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0018 NORTH WEST LANE
lcp O ' IP a. t t , � x i N , r , y i 4 H C. ., ,. .. _ •� rr._ � fry � `i. ,.0 � V ❑ � it N ,. { } - :.i nt� l� j 4 , y , a r , r a •.r. - _ w i s r IRE Application number.A.I c7.:'.. Date Issued....5:�-5 0................. eAxNSTABi:B. ..,. nsAss. - moo sa3� AUG p 8 h WIN Building Inspectors Initials. ..... L d Map/Parcel........ .......°S D . .. ...................... 8AH f/ .... TOVVN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATIIERIZATION PROPERTY MORMATION Address of Project: / rV1 e NUMBER STREET VILLAGE Owner's Name: t*'1idaa / ("ar/c, Phone Number 7 7�( Alf l Z Email Address: e cnff,/.Com Cell Phone Number Project cost$ Z t Z, Z 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: See ma k fa�i rCc Date: TYPE OF WORK ❑ Siding IZWindows ( change)no header e)# 3 ❑ Insulation/Weatherization ❑ Doors (no header change)# Commercial Doors require an inspector Is review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to w a-S-f e-=�Q�e �,`='_C�J�,r„o ,fiL, MA CONTRACTOR'S INFORMATION Contractor's name Ate,fte,/ �i,✓' P — o�e l US Home Improvement Contractors Registration(if applicable)# �/Z-7 8 S (attach copy) Construction Supervisor's License# _I00—`j,/6,_ (attach copy) Email of Contractor Swe S�� M a • C c3--- Phone number 4/o/- 7/ - 6 3'�9 ALL PROPERTIES THAT HAVE STRUCTURE OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS/IV A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. a z APPLICATION NUMBER............................................................ *For Tents Only* 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/C®AL/PELLET STOVES x Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles:front back left side right side HOMEOWNER'S E 9Y NER'S LICENSE EXEN Y H JIO II� 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 CIVVBR 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 /APPLICANT9S SIGNATURE Signature Date All permit applicado are subject to a building official's approval prior to issuance. Home Improvement;Agreement: Pagel Home Depot License#'s - For the most current listing www'.Hor-hedei)ot.com/LicenseNumbers MA: 107774, 112785 { Janice Campbell Salesperson Name: Registration No. (if applicable): Home Depot U.S.A., Inc. ("Home Depot") or Service Provider named below will furnish, install and/. or service the equipment listed below at the price, terms and conditions as outlined on this form: Carlon Michael New England South 1-MF4E11F Customer Last Name Customer First Name Store#/ Branch Name Customer Lead/ PO# 18 North West Lane I Centerville MA 02632 Customer Address City State Zip (774) 487-1121 mickgcarlon@gmail.com Home Phone# Work Phone# Cell Phone# Customer Email Address NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY, OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 908 Boston Turnpike Unit 1 Shrewsbury IMA 01545 Address City.. State Zip Or Email' customercancellationnortheast@homedepot.com Service Provider Email Address BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED.BY LAW IN YOUR STATE. YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN•GIVEN ORAL AND WRITTEN NOTICE 0 YOUR RIGH TO C Acknowledged by: 07/18/2019 Customer's Signature Date Contract Price and Payment Schedule : Payment of the Contract Price is due upon signing unless'a !n: different payment schedule is required by law, specified below or in a payment addendum, �- Contract Price: $ 12132.00 Includes all applicabletaxes: Excludes finance charges.* Sales Tax: $ 10.00 (If applicable) , y r 4 e *Maximum deposit ONLY applicable in MD, MA, ME(33% , NJ, W1(99%) pep. 25.0 % Deposit Amount $ 533 Remaining Balance $ 11599.00 The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care: 1-800-466-3337 460FI HDE Customer Agreement(24 Jul.18) v 0.1.8 Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructipp rvigor Speciaity CSSL-10€54-6 �r : OS118/2�20 ERICSSON TORRES P.O.BaXT3 � t SOUTH YARMTI . a� t' 1:UL aq- Commissioner VA e Oftici�otonsumer utato 24 IMPROVERRCONTRAC�O 1 , 3 rcERa1CSSONH. Vit t - •r'�,«e°'wy?� ,ux+,. _ g,��.' # -»,. y `c, ', - icy 44 . � r z ��..... I The CGMMOMwar&4mamwhwetfs Office Oorpedgaa0m. 600 WashfiWon&eet Mmmasmg-OpId a Wnrlmm' Ca mPensagm Li=mcp-Affidavit REM&7jcnnh7chwsxlec u. n'�*=*_.._�ers Anifigmt Iuf rmatiEm Please print • ��� �!'I,CSS�t1 lorreS Ad&e= tom.O . aC26,5`7,3 Cit era h I�1A 6zw Ph 50 -4bz-69Y7. tote you an employer?Check the'appragxiate ba= Type of project (red)= L❑ Iama employerwffi 4_ ❑I ant a general conhsctUCandI .10yew(fall andlor par-lime).* Irani Imed8ie sub coakraof 6_ El New °U' 2. I am a sole prgPdelatr orgartnw- Usted•onthe altm� sleet. 7- ❑Ran derwg and Have no employees Thesestab-ca radars has*a $ ❑Demaliiiflg wading far me m2ay capamty employees andh me xzo€kess' 9_ S addition[NO wud=re Camp-fim==e comp.�.,'a•�# ❑ r,egnired 1 5. We are a span mn.and i£a 1'L❑Elul repairs oradrfdionx 3.❑ lama bameowner doing ail vFmk or=m have•tercisad dmir 1L❑Plnmbsagrepaim or adclidams ' myself[No wad'oomp_ a�ofex=Pfiflaper MQ. 1-7 El�]Y c.M,§1(4�andwe lama} empleyem(NO VQA=e 1311other comp_;.,mnance nxpireq °AnyagpEcmtdmtcb RMnst also ffias theseriioandoar gfieauxmke1ecmmpenmjfio.peS_7kE=w6e3- T oocr �sahaa3citisttf�da�*ifi gStegssetiaings]E�asi�s�3tlaeabmwmid¢coanscrosamatsab�tanewaffidae�t sar5 rCa as dazf�etiC flat box==lift fi=xAmfima2 sheet shauzEag&enameof the sdj_a�snd t=W}lefbei araotfhnse eatrtiesha� eom3eYees.TtthesnB ra d�eshavee�gIa ffieY�srFmuidetllkew—mp.palky-mbet aw an evep trr fTiat is praur'riiirg n�rkers'ca�eresrr[iari i3rsrircrm;s�vr empta} es.. �dontr is fI[e par&c y asui jab a1� Fr�farma�inrt - I eCompanyNanie: 'PbRcy 4-t'cr Self Iic;ff: nDafe Job Site Addre= CidplSb1terTxr At€acls a cflPY afthe wo-rksrs°caaapensa$aagoIicg decIaralion page.(sho ywg the policy saber and•,ezgu atioa fie). Fatima to secure coverage as requuedunder Seaton 2 5A o€MGL c.15 cm lead to tiie imposifun of rdminal peTmlfies of a fine up to$L50D QQ anVor one-yearsmpfssoament,es well as d-O peauNes.&flee farm of a STOP WORK 4BDERand a Hm of up to$25,G (i a&y a,-aiasE the violafnt Be advised ffiat a copy oftlzk zhkmerd=Wbe faswarded to the Office of Invvestigations offEn D-TA for m��canmge woes. Ida tter6p r ndw tlts pmbw dies r fp dWy f ldtf lS i Zforma tkwprmz�dahmw h bm mid cm7act Sigaatutu Data- PhMMA- fr796Z-6yyv aid nw a* Do wt wrAr in M&area;to he cmapletad by Qfp arlptvn q&&I City or Town: PernifffficensciE Bma mg-kaffiardy(cur.Ie one): L Board of Health. 17 Ruffi mg Dep� 3.CApfrawn Clrrk 4 nk,& al lmspeefinr 3' Impector 6.C her: . €► act PFerson: Phow . 6 I� ' The Commonwealth of Massachusetts x Department of.IndustrialAeeidents 1 Congress Street,Suite 100 Boston,MA 02114 2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): H tZ Q� Address: 01 0 S 2 Slan T,rn p i K City/State/Zip: S w/'Y. MA 01 TLA S Phone#: -7 7 L4 _.)