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j
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map 250 Parcel � � .Application
Health Division� t � � �JI�tJ�l �� `��` I f Date Issued
Conservation Division Application Fee
Tax Collector Permit Fee ' 137, �
Treasurer
Planning Dept.
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis v
Project Street A dress_
Village x.
Owner �� '� v�5� Address �w\
tA
Telephone b" J \��9 �►� �+'
Permit R quest�Q S`
Square feet: 1 st floor:existing proposed 2nd floor:existing_ proposed o \ Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuatio Construction Type rQRmA0\
Lot Size Q`3 GrandfatherW 15 Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure �AS r5 Historic House: ❑Yes{ \f$No On Old Kings Highway: ❑Yes �No
Basement Type: ❑Full ❑Crawl ❑Walkout 4d Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.fti)
Number of Baths: Full:existing new Half:existing 1 new
Number of Bedrooms: existing_ new
Total Room Count(not including baths):existing J new First Floor Room Count
Heat Type and Fuel: 4 Gas ❑Oil ❑Electric ❑Other
Central Air: )4 Yes ❑No Fireplaces: Existing _ New Existing wood/coal stove: ❑Yes *0
Detached garage:❑existingg Dnew size Pool:❑existina Q new size Barn:❑existing new size
Attached garage::6kexisting ❑new size Shed:❑existing ❑new size Other: i
CD
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes -V'No If ye site plan review# a ;�'
Current Use Proposed Use K .
BUILDER INFORMATION
Name Telephone Number �( ���= / 60
Address License#
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCT EBRIS RESULTINGTROM THIS PROJECT WILL BE TAKEN TO
QSIGNATU -� _.DATOS
---�~—�
FOR OFFICIAL USE ONLY
APPLICATION# ,
t
DATE ISSUED
MAP/PARCEL NO.
ADDRESS• VILLAGE
OWNER
}
DATE OF INSPECTION:
f-,
*' FOUNDATION 3mJas 11 29107 -
FRAME C► ��I�I�
r
INSULATION ��1' 9112
�k
r
FIREPLACE
y
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
f
GAS: ROUGH FINAL
FINAL BUILDING
s
,
DATE CLOSED OUT,
ASSOCIATION PLAN NO. '
i
INEow , Town of Barnstable
Regulatory Services
BA MASS.LE � Thomas F. Geiler,Director
.9 .MASS. g ' , '
E16 9 Building Division
Thomas Perry, CBO,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
PLAN REVIEW
F
Owner: Map/Parcel: .2-30 6-67 '
Project Address 1�2 PEA-7 M AeS) Builder: 0 L4?jCk' ,
The following items were noted on reviewing:
k-- n6K
W 9r. nw Ling
'
Reviewed.by:
Date:
Q:Forms:Plnrvw.
The Commonwealth of Massachusetts
Department of Industrial accidents__
Office of Investigations
_ d 600 Washitzgton Street
Boston,MA 02111
www.mass.gov/dia
Workers"Compensation Insurance.Affidavit;'Builders/Contractors/Electricians/PIumbers
Applicant Information Please Print Le 'bl
Name(Business/Organizatio dividu ):•
-Address:
City/State/Zip:�l v� t�\Q- 1� �1�- �3� Phone.#: (o U
Are you an employer? Check the appropriate box: 'Type of project(required):
1.❑ I am a employer with 4. E] I am a general contractor and I
have hired the mb-contractors 6. ❑New construction .
. employees(full and/or part-time).. -
2.❑ I am a'sole proprietor or partner- listed on the•attached 7. VRemodeling
b sheet.
