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HomeMy WebLinkAbout0073 JUNIPER ROAD . :. y. ... .. t• f .L i , � _ �:.. �. i. /' i '' t 1 ... .. '. .. �. .. .. ., .. "_ .. .. .. - .. �. F ENE T Town of Barnstable Expires 6 n:ot from issue dale Regulatory Services Fee * BARNSPABLE, " MASS. v�l ,�g Thomas F. Geiler, Director i639. q A ED MA A ]building Division 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 a Prop�rty Address Residential Value of Wort. V 0 Njininnum, fee of S25.00 forwork under�6 00.00 ,T A e& Address t - vN Owner's�ncr's Name � >� C V11���` a C z 1l � e,,� cx _S !t 11�t/oTel hone Number .f j 0� Contractor's Name p p ( applicable) /T b� r,.. S I tome Improvement Contractor License# if a licable 9 1, Construction Supervisor's License # (if applicable) SQ �/ 0 ❑Workman's Compensation Insurance _ m �`�' Check one: XPRESS ❑ 1 ap a sole proprietor EP 21 200q ❑ m the Homeowner I have Worker's Compensation Insurance / TOWN OF SARNSfAIKE Insurance Company Name NeW /V Workman's Comp. Policy 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) Vae,-Pdecemen Windows doors/sliders. U-Value _�,� (maximum .44) *Whcre 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., �7L SiGNATL•RE: _— Q.`ti Pl-il.l.Stl OR MS\huilding permit forms\EXPRESS.doc Revised 100608 a 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): / O v c) Cam' Address: 2 a City/State/Zip: h Y,/� Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.Yam a employer with 4. ❑ I am a general contractor and I loyees(full and/or part-time).* have hired the sub-contractors 6. ❑New onstruction 2. a sole proprietor or partner- listed on the attached sheet. 7, emodeling ship and have no employees These sub-contractors have g. ❑Demolition workingfor me in an capacity. employees and have workers' y p 9. ❑.Building addition [No workers' comp. insurance comp.insurance.$ requi red.]ui 5. ❑ We are a corporation and its h WE] Electrical repairs or additions q ] 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. righi of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' - 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. 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: ;dq _ Policy#or Self-ins.Lic. P 7 Expiration Date: 7J y Uiv{p�% I'C City/State/Zip:C '1P .Job Site Address: /�/ �' �t7Jp� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1.,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator..Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under ains and penalties of perjury that the information provided above is true and correct. Sian re: 5- ` Date: Phone#: moo - 160 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#: L . f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, 1U.4 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibly Name (Business/Organization/Individual): - r'r� 16L'.S Address: (.2 U IVL � Cz City/State/Zip: T" 6i, t A3 S 3 Phone Are,you an employer?Check the appropriateA�x; Type of project(required); with 4. general contractor and I N construction 1. Iamaemployer '6. * have hired the sub-contractors ❑(full and/or part-time).*employees fu ) ( p listed on the attached sheet. 7. Remodelin 2.❑ I am a sole proprietor or partner g -. ship and have no employees partner- These sub-contractors have 8. ❑Demolition employees and have workers' working for me in any capacity. 9. ❑Building addition [No workers' comp. insurance comp.insurance.t 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] 3.El I am a homeowner doing all work officers have exercised their 1 I.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs required.]t c. 152, §1(4),and we have no insurance re ]q . - _ employees. [No workers' 13.❑Other comprinsurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers compensation insurance for my employees. Below is the policy and job site information. ` Insurance Company Name: V r! ZZ �J� Policy#or Self-ins.Lic.