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Date Issued..................Q.!.
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Building Inspectors Initials
Map/Parcel. ��...................................................
TOWN. OF BARNST"LE
EXPEDITED PERMIT APPLICATION:
ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION
PROPERTY INFORMATION
Address of Project: /b 17 Zel,
NUMBER, STREET VILLAGE
Owner's Name: 5�11�J-� ` rrakf" Phone Number
Email Address: Cell Phone Number <`
t :
Project cost $ �� Check one 'Residential Commercial
OWNER'S AUTHORIZATION
As owner of the above property I hereby authorize
to make application for a building permit in'accordance with 780 CMR
Owner Signature: Date:
TYPE OF WORK
❑ Siding. F-1 Windows (no header_ change)# 0 •Insulation/Weatherization
Doors (no header change)# Commercial Doors require an inspector's review
Roof(not applying more than 1:,layer of shingles) /
Construction Debris will be going to ,� ✓ i^^r/ 4
CONTRACTOR'S INFORMATION
A.Contractor's name tkl 2 5
Home Improvement Contractors Registration(if.applicable)# �p 'b �,® � (attach copy)
Construction Supervisor's License,# f 6 Q �J (attach copy)
. c�s�
Email of Contractor
hone number *" , .emu Id d xz l ALL PROPERTIES.THAT HAVE STRUCTURES OVER`75 YEARS OLD OR IF THE SUBJECT PROPERTY IS 1N
A HISTORIC DISTRICT,.YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED.
e, -
APPLICATION NUMBER............................................................
*For Tents Only* I..
V'
Date Tent(s)will be erected Removed on number of tents total
Does'the tent have sides? Yes No (If yes please attach floor plan with exits marked)
Dimensions of each Tent X X X
Additional tent dimensions can be attached on a separate piece of paper.
Check one: this event is a: for profit non-profit event
Check one: Food served Yes No
Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent
If food is being served at your event please obtain a Health Department approval between the hours
of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval
*WOOD/COAL/PELLET STOVES
Manufacturer# Model/I.D.
Fuel Type Testing Lab
Offsets from combustibles: front back left side right side
HOMEOWNER'S LICENSE EXEMPTION
Homeowner's Name:
Telephone Number Cell or Work number
I understand my responsibilities under the rules and regulations for Licensed Construction
Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand
the construction inspection procedures,specific inspections and documentation required by 780
CMR and the Town of Barnstable.
Signature Date
APPLICANT'S l NATURE
Signature Date
All permit applications are subject to a building official's approval prior to issuance.
CIO`
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 'bl
o 6,264u
� r
Name(Business/Organization/Individual): �L ,�Y `�,Z 64u # A a '/roy q�4®/i��' ✓
Address: �� d /y7' Lrq crl,-1' �
City/State/Zip: cck'Af`le /V'� d'� �� Phone#: �a�0 ry
Are you an employer?Check the appropriate box: Type of project(required):
1.El am a employer with ' 4. VI 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.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 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 e
PF
comp.insurance required.]
*Any applicant that checks box#I 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:
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 cari 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 t e ins a d penalties o 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#:
11
Information and Instructions
zf
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."
MGL chapter 152, §25C(6)also states that"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."
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 number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
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
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 bum 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 021,11
f -Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 !,Z Fax#617-727-7749
vvww mass.govfdia
.4c v® CERTIFICATE QATEI!®NiDD1YYW)
OF LIABILITY INSURANCE 2/12/18
D'ym)
THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFMNO RIGHTS UPON THE CERnRCA'�E HOLDER THE
CERTIFICATE DOES NOT AFFffHAMVELY OR N6GATNELY AMEND, DCTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THiS CERnFICATE OF INSURANCE.DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS),AUTHORIZED
REPRESENTAME OR PRODUCER,AND Ttf cERnRCATE HOuot
IMPORTANT tithe certificate holder is an ADDrflO NAL INSURED,the policyt{ies)norst be endorsed. if SUBROGATION-IS WAIVED,subject to
the terms and conditions of the poky,certain poncies any reOpire an endorsement A statlunent on tins certificate does not confer rights to 11he
certificate holder In lieu of such endorsemengs).
PROWCER CONTACT SIM B:IlIDMAN
Schlegel & Schlegel Ins Broker PHONE 506 771-8381 (soe) 771-0663
34 Main Street E49ML sChl ce@ .cam
West Yarmouth, MA. 026f3
APFORDIAG COVERAGE NAIC#
1 A:TRAVELERS PROPERTY AND CAS
INSURE)
INSURER B.
