The URL can be used to link to this page

Home My WebLink About0006 JACQUELINE COURT (p �a.G tc� 1 i h e ��--�-�� - � v ti - - .. - y. .. - ,. a r ,. n .. � .. ,. o �+ .. f �r�A�� I >Y # Ce J Z/23 l/y Cf` �.►�, Town of Barnstable .Permit# Expires 6 mont u Ce h,from s Regulatory Services Fee ` i s + BARNSrABLE, v MAss' Richard V.Scall,Interim Director EDMArp Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us f Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Numbere�//1 Property Address V Residential Value of Wo $ �p/�� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable)/,V/C&e Email: Construction Supervisor's License#(if applicable) nq e pe ocipaill-W [�Workm n's Compensation Insurance '\ DEC 22 2014 ❑ I am a sole proprietor ❑ I am the Homeowner TOWN .OF BARNSTABLE [ I have Worker's Compensation Insurance Insurance Company Name /�� Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Re uest(check box) IAIWAldf R Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *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: TAKEVIN_MBuilding Changes\EXPRESS PERMIDEXPRESS.doc Revised 061313 i f0))Y1W0A?(VeCA1' ? 0/ Office of Consumer Affairs and Business Regulation 10 Park Plaza m Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 162600 Type: Supplement Card Expiration: 3/26/2015 BAKER & ASSOCIATES INC. RICHARD GARNEAU ----- - ----- 521 SHOOTFLYING HILL RD -- - --- CENTERVILLE, MA 02632 Update Address and return card.Mark reason for change. sCA 1 0 20M-05/11 Address ❑ Renewal Employment ❑ Lost Card �itB 1�07![)J(011fUl'C(ltf7 0/^hraijackliPfCJ ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration: 162600 Type: 10 Park Plaza-Suite 5170 Expiration: 3/26/2015 Supplement(:erd Boston,MA 02116 BAKER&ASSOCIATES INC. RICHARD GARNEAU P.O. BOX 923 CENTERVILLE, MA 02632 Undersecretary Not ialid withou ' ignature 4 , .-....r-,...rm.ron:.....:::.w�'w....^a.rt.rufwa•um.+.......s...••oC'Ja...r.,: - i ..+-.n.r...r. wi.M..,...-+.a+r+w•.w�wmw'..�+—"- _.. i..•.+.w.c....n�a--�:. 1 `11I G I:US4 - ri .r, ��i z q::.i iJT �i.11�li?=-j Cy7iii,-•l j^.,.liJ a:ld R RICRARD P.GA4NEAU JR PO BOX 476 f C� West Barnstable MA 02668 I 04/04/2016 j The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 lop www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Baker & Associates Inc ' Address: 521 Shootflying Hill City/State/Zip:Centerville MA 02632 Phone#:508-362-2445 Are you an employer? Check the appropriate box: Type of project(required): 1.5Q I am a employer with 1 4. ❑ I am ageneral contractor and I 6. ❑New 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. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9• '❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself [No workers' comp. . c. 152, §1(4), and we have no 12. Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.� Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation'policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance or m employees. Below is the policy and job site P g P f YP Y J information. Insurance Company Name:Associated EmployeerS Policy#or Self-ins. Lic. #Zu"_a! �' _' ��' Expiration Date: ( Job Site Address: City/State/Zip: Attach a copy of th wor rs' 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 $1,500.06 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 ce n r the pai and penalties of perjury that the information provided above is true and correct. Sign e: ✓'. - Date: Phone# ,�)U a t� Tim Official use only. Do not.write in this area, to be completed by city or town official 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 g Contact Person:, Phone#: Client#:9742 2BAKERAS AGORDL CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYYY) C 04/23/2014 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). PRODUCER CONTACT Dowling&O'Neil NAME: HONE Insurance A enc A/C,No,Ext:508 775-1620 c,No): 5087781218 g y E-MAIL 973 lyannough Rd., PO Box 1990 ADDRESS: Hyannis,MA 02601 INSURERS)AFFORDING COVERAGE NAIC# INSURER A:National Grange Mutual Insuranc INSURED INSURER B:Associated Employers Insurance Baker&Associates,lnc. P O Box 923 INSURER C: Centerville, MA 02632-0071 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUB7MPJJ7223M LTR TYPE OF INSURANCE (INSR WVDOLICY NUMBER MMLDD/YYYY I MM/DDIYYYY _ LIMITS A GENERAL LIABILITY I 4/19/2014104/19/201 EACOCCURRENCE i$1 000 000 X COMMERCIAL GENERAL LIABILITY I DAMAGE TO RENTEDPREMISES Ea occurrence $500,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) J$10,000 I I PERSONAL&ADV INJURY !$1,000,000 j I GENERAL AGGREGATE i$2,000,000 GEN1 AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG '$2,000,000 POLICY I JEC PRO- Ti JILOC Is i AUTOMOBILE LIABILITY II COMBINED SINGLE LIMIT -- Eaaccident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS AO OWNED I i PROPERTY DAMAGE Per accident I$ UMBRELLA LIAB J OCCUR $ EXCESS LIAB I I I EACH OCCURRENCE i$ CLAIMS-MADE AGGREGATE $ DED . I RETENTION$ I $ B WORKERS COMPENSATION WCC50050024542014A 4/23/2014 04/23/201 X WC STATU- IER 1 OTH-1 AND EMPLOYERS'LIABILITY TORY LIMITS ANY PROP RIETOR/PARTNER/EXECUTIVE�J Y�/N i OFFICER/MEMBER EXCLUDED? L I N/A; j E.L.EACH ACCIDENT I s500,000 tl Mandatory in If yes.describe under I I E.L.DISEASE-EA EMPLOYEE!s500,000 I _ _ - I DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT is500,OOO I I I DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION ANY OFELLED Barnstable Town Hall, {p THE SHOULD EXPIRATIIONH DATE VT EREOF,DESCRIBE NOTICEI ES WILLL BE CBE CDEL VEREDBEFO NE 367 Main Street, Hyannis, MA. ACCORDANCE WITH THE POLICY PROVISIONS. 