—-7 5 - Z 1 5 5 Are you-an employer?Check the appropriate box: Type of project(required): 1.Q i am a employerwitht employees(full and/or part-time).* 7. El New Construction 2.a I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required_] 3.®I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition 4.r-1 I am a homeowner and will be hiring contactors to conduct all work on my property. I will10 Q Building addition ensure that all contactors either have workers'compensation insurance or ace sole 1 Ln Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.ElI am a general contactor and I have hired the sub-contactors listed on the attached sheet 13.❑Roof repairs These sub-contactors have employees and have workers'comp.insurance 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other t,J/rl L GB+•✓ 152,§1(4),and we have no employees.[No workers'comp.insurance required.] rP�l9CQ�r Pit *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 ail 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-contactors and state whether or notthose entities have employees. If the sub-contactors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Belmv is thepolicy and job site information. _ Insurance Company Name:. Akb�lal (IMI.0,1 ��tle 1�90ril/1C_s__(�i,,�a�✓ Policy#or Self-ins.Lie.#: )(1,f(' S.&5 5 Expiration Date: Job Site Address: 16 rl- l/a S-/ 1Ri7t: City/State/Zip: 6'11 Attach a copy of the workers'compensation:policy declaration page(showing the policy number and exp ation date). Failure to secure coverage as required under MGL o.152,§25A is a criminal violation punishable by a fine . to$1,500.00 and/or one-year imprisonm as ell as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. py this statement may be.forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un an enalties o information provided above is true and correct Si mature: Date: k Phone#: Official use only. Do not write in this area,to be completed by city or tmpn 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#: ll Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement_Contractor Registration — _ - Type:_ Supplement Card - Registration: 112785 HOME DEPOT USA INC : ._._.._ 2 2021 -,,-� :�---� Expiration: 04/2 /. P O BOX 105451 �- =l ;' P ATTN: LICENSE MGMT TEAM ATLANTA, GA 30348 - = - Update Address and Return Card. SCA 1 0 20M-05/17 - - Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE-:.,%Pplement Card before the expiration date. If found return to: Registrelion_ Expiration Office of Consumer Affairs and Business Regulation 04/22/2021 1000 Washin4on10 HOME DEPOT ) = Boston,MA ANDREW SWEET...=` 2455 PACES FERR'Y.if�£Cvtl HSC a(.�G i�zGhsok ATLANTA,GA 30339 - Undersecretary NoI nature • K DATE(MM/DDffYYY) ACo® CERTIFICATE OF LIABILITY INSURANCE 02/0612019 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 BY 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(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT , MARSH USA,INC.. NAME` TWO ALLIANCE CENTER WC. o ' FAX Not: 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA.GA 30326 ADDRESS: INSURER S AFFORDING COVERAGE NAIC p CN 10 1 642069-HomeD-GAW-19-20 _ INSURER A:Old Republic Insurance Co 24147 INSURED - INSURER B:New Hampshire Ins Co 23841 THE HOME DEPOT,INC. HOME DEPOT U.S.A..INC. INSURER C:HomeRisk Captive Insurance Company 2455 PACES FERRY ROAD BUILDING C-20 INSURER o ATLANTA.GA 30339 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-004353439-28 REVISION NUMBER: 21 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 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. INSR TypEOFINSURANCE 1ADDLjSUBR E POLICY EFF : POLICY EXP LIMITS LTR' POLICY NUMBER ! MM/DDIYYYY I MMIDDIYYYY i A X iCOMMERCIAL GENERAL LIABILITY MWZY314574 03/01/2019 0310112022 EACH OCCURRENCE 3 1.000,000 DAMAGE TO RENTED CLAIMS-MADE JI OCCUR 'PREMISES Ea occurrence 3 1.000,000 X I SIR:$1,000,000 MED EXP(Any one person) $ EXCLUDED PERSONALS ADV INJURY 3 - 1.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE ; 1 000,000 X POLICY J PRO 1.000.000 JECT J LOC PRODUCTS-COMPIOP AGG 5 OTHER: 3 A i AUTOMOBILE LIABILITY MWTB314573 - 03101/2019 103101/2022 'COMBINED SINGLE LIMIT 1.000.000 _ (Ea accident) X :ANY AUTO BODILY INJURY(Per person) $ OWNED ^SCHEDULE[) SELF INSURED AUTO PHY DMG AUTOS ONLY AUTOS BODILY INJURY(Par accident) S HIRED NON-OWNED PROPERTY DAMAGE 3 - _ AUTOS ONLY AUTOS ONLY Per accident . 3 i UMBRELLA LIAR _J OCCUR EACH OCCURRENCE i S EXCESS LIAR CLAIMS-MADE' - ;AGGREGATE - l 3 DED RETENTIONS S B i WORKERS COMPENSATION WC 012717099(AK,NH.NJ,VT) I I 03/0112020 X S PER TATUTE I ER H B AND EMPLOYERS'LIABILITY YIN WC 012717100 WI 03I01I2019 €0310112020 ANYPROPRIETOR/PARTNER/EXECUTIVE ( ) E.L.EACH ACCIDENT ".S S.000,OOO ''OFFICER/MEMBER EXCLUDED? N ;NIA: - (Mandatory in NH) E.L.DISEASE-EA EMPLOYEES 5,000,000 If yes,describe under Continued on Additional Page I 5.000,000 i DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT i S C i Excess Auto 297110011002019' 03101I2019 03/01/2020 Limit: 4.000.000 A ;Excess General Liability MWZX 314580 03/01/2019 03/01/2022 Limit: 8,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING C-20 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee ,1Kauaer•: ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101642069 LOC#: Atlanta ACCOR L? ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY :NAMED INSURED MARSH USA,INC. THE HOME DEPOT.INC. HOME DEPOT U.S.A..INC. POLICY NUMBER 2455 PACES FERRY ROAD BUILDING C-20 ATLANTA.GA 30339 CARRIER - NAIC CODE EFFECTIVE DATE: - - ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Compensation Continued: Carrier.Indemnity Insurance Company at North America Policy Number.INLR C65890549(AL.AR,FL.ID.IA.KS.KY.LA,MS.MO,NE,NM.ND,OK,SC.SD.TN,WV.WY) Effective Date:0310112019 Expiration Date:03101/2020 (EL)Limit 55,000,000 Carrier:New Hampshire Insurance Company „ Policy Number:INC 012717098 (OC.OE,HLIN.MD.MN.MT.NY,RI) Effective Date:03101/2019 Expiration Date:03/01/2020 (EL)Limit:55.000.000 Carrier:ACE American Insurance Company Policy Number:'NCU C65890586(OS0 (AZ,CA,IL,NC.OR.YA,'NA) Effective Dale:03101/2019 Expiration Oats:03101/2020 (ELI Limit:34,000,000 SIR:31,000.000 SIR for the slates of AZ,CA,IL,NC.ORVA,WA Carrier:National Union Fire Insurance Company Policy Number:XWC 5565596(QSI)(CO.CT,GA,ME,MI,NV.OH,PA.UT) Effective Dale:031012019 Expiration Date:03101/2020 ' (EL)Limit:S4,000,000 31.000.000 SIR for the states of COMEAVAL OH,P.A.UT $750.000 SIR for the state of GA $350.000 SIR for the slate of CT Carrier:National Union Fire Insurance Company Policy Number:XWC 5565591(QSI)(MA) Effective Date:03101/2019 Expiration Dale:03/0112020 (EL)Limil:$4.500.000 s SIR:3500.000 TX Employers XS Indemnity: Carrier:lllinios'Union Insurance Company Policy Number.TNS C65221019 JX) Effective Data:031012019 Expiration Date:03101/2020 " (EL)Limit:310,000,000 �. SIR:31.000,000 ACORD 101 (2008/01)- ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Town of Barnstable *Permit#,2667 Xa Expires 6 m onths from issue date IT Regulatory Services Fee 0?