanl 1,000,000 Ea 4/1/2013 4/1/2014 BODILY INJURY(Par person) $ ALL OWNED -- SCHEDULED _ AUTOS X_ AUTOS BOOILY,INJURY(Per acGdan!) AUTOS $. X hIIKEU Alfl OS X AUTOS ED PRO R $ TY DAMAGE A ER ACCIDENT $ _ X UMBRELLA LIAR X OCCUR - - : - EACH OCCURRENCE. $ 1,000,000 C Excess uae _ CLAIMS-MADE XONJ453512 4/1/2013 4/1/2014. -� AGGREGATE $ _ 1,000,000 DEDuREl_ENI'ION�� 1�,000 - _WURKERSCOMPENSATION - $ AND EMPLOYERS'LABILITY - O STATUS OTH- LIM D ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WCA00525904 6/30/2013 6/30/ZQ14 A - OFFICER/MEMBER EXCLUDED? _ NIA E.L.EACH ACCIDENT $ 1,000.000 (Mandatury In NH). .____-_____ It yes,describe undar E.L.DISEASE-EA EMPLOYEE $ 1,000,000 J.tLESCRITION OF OPERATIONS below •• - E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If mare space Is required) Workers Compensation includes Officers or Proprietors. Addtional Insured status is provided under the General Liability when required by written contract or agreement with the Certificate Holder. I _ I . CERTIFICATE-HOLDER ^� y CANCELLATION A_ _ i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Caps Cod Insulation,Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE- t_--._......... (/14hCd1`/l i . 01980-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD C S, �oFitttrolyy Town of Barnstable *Perini # o Regtlla tor'y Services �Feees rS moxl s ront issue drrrr a, vsr�gra, i6J �m�a Thomas F. Geiler, Director Building Division - Tom Perry, CBO, Building Commissioner 2.00 Main Street, Hyannis, MA 02601 www.town.barnstable;rna.us Offi c e: 5 08-8 62-403 8 Fax: 508-790-623 0 EXPRESS PERMIT APPLICATION - RESIDENTIAL QNLy Not Valirl tvitholrt RedX-Press Imprint Map/parcel Nunber Ji /Resiytritial Address } I Value of Wo j�j ��/ U Nlir 'mum fee ofS35.00 for work underS6000.00 Owner's Name & Address Contractor's Nam /Y;�s-I'VICe G QSC a�/ Tele hone NumberJc Home Improvement Contractor License#(if applicable) 3 � Cons action Supervisor's License#(if applicable) 200;?l Work nan's Compensation Insurance Check one: ❑ am a sole proprietorY 8 �M�� I am the Homeowner O I have Worker's Compensation Insurance *2101�/' Insurance Company Name ��UV. 17�/� ;� f�e AM Cp Workman's Comp, Policy# Copy of Insurance Compliance Certificate must accompany each permit, d Permit Request(check box) ❑ Re-roof(hurricanenailed) (stripping old shingles) All construction debris will be taken to ❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re ide of doors Replacement Windows/doors/sli.ders. U-Vahlt G (maximum.3S) #of windows *Where required: Issuance of this permit does not exempt compliance with other totivn department regulations;i.e. Historic,-Consen anon,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License & Construction Supervisors License is renuir 7NATURE: TF[LESTORMObuildingpc„nitfo:msjEXPR SS.doc The Conastonweadth of Massachusetts Department of Industrial Accidents . OJ}Rce of Inveshgadons 600 Washington Street Boston,MA,02111 www.nraz&gov/din Workers' Compensation Insurance Affidavit; Bullders/Contractors/Electricians/Plumbers Al2iftagi In ormado Please Print LexibIl Name(Business/organizatioulIndividual): jUSC? Address: /.S 1�/ 3 (»/ WA ' x G / te/Zi : /rh' /erro, If 1 07)3 Phone#• Are u an employer?Check be appropriate boi: l. I am a employer with 4. Q I am a general contractor and I Type of project(required): employees(full and/or part-time).* . have hired the sub-contractors 6. Q M construction 2.Q I am a sole proprietor or partner- listed on the attached sheet, 7. e modeling ship and have no employees These sub-contractors have working for me in any capacity. employees and have workers' S. Q Demolition [No workers'comp. insurance comp.insurance.t 9. Q Building addition regained:] 7 5. Q We are a corporation and its 10.0 Electrical repairs or additions 3.Q D am a homeowner doing all work officers have exercised their 1 l.Q Plumbingairs or additions m right o mF ,self.[No workers comp. gh f exemption per Mt3I. insurance required.] t c. 152, §1(4),and we have no 12.0 Roof repairs 3a.