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0005 WEST TERRACE
Ae'S77 1 �L-n April 20, 2016 -� ,Q Town of Barnstable Building Division 200 Main Street , H annis MA 02601 Hyannis, The homeowner at 5 West Terrace has cancelled the roofing job with Home Depot. It was building permit# B-16-742, and we had paid $45.83. Would you please cancel this permit, and make refund check payable to: Permit Services, LLC 303 Narragansett Avenue Barrington, RI 02806 If you have any questions, please call me at 508-962-6942, or email me at Mike_W_Bedard@homedepot.com. Thank you, 4ike Bedard Permit Coordinator THD At-Home Services,Inc. 908 Boston Turnpike• Unit 1 •Shrewsbury, MA 01545 Phone:774-275-2139•Fax:508-845-6076 9 Toll Free:800-657-5182 1 Town of Barnstable , Pit '�p RegWatory.Services Fee Richard V.Scaij,Interim Director .BII Ztin g 'VISIOII Tom Perry,CH% AWding Commissioner. .. ...... 200"V n Street,gyannijj�MA 02601 Office. 508-862-4038 www town.l>amstaaWe ms.us } — EX MESS PERMIT APPLICATION - j ,gj� Fax:508-790-6230 Ma /parcel Number Nat valid cr ,� X-Presslrnp,�it 1r_TLAL O Property Address s We$r I KRC-Si4eatial Value of%&$ V/LLB Minimum fee of$35.00 for Owner's Name&Address tvergder S6000.00 7Are, , Contractor's Name Home.Improvement Contractor License# Te phone Number (ifapplicable)�oZ Construction&VeMsor's License#(if applicable Wok's Compensation Check one: ❑ I ata a sole proprietor. ❑ I am the Homeowner I have k Worer's . anInsnrance ice CompanyN MAR 28 2016 If W0rkma°'s CMV_poky# WC d - OF BARNS TABLE Ce"of hAranee Compliance C ertifieate must accomFapy each permik _ Permit (check box) Re-roof(hurricane named)(strtPing old shi files) All cow d s will be#aken.to SO w� tf � 905*4- ❑Re roof(hurricane nailed - _ �014 stripping Goia❑ Re (not -side g(j, existinBlaYers Of roof) ❑ Replai;ement Windp ws/dOw-Jslide rs,.0 Va1ne (maxims 35#ofaimdows ❑ Smoke/Carbon Monoxide #of doors: detectors 4 floor plans marked with red S and *MMn m af*& inw.citifts required. Note. wrth ot6�towndepar�aczeroes.Lim Hiss,Coal vst 08,�c Property er A ropy of H fin Pro Owner Letter of Permission. required. �Frooe nt Ccaftad. er &Cons"etion Stipv3sors License Is SIGNATURE: T:IIMM Dlauffftg Revised 061313 RBssaoc .p HOME IMPROVEMENT CONTRACT Sold,Furnished 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 North Date:3/15/2016 Toll Free 8779033768;Fax 8009863610ME Lic#C 02439 RI Cont.Lic#16427 CT Lic#HIC.0565522 MA Home Improvement Branch No: 33 Contractor Reg.#126893 Federal ID# 75-2698460 Installation Address: 5 west terrace CENTERVILLE t MA 02632 City State Zip Purcbaser(s): Work Phone: Home Phone: Cell Phone: M/M ed per (508)775-8632 Mrs. Patricia Pe 508 775-8632 Home Address: 5 west terrace CENTERVILLE MA 02632 (If different from Installation Address) City State Zip E-mail Address (to receive project communications and Home Depot updates):ediopel(afgmail.com Marketing emails will not be sent from The Home Depot. Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,and THD At-Home Services,Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installation("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 9107116 Roofing 9107116 $8,987.00, Minimum 25% Deposit of Contract Amount Total Contract Amount $8,987.00 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# 9107116 ,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). 06117114-SA 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)9o3-376R ,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 -�FC9 - � Submitted b Accepted b y� P Y: MtM ed RAY(MW 15,its.5t9 PM) Sales Consultant Christopher G.Read Customer .Signature: License Name. (877)903-3768 Customer Telephone No. Signature: Sales Consultant License No. Au�pted by:Chr'�stoph@r Rend(Mar i5,'441fi,5:20 (as applicable) PM) CANCELLATION:CUSTOMER MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION Bl DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY 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 06/17/14SA Page 7 of 7 �1 y n o 0 I � �C�/!�+�IR'JS�z'C1l"i�/Jn1�� � l�`C• p,� �. � �, CL ` Office of Consumer. Affairs and Business Regulation ti 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 174817 Type: DBA a c". 0 cr Expiration: 3/20/2017 Trk 263215 CL to ra JOHN CARTER CONSTRUCTION JOHN CARTER ao:� 99 BRIGHAM ST .. WHITMAN, MA 02382 ` Update Address and return card.Marti reason for change. Address ' Renewal ` )employment• Lost Card SCA 1 « 20M-05;11 .•_74•.Y1'(411Y)/(.dfPr1(I�l�1. r'•�(!/JJI(!'�N3/'��i License or registration dnlid for individui use only a\- office of Consumer Affairs&Business Regulation before the expiration date. If found return to: OME IMPROVEMENT CONTRACTOR office of Consumer Affairs and Business Regulation egistration: 174817 Type: 10 Park Plaza-Suite 5170 xpiration: DBA 3120I2017 Boston,MA 02116 JOHN CARTER CONSTRUCTION i �j 22 JOHN CARTER $ 99 BRIGHAM ST WHITMAN,MA 02382 Undersecretary Not valid without signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 y www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): To if Cq,r►6'r- Address: q q j r 1 q oe m St. Appt 4 2 City/State/Zip: l,( ,�'m ar n /�A 02-3 8l— Phone#: 7 8r`u - b/2 7 . . Are you an employer? Check the appropriate box: Type of project(required): I.❑ I ark a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time). ..- 6.have hired the sub-contractors F1'New construction 2.[ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any,capacity. employees and have workers' 9. ❑Building addition, [No workers' comp.insurance comp.insurance.t required.] 5. ❑ We area corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).-' Failure to secure coverage as required under Section 25A of MGL c. 152 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 u der tfie pains and penalties of perjury that the information provided above is true and correct Si ature: - Date: Phone#: 711rl—z?3 &1227 _ 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): LBoard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: IL The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Stree4 Suite 100 Boston,11L4 02114-2017 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leg-ibly Name (Business/Organizationdndividual): The Home Depot At-Home Services Address:908 Boston Tpk City/State/Zip:Shrewsbury,MA 01545 Phone#:506-962.6942 Are you an employer? Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 200, 4. ❑ I am a general contractor and I 6. ❑New construction employees-(full and/or part-time).* have hired the sub-contractors 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 _ workingfor me in an capacity. employees and have workers' y p tY� 9. ❑Building addition [No workers' comp. insurance comp.insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑■ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also till 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: New Hampshire Insurance Company Policy#or Self-ins'. Lic. #:WC 015519215 Expiration Date:3/1f2017 Job Site Address: City/State/Zip: Vi 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' surance coverage verification. I do hereby certify under t ai s and penalties of perjury that the information provided a ove 's true and correct Si ature: Date: �� Phone#: 401-714-63 ' 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#: Office of Consumer affairs and Business Regulation _- -� IO Park Plaza - Suite 5170 ` - -- Boston, Massachusetts 02116 Home Improver-e'nt Contractor Registration - _ Registration: 126893 _ — = Type: Supplement Card THD AT HOME SERVICES, INC: Expiration: 8r312016 ANDREW SWEET 2690 CUMBERLAND PARKWAY SUITE S66: .�:- — ATLANTA, GA 30339 = ----- -- Update Address and return card_14ark reason for change s,�, zo)a asnl - Address Q Renewal Employment f j Lost Card r-- ��tie Udmm¢�ac%vUIC����Glaoaaclicc;elZs Office of Consumer Affairs&Business Regulation License or registration valid for indiv►dul use only gOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: w Office of Consumer Affairs and Business Regulation Registration � Type: 10 Park Plaza Suite 5170 Expira �n g/ F�f6, , Supplement Card Boston,MA 02116 THD AT HOME SERVICES FK—G , ! - THE HOME DEPOTZ76CIFt SERVICES ANDREW SWEETir`WUII 2690 CUMBERLAND PARfM-- S --- A' I ,GA 30339 Undersecretary Nov t with ut signature h ' Al,O® • DATE(MMIDDMfYY) CERTIFICATE OF LIABILITY INSURANCE 02118/2016 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 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). CONTACT PRODUCER NAME: MARSH USA,INC. PHONE FAX TWO ALLIANCE CENTER A-MAIL/C AIC No 3560 LENOX ROAD,SUITE 2400 L ADDRESS: ATLANTA,GA 30326 INSURE S AFFORDING COVERAGE NAIC# 100492-HomeD-GAW*-16-17 INSURER A:Steadfast Insurance Company 26387 INSURED INSURERS;Zurich American Insurance Co 16535 THD AT-HOME SERVICES,INC. New Hampshire Ins Co 23841 DBA THE HOME DEPOT AT-HOME SERVICES INSURER C: P 2690 CUMBERLAND PARKWAY,SUITE 300 INSURER D:Illinois National Insurance Company 23817 ATLANTA,GA 30339 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003746646-14 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. 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 ADDL WBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DD MMIDD/YYYY A X COMMERCIAL GENERAL LIABILITY GLO4887714-06 03101/2016 03/01/2017 EACH OCCURRENCE $ 9,000.000 DAMAGEONTED C S rre nc 1,000,000 CLAIMS-MADE PREMISES LIMITS OF POLICY XS MED EXP(Arty one person) $ EXCLUDED OF SIR:$lM PER OCC PERSONAL&ADV INJURY $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 9,000,000 PRODUCTS-COMP/OP AGG $ 9,000,000 X POLICY❑JECOT. LGC $ OTHER: B AUTOMOBILE LIABILITY BAP 2938863.13 03101/2016 03101I2017 COMBINED SINGLE LIMIT $ 1,OD0,000 Ea accident X ANY AUTO BODILY INJURY(Per person) I$ ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS eracciderri $ UMBRELLA LIAB OCCUR EACH OCCURRENCE .$ 4 EXCESS U AS HCLAIMS-MADE AGGREGATE $ DED RETENTION$ Is C WORKERS COMPENSATION WC015519215(AOS) 03101/2016 03/01I2017 X STATUTE ER AND EMPLOYERS'LIABILITY WC015519217 AK,KY,NH,NJ,VT 03/0112016 0310112017 1,000,000 C ANY PROPRIETOR/PARTNER/EXECUfIVE YIN N ( ) E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? FN N/A D (Mandatory In NH) WC015519216(FL) 03/0112016 03101/2017 E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under Conitnued on Additional Page E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If 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 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee _MAvaarow: .._ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 1 Cape Save Inc. 7-D Huntington A f tO)'F BARNSTABLE South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 568-3984(399i 10, 1/2/15 'tIQ Thomas Perry CBO Town of Barnstable Building Division 200 Main St. 5 Hyannis,MA 02601 G RE: Insulation Permits ( w Dear Mr. Perry This affidavit is to certify that all work completed for 5 West Terrace, Centerville(201408522) has been inspected by a third party Certified Building Performance Institute(BPI) Inspector. All work performed meets or exceeds Federal and State Requirements. . Sincerely, William McCluskey TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map_ 'a �^ Parcel Application # C;?6 Health Division Date Issued S / Conservation Division Application Fee Planning Dept. Permit Fee 2 Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address ujc ' 1 e- t`11�1 Pi Village (--© 64--e-C�b I I e Owner r�W�oO J P[,�n, Address Sr�rhG' Telephone Permit Request rt �. Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation ( ?c� 0 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout. ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq ) Number of Baths: Full: existing new Half: existing new: Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room ount v Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ 4 Commercial ❑Yes �KNo If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) ' Name 110 C C l �� v �(°i�r►e. Telephone Number S � � 699 B Address License # Home Improvement Contractor# � Email Worker's Compensation # W WLQ 0 85b B ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Q paq � SIGNATURE DATE C� L f 4 . FOR OFFICIAL USE ONLY APPLICATION# I DATE ISSUED t MAP/PARCEL NO. l ADDRESS VILLAGE OWNER DATE OF INSPECTION: • FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING _4`_ t DATE CLOSED OUT ASSQCIATION PLAN NO. o - g PAIMCIPONG C 0 sass .sav� CORTRACTOR ry�9 .a..naz cf+evu:,iatw;t J9^1rcc.>ne PERMIT AUTHORIZATION FORM .. 0 d! z� Pif2 _ ,owner oft pro erty located p ;:at: (Owner's Name,printed) (Property Street Address) (City/Town) hereby authorize the Mass.Sav'e Home Energy Services Program assigned Participating Contractor listed below:to act on my behalf and obtain a building permit to.perform insulation and/or weatherization work on rriy property. Owner's Signature Date FOR.CSG OFFICE.USE ONLY Conservation Services Group has assigned the following Mass Save.Home Energy Services Participating Contractor to the above referenced'project: I L Participate g ICOntractor Nate Rev:12132011 The Commonwealth of Massachr�sea Department of Industrial Accidents W. Office of Investigations ry t: I Congress S(reet, SO 10 � r F Boston,.MA 02114-2617` r. wivw.mikss,gov%dia' Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers; Applicant Information Please°Print;Legibly: Name (Business/Organizaiibwlndividual): Cape Save 7D Huntin Ave Address- toil. 9 . City/State/Z : South Yarfnouth. MA 02664 Phone#: 508-39870398. Are you an employer?Chec the appropriate box. . , Type of project(required)-. [� 4 [] I ain a general contractor and 1 1.�✓ 1 am a employer with - 0. ( .1 New construction; employees(full and/ox part-trme): have hued the sub-contractors 2.0 I am:a sole proprietor or partner r lisied on the attached sheet.. 7. [];'Remodeling ship and have no employees These sub-eonhactors have g' �]Demo) ion working for me in any capacity, "etnpl.ovees and.have workers'' tom insurance* 9 'Bwtdin-addition " [No workers comp:insurance. d 10[ We a required.] 5• Q re a corporation an its: O`Electricai repairs or additions 3.;❑ . officers have:exercised their 'Plumbing repairs or additions 1 am a homeowner doing ail'w.ork, > right of.exemption per MGL myself. [No workers comp;: tj m koof repairs insurance required.]t c. 154 §1.(4);and we have no ' 13,[]✓;Other._Insulation employees. [No workers.' - comp,insurance.required,] "Any appi icant that checks bon `t must also Fill ourahe section below showing their.yorkers'compensation policy intorinat141M t Homeowneis Who submit this affidavit inificat ng.Ithey are doing all work and then hire outside contractors musisuhmit a newa"Idavii ihdtcat,ng uch.. 'Contractors that check this bo imust attached tin additional sheet showing the name o'F the sub-con'ttnctors and`state whether or not those eiititiesliave: employees. if.the sub-contractors have employees,they must provide their Hrorkels'comp;.policy number. I rr»:aii employer that is proviriing�vvrkers'can pensue vn insurance for my employees. Be/afv is thcpolrty:und job:sitie infvrnit�tivM.. • - Insurance Company Name: Wesco IWAttince�Comparty —. Policy.#or Self-ins Ltc.# . .WWC3.0$5633. . :. E xpiration Date: 04f09/2015 ( . Job Site Address: ) W eS-E- cr_4City/St6te/Zip: PL° �r .. Attach a copy of'the workers'compensation policy declaration page;(show ng the;polit number and expiration'.ate) Failure to secure,coverage.as,required ttxider Sect oin 25A of WaL c. l52 can iead to the iniposition of criminal:penalties of a t'►rie up to 51,50000 and/or one-.year imprisdnmertt,as well as civil penalties in.the.forth ofa STOP WORK ORDER and a file of up to$250.00 a day against the violator. Se advised that a copy of this statement may be forivarded to the Offzce of g coverage verification: In:vesti ations of the DlA'or tnsurance . . , 1-do here b' eerti ender the ain aiad enalties o er' that the r; orrnatiait provided above is true and correc4 i Senature Date Phone50 408.-039°8' •#: . z Official iise�r�1y Do4g?o,ivr[e 1 tl s grew,fo he cofripleted by ciry.nj town;"official: City or Town.Permit/License:# �,. lssuiug Authority(circle one} . • � � - 1.Board:of Health 2, Building Department-3'.City/Town`Clerk. 