- 00 ® Thomas F.Geiler,Director Co APR 0 4 2007 Building Division TOWS► OF BARNSTX%E Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA.02601 www.town.bamstable.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 y t4or 6 U),*—,S Property Address /C1 �e4 11 -f ❑'Residential Value of Work ®x Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 141 C Q r- Ce l� [/ova We Lli.tr Cr-,Te— i //e 0 o ?,6A Contractor's Name /�k I � 5'e, z r S Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner (v]'I have Worker's Compensation Insurance Insurance Company Name !1/e W rn 02 s A i r le fH 5 C©. Workman's Comp.Policy# 7a la O a Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value J V (maximum.44) "Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. r SIGNATURE: Q:Forms:expmtrg Revise061306 i i 1 The Commonwealth of Massachusetts ~ Department of Industrial Accidents Office of Investigations , 600 Washington Street a �- Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ApRlieant+tfor ma>>Io Plea ,._4..• t t bl Name (Business/Organization/Individual): Q Address: / Teo' 6 Ce, F 9 V Cit /State/Zi I Phone #: 9b 7- Are you an employer?Check the appropriate box: Type of project(required) 1.M I am a employer with_� 4. ❑ I am a general contractor and I 6. 0,Lyew-construchon - � 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 These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. ,' 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I LE] Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13:❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees..Below is the policy and job_ site. information. �. } Insurance Company Name: 04 .S J i'L RXN s - Co Policy#or Self--ins.Lic.#: -1 �'2 ®. Expiration Date: j D 77 Job Site Address: A01rI x (Ut s T 6e, t e City/State/Zip6elllta^d/f yl 4 19y 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 certi der the p ins nd penalties of perjury that the information provided above is true and correct. P _ / � - Si nature: /-^ Date: �' d Phone#: J l 10 Official use only. Do not write in this area, to be completed by city or town officiaL xt 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: ``v`' Phone#: Information and Instructions Massachusetts Gene 1 Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statu e,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,o I 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 in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an i ividual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house aving not more than three apartments and who resides therein,or the occupant of the dwelling house of another o employs persons to do maintenance,construction or repair work on such dwelling house - or on the grounds or building ppurtenant thereto shall not because of such employment be deemed to bean employer." MGL chapter 152, §25C(6)also tates that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit t operate a business or to construct buildings in the commonwealth for any applicant who has not produced ceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §2 (7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perfor nce of public work until acceptable.evidence of compliance with the insurance requirements of this chapter have been resented to the contracting authority." Applicants Please fill out the workers' compensation a davit co pletely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),a dress(e�)and phone number(s)along with their certificate(s)of rY pP Y insurance. Limited Liability Companies(LLC) r Li 'ted Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry w ker compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that t a fidavit may be submitted to the Department of Industrial Accidents_for confirmation of insurance coverage. so be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application fo he permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions arding the law or if you are required to obtain a workers' compensation policy,please call the Department at the mber 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 egibl The Department has provided a space at the bottom of the'affidavit for you to fill out in the event the Office e f Inve igations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which ill be , ed as a reference number. In addition,an applicant that must submit multiple permit/license applications in a y given ear,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Ad ess"the, plicant should write"all locations in (city or town)."A copy of the affidavit that has been officially sta ped or in I ked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future ermits or li enses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license permit no elated to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person i NOT requir d to complete this affidavit. The Office of Investigations would like to thank you in advan a for your coa eration 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 o assachuse s Department of Industr 1 Accidents Office of Investi tions 600 Washington eet Boston, MA 0211 Tel. # 617-727-4900 ext,406 or 1--8 -MASS E Fax# 617-727-7749 www.mass.gov/dia ,� <, <x,.. ;c.:.y..,..z� :xm y«� �a a � �f3�' =F` '"� '=z 'a"-. ���s ::a.,'5 *r";.�"�' £...: a'�a. '_'-•T�'�. CERTIFICATE NUMBER MAR: Hz � &R� F �� �CEITIF�CATEOFNINSURANCE ATL-001234410-01 PRODUCER THIS CERTIFICATE I$ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS MARSH USA,INC. NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE homedepot.certrequest@marsh.com POLICY.