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I r I _� _1: �, � ,, ,__ - - co Town of Barnstable *Permit# ExpkeRegulatory Services Fee I&S.Law a »Aantsr,�is. 1 iNAM Richard V.Scab,Interim Director Building Division YORE YORESS PERMIT Tom Perry,CBO,Building Commissioner AUG 2 7 2014 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 EXPRESS PERMIT_APPLICATION - RESIDENi ffl! Not Valid witMout Red X-Press Imprint Map/parcel Number pia Io�0� Property Address t9 0 1 It I R4 Ot ta- 00 P�Residential Value of Work$ TrZ I Minimum fee of$35.00 for work under$6000.00 . 1J Owner's Name&Address Eon on -9L /�� A7d ll a A I l t Rr&4*,tV11 u, - — Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) ® to k 9.3 Email: Construction Supervisor's License#(if applicable) Lll 0 l!!3 Workman's Compensation insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner 1 have Worker's�Compensation Insurance co Insurance Company Name /�di-0 �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 taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value 3 (maximum.35)#of wind s �� #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red Sand inspections required. Separate Electrical&Fire Permits required. *Where required: Lssuauce of this permit does not exempt compliance with other town department t bulatioms,i.e-Historic,Conservation,etc. ***Note: Property er sign Property Owner Letter of Permission. A copy of H Improvement Contractors License&Construction Supervisors License is. required. SIGNATURE: TACEVIN Muilding Changes\W SS XPRESS.doc Revised 061313 MA5R REAM TIIb4 Sold,Furnished and Installed by:. Breach Narue:.Beston Nar1h Sotrt>t. Date: THD At-Home Services,:dnc dRft The Home Depot At Horne Services Branch Nmnbet.31 and 33 908 Boston Tumpxke,Ux it 1,Shrewsbury,MA 01545 old tree 87.7-�J,U3-3768 FcdciW.W#75-2699460.N12 Lie#C 0,2439;Ri Cont.110 16427 f CT Lie a HIC.p565522;MA Hume Iurpro�c n Carttrwa Rcg.#126893 Installation Addr'es's: 1 U oaf., -a— city State Zip Work Phone.• Home Phone: Cell Addre4� CJ 8 (If differeau from Installation Addtcss) city State zp- il E-Ind Address(to receive project communications and tfome'Depot updates): ❑.I DO NOT.wish to receive any mating mmis fin The home Depot' ec[the rmacion: Uadersii pted("Customer"),the owners of ire property located at the abavelastallatiou addrvss,agrees to buy,. and T At-Home Services,Inc.("T6e Home Depon agrees to famish,deliver and arrangc for The installation("Iustallation")of 4 all materials.described on the below rind on the tie W=ccd Spec Sheet(s),all of which are meorpcuutc d into this Contract by this reference, along with any appilcabie-State Supplement aar l Payment Summary attached hereto and any Change Orders(coll6edycly, "C�tract"): . job#e'parser ) Protswe sheet(s)#: Project Amount ltlmfm8 LtSidng vViadows U Insrd>— $ ty pGattera r covets pl�,ny Doara p © 02 Lit %mflax Skli Windows 1- Insulation prudes 0 i covers oEntry Doom -- > S SWn El Windows Q Insulation . �©Czuttcts!Cweis©Eddy Doors❑ $ !, R.00tlgg stding windows Insulation © Ic 'ORn"Dom o l+ malnae>=roD affceo�:tAl tee dam TotdCa r Amount MAw PardmusmayiWd tnwmthanoo&tlandortheC uhadAma®t Customer agrees that,imine&atdy upon completion of the wank for each Pfoduct,Car11oater will execute a Completion tertificate (one for each Product as defined by an iMvidud Spec Sheex)rand pay any balance due. As applicable,each Customer undei this Contract