`324TJWA CAHOON Ie>suReRc-
DBA CAHOON CO3JS'TRIICTION IraxlRlD
16 WEQMQUET AVE
M 026323 INSURERE•
INSURER F
COVERAGES CERTIFICATENUMBER. REViSION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WiTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE fSSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN iS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OFSUCH POLICIES-LMS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAM
LTR 7YPEOFINSURANCE POLICY NUMBER YI�ODIE� �EXP uarrs
GENBZALUAISLIIY EACH OCCURRENCE S
COMERCIALGENEPALLIABIUTY DAMAGE TO RENTED $
CLAM44ADE (Ea cccuffen2v)
�OCCUR MED W(Awof a perm) S
PERSONAL&ADVINJURY S
I GENERAL AGGREGATE S
GEN'LAGGREGATE LMT APPLIES PER PRODUCTS-OOMPIOPAGG S
POLICY PRO LOC $
AUTDMOSILE UASIUTV INGLELMtr
a eon$ S
ANYAUW BODILY WJRY(Perpeaon) S
A OS SSCHEDULEDU BODILY QUURY(Peraddent) $
H<iZMAU70S _AU -0SYMNED PROa AMAGE S
UMB IIALiAB OCCUR EACH OCCURRENCE $
EXCESS LWB CLAIMS AGGREGATE $
DED RETENTIONS S
A AND E ERs YERT l�a7aN I WC-1165040 2/13/18 2/13/19 Yvc srAn1 oTH-
AND EMPtAY9rS'IJABiLITY YIN
ANYP OPIR NE NIA EL-EACHACd NT $ 100,000
OFFIC(Mandatory In NH) EL DI EASE-EA S 100,000
DEMO
EL-DISEASE-POUCYLIMiT S 500,000
QESL'RIPTION'OF OPERATIONS Below
DESCRIPnON OF OPERMK NS I LUCAMM l V99CLES(Atlazh ASS 1W.Add mid Reaed6 Ste,Emo�e space scegi�
JINTANA CAHOON HAS ELECTED NOT TO BE COS UNDER HER CURRENT WARS COMPENSATION POI,ICY
cewnFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE .
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED. iN
RICEVM CAZEAULT ACCORDANCE WITH THE POLICY PROVISIONS.
CENTERVILLE MA 02632
AU7HORIZEDSENTATNE
1 8-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered of ACORD
Phone: Fay- E Mein: CAZEAIILT7 @caw-AST.I3ET
i
/R_
CAZEAULT\
ROOFING & REPAIRS
PROPOSAL
Proposal No. 18-71018
July 10,2018
To: Steve Farrow Work to be performed at
19 Mizzentop
Centerville MA
We hereby propose to furnish the materials and perform the labor necessary for the
completion of:
f
NEW ROOF
l. Remove existing shingle roof
2. Ice&Water First 3 ft, valleys and penetrations
3. Cover roof with Rhino paper
4. Re-roof with Lifetime architectural Shingle F
5. Install ridge vent
6. Flash all pipes and penetrations
7:' Remove all rubbish from project f
Labor and Materials $5,400
. i
All material is guaranteed to be as specified, and the above work to be performed in
o
accordance with the specifications and completed in a substantial workmanlike manner for
the sum of Five Thousand and Four Hundred Dollars $5,400 with payment as follows:
Two Thousand and Seven Hundred Dollars $2,700 with acceptance of proposal and
Two-Thousand and Seven Hundred Dollars $2,700 due upon Completion
Respectfully submitted,
---------------------------------
{
Richard P. Cazeault, Jr. HIC# 168607 CSL#100393
198 Five Corners Road Workmans Comp and Liability with
Centerville, MA 02632 Leonard Ins of Ost
(508) 420-5482
Acceptance of Proposal No. 18-71018
The above prices, speci cations and conditions are satisfactory and are hereby accepted.'
Yo a e auth e t do the work as specified. a e t is outlined above.
----- ----------------
Signatu Date
*Remo 1 of additional layers of roofing not forseen with result in additional fees of$75 per Sq
*All quotes are valid for 30 days
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
� nSii rvisor
Constr*.tt' p
CS-100393 Expires: 02/03/2020
RICHARD P CAZEAULT JR
198 FIVE CORNERS ROAD,* '
CENTERVILLEIMA 02632
r
Commissioner CIL
^'Office of COnSU_ e[A#fairs&Business Regulation
OR
HOME IMPROVEMENT CONTRACTOR
— — Reglstration valid for individual use only t
TYPE:intiitndtra! before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
168607 ,. ,.--.03/07/201.9 _n_ _-,._ _r 10 Park Plaza
Suite-, -
_' � Boston,MA 02116 -
RICHARD P CAZEAULT`J `
D/B/A R Cazeault Roofing&Repairs
RICHARD CAZEAULT JR
198-Five Comers-Rd =� .