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE FAX(212)948-0902 AFFORDED BY THE POLICIES DESCRIBED HEREIN. _-. _ - 3475 PIEDMONT ROAD,SUITE 1200 ATLANTA,GA 30305 COMPANIES AFFORDING COVERAGE . ` COMPANY - 00492-THD-IPUSA-07-08 IPUSA. A STEADFAST INSURANCE COMPANY INSURED COMPANY HOME DEPOT USA,INC. B ZURICH AMERICAN INSURANCE COMPANY 2455 PACES FERRY ROAD NW BUILDING C-8 COMPANY ATLANTA,GA 30339 C AMERICAN HOME ASSURANCE COMPANY COMPANY D NEW HAMPSHIRE INS COMPANY COVERAGES f�"�'� s�� ;���Thls cert(fcate snipe{cedes aridrrepfaces any:preulous ykissyetl,c_ertlficae for file pollcy,penod ngted,�below s';;" t_2 ' THIS IS TO CERTIFY THAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,CONDITIONS AND EXCLUSIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO POLICY EFFECTIVE POLICY EXPIRATION LTR TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDIYY) DATE(MMIDDIYY) LIMITS A GENERAL LIABILITY IPR 3757 608-02 03/01/07 03/01/08 GENERAL AGGREGATE $ 4,000,000 X COMMERCIAL GENERAL LIABILITY 'LIMITS OF POLICY ARE EXCESS' PRODUCTS-COMP/OP AGG $ 4,000,000 'CLAIMS MADE occuR OF SIR:$1,000,000 PER OCC' PERSONAL&ADV INJURY $ 4,000,000 OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 4,000,000 FIRE DAMAGE(Any one fire) $ 1,000,000 MEDEXP(An oneperson) $ EXCLUDED B AUTOMOBILE LIABILITY BAP2938863-04 03/01/07 03/01/08 COMBINED SINGLE LIMIT $ 1,000,000 X ANY AUTO ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) X ELF-INSURED AUTO HYSICAL DAMAGE PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: ra,,s EACH ACCIDENT $ AGGREGATE $ A EXCESS LIABILITY IPR 3757 608-02 03/01/07 03/01/08 EACH OCCURRENCE $ 5,000,000 X UMBRELLA FORM AGGREGATE $ 5,000,000 OTHER THAN UMBRELLA FORM $ C WORKERS COMPENSATION AND 2921209(CA) 03/01/07 03/01/08 X_FT CRY LIM S ER EMPLOYERS'LIABILITY E 2921210(FL) 03/01/07 03/01/08 EL EACH ACCIDENT $ 1,000,000 F THE PROPRIETOR/ X INCL 2921211 (AZ,ID,MD,VA) 03/01/07 03/01/08 EL DISEASE-POLICY LIMIT $ 1,000,000 PARTNERS/EXECUTIVE 2921208 AOS D OFFICERS ARE: EXCL ( ) 03/01/07 03/01/08 EL DISEASE-EACH EMPLOYEE $ 1,000,000 C OTHER 2921213(OSI) 03/01/07 03/01/08 E WORKERS'COMPENSATION 2921212(KY,MO,NY,WI) 03/01/07 03/01/08 G TEXAS EMPLOYERS TNS-C44642086(TX) 03/01/07 03/01/08 EACH OCCURENCE 215,000,000 EXCESS LIABILITY SIR 2,000,000 DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESISPECIAL ITEMS CERTIFICATE,HOL-E. CANCELLATIQN 4 t „�r .,.:- ,_.. ,= z. _.'?S'y SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL -10.DAYS WRITTEN NOTICE TO THE FOR EVIDENCE ONLY CERTIFICATE HOLDER NAMED HEREIN,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE,ITS AGENTS OR REPRESENTATIVES,OR THE ISSUER OF THIS CERTIFICATE. MARSH USA INC. BY: Mary Radaszewskl �s �r MM1(3/02 VALID AS OF 02/28/07 ,. ,�i, r '* �.. s,., wa (MMfDD1YY) _02/28/07 PRooucER COMPANIES AFFORDING COVERAGE MARSH USA,INC. COMPANY homedepot.certreq uest@m arsh.com FAX(212)948-0902 E ILLINOIS NATIONAL INSURANCE COMPANY 3475 PIEDMONT ROAD,SUITE 1200 ATLANTA,GA 30305 COMPANY F NATIONAL UNION FIRE INS CO 10 04 92-TH D-I P U SA-0 7-08 I P U SA INSURED COMPANY HOME DEPOT USA,INC.2455 PACES FERRY ROAD NW G ILLINOIS UNION INSURANCE CO BUILDING C-8 ATLANTA,GA 30339 COMPANY H TEXT --`- � + w�.. .+`,-L.�- i•2�. &�..�.M c:"<.°.a�� ...N.wx".,��.r,�..,�°.wrr.�,` :'�,�..sa:a.-'��."�"az�aa�s.�.�.��`�,.�,� �`..s�;��r�w"��w,:z,x,,._�t`r.�'.'`...,a'�,r.'.'„�.:.� a�Yr kz._:�..�.s�.a'�.�.-,:.:41°�.�.,...k5 a ;°.'��u`...:..,'�k��'.�'zti.ice'. CERTI HOLDER FICATE � � j a., . ..',.a..,., t�. FOR EVIDENCE ONLY . MARSH USA INC.BY Mary Radaszewskl s � o ig 4a bra - � 2� f '� 3FIN .�,x � :;, .�'sn,,v�� sMo "' „ar< �,,. � ,rc .. I 063-A-033 40-4 s DH CM 6100 Renovations Nrxc Dodble Hunq - Vinyl . Ai:-gOn/l.-OW i E SC SS Na elF�stratlon No Grids' ® 1-000-746-6686 NFRC 2001 ENERGY PERFORMANCE RATINGS U-Factor(U.SA-P) Solar Heat Gain Coefficient 0 . 34 0 . 29 _ ADDITIONAL PERFORMANCE RATINGS Visible Transmittance 0 . 49 Mam �� rdpuwst mthese ratings co*nyi to oppllcable NMC proceduresfar detennlnfng Whole product performance.NI1lC ratings are determined for afbmd set of erwlronmenW conditions and a specfficproduct size.Consult manufacturer's literature for other product performance Information. www.nfrtorg E`�Eii'SCAN Unit qualifies for Energy Star Region(s): Northern, North Central, South Central, Southern r IND; REIN OOJGLASS SSJH-R30 i)P = 30 Test aiee: +44 x 60 order 4:3$3i18?3b3t]U01 40318 HS _:..... _.._._.. ; ✓� -�oanirr�zuseal�C o��/�aac��ivaelta ! S\— Board of Building Regulations and Standards 'License or registration valid for individul use only i HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registratrori: 26893 One Ashburton Place Rm 1301 Expiration 8/3/2008 Boston,Ma.02108 Supplement Card THE Home Depot�At� m Hoe Sery c DANIEL PELOQUIN ,'' 3200 COBB GALLERIAPKWY#20 Atlantic,GA 30339 Administrator Not valid without signature Proiect Information: UWe/You ("Purchaser"), the owners of the property located at the above installation address, offer to contract with Home Depot U.S.A., Inc. ("I-Igme Ipe t") to furnish, deliver and arrange for the installation of all materials as described on the attached Spec Sheet Ir 1 t, incorporated herein by reference and made a part hereof. Home Depot reserves the right to cancel this contract if, upon re-inspection of the job,Home Depot determines that it cannot perform its obligations due to a structural problem with the home,pricing errors or because work required to complete the job was not included in the Spec Sheet or Contract. DEPOSIT PAYMENT OPTIONS (Subject to fund verification and/or credit approval.) 1. Check,Cashiers Check or US Postal Service Money Order CONTRACT AMOUNT S I,J b (Made payable to The Home Depot). *LESS DEPOSIT S 2. Credit Card"and/or other payment options Circle One Below Visa MasterCard Discover American Express BALANCE DUE The Home Depot Home improvement Loan The Home Depot Credit Card ON COMPLETION $_--I I _ ' I I New Account l Existing Account (HiL&HDCC UV LY) *Minimum 25%of Contract Amount due upon Available Credit:$ (HIL&HDCC ONLY) execution of this contract. Acct#: M Exp.Dante:_ name as it appears on card: f I C� � �. {� a-tj .. Indicate Payment Method For *By VVour signature lowL7edit e agree to allow Home Depot to BALANCE DUE ON COMPLETION": char the above of n edrd for the deposit indicated. �� a toidcr's Si matu r f�� "May be subject to Credit Approval,Fund HIL or HDCC Authorization Codes Verification and/or Credit Card Authorization Deposit Final Payment Purchaser agrees that, immediately upon completion of the work, Purchaser will execute a Completion Certificate and pay any balance due. Purchaser also agrees to he jointly and severally obligated and liable hereunder. Entire Agreement: This agreement and its attachments, including any financing agreement,contain the complete agreement. between the parties rties and can not be amended or modified unless in writing in a separate agreement signed by both parties. NOTICE TO PURCHASER Do not sign this contract before you read it. You are entitled to a completely filled-in copy of the contract at the time you sign. Keep it to protect your rights. Do not sign a Completion Certificate before this project is complete. Law prohibits home repair contractors from requesting or accepting a Completion Certificate signed by the owner prior to the actual completion of the work to be performed under the contract. You may cancel this transaction any time prior to midnight of the third business day after the date