These sub-contractors have
' ship and have no employees 8. []Demolition
working for mein any capacity. employees and have workers' 9 [],guilding addition
[No workers' comp.insurance comp.insurance.$.
required.] 5. ❑ We are Ia corporation and its 10.0 Electrical repairs,or additions
officers have exercised their
f�3� I am a homeowner doing all work 11.[]Plumbing repairs or additions
rnysel£ [No workers' comp. right of exemption per MGL 12.❑Roof repairs
c. 152, ,
insurance required_]t §14 and we have no
employees. [No workers'� ) •.13•(]Other_ '
comp. insurance required.] • '
'Any applicant that cheeks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homcowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
IContracto s 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. rf the sub-contractors have employees,they must pravidb their workers'comp,policy number. ;
lam an employer that is providing workers'compensation insurance for my employees. Below islhepolicy 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(sho7ing 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 tip 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 maybe forwarded to the Office of
Iavesti atiow a or insurance coverage verification.
16 hereb certi e ns'•4,V-dpen s ofperjury that the information provided above is true and correct:
Siena 6. a<� t Date: �� U
Phone #: u
Official use only, Do not write in this area,'to be completed by city or town bciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.BtuI ding Department 3. City/Town Clerk 4.Electrical Inspector S.PIumbing Inspector
6. Other
Contact Person: Phone#:
r
°FZHE, Town of Barnstable
° Regulatory Services
�MASS.i E�` Thomas K Geiler,Director
.q,ArEv +p`m Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-8624038 Fax: 508-790-6230
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW,
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the"reconstruction, alterations,renovation,repair,modernization,conversion,
improvement,removal, demolition,or construction of an addition to any pre-existing owner-occupied
building containing at least one but not more than four dwelling units or to structures which are adjacent to
such residence or building be done by registered contractors,with certain exceptions,along with other
requirements.
Type of Work: Estimated Cost \171V V
Address of Work:
Owner's Name:
Date of Application: 114
U
I hereby certify that:
Registration is not required for the following reason(s):
OWork excluded by law
❑Job Under$1,000
[]Building not owner-occupied
&Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit
Date . Contractor Name Registration No.
/ � v OR
//'// /C`y
` Date C , Owner-'s-Name•---- J
Q:foims:homeafdav
oFVE, Town of Barnstable
Regulatory Services
z,►MSTABM t Thomas F. Geiler, Director
MAss.
0.19. a��� Building Division
ED MA'I .
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
/ Please Print
r
DATE:i`J 0
JOB LOCATION: tll,�{`�—� I t✓ Z� ✓
m er street /Q /, Village
"HOMEOWNER": t tJ ► ✓ `J�� 7t, ` /6
name �j home p one# work phone#
CURRENT MAILING ADDRESS: " �� � QS Ij_
4
L Ic MA 7 /
ci /own state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to
be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes, bylaws,rules and regulations.
T n ned`,`homeowner"certifies that he/she understands the Town ofBarnstable.Building Department.
i pec 'on procedure d requirements and that he/she will comply with said procedures and
re re Fits.
VA
Signal u a of Homeow r
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 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.
Lew
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aMt Utee NOTES TO MA,(@upoing pope►tn' OnW
Town of Barnstable *Permit# oU ( )21
Expires 6months roes issue date
�� .Regulatory Services Fee . ( 0
SEP 2 5 2007 Thomas F.Geiler,Director
R
MSTABLE Buildin Division
F BA g
TOE Q Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA.02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number 10007
L �'
Property Address
g Residential Value of Work O Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address ) S 4t^ L e cL�S o A b �� e�f 94& c-c��•C
Contractor's Namelrl p HewtP Deis i 4} a6 il,e Telephone Number 8-q 6 a-6 y y
Home Improvement Contractor License#(if applicable) f d 6 8 Y ?
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
[v]"I have Worker's Compensation Insurance
Insurance Company Name 6 o
Workman's Comp.Policy-# I a o fl
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
Replacement Windows/doors/sliders. U-Value / (maximum.44)
"Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission. ,:,...
A copy of the Home Improvement actors License is required.
SIGNATURE: l
Q:Forms:expmtrg
Revise061306
..
