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HomeMy WebLinkAbout0126 OLD POST ROAD (CENT.) y Cie) "do s- , o n 0 o 0 06P Town of Barnstable V Regulatory Services Fee m& Richard V.Sea%Interim Director $[aiding DivWon Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis;MA 02601 www town.bamstable ma_us Office: 508-862-4038 Fax7 508 790-6230 +; EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not YalidwmoutRed%Presslmpriat Mto/parcel Number ,R 0'! 0'1 I- Property Address /,Z (o 0& ❑Residential Value of Work S� A futimum fee of$35.00 for work under$6000A0 Owner's Name&Address W-e-M A iviie klle-Pl MA bL 3Z Contractor's Name �i�/ i�l 1✓L- Telephone Number Rome Improvement Contract License#(if applicable) LaZ 6 9- Email: _ *SS,—ar Construction Supervisor's License#(if applicable) 0 9 Z Worlanan's Compensation Insurance ®Cr 0 e 201 Check one: Tp�N rr 5 ❑ I am a sole proprietor ®r BryR u S T/q ❑ I am the Homeowner BCE I have Worker's�Colmpens fm Insurance D Insurance CompanyName 1A)S ` .: AA ,,tt Q Worlanan's Comp.Policy# W 6- 0 t 7 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) _ ❑ Re-roof(hurricane nailed)(stripping old shingles).All construction debris will betaken to ❑Re-roof(humeane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side [TReplwement Windows/doors/sliders,.0 Value 3 O (maximum 35)#of windows ` #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red Sand inspections-required. Separate Electrical&Ftm Permits required. _ *VAnm regntte& issuance of tbkpezmh does not exempt comgmcevM other town depa#mzm=gnlations.L&SisW&-Conservation,etc- Note Property er gn Property Owner Letter of Permission. A copy of H Improvement Contractors Diem&COnStImcdOu SuPer-Mors License is required. SIGNATURE: T:IBH M'Bmldmg Changes\M S RESS-dnc Revised 061313 HOME IMPROVEMENT CONTRACT PLEASE READ THIS qp �^ Sold,Furnished and installed by: Branch Name:Boston North&South Date;J / THD At-Home Services,Inc. dWa The Home Depot At-liomc Services 908 B Branch Number:31 and 33 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free 87.7-903-376.8 Federal ID#75-2699460;MF Lac#C 02439.RI Cont.Lic#16427 Cl'Lie#Hl .0565522;MA Home Improvement Contractor Rcg.#126893 Installation Address: f� 61 t./ Ad,,.-P Arl -l/Z>L(///!� � 7 12— City State Zip Pmehaser(s): Work phone: Home Phone: (;ell Phone: [ ] t ] 1,S Rohe Address: / (If different from Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates): ❑1 DO NOT wish to receive any marketing emails from The Home Depot Project Information: Undersigned("Customer'),the owners of the properly located at the above installation address,agrees to buy, and THD At-Home Services,Inc.("The Home Depot")agrees to fumish,deliver and arrange for the installation('Installation')of all materials described on the below and on the referenced Spm 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, 'Contract"): Job#: tmurom wrnv o p Spec Sheets #: Project Amount Roofing Siding endows Insulation -d S ❑Gutter/Covers ❑Entry Dr�on ❑ Il RoofingLISiding 0 Windows LJ Insulation ❑Gutters/Covers ❑Frury Doors ❑ $ Roofing Usiding ElWindows U insulation ❑Guuen/Covcrs []Entry Doors❑ $ Roofing LISiding U Windows U inxulatioo gcuners/Covers ❑Entry Doors Cl $ MinJntmr25%De atirt orcodradA. 1tdueWme=mtlWQf"_cofltracL Maine Purehasers may tent deliosit more that[one-third of the contract AmotmL Total Contract Amount $ / Customer agrees that, inutiediately upon completion of the work for each product,Customcr will execute a Completion(ertifcate (onc 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'Honte.Dcpot reserves the tight to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at its discretion,if The Home Depot or its autho&W service provider determines 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. Pa ment Sumtrra :' The Payment Summary#_/fib Y� _, included as part of this Contract,.sets lbrth the total Contract amount and payments-required for the deposits and final payments by Product(as applicable). NOTICE.TO CUSTOMER You are entitled to a completely filled-in copy of the Contract at the time you ti lgn, Do not sign a Completion.