Centerville,MA 02632 Undersecreta
ry Not valid wit
tytat signature
# � t,�
Occupational Safety and Health Admmistratwn
f R1aharq'Cazeault'
flas= oessf ��mple Aw
111,
end a�t0,tioiar Oecupattgnal Safety and�Hea�,th�°`'�
" . 'ConstiucUonfe
Parcel Detail Page I of 4
5 On
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Logged In As: �..., Pa rce I Detail ... �Wednesday,"Auguste'
15 2018
Parcel Lookup
Parcel Info
_...... ......................_.. __...... .........
Parcel ID22 069N »»f Developer Lot LOT 36 »»Y�
Location 19 MIZZENTOP LANE j Pri Frontage 7i —'----
Sec ..,». ...,..,
sec Road sec Frontage
Village FCenterville W ( Fire District
Town sewer exists at this address No Road Index 1033
°VN'
Asbuilt Septic Scan:
227069_1 Interactive Map '
• Owner Info
owner MULLIGAN,ALLEN C JF) Dwco- ,RL20u1/;STEVEN'J'� M µ YP"
Streets F19 MIZZENTOP LANE—1 Street2 F .. a.» »—'�e tl l
city,,CENTERVILLE .w,. ,,. .._I state MA ----- vIzip�02632 Country
Land Info
..... . .... .._ ......... ......_ ........_ .. ......... ....... ... ........... ................................... ......... .........__
Acres 0.17 N» use Ingle 1 MDL-01 zoning RB �H »a' 1 Nghbd 0107
Topography rLevel M ( Road Paved � .
Utilities ublicVGter,Gas,Septic( Location
Construction Info
Building 1 of 1
Year ....�_,,.. Roof>"a"'�" pea.., ....� EM ,.»,
aunt 1965 so-uct IGable/Hip Wall Wood Shingle
Living 1008 Roo'As h/F GIs/Cm AC Central
Area _ Cover p p Type
Style i anchh Int D wall Bed Bedrooms-» ,
Wall§ry Rooms.l
Model Eii ential �1 Flop o
Carpet — Rooms 1 Full 0 Half
Average "eat Hot Air Total
Grade 5 Rooms
Type RoomsHeat
und
Stories�1"Story Fuel PasF ation rBlk/Pour Ftgs
Gross
Area
Permit History
Issue Date Purpose Permit# Amount Insp Date Comments
Visit History
Date Who Purpose
7/18/2017 12:00:00 AM Susan Ricci Cyclical Inspection
http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=15858 8/15/2018
0pTHE r Town of"Barnstable *Permit f a S Z
#
Regulatory ServicesJBIARNSTAB Expires 6m°nthsfr°"`issue date
MAM
2639. � Thomas F. Geller,Director 9'1L4h1prf0 MA'1 A
BuildingDivision � �� � ..
,w3 EIT
Tom Perry, CBO, Building Commissioner
200 Main Street, Hyannis,MA 02601 S P )
www.town.barnstab le.ma.us
Office: 508-862-4038 TOWN OF Spfii '�" L
EXPRESS PERMIT APPLICATION - R NTIAL ONLY
ESIDE �` 8 90-6230
Nor Valid without Red X-Press Imprint
Map/parcel Number Q
JeR
rtyAddress zZely C �e �rV e3�s identiall Value of Work "--
Minimuum fee of$35.00'for work under$6000.00
�I C j
Owner's Name&Address 0i
Contractor's Name I
N Telephone Number
7 90$
Home
Improvement Contractor License#(if applicable) �j S'
Con uction Supervisor's License#(if applicable) 0,5 V�
i
Workman's Compensation Insurance
Check one:
❑❑ I a sole proprietor
L"I the Homeowner
I have Worker's Compensation Insurance
Insurance Company Name >e `.�j/Yl. .S rI' / C'(�
Workman's Comp. Policy# /
Copy of Insurance Compliance Certificate must accompany each permit
Permit Request(check box)
❑ Re-roof(stripping old shingles). All construction debris will be taken to"
❑ Re-ro (not stripping. Going over existing layers of roof)
❑ -side t
Replacement Windows/doors/sliders. U-Value 0, S� #of doors
(maximum .44)#of windows
*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& Construction Supervisors License is
re
SIGNATURE:
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doC {
Revised 0701 10 d
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/OrganizationlIndividual): ��� D
Address:
City/State/Zip: f G�vt�•Tf -30339 Phone#:
Are you an employer? Check the appropriate b Type ofE
' quired):
1 ' I am a employer with , 4. I am a general contractor and I
�* have hired the sub-contractors 6• �Nction
employees(full and/or part-time). _�....