agrees to be jointly and severallyof gated and liable hereunder. The florae Depot reserves the right to k sue a C'.hmtgc Order or terminate this Contractor any-individual Produci(s)included herein,at its discretion,if The Home Depot or its authorized service provider determines that It cannot perform its obligations due to a structural prp19 with the home,eaviron neural hazards such as mold,asbestos or lead paint,ad)el safety concerns,priciao errrr»or be nose ,York required to complete.titc job was not iad fed in the Contract. Pav t Summarw The payment&rmyr y,# 0 Q�7ed. 3 _included as part of this Contract, sets forth-the trial Cunu=n amount and payments required for the deposits and final payments by product(as applicable); NOTICE TO CUSTOMER You ire entitled to`a cahtpte teep tMed--coy of the Cbatraei at.t he flame you sign. Do tot sign a Cimopkfin r cerwciie( there is one Completion Certificate for each fisted Product as defined 1►y individual Spec b9 cob)before wok 4n that Pt odoct h complete. In the event of tam nation of this Contract,Ctts"mer agrees to pay The Hance Mpot the casts of materials,debar,ernes and services provided by The Hanna Depot or Atdhotbe d Seryke Provider tlwuuo the elate of'•ter tninatoo,plus aW(Aber ttmtitifAts set frrrth is this Agreement or allowed under law. THE IOMF DEPOT MAY WI IY3HOL<l AMOUNTS OWED TO THE HOME DEPOT FROM rHE DEP TPAYMENT Olin OTHER PAYMIa'A IS MADE, WITHOUT' LIMITING THE HOME DEPors OTHER RKwEms FOR RErCOVFRY OF SUCH AMOUNTS. Aeeeutanee and Authorization: Customer agrees and tmderstends that this AgFeemcxd is the entire agreenledtt he[wcen CUEUw to. and The Hone Depot with regard to the Products and Lassallad n ser'vtot:s and supersedes all prior discussions and agrcctneuts,either oral or written,relating to said Products and Installation.This Agreement cannot be assigned or amended except by a venting signed by Customer and The 14ome Depot.Customer acknowledges and agrees that Custonier-bas read,undersrntds,voluntarily accepts the terms of and has receives a copy of this Agreemcm Accepted by: +1� r 41ne'S signat - Date �) Sales nstdtant'S gn�aiI / Date ' 7 Telephone No._ f G� !: (V 41 Customer's Signature Date: $ales Consultant License No. CANCELLATION CUSTOMER MAY CANCEL THIS (a5 aNrltcab3el Afs REEMENT WITHOUT PENALTY OR OBLIGATgON BY DELIVkRING WRITrjKN Nt TKZ TO THE HOME DEPOT BY MIDNIGHT ON THE TEMW BUSWESS DAY .AFTER SIGNING THIS AGREFMF_NT: THE a STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPEOWICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE, IVt)TIL7i:h8it}P140NA1.'11yB14r5 AND t"t)NDI740M Atj SIATR9 AN THE BEVERS'E S'ME AND ARL PART Of TM Cpl'rr'lmm ' ilidi714 Wlt�—f3taAChFiiB Yellow—tt+stottier• Td WbVE:S TTOZ 4T '9a.d TLZZZ9MOG: 'ON Xtld pie6wef: W08d r t. a l y i a e t +` 9 ♦ ..-q aw kT.fi 'L'.r �. .+' P. ..� � � -w „� ..� i' 'A,.,' ".. ,¢,:fir. W.. .'Frd'R""'' P.F+E"'_ e .. •. :..� f d "S p.. urs - r` Yr��. r,.A.:`�: .se.' .F. A# 9W.t � � b9 � m � d- >•� � �� _ x y '�' _ 4 � n n R. x � s rT 01 m"-00 j.w�+ ';�" A"i 5 N .•A �v�"'�yy y "YP"M�%v�� ..K,i,.,, 1 TIT pf py{ Jc A ari� -v x '� - t^ •e � �F �' 4 � t lift3l r�- ].fit.;, ''� �rg 3-t � � •"�. :;��+y� aa�.f AN,:t. �'•& � "P ''..f :;aa�• ��' .a�.p� , �.,, mr' �. P � „w „7- "' ">` } �`�,, •ya r ,a �, •��r�� � r` � ��� �.� � x" .,,;,, ,n r•': ���,.fi � '."��.�, '^ °s�'.s, k' ���;kf �,., N� s .�a': �y�`' #,t,� ' �"4• �,� +� R `,�:j 'x+.y ''�, ..' � Y _ilk A y 6`-j q . 