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HomeMy WebLinkAbout0081 WARWICK WAY �. __ ;, f u n � � ` i �oprr�r>o�i, Town of Barnstable *Permit# 0 Regu]atory Services. l.rprre , „ram ,, ro,rrfs-rue dnrr �ewRvsr.st> *, n!„ � . Fee l Y #A $ 'b`6i t J e 6J9 ,� Thomas F. Geiler, Director . LW Building Division 14„t ' `r `� NS M1 � a Tom Perry, CBO, Building,Corrrmissioner - 200 Main Street, Hyannis, MA 02601 www,town,barnstable.ma.us Office: 508-862-4038 Fax; 508 790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid williout Red X-Preis ImPrin/ Map/parcel Number O Prop Address gl l� e ' er V, �e Residential Value of Work DO Minimum fee orS3S.00 for work under$6000.00 Owner's Name & Address F4 TPOAl d C Contractor's Name iJ 0sc r - Te ephone Number Home Improvement Contractor License #{if applicable) 7or ction Supervisor's License#(ifapplicable)_ 70077man's Compensation Insurance Check one: ❑ Tam a sole proprietor Ej/am the Homeowner En I have Worker's Compensation Insurance Insurance Company Name W1416 n Workman's Comp. Policy Copy of Insueance Compliance Certificate must accompany each permit. Permit Request.(check box) Ej Re-roof(hurricane nailed) (stripping old shingles) All construction debris will be taken-to Ej Re-roof(hurricane nailed) (not stripping. Going over' existing layers of roofl V[:] R de #of doors acement Wind otivs/doors/sliders. U-Value 33 (maximum..35)tl of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i-e. Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the`Home Improvement Contractors License & Construction Supervisors License is required, SIGNATURE: ):IWPFIt Fe1FnRM.Slhuildinencrmii rnrn6PYPPI:QC.1,, The.Commonwealth of Massachusetts. Department of Industrial Accidents Office fInvestigations 600 Washington Street: Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance.Affidavit:Builders/Contractors/Electricians/Plumber-s,. A ticant-hnformation Please Print 0 ibh Name(B.usiness/Organization/Individual) t� U Address. S N ;� City/State/Zip: e lJo d G 3 Phone#eAre you n employer? Check the:ap ppriate bog Type of project(required): 1.❑ I a e lo. er with 4. 0 I:am a.ggimil:cor<tractor and I 6. N construction mp y mployees(full and/or part-tune)* have hired the s*contractors... 2. I am a,sole proprietor or partner- listed on the attached sheet. 7,:. emodeling slnp:and=have no.employees These sub-contractors-have g,. Demolition working for in any capacity. employees.and have workers' 9 Building addition [No workers'comp.insurance comp.insurance3 requtred:] 5.;E We area corporation and its 10.E:Electrical:repars or additions 3.�.I qu a homeowner doing all work officers have exercised their 1 i Q°Plumbing repairs or additions myself`[No workers'comp. right of exemption per MGL 12❑Roof repairs insurance re aired t :.c: 152;§1(4);`audwe have no required.] employees [Na workers' 13.[1 Other comp.insurance required.] *�Y applicant that checks box A.must also fill out tfie section below showing their workers'compensation policy information. t Homeowners who submit this:affidavitindica g.#hey re doing all+work and the hire outside contractors nwst submit a new afidivrt indicating such: =Contractors tha(-check;this:box;must.attached an, ditional sheet showing the name of the;§4b,.;m ractors and state:•whether or not those endues 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.. :: c^ Yfr/110A /�AJ,11 .�w Insurance Company Name. (� l l — . Policy#or Self ins Lic # 1:P 0 a O _ Expiration Date: Job Site Address. �/l/. 