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_ EE6 Town of Barnstable Permit# l�®�� f
'U N 0 3 2015 Regulatory Services l= 6 �a an elate
F B A R N S T ARichyard V.Scab,Interim Director
Building Division
Tom Perry,CBO,Building Commissioner
200 Main Street,Hyannis,'MA 02601
www.towabamstable.mh-us
Office. 508-862-4038 Fax:508-_790-6230
EXPREss PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid widwrdRedX-Pressiniprint
Ma /parcelqq
Number
Property Address I(J�Fi �� �eIV/ A
�
Residential Value of Work$ `� -- Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address —7—u s
LIP A
Contractor's Name A W'�CI 0Ld Telephone Number
Home Improvement Contractor License#(if applicable). IR(o �"/�3 Email:
Construction Supervisor's License#(if applicable) /0 PA Q,) 7
( ,workman's Compensation Insurance
"�\\ Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
I have Worker's Compensation Insurance
Insurance CompanyName //1/S _ °
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit. c
Permit Rfgest(check box) ✓� S � � ��
J�,� Re-roof(hurricane nailed)(stripping old shingles) All construction debris will betaken
to
( \ e-m f(hurricane palled)(not stripping. Going over existing layers of roof)
Re-side
❑ Replacement Windows/doors/sliders,Z-Value (maximum 35)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*%em regdre& tssnance of this permit does not exempt compliance with odw town department regulations,it.Historic,Conservation,etc.
***Note: Property er ign Property Owner Letter of Permission.
A Dopy of H Improvement Contractors License&Construction Supervisors License is
required.
SIGNATURE:
TAKEVIN D1Bm7ding Changes\�E 0 S RBSS.doc
Revised 061313
�fI1 � . �zn�zr�ea��G�
s_ orr Consumer Affairs and Business Regulation
�31 10 Parr Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
7.
- Registration: 126893
- Type: Supplement Card
THD AT HOME SERVICES, INC. . . - Expiration: 8/312016
ANDREW SWEET _ - --
2690 CUMBERLAND PARKWAY SUIT1=300:
ATLANTA, CA 30339
Update Address and return card-Iti•Iark reason for change-
SC:.t :: zo.a osn i f—i Address -I Renewal Employment f j Lost Card
C�r—
fe U�anvrnoaauleal�¢��/frcaau�uaeC7
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
before the expiration date. If found return to:
OME IMPROVEMENT CONTRACTOR
Re istration '� µ Office of Consumer Affairs and Business Regulation
9 1-26893- Type: 10 Park Plaza-Suite 5170
Expirdt�og 3l20�,yt Supplement Card Boston,MA 02116
THD AT HOME SERVaGES�INC
l 1=
THE HOME DEPOT AT HOME SERVICES
ANDREW SWEET
2690 CUMBERLAND PARKWA1 YS
A'aL-'A- ,GA 30339 Undersecretary Noksignature
Tire Commonwealth of Atassackuse&
Department of Industrial Accidents
0ffwe of.Inves*a&ns
Ut 1W >R'ashiizgton 3'tineet
Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit; Sanders/Contractors/Eleetriciang/Plumbers
An heant Information Plena Print Legibly
Name(Business/Organization/Individual): Omle-
address; 08 6 o s-4N vr�v
City/State/Zip: s v v/,VAr Phone #: So
Are you an employer?Check the appropriate box. Type of project(required):
1.❑ I am a employer with 4. [9 I.am a general contractor and I
6. New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ l am a sole proprietor or partner- listed on the attached sheet.$ 7- n Remodeling
ship and have no employees These subcontractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. g, El Building addition
[No workers'comp.insurance 5. ❑ We are a corporation-and its I0.[]Electrical repairs or additions
required.] officers have exercised their
3.0 I am a homeowner doing all work right of exemption per MGL 11.❑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'
I3. Other
comp.insurance required.]