�\
The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
,t Boston,.MA 02111
•
�_°_ _ . www.massgov/dia •
Workers':Compensation Insurance Affidavit: Builders/Contractors/Electricians[Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): r� 0
Address. -�155 e� o
City/State/Zip 8 3 Phone#:
Are-you-aft employer?Chock the appropriate box Type of project(required):_
i I:am a`ertiployerwtth d 4. I:'
am a general contractor and I 5. 0 New construction
employees(full and/or part=time)* • have hired the sub-contractors
2.❑ I am a sole proprietor or partner.. listed on the attached sheet.$ : 0 Remodeling
ship and have no employees These sub-contractors have 8.. Demolition
working, for.me.in any capacity. workers' comp.insurance. 9. ❑Building addition
[No workers'comp insurance 5 El We are..a corporation and its.:
required.]. . officers have exercised their 10 ❑ Electrical repairs or additions:
3.� I am a homeowner doing ali work right of exemption'per MGL 11. Plumbing repairs'or additions
myself. [No workers'comp c 152, §1(4),an we have no 12 Q Roof repairs
insurance required]t employees. [No workers'. /
4 14.1e. 13 �,Qther,.
.. - red'.] ..
_ comp.insurance regiti _
*Any applicant that c(tecks box IVI must also fill out the section below showing tfie'ir w&kers'compensation policy.information. :
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractois Must submit a new affidavitindicating such.
tcontractork.at check this box must attached an.additional°sheet showing the name of the sub-contractors and their workers'_comp:policy information,
I am an employer that is providing workers'compensation insurance for rrry employees. Below is the policy and job site
information.
Insurance Company Name: CO
Policy#or Se -1 Lic:# a R `�. �: ;Expiration Date: Q
Job Site Address In ` °/ �.°'S(7 City/State/Zip. P �' 116
Attach a copy of the workers'compensation.policy declaration page(showing the policy quinber 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 MOM a day against the:violator.,Be advised'that a copy of this.statement may be forwarded to the Office:'f
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the ains and ena ies of perjury that the information provided above is true and:correct.
Signature-' JAA e Date: 5�. 7
Phone#: _...__
Official use only. Do not write in this area, to be completed by city or town offciaC
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#:
Information and .Instructions I
Massachmetts.General Laws chapter 152 requires all.employers.to provide workers' compensation for their employees. 4
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an-individual,partnership,association,corporation or other legal entity,or any two or more
� . r the .
including the legal representatives of a deceased employer,o. .
of the foregoing engaged in a�omt enterprise,and inc g g p
receives or-trustee, an:individual,:partnership;association or other legal 'entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
maintenance,construction'or repair work on such dwelling house
dwelling house of another who employs persons to do
or on the grounds or building appurtenant thereto shall not because.of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal ' a license or perm t.to operate a business or to construct buildings in1.the to.mmonwealth.for any
applicant who'has not produced.acceptable.evidence of compliance with the insurance'C..yerage required."
Addrtiorially'MGL-chapter 152i:§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract:for.the performance of public work until.acceptable evidence of compliance with the insurance
requirements.of this chapter have been'presented_to the contracting authority."
Applicants
Please fill out the workers compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone numbers)along with their certificates)of
m anies. or Limited:Liability Partnerships(LLP)with no.employees other than.the',. . .
insurance:`:Limited Liability Co p (LLC)
members or partners,are.not required to carry.workers'compensaiion insurance. If an LLC or LLP does have
employees,a policy is requited."Be advised that this:affidavit maybe submitted to the Department of Industrial
Accidents for confirmation of msurance.coverage Also be sure to sign and date the affidavit. The affidaviEshould
be returned to the city or sown that the application for_the permit or license is being requested,not the Department of
Industrial Accidents Should you.have any questions regarding the law or if you are_required to obtain a workers'
compen �tidti lioLcy,"please call the Department atthe number listed below .Self insured companies should enter.their
self=insurance license number on the'appro riate line.