(:ertifictate(note: there is one Completion Certificate for each listed Product as decried by individual Spec Sheets)before work on that Product is complete. In the event of termination of this Contract,Customer agrees to pay The Home Deport the costs of materials,labor,eapensev and services provided by The Home Depot or Authorized Service Provider through the date of termination,phi s.any other amounts set forth in this Agreement or allowed under apppllicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPC).SIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acc [tone and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer and The Home Depot with regard to the ProduLu 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 DepoL Customer acknowledges and agrees that Customer has read,understands,voluntarily accept.-,the terms of and has received a copy of this Agreement. Ac,eQted by: I? X A'4, Customer's Sign c Date !� g Sales sultaut'spSignature Dale. Tel No. /�� Customer's Signature Date Sales Consultant License No. CANC.'F.I,LATION: CUSTOMER MAY CANCEL TIII,S (sc applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WPXrrEN NOTICE TO TIME HOME DEPOT BY MIDNIGHT ON TIME THIRD BUSINESS DAY ArTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE., NOTWE:A,DDITIONAt,TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE.PART OF THIS CONTRACT os-1415 White Sranch Fife YoHow=Custorree Td WdTZ:2 ZTOZ b adtl T4Z7_Z9£80S: 'ON Xtid pe6wef: W084 Massachusetts-Department of Public Safety Board of Building Regulations and Standards Cnnsi ctr�r�Supea d.jer snecialtr .' License: CSSL-OW62 ct•'� , -``, ^ p __ T.QbIUT$Y P .,., 4 CIRCLR iDRWI r is Warebam MA 0871E Va ,�.....PJ. c.'"" Expiration Commissioner 0610402017 wee of Cwxanw ABdwit Ewr"J OffCOMRAC'tOR . 4sszsTim ' !a6an: ;NNW5 trdit�idui;l Tasn/Tfli fV6lNT1/NPYi,, 4ORCIE OR. C The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 -www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Conn-actors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Busiuess/Or do�niza n/Individual): � //►�����/ P Address: e- City/StateZi : Dfeh Qm M 0,— oaS71 Phone#: S-0 r-- 6c2- ( Are you an employer?Check the appropriate box: . I am a general contractor and I Type of project(required): 1.Q N am a employer with 4 ❑ /employees(full and/or part-time) have hired the sub-contractors . 6. ❑New construction 2.® 1 am a sole proprietor or partner- listed on the attached sheet. 7. []Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' (No workers'comp,incnranCe comp,insurance.: 9. ❑Building addition required.] 5. ❑ We are-a corporation and its 10.❑Electrical repairs or additions 3.Q I am a homeowner doing all work officers have exercised their . 11. Plumbing r myself � " ❑ g repairs or additions . y (No workers comp. right of exemption per MGL 12.❑Roof repairs 3a.(] insurance required,]t c. 152, §1(4), and we have no I am a Homeowner acting as a employees. [No workers' 13.0 Other general contractor(refer to#4) comp.insurance required.]