'A' .,_a ` .. k'L•w 1 Oe h;'°Y ��y'.''t¢ ,�.s.R4. y' '�. '&�2 - 6 G �W. N ^��V"F � +F h a _ � ] ir � :� "�, S`y�� � °"g ;: r.� ,'• '" '�« � �^' t J T FAY 'Y 3 Atto MIA ; EN � � 5 � yak ¢�v, 1.4` r � e The Commonwealth of Massachusetts Department of Industrial Accidents c °Office of Investigations 1 Congress Street, Suite 100 Boston,- MA 02114-2017 Sa # www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly ........ - IV Name (Business/Organization/Individual): JQm o Address:_ 2 ,1D 047FUE4-4 City/State/Zip: j�J Phone#: �.�-�36 ® 6 7 '� Are a an employer? Check the appropriate bog: Type of project(required):, 1. I am a employer with �t._ 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I.am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5: ❑ We are a corporation and its 10:0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp..insurance required.] *Any'appli.cant 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 anew affidavit indicating such. lContractors 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: VCR/"s &e N 1TV or— Policy#or Self-ins.Lic. #: (,�,( — Q�� M L q Expiration Date: '`� o1-5 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 o the DIA for insurance coverage verification. I do hereby c rti y nder the ains and e lties of perjury that the information provided above is true and correct ;- — - — Si atute' _____ _. _ _. ___-.- _ _.__ _.____ ____=Date:_...._ Phone#: " 6 3 II� 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 I Contact Person: Phone#: Information and Instructions y Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. 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 of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of 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 dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because:of such employment.be deemed to be an employer." t MGL chapter 152, §25C(6)also''states'thdt"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §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." R Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s)'address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies LLC or Limited Liability Partnerships LLP with no employees other than the rated L ab y p ( ) ty p ( ) members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town 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' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials 4. Please be sure that the affidavit is complete and printed legibly. 'The"Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill 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(if 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. A new affidavit must be filled out each year. Where a home 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: 4 The Commonwealth of Massachusetts s. Department of Industrial Accidents Office of Investigations 1. Congress Street, Suite 100 Boston, MA 02114-201.7 Tel. # 617-727-49,0.0 ext 406-or 1-877-MASSAFE - Revised 7-2010 Fax# 617-727-7749 www.mass.gov/dia ACORD� DATE(iBIiDdYYYY) CERTIFICATE OF LIABILITY INSURANCE 4/10/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED 13Y THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,Main policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsemsn PRODUCER fame Bianca Dunn Dowling Insurance Agency, Inc PHONE (781)848-7652 Ax Mak(�1) -STas 44 Adaats Street fA Apms .bdunnedowlingins.cam P.O. Box OS0962 IMM S AFFORMOCOVERAGE NAIC# Braintree MA 02195-0962 .Travelers fiance Co. 9357 INWR:ED marRER a Arbella Protection Insurance McKeon, Jennifer -mmac:Trav+elers IndWmn Co. of CT 5682 DBA: J S J Rome improvements ROMER D 250 Hatfield Street West BrLdigeMater HK 02379 Irtsll Fc COVERAGES CERTIFICATE NUMBER. 