City or Town Officials
Please be`sute that the affidavit is complete and printed legibly. The Departmenthas provided a space at the bottom
of the affidavit for you Io fill out in.the event:the Office of Investigations leas to contact you regarding the applicant..
Please be"sure'to f it in.the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple'permit/,license applications in any given year,need only submit one'affidavit.indicating current
policy information.4if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)''A copy'of the affidavit that has been officially'stamped or marked by the.city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be, filled out each .
year.Where a borne owner or citizen is obtaining a license or permit not related,to any business or.commercial venture
(i.e:a'dog license.or permit to burn leaves etc:)said person is NOT required to complete this affidavit. .
The Office of.Investigations would like to thank you in advance for your cooperation and should you have,any questions,
please do not hesitate to give us a call :.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900.ext 406 or 1-977-MASSAFE
Fax#617-727-7749 .
Revised 5-26-05 www.mass.gov/dia
X' d.
'ATL 01234410-01
PRODUCER "' THIS CERTIFICATE IS ISSUED AS A MATTIBR DF INFORMATION ONLY AND CONFERS '
MARSH USA,INC NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE
f10r118d6pOt.CQRf@QU65(Oetllaf$h.CORi POLICY.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE..
AFFORDED BY,THE POLICIES DESCRIBED HEREIN.
3475 PIEDMONT ROAD,SUITE 1200 COMPANIES AFFORDING COVERAGE
ATLANTA,GA 30305
COMPANY s
00492-THD-IPUSA-07-08 IPUSA. ' A STEADFAST INSURANCE COMPANY.
INSURED CCMPANY
HOME DEPOT USA,INC. 8 ZURICH AMERICAN INSURANCE COMPANY ;
2455 PACES FERRY ROAD NW.
BUILDING C-8 COMPANY '
ATLANTA,GA 30339 C . AMERICAN HOME ASSURANCE COMPANY
COMPANY
D NEW HAMPSHIRE INS COMPANY
x 2+-3 ..
,:-_�• �..,�q..�., .�� � ls�ertlficat�;sy�ecs`edes�,8((d:Fop(ac �a�u�rt��Qus1�,Issu��E�edtf�ate�te Al
below,, �,t.�,,,c,��,�,�,�H _
THIS IS TO•CERTIFY.THAT'POUCIES:OF;INSURANCE;DESCRIBED HEREINHAVE.@EEN'ISSWEQ TO'THE.INSURED,`NAMtED'.H,EREIN FOR THE POLICY PER100 INOLCATED ;,
NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECTTO WHICHTHE CERTIFICATE MAY BE ISSUED OR MAY
PERTAIN,THE INSURANCE AFFORDED 9Y THE POLICIES DESCRIBED HEREIN IS SUBJECT MALL THE TERMS,CONDITIONS AND EXCLUSIONS OF SUCH POLICIES.AGGREGATE
LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER ' POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE(MMIODIYY) DATE(MMIDDIYY) -
A GENERAL LIABILITY IPR 3767 608-02 03/01/07 03/01/08 GENERAL AGGREGATE $ 4.000.000
X COMMERCIAL GENERAL LIABILITY 'LIMITS OF POLICY ARE EXCESS' PRODUCTS-COMPIOPAGG $ 4,000,000
CLAIMS MADE OCCUR 'OF SIR:$1,000,000 PER OCC' PERSONAL 3 ADV INJURY $ 4,000,000
OWNER'S 3 CONTRACTOR'S PROT EACH OCCURRENCE. $ 4.000,000
FIRE DAMAGE(An one fire) $ 1,000,000
MED EXP(An one person) $ EXCLUDED
B AUTOMOBILELIABILITY BAP•2938863-04 03/01/07 03/O1/08 COMBINED SINGLE LIMIT $ 1,000.000
X ANY AUTO
ALL OWNED AUTOS BODILY INJURY' $
SCHEDULED AU7pS (Per person)'
HIRED AUTOS BODILYINJURY
s (Peraeeident) $.