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7.
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 10.❑ Electrical repairs or additions
required.]
5. We are a corporation and its p
3.❑ I am a homeowner doing all work officers have exercised their 11.E Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL, 12.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site
information. ,te�re t
Insurance Company Name: 5t c �o `
Policy#or Self-ins.Lie. it: Q (0 t 4P 3 Expiration Date: ` I
P
Job Site Address: ZZeN City/State/Zip: 10
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,lb s and penalties o perjury that the information provided above is true and correct
/' ,� Date: 7
Signature:
Phone
Official use only. Do not write in this area,to be completed by city or town ofciaL
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#•
I
I
flffce of Consumer Affairs& smess Recruladw
; `==HOME IMPROVEMENT CONTRACTOR
J 1
`S Registration .A26893 Tyre:
Expiration::-81312012 Supplement C
The Home Depot:.;At-Home=Services "'"°�"�""" "
DARREN DEMERS i
2690 CUMBERI.AND PARKIIIIAY S e-W -- -
r .:._
AL�AN�`A, GA 30339 Undersecretary
i
License or registration valid for individul use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 5170
;and Boston,NIA 02116
I
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r
I
Not valid without signature
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lam. its« ib fk.Saki
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s .�- „.,.: iP� •nee a `�
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n HIOME t O C,09TRACTOR Type,
Expiraflom D
BA
16 H06VER RD
WEST fA€ MOUTH,. . , 9 axes �
Sep 18 11 07:33p Robert Higgins 508-444-8882 PA '
��. HO-ME IIV7PROVEMENT CONTRACT
PLEASE READ THIS Y/t
Sold,Furnished and Installed bv:
L1��1� THD At-Home Services,Inc.
Date:
Branch dame: Boston dlbla The Home Depot At-Home Services
345A Greenwood Street,Unit?.Worcester,1,4A 01607
Branch Number:3I To Free(800)657-5192. Fax(508)'56-9823
Federal ID#75-2698460;ME Lic#C 02439;RI Cont.Lic#16427
A CT Lic#565522; Home IrnprL e =Conaactor Reg.If 126893
C7,>
Installation Address: City State Z+p
Purchaser is):
York Phone: Home Phone: Cell Phone:
c�
Home Address: State zip
(If different from Installation Address) City
E-mail Address(to receive project communications and Home Depot updates):
❑I DO NOT wish to receive any marketing entails from The Home Depot
Project Information: Undersigned("Customer'),the owners of the property located at the above installation address:agrees to buy.
and THD At-Home Services,Inc.("The Home Depot' agrees to furnish,deliver and arrange for the installation("Installation")of
all materials described on the below and on the referenced Spec Sheet(s),all of which are incorporated into this Contract by this
ement and Payment Summary attached hereto and any Change Orders(collectively,
reference,along with any applicable State Suppl
"Contract"):
-)ob#: tuner lure-0 Products: Spec Sheet(s)#: Project Amount
❑Roofing ❑Siding 'indows ❑Insulation $ ( o
❑Gutters/Covers ❑Entry Doors ❑ 7 v
Roofing Siding ❑Windows ❑Insulation $
❑Gutters/Cover, ❑Entry Doors ❑
❑Roofing ❑Siding Rindows Insulation $
❑Gutters I Covers ❑Entry Doors❑
❑Roofing ❑Siding ❑Windows ❑Insulation
❑Gutters/Coves ❑Entry Doors ❑
hPinimum 25%Deposit of Cantrrd Amount due upon execution of this contract. Total Contract Amount $ „/ {
Cvlaine Purchasers may not deposit more than one-third of the Contract Amount T
Customer agrees that.immediately upon completion of the work for each Product, Customer will execute a Completion Certiflcate
(one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Horne Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at
its discretion,if The Horne Depot or its authorized senrice provider determines that it cannot perform its obligations due to a structural
such as mold,asbestos or lead pain '!
t,other safety concerns,pricing errors orbecause
problem with the home,environmental hazards
work required to complete the job was not included in the Contract. 1
Payment Summary: The Payment Summary #r 3_���` included as part of this Contract, sets forth the total
deposit and final payments by Product(as applicable).
Contract amount and payments required for the
NOTICE TO CUSTOMER
You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign[a Completion Certificate(note:
there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on thatProduct
is complete.