of this contract. See Notice of Cancellation for an explanation of this right. There will be a service charge equal to 10% of the contract amount if job is cancelled by Purchaser AFTER the third business day,but BEFORE materials are ordered.There will be a service charge equal to 25%of the contract amount if job is cancelled by Purchaser AFTER materials are ordered. BY MY/OUR SIGNATURE BELOW, IlWE AGREE TO BE BOUND BY THE TERMS OF THIS CONTRACT. I/WE ACKNOWLEDGE RECEIPT OF A COPY OF TI ItS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE OF CANCELLATION. BY MY/OUR SIGNATURE BELOW, t'Wf UNDERSTAND THAT THE AGREEMENT IS SUBJECT TO REVIEW OF MY/OUR CREDIT HISTORY AND I/WE AUTIIORI%E: HOME DEPOT TO VERIFY AND REVIEW MY/OUR CREDIT RECORD WITH AN IND 'PffDT CREDIT REPORTING AGENCY AND RELEASE THEM FROM ALL LIABILITY INCURRED FROM NA EOMISSIONS OR ERRORS. SUBMITTED BY: I Date: Sales Consoltan - y d C ACCEPTED BY,._, tit. Date: llomwt�ncr - Date: Homeowner NOTICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT 10-24-06 C-SC White-Branch File Yellow-Customer Pink-Sales Consultant S -4ot..IeW eRuea Town of Barnstable *Permit Expires 6 months from issue date Regulatory Services Fee X_PRESS PERMIT Thomas F.Geiler,Director PERMIT Building Division J,,0)/-7/df0VZ' OCT ® 3 2006 Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 TOW N OF BARNSTABLE 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 [ap/parcel Number 9 6 IT-0 N b Loeg+ roperty Address CIO Residential Value of Work I d-O"0b Minimum fee of$25.00 for work under$6000.00 a ° 1wner's Name&Address 4- j S A' OLam© .ontractor's Name Telephone Number 5_Z)1P_ ��' © �® [ome Improvement Contractor License#(if applicable) '�a�cfT�ir`�pervisor's�icerrs�#(�appiiealrlej ]Workman's Compensation Insurance Check one: ❑ I am a sole proprietor Ih❑ Lam the Homeowner ave Worker's Compensation Insurance j< lsurance Company Name vorkman's Comp.Policy#__ 'opy of Insurance Compliance Certificate must be on file. 'emut Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side VReplacement Windows/doors/sliders. U-Value 0 e 35— (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Prop5r4 Owner Letter of Permission. A e Home ove nt ontractors License is required. c y of lyz IGNATURE: 4a",� ):Forms:expmtrg .evise061306 uepanmenr of inausrriat ficciaenrs Office of Investigations 600 Washington Street Boston, MA 02111 www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers �pplicant Information Please Print Legibly 'v ame (Business/Organization/Individual): elt ,ddress: r5A9,40�. . - N h/ _'ity/State/Zip: 36 3 3�`l Phone :-e you an employer? Check_ the-appropriate box:. _ Type of project(required): YI am a employer with ! 4. El.I am a general contractor and I 6. El New construction employees (full and/or part-time).* have hired the sub-contractors El I am a sole proprietor or partner- listed on the attached sheet 1 7. ❑ Remodeling ship and have no employees :. "These.sub-contractors have 8-- Demolition - working for me in any capacity. workers' comp. insurance. 9. F� Building addition [No workers' comp. insurance.. . 5. ❑ We aiea corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions I am a homeowner doing all work - right of-exemption per MGL 11.❑ Plumbing repairs or additions myself o workers'. comp. c..152, 1(4 ,and we have no y [N P §:.- ) 12:❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.[t )ther lte� ;y applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: �@ ..)meowners who submit this affidavit indicating they are doing all work and then hire-outside contractors must submit anew affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy infoTrnation. m an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site Formation. urance Company Name: VfAjS dl t� icy#or Self-ins.Lic. #: 6 - Expiration Date: . / 0 `1 i Site Address: o!` � L--t TN� City/State/Zip: (/! • pad 3 _ .. :ach a copy of the workers' compensation policy declaration page:(showing the policy number and expiration date). lure to secure coverage as required under-Section 25A of MGL c.,1.52 can lead to the imposition of criminal penalties of a up to$1,500,.00.and/or one-year imprisoiuxlent- as well as civil penalties in the form of a STOP WORK ORDER and a fine ip to$250.00 a day against the violator. Be advised that a copy of this statement.maybe forwarded to the Office of estigations of the DIA for insurance coverage verification. 3 hereby certify and the pains and pen ' s of r ury that the information provided above is true and correct nature: ��U me#: 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#: S„. .,.___ t'� ;:� � ..m„•�e r.z� �,� ,...�:a ^;�,� .�C.., <�...,��� a"'�M_�.a;,.fi'� ATL-000915907-11 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS MARSH USA,INC. NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE ATTN:BRENDA BOOKER (404)995-2594 POLICY.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE MAYA MCCLURE(404)995-3206 OR AFFORDED BY THE POLICIES DESCRIBED HEREIN. TAM!ROUSE(4041995-3430 FAX(404)760-5663 COMPANIES AFFORDING COVERAGE I 3479 PIEDMONT ROAD, SUITE 1200 - - — A"'.LA N T A,GA 303'v'S CC^•I?..,,. 1CC 924PUS -G`IA-03/0 STE. ,FAST;N vRAI�iCE ?aPAN INSi;RED 1r ( CC-.MPANY -- -- ---� i II D AT-HOME S- VICES'INC. I " — I 1 ':^iSl;� r �'Y Zu. .AMtR..Cr'.i) I'i�i'SvC �JIJ1�'-tl1 C/;� �.T_!-!E HOti1E_D1YrOTAT rCNlc SERVICES,INC. I I .l-'.IJiJIZ✓C?OTI.•Jr. I�IC I .l.v.�..\I! -d PACES FERRY ROAD,-':l C PI=i'/.�711AINIPSF;;'_NS COMP I NY BUILDING C 8 ATLANTA,GA 30339 COMPANY D AMERICAN HOME ASSURANCE COMPANY .COVER 6,tSS Thlg;c.ertlfcate su,ersedes and,ceplacesany Previously issued certtf'eate forahe gilt enod;notedAbelow 3�z 'u' p.. Y P. .�. r..y n. .- THIS IS TO CERTIFY THAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,CONDITIONS AND EXCLUSIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MMIDDIYY) DATE(MMIDDIYY) A GENERAL LIABILITY IPR 3757 608-01, 03/01/06 03/01/07 GENERAL AGGREGATE $ 4,000,000 X COMMERCIAL GENERAL LIABILITY 'LIMITS OF POLICY.ARE EXCESS' PRODUCTS-COMP/OP AGG $ 4,000,000 CLAIMS MADE FJ OCCUR 'OF SIR:$1,000,000 PER OCC' PERSONAL&ADV INJURY $ 4,000,000 OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 4,000,000 FIRE DAMAGE(Any one fire) $ 1,000,000 MED EXP(Any one person) $ EXCLUDED B AUTOMOBILE LIABILITY BAP 2938863-03 AIDS 03/01/06 03/01/07 COMBINED SINGLE LIMIT $ 1,000,000 X ANY AUTO ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS . HIRED AUTOS BODILY INJURY XNON GINNED AUTOS (Per accident)9 $ ELF-INSURED AUTO PROPERTY DAMAGE $ H-YSICAL DAMAGE GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ STATG WORKERS COMPENSATION AND ( ) 03/01/06 03/01/07 X ORY LIMITS ER �•�"�p 6610998 AZ,ID,MD,VA EMPLOYERS'LIABILITY — C 6610995(AOS) 03/01/06 03/01/07 EL EACH ACCIDENT $ 1,000,000 G THE PROPRIETOR/ X INCL 6611326(OR) 03/01/06 03/01/07 EL DISEASE-POLICY LIMIT $ 1,000,000 P ERS/EXECUTNE 6610999 NY, 03/01/06 03/01/07 E OFFICERS ARE: EXCL ( 1N� EL DISEASE-EACH EMPLOYEE $ 1.000,000 OTHER WORKERS E COMPENSATION CONTINUED 6610997(FL) 03/01/06 03/01/07 D 16610996(CA) 03/01/06 03/01/07 DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESISPECIAL ITEMS C:ERTIFIC/47E HO l)'ER a ;: a>< s CANCEL ION g •.,d F..r.�"AG":r.'� ., .�:�.#.o.....s�r�.=.,r.- �+��. n{r,so ax..c..,+v.^•.,.,ms«.r r.r...:� .;,�F,„o..�`'m�.`ML .�''�:; a^..uw..:�-53m�".F.... :��-. -a.Y.s..: s�x$� n �2t: SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL An DAYS WRITTEN NOTICE TO THE FOR INSURANCE PURPOSES ONLY CERTIFICATE HOLDER NAMED HEREIN,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE.ITS AGENTS OR REPRESENTATIVES,OR THE ISSUER OF THIS CERTIFICATE. MARSH USA INC. BY Walter Gllstrap `fit. clr4*'k NMi(3/Q2) „q1Mx VALID AS OF k02/27/O6 A .�.rri ' _ ,.: ,:`�> ,°br'£,•� ai's;fi 3',. ,. y„„,�3+ aF�.S:• 'S:�. :: �-� �"�- F 'API `.z„` :.'�&a"��" I f Dania Mahat 7743230034 p. 4 HOME IMPROVEMENT CONTRACT C O 5-0 Sold,Furnished and Installed by: Branch Name: N Date: �� C� 1 ?) THD At-Horne Services,Inc. d/b/a The Home Depot At-Home Services 345A Greenwood Street,Worcester,MA 01607 Branch Number: -m31 Job#: Toll Free(800)657-5182; Fax: 508-756-2859 Federal ID 9 75-2698460 ML:Lie N C 02439 R1 Cont.Lief t6427 CT Lic fi 565522: MA Home Improvement Contractor Reg.9126893 Installation Address: b t W MIL14Z + "r► U.kwt1llk City State Zip Purchase s: Last 4 Digits of Driver' laq.0&Exp.Mo/Yr: work Phone: lloine Phone: Ar N ,J ) A ( ) ( ) Home Address:Ad* (If different from I stallation Address) City State Zip E-mail Address(to receive updates and promotions from The Floine Depot.)+L Proiiect Information: I/We/You("Purchaser"),the owners of the property located at the above installation address, offer to contract with Home Depot U.S.A., Inc.("I-I t De) t"1 to furnish, deliver and arrange I'or the installation of all materials as loco .oraled herein by reference and made a part hereof.described on the attached Spec Sheet#:_W fforne Depot reserSes tlic right to cancel this -_ontrac: ?i; 7" D1.`.;: t'C-'S hil➢P,:L' ii? @ of tl'? .11+9 9 :aortae Depot t{^tcrmhies th;ai it F�nnni)t gtC:fOt^53 its obligations due'to a strtictltr_;° l'�r•,;.uj�:?t?::. ';'ti:...- `.1t� IE?;7t'd'", �j' r�p.n!:err "a, ren is r ..T'."L 41 i complete the Job was not included in the Spec Sheet o --TT-..--s,.-.�.s..,..� rAmmaa +®.c ---.v.=__._ - i'1`n,'1`' ,�lj T"✓I:a;l'1{'^'.� M `fu11d•:oriiIC;itit)o ami Ic:ulit app!,, S uI. d.j b�� CONTRACT AMOUNT $� •... ,, ;:,;,'. .,. �I,: .,,,;.:•I).:,,<,t�. �� '' '`�,�.,�:)d�.C"s..':�!-.•!i �> ^✓v! . ... .;r•al,i i;li::` a111`.1'!:'::I!1dr11"',Il::al.V1)I:UnS-\�IS'C�!'Gf:r� :At.l,>4:' n ' �! 'v'is❑ Ntasic;r ',ar/i lii:a:rvr.r \mrricnn I{sores:: BALANCE DUE ' I� 2 ?'ht l ion,e;mpro:•onxn;i.o;ni Ti,c I Iona:Dep.�l.Credit C_;trd ON COMPLETION $ L� .•:rrat'_i .......i:r;, '.eco;mt (`I!!,&T!DC'C ONI"k� `N`nln!uin 25%of Contract Amount due upon exectsti':> JJ_N ." `a;.e�C'�3ir::':_LQ�__....__ (;'It,& rri)G'C:ONLY) f this cartrnct. Indicate Payment Method For Namc a.<it a1,!Y al{on car,': BALANCE DUE ON COMPLETION: h *Hl',„,',0U; rdn:an(e 11clow,UWe agree Io.allow l lomo Depot to charge itie aluwc I ct—Jit card forthe dep�Ky indicated. 06 rdltoldc Sign:duro )ate HJL or HDCC Authorization Codes Deposit Final Payment Purchaser agrees that;immediately upon satisfactory completion of the work, Purchaser will execute a Completion Certificate and pay any balance due. Purchaser also agrees to bejointly and severally obligated and liable hereunder. Entire A reement: This agreement and its attachments, including Any financing agreement, contain the complete agreement perEles and can not be amended or modified unless in writing in a separate agreement signed byboth parties. NO TICE TO PURCHASER Do not sign this contract before you read it. You are entitled to a completely tilled-in copy of the contract at the time you sign. Keep it to protect your rights. Do not sign a Completion Certificate before this project is complete. Law prohibits home repair contractors from requesting(it-accepting a Completion Certificate signed by the.own,r prior to the actwlI completion of the work to he performed under the contract. You may cancel this transaction at any time prior to midnight of the third burin%ss day sifter the date o;this contract. See Notice of Cancellation for an explanation of this right.' There will be a service c1mr,ge equ:0 :o 25% of the contract amount if the job is cancelled by•Purchaser AFTER the third business day. 13Y NY/OUIt SIGNA"PURE BELOW,PNE AGRY:li 1'0131:13OUi`If)ln;"F11 '. i lilavi ,(ii 'i i!1ti(:UN 1,1<.AU F. !i`.V'.At'KNOWI.FOG!;. iZF(TIP'f OF A COPY OF THIS CON'I'R 4CT AND"PHO CONIIIIJ;'1'1:1'?C't';Pl :5(.)F I i 1 a.,'1{t_:i:(:AN- CT,1.LATFOh. ; ! :i! i !'t aVi.v OF ivtiOi3Y Nl)'/OUR SGNAIMIZE BELOW, 1AVE UNI.}F1RS!:\N,D "!11! i'iIF UR CRi:C1T HISTORY :1 [vli ND 1 VE AUTIIOR1;'F I10 . C;!D1 P 0 i'P!'� .,P, J i+`iLl \ rvil (1tJ1C 1<l l>I1 IiL'('(JIZD !NIT11 AN FNPF.PF')`IF)FT1"l ( !?i)I'1 1<1'�(�Ryl�1Ci AGIiNt''* it�l% n , :�`.. i lil,l.t 1 ROi i 1.I 1 '.1311.1"1 Y IN�'Il;<I<!'.0 Fi(Oki 3 07. TDo�ruraoauueall/c o�✓�/laa�acl�uaelf Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: y Board of Building Regulations and Standards Reg.stration 126893 Expiration 8%3/2008 One Ashburton Place Rm 1301 Boston,Ma.02108 Type Supplement Card THE Home Depot At Home Seruc FACHAEL BEDARD 3200 COBB GALLERIA PKWY`#20, 4 HtIANTA,GA 30339 - Administrator Not valid vOthout signature - } d ok 6�I3�oC �� Town ®f Barnstable *Permit# A t2- Expires 6 months from issue date Regulatory Services Fee Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner - ' . SS ERMIT 200 Main Street,Hyannis,MA 02601 www.town.barmtable.ma.us JUN 1 3 Z006 . Office: 508-862-4038 TOW���°g;�ffi `�BLE EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address 106 din h2ei 1A 00 (ems o [residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address `Ct , r Contractor's Name �' � pow.. / Telephone Number Hal 936aL53 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor the Homeowner 2.11, 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) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side �r9]Replacement Windows. U-Value _(maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner m t sign Property Owner Letter of Permission. me pro t Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise071405 f - UUu hm MARSH USA,INC. THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFL'RS No RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PRUVItlEO IN THE ATTN:BRF_NDA BOOKER (404)995-2594 POLICY.