NOWOWNED AUTOS
X ELF-INSURED AUTO
_ PROPERTY DAMAGE $
HYSICAL DAMAGE
GARAGE LIABILITY AUTO ONLY EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY =
EACH ACCIDENT $
AGGREGATE $
A EXCESS LIABILITY. IPR 3757 608-02 03/01/07 03/01/08 EACH OCCURRENCE $ 5,000,000
X UMBRELLA FORM AGGREGATE $ 5,000,000
OTHER THAN UMBRELLA FORM $
C WORKERS COMPENSATION AND 2921209(CA) 03/01/07 03/01/08 X TORY LIMITS ER 5 ''
EMPLOYERS'LIABILITY 03/01/08 EL EACH ACCIDENT $( 1,000,000
E. 2921210(FL) 03/01/07
F. . THE PROPRIETOR/ X INCL 29212.11 (AZ,ID,MD,VA) 03/01/07 .0.3101/08 EL DISEASE-POLICY LIMIT $ 1,000,000
PFFIC ERSIEXECUTIVE 2921108(AOS 03/01/07 03/01/08„ ELDISEASE•EACH EMPLOYEE $ 1,000,000
D OFFICERS ARE: EXCL )
C H' 2921213(QSI). 03/01/07 03/01/08
E . WORKERS'COMPENSATION 2921212(KY,MO,NY,WI) 03/01/07 03/01/08
G ' TEXAS EMPLOYERS. TNS-C44642086(TX) 03/01/07 03/01108 EACH OCCURENCE 25,000,000
EXCESS LIABILITY SIR 2,000.000
DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESISPECIAL ITEMS
a p C yi�,.p� '�:*.+r 4 Y�r a�'��N'.,. ,,.�j..i,II. ,..n`.F`r, I^t5'+�°it'+�.�.;` �' ,ysAi`; • h4 :4'�re'� 7�J...r:W.',�'�'`'•�i `•.r.r.iR'� ^'i+L..nz ��'"� �5".n i��t +t ^a ".
Fr},� � 5i�� 7 ....., firm .y�y a {sy $�.bh � .�,., f ..uR.;sgy,, w..,,,,s f' _,tk� ,.: §�C ,pF• �; Er.;t:� v m axr,,,K t.. •. trF�s�:y
:F,ksm1J7'"•v',Ya;k,3.�:_• a'�f vsv.7..icry.d .t4'$�idsawv��r°�f.'�iL'Y`w:•n°,ti;i� .i`.a�''�u�.�'t�,'�`k.�:.�So��,••,..flf.>,I.°''�. .�^'"'i`�•:n�x.i7 daSL.�� .,s.i}.Sfie.:w:�:s.^d.iclYr',�.+:�_2 a:-R: ✓"�":a,.:a: s.•vitiTlr.�. ,
SHOULD ANY OF THE POLICIES DESCRIBED'HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE.THEREOF,
. - - THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL. An DAYS WRITTEN NOTICE TO THE
FOR EVIDENCE ONLY -. CERTIFICATE HOLDER NAMED HEREIN,BUT FAILURE TO MAIL SUCH NOTICE'SHALL IMPOSE NO OBLIGATION OR
' - LIABILRY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE,ITS AGENTS OR REPRESENTATIVES,OR THE,
• ISSUER OF THIS CERTIFICATE
:.. .._.:_.._....__�..�._.c.MA H
RS USA INC. ,
. BY... Mary Radaszewski t;"'" t� ,, / ►x`e>ti r��.� t
" MIV�1 ,;10lolwIlw1w
VALID AS OF 2128/07 "=`
H x rir a,, o C.