02601 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25 439/ 1 of 1 The ACORD name and logo are registered marks of ACORD #5129439/M129438 KKM i Authori ation F - t as owner of the subject L4 z OE c, .e 2-1A V//� property, hereby authorize'Baker & Associates to act on my behalf, in all matters relative to work authorized by this building permit application for Address of property:-.,, _� �1 Signature„of.owner - �. zPrint.Name. 6 Date TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map .�L10 Parcel A09 Application # Health Division Date Issued .24 1 N Conservation Division Application Fee - Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board , Historic - OKH Preservation / Hyannis Project Street Address Village Owner 9 wa 1y0 &ty Address Telephone BSI • 7 '? 'Permit Request l �/l� <Z l�-' �� G6 l� Square feet:.1 st floor: existing proposed 2nd floor: existing proposed Total new' Zoning District Flood Plain Groundwater Overlay Project Valuation 21 aConstruction Type q 4A Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting doe9me_4 tion. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's H g,i,way: ❑Yes O,No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Otherµ. Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) 00 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 Au rization ❑ Appeal # Recorded ❑t Commercial ❑Yes �o Ifyes sito pIan revi Current Use Proposed Use APPLICANT INFORMATION G �A (BUILDER OR HOMEOWNER) -on Name At* Telephone Number Address r4 �xdt-j License # Witt 41(10 Home Improvement Contractor# `� � 5 Z Worker's Compensation # U" D `J b ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PRO ECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY --` APPLICATION# DATEISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: IN FO,UNDATLONrj,.+g -A*gl'_jtYuAt k: ;, - FRAME - - - - INSULATIOR r-±c"ua� .A iw, ;ALA 11:". FIREPLACE 6 ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING: . - DATE CLOSED.OUT ASSOCIATION PLAN NO. Massachusetts -Department of Public Safety Board of Building Regulations and Standards - Construction Supen'isor License: CS-100988 HENRY E CASSDO 8 SHED ROW WEST YARMOIJ H 02' Expiration Commissioner 11/11/2015 li �� 1 vz:r'�fr.cl c�r�// r.,' I Of fice O1._C,or),iumer Affairs and Business hegulati'oll. 10 Park 1'l in - Suite 5170 BOStOfI3 NlaS&'1ChLLSettS 02116 l-fiat-ne Improvement Contractor Reglstratioil Registi'Eltiorl: 153567 Typo: Private G oi —t.wiatio{t Expiration, 12/15/:2'b14 1'r# 2J;fUJ1 CAPF COD INSULATION. INC HFARY CASSIDY Id R)FAF_D0N CIRCLE_ _ .... ,iO,YARMOUTH, MA 02664 - Update A(ltlress autl return C1krd. Mark reason fill dwilge, {_] Address ( j Rencw;tl _l 1?.tntlluynu:nt I I,iurCurd ., ,i (('r�:/!//cn/ !!•crfl/�/l l� li.l't/fJ.li(i. AHIIn, t Itusul�ss Ilegula[iau License in reglsmitiuu i'alitl for individul use. unly I �f17a{Umr IMNKOVEME'.N l COtV(kACTOR llclulc.the expiration date. 1C Ibuud rclur(i to: T'$ uyl�trutwll: 1535CiI Type: OflitcuFCunsumerAlfl)irsaniiBusincssRegulatiuu :f.ipu2II10I 121 Private Corporaticn 10 P.uLPIi(tl( Suite 5170 ttustun,MA 02116 IJud�l+ierelar�' otstil 1)'ithu t u;tt TV ' The Commonwealth of iVassachusetts I i Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 w►vw.erne ass.go v1d i a Workers' ColiuPeusutiOu Insurance Affidavit: builders/Co'tractors lectrici tnsiplurrnbers � rlic:rtl�t l[t>if®rr�wat�u>t:u / Meuse Print Legibly iV,f.litC (13uswcsslOrganizatiot)/Individual ' �G' �� / ,; City/Stat&ZI G -�r�? /. G� Phone #: 2 %4/- w.r you Un employ rZ Check the appropriate box: 1.0.1.urt a 4trrployer with. I 4. [] 1 am a general contractor and 1 Type of project (eery fired): I crttployccs (full andj-oe part-time).,o have hired the sub-contractors . 6• ❑ New construction ❑ i ant a solo proprietor or partner- listed on the attached sheet. 7. ( Remodeling 1 ship and have no employees These sub-contractors have 8. Demolition ,vork' g for ine in any.capacity. employees and have workers' [No workers' comp. insurance comp. ins�uartce.j 9. ❑ Building addition regLared:] 5. [] We are a corporation and its 10.❑ Electrical repairs or additions S.❑ 1 an a homeowner doing all work officers have exercised their ;>l.l Plumbing repairs or additions myself. [No workers' comp. tight of exemption per MGL 12 Roof repairs insurance required.] .t c. 152, §1(4),and we have no ;u.❑ 1 am a horrtcowncr acting as a employees..[No workers'. 13.J�?Other S �� general contractor(refer to #4) comp,insurance required] t'may apphcsnl that checks tax tk1 must" fill out the section below showing their workers'corrtpcusatiodP olicy into nnation. Huutcowacn who subaut this affidavit indicating they are doing all work and then hire outside contracton tnust submit a new affidavit indicating such. :C01luuE-3 that check this box roust utlachad an additional sheet showing the mama of the sub-coau-naon and state whether or not those entities have cmployccs. ttthc have ctnployecs,'they trust provide choir work-m,comp.policy number.,.. l um an employer that is providing workers'compensation insurance for my employers. Below is the policy and job site in1urmatiun. Insuraucc Company Name: Policy#orSclt=ins. Lie_ Expiration Dater Job Site,�ddrrss: C,I Ci /State/zi :C4d4(/(/k �lq d Z6 tY p .-ttach u copy of the worke compeusation policy declaration page(showing the poilcy number and expiration date). 