4/10/14 ED REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERK INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DCSCRIW HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS." TYPE OF INSURANCE PO LB8r8 GENERAL ' EACH OCCURRENCE $ 1,000,0001 8 COMMERCIAL GENERAL LIABILITY AJ A CLAIMSJIADE ®OCCi1R $ 017671dMSO /8/2014 /S/2015 $ 300,000 MED ExP one S 5,000 PERSONAL 8 MN INJURY S 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEH AGGREGATE umT APPLES PER. PRODUCTS-COMPROPAGG S 2,000,000 X POLrcY PRO• LOC $ AUTOMOBILE LIABILITY BMW SINGLE500,000 B ANY AUTO BODILY INJURY(Per Peraon) $ AU T® M �AUTOS SUD 020015650 /14/2014 /14/2013 LY INJURY MetU $ gNOWNiNED HIREDAUT08 A g OCCUR UMBRELLA LIAR EACH OCCURRENCE $ EXCESS LIAR CLAIMS MADE AGGREGATE $ DED RErepmcws C WO RKERS COMPENS LIA�t g WC S'rA'fU OTH $ ANY YIN EL EACH ACCIDENT S 100 000 ORFICEt11�19d86R DCCUJpEp7 Q M I A (Manda�my m mq �1923N2 89 /26/2014 /26/2015 EL DISEASE-EA EMKOYEA S 100,000 ayye SCRIPnOM de�rBe ur OF OPERATIONS hebw EL.DISEASE-POLICY LIMIT $ 500 000 DE DESCRNrnm OF OPERATIONS J LOCAMONs r YBOMM Mmh ACORD IGI,Adrift"Remft sahsduw R moro apace b r"Wcad) THD Home Services, Inc. and The Home Depot are listed as Additional Insureds with respect to General Liability as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIEB BE CANCELLED BEFORE THE OVIRATION DATE THEREOF, NOTICE WILL BE DELB OM IN THD At acm Services, Inc. ACCORDANCE WITH THE POLICY PROVISION& & The How Depot 2690 Cuberland Parkway AUTHORIZED REPRESENTATIVE Suite #300 Atlanta, GA 30339 Paul Dowling/aLMMA ACORD26(MOM) ; 011M8-2010ACORDCORPORATION. AN rights reserved. rWSD26 Mn,rruc,m Tk a Amen nunw aM1 Innn sons.enw".d nx+Are oW Annpn ti i ' z 3 Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration 1 893 Type: 10 Park Plaza-Suite 5170 Expirati6w 8/3/2016 Supplement Card Boston,MA 02116 THD AT HOME SERVC€SING THE HOME DEPOT AT HOME SERVICES ANDREW SWEET :r—4 t 2690 CUMBERLANDPARKWAY S -- XfLL.'M,GA 30339 Undersecretary Nov with ut signature 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 Legibly Name (Business/Organization/Individual): Address: u_ City/State/Zip: k�_ b 19. 303 Phone#: Are you an employer?Check the appropriate bpx: Type of project(required): 1.❑ I am a employer to er with 4. I am a general contractor and I Q employees(full and/or part-time).* have-hired the sub contractors 6. New construction - _ - listed on the attached"sheet. 7. ❑Remodeling 2.El am a sole proprietor or partner- 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.F Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 1 . Roof repairs insurance required.]t c..152, §1(4),and we have no 13 employees..[No workers' . Other �U�,()�� ) comp.insurance required] AlCl *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.M W(21 0 7 ® � � g o2 Expiration Date: 3 5— Job Site Address: IO II /1 PCC City/State/Zip: Attach a copy of the,workers'compensatioU4olicy 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 S1,500.00 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' ance coverage verification. 