- 'Any applicant that checks box Rl must also out the section below t showing their workers co ti on`' information. Homeowners �°� Po�Y ers who submit this affidavit indicating they are doing all watic and then hire outside contractors must submit a new davit=Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or nowt those entit ies snhavech employees. If the sub-contractors have employees,they must provide their workers'comp.Policy oli number. am an employer uaal 1S providing workers'compensation insurance for my employees. Below is the policy and job site information n r Insurance Company Name: A S c iMll (t) CQ,l1 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 Sectioa 25A of MGL e. 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 under th pains and enalties ofperjury that the information provided above is true and correct.— Si ature: Date: /a G Phone#: OfflCial use only. Do not write in this area, to be completed by city or town official City or Town: PermitlLicense# Issuing Authority(circle one): I.Board of Health 2. Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• The Commonwealth of Massachusetts in Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):VhMe— Address: qoS T,as-{-o n hurnopi Ke- City/State/Zip: yews 6u r -5 Phone#: S Off 96 7- 09 4 2- Are you an employer?Check the appropriate box: Type of project(required): 1.91 1-a employer with 10 + 4. � I am a general contractor and I have hired the sub-contractors 6. ❑New construction emp loyees (full and/or part-time).*.._ 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. FJ Building addition [No workers' comp.insurance comp. insurance.t required.] 5. ❑ We area corporation and its 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.R0therbJind ,) o4ce,�_y 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 tl:e policy and job site information. Insurance Company Name: �l°Sa�-f'tG1A1p i/2 1�c Lo Policy#or Self-ins. Lic.#: (A)G 017 73 1 q 9 3 Expiration Date: Job Site Address: /2-(,,y 0 L t'> POST City/State/Zip: cen"f e-C y 10 P. MA 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 aga' s violator. Be advised that a`copy of this statement may be forwarded to the'Office of Investigations of the DIA o in ance coverage verification. I do.hereby certify and tl ain and ell at the information provided above is true and correct. Signature: Date: Phone#: - Official use only. o_not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): I.-Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: v Office of C f F ; onsumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home finprovemei of Contractor Registration - Registration_ 126893 - Type: Supplement Card THD AT HOME SERVICES, INC. - - Expiration. 8rJ12016 ANDREW SWEET 2690 CUMBERLAND PARKWAY SU1TE=300:--- -- ATLANTA, GA 30339 Update Address and return card.Mark reason for change. �c 20rd-OS111 J Address !jQ Renewal Employment rj Lost Card �e��i�rczc�zcuealf/a�C/Glaa�ac%cc�eCli Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: . Office of Consumer Affairs and Business Regulation Registration, Type: 10 Park Plaza-Suite 5170 Expiration, Supplement Card Boston,MA 02116 THD AT HOME SERUCCESWC THE HOME DEP&-,kW,'ME SERVICES ANDREW SWEET\ ; 2690 CUMBERLAND PARINVAY AYaf %,GA 30339 Undersecretary Nov i wit t signature A��® CERTIFICATE ®F LIABILI`fY INSURANCE IDo M52015�) 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 be endorsed. if SUBROGATION IS WANED,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 NAO TACT MARSH USA,INC. AX TWO ALLIANCE CENTER PHONE o Ext No 3560 LENOX ROAD,SUITE 2400 EAon1DARtess. ATLANTA,GA 30326 INSURER(S)AFFORDING COVERAGE NA1C S 100492-HornaO-GAW-15-16 Steadfast It>suranM INSURERA: Cotliparry 26387 INSURED THD'AT HOA1E SERVICES,INC. INSURER B:Tlllfdl ATnPJICan IrLSIuanCe Co 16535 " DBA THE HOME DEPOT AT-HOME SERVICES INSURER C:NEW H2MP re InS Co 23N1 269D CUMBERIAND PARKWAY,SUITE 300 INSURER D:Illinois National IlLsurance CnRylany t7 ATLAkA,GA 30339 ` INSURERE- ENSURER F: COVERAGES