In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses
and services provided by'The Home Depot or Autborized Service Proc]ider through the date of termination.plus any other
amounts set forth in this Agreement or Allowed under applicable law. THE HOME DEPOT MAY WTTHHOLD A_NIOUNTS
T PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
OWED TO THE HOME DEPOT FROM THE DEPOSI
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceutanee and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
a�td The Home Depot with iegard to the Products and Installation services
cannot and supbe ersedes
all prior
r discussion,
lion,pt by and awriting sig signed
oral or written,relating to said Products and Installation.This Agree
by Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,understands.voluntarily accepts the
terms of and has received a copy of this Agreement.
Acce�i efl�' j
Submitt b 1/I
/ x s.
Date Sale Consultant's Signatu �� D^7ate ? '.
tg a r �f 6 �1�
X Telephone No.
Customer's Signature Date Sales Consultant License No.
ias spplicablel
CANCELLATION: CUSTOMER MAY CANCEL THIS
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
T)AY AT TER SIGNING THIS AGREEMENT. THE
STATE . SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS I
SPECIFICALLY PRESCRIBED BY LAW 1T
CUSTONIER'S STATE.
NOTICE:ADDITIONAL TERMS AND CONDMONS ARE STATED ON THE REVERSE SIDE AND ARE PART'OF THIS CONTRACT
,
. 1'he Commonweaith of Massachusetts
Department of industrial Accidents',
l q � Office of Investigations
600 Washington Street
13r Boston, MA 02111
`y www.mass.gov/dia
f
Workers' Compensation Insurance Affidavit: Builders/Contractors/Ei-ecti-icians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): OV S 1 _
Address: )
Ci ty/State/Zip:lN /'ll��U � Phone #: 0�•1b V�T
Are you an employer. heck the ap opriate box: 'Type of project(required):
1.❑ I a employer with 4. 0 I am a general contractor and I
mployees(full and/or part-time).* have hired the sub-contractors 6. :❑N construction
a. listed n the attached sheet. 7. emodelin
or partner-
ship
Its o g
2. I am a sole proprietor
These sub-contractors have
and have no employees _ 8. .❑ Demolition
workingfor me in an capacity. employees and have workers!
Y p tY• 9. � Building addition
[No workers comp. insurance
comp. insurance.
required.] 5. Q We are a corporation and its 10.[J 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' 13.0 Other
comp. insurance.required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policyinformation.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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 insuran e for my employees. Below is the policy and job site
information.
Insurance an Comp Y Name: (Ale—S dk
Policy# or Self-ins.Lic. #: Expiration Date:
Job Site Address: 91
r Z.z e1v /0D City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policynumber 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains andpenalties of perjury that the information,provided above is true and correct.
Si nature: CJ4Date:
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#:
Information and Instructions
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, al or written."
An employer is define s "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engage 'n a joint enterprise, and including the legal representatives of a deceas d employer, or the
receiver or trusteeof an in 'vidual, partnership, association or other legal entity, employing e loyees. However the
owner of a dwelling house ha 'ng not more than three apartments and who resides therein, the occupant of the
dwelling house of another who ploys persons fo do mainfenance, construction or repai ork on such dwelling house
or on the grounds or building app enant thereto shall not because of such ernployme )e deemed to be an employer."
V, _.
MGL chapter 152,r§25C(6)..also.state hat"every state or local,lieen`sing agency all withhold theIiisuance or
renewal of a license or permit to oper e a business or to construct buildings the commoriivealthlor any
applicant who has not produced accept le evidence of compliance with th insurance coverage required."
Additionally,MGL chapter 152, §25C(7)st es "Neither the commonwealth r any of its political subdivisions shall
enter into any contract for the performance o ublic work until acceptable e rdence of compliance with the insurance
requirements of this chapter have been present to the contracting authori
Applicants
Please fill out the workers' compensation affidavit c mpletely,by the ing the boxes that apply to your situation and, if
necessary; supply sub-contractors)name(s), address( )and phone mber(s) along with their certificate(s)of
insurance. Limited Liability Companies (LLC) or Limi d Liability artnerships (LLP)with no employees other than the
members or partners, are not required to carry workers' mpensat' n insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affrd it ma be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also b sur to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the pe or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regardin the law or if you are required to obtain a workers'
compensation policy, please call the Department at the numb r 'sted below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed egibly. :T\na
ent�has pr"ovided a space at the bottom
of the affidavit for you to fill out in the event the Offic of Investig to contact you regarding the applicant.
Please be sure to fill in the permit/license number wh' h will be userence number. In addition, an applicant
that must submit multiple.permit/license application in any given only submif one affdavit indicating current
policy information(if necessary)and under"Job S' e Address"theould write"all locations in (city or
town)."A.copy of the affidavit that has been offc' lly stamped or th city or town may be provided to the
applicant as proof that a valid'affidavit is on file r future permits s. A ew affidavit must be filled out each
year. Where a home owner or citizen is obtaini a license or permit not related to�ny business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) aid person is NOT required to complete this affidavit.