*Any applicant that checks box#1 must also fit out die section below.showing their workers'compensation policy h&nnation.
t Homeowners who submit this affidavit indicating they are doing all.work and then hire outside conhacmrs must submit t,new aim indicating such.
tconuactors.that check this box must attached an additional sheet showing the name of the sub-coutraetars and their workers'comp.policy infomtation.
I ram an employer that Is providing wOPkees cmnpensadon insumwe for►ray errtpdoyees. Below is the policy and job site
anformadon.
Insurance Company Name:_`�� 15 X rr'C, l$ (�O .
Policy#or Self-ins.Lic.#: d /7 3 / l 3 Expiration Date: 3
Sob Site Address: ���� i�i(/ �-!�• City/State/Zip
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil.penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the D fo surance coverage verification.
I do hereby eetb)51 ran pains d pen 111 of perjuvy that theoafn providedr is a and corrsec .
i nature; Date:
Phone#: 5b (O 7�-
00chd use o*. IAo not write in 1kh area,to be conrk1ed by city or town offmial
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/To"Clerk 4.Electrical bspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
7
.1
HOME IMPROVEMENT CONTRACT Sold,Famished and Installed by:
PLEASE READ THIS CONTRACT THD At-Home Services,Inc.
d/b/a The Home Depot At-Home Services
908 Boston Turnpike Unit 1,Shrewsbury,MA 1545
Branch Name: Boston South Date:5/15/2015 Toll Free 8779033768;Fax 8009863610ME Lic#C 02439 RI Cont.Lic#16427
CT Lic#HIC.0565522 MA Home Improvement
Branch No: 31 Contractor Reg.#126893 Federal ID#
75-2698460
Installation Address: 130 Phinneys Lane CENTERVILLE MA 02632
City State Zip
Purchaser(s): Work Phone: Home Phone: Cell Phone:
M/M stanley tucholski (508)775-2819
Mr. HenryArden 508 775-2819
Home Address: 130phinisline CENTERVILLE MA 02632
(If different from Installation Address) City State Zip
E-mail Address (to receive project communications and Home Depot updates):capecodl30(a),yahoo.com
Marketing emails will not be sent from The Home Depot.
II Proiect Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to
buy,and THD At-Home Services,Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installation("Installati "
on")of all materials described on the below and on the referenced Spec Sheet(s),all of which are incorporated into this Contract
by this reference,along with any applicable State Supplement and Payment Summary(where applicable)attached hereto and any
Change Orders(collectively,"Contract"):
Job#:(Internal Reference) Products: Spec Sheet(s): Project Amount
8264565 Roofing 8264505 $11,450.83
Minimum 25% Deposit of Contract Amount Total Contract Amount $11,450.83
due upon execution of this contract
Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion .
Certificate(one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each
Customer under this Contract agrees to be jointly and severally obligated and liable hereunder.
The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included
herein,at its discretion,if The Home Depot or its authorized 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.
Payment Summary:
The Payment Summary# 8264505 ,included as part of this Contract,sets forth the total Contract
amount and payments required for the deposits and final payments by Product(as applicable).
06117114SA Page 1 of 7
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS CONTRACT
NOTICE TO CUSTOMER
You are entitled to a completely filled-in copy of the Contract at the time of sign.Do not sign a Completion Certificate(note:
there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that
Product is complete.
In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,
expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus
any other amounts set forth in this Agreement or allowed under applicable law.THE HOME DEPOT MAY WITHHOLD
AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE,
WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVER OF SUCH AMOUNTS.
Acceptance and Authorization: Customer agrees and understands that this Contract is the entire agreement between Customer
and The Home Depot with regard to the products and installation services and supersedes all prior discussions and agreements,
either oral or written,relating to said products and installation.This Contract cannot be assigned or amended except by a writing
signed by Customer and The Home Depot.
Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has received
a copy of this Agreement.
You are entitled to a paper copy of this Agreement if you choose. If you consent to an emailed copy,your consent applies
only to this Agreement.By contacting sales office(R77)9o'i-376R ,you may update your email address,withdraw your
consent,or obtain a paper copy of the Agreement at no charge. By signing below,you confirm the following:
• You consent to receive only an emailed copy of this Agreement
• You have access to a computer that can receive and open emails and PDF(Adobe Reader Version 10.1.4 or
later)formatted documents.