CERTIFiCATE_NUMBER: ATL4)0374664s-13 ' REVISION NUMBER:8 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTVVITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE 114SURANCE 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 TYPE OF INSURANCE AD S BR ' POLICY EFF POLICY EXP LTR INSD POLICYNUMBER 1 MM@D MMIDD LIMITS A I X COMMERCIAL GENERAL LIABILITY �GLO4887714-05 103/D1J2p15 031D1@O76 EACH OCCURRENCE $ 9,000,000 -DAMAGE TO RENTED CLAIMS-MADE OCCUR i PREMISES Ea occurrence) S 1.0mom 'UPlJTS OF POLICY XS MED EXP(Arty one person) S EXCLUDED `I :CIF SIR:S1tA PER OCC 9.0M,000 PERSONAL&ADV INJURY S GEN'L AGGREGATE LIMIT APPLIESPER: i GENERAL AGGREGATE S 9�•� X POLICY❑JECT ❑LOG PRODUCTS-COMPlOPAGG $ 9,000,000 OTHER: j S B AUTOMOBILE LIABILITY ' iBAP293B86&t2 '0'JOt/�15 03101/2016 ►BtNEDSINGLELIMIT 5 1.000.t>DO i Ea-ZIN X ANYAUTO I BODILY INJURY(Per Person) is AUTOS ALL OWNED ISS�SULED I ,SELF INSURED AUTO PHYD)fG BODILY INJURY(Peramdeng S HtREDAUTOS AUTOS NON-OWNED i ! PROPERTY DAMAGE S (Par accident s UMBRELLA LIAB OCCUR EE� I EACH OCCURRENCE S EXCESS LIAR CLAOASMADE I i AGGREGATE $ DF-D RETENTIONS i $ C WORKERS ComPENsAnoti WC017731493(ADS) 031012015 M1012016• X EA� AND EMPLOYERS'LIABILITYER C ANY PROPRIETOR/PARTNERIEXECUnVE YIN WC017731495(AK,KY,NH,NJ,Vr) 031012015 03/012016 100.000 N❑NIA EL EACH ACCIDENT S D OFFICERIMEMBER EXCLUDED?(Mandatory In NH) WC017731494(FL) 103/012015 03/012016 E.L.DISEASE-EA EMPLOYEE 5 1 If yes.describe underP,E Conitnued on AdMonal Page 1 1,000,000 DESCRIPTION OF ORAJIONS Maw j 9 � E.L.DISEASE-POLICY LItAIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached It more space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 3D339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014f01) The ACORD name and logo are registered marks of ACORD r . -70 Towne of Barnstable �t Qn Expires 6 mondhs m ue t Rg e ulatorY Services Fee- . snaivsrna�. • .. Thomas.F.Geiler Director. 1639•��� F. _ ' Building Division 312 dl4jl —Tom,Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 c www.town.barnstable.ma us Office: 508-862-4038 -y: Fax:,508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY' Not Valid without Red X-Press Imprint Map/parcel Number Property Address /Z4 Ole/ 05 T 24 C,:L4iA--rV1 I�c /9`i Residential Value of Work Sq 6-q6- . Minimum.fee of$35.00 for work_ -under$6000:00 Owner's Name&Address .' '1hn� IAJ Contractor's Name/pav ' Telephone Number. /7`/ _Z J Z 3J G Home Improvement Contractor License#(if applicable) ,; Zdn PERM ® ' Construction"Supervisor's License#(if applicable) [(Workman's Comp ensation4risurance MAR �. Check one: ❑ I am a sole`proprietor ' + �A�NSTABLE ❑ I am the Homeowner` ', `' ®WN of [ I have Worker's;Compensahon Insurance L C Insurance Company Name � • .N Workman s Comp:policy# �>C�� � 06 Q� 101 Copy of Insurance Compliance Certificate must accompanyeach permit. Permit Request(check box), (hurricane nailed)(stripping old shingles) All construction deb will be taken to Re-roof(hurricane nailed)(not stripping: ,Going over. existing layers lof roof)` Re-side: #'of doors ❑ Replacement Windows/doors/sliders.,U-Value -(maximum.35)#of windows x } F *Where required: Issuance of this permit does not exempt compliance with other town departmentregulations,'i:e Historic;Conservation etc. > ***Note Property.Owner must sign Property Owner Letter of Permission. L • t ,A copZ,- C:\Users\decollik4ftaIr-.eMckosoft\Windows\Temoorary a Improvement Contractors License&Construction Supervisors License `is r uiN. SIGNATURE: ,f Intemet Files\Content.0utlook\DDV87AAZ\EXPRESS.doc $_- Revised 072110 . The Commonwealth ofMassachusetts Deparunent of Industrial Accidents ' Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information / Please Print Lelnbly Name(Bus;Hess/Organi7atioo/Individual)• /'�. /'1► C-0,r-�W, -44 Address: ; city/state/Zip-IA j4hone#: ZI Z"=-3.3Z 7 Are u an employer?Check the appropriate box. of project Typep 1 (required): 1. I am a employer with Z 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6• ❑New construction 2.