.�.r = -" . '
4' � .t . s t s:.,a�.,.,...r ^`u.4.. 1. .
m e se p s yu t �� , 8°s a �i�i}k�d1 ridi DATfi MMf001YY1
t s ._w^ ,. -dam 'A''• °^' A t u�,�'r '1v rigs€ x .era y i
+ ay �-
'� 1 02/28/07
PRODUCER COMPANIES AFFORDING COVERAGE
MARSH INC' COMPANY
homadepot.certrequest@marsh.com E ILLINOIS NATIONAL'INSURANCE COMPANY
FAX(212)948-0.902
3475 PIEDMONT ROAD,SUITE 1200
ATLANTA,GA 30305 COMPANY
F NATIONAL UNION FIRE INS CO
1-00492-TH O-IPUSA-07-08 IPUSA
HOME DEPOT USA,INC.
2455 PACES FERRY ROAD NW. G ILLINOIS UNION INSURANCE CO
'BUILDING C-8
ATLANTA,GA 30339 COMPANY
'• :a: 7 ra. �, `k. `s�": z Y S :� a•, Ns'� f •�r :. n t '• .;..+ " ,.+ 9,L �,
s?• s �! �.. a> 3.L rT��'A�.Y.xuc3.^x+ss.a '4 e Ztr
. �•ems."•.
• .
s�; dL.r, ,"k �" .ry h iKi�xtn��_..,,y�,:��.,z�, `1ii�'af�a,•�nk.�F�#u
.arc xy 3� ai xa. 1�,.�.. 1 d'". a.` s�:•r%5b'Y1'wwu^d ' .'" +1.•r l,`�' :
CERT;I:FICATE;FOLO :il �� a �� l� q t:•x t
�a�..�dd,.� ;> a�.,���*
FOR EVIDENCE ONLY
,MARSH.0 AIN � _
Mary R wski��a �� �� �< F, �•_�w�-`��:
a asze
r
063-A-039
40-4 5 DH
C
100 'Renovations
tNdQWWMWWM,
Double Hunq - Vinyl
ArganfLuwE SC
No Gricis
Cod
1-000-146-6; 86
NFRC 2001
ENERGY PERFORMANCE RATINGS
U-Factor(U.SJI-P) Solar Heat Gain Coefficient
0 , •0 . 29
ADDITIONAL PERFORMANCE RATINGS
a Visible Transmittance
0 . 49
--r
Memdacdnar stlpubtas that ffiese mtinga caMorm to applcable NFltC procedures for detennfnmg whore
productperformance.NRIC ratlngsare detumtnedtoraraed setorenvimmnerdal condillons and a
aPeCillcproductsize.fansuftmanutact mesifteraWreforotherproductperronnancelnfomiadon
www.nftorg
END tay sm
Unit qualifies for Energy Star
Regions?: Northern, North
Central, South Central,
a Southern
An
3NA: REIN 00/GLA99 SSJH-R30
IT : 30 Tact Si2®:. 44 x 60
order #:3830873030001 40318 HS
-71ie �ja,,,,�nauueat a�,/ucu�euaella
Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
Registration.....126893 One Ashburton Place Rm 1301
Explraflon :8/312008 Boston,Ma.02108
'h Type -Supplement Card
THE Home Depot`At Homeervc
MNIEL PELOQUIN
3200 COBB GALLERIA PKW.Y,#20Q°,^.,�
Atlantic,GA 30339 Administrator Not valid without�siznature
Spp,10"D7 02:55p Hession Enterprises 781-545-6266 p.1
HOME IMPROVEMENT CONTRACT
,. Sold,Famished and Installed by:
h Name: f,30-Z�Z� Date.• t7 THD At-Nome Services,Inc.