1 do hereby certify and t pains and penalties of perjury that the information provided ab a is tr a 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: PF one#: A.co DP CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. ? !S CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES i BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETY/EEN THE ISSUING INSU'RER(S), AUTHORIZLED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. S si'Y� Nr•+v9T. i• L, - t..-i �tiS-p p ` •'.F .{sL, t,° �'?� ;iv{8.'C si'rnY4+Y.2 :�. i sc i. Div -3+a?=�4;'3a'�J:cic: ..5 c.t i'45:5.•I.1�`::i��I.a� f::. jj- of. �. '=>�r�r...S+ :J } biL�' the terms and condiir ns ofithe policy,Certain polia:".inay require an endoizeinern. A S(aternent On VMS Cei tificale doe!c no!confef ixj tl5 to Ut2 certificate holder in lieu of such endorsement(s). PR OOUCER CONTACT MARSH USA,INC. NAME: -- PHONE ,FAX TWO ALLIANCE CENTER o Ext: I(aft Not: 3560 LENOX ROAD,SUITE 2400 E MAIt ATLANTA,GA 30326 ADDRESS: ------ - --- _--- INSURER(S)AFFORDING COVERAGE NAIC - ----- INSURED 11a53� Zunch Amoican Insluanrx''J THD AT-HOME SERVICES,INC. INSURER B: -----_..---- DBA THE HOME DEPOT AT-HOME SERVICES INSURER C:New Hampshire Ins Co 123841 2455 PACES FERRY ROAD Illinois National Insurance Co an i23817 ATLANTA,GA 30339 INSURER D: mP Y INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATt+;�2t�a(s' REVISION NUMBER:3 THIS IS TO CERTIFY THAT THE POLICIES OF 1NSURA^IC= USMED B=_LOW AVE.BEEN ISSUED TO Tt''c INSURED MALE.^.ASOVE POR THE P^LICY PER!CC, INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY SE 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. ILTR TYPE OF INSURANCE ` POLICY NUMBER MPIp EFF PMhO1L�lp LIMITS A I GENERAL LIAa1LITY GLb4887714-04 03/01/2014 03/01/2015 EACH OCCURRENCE S 9.000.000 COMMERCIAL GENERAL LIABILITY I 1,000,000 -_, PPEMiacc rc���.•:...�..e., 1$ —_ L1:;;, ,.,R. `J OCCUR I I. -Llu.fti�..'1-(Q Ur y' ` I I LicQ EXE'fitiv u:ie oetscrr� S. 1-t..:Cr;l 0FSiR:$IMPERCCC R _ rPERSONAL 8 ADu INJURY $ yow"OwI GENERAL AGGREGATE $ 9,000,000 GENL AGGREGATE LIMITAPPLIESPER:. PRODUCTS-COMPIOPAGG $ 9.000000 X POLICY PRQ LOC $ B AUTOMOBILE LIABILITY BAP 2938863-11 03/01/2014 ION0112015 COMBINED SINGLE LIMIT 1�� Ea accident $ Y I ANY nt,'T 1 'I - , SC-C, Y ?SU Aa:L(7'YNEO I SCHEDULED ' Ia F "tiS' r rl IT -- AU ALL Tw^ EL. I, SUR.- At. O r,: NON-OWNED I PROPERTY DAMAGE V HIRED AUTOS AUTOS eraccident) $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE 5 DED RETENTION$ $ ;P=Rs Fce* 4 =?^i f'f ? ��s a4 i`v'i o- :�� . -.il' it - i �..ii/Gt!'. 7 Nvr RT.4T AND EtP'OYsR StLI 4 I I I. P , —LT{J Y L?nnirg ANY PROPRIETORIPARTNER/EXECUTNE 1r`CG43 i0IGN(AK,A7.,VA) I r0ii�014 -03t iiG015 I ixhl,irii0` OFFIGERlMFJdBEREXDLUDED? N N!A f EL EACH ACCIDENT $ D (Mandatory In NH) WC049101883(FL) 03101/2014 03/01/2015❑ -- 1000000 E.L.DISEASE-EA EMPLOY $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000000 C WORKERS COMPENSATION WC049101885(KY,NC,NH,VT) 03/01/2014 0310I 015 I(EL)LIMIT. 1,000,000 .-. C WC049101886(NJ) 03/01/2014 03/01/2015 DESCr:.IP tON OF OPERATIONS T LOCATIONS!VFNCLE_S ,Attach A^ORD; ,Additional Remark's 8._riedule,Ir n?ore 9(i?cE EVIDENCE OF INSURANCE t CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. SHOULD-ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHOREZZED r__=?R=.sSVgTA:NwE a;Marsh USA itrc. _ I Maneshi Mukherjee -1�+La�+�no►w 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Town of Barnstable *Permit# aLol 0 ��r? Expires 6 months fro issue date X-PRESS PERMIT Regulatory Services Fee - � SEP 2 2007 Thomas F.Geiler,Director Building Division Co�ql2_F167 TOWN OF BARNSTABLE Tom Perry,CEO, 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 4.3;.®(Q�}� Property Address (�'.1 r 14O L.L residential Value of Work` ( 006 _ Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address (�ON/1)_n + J U.J R I±l I-L SI�hA Contractor's Name E Rd�.y�S �2 44- Ul/!N i_10w Telephone Number' SUF) _� 1.3 80 Home Improvement Contractor License#(if applicable) 4J7 �•�a� Construction Supervisor's License#(if applicable) - C �3& ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner have Worker's Compensation Insurance Insurance Company Name Workman's Comp,Policy'#. Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) AR.constniction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ie-side CZ 0164 r;� C 0416 S , ❑ Replacement Windows/doors/sliders.. U-Value (maximum.44) *Where required: Issuance of this permit does not'exempt compliance with other town department regulations,i.e.Historic,Conservation,eta ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATURE: 0 LJ31 ; Q:Forms:expmtrg Revise061306 The'Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers" Compensation Insurance.Affidavit: Builders/ContractorsCEl Please Print Le bl ' � licant Information • Name(Business/organizetion/Individual): , I" S ' 1 2 VR Address: A S_ Cta ►= city/State/Zip: Sla r4 Phone.#: 0 7•a`1" '�I B c� Are you an employer? Check the appropriate box: Type of project(required):. 4. ❑ I am a general contractor and I 6 ❑New construction 1.[] I am a employer with- —* have hired the sub-contractors employees(full and/or part-,time)_ ❑Remodeling 2,(�I am a'sole proprietor or partner- � listed on the-attached sheet. �, ' These sub-contractors have 8• ❑ Demolition ship and have no employees . employees and have workers' 9• ❑Building addition working for me in any capacity. insurance.$' [No workers' comp.insurance 5 ❑ comp. corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 11.❑Plumbing repairs or additions 3.❑ I am a homeowner doing all work myself [No workers' camp. right of exemption per MGL 12,❑Roof repairs c, 152, §1(4),and we have no insurance required.] t e to ees. [N o workers' • •13.❑ Other�e - S��•!' Y comp, insurance required.] . *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractor 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 zve employees,they must providb their workers'cornp.policy number. lam 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 Invesdizations of the DIA for insurance coverage verification, Ido hereby certify under the pains•and penalties ofperjury that the information provided above is true and correct. Sisnature• Date: - a Phone#• S^015 as m ?0 Official use only. Do not write in this area,fo be completed by city or town ofjleiaZ City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: UU/L1/ZUU7 11:45 FAX 5087753821 OLDE CAPE COD IMS AGENCY 16001 _ AC-M CERTIFIPRODUCER CATE OF LrAErLlTY INSURANCE OPID 8°�t�(MMlroarYrYY) 01111 'Cape Cod Insurance TH! CER �( A rE IS ISS ED AS q Y,2 09 21 07 Martha Findlay ONLY AND CONFERS NO RION TER CEI�TIFICATATIO 296 Winter street ALGTER THE COVERAGEDAFFp pEQ SY THE POD'IC T BELOW Hyannis VA 02601 Phone: 508-771-3300 Fag:508-775-3621 i INSURED INSURERS