❑ I am a sole propridtor or paitner- listed on the attached sheet t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. q 0 g��g addition (No workers'comp.insurance 5. ❑ We are a corporation and its required] o�cers have exercised$heir 10.❑El=Wcal repairs or additions 3.(] I am a homeowner doing all works right of exemption per MGL I LEI Plumbing repairs or additions myself[No workers'comp. c. IA§1(41'and we have no lnsarsma ]t rloras' 1Z.❑Roof repairs employes [NO wo comp.knsurance,required.] t�3-0 Other *Any applicant tit sheds box 91 aast dso na out die section below showing their vat'compensation Policy ia5ocmadon t HortlboWnms v&o submit dais aSidavit indicating they an:doing aU wodc and then hhe oatside oontmcbm mast submit a new affidavit indicating saclL tContraMM that dick this box must attached an additional sheet shMft the name cf diesubommuctm and thw vgorlaus'gyp,pal'icy radon ]"aft!an employer that is providing workers'compensation Insurance for my eMleyeem Below is the policy and Job site information. Insurance Company Name: Policy#or Self-ins.Lie.#:�G �7 D�D 0 W Z/ Epitation Date: Job Site Address: City/State/Zkp Attach a copy of'the workers'compensation policy declaration page(showing the policy number and expiration date). Fail=to seam coverage as required under Section 25A of MGL.c. 152 can lead to the imposition of criminal penalties of a. fine up to$1,5D0.00 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 violater. Be advised that a copy of this statement may be forwarded to the Office of Invertigations of the DIA for insurance coverage verification• I do hereby certify under the palm a ndpenalties ofperjW that the lnformadon provided above Is ftm and correct Sipnntnre: Date Phone#: Oj?clal use only. Do not write in this areay to be torripleted by efiy or town official Cly or Town: PermiYucense# ' Ensuing Authority(circle one): 1.Board of Health Z.Building Department 3.CityTOwn Clerk 4.BIechical Inspector 5.Plumbing Ltspector 6.Other Contact Person: 3 Phone#: rayscvi4 vaceaicuizuILuisisr1V1r-age:zorc ter", RACAM-1 OP ID: MD �oRo� CERTIFICATE OF LIABILITY,INSURANCE DAT 03120112 03/20/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY ORNEGATIVELY 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 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 - SOH-255-SOOO .CONTACT .. Kerryenc Insurance A Inc. NAME` g y' 508-240-1860 PHONE FAX Scott Kerry � � - - .. _ A/C No Ext• A/C No PO Box 1945 E-MAIL North Eastham, MA 02651 ADDRESS: W.Scott Kerry - - - - -INSURER(S)AFFORDING COVERAGE - NAIC S INSURER.A:ASSOCIated Employers Insurance . INSURED R.A.Campbell Enterprises Inc. - .. - INSURER B: - - Ryan A.Campbell 126 Bayridge Drive INSURERC: South Dennis, MA0266O - INSURERD: - - INSURER E - INSURER F COVERAGES CERTIFICATE NUMBER: 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. NOTWrrHSTANDING 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. . INSR ADDL.SUB POLICY EFF POLICY EXP. - LTR TYPE OF INSURANCE ?POLICY NUMBER LIMITS - GENERAL LIABILITY - - - EACH OCCURRENCE $ -. O RENT D COMMERCIAL GENERAL LIABILITY - .. DAMAGAMAG PREMISE 1 RENTao rrence $ CLAIMS-MADEOCCUR - • MEDEXP(Anyone person) $, PERSONAL-&'ADV INJURY $ �., GENERAL AGGREGATE $ GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ POLICY PRO- LOC: $ AUTOMOBILE LIABILITY " - 'COMBINED SINGLE LIMIT Ea accident $ ANY AUTO - - BODILY INJURY(Perperson) $ALL OS SCHEDULED BODILY INJURY(Peraccident) $ AUTOS AUTOS � � _ ," II NON-OWNED - - PROPERTYDAMAGE HIREDAUTOS AUTOS'. - P 0"ccident - $ .. $ UMBRELLA LIAB OCCUR - -" - EACH OCCURRENCE $ �DXED ESS LIAB HCLAIMS-MADE ' - AGGREGATE.. '$ RETENTION .._.. _ .. - $ . MRKERS COMPENSATION - - - _ WC STATU- OTH- AND EMPLOYERS'LIABILrrY . ^ TORYLIMTTS ER A ANY PROPRIETOR/PARTNER/EXECUTIVE V� N/A ' 5009706012012 ". 01/11�/12 01/11/13 E.L EACH ACCIDENT $ 100,00 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) .. ... - -" E.L.DISEASE-EA EMPLOYE $ - 100,00 If yes,describe under DESCRIPTION OF OPERATIONS below - - - E.L.DISEASE-.POLICY LIMIT $ - - 500,00 DESCRIPTION OF OPERATIONS/LOCATIONS/V'EHICLES (Attach ACORD101',Additional Remarks Schedule,if more space is required) ` Residential Carpentry Ryan A. Campbell elects coverage under this workers.compensatin policy. CERTIFICATE HOLDER CANCELLATION " SHOULD ANY OF,THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE . THE. EXPIRATION' DATE' THEREOF, NOTICE'"WILL"•BE ;DELIVERED IN ACCORDANCE WITH THE POLICY'PROVISIONS. ; Town of Barnstable Building Department ZOO Main St AUTHORIZED REPRESENTATIVE ` Hyannis, MA 02601 („ 01988.2010 ACORD CORPORATION. 'All rights,reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Boa rum; � 3 a4si3� �'dj icy at�ir�l3 �ml Offilof�`ADSQO1tc�aAttatt3 dC Qtss��Qhon k i-A HOME UI9PROVEMEN17 CONMCTOR s `?ic4nse: CS 937-16 = RealsbatioTM 163732 Type: ' ` tc `7/17aM3 -Private Co Resincied sc}: QD Expiratio rpp T R A`CABMBELiB4TERPRiSES INC. - RYAN CAMPBELL 126 BAYRIDGE DR RYAN CANlPBELL ` S DENNIS,MA 0266t} '` 126 BAYRiDGE DR ' 1 SOUTH DENNIS,MA 02660 on valid for individul use only License or If found return to: t - before the expiration date- on Office of Consumer A�and Bnsmess RegnlaU 10 YarkYtaza-Suite 517Q KA 6116. ; r - e. V with 09"'Ure Y R.A. Campbell Enterprises Inc: Invoice 126 Bay Ridge Rd Date Invoice# South Dennis,MA 02660 2/13/2012 53 Bill To Beth Anne Allen 126 old post rd Centerville,MA 02632 Terms Project Quantity Description Rate Amount Remove the existing roof shingles and underlayment to expose the plywood sheathing 5,400.00 5,400.00 Inspect the roof sheathing for rot or water damage,if there is damage replacement would be an extra Remove and install a new rake board at the chimney rake area for proper flashing Install new ice and water membrane,felt underlayment,drip edge and flashing in the appropriate area's Install new roof shoe vents Remove the old-rafter vents and install anew ridge vent Install new architectural shingles to MA state code(color chosen by Home owner) All debris will be removed from the job site and will be left clean. Going price for your size roof is$6300.00(your price is in the total column) Deposit at the signing of the contract $2700.00 Final at completion $2700.00 ' Customer Si re: Contractor Sign Ot. , bo Total $5,400.00 i � I TOWN OF BARNSTABLE Permit No. --------__--------- sAUnA Building Inspector cash. .Y` --------------_____-_______ tC7V �� OCCUPANCY PERMIT Bond ----—__-------_—_ jA No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor firstjhaving been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to iSc3ysi&ct t :lilcinq Co. Address Lot 0%, 126 01.d P o s Rua,! , „j rvz 1.1.P Wiring Inspector , Inspection date Plumbing Inspector �`'�} r^,� Inspection date Gas Inspector Inspection date Engineering Department % �/d��r.:• Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. .....................................................1 19_...._ ........................................... ......_...:.... ._. ..: _� .. . .. .�. _._ Building Inspector 78 h P c'•� \ ACHAiiD`v A. BAXTER No:24046 SUR��' /io.G7 . CEC'TI'F1Et� pL�7" PL.I�,�-.1 LOCAT101,4 c CA/TCReviI-LE, s-S . 