❑ I am a homeowner acting as a employees.[No workers' 13.®Other general contractor(refer to#4) comp,insurance ] 'Any aPplic>tast that cbacka box Nl must also fill out the section below showing*,4*wMkCW co icy information Homeownmti who submit this affidavit indicating they are doing ad work and then him ouW&connectors must submit a new atHdsvit indicaung such, tCouttacto s that cheek this box must attaches an additional sheet showing the narme of the nod state whether or not ea don entities have aployeea It the sub-contractors have employees,they must provide thadr workers°comp.Policy number, I am am earpioiner that Is providing worker:'conrpeaasation insuraMe for. y entpioyees. Below is ike popsy and Job shw infornra&mL Insurance Company Name*.---!!:. ,� TiAl JVA Policy#or Self-ins. Lic.#: CA/G wo - C.) Expiration Date; I Job Site Address: q � L. S J pJ P City/Stawn .LPsi�l�/^V,d%Ile r1 r3 z Pd Attach a copy of the workers'campensation decian G page(showing the pelley number and up tio®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 31;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 s 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 d®hereby emrd�► Awthepa)Owandpe ofpaj that the infer nation provided above is drat a�eosamea 'J Date- O,Q'kW use onl)% Do not write in this arts.to be crosrplesyrd by clip or town offlefel City or Town: Pernmit/License# Issuing Authority(circle one): " I- Board of Health L Building Department 1.City/rowis Clerk 4.Electrical Inspector S. Plumbing Inspector Other Contact Person: Phone#: 4/26/2012 8:30:17 AM PST (GMT-8) FROM: 100005-T'O: 15087302086 Pane.: 2 of 2 CERTIFICATE OF LIABILITY INSURANCEEn-4&=J2BfMefQ�"�' 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, E=EM OR ALTER THE COVERAGE AFFORDED 13Y THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT„BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATfVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDRIONAL INSURED,the pollcy(ies)amst be endorsed. It SUBROGATION IS WAIVED,subjrct to the tome and conditions of the policy,certain policies may requite an eadwsemmt. A Statement on this certificate does not confer rights to the certificate holder in Neu of such endorseme e. PRODUCER PAUL B SULLIVAN INS AGCY INC2911FACT 1467 S MAIN ST PNOIE FALL RIVER, MA 02724 RIB APAORDBlO.COVER"E NAICI - INSURER A JVSURER a IEPH DUARTE&JOHN DALEY INSURER C: DBA J&J REMODELING 15 WILSON WAY Nsu o: MIDDLEBOROUGH MA 02346 ns~rA R COVERAGES CERTIFICATE NUMBER: i=1222 REVISION NUMBER: THIS 1S TO CERT)FY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT;TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANO CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIS• KooY�fMP Mi9R POLICY NUMBER LM018 L TYPE OF INSURANCE £RCN OLCURRk'r1tICE GENERAL LIAS&ITY IS a_carbnoe $ COhMIERCIAL 084ERAL L"tLI Y CU FAS A W OCCUR tdED OQ' one person) E PE! WLL 9 AVV INJURY S GENERALAGGREGATE $ PRODUCTS•COMPfOP AGG $ GENZ AfiOREOATE L11M T APPLIES PER: S POLICY PRO- LOG - - AUTONOBR.E LIABILITY a a BODILY"JURY(Pat parson) ANY AUTO BODILY NJURY(Pet accdera) ' ALL OWNED H AUTO$111E0 AUTOS "ON-0WNm eyq GE141M AUTOSAUTOS $ i S Et�tOCGUR,RENGE $ �fACUS RELLA LIAN OCCt1RLUB CIA�IS-MADE AGGREGATE f QED fIETEM10N li $ DWI A WORKERS COMPMATION WC5.31 S384800-012 212/2012 21I/2013 Y ,et 90t)00 AM EMPLOYERS'LlAIS LRY YIN F_ EACH ACCiO>rNT $ ANY pROMTyOAA'ARTW9KXECVT{VE u t^,� OFCI�wMENBEA&ICLu0E0? NIA EL.DISEASE.EAEI4KOYEE S 1 (ahndalory in NH► E.C.DISEASE.POLICY LkkpT $ 50000 11 es,desaDe wrdN D TION OF OPERATIONS babW OESCR®TION OP ERATIONS/LOCAT10M31 VEI9CLES W Ish ACOR0101, dddia-W eemulre Bolw duo,Anote We°e b�aquitedl Workers compensation insleance coverage applies only to the Workers compensation taws of►he State of MA.' NO PARTNERS ARE COVERED BY THE WORKERS'COMPENSATION POLICY. TJ9ff L T AT ER D ANY OF THE ABOVE 0£t>�RIBED ppLICIES GANCEII ED AFORE TOWN OF BARNSTABLE �'+�►� DATE TfItRtEOF, N0T1c£ WILL BE O£uv£ttEv IN DAtiC£V1flT}I TI9E POLICY PROViStONS. 