AFFORDING COVERAGE NAIC# INBUMA; SafNBt aabura>1lCe CO qz ► INSURER B 7 L/ndsOMB �rm And Windows INSURERcr andwieb MA 02563 INSURER al i COVERAGES INSURER E; THE POLICIES OF INSURANCE LISTED BELOW HAVI!BEEN LSSUED TO THE 1NSLIREd ANY RE4UIRENT,TERRA OR CONDITION ANY CONTRACT OR OTHER NAMEd ABOVE FOR THE POUCy MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICES DESCFLBEp HEREIN IS SUBJECT ES ALL THE TERMS, PERIOD FICI TE MAY BE LqS ED OR ING DOCUR4ENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 133UED OR POLICIES.A3GREN3ATE LRIATTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAM. EXCLUSIONS AND CONDITIONS i LTR NSR TYPE� +RANCB OF SUCH POLICY NUMBER DA LIABILITY Ill Te OF-�1ERAL umrTs X COMMERC1ALOENERAI.UAll BPO0006236 EACH OCCURRENCE $1000000 CLAIMS MADE OAR 10/2I/07 ,10/21/08 PRt;M16Eg 21owu $300000 ml WIr W*PAN $5000 PERSONAL&ADV INJURY s 1000000 GEN4 AGGREGATE LIMIT APPLIES PER: GENERALAGGREcaATE $2000000 POLICY I PRRII-COMP*PAw $2000000 AUTOMOBILE LIABILITY ANY AUTO C ���SINGLE LIMIT IMIT $ ALL OWNED AUTOS SCHEDULED AUTOS 800I4Y INJURY HIRED AUTOS (Par parson) S NON•OWNHD AUTOS BODILY INJURY PROPERTY DAMAGE OARAOE LIABILITY Ift°Qpwel S ANY AUTO AUTO ONLY-EA ACCIDENT g OM TNAN EA ACC $ M EMWA 14MILLA LIABILITY AUTO DNLl" AGO g OCCUR CLAMS MADE EACH OCCURRENCE $ AG43REGATG g ~— DEDUCTIBLE g RETENTION $ $ WORKERS OOMPENSATION AND g EMPI,QYERS*LIABILITYANY T uM Will ER' Ot FICERIMEAlBd2 EXCL DEDE E,L.EACH ACCIDENT $ t�fy�,�tlMMO EL DISEASE•5A EMPL $ SPI:GIAL PROV�NS below EL,OISEASE-POUCYLIMIT $ A Property Section A Comtlmescial li BP00006236 DESCRIPTIONOFOPERATt lLOCATIONSIVF}}IGLESIFf(I;d,UglOhiSADDEOBYEN�ib Ey1T��21/p 10/21S07 B CERTIFICATE HOLDER CANCg1.LAnpN TOMN-01 SHOULD ANY OF T K ABOVE OUCRISED POLICIES BE CANOE1LEp BORE THE EXPIRE DATE TNT,THE MMINIG INSURP,R WILL M0MVOR To MAIL ITTEN Town OF Ra=8t&le NOTICE TO THE CERTIFICATE HOLDER MAMED TO THE LIl BM FAILURE To go So&HALL e Building Depaxt=nt IMPOSE NO OBLIGATION OR LIABILITY of ANY KIND UPON TK 367 Main Street REPRL MNTA INSURER fro AeelvTB OR »yards Ill 02603. A C RD AD{ f08) a 0 C D CO P0IiA'r10N 9 Town of Barnstable Regulatory Services Thomas F.Geiler,Director ,� truss g , q,A 1639 A,� Building Division lFD MPi bg Tom Ferry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using ARuilder R oN hLb 1+1>1 L L ,as Owner of the subject property hereby authorize fit^(3( v'S bCe--,R 4. \O-A _ CE um a SQ 1�6 act on my behalf, in all matters relative to work authorized by this building permit application for; . I-)Cc.Ly R? i2� (� Adiress of Job) Signs e,d Owner Date (�ut�P�t✓� l-}-IBC LL- Print Name Q:FO P-M S:O W NERD ERM IS S ION I Map Town of Barnstable Geographic Information System Parcel Viewer custom Map Abutters Map size Zoom Out In (1p y R.� , 1 [/��) a tt W 0 S 1_ 3PG Map: 232 `P .. r y t 7 r0 �3` f''``' "''Pik" .r+`` i Location r s; 2527Owner: r ' 23ilk38 91 t40 t ( =,7 25219139 _ t s r 1 252105 "32o79 _ 9150 9138dScaIorE In r252109 256 2332 It 1d2] Q yMap$Paroe -� 232047 232038' Location 9236 " 9 ISO 9 i68 � Acreage #226 $ T, r S+o 232Ai5 F 5� 4 1 232034 IV Igo, - �4 �. 2 209D h Current O% ` 232870. ,C y M.. 9 212 t t i 4 9145 _ ✓... 9249_; g , Y3205ti .91555 Mailing Addr L YA 232025 4.. 9233 rw y 231D17f � �t , 232M 23711 175 1aQ, g 9219 9155 1:'4 Appraised 1 i Y,. 232082 F�,r 1 s 9213 Y �s ?jxa Extra Featur ,+ 4 232087 r '' •U ° r Y ` Out Building t 9 24 232066 23�65 1 x. i` 914 86 2=61 t r� ' t r s a` , js x'. Land _.,_. 