d/b/a The Home Depot At-Home Services
345A Greenwood Street,Worcester,MA 01607
h Number: �1 Job#• 3% 513 f Toll Free(800)657-5182; Fax:508-756-2859
Federal ID#75-2698460 ME Lic#C 02439 R1 Cont Lie#16427
CT Lic#565522; MA Home Improvement Contractor Reg.#126893
ation Address: �o �SI- P�`� MA I .S 11 e i. N DZ 3 Z
City State zip
Last 4 Digits of Driver's
iser(s): Lie.#&Exp.Mo/Yr: Work Phone: Home Phone:
Address:
ferent from Installation Address) City State Zip
it Address(to receive updates and promotions from The Home Depot): .
ct Information: I/We/you("Purchaser"),the owners of the property located at the above installation address,offer to
Let with THD At-Home Services,Inc.("Home Depot")to furnish,deliver and arrange for the installation of all materials
cribed on the attached Spec Sheet incorporated herein by reference and made a part hereof.
z Depot reserves the right to cancel this contract if,upon re-inspection of the job,Home Depot determines that it
)t perform its obligations due to a structural problem with the home,pricing errors or because work required to
ilete the job was not included in the Spec Sheet or Contract.
DEPOSIT PAYMENT OPTIONS
(Subject to fund verifi cation and/or credit approval.)
Q �
'ONTRACT AMOUNT $_ � 7 1, Check*,Cashiers Check or US Postal Service Money Order
(Made payable to The Home Depot).
-LESS DEPOSIT $ 3703 2; Credit Card"and;or other payment options-circle Onc Below
BALANCE DUE Q visa MasterCard Discover =Depot
ON COMPLETION $ 7 6 The Home Depot Home improvement LorMinimum 25%of Contract Amount due upon C New.Account ❑Existing Account
execution of this contract. Available Credit:S I � (HIL&HDCC ONLY)
Indicate Payment Method For Acct# Exp:Date`
BALANCE DUE ON COMPLETION: Name as it appears on cardSl) rl
Z Mfg - -By my/our signature below,I/We agree to allow Home Depot to
ghae the above referenced credit card for the dep sit i dicated.
ien you provide a check as payment,you authorize us either x information from your check to make a one-time electronic lder's Signature
transfer from your account or to process the payment as a
k transaction,When we use information from your check to HIL or HDCC Authorization Codes
e an electronic fund transfer, funds may be withdrawn from Deposit Final Payment
account as soon as the payment is received,and you will not p
ive your check back. 00 # 0,0 J
-haser agrees that,immediately upon completion of the work,Purchaser will.execute a Completion Certificate and pay any
_ tnee due. Purchaser also agrees to be jointly and severally obligated and liable hereunder.
ire Agreement; This agreement and its attachments, including any financing`agreement, contain.the complete.agreement
Keen the arties and can not be amended or modified unless in writing in a separate agreement signed by both parties.
MY/OUR SIg'.�BELOW, /WE•AGREE TO BE BOUND BY THE TERMS OF THIS CONTRACT. I/WE
KNOWLEDG OF A C Y OF THIS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE
CANCELLATDate:BMITTED BY
Sales Consul t,
Date:
,CEPTED BY:1l n't
Purchaser Date:
Purchaser
NOTICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE
AND ARE PART OF THIS CONTRACT .
>_•07. C-SC White—Branch File Yellow—Customer Pink—Sales Consultant
PERMIT PAYMENT RECEIPT,'
TOWN OF BARNSTABLE
BUILDING DEPARTMENT
200 MAIN STREET
HYANNIS, MA 02601
DATE: 09/19/07
TIME: 13:58
-----------------TOTALS-------------------
PERMIT $ PAID 25.00
AMT TENDERED: 25.00
AMT APPLIED: 25.00
CHANGE: .00
APPLICATION NUMBER: 200705912
PAYMENT METH: CHECK
PAYMENT REF: 427
Town of Barnstable *Permit# — /c
Expires ti mo the from issue date
Regulatory Services Fee 1 '
®PRESS PERMITThomasF.Geiler,Director
SEP 1 9 2007 Building Division
Tom Perry,CBO, Building Commissioner
TOWN,1 OF BARNSTABLI200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
`` Not Valid without Red X-Press Imprint
Map/parcel Number V(� Z
Property Address G 7 y c s'l�
tjK
esidential Value of Work w Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address ij 4Z4d�3
req (-el4
Contrf.actor's Name Telephone Number J V 7
Home Improvement Contractor License#(if applicable) 7
Construction Supervisor's License#(if applicable)
"oran's Compensation Insurance
Chec one:
1 !am a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name (✓
Workman's Comp.Policy# v -Z— LA-
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
e-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 Owner must sign Property Owner Letter of Permission. .