1 ailurc to scciuc.covCragc as required tinder Section 25A of MGL e. 1S2 can lead to the imposition of cruuwal penalties of a [Inc up to S 1,500.04 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to D250.00 a day against the violator. BC advised that a copy of this statement may be forwarded to the Office of lnvestigationx of tho DIA for insurance coverage verification. I do hereby certify/ nacr a it bra'penalties of perjury that the informadon provided above is true and correct. Date: 'U,( u3c orue only Do not write in this area, to be completed by city or town official Gq or TUwat: Permit/License# Issuing Authority (circle oue): i.ward of Heailth 2, iB!uidding Department 3. City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector 6.Other Cull(act Person: Phone#: CAPECOD-27 MYOUNG ,-��:��i�`L3'` - DATE(MMloorcyrYl fir•- CERTIFICATE ER ggFICr E OF LIABILITY INSURANCE W URYN CE 7/812013 _ TFIIS C:ERITFICATE 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. BYTHEPOLICIES 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 olic les must be endorsed. If SUBROGATION IS WAIVED,subioctto Ow terms and conditions of the policy,certain policies may require an endorsement. A statement on this Certificate does not confer rights to the curlihcalu holder in lieu of such endorsement(s). _ ............ ._..---....� ---- `--�------ j l"WOUCEI License'# PC-514062 NAME:_CONTACT Margaret Young Buyers u Gray Insurance Agency,Inc. PHONE I FAk 474 Rte 134 AIC o Ex E-MAIL ISDUNrDannis,NIA 02660 ge-g _g i - - LA m OUII ( r0 BrS fay Conl INSURERS AFFORDING COVERAGE _NAIC0-- - j --- ........---...._.:_. INSURER A:PEERLESS INSURANCE COMPANY INSURER 8:COMMERCE INSURANCE COMPANY - INSURERC:Evanston Insurance Company Gape Cod Insulation, Inc. ---- '18 Reardon Circlo INSURER 0:ATLANTIC CHARTER IlVSURANCE_GROUP j South Yarmouth, MA 02664 wsuRERE - _..._ _ -_ I . INSURER F i COVEP.AGES CERTIFICATE NUMBER: REiVIS1(514 NUMBER: I "frn IS 10 CER I-IFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICAIED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECTTO WHICHTIIIS CkR'NF'ICAIE MAY '9E ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED,BY THE POLICIES DESCRIBED HEREIN ISSUBJECTTO ALL THETERMS, LAUL01ONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR -'--' -A55C SpBR - L.fR TYPE OF INSURANCE POLICY NUMBER IDOIY1fY MIDDIY Y LIMITS L_.... _,........_._.._.__-._._..-_._._..-...-._... - UtNtKALUAUILITY EACH OCCURRENCE _ i _-_-- 1.000,000 CBP8263063 41112013 411/2U'14 I)AMAGE TO-RCNTEo' -- 100,000 A - I;iJNIMI Rl'lAL GENERAL LIAkTILI fY PREMISES IEa nculnanLn) �_ _ .:. . . (;LAIM5 MADE OCCUR MED EXP(Any ula Pofvan) b _ 5,000 J -- I PERSONAL S ADV INJURY Y_ 1,000,000 j GENERAL.AGGREGATE - 5 __,_ 2,000,000 !tEN1'l A66RkCAlt LIMITAPPLIES PER:- - _ ePR(0�OAD8U11NC�TDS•C�IOTi-MCEP InOiPM lAf GG_ _ _2,000,000 PRO Y .1.. AU MOUILE LABLITY 1, 000,00 B -f AN', ulTu 13MMBCKVMK .41112013> .4/1/2014 BQDILY INJURY(Pal pmaon) - ALI.UWNEU -- SCHEDULED BODILY INJURY(Per acddent) b AMOS x AUTOS - '- -- --" NON-OVVNEO PROPE TY D%LMA�iE b X WRED AUTOS X AUTOS r: : PE ACCIDENTI b X uMBKeLLA LIAtl X OCCUR - EACH OCCURRENCE $. 1,000,000 T AGGREGATE b 1,000,000 C E-xCESS LIAtI -- CLAWS-MADE XONJ453512 4/112013 4/112014 _ _ . ur.0 II X II nE 1L'N I ION -^ 10 000 — — a L l__.1_ ____....,._.�._. L_-.. — V_4C$TAfl1- OTII• I. WORMERS COMPENSATION AND ENIPLOY'ERS'LIABILITY YIN ) — - --- T 1 000,000 - D ANY PROPRIErONIPAR I NERJEXECU rIVE -- WCA00525904 '613012013 613012014 E.L.EACH ACCIDENT b _- __— t?FFiCLR1NIEM15ER EXCLUDED? N 1 A _ EMPLOYEE - 1000,000 E.I.DISEASE b {MaPdalury In NH) . rt Yea,desamo Urular ----- 1,000,000 ❑@SCRIP f ON OF OPERATIONS below _ ' E.L�DISEASk-POLICY LIMIT $-b- , I Wc5CHIFIION OF OPERATIONS"I LOCATIONS I VEHICLES (Attach ACORO IQI,Addiliunal Re01arka Schedule,If Pnore space Is rnqulfud) ' Wufkers Compensation includes Officers or Proprietors. Addtioaal Insured status Is provided undeF the General Liability when required by written contractor agreement with the Certificate Holder. l.. I I ' CANCELLATION CERI'IFICATE'HOLDER -_--.-- -_ SHOULD ANY OF THE ABOVE DESCRIEIP13 POLICIES QF_CANCELLED DEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL, BE DELIVERED IN Cape Cod Insulation, Inc ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I f 01988-2010 ACORD CORPORATION. All rigIlts reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Housingkill Assistance Corporation Cape Cod HOME OWNER I RESIDENT WEATHERIZATION WORK PERMIT& FUEL RELEASE: PLEASE FILL OUT AND SIGN THIS FORM IF YOU ARE THE APPLICANT HOME OWNED. hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation (herein after referred as "Agency")on the property located at , The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures: Weather-stripping&caulking of windows and doors, insulation of attics, sidewalls & basements, attic and other ventilation measures and possibly replacement of badly deteriorated windows. In consideration of the weatherization work to be done at my home I agree to the following: t. I give permission to the"Agency"its agents and employees to travel onto or across said property with such equipment and materials as may be necessary to perform weatherization work on said property. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five (5)years after the weatherization work is completed. I have read the provisions of this agreement as listed-end freely give my consent. f`�. . . Home Owner: (Sign ture) 1vb, 1 :/,,i x. `Lt Date: L , Agents (signature) Date; �.