200 MAIN STREET HYANNIS MA 02601 r e 01968-2010 ACORD CORPORATION. All lights rasBn+ed• ACORD 25(201005) The ACORO name and 1090 are M%Wered marks o!ACORO tris NnrcLlicn el?ancels andrdspupessedesrA"Psevtausl7sissued?cesttf:cate$ Pepe 1 of t resumer Affairs arad�si�^.ess Re�F�Iatic�n �.��.,. ..f�� i:9 Pars.Pura �U.i�e �i;'fir Boston, I��assac"- Setts 021 i b Tome improvement faotor Registrati0lh Registration: 132349 Type: Partnership Expiration: 1i11/2D13 J & J Remodeling P, Joseph Duarte -�-- --- — 15 Fall St. 77 , Wareham, ma 0257� Upd"ate Address and return card.Mark reason for ct+aoge �.Address 'D.Rtt+xwal ..Employment [] T�s�Cstd 1P5-0A1 0 SOM44104-0101216 e1* Lit:ense or registration valid for tndividul use only ptfiee�i`�oasum a rs�FBtine"s8ntaon before the expiration date. If f°uad return to: HOME IMPROVEMENT C0NTRACTQR Type: OffiCe of Consumer Affairs and Business Reattlation Registration: _,•132349 10 park Plaza-Suite 5170 Expiration. :1(11/2013 Partnership Boston,MA 02116 J emodeling : Josaph Duarte 15 Fall St. •� ��� —?Vol v d without sigtlature Wareham,ma 02571 tlndersecratary \las:achu±cet>.f?cp:tthttnnt of Ptthtic Nafct> . 4 Btrtcd of t3ttiltlin�Re'-'.ttLtu[m•at,t1 tit:utdard: ConstruCtion SuPefvisor License License: 'rS 70077 j0SEPH C DUARTE 15 FALL ST WAREHAM,MA 02571 e• _ Expiration: 1y3Q/2012 Tr#: 7046 ..,,,ulre:K1c1' Z9LGSGZ ES:TZ TTOZ/ZO/10 TO 39dd r The r. O„n, .,,b�avim}' �yy, s:}a Off rc600 t3 � 1 � y t- t g r, d e. 39SIVA,M4 02111 `workers' Co pens bo Insurance Affidavit'. At��llet Information please Print I�elbl . . �.ra _-_r._ _.--__w _ —._ -- Name (Business/Organizationrndividual): d E ✓ Address: ,)- 1 5,75_ Lce,5 efT-rV ZQA-b City/State/Zip: t: go , 303,4 Phone#: Are you an employer?Check the ppropriate b : Type of pro' ct(required): 1.C'j I am a employer with s',' ? 4. I am a general contractor and I 6 ❑ construction employees(full and/or part-time).* have hired the sub-contractors 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' 9 ❑Building addition o workers'camp,.insurance C. insurance. P 10. Electrical repairs or additions required.] 5. ® We are a corporation and Its ❑ 3. I am a homeowner doing all work officers have exercised their l 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#I must also fill out the section below showing their workers'compensation policy information. t Homedwners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have. employees..If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: eu) S o Policy#or Self-ins.Lic.M C00136 q 15" Expiration Date: Job Site Address: lV• I C City/State/Zip:�✓���tr �e 0943')_ Attach a copy of the workers'compensation poi cy declaration page(showing the policy number and a radon 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 fuse of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the and penalties of ' ty that the information provided above is twe ana correct: Signature: - Date: 12 Phone#• ---- Of) vial use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other # Contact Person: Phone •�� '' i DATE(MMID lYYVY)�1 CERTIFICATE LI ,LIT INSURANCE o2/a7/2oia THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT S UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT.::CONSTITlJTE A CONTRACT BETWEEN THE ISSUING iNSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER; IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain._policaes may ref use.ala end, sernent. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsernent(s). PRODUCER 1-866-966-4664 CONTACT Marsh USA Inc. NAME: -PHONE ^ FAX — IC A( IG No): ---- homedepot.certrequest@marsh.com E-MAIL r Two Alliance Center, 3560 Lenox Road, Suite 2400 ADDRESS: Atlanta, GA 30326 INSURER(S)AFFORDING COVERAGE NAIC# Fax (212) 948-0902 INSURER A: Steadfast Ins Co 26387 INSURED INSURER B: Zurich American Ins Co 16535 The Home Depot, Inc. Home Depot U.S.A., Inca tN$URERC: New Hampshire InsCo 23841 2455 Paces Ferry Road NW INSURER : Illinois Natl Ins Co 23817 Building C-20 NATIONAL UNION FIRE INS CO OF PITTS 19.445 Atlanta, GA 30339 INSURERE: INSURERF: Illinois Union Iris Co 127960 COVERAGES CERTIFICATE NUMBER: 257760.28 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. I R TYPE OF INSURANCE A DL SUBR POLICY NUMBER MM POLICY EFF MMIDDY EXP LT LIMITS LTR A GENERAL LIABILITY GL04887714-02 03/01/1 03/01/13 EACH OCCURRENCE $ 9,000,000 X DAMAGE T RENTED 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE [_i] OCCUR MED EXP(Any one person) $EXCLUDED X LIMITS OF POLICY XS PERSONAL&ADVINJURY $9,000,.000 X OF SIR: $lM PER OCC GENERAL AGGREGATE $ 9,000,000 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS COMP/OPAGG $ 9,000,000 jr X POLICY PRO-cT LOC $' B AUTOMOBILE LIABILITY BAP 2938863-09 03/01/1,-, 03/01/13 COMBINED SINGLE LIMIT 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ . ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS I-NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per X SELF INSUR D PHY DMG $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ TO C WORKERS COMPENSATION WC019736915 (AOS) 03/01/1 03/01/13 X WCSTATU- OTH- AND EMPLOYERS'LIABILITY D ANY PROPRIETORIPARTNER/EXECUTIVE YIN WC0197 3 6 917 (FL) 03/01/1 03/01/13 E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? N❑ N I A E (Mandatory In NH) WC019736916 (CA) 03/01/1 03/01/13 E.L.DISEASE-EA EMPLOYE $ 11000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 E Workers Compensation WC1 192494 (QSI) 03/01/1 03/01/13 SIR (AOS)/SIR (GA) 1M/750,000 C Workers Compensation WC019736918 (WI) 03/01/1 03/01/13 F TX Employers XS Indemnity TNSC46566397 (TX). 03/01/1 03/01/13 Occurrence/SIR 30M/1M DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HOME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C-20 ATLANTA, GA 30339 'USA ©1988-2010 ACORD CORPORATION. All rights reserved. ��`• Office of Consumer A€f'airs& Regulation I�HCME IMPROVEMENT CONTRACTOR Type: Registraticin: .126893 Expiration: Sf312412 Sugpiement The Home Depot At:N6� e Services DARREN DEMERS _ 2690 CUMBERtAND PARKWAY S GA 30339 Undersecretzry License or registration valid for individul use only ate. If found return t0' before the expiration d office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 ,arc Boston,MA 0211.6 Not valid without signature HOME IMPROVEMENT CON TRACT PLEASE READ THIS Sold,Furnished and Installed by: Branch Name: Boston Date: THD At-Horne Services,Inc. d/b/a The Home.Depot At-Home Services 908 Hesston Turnpike,Unit 1.Shrewsbury,MA 01545 Toll Free(800)657-5182:Fax(508)845-6017 Branch Number:.1 Federal ID#75-2698460.ME Lie#C 02439:RI Cunt.Lie#16427 Y j Cd'Lie#HIC.045220_44ec MA Home.Improvement Contractor Reg.#1'26893 ibj Installatlon Address: aZ +� �Ca.p-f l N! t Q v(�tf�.. �-.0. � City State. Zip Purchaser("): Work Phone:._ Home.Phone: Celt Phone: Ma r Home Address: (If different from Installation AddreNN) City State 7.ip E-mail Address(to receive pr(Iject communications and Home Depot updatos): ❑1 i.X)N()'I'wish to receive any marketing emalls from The Home Depot Proicct Information: Undersigned("Customer"),the owners of the property hxated at the above.installation address,agr Ts lu hay, artd TIID At Home Services, inc.(`"I'he Home Depot")agrees to furnish,deliver and arrange for the installation("Installat[on")ul' all materials deseihcd on the below and on the referenced Spec Sheet(s), all of which are.incorporated into this Contract by This reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively. "Contract"): Job#: m,u o ttA ww) Produrts: Spec Sheet(s)#: Pru'ect Amount , ❑Itarfiug []Siding Windows Li Insulation q $ j �� ❑Guar:%"/Covers ❑Frilry l)6ors El1 6 d /6,_ rj Roofing OSiding LJWindows Insulautm $ ❑(iut.tev,/('over" []tinny o'nom ❑ Ruining LjSiding Windows❑lasul'a(ion I S I 1 []Gutters/Covers, ❑Entry Doors❑ _ Roofing OSiding❑Winduws ❑Insulation I $ ❑(iutte,�/Covers ❑t:noyDix�rs Minimum 25%Delimit of CunUmt Amount due ulxxt exccatdou of this cOm"m Total Contract Amount Malne Il mhosem may nnt deprttat mnre than one third of the Crarttuct Amount. J l Customer agree%that,immediately upon completion of the work liar each Product,Customer will execute a Completion Certificate (one for each Prtxluci a%defined by an individual Spec Sheet)and pay any balance due. As applicable,each CwNtomer under this Contract agrees to be jointly and severally obligated and liable hereunder. 