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGr MAMA MCCLURE(404)995-3206 OR AFFpRDEb 9Y 7HE POLICIES DfiSCRIBHD HEREIN.TAINII ROUSE(404)995-3430 FAX(404)760-5663 __ 3475 PIEDMONT ROAD,SUITE 1200 COflAPANIES AFFORDIAIG COVEFiAG ATL.ANTA.GA 30305 cCmlPArn C 192 IPU5A-GWA-03/04 ,4 5TE4pF ST INSURANCE COWIP;LiNy NSUR2O 1 I CCMF.VIY THD AT-HOME z�:_:?VICES INC. 8 ZUR'. .'ri A?iEF;CA;.;iP> ;JRA�ICc DSA T'rIE HOME m E?OTAT-rii;ME SERVICES,ING. r:l ?,!PAPI`I HOME DE?CT US.A. INC. �CCbI?a 2455 PACES-E ROAD iVb`I C NET. 'AtNIFSHIF?E'N:3 COMPANY BUILDING:,-0 ATLANTA.GA 2C313 I--y` I CCU. 0---AM(:;?ICAj I Hol;iE;ASSURANCE CC7jP::,,ANY_— —_.... 3k3VE'q::GES This cerli::.�ate supersedes.and repla.ce�any pre�icUSly issued c r;ificate`Cr the t lic Y THIS •S TO CERTFY THA- POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN I53UCD TO THE INSUgED NAras; F; /period�`.,:d below.: 3 NCT.y!THSTANDING ANY RECUMEMENT,TERM OR CONDITION OF ANY CONTRACT Or,OTHER COCUMENT WITFI RESPECT TO-, V4FAHICH THE-CERTIFICATER THE ,I��� PERIOD�INCICAAY HE ISSUED Op TF:, PERTAIN.THE INSURANCE.4FFORCED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,CONDITIONS AND EXCLUSIONS OF SUCHIPOLICIES.AGGREGAI'F LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. .T TYPE OF INSURANCE FOLICYEFFECTIVE POUCYIFXPIRATION TR POLICY NUMBER DATE(MMIODIYY) DATE(MMIDDIYY) LIMITS q GENERAL LIABILITY IPR 3757 608-01 03/01/06 03/01/07 X COMMERCIAL GENERAL LIABILITY GENERAL AGGREGATE $ 4,000;Q( LIMITS OF POLICY ARE EXCESS' PRODUCTS-COMPIOPAGG 4,QJQ,Q( CLAIMS MADE ®OCCUR OF SIR:$1.000,000 PER OCCI PERSONAL a OM INJURY $ 4,O0Q,0( OWNER'S 6 CONTRACTOR'S PROT EACH OCCURRENCE $ 4,OQO,Q( FIRE DANWGE A one nna) $ 11000,0( 3 AUTOMOBILE LIABILITY MED EXP(A one peroon EXCLUDE BAP 2938863-03 AOS 03/01/06 03/01% 7 " X Ally q�0 COMBINED SINGLE on $ 1,OOQ QC ALL OWNED ALTOS SCHEDULED AUTOS BODILY INJURY $ (Per Person) HIRED AUTOS _ BODILY INJURY NON-OWNED AUTOS (perinedllant) $ X ELF-INSURED AUTO HYSICAL DAMAGE PROPERTY DAMAGE $ GARAGE LIABILITY ANY AUTO AUTO ONLY-EA ACCIDENT $ OTHER THAN AU Tp ONLY, EACH ACCIDENT $ _ EXCESS LIABILITY AGGREGATE �+ EACH OCCURRENCE $ ~Y�y UMBRELLAFORM OTHER THAN UMBRELLA FORM AGGREGATE 5 I�SORKERS coalF NSATIO ANo 6610996(AZ,ID,MD,VA) ✓SMPLOYERS-LIABILITY 03/01/06 03/01/07 � 1H• 6610995(ADS) X TORT LIMITS ER _�„_a,e«_i�_,^;•1, y THEPROPRtETOR1 X 03/01/06 03/01/07 EL EACH ACCIDENT $ 1,000,00 PARTNERSIEXECUTIVE INCL 6611326(OR) 03/01/06 .03/01/07 EL DISEASE POLICY LIMIT $ 1.00Q,65, OFFICERS ARE: EXCL 6610999(NY,WI) 03/01I06 03/01/07 0 H WORKERS a?, EL DISEASE-EACH EMPLOYEE $ 1,OQO,OOI COMPENSATION CONTINUED 6610997(FL), 03/01/06 , 03/01/07 _ 1 6810996(CA) 03/01/06 03/01/07 IESCRIPTION OF OPF.FIATIONSILOCATIONSIVEHICLESISPECIAL ITEMS w. ry r.,_a{.�. 53,.'3•...n+wrrs''i'_r,,.::�:s.tw,,,.t�v..: s - f-._ i . 9HDULD ANY OF THE AOLIC,✓ER DESCRIBED HEREMI BE CANCEIC£D BEFORE THE EKPIRATWN DATE YwitE01 FOR INSURANCE PURPOSES ONLY THE INSLeIER AFFORDING CovERAGE WILL ENDEAVOR t0 MAs �� OAY9 YJRITTEN NOTICE.TO TH CERIfFlCATE HOLDER NAMED HEREIIK BVT FAKtAaE 70 MA4 SUCH NOTICE SHALL IMP07E NO OBLIGATION 0 LIABO.RV OF ANY RINp UPON THE INSURER AFFORDING COVERAGE,ITS AGENTS OR REPRESENTATNES,OR TN ISSUER OF THIS CERTIFICATE. MARSH USA INC. MY Walter Gilstrap �+ a .}; �{ .r y ��._�!:^ �.I`,•_., + .!'�r., ` ,ts t�.,,i`r'�mud i y t k� bl z. .�^'s i.{. �s,a,!F;� � a�.- .,l • Cm N�onel f3srertradon '.. i p�C� '~�'..� .. ..... ...... �• i ENERGY PERFORMANCE RATINGS U-Factor(U.&A-P) Solar Heat Gain Coefficient ADDITIONAL PERFORMANCE RATINGS Visible Transmittance I gWfgC4inrsdpWa6ssWtheseratlngscoMormtoapplicableNRiCpmcedureafordetennlningwhole WtAdperfortnei CL NMCratlngs are determined fore fbmd set of emlmnmervW conditions and a SWhIepmductslu.Consult manufachrrees literature for other pmductperformance Information. www.nft.org . vWL r114oii.1C191 fAC Z1WCq,T '-;r1C . Bc:l:iyr:t3j : il�i::Lt:�L".. PIGt:Cli CentCdl.. South t;)titca", .. 9ou:hec r DP Size-.` Tnr.• o�'ru! ni1.��::y`-::'r `c`5%tix_:y.;i1 .!_i(i`ji 41) Pi ✓�te �arn�na�uueall�t o�..�aa�ivae� Board of Building RcuulatiuM and Siand .+ls HOME IMPROVEMENT CON'fRACTON Registration: 126853 1 Expirations �!3/2006 Type: Supplemen!Gard I i THE Home Depot At-Home Sorvic RICHARD FALLGNE 3200 COBB GALL�RIP.PKWY�20 ��� -�••�7r� � ALTANTA,GA 30339 w t.��rttinistratar' ' The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www rnassgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plunjibers Applicant Informattion Please Print Let=ibly Name (Business/organization/Individual): _THD 140tk:5��a Address: Qq,55 C Gi ?S Iri 4 11 City/State/Zip: Gv1'fA_��g 3t)3�q ' Phone#: '20b Cr�7 57Q;Z Are puTh employer? Check the-appropriate bog, Type of project(required): 1. I am a employer with)00 4. ❑ I am a general contractor and I 6. employees(full and/or part-time).* have hired the sub-contractors El New construction 2.❑ I am a sale proprietor or partner- listed on the attached sheet # t 7. ❑ Remodeling ship and have no employees These sub-contractors have {" 8: ❑ Demolition working for me in any capacity. workers' comp.insurance. g, ❑ Building addition [No workers' Comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repass or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.(No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees.(No workers' 13.�er )11 - camp.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 ibis affidavit indicating they are doing all work andthen hire outside conhactors must submit anew affidavit indicating such tContractm that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that Is providing workers'compensation Insurance for my employees. Below is the policy and job site Information. , ` s Insurance Company Name: t�1 Policy#or Self-ins,Lic.#:_���e � Expiration Date: + Job Site Address:_ Vq �1�`` 'Lt l-(w City/State/Zili:a�e")l� CQ&a2 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$1,50Q.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. 1 do hereby certify and 'ns a pe ties of perjury that the information provided above is true and correct. Signature: Date: Phone#; Official use only. Do not write in this area,to be completed by cityr town;officiaL City or Town: Permit/License# i Issuing authority (circle one): 1.Board of Health 3.