The Office of Investigations would like to th k 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 1-877-MASSAFE
Revised 4-24-07 Fax# 617-727-7749
www.mass.gov/dia
of HE ram,
Town of Barnstable, *Permit# ;
I. Expires 6 nront6s roar issue date
Regurafory Services Fee y�,
BARNSTABLE
y' Muss. Thomas F.Geiler,DirectorRE
TED P't
5►S PERART
Building Division
Perry; CBO, Building Commissioner
MAR 1 � 2010 200 Main'Street, Hyannis, MA 02601
www.town.barnstabie.ma,us ,
Office: 5TAPONP-6 BARNSTABLE Fax: sos-79o-6230
9XPRESS PERMIT APPLICATION -' RESIDENTIAL 4NLY
Not Valyd without Red X-Press Imprint
Map/parcel Number
Property,4ddress Mf7,7-CvV iop'lAl C _ :try B
residential Value of Wort. 6' Minimum fee of$25.00 for work under$6000,00
O%vner's Name& Address f�J V U
i
Contractor's Name �. c 1^( (�` �(C,11 Tele' one Number_ 5,d�'/
r
1 Ionic Improvement Contractor License#(if applicable) .b +
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
El 1 a a sole ro rietor c
p p -..
0
1/"Clrn the Homeowner`
have Worker's Compensation'Insurance
Insurance Company Name J
Workman's Comp. Policy
Copy of Insurance Cotapliance Certificate must.be on file.
Permit Request(check box)
❑ Re-roof(stripping old shingles)" Ail construction debris will betaken to
Re-roof(not stripping." Going over 'Y existing layers of roof)
❑ Re side
CC!
Replacement indowhdoors/sliders.U-Value �r 3.J (maximum .44)
*•Where required: Issuance of this permit does not compliance with otheir 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.
vn
SIG ATUR
Ks, I
i�`1�THI.AStiI'C)RMSlbuilding perniit fomulEXPRESS.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
W Office of Investigations
d 600 Washington Street
Boston, MA 02111
6 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicaat Information Please Print Le ibl
r
Name (Business/Organization/Individual): 1h
Address: e 1✓p `
City/State/Zip: � 7 Phone-#: �® �
_
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I a employer with 4• ❑ I am a general contractor and I 6 ❑New construction
mployees(full and/or part-time).* have hired the sub-contractors //
2. m a sole proprietor or partner- listed on the attached sheet. 7. [ 'Remodeling
ship and have no employees These sub-contractors have g. 0 Demolition
working for me in any capacity. employees and have workers' 9 Building addition
[No workers' comp.insurance comp. insurance.
5. We are a corporation and its 10.0 required.] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 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
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.
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 providin workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: II Jam
Policy#or Self-ins. Lic. #: �O d 9 d / Expiration Date: a"
Job Site Address: xfz_7� LVV City/State/Zip: ;J�AtAll'�AA, v
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
Investi ations of the DIA for insurance coveraLye verification.
Ida hereb -c er th ains a p nalties of perjury that the information provided above is true and correct.
Date:
Si attire: p
Phone#: d�d� (�
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#:
Feb'28 10 06:57p Robert Higgins 508-444-8882 p.1 ,
HOME I'MPRO V CMENT CONTRACT
PLEASE READ THIS
Branch Nam'. Boston
Sold,Furnished and Installed by:
Date: THD At-Home Services,Inc.
dfb/a The Home Depot At-Home Services
345A Greenwood.Street,Unit 2,Worcester,MA 01607
Branch Number:31 Toll Free(800)657-5182; Fax(508)756-8823
Federal ID#75-2698460,ME Lic#C 02439•RI
Cont.
.Lic#164_7
CT Lie it 565i22;NIA Hontc Improvenienl.Contractor Reg.f 126893
Installation Address: ,o< _*&,F1✓�I-s /��f���-<
City' State Zip
Purchaser(s): Work Phone: a Home Phone: Cell Phone: 5
� - z C..14 [ ]- G 3D
Home Address:
(If different from Installation Address) City,,,' State Zip
E-mail Address(to receive project communications and Home Depot updates):
❑]DO NOT wish to receive any marketing emails from The Home Depot
Protect Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, f
and"1'HD At-Home Services,Inc. (�Phe Home Depot")_agrees to furnish,deliver and arrange for the installation("Installation")of
all materials described on the below and on the referenced Spec Sheet(s), all of which are incorporated into this Contract by this
reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders,(collectively,. 't
'Contract"):
Job#: P"r,m r4rr,.o«t •4
Products: r Sec Sheet(s)#: Project Amount
❑Roofing ❑Siding •Vindows EJ Insulation
❑Gutters/Cover;❑Entry Doors ❑ /L/1 "
77 c/ r Gam- /1
❑Roofing ❑Siding ❑Wmdow•s ❑lnsulation t.