7' (%V City/State/Zip. : . e 3 Attach a copy"of the workers'compensation policy eclarationpage(showing the policy number and egpiratton date) Failure to secuie coverage as requtred under Sectton 25A of MGL c.1,52 can lead to the imposition of criminal penalttes'of a fine up to$1506.00 an, or`one year`imprisonment'as well as civil penalties�n the'form of a S fOP WORK ORDER and a fine of up to$250 00°a.day against the'violator B64dvised that:' copy of this statement may forwarded to, Office of Investigations-.of the DIk.for insurance coverage verification. I do hereby cert' under the pa' s and penalties of perjury tha the information provided above is true and correct. Si nature. Phone# � Official use only.. Do'not write in.this.area,to be complete¢by°city or town'o ciaL City or Town `' Permit/License:# Issuing Authority(circle one): . 1.Board of Health 2.Building Department'-3 City/Town Clerk 4.:Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to'•provide''workers'compensation for their employees: Pursuant to this statute,an employee is defined as"...every,person,in.the'service of another under ary-contract of.'hire,'"; express or implied,oral or written." An employer is defined as"an individual,partnership,association;corporation or other legal entity,or any two or more of the't�oregoing engaged m a�ouit enterprise;an including`the legal representatives of a de"ceased employer,or the receiver or:trusted of`an individual;:.partnemhip,.associatipn or other legal entity,.employing employees: However the. owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house, or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or.permit to operate a.business or.to`construct,buildi.n nthe:commonwealth for, applicant who has not.prod Additionally, p lMGL chapter uced acceptable evidence of compliance with the insurance coverage`required.' 52, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall n enter into any contract for the'performance of public work,,until'acceptable evidence of compliance:with the insurance requirements of thivdhapter have been presented to,the contracting authority." Applicants Please flout the workers'•compensation affidavit completely,by checking theboxes that apply to your situation:and,if. necessary,supply..sub-contractor(s)name(s),addresses)and__phone.-:number(s)along with.their certificate(s)of. insurance. Limited Liability Companies(I LC)or,Limited.Liability:Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'.compensation insurance. If an LLC or LLP does.have employees,a policy is.required` Be advised that thisraflidavit may be submitted to the Department of'Industrial Accidents for confirmation of insurance coverage .:.Also,be, to:sign.and date the affidavit. The affidavit should be returned to the city or town-that the.application the pemnt or license is being requested,notahe.Department of Industrial:Accidents:_;.Should,=you have.any questions regarding the�law or if you:aie.requiredto>obtain.a workers'.: . . . compensation pokey;please call the>Department at the number listedbe'low. Self-'insured,companies should enter their self-insurance license number on the a • ppropnate,line; `:` ; . : City orTown Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided Ea space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has 6contact you regarding the applicant. Please be sure to fill,in the permit/license number which will.be used as a reference number.. In addition,an,applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under:"Job Site Address".the.applicant'should write"all locations in (city or town):"A.copy of the aflidavit:that has beenoflicially-stamped or maiked.by the.citor y .town maybe,provided,to.the applicant;as proof that a valid affidavit is on file for future permits.or,licenses. Anew affidavit ppst.be.filled out each. year.Where a home owner or citizen is obtaining a license or permit.not related to,any business or.commercial.venture (i.e.a dog license or permit to burn leaves etc.)said:person is NOT required to complete this affidavit. . The Office of Investigations would,like to thank you.in.advance for your cooperation:arid should you,:have;.any. questions, Please do..not hesitate,:to give us a call:, The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial:Accidents •' . Office:of Jnvestigations . 600 Washington Street Boston,MA 02111 Tel. #:617=727-4900 extA06 or;1477-MASSAFE Revised 4-24=07 Fax#617-727-7749 www:mass.gov/dia HOME.flV1T'ROVZM9K TT:CONTRACT ]RETA4SEREAD: S {O l�_./ b Sold.Furnished andInstalled by.-.` BranclrName:--Boston: f�J(�_•_t_, -.•,; .•:•_::.: ,.:..,, TI�3,AY=EIomaServices,Inc. dlb/a:IYec.klotne Depot At Homc Services. • •. ,.; .. :, : 345A.GreenwoodStt+ L Unit2,.Worcester-MA:0I607 Brandt Nnmbe. .3l ;.... ....; Tolt Free(800)657-5.182;.Yax.(508)756-8823 ;..• ,.;•.. •. .. .... C t')2439:RTC nt-ho#1 27 . ..... � ._ .:.. Fcderal.lD#-75-2698460:M8 J.� #C 0 64 j , f CT lie S 565522:MA Homc7mprovc/mcnt Cge/tntct Reg:ii I2 3 Insntllation Address: dT 1__��, G���A "�t�4�. . _ r� Q t T "••. "r Cf D.Z `L Puurcnosc*(s):. Work-Thune! Aume atePh :: - CCUP'hm*: [Or . . . ].. ��� Hottto Address: (If different from Jnsaillaiioo,Addtesc) GSty: . ,.._ . . . ....- :..State Zip E-triad Address to receive ect commmnicationx-and;Home I DO NOT wish to rmcive,aan mvketin czuWJs'from: depot updates).' M - y g- The•Iiomc'DcpoC:• - . _ . . .. ... Pioieetlidnrnuttim buy; and and THD At-Home Services,Inc.("The Home Depot")agrees.to;furnish;deliver'and•arrange for the'instailation{"Inslailagon")of albmatcrials.deserxbcd•on?the:below.and-on thetefereneed-Spee:Sheet(s),all of.wlrich are.incorporated_into•ttus Contract by,.this reference;along.wi hany.applicabie.Shate;Supplemnt and Payrment,$umtnaty attaehed.hereto and•any Cliange;0iders:(c0llecrive1y, „Contract'): ... Job# tr>va,rtrd i .;,...,.•.... ...: .... _ .. ucts: '., `Sheets ff� "-Pro'eet Attionrit L3Roo1[mZ-LjSidingXWhWows Insulad �Guttas7 Ccwcts �FittrY-Door i�J :. $, oofing' Siding" windows ..Insa]atioo ,�Gutteic/,Coyixs..❑SntryJloo[s.•[]'. -. :, . . .. . ,. . ... $? . •. . .. '�. ooCutg: Siding. W.indowx Lnaila00n • :flGuttezyl•Covers:�Eony.Dooxa•❑.: .. .. :� ... .,. -�•. .. .. /! Roofing siding'• Windowr, insulation Cpvcrs t Bntrar Doors n � :Ntimmnnn2s%•!?epoaitofeonaaanmmmtene.�aeaccCutsoac£trlisoonanxi.•..,:.;•� • ._ _ ... e _ ...- Maroc J'ur'�ets trtgy rat dytoRtt ttwre then ame.thfid ot'tbe C0�'sctAmnui�• Totai Contract A•i>mnnt• $ ��f ;��:�, Ctietoruer agrc ,that;immediately_atpon completion:of the:work for,each Product;Custo r wdt exeailtc a Cw-victimir Certificate (one fdr eaeN P�oduet.as de5ned'by,;an individrtal°Spec Sheer)sind'.pYY_auybajitce'dne:: ri appheah]e,eac$;Cictojmer under this Contract agrees to:be jointly:and severallyobPlgalect attd liable hereorider;.; '' .. _'`.: '•':•' : .,•.• . -.. • The Home.Depot fescrves,the'right to Issue a:Change Order or terminate ibis,Contract;or•anyindividuel•P.roduct(s)included•herein,at its dist:refion,if The Home Depot or its authorized service pmyider•deternfmp.dart it cannot:perform:its:obligations,due to a stmctnr tl problem with.tbe:home,environmental hazardx.suchoas mold,asbestos.or lead paint,other safety..conu�s,pricing errors_or because work required to connpfete;ilic job-was notiticl»ded.in fate Contrriif ' :. !;:: Payment Sumn-._: The.Payment Strmu>nry:# O C3 :incladed.as part'o£.this Contract;:sctt forth tticv_-toml Contract amount and•paymemsaequired f&;the:depositsaWfiinal paymAts•byProdoct(as applicable):. ,•:_:. . `15OTICE TO CUSTOMER You•are'entided to a-completefy Sled=in copyorft Contract atthe tune"you sigi%.'Do riot sio'a Compk&ii Cerfiffcate'(iiote: there is one Completion.Cerfir=tefor each listed Produd-W6fned by.indivtduaXSpec•Sheetgbdore•work-on that Product is complete. In the event of termination of rhea Contract,Cu—sto-ner agrees to pay The Home Depot the cost%of•materials,labor,expenses and services provided by The Horne 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 ROME DEPOT MAY W TEMOLD AMOUNTS OWED TO THE ROME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES b)OR RECOVERY OF SUCH AMOUNTS. Acceptance and Anthorrcation: Customer agrees and-understands-that this Agreement is the entire agreement between Customer and The Home Depot with regard to the Products and Installation services and%Wersedes all prior dimnsdons and agreements,either oral or written,relating to said Products and Installation.This Agreement cannot be assigned or amended except by a-writing sinned by Customer and The Home Depot Customer acknowledges and agrees that Customer has read,undeintands,voluntarily accepts the _.teens of and has received.a copy of this Agreement cceptedby- .. Sub... hy. _ !X �� � :�� P• � • air � �n. X a 's$i Lure Date _ Sales nsultant'sSignat Date Telephone No. 5j� Cu 's Signature Date. Sales Consultant License No. CANCELLA't,TON: CUSTOMER MAY CANCEL THIS (asapplieabb) AGREEMENT WrMOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE.ROME. _ DEPOT BY MIDNIGHT ON THE THIRD BUSINESS . DAY AFTER SIGNING THIS AGREEMENT. '.THE STATE SUPPLEMENT ATTACHEDd HERETO CONTAINS A. FORM TO USE IF ONE IS SPECJFICALLY PRESCRIBED BY LAW ' IN CUSTOMER'S STATE. NOTICp:ADDITIONAL TF,RMS AND COMMONS ARE STATFOON TMX REVERSE SIDE AND ARE PART OF THIS CONTRACT 11-3"0 C-SC Whits-BtanchFile Yellow-Customer Pirk_cio�r „ham.. T00'd SIXXV10 locizT 3WOH Sir:ZT OIOZ-LI-100 it 23 1.O_ 03: 14a f lane CARD_ CERTIFICATE OF LIABILITY INSURANCE 03/15/2010 � ! T}{iS CgRTlFiCATE tS ISStiEI?AS A IUSATTER OF IIdFORMATiON ?^nGDUCER 508.29�.4440 FAX 508.295.SS#i4 ONLY AND CONFERS NO R.'GktS upoN THE CERTIFICATE Paul B. Sullivan Insurance Agency Inc. BOLDER.THIS GERTiFICATI=DOES B TAiVI PiR EXTEND OR D Cranberry Highway ALTER THE:COVERAGE A¢Ft?RDED'3 f Ty E cpLICiES 8EL4`1':. 2S7 y P. 0.. Box 551 N4..�^R AFFORDINIS I-IOv?; AGXL Nri,G T S 25.�13 =ast varena^!, "'A 0253c yer'ncnz yu.ual :Insurance CO. 34754 e:-Ing Cor>:merce Insurance Company li Wilson Way _ +.A L-734c rsL = I Yliddl ebarougfT, ---- i 3. COVERAGES riSTANC:AG TKE POLICIES OF INSURANCE LISTED T EO BELOW HAVE 3E£N ISSUE[)TO:fiIc{n bURcO NT NAA1E'�ASOv AC TH£TERMS, ZX'ERI.5ION SAND COND TIONS OF SUCH ANY REQUIREME cT-TERM OR CO DITIAFFORDED t3Y T r CNT S DE6COTHER ItlB O HEREIN£$SUaj;:C TO ALL TO V'• T?.S Ef2T*FICATE MAY BE ISSUeO OR MAY PERTAIN.THE INSURANCE POLICIES.AGGREGATE UM[TS 5t'QWN MAY HAVE 6ctN REDUGE0 Bl'PA t7%LA ti LIMITS 11 'LTR k5rGENA NCE POLICY NUMBER DATE MMIODI1 0 V' OATS aBMiDWYYYYI i'3 1,00AOO 2/2010 03/ZZ/201Z EACHOCCJRRENCE r f r, MtsEs I �, S'o0 { rALL L'AO(L!TY MED I XPAnny 3neGerson: 01 CCCUR j PERSONAL&AIIV t,WURYUOQ,00As i I G_AERAL AGGRfiGATn 3 2,000,00 { 1 ,i 2 000,00 { !PRODUCTS-COM?lOPAGG 3 - 1 y t CEN'L AGGREGATE LIM;T APPLIES P£R. I PRO- 11/26/2010 QVZ2 76 11/26/2©OS i EaMaodde0:}INuLE LIMIT 3 I AUTOMOBILE LIABILITY i ! BG ANY AL:0 1 s+iLY SN.it1RY 3 100,00 �1 ALL OWWCC AUTOS I yyy !(Per person) .—... :I 1 X SCHEDULED Ali T OS ; t BODILY:WURY t o hiRED AUTOS I Per accident) 1' 300,00 i _ j !NON-OWNED AUTOS i I F ,yDIAh9AG ( { Per 100,000 AUTO ONLY-EA ACCFOENT 5 gACG S GARAGE LIABILITY OT4!ER THAN AUTO ONLY- AG3 5 I i i ANY ALTO EACH OCCURREHCf S I f EXCESS!UMBRELLALtA81LiTy _ I AGGREGATE F .s OCCUR CLAIMS MADE I i ! } i'EDUCT1B E TORY LBeItTS FIR f RETENTION S WORKERS COMPENSATION ;EL.EACH ACCIDENT $ AND EMPLOYERS'LIABILITY Y i N S 4 I - y 'ANY PROPRIETORIPARTN£RicXECUTItit "1 ' t I a�L pSEASE E� LOPE I OFFICERIMEMSER EXCLUOED? (t E-L.DISEASE•POLICY LIMIT S 1(Mandatory in NH) f , I if . abe under I t ' S?Eyes C!ALdesc PROVISIONS be:ow I f i 1 DESCRIPTION OF OPERAT1oNS f LOCATSDNS I vEHiCLEs I EXCLUSIONS ADDEa BY ENOOincluded ilclSldt'd d5 PAdditional Insured with respertS t0 Q AT Home Services, Inc and The Home Depot Are perneral Liability Insurance CANCELLATION noN; CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRISEfl POLICIES BE CANCELLED gjO DAYS WRITTEN DATE TMEREOF,TmE ISSUING INSURER WILL ENDFAVOR TO MAIL BUT FAILURE TO DO SO SHALL ( MOTICE TO THE CERTIFICATE HOLDER NAMED TO THE t.EFT. OR' AGENTS THD At Home Services, Inc 1 L Services NEpoS£NOOgLI(;AtTON OR LIABILITY OF ANYUND UPON THE INSURER.ITS . 1 DBA The Horne Depot At Home 1,690 Cunberland Parkway 1 rr�RESENTAnVfmS. RES � Suite 300 AUTHORIzeoREPS.ITATWE Atlanta. GA 30339 Edward Sullivan ANNE tc;99@8-2099 ACORD CORPORATION. All rights reserved. ACORD?5(20091011 The ACORQ name and logo are registered marks of ACOR R�:;Y;'f1 ttt stlPt<ttR°� �C'�.:►.:tPPtP:�;171i1 lt.:iflt�.lP'l1� License: CS 70077 Restricted to: 00 XSEPH C OUARTE 15 FALL ST WAREHAM,AAA 02571 , Expiration: QW/2010 Tra: 7662 sad`esesiar't> i.icsr�ag teEitl:Nion dslid for indis'idulvsr>��}: I qed of BriWisglu eft°°0" Urfole Ike elyk_tion dratc. 9f found m"S"tv: "ME OAPROVEMEW C MACTf91� it�r�d cr�C+6l►"Y S�ytytinns eve'teaAdaeds p Fp r"ioo' 13234 (a,te•ash®uatnes Y1ser itst i_iW - Espetilbr►: tft}i20%1 i� VOW 41&It21(I� Type: i'adritnhap J g J Ron iOUMI SS Fall 51 !,Fasi+ei�ir:h� vya,(Ogm. ma 0257, i . ., � \ 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 Office of Consumer Affairs and Business Regulation Registratlon.1. 26893 Type: 10 Park Plaza-Suite 5170 1 ExpiraEiorr $/a/2012. Supplement Card Boston,MA 02116 The Home Depot'A Hoc b Services j DARREN DEMERS 2690 CUMBERLAIRP PARKWAYS Not valid without signature 1 gi'[rq ,GA 30339 '_`"'..`; Undersecretary ; i , Ate°?® _ CERTIFICATE OF LIABILITY INSURANCE - � 02/19/10 PRODUCER 1-404-995-3000 FHIS CERTIFICATE IS ISSUED AS A. MATTER OF INFORMATION Mar3h USA, Inc. --ONLY AND CONFERS NO RIGHTS L'rCN THE _RTIFlt', H'3L.D R. THIS CERTIFI CA. DOES NiCT EXT'END 1 R � homece_�o .carcreq.:estCwnarsh.com TER THE :OVERA' = A_OR''ED, � -, o_ ' J Twc Al-.Aanc- Center, 3550 Lenox Road, Su=.te 2400 �---_- -- - — I Atlanta. GA 303213 I Fa ( 12) 548-03! — — ... The done Den-. , Hcme Depot U S Tn : t 3 .,ur-_n American Ina Cc 2455 Paces Ferry Road NW INS!iR:.RC:New :a-m shire Ir.3 Cc Building C-20 -- - ----- ---- ----- - Atlanta, GA 30339 � INSURERD:NATIONAL UNION FIRE INS CO OF PIT'rS__.i 19445 1 tNSURERE:Illinois Union Ins Co 27960 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DDT POLICY EFFECTIVE POLICY EXPIRATION - TR NSRD TYPF OF INSURANCE POLICY NUMBER DATE MMIDD/YYYY DATE MM/D /YYYY `LIMITS A GENERAL LIABILITY GL04887714-00 _ 03/01/10 03/01/11 EACH OCCURRENCE_ $4,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 1,000,000 — CLAIMS MADE a OCCUR MED EXP(Any one person) $EXCLUDED_-__ PERSONALBADVINJURY $4,000,000 GENERAL AGGREGATE S 4,000,000 - GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $4,000,000 X I POLICY PROT LOC ----- -------------- JEC B AUTOMOBILE LIABILITY BAP 2938863-07 03/01/10 03/01/11 'COMBINED SINGLE LIMIT $ 1,000,000 ' X ANY AUTO (Ea accident) ALL OWNED AUTOS - BODILY INJURY $ .. SCHEDULED AUTOS (Per person) HIRED AUTOS _ BODILY INJURY $ NON-OWNED AUTOS (Per accident) X SELF. INSURED AUTO PROPERTY DAMAGE $ PHYSICAL DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ �- ANY AUTO - OTHER THAN EA ACC $---__--..