• Your email address is correctly listed on the Home Improvement Contract
Submitted by: Accepted by:
Christopher Customer her G.Read •�
Sales Consultant p Signature:
License Name.
(877)903-3768 Customer
Telephone No. Signature: ?iY1�t� IU. 1f 5Kai'VIa'r` 1`". 20 1 b. 12
Sales Consultant
License No. (as applicable)
CANCELLATION:CUSTOMER MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION/
BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIR)i yICIF1SkSE .nr; !'�r�en r F;1a; 1:�. 01= 1
AFTER SIGNING THIS AGREEMENT.THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM
TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE
j
06/17114-SA Page 7 of 7
i,-
Department of Industriarl Accidents
Office of Invesdgations
1 Congress Street,Suite 100
Boston,MA,02114--2017
.www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant.Information Please Print Le 'bl
Name (Business/Organization/ladividual):
Address: __74!3 WaOerlv ,
City/State/Zip: 6/7QZ- Phone#:
Are you an employer?Chec the appropriate,bog: Type of project(required):
l.❑ I am a employer with 4. ❑ I am a general contractor.and I
* have hired the sub-contractors 6: El New construction
. employees(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 S. ;❑Demolition v
working for me in any capacity. employees and have workers'
insurance.$ 9:`❑Building addition
comp.[No workers' comp.insurance P•
required.] 5._❑ We are a corporation and,its 10.❑Electrical'repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
m self o workers'com . right of exemption per MGL: '
y p 12:E Roof repairs
c. 152
insurance required.].t , §1(4),and we have no
employees. [No workers' 13.❑Other
comp. insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: _
Policy#or Self-ins.Lic.#: 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). µ
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 verage verification. .
I do hereby u t e aim a4f&aldes o er u that the in ormation provided above is true and correct .
'Si ure:a aid— — - Date: rc
- Phone#: %5_08
Official use only. Do not write in this area,to be completed by.chy 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#: °r
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F Engineering Dept. (3rd floor) Map Parcel 191 ` Permit# 19 a 7
House# - oo Date Issued
Board of Health(3rd floor)(8:15 -9:30/1:00-4:30 �� I ee 7 �8
./Conservation Office(4th floor)(8:30-9:30/1:00-2:00)
P - oo mm. g.) cFIKE ,
D m i an pprove y Fa 19 SEPTIC S T BE .
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IN."AALLED e ➢ F `
TOWN OF BARNSTABLF TH ° 'A
r-V,iR0N,mgENTYaL C' 7
Building Peit Application
/` Ln treet Address 130 Vh,)naeul�
Village ��1
Owner �� Address 1
Telephone 7 7 C� al 1
Permit Request n "f
First Floor square feet Second Floor square feet
Construction Type gg .
Estimated Project Cost $ 0 E?; 00o 7v96�0
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House ❑Yes ❑No On Old King's Hi way ❑Yes ❑No
r1
Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing New Half: Existing New
No. of Bedrooms: Existing New
Total Room Count(not including baths): Existing New First Floor Room Count
Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other
Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No
GaraglZ�Detached(size) X( Other Detached Structures: ❑Pool(size)
❑Attached(size) ❑Barn(size)
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes No If yes, site plan review#
Current Use Proposed Use
p � -
al C&V-n`$`k -C>VYY1 (0(-fBuilder Information
Name 0(9"1` P1�4ewbv`• wQ� t( Telephone Number
Address by License#
Home Improvement Contractor#
Worker's Compensation#
7
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE - DATEIAN
BUILDING PERMIT NIED FOR THE FOLLOWING REASON(S) r' ..
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.PLOT PLAN
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Indicate location of garage or accessory building
Additions with dashed lines ---------------
Sewerage disposal (cesspool) ED
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Abuttores
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(Lot....................fr- fzastage)
\ --------------------------------------------------------
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/ \ Information
\ Supplied by —
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