'lire Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included hertan,at its discretion,if Home Depot or its autborized service provider determines that it cannot perform its obligations due to a structural problem with the hone,environmental hazards such as mold.asbestos or lead paint,other safety concerns,pricing errors or because work required to complete the job was not included in the Contract. Payment Summary: Tlne Payment Summary# , included as part of this Contract. sets forth the total Contract amount and payments required for the deposits and final payments by Product(as applicable). N(D'l'i(,b't'O CUSTOMER , You are entitled to a completely filled-in copy of the Contract at the time you yi}m. no not sign a Completion Certificate(note.- there is one Completion Certificate ror each listed Product as defined by individual Spec Sheet.%•)before work on that Product. is complete- In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus any other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DF.,POT'S OTHER RFMFDIFN FOR RECOVFRY OF SI)CH AMOUNTS. Acceptance and Authorization: Customer it and tmdcrstands that this Agreement i;the entire agreement between C'ustoner, and The Home Depot with regard to the Products and inMullat.itn service%and supersedes all prior discussions and agreements,either oral or written,relating to said Products and installation.This Agreement cannot.he assigned or amended except by a writing signed by Customer and The Horne Depot.Customer acknowledges and agrees that Customer ha%read,undtsrstnds,voluntarily accepts the terms of and has received a copy of this Agreement. Acce d by: Suhm hy: rv-77 C`f X 1. CuscA•r' lure Date Sales .on Moan's S( ,,an' gate X � 7'cicpluvne No. /s-'S C �ipaluc 1)atcSales Consultant License No. ,.•-,___.__.__.-._.. ._ ras applicable) CANCELLATION: CLI,STOMF.R MAY CANCEL 'rHLS AGREEMENT WITHOUT PENALTY OR OHlX;A'rION BY DELIVERING WRITTEN NOTICE TO TIIE HOME I DEPOT BY MIDNIGHT ON THE '1111RD BLTSBV, S DAY AFTER SIGNING *]'HIS AGRFF,MENT. THE STATE SUPPLEMENT ATTACHED HFRF'I'0 1 CONTAINS A FORM TO IISF IF ONE IS SPECIFiCALLY PRESCRIKED IiY LAW IN CUSTOMER'S STATE NOTICE:ADDTTiONALTRRMS AND CONDI•rtON,CARF.STA9•KnONTHKKh:YF:KSF SIDE AND ARE I'AHTOFTHISCONTRACT •. --9A d SHV lodoa aWOH << tiWIL56805 3NOHd'blad M9Z 65:ZZ 62-h0-ZL02 Town of Barnstable 1is= Fjf , Til oFT ,ti Regulatory Services •� Thomas F.Geiler,DirectorIi EARNSTABLE. ` MASS. Building Division 1639. ,0$ Tom Perry,Building Commissioner FD MA A 200 Main Street, Hyannis,MA 02601 = — - www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 PERMIT# �CJ !U y� 1 FEE: $ v SHED REGISTRATION 120 square feet or less /,A/ Location of shed(address) Village AtIv,f Property owner's name Telephone number. �X Size of Shed Map/Parcel'# Sig atur Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction'? Conservation Commission(signature is required)` Sign off hours for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF Y6U ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMI,SSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN . Ck Q-forms-shedreg REV:042506 NP �47 Or ,Egs� ivr 0 . �+ E rm� z � I � 2� • TTHOMAS E. KELLEY 00. .ENGINEERS-=SURVEYORS 346 LONG POND D41V. F SOUTH.YARMOUTH,MASS, . A2664 . I i : CERTI d=I ED. . "T PLAN U)CATION (44: XCX!4, * -j R 5,ri : .. SCALE`• .�_ 3a DATE - PLAN REFERENCE . . ... 76 c�4.a- �L``� ! Zs fC. 7. 