15CAL_t. ��30, CG3ZTt1+,( Tt-(AT T14t= FovNDAT/dV 514a-utJ t--1EQEo1a GO&A%PLYG W tTN TI-AV-- �jIL�E I-I►-l� LoT 'Z oAj PLAAJ of Awr SE--Tt3AC4 �G4wiZEMEWT,, O THE LAND Fog NoR 4 SIA15 .• ~ O VJ LJ of 6A AN STA B L G' A."Ic> is A/0 r 9Y BAX TE2 � Nt✓E .zvc. LvGATE D .. .W 1 Tt-11�1 �= 000 R.:A I N DATED APR///P Z. BQXTEIZ . a „ hAT� 8— /Z. 9z REGtStZtZ►=ta I.�I-1p 5t��.v�`(o�s j "( "IS VLAW 115 QOT Bt%'S :c.t�l p►-f A� OSTE��/tt_t� o AX/�SS tW;TCtJc�tc_tJT 5��vc=-� s T:a� c�c=�SrT!> >i1Gl��a 1�PP�tf.A.NT' 612,JAN 'DAC-Gy W�s`seftr's map and lot number ......................................... .� TNe r Sewage Permit number ...... Z.?,�..............:..............' ,fM SEPTIC INSTALLED INC SLIT •�- LIA 9TADLE, i House number ....�....�Z.�........................................ - L IT TITLE S goo M6 q ��. r :afENVIRONMENTAL COCA � �� 0NoAv TOWN OF " BAR NS OI§S :: ��� ��I . 1 i BUILDING IDS BUR. APPLICATION FOR PERMIT TO ...U%i�..... L...... (�— ��� 0 TYPE OF-CONSTRUCTION ......(�.42_6........ ...... ..... ..................................................................................... ......... .............19.. j TO THE INSPECTOR OF BUILDINGS: The undersigned hereby . pplies/for a permit ccor ing t the fo � win informaGto .....�..... .....Location ....12�.. . .................................................... Proposed Use ..... ....................... .. ... . ...... .. . ..... Zoning District ............ ../y.�....`..� ....... .. .................. . .....Fire District,.. .. L ....... ....... Name of Owner .... � ::S-f �. ....... ..... ....Address ... ...�. .... .!1.... .1.-..� .V .... ... �. Name of Builder' ........ ....... ..........................Address ... ........... :........................ 00 Name of Architect . � =:........ ..1 l/`.. ...... ......:...Address ...... ...��� f.... 1.1 . ................ . ....................... Number of Rooms .......... ........................................Foundation . .... .. ... ... ..... V..Gr. . Exierior .. . . ./.....�...............� .... ......./..... ....... -(e . 1 �/ �/�. Roofing ............ ........... .. j� . Floors .... .. ....�fi... ...//....................... ...................................Interior ..... ........... .. ....... ................................................... Heating f--l .... �..� ... ...... .......Plumbing ...................... %' ...................... Fireplace ..... . �..........................................................Approximate Cost .....�.. .�./�..` .....?........................ ..... ?W0 Definitive Plan Approved by Planning Board ---_---------------_-----------19________. Area ....:....... ............................. Diagram of Lot and Building with Dimensions Fee �� SUBJECT TO APPROVAL OF BOARD OF HEALTH �1 Z • OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town ofZBrnst le rding?kje ove construction. . Name ...... .. . ..... .. ......... ........................ � YSIDE BUILDING CO. , inc. No 2 4 2 8 6.... Permit for l. Ats 9K-................. v 01 C# Single Famil ,Dwel in •.,,,.,,.,.............. ..... . ... ........Y: .... .......�...... Location .. ot... 2...... 2.6: Qld... 0 ...Road ~ . Centerville _.� ............................................................................... Owner ....B'ayside...Buildi?�9..CQ:..�...Inc. ? x J r Type of Construction ......FrAMe....................... r y` ......................................... ................................... J Plot ......................... .. Lot ................................ i 8 .�- Permit Granted ......August...................1..3...,..........19 2 r _ Date of � � y:r ....................19 f Date CRmplete ' 'J t 4 G