9229 Buildings t... Total Appral l ` f ty 5 d w� <?t fi;r xs 9241 r- ` r ' f.t + d u Ashes§lad 232024 t 9 i9 232072 4U Extra F@attu r 93 y f' Out Building t211 FIA V63 * h f Y � � raj tr232019 r '4 ti 4 r Land tr :69282<• 1 9278 90 Buildings Hvxz ,,�re a.ar Total Assess Set Scale 1" = 211 ' , Aerial Photos Copyright 2005 Town of Barnstable,MA All rights reserved.Send questions or comment BarnstableMA v0.2.91 [Production] http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=232017&map... 8/27/2007 VV/Li/GUU7 11:413 1"Aa 5U6775-36Z1 ULVE L;AYt (:UV Ilia AlibiV41 LwVV.LAcORD _ - CERTIFICATE OF LIABILITY INSURANCE OpIDp aAU(wm ff") > ODUCE R THIS C ER FI TE S I Y'2 0 21 07 Olds Capin Cod Insurance ONLY AND CONFERS NO RI[3HTg UPON THE CERTIFICATE CATS 296 Winter ter street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 29b il3nter Stet ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW NYanui s MA 02 601 Phone: 508-771-3300 Faa:508-775-3821 INSURERS AFFORDING COVERAGE W8URED TNAIC INGURM A; Safet Y---ance Co ray INSURER -an s Doers AndWind*ws INSURER C; sanwich � 02&B3 INSURERQ COVERAGES WWRER E, THE POLICIES OF INSURANCE LISTED BELOW HAVE BEN ISSUED TO THE INWRED NAM ABOVE FOR THE POLICY PRRK7D INDiGI�TEO.NOTWITHSTANDItdG ANY PERTAIN, HE I T6fiBA CR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANOE AFFORDED BY THB POLICIES DESCRIBED HEREIN IS SMELT TO ALL THE TEMA.EXCLUSIONS AND CONDMONS OF SUCH POLICIES.AGGREGATE LAIAIT'S$MOWN MAY HAVE BEEN REDUM BY PAID CLAW. LTR SR OF RAMC POLICY NUMBER DA GGENERAL LIABILITY 8 umn X COMMIERCIALCaENERALUALa1LTY Hpq�ppQ623pRRENCH s1000000 (� 10/21/07 10/21/08 P aoccurencs $300000 CLAIMS MADE C: OCc�R nar D E7O"(Any one P rd $5000 PERSONAL aADVINJURY $1000000 GENERAL AGGREGATE $2000000 GENL AGGREGATE LIMIT APPLIES PER: 7UA PRa Loc PRODUCTS-COMP/OP AM s 2000000 BILITY I �M�+LE LIMIT $ AUTOS AUTOS BODILY INJURY $ �pww) S AUTOS s I PROPEMOAMAGE $ CdARAO6 L IABILTY ANY AUTO AUTO ONLY-EA ACCIDENT $ EA ACC $ ado oN AGO $ SNMERBLLA LIABILITY EAGhIOCCURRENCE $ OCCUR CLAM MADE AGGREGATE S DEOUCIIBLE $ RETENnON s $ WORMS OOMPEMSATION AND $ EMPLOYERS'LIIAMLTY y RY U ER OFFlI TREM6�DtCLUDPD7�CUT� EL.EACH ACCIDENT g a�7q�,�d6 POZO u��((er EL.OMASE.6A EMPLOY S SP�AL PROVI81ON8 below E.L,WEASE-pOUCY U tr $ A Property Section A CCImoaLerciai if f SP00006236 10/21/06 10/21/07 DE�SCR N OF Tt f LOCgTIONS 1 0LE81 F.M VSIONS ADDED UT L:NOOR$ ENT! AL R VL'RON i CERTIFICATE HOLDER CANCEL U 10N WVN-01 9HOVLD ANY OF MG AWVE DE8msw POLOW BE GANOEL leb BEFORE THE mm!q DATE TNT.TNS O WNG INSURER WILL eMEAV"TO AWL GAYS M�RnTEN Town Of Barnstable' NOTICE TO THE CORTWICATE HOLDER k WED To THE LLB`T,BUT MUM To go So BHALL Building O@paxtment p OS0 40 OBUGATION OR LIABILITY OF AMY KIND uRON TK WgUR>T+,rTo ABMs OR 367 Main Street REPMENTATIMAU Hymania NA 02601 ACORD 25(200 /08) a ® RD C ON Feb 22 07 09: 37a JLS 5089337692 p. l IrF• k.. Board of Building Regular ons and Standards One Ashburton Place - Room 1301 Boston_ Massachusetts 02108 Home Improvement Contractor Registration Registration: 128281 Tvpe: Individual Expiration: 3/22/2009 Ttj 127G74 GERALD L. SELBY T_...._._.. ,. .___._..___ GERALD SELBY -� 7 LAND END LANE SANDWICH, MA 02563 yrY tllktate Addreo wad return core!. Mark tv saw rar cbourc. ons cot o 5OM-05ft-1'(;W'!! Addrts. Renewal �� Lmplay t LoA Card L'd L996-OZZ-809 uesnS 860:M LO LZ deS