4.Eleetrical lnspectar 5.Plumbing Inspector: 6.Uiher _ CantactPerson• `,.. . _ Photne#. .+ ACCOR& CERTIFICATE OF LIABILITY INSURANCE i1/10/2o 4' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOdV. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE GERTIFICAtE HOLDER, IMPORTANT: If the certificate holder Is an ADDITIONAL INS RED,the poll.cy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to theterlms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in.Ileu of such endorsements. CONTACT PRODUCER NAME: Colleen Crowley Risk Strategies Company PHONE (781)986-4400 ,AM NI:(701)963-4420 15 Patella Park,!Drive ccrowley®risk-strategies.com , :Suite 240 INSURERS AFFORDING COVERAGE . NAICA Randlolph. Mh; 02368 INSURERA:Seleetive Ins. I of America INSURED `INsuREae:A1Lmerica Financial Alliance 10212 Cape Save, Inc INSURER c Wesco Insurance CoMany ` 7 D Huntingtoa•,l%,ye INsur Ro: INSURER E south Yarmouth lei .02G64 INSURERF: COVERAGE$ CERTIFICATE NUMBER:CL14111085532 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE,BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT;TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 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 AODLS LT TYPE OF INSURANCE POLICYEFF 'POLICY.EXP POLICY NUMBER IDD 1 LIMITS GENERAL LIABILITY EACH OCCURRENCE X COMMERCIAL GENERAL LIABILITY PD REMI EaEN Iran $ 100,000 A CLAIMS-MADE Q OCCUR S1994480 O/16/2014 0/16/2015 MEDXP E (Any one person): $ . 10,000 PERSONAL&ADV IN $ 1,0001000 GENERAL AGGREGATE GEN.AGGREGATE LIMIT APPLIES PER: PRODUCTS=COMPIOP AGG $ 2,000 000 POLICY rX: PRO-ECT X: LOC $ AUTOMOBILE LIABILITY COMBINED SNGLE LIMIT .(Feaccident 1 0001 000 i---„ . ANY AUTO BODILY 1.WJURY(Per-person), $ B ALL OWNED SCHEDULED 6796600 1/6/201:4 1/6/2015 AUTOS X AUTOS BODILY INJURY(Per eccident) $ NON+OWNED PROPERTY AG X HIRED AUTOS X AUTOS Perecddent - $ $ . X' UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE: $ 11 600,000 DED RETENTION 911 1994480 0/16/2014 0/16/2015 $ C a NORKERSCOMPENSATION -facers Included for X; VSCSTATU- OTH- AND EMPLOYERS'LIABILITY YIN IM ANY PROPRIETORIPARTNERIE)ECUTIVE Coverage. E L.EACH ACCIDENT $ 500 000 OFFICERIMEMBER EXCLUDED? NIA 7085633 /9/2014 /9/2015(Mandatory In NH) E.L.DISEASE:-EA EMPLOYEE $. 500 000 MIf yyes describe under I dRIPTIONOFOPERATIONSbelow E.L:DISEASE-POLICY-LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIUNS4•VEHICLE3(Attach ACORD'im,AddRlonal Remerke Schsdute;)f more space Is required} Issued as evidence of insurance. Issued as evidence of insuiinoe. Thielseh Engineering, Inc: is listed as additional insured as respects General. Liability as required by written contract. - CERTIFICATE HOLDER CANCELLATION msong@capelightcompact,.org SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Cape Light Compact ACCORDANCE.WITH THE POLICY PROVISIONS. Attn: Margaret song PO Box 427/SC7i' ALnxoaIz�REPREstrraTlvE 3195 Main street Barnstable, MA 026.30 �, J� 'chael Christian/CLC ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD �fZ� ��?`I`Z��21�I�1•���fxG-�/?, (�� �1� Office of Consumer Affairs and Business Regulation ' 10 Park Plaza Suite 5170 Boston; Massachusetts 02116 Home Improvement Contractor Registration Registration: 171380 Type; Corporation Expiration: 3/14/2016 Tr# 249649 CAPE SAVE INC. 7-1 WILLIAM McCLUSKEY - 7-D HUNTINGTON AVENUE k SOUTH YARMOUTH, MA 02664 -- E Update Address and return card.Mark reason for change. scA i 2oM-osn i Address (� Renewal E] Employment E] Lost Card Office of Consumer Affairs Business Ree Iat,on� J. License or registration valid for individul use only l OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 071380 Type: Office of Consumer Affairs and Business Regulation `Expiration 3/1 1201:6, Corporation 10 Park Plaza-Suite 5170 Y f. Boston,MA 02116 CAPE SAVE INC. 7-D HUNTINGTON AVEWILLIAM McCLUSKEY NUE' SOUTH YARMOUTH,MA 02664 Undersecretary Not vali rthout signature } Massachusetts -Department of Public Safety Board of Building Regulations and Standard Construction Supervisor Spvcialt License. CSSL-102776 WILLIAM J MC C-LUS ' 37 NAUSET ROAD '~^ West Yarmouth 1dIA Exp:rataon t Com rassioner 06/28/2015 t• f,• y " TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel I Application # Q d I��c,�( (Dc( Health Division Date Issued 0 /4 Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address �J W e,tt r f,c P Village ��n-i'e fv (?, Owner d M -d 1 Address S q,,M t, Telephone 5 o 6A Permit Request r S 0. P)QAAA ZAI%, Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No 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 Number 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 Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes �(No If yes, site plan review# _ !