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Flumbing lasper tar 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,oial 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 represen ` es of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal en ' employing employees. However the owner of a dwelling h se having not more than three apartments and who r ides therein, or the occupant of the dwelling house of anothe ho employs persons to do maintenance, cons On or repair work on such dwelling house or on the grounds or bul7ding purtenaut thereto shall not because of suc. employment be deemed to be an employer." MGL chapter 152, §25C(6)also s es that"every state or local lice g agency shall withhold the issuance or renewal of a license or permft to erate a business or to construe buildings in the commonwealth for any applicant who has not produced ac ptable evidence of complian with the insurance coverage required." Additionally,MGL chapter 152,§25C states"Neither the comet wealth nor any of its political subdivisions shall enter into any contract for the performan a ofpublic work until acc table evidence of compliance with the insurance requirements of this chapter have been pr ented to the contracting thority." Applicants Please fill out the workers'compensation affid vit completely,b checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),ad s(es)and pho a number(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC)or united Liab Partnerships(LLP)with no employees other than the members or partners,are not required to carry wor ' compen ation insurance. If an LLC or LLP does have employees,a policy is required. E e advised that this ffidavit y be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. o be s to;sign and date the affidavit. The-affidavit should be returned to the city or town that the application for p ermi or`license is being requested, not the Department of Industrial Accidents. Should you have any questions reg ding a law or if you are required to obtain a workers' compensation policy,please call the Department at the er ' 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 a Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Inv lions has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will b us a reference number. In addition,an applicant that must submit multiple permit/license applications in any ' en y need only submit one affidavit indicating current policy information(if necessary)and under"Job.Site Address' the appli t should write"all locations in , (city or Gown)."A copy of the affidavit that has been officially stamp or marked �the city or town may be provided to the applicant as proof that a valid affidavit is on file for future p 'ts or licenses. A new affidavit must be filled out each year.where a biome owner or citizen is obtaining a license or ermit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person ' OT required to complete this affidavit. The Office of Investigations would like to thank you in adv ce 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/aashington The Commolth of Massachusetts �. Departmendustrial Accidents Officnvestigations 600 Street BoMA 02111 Tel. #617-727-4900 ent 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 yjVW.mass.olov/Ciia Danya Mahot 7743230034 p. 4 HOME 11"ROVEMENT CONTRACT Sold,Furnished and Installed by: Branch Name: (t1.J Date: J 17 THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services 345A Greenwood Street, Worcester,MA 01607 Branch Number: To Job,#: �C1b7 Toll Free(800)657-5182; Fax: 508-756-2859 2- t-j. b C -7 57 Federal ID#75-2698460 ME Lic#C 02439 RI Cont.Lic#16427 CT Lic#565522; MA Home Improvement Contractor Reg.#126993 Installation Address: City State Zip Purchase s: Last 4 Di Us of river's Li c#&Exp.MolYr: Work Phone: Home Phone: ( ) ( ) Home Address: R h Z (If different from Installation Address) City State Zip E-mail Address(to receive updates and promotions from The Home Depot): ►'l Project Information: I/We/You("Purchaser"),the owners of the property located at the above installation address,offer to contract with Home Depot U.S..4., Inc.("Ho e De ot;')to furnish,deliver and arrange for the installation of all materials as described on the attached Spec Sheet#: b � ,incorporated herein by reference and made a part hereof. Home Depot reserves the right to cancel this contract if,upon re-inspection of the job,Home Depot determines that it cannot perform its obligations due to a structural problem with the home, pricing errors or because work required to complete the.job was not included in the Spec Sheet or Contract. DEPOSIT PAYMENT OPTIONS (Suhjco to find verification andior credit approval.) ( l.J Check,Cashiers Check or US Postal Service Money Ordcr CONTRACT AMOUNT $ (Mmuic payable to The Ilome Depol). 'LESS DEPOSIT $ 2. Credit Card'and.'or other payment options-Circle One 13e1cw Visa MasterCard Discover American F.xpress BALANCE DUE The Home Improvement Loan The Home Depot Credit Card ON COMPLETION $ New Account ❑Existing Account (HI &IIDCC ONLY) ' `Minimum 25%of Contract Arrtount due upon execution Available Credit: (HIL&HDCC ONLY) f this contract. Accdf: Exp.Date:_ Indicate_Payment Method For Name as it appears on card:______..______,__.,___,_•-_____ _ BALANCE DUE;ON.COMPLETION: "By my/our signature below,L'We agree to allow home Depot to charge the above referenced credit card for the deposit indicated. CCardholder's Signature Daze HIL or HDCC Authorization Codes Deposit Final Pavment # # , Purchaser agrees that,.immediately upon satisfactory completion of the work, Purchaser will execute a Completion Certificate and pay any balance due. Purchaser also agrees to be jointly and severally obligated and liable hereunder. Entire A Agreement: This agreement and its attachments, including any financing agreement, contain the conplete agreement between the parties and cannot be amended or modified unless in writing in a separate agreement signed by both parties. NOTICE TO PURCHASER Do not sign this contract before you read it. You are entitled to a completely filled-in copy of the contract at the time you sign. Keep it to protect your rights. Do not sign a Completion Certificate before this project is cum lete. Law prohibits home repair contractors from requesting or accepting a Completion Certificate sighed by the owner prior to the tictual completion of the work to be performed under the contract.... You may cancel this transaction'afany time-prior to midnislf of the third business day after the date or this contract. See Notice of Cancellation for an explanation of this right. There will be a service charge equal`to 25% of the contract amount if the job is ` cancelled by Purchaser AFTER the third business day. BY MY/OUR SIGNATURE BELOW,I/WE AGREE TO BE BOUND BY THE TERMS OF THIS CONTRACT. I%WE ACKNOWLEDGE RECEIPT OF A COPY OF THIS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICL OF CANCCLLATION. BY MY/OUR SIGNATURE BELOW, 1/WE UNDERSTAND THAT THE AGREEMENT IS SUBJECT TO REVIEW OF MY!OUR CREDIT HISTORY AND I/WE AUTHORIZE HOME DEPOT TO VERIFY AND REVIEW MY/OUR CREDIT RECORD WITH AN NDFPFNPI?NT ('RFDIT ,1REPY)RTING AGENCY AND RFLFASF. THEM FROM ALI., LIABILITY INCURRI-M FROM