__-_ AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY GL04887714-00 03/01/10 03/01/11 EACH OCCURRENCE $5,000,000 X OCCUR CLAIMS MADE AGGREGATE $5,000,000--_ $ DEDUCTIBLE $ RETENTION C WORKERS COMPENSATION WCO20342355 (ADS) 03/OS/10 03/01/11 X WRySLAMU OTH- AND EMPLOYERS'LIABILITY --- — -- ------------- D ANY PROPRIETOR/PARTNER/EXECUTIVE WCO20342356 (CA). 03/01/10 03/01/11 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED] " -- --- -- E (Mandatory in NH) WCO20342357 '(FL) 03/01/10 03/01/11 E.L.DISEASE-EA EMPLOYEE $ 1,000,000_ If yes,describe under - HD PECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1,00 0,006 THER X EmployersExcessTNSC46242373 (TX) 03/01/10 03/01/11 Occurrence/SIR 30M/2M orkers Compensation WC0910566 (QSI) 0.3/01/10 03/01/11 orkers Compensation WCO20342358(KY,MO,NY,WI, ) 03/01/10 1 03/01/11 .DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THE HOME DEPOT, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN HOME DEPOT U.S.A., INC. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 2455 PACES FERRY ROAD NW BUILDING C-2.0- REPRESENTATIVES. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE USA ACORD 25(2009/01)Jthornton_hd ©1988-2009 ACORD CORPORATION. All rights reserved. 14481889 The ACORD name and logo are registered marks of ACORD The �r�ran?r�n;vetrlrl�t t�t'M is$ri�iti�$eti$ ✓epart19'ent Of Indu$t7ial t�iCiiilP.9^it'$ ©/JiCL'of Investigrttir)its Y aJ00 �7 iisi fngiDdt si eei �ir.�itu:+r L -� v% aJi4 l:i r�vr/St.a Insurance �i fl;e print ��Oi i�2r5� Com;�ey3 a`. r! ?1r ant e i� ��it: 7al�L�2:S/coPt r�CtO!S/ )'C=1'lilrl i� �—— Na-me(Ousiresj5lUraarizaticn/l::^t rt,:tail• ; ) 1 Address: r , -1�s✓,. ' Phone 9:City/State/Zip: �f ' " r Type oa (required): Are you an employer?Check t e a prop ate b I am a general contractor and I 6 ❑ truction I.M I am a employer with_�llDhave hired the sub contractors ng employees(full and/or part-time).' listed on the attached sheet. 2.❑ 1 am a sole proprietor or partner- These sub-contractors have S. []Demolition ship and have no employees employees and have workers' 9 ❑Building addition working for me in any capacity. comp.insurance? [No workers'comp.insurance 5 We are a corporation and its 10•❑Electrical repairs or additions itt repairs or additions 11. Plumbing P v exercised their ❑ required.] r ha e office s caner doing all work er MGL e airs 3.❑ 1 am a homeowner i' right of exemption p l2.❑Root.r p myself.[No workers'comp. c.152,a 1(4),and we have no 11 Other insurance required.]t employees.[No workers' comp.insurance required.] Any applicant that checks box 1 must also fill davit indicating tihey are doin,all wo the section below rk and hen hiwing their re outside sidetcontracto s thust sub t information.n w affidavit indicating such. t Homeowners who submit this afft Contractors that check this box must attached an additional sheet showing the name of the sunnu nbesand state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. p. Insurance Company Name: K n L•� � Expiration Date: � I Policy#or Self-ins.Lic.#: o © � + 1 v O X 3 City/State/Zip: Job Site Address: e e date Attach a copy of the workers'compensation policy5A of MGL ation page an lead to the imposie policy tion of,cr m nalmber nd tpenalti s of a Failure to secure coverage as required under Section fine up to$1,500.00 and/or one-year imprisonment, that a copy of this il tstatement may be forwarded to he Office es in the form of a STOP WORK d a tine Of of up to$250.00 a day against the violator. Be advised investigations of the DIA for insurance coverage verification. do hereby certify under ns and penalties ury that the information provided above is true and correct. Date: 0 Si nature: [6.Other se only. Do not write in this area,to be completed by city or town official. Permit/License# own: uthority(circle one): of Health 2.Building Department 3.Cityr'rown Clerk 4.Electrical Inspector 5.Plumbing Inspector Phone#: Person: i71 � a. Assessor's map and lot number ...............