7 PRG,E' 98 - s ; i CERTIFY THAT TN E ! D ej IaDR 7/4 mot, SHOWN ON THIS PLAN IS LOCATED ON THE GROUND' A$.gHOWIN HEREON SATE .PETITIONER R .......Assessor's map and lot number f` I�. ...... n Sewage Permit number ...,` ,�.....1h2 - ......................... QyQF7MEt0�♦ TOWN OF BARNSTABLE fSs �� O•w 89HII9TADLE, i o 39. BUILDING INSPECTOR APPLICATIONFOR PERMIT TO ............................................................................................................................. TYPEOF CONSTRUCTION ..................................................................................................................................... ................................................19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ....................................................................................................................................................................................... ProposedUse ............................................................................................................................................................................. ZoningDistrict ........................................................................Fire District .............................................................................. Nameof Owner ......................................................................Address .........................,.......................................................... Nameof Builder ....................................................................Address .................................................................................... Nameof Architect ..................................................................Address .................................................................................... Numberof Rooms ..................................................................Foundation .............................................................................. Exterior ....................................................................................Roofing .................................................................................... Floors .Interior .................................................................................... Heating ..................................................................................Plumbing .................................................................................. Fireplace ..................................................................................Approximate Cost .................................................................... Definitive Plan Approved by Planning Board ________________________________19________. Area J v ......... ........ ...... Diagram of Lot and Building with Dimensions Fee . i . ...... .: iJ.f... ......... . . ........... SUBJECT TO APPROVAL OF BOARD OF HEALTH 6arei.6e. 7ofaL I r�' f i I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .................................................................................. C. F. S TANLEY 0T0=9 3-131 No 2 3 A U permit for ......................Ll One Story Sin91e Family Dwelling Location .Lot,,,#45,,,,,225........ n...Lijah Rd. ................Cg. der„vi l le.................................. Owner ...C.:...FI...Stanley'............................. Type of Construction ...Frame ............................ ................................................................................ Plot ............................ Lot ................................ Permit Granted ...August 25. 19 81 Date of Inspection ....................................19 Date Completed ......................................19 PERMIT FUSED ................................................................ 19 ............................................................................... ............................................................................... ............................................................................... orr ....1...:.1. '�............................ Approved ................................................ 19 ............................................................................... ...............................................................................