A copy of the Home Improvement Contractors License is required.
SIGNATURE:
Q:Forms:expmtrg
Revise061306
HOOFING - SIDING - REMODELING
17 CIRCLE DRIVE • HYANNIS,MA 02601 Date 9/18/2007
508-771-1608 Invoice # 157
6 Great Marsh Rd.
Centerville, MA
Terms Due on receipt Due Date 9/18/2007
- ..hs._,.__... ._,i. x.�.._...__. ,___�`-.� ,.w..... .._•_ `._,__. .: 'r-'-_�_ ..__...._._ try _F_..,;. _..,_..._�` fr --.;,_.:: <.:._� _ . _
Carpentry Time($48 Per Man Per Hour) Plus Materials: Remove 0.00 0.00
and Replace All Rotten Wood; Re-Point Chimney and _
Re-Flash As Necessary; Fix Front Steps
Roofing Professional Roofing Service: Remove and Replace 8,;550.00 8,550.00
Asphalt Shingles With 30-Year Architect Shingles; Install
Ice and Water In All Valleys; Install Cobra Ridge Vent
Along Ridge Where Necessary; Clean-up All Debris
Siding Professional Siding Service: Remove and Replace Cedar 5,650.00 5,650.00
Siding on Specified Areas With Resquared and Rebutted
Clear B's �//'� A�
V V" VX
-
Dumpster At Cost Depending on Jobs Completed 0.00 0.00
Total $14,200.00
Payments/Credits $0.00
Balance Due $14,200.00
Board of Building Regula ions and Standards
One Ashburton Place - Room 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
Registration: 133704
Type: DBA
t Expiration: 7/31/2009 Tr# 130177
JFM CONSTRUCTIONr=
JAMES MCMORROW
17 CIRCLE DR.
HYANNISPORT, MA 02601
s Update Address and return card.Mark reason for change.
❑ Address ❑ Renewal Employment Lost Card
DPS-CA1 0 50M-05/06-PC849007
. x. xr4 t t r Zfl," •
QtlL CJ'_ Y u
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeLibly
Name(Business/Organization/Individual):_ of yv,,_<f S 196 ��
Address: V X. \
City/State/Zip: L 0 yl `7 Phone.#: �OX27,
Are you an employer? Check the appropriate bog: Type of project(required):
1.El I am a employer with 4. I am a general contractor and I
❑New construction .
e ees(full and/or part-time).'" have hired the snb-contractors 6. ,
2. am a•sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. rj Demolition
working for me in any capacity. employees and have workers'
co insurance.$' 9• []Building addition
[No workers' comp, insurance �• •
required.] 5. We are a corporation and its 10.❑Electrical repairs or additions
3.❑ officers have exercised their I am a homeowner doing all work 11.❑Plumbing repairs or additions
myself (No workers' comp. right of exemption per MGL 12•[]Roof repairs
insurance required.] t C. 152, §1(4),and we have no
employees, [No workers' 13.❑ Other
r` comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors f ave employees,they must providb 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.M Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(shoving 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 a :ender the pains•and penalties of perjury that the information provided above is true and correct:
Signature: Date: G
Phone#:
Official use only. Do not write in this area,'fo be completed by city or town of
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Buffding Department 3. City/Town CIerk 4.Electrical Inspector S.PlumEInwspectdr
6. Other
Contact Person: Phone#: