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HomeMy WebLinkAbout0015 HAYWARD ROAD /�` a , ��- �w� � . �'. � s , w-.0 _ T.J. �.. �.+. .. Y t :: �. ... WT '+�r `p �� � -' �. 7 .. ., � .. _ tda e� R ,- e;' ,y � ,^ t �;, �a - .. .. _ i _ _ „ � � vt - _ � ' A - Town of Barnstable -Permit# Expires 6 mondis from issue date Regulatory Services Fee 9� tom, ,e�' `x{ cali,Interim Director 63 /'A Building Division Tom Perry,CBO,Building Commissioner f14p Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508490-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number /Lf!(o O�S Pro a "Add S N A v /a rap R dC ���(✓� [e P nY' ress , AResidential Value of Work$ .1. 2 $ 0 Minimum fee of$35-.00 for work under$6000.00 Owner's Name&Address( Karl t;S 1,a✓►d c,a 1 1 1A Dot 2— Contractor's Name? >F OT ? fi��a Telephone Number 401-71y`d.3I7 -- Home Improvement Contractor License#(if applicable),( 1,2_7 F z . Email: Construction Supervisor's License#(if applicable) O 700 7 `` ``9 orkman?s Compensation Insurance Check one: '`- ❑ I am a sole proprietor ❑ I am the Homeowner XI have Worker's Compensation Insurance Insurance Company Name 1 J r)-TV/�/�L- ? l Workman's Comp.Policy# S� Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ e-side [�Replacement Windows/doors/sliders.U Value .3O (maximum 35)#of windows Z- #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"permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: 4pe � weer must sign Property Owner Letter of Permission. the Home Improvement.Contractors License.&Construction Supervisors License is SIGNATURE: Q:IWPFILES\FORMSWuildinEXI'RESS.d c Revised 061313 ! ���. 9/ 1 The Commonwealth a Accidents Departmenhusetts t of In Office of Investigations l� 1 Congress Street, Suite 100 Boston,MA 02114-2017 ww mass.gov/dia w Insurance Affidm it: Builders/Contractors/Elep ease Prinit Le ibh workers' Compensation A lie-ant Information Larne (Business/Organization/Individual): The Home Depot At-Home Services Address: 908 BOSTON TPK (508)942-6942 SHREWSBURY, MA 01545 Phone#: City_ /State/Zip. Type of project (required): lover? Check the appropriate ox: Ar ou an emp 4 ]am a genera] contactor and l 6 New construction 1 am a employer with 200�— /°� have hired the sub-contractors 7. Remodeling employees (full and/or Part- °e)'* listed a attached sheet. ] am a sole proprietor or partner- ese sub-contractors have 8. ❑Demolition ship and have no employees employees and have workers' 9 Building addition working for me in an,,: capacity. comp. insurance.: ]0_[]Electrical repairs or additions [No workers' comp- insurance r We are a corporation and its required.] officers have exercised their ]l.❑Plumbmg repairs or additions ] am a homeowner doing all work right of exemption per MGL 12.[] of repairs myself. [No workers' comp. c 152: `1(4).and we have noother insurance required.]+ emplovees. [No workers' comp. insurance regtured.] 0 1 work and then hire outside contractors must submit a new not those davit tentit havendicalino such. qnv.applicant that checks boa€l must also fill out the section belo-* showing their workers compensation police information. +Homeowners who submit this affidavit mdicatingthe\ are domes a] olio number. Contractors that check this box must am �oan additional sust heet o�ide their worae a ocompsp -contractors and state whether and job site emplovees. If the sub-contractor=have p I emplover that is providing workers'compensation insurance for my-employees. Below is the po icl am an information. NATIONAL UNION FIRE INSURANCE COMPANY — Insurance Company Name: XWC 65831 45 (QSI) 03/01/2018 Expiration Date: L Policv� or Self-ins.Lic.#: CiN/State'Zip= C f l e A �a y04 f 0 the policy number and expiration date). Job Site Address: �S a e showing penalties of a Attach a copy of the workers' compensation policy declaration p g ( imposition of criminal p Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the one-year imprisonment_ as well as civil penalties the m be for�*��edto Office of d a fine fine up to$1,500.00 and/or y of up to$250.00 a day aga a violator. Be advised that a copy of this statement cL Investigations of the D r cc coverage verification. e �� d fPeTJur1'that the information provided above is true and eorre I do hereby-certify un Date: Si ature: Phone#: tilt'or town official. pff cial use only. Do not write in this area,to 6e completed 61 Permit/License# City or Town: Issuing Authority(circle one): nt 3. City/Town Clerk 4._Electrical Inspector 5.Plumbing Inspector 1.Board of Healtb 2. Building Departme 6.Other Phone#: .Contact Person- -= �- Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 51 f 0 Boston; Massachusetts 02116 Home Improvement Contractor Registration Type: Supplernent Care Registration: 112785 HOME DEPOT USA INC Expiration: 04/2212015 2455 PACES FERRY RC- C-11 HSC ATLANTA,GA 30339 Update Address and return card. Mark reason for change. ❑ Address ❑ Renewal ❑ Employment ❑ Lost Card Office of Consumer Affairs&Business Regulation Re istration valid for individual use only HOME IMPROVEMENT CONTRACTOR 9 before the expiration date. it found return to: m TYPE:Suooleent Card Registration Exni_ r_a_lion : Office of Consumer Affairs and Business Regulation 04/221201 Q ?0 Park Plaza-Suite 5170 12785 Boston.MA 02116 FTOME DEP07 USA INC AriDREW SWEET u 2455 PACES FERRY RD C-11 HSC d ithou signature ATLANTA,,GA 3033Q Undersecretary t DATE IMMIDDrtYYri ACC>RD CERTIFICATE OF LIABILITY INSURANCE 0217,0117 THIS CERTIFICATE IS ISSUED AS A MA7 I ER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDEFL THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES i iBELOW. 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 certiTicate holder is an ADDITIONAL INSURED,the policy{ies)must be endorsed. If SUBROGATION IS WAIVED,subject to i ! the terms and conditions of,the policy,certain policies may require an endorsement A statement on ibis Certificate does not confer rights to the ll certificate holder In lieu of such endorsement(s). I PP.DDUCER - CONTACT MARSH USA,INC. NAME .PHONE Th0 ALLIANCE CENTER AIC No I AfG No): 3550 LENOX ROAD,SUITE 2400 E-mAIL F.TLANTA,GA 30326 ADORE55: INSURERIS)AFFORDING COVERAGE I NAIL t' 100492-HomeD CAV@'-17-1A INSURER A:O;o Republic Insurance Co I24147 INSURED �THE HOME DEPOT,INC. INSURER E:Agri General Insurance Company 14275i I HOME DEPOT U.S.A.,INC. 'INSURER C:New Ha71PSWE Ins Cc 123841, 2455 PACES FERRY ROAD INSURER D: BUILDING C-20 j A i LANTA,GA 30330 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003746387-14 REVISION NUMBM2 THIS IS TO CERTIFY T FLAT i HE 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. INS I TYPE OF INSURANCE IAD I BRI POLICY NUMBER I IPIOMIIJDCY EFF PMNIUDIY�Yrf I L0111Tr A X I COMMERCIAL GENERAL LIABILITY I �h1VV7Y 310022 I031012017 10310112018 !EACH OCCURRENCE j s 9,CDC,OCG I I CL4iM5,:1A0E X OCCUR„ I - OA1.- E T RBJTET I i,D00,ODD '?R2MSES fee cta0rencel 15 ILItdfTS OF PQLICY XS VED EXF(Am,cmep=6nn) i S EXCLUDE IQF SIR S1k PER QCC I y !c 9,DOG,OD JtSDNAL 8 ADV INJURY iGEML AGGREGATE UM[7 APPLIES pER. I GENERAL AGGREGATE I S PRO- 1 n I LOC I I 7 RODUGS-COMF/OF AGCS POLICY . S,DQG,DGG i 1I07HEP' I I ! I5 -- ! r A I AUTOMOBILE LIAeIUTY ,IlIWT8310021 D31D i201 i 03/012016 t 2mdPJOdSINGLE uMr 15 :,DOD,OOL ANY AUTO I I I - eODILY INJURY(Per person) I c- I !A`LLirros� AUTOL Uc iSELF INSURED AUK O PHl'DMG f BOD;LY INJURY(Peracdenl's !NON-OM,ED I PROPERTY DAMAGE I—j HIRED AITOS ���AUTOS II I iper accidenll 15 I I i !UMBRELLA LIAe OC,Cf ! ! I 'I J I EACH OCCURRENCE -. 5 I I I EXCE_F.LIAS i I CLAIMS-MADEI I I AGCREGA E I c II ! I DEC I I RETENTIONS �S E IwORItERs COMPENSATION I VJLR C49712300{iN) 03/D1=7 1x PER 'O'H- ANDEMPLOYERS'LIABILRY Y I I�ATUTE ! I EF.C 'ANY PROPR)ETORMARTNER c�Cllnuc /NWCO23102423(AfCNH,N 1.V7) I03fD112017 �030121)115 G31D11201E I E L EAC'ACOID3T 15 I C I OFFICERIMEMBER FXCLUDEO= 11 iNJA !(Mandatory in NH) - WC 023 i02424(tM) .l031D11201 i G310t72D16 E L OtSEASE B.dViPiOYEE S i,000,GL'G ii yes.tlesu'be under Cenrinued on AddiEtlnal Pepe I I CESCRIP.10N OF OPERATIONS beiOw I ! i E L DISEASE-POLICY 1)MR I s I � I DESCRIPTION OF OPERATIONS/LOCATIONS i VEHICLES (ACORD 101,Additional Renurks Schedule,may be attached 11 more apace b retluhed) I EVIDENCE OF INSURANCE j . I L CERTIFICATE HOLDER CANCELLATION l ! HOME DEPOT USA:INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE GANGS I rn BEFORE j 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ) ATLANTA,GA 30339 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE aI raarsr:USA Inc i I Manashi Mukheriee ©1988-2D14 ACORD CORPORATION. All rights reserved. ACORD 25(20 115101) The ACORD name and loot:are registered marks of ACORD AGENCY CUSTOMER ID: 00492 LOC#: Atlanta ACC)" oR � ADDITIONAL REMARKS SCHEDULE Page 2 of ' y NAMEDIN5URED AGENCY HOME DEPO i U.S-A-,INC. MARSH USA.INC. DIBIA THE HOME DEPOT 2455 PACES FERRY ROAD POLICY NUMBER BUILDING C-20 ATLANTA.GA 30339 NAIL CODE CARRIER EFFECTIVE DATE ADDITIONAL REMARKS TH15 ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE certificate Of LIabili InSUrance l i Worker:comoensallon Continued: Carrier IndemnitY'Insurance Catllpatry m Nonh Amerit`c Policy'Number WLR C49112294(AL AKFL IL,IA,KS,KY,LAMS,MO.NE,NM,ND,OK,SC,SP,,M,W'Y) Efte�tivE Data:031 1=7 Expiration Date:030016 (EL)Limit S'•OXOM c Carrier.New Hampshire Insurance CDmparrY• Policy Number.WC 023102422(DC,DE.HI,IN.MD.MNA .NY,RI) Eflnb*Date:03101rM7 ExOrdtror Date:030W't i (EL)Ume:St,0W,DO0 Carrier.ACE American Insurance Company Policy Number.WCL'C45ill=2(051)(AZ,C�X-NC.OR,VA,WA) Efteclin Dale:D310=7 Expiration Dale:03012D1E i rr;Limit S1,OOD.000 I SIR 5?.0N.00D SIR lar the sta1F o1 AL WL'NC,OR,VA,WF Camara NaliDrra'Urimr,Fue Insurance Company j Paler•Number XWC M3144(OSI)(CD,CT,GA,ME,MI•NV.OF..P'tXT' Eftedr"Dale 03101r201 f Expiration Date:031011201E I (EL`►imi::S'.0m.000 i S1,OD0,90D SIR for the stales o1 CO3ME.NV.IA1.OH,PA.Llr 1 S750.001)SIR tar the stale o1 GA 5350.0M SIR tar Ore state e-C7 1 I ` Carrier National Union Fire InsurdnCE Company PohLT'Nlenber.XWC 65B3145(051?IMA) Ettecfrve Date:031D1/20 7 Expiration Date_OD'12018 (EL)Lund:S1.00D.00D SIR M.11M TX Employers XS IndemnAy ' CarrierffffLq3s U=n insurance ComIDWY Poi¢Y•Number TNS C48E13202,IT>h Effective Date:OBID1017 Exp)rajj�an Dam:0310112DIE (Ei)Limit S10.000.ODD , SIR S i3OaD,000' C 200B ACORD CORPORATION. All rigtl>~reserved. ACORL 101 (2008101) The ACORD name and logo are registered marks of ACORD Home Depot Contractor License Numbers: MA: 107774, 112785 Salesperson Name and Registration Number: Janice Campbell : R-1-073-13-00016 Home Improvement Agreement Home Depot U.S.A., Inc. ("Home Depot") or Service Provider'named below will furnish, install and/or service the equipment listed below at the price, terms and conditions as outlined on this form. Customer Information: '[ Charles Lanigan New England South 10357900 I First Name Last Name Branch Name Lead# 15 Hayward rd CENTERVILLE MA 02632 Customer Address City State Zip F(508) 775-4711 Home Phone# Work Phone# Cell Phone# clanigan2@aol.com Customer E-mail Address NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 908 Boston Turnpike Unit 1 Shrewsbury MA 01545 Address City. StateZip or Email CustomerCancellationNorthEast@homedepot.com r BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A different CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR PROFESSIONAL, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT THE CONTRACTOR GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR RIGHT TO CANCEL. Acknowledged r' X 09/12/2017 Customer's Signature Date • Fp��eARTE r' ol u A The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' a I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): P Address: LY_ S�' Ci /State/Zi OM-7 Phone#: 77 746 - c2da�5"" Are you an employer?Check the appropriate box: . I am a general contractor and I Type of project(required): I.❑ 4 I am a employer with . g 6. ❑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. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, Q Demolition working for me in any capacity. employees and have workers' insurance.: 9. ❑ Building addition [No workers comp.comp.insurance p• required.] 5. We are a corporation and its I OQ Electrical repairs or additions 3.❑ 1 am a homeowner doing'all work officers have exercised their 11.F]Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12Q Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers 1.3.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ceI unde the pain5wnd penalties of perjury that the information provided above is true and correct. Xa Official use only.Do not write in this area,to be completed by city or town offlciaL 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#: �0. r Town of]Barnstable *Permit# c ' 0 Expires 6 months front issue dare Regulatory Services Fee 36 Apgsr LE, + ,6 ���q J9- Thomas F. Geiler, Director Building Division �Z Tom Perry, CBO, Building Commissioner /`� 200 Main Street, Hyannis, MA 02601 / www.town.bamstable.ma.us Office: 5 0 8-862-403 8 Fax: 508-790-623 0 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid wlthorrt RedX-Press Imprint Map/parcel Number Pr erty Address '11, e Residential Value of Work 206 Minimum fee of$35.00 for work underS6000.00 Owner's Name AddressN Contractor's Name p 4/h-e.� �OD� Telephone Number �( f� /—C 0 Home Improvement Contractor License #(if applicable) Co "ruction Supervisor's License#(if applicable) Workman's Compensation Insurance -PRESS P .g Check one: I y El am a sole proprietor ,�,��. fl/fam the Homeowner [ I have Worker's Compensation Insurance TOWN OF BARNSTABL Insurance Company Name CUA) U�(f/►r Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request (check box) ❑ Re-roof(hurricane nailed) (stripping old shingles) All construction debris will be to /Replacement hurricane nailed)(not stripping. Going over existing layers of roof) #of doors Windows/doors/sliders, U-Value 030 0 (maximum .35)#of window *Where required: Issuance of this permit does not exempt compliance will,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& Construction Supervisors License is required, NATURE: ` rILMFORMStbuildingpenniiformsiEXPRESS.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/In ividual): ) AVIV NC- Address: City/S to/Zip: (y(J . Phone#: Are ou an employer?Check the appropriate box: Type of pro' ct(required): 1. I am a employer with . 4. ❑ I am a general'contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑N construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. �Zodeling ship and have no employees These sub-contractors have . g: ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 11. Plumbing repairs or additions 3.❑ I am a homeowner doing all work- ❑ g P myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. 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: M CVAV AVA14 Policy#or Self--ins.Lic.#: d S b Expiration Date: Job Site Address: 1N JJod City/State/Zip Z�dcw� AwOC Attach a copy of the workers'compensation policy declaration page(showing the policy number'and expiration date). Failure to secure coverage as required under Section25A 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: ?" Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: CERTIFICATE OF LIABILITY INSURANCE OP Id SR MOONA-1 10/05/11 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Hunter Insurance, 'Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 389 Old River Road, P.O. Box 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Manvi,ll.e RI. 02838-0001 Phone:401-769-9500 Fax:401-769-9502 INSURERS AFFORDING COVERAGE NAiC INSURED Moon Associates Inc. INSURER A: stational Czangq Insurance co 14788 DBA Gutter Helmet DBA Renewal by Andersen of RI INSURERB: Beacon Mutual. DBA Gutter Helmet Roofing DBA Moon Works INSURER c: 1137 Park East Drive INSUR�RD: " Woonsocket RI 02895 INSURER E: COVERAGES THEPOLICtE$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 COMRACT 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'. BQLIGIE$.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE(MM1DD/YY YY) DATE(MMIDD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 10 0 0 0 0 0 A X COMMERCIAL GENERAL LIABILITY MPS26619 09/16/10 09/16/11 PREMISES(E occurence) $5000Q0 CLAIMS MADE X]OCCUR MED EXP(Any one parson) $.10000 PERSONAL&.ADV INJURY $ 10 0 0 0 0 0 GENERAL AGGREGATE $2 0 0 0 0 0 0 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $2000000 POLICY JEa r7l LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMB $10 0 0 0 0 0 A X ANY AUTO B1526619 0,9116110 09116/11 (Ea accident) ALL OWNED AUTOS BODILY INJURY I SCHEDULED AUTOS - (Per person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGELIABILTY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTQ ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $10 0 0 0 0 0 A X OCCUR CLAIMS MADE CUS26619 09/16/10 09/16/11 AGGREGATE $ hDEDUCTIBLE $ X RETENTION $10000 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN X TORY LIMITS ER B ANY PROPRIETORJPARTNERIEXECUTIVE 28586 lO/01/10 10/O1/17 E.L.EACH ACCIDENT $500000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500000 OTHER DESCRIPTION OF OPERATIONS-I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS CERTIFICATE HOLDER - CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIC MOONASS DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL . 10 DAYS WRrn E NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. r AUTHORIZED REPRESENTATNEE�y�.,, Pam(. ACORD 25(20091011 ©1988-2009 ACORD CORPORATION. All rights reserved, The ACORD name and logo are registered[narks of ACORD 1137 Park East Drive Woonsocket,Rhode Island 02895 Vc. s I Reg.a,1.'r:59iV839;Mao,Asao%'L l /^`a(srtys`r� yp { N r Rely.<,1:e59i3C839;Mao,Assaoats^s In,I Ir1OOMOM nw,w,r, Conn.HIC OSQ775(Moon Ass:ate,ter: nr (800I975-6666 ,/ ,, Mass.Hl v 11953S:Moan A,.- axes11- Purchaser l�s)Name: ll�L.(��� fK—)z Art/ Installation Address: ���+�,r�,r��4lel/l/7� Mailing Address: Home Phone;,2Z!L V71'I CeIIPhone:X17 SYB 7177 E-mail: Year Home Built:Customer Initials:f'-— Taxes Paid in Town of: I/We,the above Purchasers)("Purchaser(s)")and the owners)of the property located at the above installation address,hereby jointly and severally agree to contract with Moon Associates,Inc.(''Moonworks")to furnish,deliver,and install of all materials as described in this agreement("Agreement-),the attached Spec Sheet(s)and diagrams)which are incorporated herein by reference and made a part hereof.A Completion Certificate will be executed for all jobs at the end of the installation. Order Number. -- Order Number. _ Order Number Project Type: Aim 4?a Gt,�t Project Type: Project Type: i Agreement Amount $ /f.4 O-A ZL Q� Agreement Amount $ Agreement Amount $ C less Depositi $ � Less Deposit* $ Less Deposit# $ o Balance Due On Completion S 4 5315 ItI Balanceire Due On Completion $ Balance D On Completion $ rn iMmimum 33.of Ag.eement Amount doe upon enrec.Aion. I Winimum 33%ot Agreement Amount due upon execution. I tM,n,mum 33%of Agreermm Amount due upon execution_ I Indicate Payment Method For Balance �Indicate Parmettt Method For Balance Indicate Payment Method For Balance Due at Time of Installation: Due at Time of Installation: Due at Time of Installation: el(-e GJ� Est.St rt Date: Est.Completion Date: Est.Start Date: Est.Completion Date: I Est.Start Date: Est.Completion Date: j DEPOSIT/PAYMENT OPTIONS(subiect to fund verification and/or credit approval) I.Ch hier's Check or Money Order Ck#11.5 Y 3.Financing e payable to Moonworks) Acct ff Approval Code 2.Credit Card"(circle) Visa MasterCard Discover Acct ti Approval Code "Ave agree to allow rdoonworks to charge the reteremed credit card for the deposit amount Acct It Exp Date Security Code Indicated.Balance to be.charged to credit card upon completion of installation dnotedaboue. It is agreed by and between the parties that this Agreement constitutes the entire understanding between the parties,and there are no verbal un&mteridings changing a modifying ally of the terms of this Agreement.Purchasers)hereby acknowledges that Purchaser(s)1)has read the frond:and reverse of this Agreement and has received a completed,signed, and dated copy of this Agreement, including the two accompanying Notice of Cancellation forms,on the date first wr en above and 2)was orally informed of his/her right to cancel this transaction.DO NOT SiGN THiS CONTRACT iF THERE ARE ANY BLANK SPACES Purchaser Purchaser Moonworks lure Signature Signature Print Name Print Name Print Name YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE NOTICE OF CANCELLATION FORM BELOW FOR AN EXPLANATION OF THIS RIGHT. _ice..- .......—_1_.�- _)_...._. _}__.:..__'--_...t.-•--.-__-- . NOTICI OF NCELLATION, NOTICE OF CANCELLATION Date of Transaction Date of Transaction You may cancel this tr +on,without any penalty or obligation, You may cancel this transaction, without any penalty or obligation, within three business days from the above date. if you cancel,any within three I business days from the above date. N you cancel, any property traded in,any payments made by you under the Contract or I property traded in,any payments made by you under the Contract,or Sale,and any negotiable instrument executed by you will be returned Sale,and any negotiable instrument executed by you will be returned within 10 days following receipt by the Seller of your cancellation within 10 days following receipt by the Seller of your cancellation notice,and any security interest arising out of the transaction will be notice,and any security Interest arising out of the transaction will be canceled.if you cancel,you must make available to the Seller at your canceled.If you cancel,you must make available to the Seiler at your residence,in substantially as good condition as when received, any residence, in substantially as good condition as when received, any goods delivered to you under this Contract or Sale;or you may,it you_goods delivered to you under this Contract or Sale;or you may.H you wish,Comply with the instructions of the Seller regarding the return wish,,comply with the instructions of the Seller regarding the return shipment of the goods at the Sellers expense and risk.If you do make shipment of the goods at the Sellers expense and risk,if you do make the goods available to the Seller and the Seller does not pick them up the goods available to the Seller and the Seller does not pick them up . w"Ntin 20 days of the date of your Notice of Cancellation,you may within 20 days of the date of your Notice of Cancellation, you may retain or dispose of the goods without any further obligation.If you retain or dispose of the goods without any further obligation. If you fail to make the goods available to the Seller,or if you agree to return fail to make the goods available to the Seller,or if you agree to return the goods to the Seller and fail to do to,then you remain(gable for the goods to the Seller and fail to do so,then you remain liable for r el this mane of all obligations under the Contract. To cancel this Performance of all obligations.under the CoM act.-To cant perfor transaction, mail or deliver a signed and dated copy of this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written notice,or send a telegram to cancellation notice or any other written notice,or send a telegram to MOONWORKS, 1137 Park'East Drive, W o ticket, R e Island Moonworks, 1137 Park East Drive, Woonsocket, Rhode Island 0289S,NOT LATER THAN MIDNIGHT OF Z Z' (Date). 02895,NOT LATER THAN MIDNIGHT OF (Date). I HEREBY CANCEL THIS TRANSACTION, I HEREBY CANCEL THIS TRANSACTION. I Consumer's Signature Date ` Consumer's Signature Date A� . . �� R.E Po'yW E R w _ [ € i ar s e e a a f i r r a tr el a valid tug-f rf dal' cis a � IMPROVEMENT COOT TO bef' r the aspiration mate. I return t . yOffice ofConsumer Affairs and Business He'RUL, Registration: 119535 10 Park Plaza- Suite!;170 Boston, NtA 02116 Type: fCorporation MOON ASSOC its# ,.i E-S MOOS 1137 PARK FAST D WOONSOCKET, Rf S .>� Not v litl. itfa w t signatury Lis us en't of Public S.,Ift ' r Sty' . el- ' Construction vior Specialty License - Lice C JAMES MOON Restricted to. RF,Ws CUMBERLAND f ,. Expiration: 312312012