-. Yd Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 1 RC L � sme_37�_rTelephone Number 509 Address n A,,P, License # 1-C I a l� 6 50 Home Improvement Contractor# 7- 3 Worker's Compensation # WWC3095631 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO�X SIGNATURE DATE to 6 F i FOR OFFICIAL USE ONLY 41PPLICATION# DATEISSUED MAP/PARCEL NO. ADDRESS VILLAGE a OWNER r ,J DATE OF INSPECTION: : FOUNDATION y ,jvi :najvuAT _ FRAME +;INS.ULATION t FIREPLACE ELECTRICAL: _ ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING- DATE CLOSED OUT r { ASSOCIATION PLAN NO. F , T'lae Corrzmonwealth of Massachusetts 4 Department oflndtstrial Accidents Office of Investigations f ; + I Congress Street, Suite 100_ Boston,MA 02I14-2617 k - w 4 . fi www.mass gov/d a ; Workers' Compensation Insurance Affidavit: Builders/ContractorsJElectricansJPlumbers Applicant Information _ __ . Please Print:Udbly t Nat71.e(Business/Or ganization/tndividual): Cape Save Inc. Address: 7D-Huntiogtori Ave _ City/State/Zip: South Yarmouth.MA 02664 Phone#: 508-398-0398. _ Are you an employer?Check the appropriate box; Type of prosect(required) 1.0 I am a employer with 4. � 1 am a general contractor and I P have hired the sub-eontractors .6 New construction. employees(full andtor part:time)': : . .Q I am a sole,proprietor or partner listed'on the attached sheet. ' " 7. ❑Remodeling These:sub-contractors have ship and have no employees 8. ❑Demolition workingfor me-in ca aci emplovees and have workers' Y P tY- 9. (�Budding addition comp:insurance [No workers comp.insurance , requi;cd,] 5. ❑ We are a.corporation and�its- 10.❑.Electrical repairs or additions :3.El I ain.a homeowner doing all work, officers have. their 11.0;Plumbing repairs ar additions myself.[No-workers'comp; right of exemption.per MGL 12.M:Roof repairs insurance required.],r c. 152, 1(4),and we.have:no - employees. [No workers' 1321`Other [nsulaficzn:. comp:.insurance required,] `, Any applicant that cheeks boat muse also Fill out the section below showing their cvorkeis'compensation policy mlormatton. t Homeowners a;bo submit.this affidavit indicating.thmarc doing all work and then,hire outside wntractrrr.must snbm i a new affidavit itrdicatirrgsuctss,. �Contracioisahat check this boxmust attached an additionaLsheet shoe ing tiie naive of ike:sub contractors and state xv el ier or iiot those entlttes Have employees. -If the sub=eoritpactors have erhployees;they must,provide their workers'comp:policy.number f I anz an employer.that is providing wgrhers'eornpensutivn instiranee for my einp%yetis.Be%u is thepoltcy_und joh ite infortnation, _ + - t Insurance;Company Name: Wesco Insurance Company Policy#or Self-ins.Lie;.# WWC3085633. ...... ___ Expiration Date: 04J09/20I5 fob Site'Address: 5 _ We,54- r f G L' City/StatetZip C�@ ( �1 1 �°C` �/e e Attach:a copy of the workers'compensation pohcyAeelaration page(showing the policy tiumber-and expiration-date}.; Failure to secure coverage as.required under Section'5A of MGL e. 152-can lead to the impositiomaf cnminal:penalties of a fine up to$1,500.00 and/or orte-year imprisonment,as well as civil penalties in the fortri of a STOP WORK ORDER and a fide:. of up to$250.00'a day against the violator 13e advised that.a copy of this statement maybe forwarded-to the:offm*of , It vestigabons of the DFA for insurance coverage a/erification: 1 do hereby.certi under the aims and enalties o er +that the in'grtnation;provided abov is true,and:correci~ , Srenature: Date . .. Phone#: ;Off,:ciat rise only #o not tivrko in this are.a,.;to be completed_:by city Or to►+.n official City ox Town:.._ P_etmit/License# Issuing Authotity('c►rcie-one):: , t Board of Health 2.-_Buitdirig Department:3 City/Town Clerk 4 Electrical Inspector 5.Plumbing l>Itspector, r6 Other f ! ., :Contact Person p' .. '_ _ . •_ : .,. _..-. _._ Phone:# __.._ '•`` i V DATE(MMIODIYYYY) CERTIFICATE OF LIABILITY INSURANCE 4/14/2014 THIS CERTIFICATE-IS ISSUED AS•A MA TTER ATTER 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 NSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE:CERTIFICATE HOLDER. IMPORTANT: If thet certificate holder Is an ADDITIONAL INSURED, the policy(les)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 cartificate holder In lieu of such endorsements. PRODUCER; COME Colleen Crowley Risk Strategies Company PHONE (781)986-4,400 F Ne.Q81)963-4420 15 Patella Park Drive .ccrowley@risk-strategies.eom Suite 240 INSURE S:AFFORWNGCOVERAGE NAIL Randolph MA 62366 INSURER.A:Selective, =ns. OF: America INSURED INSURERB;Safety Insurance CcmpanV 33618 Cape Save, Inc INsuRER c'Wesco Insurance Company 1 D Huntington..Ame INsuRERo: INSURER E South Yarmouth. MA. 02664 INSURER.F:.. .. .. __.. COVERAGES CERTIFICATE NUMBER:CL1441475243' 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. NOTWITHSTANDWG ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOC.UMEN,T WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE'ISSUED OR MAY PERTAIN,,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE.TERMS; EXCLUSIONS AND CONDITIONS OF SUCH;POLICIES.LIMITSSHOWN MAYHAVEBEEN REDUCED BY PAID CLAIMS. 1NSR` _ __.... AUULUB 'POLICY EFF POLICY'EXP LTR TYPE OF INSURANCE POLICY NUMBER. MMIOD MMlDDlYYW LIMITS GENERAL:LIABILIT..Y' EACH OCCURRENCE. $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Me ourrence $GE TO RENTED 100,000 cc A CLAIMS-MADE ❑X OCCUR 1994480 0/16/2013 0/16./2014 MED EXP iAny one person} $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,004,000 GEN'L AGGREGATE LIMIT APPLIES;PERP PRODUCTS.-COMPIOPAGG $. 2,000,000 PR0. _ POLICY X T X :LOC AUTOMOBILE LIABILITY COMBINED M SINGLE.LIMIT I � 1 000 000 _ ANY AUTO BODILY INJURY{Per person) $ BIALLOrED .SCHEDULED 208200 1/6/2013` 1/6/2014AUTOS $ A.UTOS. BOL�ILYWJURV(Peraxident) $ '.:X 'NON-OW4ED PROPERTY DAMAGE $ - - HIREDA.U.TO.S AUTOS Perooddent X UMBRELLA LtAB X, `OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAR` :CLAMS-MADE •: AGGREGATE $ 1,000,000 Iy � 1994480. 0/16/2013 0116/2019. -- - - D€D RETENTION$. $ C fficers Included.For VIC STATU- OTH-WORKERS COMPENSATION X. ORLIMITS AND EMPLOYERS'LIABILITY ANY PROPR(ETORIPARTNERIEXEQITIVE YIN N overage E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBEREXCLUDED9 NIA 085633 /9/2014 /9/2015 (m datoryin NH). E.L.DISEASE:-:EAEMPLOYEE $ 50.0 006 MIf yyes,describe under- DESCRIPTION OF OPERATIONS below E:L DISEASE-:POLICY LIMIT '$ 500 000 DESCRIPTION,OF OPERATIONS I LOCATIONS 1 VEHICLES"(Attach ACORD'101,Additional Remarks Schedule;;if more space-ls required) Issued as eV]:dence'of insw-ance. Issued asevidence,of insurance.. Thi.eisch Ehaineering., Inc. is listed as additional insured.as respects General Liability as required by written contract.. CERTIFICATE HOLDER CANCELLATION msong@capelightcomact,..org SHOULD ANY.OF THE ABOVE`DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Cape Light Compact ACCORDANCE WITH THE POLIICY PROVISIONS:. Attn. Margaret song _ PO Box 427/S.CH AUTHORIZED REPR ESEWATIVE e 3195 ;Main Street Barnstable, MA. 02630 chael Christian/CLC ACORD 25(2010l05)'; .. ©1988-201,U ACORD CORPORATION:.All rights reserved. INS0251zotoosj.o. :The ACORD.name:and logo.are registered marks of ACORD 1 Office of Consumer Affairs and Buslriess Regulatlol -10 Park Plaza Su1te.5170 =Boston, Massachusetts-02116 " Home Improvernent Contractor Reg>stratlon `��"° .„- -.�„ Registration -171380 ��:��• y� Type ''CorPoration x r Expiration `3l14/2t)16 Tr# 249649 CAPE SAVE C.,� P-5 WILLIAM McCL'USKEY � a 7-D HUNTINGTON AVENUE ' M "" SOUTH YARMOUTH, MA 02664 rUpdate-Address an for c d return card::Mark r h eason ange ` � `0 Address 'Renewal Q Employment :Lost Card SCA 7 is:20M-05/11 - - t _ s V/LC-.�P�/9299t•6'J2C11BCGGtfL 6��/�GCl9�CGGi2LCJP.�t�- s''' •:. -.'r- Office of Consumer Affairs&Business Regutaaon License or registration valid for indrvrdul:use only'; , OME IMPROVEMENT CONTRACTOR beforethe expiration date If found return to 9 171380_ yp Office of Consumer Affairs and Business Re ulat1on - e istration T e g Expiration 3/14/2016 Corporation 10 Park;Plaza Swte 5170 t Boston,MA 02116 CAPE SAVE INC: � WILUAM McCLUSKEY s 7-D HUNTINGTON AVENUES SOUTH YARMOUTH MA 02664_t Undersecretary Not vali tthout srgnafure 7 4 Massachusetts -Department of PUbifc Safety F Board of Building Regulations-and-standards Construction Supenisor.Specralty License: CSSL-10M6 W ILLIAM J MC CLUSKEY' 'F 37 NAUSET ROA1D West Yarmouth N3A 02 r Expiration F Commissioner 06/28f2015 i=, r MAd 000 mass save "Now PERMIT AUTHORIZATION FORM owner of the property located at: (Owner's Name,printed) (Property Street Address) (Cityrrown) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's signature Date FOR CSG OFFICE USE ONLY, Conservation Services Group has assigned the following Mass Save Home,Energy Services Participating Contractor to the above referenced project: CSOL VP-- Participating Co tractor Date Rev.12132011 i Town of Barnstable *Permit# Expires 6 months from issue date Regulatory Services Fee Thomas F.Geiler,Director Building Division 9�/ofo-r ' 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 I`f d Property Address rRResidential Value of Work S, JUD r Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address e _ / C,e,/e/- Contractor's Name Az &Jdo Telephone Numbe4,0 0 -77,5 S 7 0 9 Home Improvement Contractor License#(if applicable) L[ 29 7 7 Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance X-PRESS P G RW Check one: . ❑ I am a sole proprietor S EP 10 Z007 WI am the Homeowner have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name r�+ Workman's Comp.Policy# 14 j 1 d 06 7-6 0 7-157 00 Copy of Insurance Compliance.Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) O/Re-side ❑ Replacement Windows/doors/sliders. U-Value *Where required: Issuance of this permit does not exempt compliance with other town_department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. a A copy of the Home Improvement Contractors Liponse,isxe,uired. SIGNATURE: Q:Forms:expmtrg Revise061306 Y a ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 , www.mass.gov/dia Workers" Compensation ksurance,Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Legibly Name (Business/Organizetion/Individual): /� (; �/ , /¢ Address: -5 C City/State/Zip. V Phone.# SW S Are ou an employer? Check the appropriate bog: Type of project(required):. 1. ✓. I am a employer with 15 4. ❑ I am a general contractor and I 6 w construction . employees(full and/or part-time).'" have hired the sub-contractors . ❑ 2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. employees and have workers' 9. []Building addition [No workers' comp. insurance comp.insurance.$' required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myselL [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' A3.0 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 ornot those entities have employees. If the sub-contractors have employees,they must providb their workers'comp.policy number. Iam an employer that is providing workers'compensation insurance for my employees. Below isihe'policy and job site information. Insurance Company Name: Z)0tV1,_,7,q /I&,L Policy##or Self-ins.Lic.#: Q(Z0. > D 6 Expiration Date: -2- lob Site Address: S W 6S t ' 3 'City/State/Zip: = � G �� Attach a co of the ' Q copy workers compensation pohcy declaration pale(showing the policy numbe 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 tip 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 1)IA for insurance coverage verification, I do hereby certify under the pains-and-pen alties of perjury that the information provided above is true and correct: Simature: Date: Phone k b(A _ Official use only. Do not write in this area,•to be completed by city or town aciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone M �pFZHE'ohti 'Town of Barnstable Regulatory Services saiwsrABLE, r asass. $ Thomas F.Geller,Director 4'Alf16 9.Ma`sA` ]Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 w'Yv w.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using ABuilder as Owner of the subject property hereby authorize ,�i� z G✓ ,7 �g �q��0 to act on my behalf, in all matters relative to work authorized bythis Molding permit application for: &4,7�P Y//A/ G (Address of Job) Gii �C.G�Ge. 00 9 710, Signature of Owner ate Print Name Q TO R.M S:OWNERPERMIS S ION �Ing&C.l'Neil Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ,2 W HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 222 West Main St.PO Box 1990 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis, MA 02601 INSURED INSURERS AFFORDING COVERAGE Michael J. Dangelo Building INSURER A: Travelers Insurance Company NAIL# &Remodeling,Inc. INSURER B: American International Companies 105 Horseshoe Lane INSURER c: Centerville,MA 02632 INSURER D: COVERAGES INSURER E: i THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIO 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 CON POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. D INDICATED.NOTWITHSTANDING LTR NSR TYPE OF INSURANCE CONDITIONS OF SUCH POLICY NUMBER POLICY Y EFFECTIVE POLICY EXPIRATION A GENERAL LIABILITY TE MM DD E D 16808433H175TCT07 01/04/07 - LIMITS X COMMERCIAL GENERAL LIABILITY 01/04/08 EACH OCCURRENCE $1 000 000 CLAIMS MADE FX]OCCUR DAMAGE TO RENTED X. PD Ded•500 $300 000 MED EXP(Any one person) $5 000 PERSONAL BADV INJURY $1 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE. $2 OOO OOO POLICY PRO'AUTOMOBILE LIABILITY T LOC PRODUCTS-COMP/OP AGG $2 OOO 000 ANY AUTO COMBINED SINGLE LIMIT ALL OWNED AUTOS (Ea accident) $ SCHEDULED AUTOS I (Per INJURY $ HIRED AUTOS Per NON-OWNED AUTOS o BODILY INJURY (Per accident) $ GARAGE LIABILITY PROPERTY DAMAGE(Per accident) $ ANY AUTO AUTO ONLY-EA ACCIDENT $ OTHER THAN EA ACC $ EXCESS/UMBRELLA LIABILITY AUTO ONLY.- OCCUR ❑CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ B WORKERS COMPENSATION AND $ EMPLOYERS'LIABILITY WC1766359 02/19/07 02/19/08 WC STAT $ ANY PROPRIETOR/PARTNER/EXECUTIVE X U- OTH- OFFICER/MEMBER EXCLUDED? If y describe u der E.L.EACH ACCIDENT $1 OO 000 es, SPECIAL PROVInSIONS below E.L.DISEASE-FA EMPLOYEE $100 QOO OTHER E.L.DISEASE-POLICY LIMIT $500 OOO DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Operations performed by the named insured subject to policy conditions and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATI( e I ff DATE THEREOF,THE ISSUING INSURER WILL.ENDEAVOR TO MAIL DAYS WRITTEI, 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 REPRESENTATIVES. AU IpRESENTATIVE dl` I'/ ACOku co r<<uvuuo of 2 . #47256 `�• LS1 © ACORD CORPORATION T Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Licen�c or rc istrat,on valid for indi idul use only befog " iatioi �date Iffound`return to: Registration` 112977 Boar Vi►tling Regulations and Standards Expiration 5/712009 Tr# 128790 One', iburton Place Rm 1301 Type Individual Bosto'S l�Ia.02108 MICHAEL J;DANGELO MICHAEL UANGE.L.O - - 105 HORSESHOE LW CE.NTERVti_LE,MA 02632 -- Adm,mstrator Not valid hout signature Tower of Barnstable *Permit 3 �� Expires 6 months from issue date Regulatory Services Feei Thomas F.Geiler,Director Building Division L��►� Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERNIIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number I Property Address � ./T tesidential Value of Work oy Minimum fee of$25.00 forI'work under$6000.06 Owner's Name&Address K-0 E AK Y Contractor's Name ,�C-- LL�&?�/?�e%� Telephone Number HomejImprovement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) orkman's Compensation Insurance X-PRESS PERMIT Check one: O C T 0 3 2006 2100,'am'a sole proprietor ❑ I am the Homeowner TOWN OF BARNSTABLE ❑ I have Worker's Compensation Insurance Insurance Company Name_ 114 r Z. /71, Workmen's Comp.Policy#. Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) e-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 (maximum.44) "Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: P erty O r must sign Property Owner Letter of Permission. copy o H e Improvement Contractors License is required. SIGNATURE: Q:Fomis:expmtrg Revise061306 4 PERMIT PAYMENT RECEIPT TOWN OF BARNSTABLE BUILDING 'DEPARTMENT 200 MAIN STREET HYANNIS, MA 02601 DATE: 10/04/06 E TIME: 10:54 -----------------TOTALS----------------- PERMIT $ PAID 25.00 {{ i AMT TENDERED: 25.00 AMT APPLIED: 25.00 CHANGE: .00 APPLICATION NUMBER: 20063686 PAYMENT METH: CASH PAYMENT REF: Department of Iridusti ial Accidents Office of lnvestigations' a 600 Washington Street Boston,MA 02111 f www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ,pulicant Information Please Print Legibly Vame(Bu nesslorganization/Jn Mdual):� kddress:_R� • ®Z.0 '32ww. eea City/State/Zip: � r/s�/�S &7,1L Phone#: ►re you an employer?Checkthe'appropriate box:: Tape of project(required): ❑ j am.a-employer with' 4. ❑ I am a general contractor and I mployees(full'and/or part-time).* have hired the sub-contractors 6• ❑ New construction I am a sole proprietor or p=er- listed on the attached sheet t ?• ❑ 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 area corporation and its . 10.❑ Electricals airs or.additions required.] officers have exercised.their ep ❑ I am a.homeowner doing all work right of exemption per MGL 11.❑ Phmibmg repairs or additions myself.•[No workers' comp., c. 152,§1(4),and we have no. 12.❑ Roof repairs insurance required.]t employees. [No workers' comp.frmuance 1equired.] 13.0 Other ny applicant that checks box#1 must alsp fill out the section.below showing their workers'compensation policy information: iomeowners who sabmittbis affidavit indicating they are doing all-work and then hire outside contractors must submit a new affidavit indicating such mtractor that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information . !m an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site formation. Durance-Co an � Y Name: ./4, 1 ]icy•#or Self-ins.Lie.#: Expiration Date: b Site Address: City/State/Zip- tack 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 e. 152 cari lead to the imposition of6riminal penalties of a e up to$1,500,00 and/or one-year imprisonment, as well as civil penalties m:&e form of a 8TOP'WORR ORDER and a fine. up to$250.00 a day against the violator. Be advised that a copy of this statement may'te forwarded to the Office of iestigations of the DIA for insurance coverage verification. `v hereby cert u r the pa' s d p ies of perjury that the information provided above is i. and correct attire:. � .. Date: /o one Off cial 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 !..Building Department 3.'City/Town Clerk 4.Electrical Insp 6. Other ector S.Plumbing Inspector Contact Person: Phone#• _ (T ,R Information and. Instructions r ; y fassachusetts General Laws.chapter 152 requires all employers to provide workers' compensation for their employees.. ursuant this statute;an employee is defined as"...every person in the service•of another under any contract of hire, press or implied,oral or written." artngbip,,association,corporation or other legal entity,'or any two or more to employer is defined as,:.a izadividal,.p .. the foregoing in a joint enterprise, and including the legal representatives of a deceased employer,or the partnership,association or other legal entity,employing employees. Howoypr;t e eceiver or trustee of an individual,p hip, ;caner of a dwelling house having not more than three apartments and who resides therein, or.the occapant of the welling house of another who employs persons to do maintenance, construction or repair woi1;on such dwelling house r on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." k. vAGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or •enewal of a license or.permit to operate a business or to construct buildings in the comm onwealth for any applicant who has not produced acceptable evidence-of compliance with the insurance coverage required." kdditionally,MGL chapter 152, §25C(7)states Neither the commonwealth nor any of its-political subdivisions shall +ntet into any contract for the perfoamance ofpublic work until acceptable.'evidence.of compliance with the insurance requirements of-this chapter have been presented to the contracting authority. 11 Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if, necessary,supply, sub-contractors)name(s),address(es) and phone number(s) along with their certificates) of Limited Liability Companies (LLC)or Limited Liab, y Partnerships(LLP)with no employees other than the insurance. members or partners,* are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of•Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should to the city or town that the application be returned for The permit or license is being requested.,not the Department of Industrial Accidents. Shouid you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below, Self-insured companies should enter their. self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is.complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant; Please be sure'to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"'Tie applicant should write"all locations in (city or town),"A copy'of theraffidavit that has been officially stamped or marked by the city or gown may be provided to the applicant as proof 1hat•a valid affidavit is-on-file for:future permits•or-libenses.•A new affidavit must be filled out-each year.where a homeowner or citizen is obtaining a license or pem it not related to any business or commercial vent<ire (i.e. a dog license or peffiit to bum leaves etc.)said person is NOT required to complete this affidavit The Office.of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: ' The Commonwealth of Massachusetts . : Department of Tndustrial.Accidents .. . >: .Office of Investigations f. 600•Washington Street, . Boston,MA 0211L Tel.#617-727-4900 ext 406 or•1,877-MASSAFE Fax#617-727,7749 wised 5-26-05 www.mass.gov/44 1' DIME Town of Barnstable Regulatory Services �BMW i'L Thomas F.Geiler,Director �A .3y s6 ♦� rEo 3916 Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601. Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject l property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (AddreU of Job) Signature of Owner Date C cCT— Print Name Q:FORMS:OWNERPERMISSION 4 I.