�� 3 15i HAC approved Weatherization Company Adam T Incorporated All Cape Energy Alternative Weatherization Building Performance Contracting LLC Cape Cod Insulation Cape Save t. Frontier Energy Solutions Lohr Home Irnprovement Resolution Energy CODservision 3�12�1 Y CAPE COD INSULATION KEEP BgTTS �ui1Ln INSOIATION CIILINO$ ' 1-800-696-6611 'town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, MA 02601 Date: Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. perfornied & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the sptcifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. Property Owner I Property Address Village � C+- ..JIB✓ ..m'.J Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrest`f%ted Ceilings Eca Slopes- Floor %e.A 4— Walls PMrk� vflk-� CtreS Sincerely He He y E Ca sidy r, President Ca e Cod sulation, Inc. Efficient Buildings, LLC October 31, 2011 F Town of Barnstable - Attn: Thomas Perry, CBO 200 Main Street Hyannis, MA 02601 re: 6 Jacqueline Court, Centerville, MA 02632 - Dear Mr. Perry: This affidavit is to certify that all work completed at 6 Jacqueline Court, Centerville, MA 02632, has been inspected by a certified Building Performance Institute (BPI) inspector. Work included air sealing, weatherstripping, and installation of 360 sq. ft. R-38 cellulose and 216 sq. ft. of R-18-20 cellulose in attic, 68 ft. of R-19 FGB to sills, 550 sq. ft. of 2" foam board to perimeter, and 228 sq.ft. of R-5 duct insulation. All work performed meets or exceeds Federal and State requirements. Sincerely, Steve C. White Owner/Managing Member = s Efficient Buildings, LLC 4� �v 8 Jan Sebastian Drive, Unit 10, Sandwich, MA 02563 Te1: 508-888-1110 Fax: 508-888-1109 of«ram Town of Barnstable *Permit I ti t# +� Erpires 6 mon n r Reguiafory Services. Pee j6 9- �Q Thomas F. Geiler, Director Bililding Division U- Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.bamstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid iP&hou1 RedX-Press imprint Map/parcel Number O t tResidential Address Ue iArr, 1 l Value of Work �(9 9 Minimum fee of$35.00 for-work under S6000.00 Owner's Name ds Address N f✓r►G� S/)L/vi Contractor's Narne rj 170M(! �P /jk eS �t/V �j Z/J//� Telephone Number 5VI — C{Y oZ Home Improvement Contractor License#(if applicable) Con ruction Supervisor's License#(if applicable) SD Workman's Compensation Insurance X-FIRESS PERMIT. Check one: ❑❑ r3m a sole proprietor S E P l2 m j i am the Homeowner I have Worker's Compensation insura ce T0VA CIF BARNSTA13LE Insurance Company Name �" ^e Workman's Comp.Policy# 0 L, j 3 Copy of Insurance Compliance Certificate must accompany each permit.` 3ermit Request(check box) ❑ Re-roof(hurricane nailed) (stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of rood ❑ -side c #of doors • Replacement Windows/doors/sliders..U-Value 0,0 (maximurn.35)#of windows _ } *Where required: Issuance of this permit does not exempt con}plianee 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 requir VATURE: •n,-.. ....,mna;tclt,,,;ia:...,.........:r__..�..-,.n�r�n� .- The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations +=� = 600 Washington Street Boston,MA 02111 --: ;�. ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): C7�1 Address: City/State/Zip: �(,t�r = 31 Phone #: 6 5-7 " s-1 g--;)- Are you an employer? Check the appropriate b : Type of projec (required): 1 =i I am a employer with , 4. I am a general contractor and I employees (full and/or`part-time).* have hired the sub-contractors 6. ❑Mem construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. odeling ship and have no employees These sub-contractors have g, � Demolition _ workingfor me in an capacity. employees and have workers' y P h' 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 requ qu a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL -12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �0 Policy#or Self-ins.Lic.#: 0 / 3 Expiration Date: Job Site Address: C4. (/;1 City/State/Zip: e -le 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 $i,500.00 and/or one-year imprisonment,as well as civil penalties in the form of aSTOP 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 certify under the d penalties of ' ry that the information provided a ve>is true and correct~ Signature Date: Phone#• Jib t5 t� 6 Official use only. Do not write in this area,to be completed by city or town ofciat 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#: CERTIFICATE F LIABILITY INS( NICE DATE(=D1YYYV1 1212812010 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Vieira Insurance Agency,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 65 Alden Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.. Fairhaven MA 02719 INSURERS AFFORDING COVERAGE NAIC# INSURED Douglas Szynal dba Szynal Property Services INSURER A: Essex Insurance Company 24 Logan Unit N504 INSURER B: Granite State Ins Co SURER C New Bedford MA 02740 INSURERD: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOWHAVE BEEN ISSUEDTOTHE 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 BYTHE POLICIES DESCRIBED HEREIN IS SUBJ ECTTO ALL THE TERMS,EXCLUSIONSAND CONDITIONS OF SUCH \ POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD'L POLICY NUMBER POLICY EFFTNE EC POLICY EXPIRATION LIMITS GENERAL LIABILITY DATE Of DAV-LMMMD= EACH OCCURRENCE $1,000,ODO DAMAGE TO RENTED 100 000 A COMMERCIAL GENERAL LIABILITY 3DE9446 11l22110 11122/11 R f cc r n $ CLAIMS MADE F OCCUR MED EXP An one erson 5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,ODO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG. 1,000,000 POLICY PRD- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ` (Ea acciderd) ANY AUTO ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) AUTO ONgACCIDENTCIDENT $ GARAGE LIABILITY ANY AUTO OTHER TEA ACC $ AUTOONAGG $ EXCESS I UMBRELLA LIABILITY EACH OE $ OCCUR CLAIMS MADE AGGREG $ $DEDUCTIBLERETENTION $WORKERS COMPENSATION OX OTHAND EMPLOYERS'LIABILITYB ANY PROPRIETOR/PARTNERJEXECUTIVE YIN WC 002-25-3582 11123/2010 11/23120 11 E.L.EANT $100000 OFFICERMIEMBER EXCLUDED9 N0 E.L.DISEMPLOYE- $100000 (Mandatory In NH) If yes,describe under E.L.OISLICY LIMIT $500000 SPECIAL PROVISIONS Wow OTHER DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS additional insured:THD At Home Services Inc and the Home Depot are included as Additional Insured with respects to General Liability Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THD At-Home Services Inc DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN dba The Home Depot at Home Services NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 2690 Cumberland Parkway IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR Suite 300 REPRESENTATIVES. Atlanta GA 30339 AUTHORIZED REPRESENTATIVE ACORD 25(200910i) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are regisleyed marks of ACORD J��ie t^u»r.»ro'nu�rca�lf r i lua.xc/iu ells License or registration valid for individul use only Office of Consumer Affairs&BiNiness Rquiation r before the expiration date. if found return to: x , HOME IMPROVEMENT CONTRACTOR � ! �f , Registration: 146142 Type: Office of ConsumerAffairs and Business itegulatior Expiration: 3t29l2013 DSA 10 Park Plaza -Suite 517() Yjr p, Boston,INIA 02116 S2�"L PROPEfjTY SERVICE DOUGLAS SZYNAL r 24 LOGON ST .,.......... NEW BEQFORD,MA d274(3 UndersecretaryN gal id wtt ut stgttatu! G ^ r,Ve dltie4�(°i 136 gr fd"#'f.1, dt alb.l�dSdiI1R 11<.8'1: N E Sa t�ua�c -SFttlr `t:t2tz4 Ir jf. t..as..t'415t; ws £)0l1LA.�, 2 +OGA? T` :NIT E vC -NEW f3E RY3 ,4f4 U i+;f� y' 10395a f / -' flff ce of Consumer Affairs&Business Regulation � W9P,---,-H0ME IMPROVEMENT CONTRACTOR Registration: ;126893 Tyre: Expiration:: 8l3/2Q1.2 . Supplement C - The Home Depot At Home Services DARREN DEMERS 2690 CUMBERLAND PARKWAY S � A'�L�N�`A, GA 30339 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 ;ard Boston,MA 02116 �.a-�.--r__•�-^ arm'"c�'' Not valid without signature G Aug 21 11 05.03d Robert Hlgglns M6-444-8802 P. HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold,Furnished and Installed by: -rf-M ArMnrrtr SPrvirrs.Inc_ Branch Narue: Busturr Dulc. _ .J— dibla The Home Depot At-Home Services 345A Greenwood Street.Unit 2,Worcester,MA 01607 Toll Free(800)657-5182; Fa-x(508)756 8823 Branch Number:31 Federal 1D#75=L69t 4W:rv7h Ltc tF u utw.iq:Ki t.ont,r.tclr 10427 CT Lic#5655522;MA Home improvement Contractor Reg.#126893 Installation Address: —O City State Zip Purchaser(s): Work Phone- Home Phone: Cell Phone: Homc Address City State Zip (If different from Installation Address) E-mail Address(to receive project communications and Home Depot updates): ❑I DO NOT wish to receive any marketing-,mails from The Home Depot L{/ pr 'vrt Tnfnrm 11 dersiEned("Customer'),the owners of the property located at the above in address,agrees to buy, and THD At-Home Services,Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installation("tnstauauon or 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 attached hereto and any Change Orders(collectively. "Contract"): Spec Sheet s)# Project Amount job#: am�n��t tt.r�R"«; Products: " ❑Roofing ❑Siding Windows ❑Insulation ^t { � ! 't 7Pumhasers ❑Gutters i Covers.❑Entry Doors ❑ ,�;Lg' $ FRoofrag ❑Siding ❑Windows ❑Insulation $ �O❑Gutters 1 Covers ❑Entry Doors ❑❑Roofing ❑Siding ❑Windows ❑Insulation $ UGutters I Covers Zi ntry Doors LJ❑Roofing ❑Siding Windows ❑Insulation $❑Gutters1 Covers ❑Entry Doorssit of ConlraM Artwttnl due upon exeattion of this oontracLTotal Contract Amount $ I .ay not deposit more than one-third of the ContractAtnnunt 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 llepo[reserves the right to issue a ChatgC Otdcr vt lcuuivatc Lhia CvutraCt yr any individual Product(3)included hor in,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. � included as part of this Contract. sets forth the total Payment Summaryr The Payment Summary # Contract amount and payments required for the deposit.-,and final payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign s Completion Certificate(note: there is one Completion Uertificate for each listed Product as defined by Individual Spec Sheets)before work on that Product is complete. The Home Depot the costs o In the event of termination of this Contract,Customer agrees to pa}' ofmaterials,labor.expenses and services provided by The Home Depot or Authorized Service Pro,.ider through the date of termination,plus any other amounts set forth in this Agreement or allotted under applicable W.Y. THE HOME DEPOT MAY WITHHOLD A;NIOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAY-AENT OR OTHER PAYMENTS NIADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. .'LCCBpt:UtCP sntl Anthnriratinn- rttctnmer n2rr-cts and Installation services and supe .ns and understands that this Agreement is the entire a1.'reetnent between Customer and The Home Depot wuh regard to the Products edes all prior discussions and a,reements,either oral or written,relating to said Products and Installation,This Agreement cannot be assigned or amended except by a writing signed by Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,understands,vntnntarily accepts the terms of and has received a copy of this Agreement. Accepted Submitt ` X -� ales Coneultunt's Signa Date) Ctistotttcr's Siguatutc Datc Telephone No. �2 -- X Customer'-,Signature Date Sales Consultant License No. CAINCELLATION: CL;3TONIER MAY CANCEL T.fII6 AGREEMENT WITHOUT PENALTY OR OBLIGATION BY 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 SPECIFTCA1`1V PRFSCRIBF.D BY LAW IN CUSTOMER'S STATE. NOTICE:.ADDITION.AL TER.NIS AND CONDITIONS ARE STATED ON THE REVERSE S16E AND ARE PART OF THIS CONTRACT TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application Health Division 'Date Issued Z a1 Conservation Division Application Fee j Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _Preservation/Hyannis Project Street Address \o ems► �� \i�l-2_ Village Owner "C> Ja2 Address Telephone s — Permit Request — o©� CC,— ak(z_ Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 0 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family . 0 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: Q existing ❑rnew size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:r` -- CD Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# " Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 3 Telephone Number c� r—G. Address C ✓ License# `M 6 Go Home Improvement Contractor# / 7 J 5`) Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE �o ; t t FOR OFFICIAL USE ONLY APPLICATION# } 'r DATE ISSUED F r t MAP/PARCEL NO. . ,{ ADDRESS VILLAGE OWNER k j ti DATE OF INSPECTION: FOUNDATION# ti III FRAME L` INSULATION!,} FIREPLACE I � ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL �GAS: ROUGH: ��'��- � FINAL v.�i€FJNALBUIL`•DING It t_ DATE CLO.SED'OUT ` ASSOCIATION PLAN NO. t r The Commonwealth of Massachusetts Department of Industrial Accidents ' ^y Office of investigations ;; 600 Washington Street "' Boston, MA 02111 r`jN www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly : Name (Business/Organization/Individual): ��2✓ Y \. Address: coA �e- City/State/Zip: e3 Phorie #: AV an employer?Check th ppropriate box: Type of project(required)- 1. am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or p -time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. $ ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance .5: El We are,a corporation and its ' required.] officers have exercised their ]0.❑ Electricalarepairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roo repairs insurance required.] t employees. [No workers' 13.E0,66her 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy'andjob site information. _ Insurance Company Name: t� Qtt S Policy#or Self-ins. Lic. #: 77(oZS�C)- Expiration Date: �- 1 Job Site Address: �P C��E �1^ Q- City/State/Zip:. c—eA&rV Attach a copy of.the workers' co ensation 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 certif n e the pains and penalties of perjury that the information provided above is,true and correct. Signature: Date: I O ' Phone#: 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual, partnership, association 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 renewaNf a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)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 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 be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should 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"the applicant should write-"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must 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 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 Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877'-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia NTassachusetts- Department of Public Safet., Board of Buildim-, Regulations and Standards Construction Supervisor License License: CS 95038 Restricted to: 00 STEVEN WHITE 147 RIDGEWOOD AVENUE HYANNIS, MA 02601 Expiration: 2/2&Ml2 (' mmi.�i•ncr Tr=: 19311 �!e �ioma�neo�euiealdaaaac/%uaek`a IZX Board of Building Regulatio and Standards HOME IMPROVEMENT CONTRACTOR Reg .:154359 a , '_ 812011 . Tr# 280764 Typi �#ti`Liability.Corporation CALIBER BUILDWAMd. DELING.LLC. STEVEN d1MITE : . 147 RIDGEVVOOt)AVE .,4..,Q.a...` Hi ANNIS,MA 02601 Administrator l imse or registration VSW-for inditidul use only before the a*ration date. If found return to: Board^of Bux'fng'.Regniations and Standards One Ashburton-10kee Rm 1301 Boston,Ma.01108 y ANotitlid'withont signature i ACORD CERTIFICATE OF LIABILITY INSURANCE °"TIE'""'°°"""' 09/1S/2010 PRODUCER S08.94S.0393 FAX S08.94S.4048 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eldredge & Lumpki n Ins. Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 697 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Chatham, MA 02633 _ INSURERS AFFORDING COVERAGE NAIC# INSURED Caliber Building and Remodeling LLC INSURER& National Grange. Mutual.°Ins CO - 14788 INSURER er Commerce Group CIG001 147 Ridgewood Ave INSURERC Granite State Ins. Co.-ARWC 13102 Hyannis, MA 02601 INSURER D: - INSURER E: 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 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN R PE OF INSURANCE ��- POLICY NUMBER POLICY EFFECTIVE POU Y EXPIRA LTR NSR 'DATE MYIDQM/W DATE MWDD LIMITS Ir GENERAL UABIUTY MP027360 09/1S/2010 09/15/2011 !EACH OCCURRENCE $ 1,000,TO RENTED 00 X I COMMERCIAL GENERAL LIABILITY - _ PREMISES(Ea commence) E SQQ QQ —�CLAIMS MADE �X OCCUR MED EXP M one 10 0 A !` » � - `h�. „. PERSONAL 8 ADV INJURY $ 1100010 GENERAL AGGREGATE $ 2 QQQ O GEN*L AGGREGATE LIMIT APPLIES PER: _ _!_ PRODUCTS-COMP/OP AGG $ 2,000,00 ! POLICY JE LOC _ AUTOMOBILE UANUTY BBNVCS 02/16/2010 02/16/2011- COMBINED SINGLE LIMIT $ ANY AUTO i(Ea accident) 1,OOO,QO i ALL OWNED AUTOS BODILY INJURY I X SCHEDULED AUTOS ,_ , (Per Ilmw) $ B i_.-. HIRED AUTOS 1 BODILY INJURY $ NON-OWNED AUTOS I(Per at) PROPERTY DAMAGE (Per aociderll) $ GARAGE LIABILITY - " - - AUTO ONLY-EA ACCIDENT $ j1 ANY AUTO OTHER THAN ' EA ACC E AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY - - EACH OCCURRENCE $ L�OCCUR LJ CLAIMS.MADE ,w :-,. AGGREGATE $ DEDUCTIBLE $_ RETENTION $ $ 1 WORKERS COMPENSATION WC742S405 03/02/2010 03/02/2011 �AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR(PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ SOO,.O C OFFICER/MEMBER EXCLUDED? --- (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ - SOO,OO 11 yes.describe under _... ._.. SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ SOO,OO !OTHER - DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPEML PROVISIONS Carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBBDPOLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL /0 DAYS WfUTTEN NOTICE TO-THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO$O SHALL Town Of Barnstable r IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Attention: Building Department' REPRESENTATIVES. 200 Main Street AUTHORQEDREPRESENTATIVE Hy nnis, MA 02601 Alan R.. Long, Presiden jkAY 4 ACORD 25(2009101) 01985-2009 ACORD CORPOR#rION. All rights reserved. The ACORD name and logo are registered marks of ACORD I i A InJe.� Main St.ree HOUSING �;Ya trice. Mt, G26G -359c x`x y AS S I S T -1 C '` ENERGY S HOME RE.FA_R CORPORATION 2A2 5 HOME OWNER WEATHERIZATION WORK PERMIT&FUEL RELEASE: PLEASE FILL OUT AND SIGN THISFORM IF YOU ARE THEAPPLICANT HOMEOWNER. C:C- 1C hereby consent to and agree that weatherization work maybe done by the Weatherization Program of Housing Assistance Corporation (herein after referred as "Agency" on the property located at: r L o; C. C-.... T he weatherizati on work done wiII be based op programmatic priorities and availability of funding and it may indudealI or some of the following measurm Weather-stripping& caulking of windowsand doors, insulation of attics, sidewalls& basements, attic and other ventilation measuresand possibly replacement of badly deteriorated windows. In consideration of theweatherization work to bedoneat my homel agreeto thefollowing: 1. 1 give permission to the"Agency" its agents and employeesto travel onto or acrosssaid property with such equipment and materials as may be necessary to perform weatherization work on said property. 2. The H ousing Assistance Corporation reservesthe right to inspect thefuel or utility bill for the weatherized unit on an ongoing basisfor no morethan five(5) years after theweatherization work is completed. I have read the provisions of this agreerpftt as list freely give y consent. Home Owner: (Signature) A. 6 qkv -. Date i f Agent: (signature) nature) 9 Date: HAC approved Weatherization Company : Caliber Bu` ng&Remodelm* _ 'i Cape Cod Insulation Cape Save Creswell Construction ron ier nergy Solutions Lohr& Sons Peter Smith Resolution Energy Rock Solid Construction Sprinkle Home Improvement ��._i.zG.-o�.-'cY.,li�n:.;,..i &1'.l'��.h••':�i`t:i'1'}Y�..p_CL7_l Y:Ic`dSE i_:^:C.;'�1C ' 'TH.r� Town of Barnstable *Permit Ex it 6 n nips rom issue date regulatory Services Feed ` STABLE, Thomas F. Geiler, Director 4�p i6159. �� Building Division o ) 9/IS�c� rEo Mai - Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, NIA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 5087790-6230 EXPRESS PERAUT APPLICATION - RESIDENTIAL ONLY Not Valid rvUhout Red X-Press Imprini Map/parcel Number IV V erty Address CC. . ` '� %� �esidential Value of Work Ot Minimum fee of$25.00 for work under$6000.00 n , I_ Owner's Name &Address Ck��6 �v�'Oc ky v C f` Contractor's Name i6w. J "r f Telephone Number Ho Improvement Contractor License# (if applicable) ©Workman'?,n pensation Insurance Chece: -P LESS PERMIT ❑ a sole proprietor � am the Homeowner ! I have Worker's Compensation Insurance SEP 1 1 2008 Insurance Company Name �� '/ � '� �� `1 s ''TOWN OF BARNSTABLE Workman's Comp. Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check.box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to . ❑ -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: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required, SIGNATURE: QWPF[LES\FOWS\building permit formsEXPUSS.doc ID ino t The Commonwealth of Alassachusetts. Department of Industrial Accidents Office of Investigations a 600 Washington Street Boston MA 02111 N sv www.mass.gov/dia `Yorkers'.Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organization/Individual): qqML b4a V 5 Address: :5 City/State/Zip:` < d33 Phone.#:" ��-' Are you.an;em lo. erTCheck the appropriate box 0. mp Y. .:Type of project(required) 1.( I air' e P o er with 4.. Q I am a general contractor and I employees(full and/or part-time). have hired the sob-contractors 6. 0 New construction 2 ❑ I am a sole proprietor or partner- listed on the,attached sheet. r 7. ❑Remodeling These sub-contractors have ship-and have,no employees. . . ... : 8. ❑Demolition working for me in any capacity. employees and have workers' [No workers comp.insurance comp.insurance. t 9. Building addition re uired 5 We are a corporation and its 10.❑ Electrical repaits.or additions officers have exercised.3 ❑ I am a homeowner domg all work I L Plumbing repairs or additions myself o workers co' right of exemption per MGL mP 12:F71Ao6f repairs insurance required]t c. 152, §1(4),and we have no rs r v� � F ^ � employees.[No worke 13. Othe 1 `J i. }, comp.insurance required] *Any a licanf that cfiecks boz#1 must also'fill out the section below showing`their workers'co y pp g mpensation,policy'information:``. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors.must.submi 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 pokcyand�ob site information. .f _ Y ,Gt &�0,5xlInsuranceCo an Name: .$ . _�`• cc ..v Policy#or Self ins. Lic.#. - - Expiration Date Job Site Address. �C.. �'i �`� City/State/Ziph Attach a copy of the workers'corn e'nsation policy declaration page(showing the_policy number and egpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of cnminal penalties of a r 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. 1 do hereby certify under the pains and penalties:of perjury that the information provided above.is true and correct 2 vv Sianafore: t.