#: Date. J 1� l Expiration Job Site Address:- 1 City/State/Zip: -��Vl" v t Attach a copy of the-workers"compensation policy declaration page(showing the policy number and expiration date).. Failure to secure coverage as required,under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and he pains and pe 'es ofnal perjury that the information provided above is true and correct. Si natur Date: - Phone 4: 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#: Licensee Details Page 1 of 1 The Official Website of the Executive Office of Public Safety and Security(EOPS) Mass.Gov Home Public Safety Department of Public Safety Licensee Complaints License Type Home Improvement Contractor License k 153140 Restriction Company Nu-vision Installations Name Stephen Restaino Address 32 Oval Drive City,State,Zip West Yarmouth,MA,02673 Expiration Date 10/31/2010 Status Current No complaints found for this Licensee. Sack To_Sea_ch. 0 SO YJ License: CS SL 99560 ,K ,f Y Restriced . o: WS jN k '3f z w STEPHEN RESTAINO 32 OVAL DRIVE i WEST, YARMOUTH, � l1A 02673 Expiration: 1/-2212Q12 C t1JI1i11is:sil►iji° ' Tr 995560 V� r�; S`fO vl /v15 6 var o u�i nkVufiis anc tantar s HOME IMPROVEMENT CONTRACTOR fy l- Registration: 153140 Expiration: 0/3112010 Tr# 27 191 'T' ► et III NU-VISION INSTALLA IOI STEPHEN RESTAINO 32 OVAL DRIVE .,. WEST YA MOUTH, MA 02673 Administrator .... ..:.... _.. 1,ieense or registration valid for indvinl use only before the expiration date. if found return to: a} Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston, Ma. 02108 Tot valid without:signature t /4o .�. +as�ra<:awfe�• :tlx.i`tt�rrc�u: Irs n Y� Board of Saildiag Regubttsas and Standards HOME tmpROVEMENT CONTRACTOR RegisV8 on: 126893 y` Expiration: 8t3f2010 - Type: Supplement Card The Home Depot At-home Service DARREN DEMERS' 3200 COBB GALLERIA PKWY 020 ATL4NTA,GA 30339 Administrator a License or registration valid for individul use only , before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston,Ma.02108 a , x Not valid without signature ACORD LIABILITY INSURANCE DATE(MM/°°"""'. ,M CERTIFICAT E OF LIABILI 02/20/09 PRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Marsh USA,.Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR homedepot.certrequestOmarsh.com ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 3475 Piedmont Rd NE, Suite 1200 Atlanta, GA 30305 Fax (212) 948-0902 INSURERS AFFORDING COVERAGE NAIL# INSURED INSURERA:Steadfast Ins CO 26387 THD At-Home Services, Inc. • INSURERB:Zurich American Ins Co 16535 2690 Cumberland Parkway INSURER C:NATIONAL UNION FIRE INS CO OF PITTS 19445 Suite 300 Atlanta , GA 30339 INSURERD:New Hampshire Ins Cc 23841 INSURER E:Illinois Natl Ins Co ' 23817 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' POLICYEFFECTIVE POLICY EXPIRATION LIMITS LTR N RD POLICY NUMBER. DATE MM DD DATE MM DD A GENERAL LIABILITY IPR '3757 608-02 03/01/09 03/01/10 EACHOCCURRENCE $4,060,000 X LIMITS OF POLICY ARE EXCESS DAMAGE TORENTED $1,000,000 COMMERCIAL GENERAL LIABILITY - PREMISES Ea occurence CLAIMS MADE OCCUR "OF SIR: $1,000,000 PER CC" MEDEXP.(Any one person) $EXCLUDED PERSONAL BADVINJURY $4,000,000 GENERAL AGGREGATE $4,000,000 GEN'L AGGREGATE LIMITAPPLIESPER: - - „ .PRODUCTS-COMP/OPAGG $4,000,000 X POLICYEl PE t T LOC. B AUTOMOBILE LIABILITY SAP 2938863-06 03/01/09 03/01/10 - COMBINED SINGLE LIMIT $1,000,000 X ANY AUTO (Ea accident) - ALL OWNED AUTOS _ BODILYINJURY s (Per person) - $ SCHEDULED AUTOS HIREOAUTOS BODILY INJURY (Per accident) '$ NON-OWNED AUTOS X SELF INSURED AUTO i - PROPERTY DAMAGE $ PHYSICAL DAMAGE (Peraccident) GARAGE LIABILITY 'r AUTOONLY-EAACCIDENT $ ANY AUTO OTHER THAN EA ACC $ ' - AUTO ONLY: - - AGG $ A EXCESS/UMBRELLA LIABILITY IPR 3757 608-02 03/01/09 03/01/10 EACH OCCURRENCE $5,000,000 X OCCUR _ CLAIMS MADE - AGGREGATE $5,000,-000 .,DEDUCTIBLE - $ RETENTION $ - - $ ' C / 03/O1/10 X WCSTATU- OTH- WORKERSCOMPENSATIONAND ` 3566916 (CA) '- 03 01/09 T Y IMIT ER EMPLOYERS'LIABILITY - - D � 3566915(AOS) - � 03/01/09 03/O1/10 E.L.EACH ACCIDENT $1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E OFFICER/MEMBEREXCLUDED? 35.66917 (FL) 03/01/09.- 03/01/10 E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under - SPECIALPROVISIONSbelow E:LDISEASE-POLICY LIMIT $1,000,000 OTHER D Workers Compensation' 3566918 (KY, MO, NY, WI, ) 03/01/09 03/01/10 F TX Employers Excess TNSC45694422 (TX) 03/O1/09 03/01/10 ccurrence/SIR 25M/2M C Workers Compensation 4801323(QSI) 03/01/09 03/01/10 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS RE: EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THD AT-HOME SERVICES, INC.. DATE,THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN 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 2690 CUMBERLAND PARKWAY SUITE 300 _ REPRESENTATIVES. - ATLANTA, GA 30339 - AUTHORIZED REPRESENTATIVE, USA ACORD 25(2001/08)ckomraus hd ©ACORD CORPORATION 1988 11172180 HOME.IMPROVENIENT:CONTRACT I t?LEASE,READ,THIS 1 ° L) Sold"Fumi:bed atxl3ttst�led�v:` Branch Names, Boston- Date .Q t.. 7 FiD•A)Home SctviCC�;Inc:"^ •._.+ s d/b!a;Tlte•Home at At-Home•Services 345A Greenwood Street:Unit 2,V lorcester,-MA,01607 �` Branch Numlber:,31 Toll Free(800)657-5182;i Fax(508)75678823. Peiicral 1 4/ bf m ti 75=2698460;MEiic#C�024 9;RI Cori:-Lic#16427 1 j g " A t CT Lie#%5522-MA Home Trnprovement 0 actcir Reg:#124W Installation Address tej •Gkty": State• wrchasa(s) :WorxPbone 13omerhene:.. h.:. CeUPhone: Home Addre,: (If different frofnInscallaaon_Address).:. :,: ,,:. . : .:.,, .•GSty.:..;... Sra�c.... zip . E-mail Address(to receive•project comnui ications and Hocne•Depot updates):--., 0 I DO NOT wish to.raceiveany.marketing emait..front'Ibt Homo Depot:..; :.. P%iect Infotmationr Undersigned•("Customer"),the ownets'of;the property t'oeaUod•at,ft above*i i..ailiSoii address-,agrees to buy, and THD At-Home Services,Inc.("Tbe Uome Depot')agrees:ta furnish,deliver and.a%xmtge•for the installa ion("Installation").of all materials desmbed•on•;the below and on.the;aeterenced,Spec:Sheet(s),all of which are.incotposated t p nl ,this Contract by.this reference,along with any applicable State Supple meat and'P4-y m ment Sumary attached hereto and any Chan p,Orde. rs(collectively, „Contract'): .., Job# (tin t T<dFimce) ProduCG9Alnoum" Roofing Siding Windows Insulation tO T �' �jGutrers 7Covers'�Entry•Doors•� Q�,�5"�. Roofing:. Siding •V✓indows'0 insulation rs _ :QCyttees..Cove 'Ql?ntryAoors-.f_l' o Roorag Siding Windows. • Insuladon _ OGutters/.Covers'op] n ry 00K.(Q Roofing • Siding'. .Windows O.Inqulatiom . . -• �Gutiera/Covcty`[lEobyDoors [ '. o. $. ,DTmimom25% tdGoatraaAmoontdu�ulwn ccudonotrbls;conhast ; " Total Contract Amount '$ Maine Purchasers my not deposit more than on third of the ContnidAmaamt Customer agrees that,.immbdiately upon-cotrtpletion-of the work,for,each Product Ca7tomee•.w.i]l'execute a;ComPieti'on Ceitificate (one*for each`Pioducr as deftaed'by,an individto'Spec�Shcct)and'pay any balancrdue. As applicable,eai li'Customer°under this Contract agree,:to be jointly and severally,oblieateei and liable hereunder:.; The lion Depot reserves.•the;righe.to issue•a-Change Order or tentbaate:tbis Conti=or,Fy-iPdividu4- Prodtu rt(s)included herein;st its discretion,if The Home Depot or iM authorized serviceprovider detennines that it cannotpe grm-its.obli;ga ions due to.a.st7tncatral problem with the home,environmental-hazards such as mold.asbestos,or.lead paint,other safety eoneems.pi,icing errors or because work.regai d to complete the iob was Aot included iii the g�o��tract „ Payment Summary:. The:Psymtrtt Summarye.V- . included as-part of this,.Come F4-xets forth the dotal Contract.amoitnt and payments tequi red for.the deposits an&final;paymems by Product(as%applicable): NOTICE TO CUSTOMER You are enticed to a completely filled-irrvopy of the Contract at the�time you sign: Do'not sty a Complt tiori Certificate(note: there is one Completion Certificate for each listed ProducCas:defi iW by individuat..Spec•Sheets)'before work an that:Product is complete in the event of termination of this Contract,.Customer agrees to pay The Home Depot the costs of neat trials,labor,expertm and services provided by The Home Depot or Authori✓ed.Service Provider through the date of termit ation,plug any other amounts set forth in this Agreement or allowed under applicable law. TY•YE IIOME DEPOT MAY W11 FMOLD.AMOUNTS OWED TO THE HOME DEPOT FROM THE DSPOSIT PAYMENT OR OTHER PAYMENTS;MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorirsttion:. Castomer,agreas and understands that this Agreement is the entire.agrees.II&between Customer and The Home Depot with regard to the Products and Installation services and supersedes 4 prior discussions;and agreements,,cithcx oral or written,relating to said Products and Installation.Thus Agreement cannot be assigned or amended exc.ptby a writing signed by Customer and The Home Depot Customer acknowledges and agrees that Customer has.read,un_dersmnds::voluntarily accepts the Jerms of and has received a copy of thiAgreement. A epted : Sv t Customer's Signs re Date Sales Consul t's.Signature 1 __3 1(M Telephone No. Z/ ' Customer's Signature Date.. Sales Consultant License No. 1 CANCRi.i,ATiON: CUSTOMER MAY CANCEL THIS lieahlo AGREEMF.cNT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE.HOME DEPOT BY MIDNIGHT ON THE .THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW- ]N CUSTOMER'S STATE NOTICE:ADDITIONAT,TERMS AND CONDITIONS ARE STATED ON.TIM REVEM SIDE AND A,RE 1'BU4& ffi^rCONTRACT 1 White.—9n m.h Ho Yeltow—Customer Pink—Sales Consultant - - - 100•d SIHNVAH 10dsa 3140H 95:e1 6009-90-9nv