❑Gutters/Covers nt'E D $
t� 1 oors
❑Roofing Siding ❑Windows ❑lnsulau.n, .
r
❑Gutters 1 Covets ❑Bntr Doors❑ .
❑Roofing ❑SidingEl Windows ❑Insulation
❑GUiterS%Cover ❑Catry Doors ❑, -
Nfinirnum 25%Deposit of Contract Arnount due upon ezecutiop of this contract.'
Ivlaute Purchasers may not deposit more than one-third of the Contract Amount. Total Contract Amount $ Q"
Customer agrees that, immediately upon completion of.(lie work'for each Product, Customer will execute a Completion Certificate
(one for each Product as defined by an individual.Spec.Sheet) and pay any balancedue. As app]icable, each Customer under this �
Contract agrees to be jointly and severally obligated and liable hereunder. j
The Home Depot reserves the right to issue a Change Order or terminate this Contractor any individual Product(s)"included herein,at
its discretion,if The Home Depot or its authorized service provider detet•mines'that it cannot perform its obligations due to a structural
problem with the home,environmental hazards such as mold,asbestos or lead paint;other safety concerns,pricing errors or because "
work required to complete the job was not included in the Contract.
.Payment Summary: The payment Summary # 7'1 included as part of This Contract, sets firth the total
Contract amount and payments required for the deposits and final payments by.Product(as applicable).
NOTICE TO CUSTOMER 4 ^
You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note:.;_
there is one Completion Certificate for each listed Product as defined by individual Spec.Sheets)before work on that Product
is complete.
i
In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses, i
and services provided by The Honte•Depot or Authorized Service Provider through the date of termination, plus any other
anwunts set forth in this Agreement or alloi,4ed under applicable law. THE HOME'DEPOT MAY WITHHOLD AMOUNTS '
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING T14E HOME DEPOT'S OTHERREMEDIES FORRECOVERY OF SUCH A-MOUNTS.
Acceptance and Authorization: Customer agrees and tindersiands that this"Agrcctnent is the entire agreement'between Customer
anc The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,either {
oral or written, relating to said Products and Installation.This Agreement cannot be assigned or amended except by a writing signed
by.Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the
teens of and has received a copy of this Agreement.° #
.) "
4ccepterL�Kc �> -� Submitt y:.
4110melo y�� %ee. Date Sal—C
s Co sultanttt�tatutik
X Telephone No. .,.
Customer's Signature Date
Sales Consultant License No.
CANCELLATION; CUSTONIER VIAV CANCEL THIS -(as applicable)
AGREEMENT WITHOUT PENALTY OR OBLIGATION i
BY D.ELIVERINC WRITTEN NOTICE PO THE .HOME �.
DEPOT BY MIDNIGHT ON.THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE �.
STATE. , "SUPPLEMENT- ATTACHED* .FLGRETO -
CONTAINS A FORA TO USE IF ; ONE IS
SPECIFICALLY PRESCRIBED BY LAW 1N '
CUSTOMER'S STATE.
NOTICE:'ADU17•IOT-ALTERMS AND comn'rIom ARE STATED ON TILL REVERSE SIDE AND'ARE PART OU THIS CONTRACT
7-15-09 C-SC
rp p
WINDOW SPECIFICATION SHEET - Spec,Sheet#: f
�.•(7 f ` L � � Sheet: � o / p^�
Customer. . Job#:_�� Consultant: 'f t G-'t �- � Date:
New Window .
Existing Window _ Hinge Locations
- Measurements Grids- Product Options Labor From outside,
Options
_ • - — Left to Right
.. Location - - Bays.Bows,
Color Rough Opening of bars #of bars Csmnis,1 Pnl,
m useL,RorS
(9 Glass Mlsc Items
«i Hardware Code
e 3 e For doors use
`0 4 _. c o c o c Screens
W :. style' Wraps ,Q �`o, v rn o - .� m- u ,,°y Mull �•S"=stationary or
., r. ._ •S - -,. B C c L "V=operating
~ Room Floor Code /N Style Code Series Code - w _ - 5 u° -a y _ �
311C� t�t� ems , 2 ,S c;
Ake-
12-- - - - -
13T
> SPECIAL.CONSIDERATIONS
Wrap color - - - "
A In Casing Type - -
n1r� kt.
A r _ ..
Bay or Bow' indow:
Seatboart Materi3l:(v}nyl only Minh or Oak} - -
Bay Projection Angleloo a or d5°) _ - -
Bay Flanker Type(OH,SH or CSmnl) -
Top or window to sofflt(Inehas)If lied to soffit,color of soffit material -
I have reviewed and agree with all the job specifications above and the
1 Construct Roof(Yec or No)' - -
- r Sdeci I Toms and Conditions en u1e ack of the yellow(Customer)copy.
Garden Window:
-
Saatboard Materia l:(vinyl onlyWhl[e Pionite,Birch or Oats)
Wall Thickness, C sto rSignature -
G-•
J Additional Shelf Ycc or No). -
- - I re i�nV>w' 1'1 nuw rilpl a,Wti mntr .sting abr. 1
vial+Io The Howflepw `-Ah -CUA—K ➢ink•$9IeSCM90.1,N _ 7NDIfiR
The Commonwealth of Massachusetts
l Department of Industrial Accidents
Office of Investigations
600 -ton Street
ashin to
Boston,MA 02111
irisr/dia
www.n .go
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organizatiot>/ltidividual): 1!"1M 491 t _-'11�
Address: �
City/State/Zip: l � .. 'fT Phone#:
Are you an employer?Check th propriate b Type of liroject(required):
1. am a employer with
4.. I am a general contractor and I" 6 New construction
employees(full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. remodeling .
2.❑ I am a sole proprietor or partner-
ship and have no employees employees and have workers' 8. ❑Demolition
" These sub-contractors have working for me in any capacity. 9. ❑ Building addition
o wor ers'com insurance comp. insurance.'-
required.]
p 5. We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs of additions
myself. {No workers' comp. right of exemption per MGL 12.❑ Root repairs,
insurance required.]1 c. 152, ��'1(4);and we have no
employees. [No workers' 13.❑Other
comp.insurance required.]
*Any applicant that checks box 91 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.#: (T'a J dL - Expiration Date:
Job Site Address:' I/ `L✓d' City/State/Zip: e
Attach a copy of the workers' compensation olicy 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
tine 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 tine
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 penaltie rjury that the information provided above
`issttrue 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#:
•
1
F
Board of Building Regulations and Standards
3 � HOME IMPROVEMENT CONTRACTOR. i
Registration: 126893
Expiration: &&2010
Type: Supplement Card
The Home Depot At-Horne Service
DARREN DEMERS
3200 COBB GALLERJA PKWY#20
ATLANTA. GA 30339 _ -
Administrator � t
1
- q
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 Rtn 1301
Boston,N13.02108
X
Not valid>rritl;out sdgnature
i
i
1 {.
• I
r ,
f
Office Of Consumer Affairs and u.siness Regulation
10 Park Plaza -'.Suite 5174
Boston., I4a.ssachusetts 02116
Horne hmprovement Co:.tr-actor.Registration _
Registration, 149128. . - -
Type: Individual
'
ation: 11 Tr# 2902"
` � • Expir 11/28!20
TIMOTHY HANSCOM
- TIMOTHY—Fi-ANSC
4 CIRCLE DR.
WAREHAM MA 02571
Updace A ddress and return card.Mark reason for chax8c. "
v
Address ; fienata¢ i✓
Ad'
ik Office of('0nsumer:trrairs&TiusiRew:iRegulati0a -
,�m, tce�nse of registration valid for indivAd'ul use on -
�:••� HOME IMPROVEbrIEWT C before the expiration date If found retut'o to:
QUIM.TOR P ems., -Y
Registration; 14912A Office of Consumer Affairs and lgusine s R.egu)atroo
`= Expirstierl:-,.,!(1,%28/2011 10 Park Plaza-Suite 5f70
Tr# 2902a4
_..__k3ustoa;NIA 0.2116
Tit-'OTriY HANS60
IMOTuv
H,gNSGO -
4 Ci2 -.
WARE ipm.MA
Clndersecretar� "" - "'�`
Not d with iiglobture — -
,"�I•,��achile,•tt. ..
a aejaat'tm(At of Public C;I)'ct�
$o:ry'f of Builtlin;; Rcluladons aril �t:lnd,trt}_
' Construction Supervisor Speci,;Iity License
Ocert.se: C5 St. 99162
R.esrrlstea to: WS
TIMOTHY HANSON
4.CIRCLE.DRIVE
�NAREHAM, MA 02571
Tr=': 99162
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