�:x,;, ... ............ oFTNero Sewage Permit number ... .......�....•�..............� .!.!�. F. House number = B9Ha9TABLS, S ...................................�.PA rasa ~�l*::.................................. Epp i639• e� .s�,0 YI►Y a� TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO I C1� �C.�'.fir"� ���'������i �G �' `l l(� 1 ... .. ......................... ............ ...... .....................................°r TYPE OF CONSTRUCTION .......�' �... .. 1�f..................�.................................................................. ...... ..................... 19 TO THE INSPECTOR OF BUILDINGS: The Undersighedl hereby applies for a permit`according to the following!A[r formation: 9 Location ...................................:"..... ............ . . ... .. .. . ... .... 4m., L Proposed Use rl1 � �/ ,. f ?.?. Y i .. . ....... ............................ ..... . ...... � , }..li' /t... r ............ ..........Fire District: ,l .!.1///�%',.�( ���r� (U/ ... Zoning District .... ..-. /.. .... � ... Name of Owner .`^ r. "....{" . .+�' '................ ..........Address ` ...r��� . f N..:............ ...•.Aw Nameof Builder ...... ................Address ...... ............................................................................. Name of Architect . ..Address .. ... ..:. .Foundation. ................................... .. .�. /.� .�.. ................ Number of Rooms f..1.! ............:............................ f'�. � .,¢`� .C......5.;... 1- . /�:.. ............ Exterior "V, ' f�t` �....'�........ J//2����11C ,...........Roofing ....//1� /...................../ `` .............. Floors /,..1......... ...... ?................. Interior .. j.. ./.�:... . `............................. �,, c. Heatingt.S....... .!./ `�..........................:.........................Plumbing ...... .................................... ........................... y r �&)Fireplace .,..1.'� .�..........................Approximate. Cost .........�...................................................... Definitive Plan Approved 'by Planning Board -----------_______-----------19________. Area .......................................... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH s _ OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ....................... .............. .................................. Construction Supervisor's License ......... ............. COOLIDGE HOMES /7 / /ql No 25.8G3-. Permit for -O��..St --- . __S ' �o I��.. .............. - � Location ..I^.ot...23.........8.l..�azv«i ...Kay. . ' Centerville ---^'~'-''~~'^~^----^-~--------- ' ' Comlid Bonzeo ' C�vnar ..--.�����.�-------------.. ^ Type of Construction �� � u�---------.� J ~ -,---.--,...---.-.------------ ` F1c» ............................ Lot ................................. Permit Granted --..De���..`j.3^............lg 83 ' Date of Inspection -.----------.lg - - Dote Completed _-----------]g _ . . . ` ` .^ ~ . � ^ - ~ . , - ) . \ � ` . '~ , ,-w ' | ` | ^ / 0 m' ` Asse ssor's map and lot number �/ ....... MtjS7 C'S { /.. �...... SIEpTlic SYSTEM THE C j Sewage Permit number .... 3...�..3 ..1 ,�►A... . ..... NS�Ai LED IN r, wiTH TITLE 5 '1 J (�f* � cl' 4 1i HAR33MLB, i House number ....................... ......... �..... ..... ` E�V19IRONNiEKT- 'o rasa t6 'TOWN RED �Tl0�9 o�OypYtr�9 TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .. �71�.. .T�. /.�' ���. .1� ��f./��7 TYPE OF CONSTRUCTION ....... ........................................................................................ T ....... ::. ..V..........................19. TO THE INSPECTOR OF BUILDINGS: The undersi ed hereby ap lies for a permit according to the following information: i9 �jl� Location .. .. ..... ................... ........ ............................................................. ........ ................................... Proposed Use .Ul` . . ��Yt // h?/ ( II���/�1..`.... ...p........Q. :. . ........ ... .l�.................... ....1�........... \ Zoning District .. !.. f Fire Districtef.%...... .. . . . ... .. . Name of Owner ....... ............/ . .. .......................Address 1 Nameof Builder .. ..............Address .................................................................................... Name of Architect ` i ( ..................................... ......... ... .#. .........:...... .......................Address ...... .. . ................................... Number of Ro ms ......... ....... ...........:..-Foundation ...... .. f Exterior v.��.7C.... ��4-.. (/.`. ......... .Roofin �.... .✓... .� C .............. g ... 1 Interior q /�. (�fj\ Floors .... {,a�..... Heating ..... ................................................... Plumbing ....1 dp. f�................ Fireplace ..y�? �.�J ..�1..l �tJ ..........................Approximate Cost .... / .. ..®.............................. ..... Definitive Plan,Approved by Planning Board -----------__—___-----------19_______. Area ...�.1.. . ..... .: ....... Diagram of Lot and Building with Dimensions Fee3.7.. � .............. SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable egarding the above construction. . Name ................. ........ ....... ................................... Construction Supervisor's License 0Mz.-� ".r COOLIDGE HOMES JV r ' 25862 One Story R Naf...........:..... Permit for .................................... s Single Family,,,,Dwelling,,,,•.,,,.,,,..,. Location Lot ..22,.... 8.1..Warwick VIC Centery .1l.e................................. Owner ....Coolidge,,,Homes..................... Type of Construction ......F r ame...................... _ Plot ........................... Lot ................................ •fix ,f � • � �'Permit'Granted ...De.c.'....1.3;..... .......1^9 83 ..... .. . .. .. . . DateLof?Inspection ..................................19 ' Date Completed ...........................` 19 ,..rr 25862 TOWN OF BARNSTABLE t Permit No. -_--------_--------------- Building Inspector S.nrsrrc t Cash ----------------— — •ua .v Bond _X r�Y►� OCCUPANCY= PERMIT ----------- -- : d Issued to Coolidge HOMPS. Address Lot 22, 81 Warwick Way, 'QgAterville Wiring Inspector �.rar Inspection date "'Te 11 r Plumbing Inspector Inspection date Gas Inspector �� t k-� Inspection date Z 9 h1x e A w X Engineering Department, 'o7 � Inspection date , '9 - Board of Health � � � Inspection date I- if I V f! 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 AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. Building Inspector t FROM TOWN OF BARNSTABLE -BUILDING DEPARTMENT Mr. Francis Lahte;ine . g � 103#i'l"M141N STREET HVANNIS, MA del# Town Clerk Phone: -1120 SUBJECT: FOLD HERE - DATE 'April '10 1984 Work hash)een ,omplet�t uar c e Pe min , 2 ,2 I oQl Cl Home? I Please release-B.md.- .R SIGN D DATE - i - p REPLY Ne7•RMt RECIPIENT:�RETAIN WHITE.COPY,RETURN PINK COPY ` - - PRINTED.IN U.S.A. SENDER: SNAP OUT.YELLOW COPY ONLY`.SEND WHITE AND PINK COPIES WITH CARBON INTACT. . ' ' � � �� �_ gyp' ?���_ •. �� Z7, 37 6 , �o-T- z�) yi - / • ZMCAZA t,f�;C`e�e�Y •c�tTiFY rN.�.�T TNT,evi��.v� � S.id.,bia/.c:/ Ort/' 7"N/� I�L.�eV �3 L�Gr�gT�.�-a�O�% Tj;IE.' . �•^`"k"`` irr4Ct,a�tl,� lqa -W WO WA.1 "e.0 k47" A.t nt TNq'T i T, '�3 t 44 710. 7-A#eA*' fO'A.i r- T.c1�' 7ba_VN ©F YA�erhou-rH , MA5s• % 5.