� �, Date: Phone#: 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#: 5 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written. An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association 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 buildings in. e commonwealth for an th y applicant Whol has not produced acceptable evidence of compliance with the insurance'coverage required." Additionally,,.MGL;chapter.152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract.for.the performance public work until acceptable evidence of compliance with the insurance of q p contracting authority." p requirements of this cha ter have been' resente to e Applicants ]?lease fill out 1the 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 certificate(s)of insurance. Lirmted Liability Companies(LLC)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 this affidavit may be submitted to the Department of Industrial ccidents for confirmation of insurance coverage Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the applicarion for the permit or license.is being requested,not the Department of IndustriatAccidents. Should you have any questions regarding the law or if you.are required to:obtain a workers' co mpen`sationpohcy,please ca11theDepartment at the number listed below. Self-insured companies should enter their self-insurance license number.on the appropriateline 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 fill in that must submit multiple permit/license applications any be used Bear need refonl C submit In addition,an applicant p __ .. p p pp y g y y one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should-write."all loca 1 1. in (city or provided to the town)"A copy of the affidavit that has been officially.stamped or marked by the cityof town may,be, applicant as proof that.a valid affidavit is on file for future permits or licenses..,A new affidavit must be filled out each year.Where ayhome 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 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 Industrial Accidents . Office of Investigations r 600 Washington Street ,Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE . Fax#617-727-7749 Revised 11-22-06 www.mass.gov/dia ✓1ze �o�rr�r.o�uaecz//a o�✓�aoac�cluaeaa : Board of.Building Regulations and Standards License or registration valid for individul use only i HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registr4ion: Board of Building Regulations and Standards at 126893 Ezpiration_gj3/2n10 One Ashburton Place Rm 1301 _ 1 Boston,Ma.02108 ,i? Ty S pe: upp� lement Card . The Home Depot�At Home Service' rwi MARK NIADA � f f 3200 COBB GALLE'RIANP�KWY.#20nignature /1GL ATLANTA,GA 30339 4 �'. -- --------Administrator Not valid withou R r f 1 PERMIT PAYMENT RECEIPT TOWN OF BARNSTABL.E BUILDING DEPARTMENT 200 MAIN STREET HYANNIS, MA 02601 DATE: 09/11/08 -TIME: 12:38 ------------ -----TOTALS------------------ f PERMIT $ PAID, 25.00 AMT TENDERED: 25.00 AMT APPLIED: 25.00 CHANGE: .00 APPLICATION NUMBER: 200805050 PAYMENT METH: CHECK PAYMENT REF: 24040 Sep 02 08 09:58p Robert Fasci 1 781 337 2259 p.1 ROME IMPROVEMENT CONTRACT PLEASE READ THIS Sold,Furnished and Installed by: (^� J Branch Name: Boston Date: THD At-Home Services,Inc. dfb/a The Home Depot At-Home Services Branch Number: 345A Greenwood Street,Unit 2,Worcester,MA 01607 Toll Free(800)657-5182; Fax(508)756-8823 ❑North 33 Louth 31 Federal ID#75-2698460;ME Lic#C 02439;RI Cont.Lic#16427 / CT Lic#565522;MA Home Improvement Coonnttraactor Reg.#126893 Installation Address: City Sta Zip Purchaser(&): Work Phone: Home Phone: Cell Phone: 7,s"787 [ Home Address: (If different from Installation Address) City State Zip E-mail Address(to receive project communications and Horne Depot updates): ❑I DO NOT wish to receive any marketing emails from The Home Depot . Protect Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, and TT ID At-Home Services,Inc.("The Home Depot")agrees to furnish.deliver and arrange for the installation"("Installation°')of all materials described on the below and on the referenced Spec Sbeet(s), all of which are incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively, "Contract"): Job#: (Inoernmaearrntt) Products: Sec Sheets #: Project Amount !V� ❑Roofing lding Windows ❑Insulation $ �v0 9pOa ❑Gutters i Covers ❑Entry Doors ❑ 3�0. ❑Roofing ❑Siding ❑Windows ❑Insulation $ ❑Gutters/Covers ❑Entry Doors ❑ ❑Roofing Siding ❑Windows ❑Insulation $ ❑Gutters/Covers ❑Entry Doors❑ ❑Roofing ❑Siding ❑Windows ❑Insulation $ ❑Gutters;Covers ❑Entry Doors ❑ Minimum 25%Deposit of ContractAmount due upon execution of this contract Total Contract Amount $ Maine Purchasers may not deposit more than one-third of the Contract Amount 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 tinder 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 Products(s)included herein,at is 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 Summarv:-The Payment Summary # d SRO JO 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). NOTICE TO CUSTOMER You are entitled to a completely£died-in copy of the Contract at the time you 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 RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization: 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 supersedes all prior discussions and agreements,either oral or written,relating to said Products and Installation.This Agreement cannot be assigned or amended except by a writing signed by Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has received a copy of this Agreement. Accepted Submitted by: to er's Signature Date Sales Consultant's Signature Date X Telephone No. 7�I o�S00 3L Customer's Signature Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS (as applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY 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 1F ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE:ADDITIONAL TFRNIS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT I AC®RDr,, CERTIFICATE OF LIABILITY INSURe NCE DATE(MM/OD 02/26/08/YYYY) PRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR homedepot.certrequE, Suite 1200 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 3475 Piedmont Rd NE, Suite 1200 Atlanta, GA 30305 Fax (212) 948-0902 INSURERS AFFORDING COVERAGE NAIC# _ INSURED Home Depot U.S.A., Inc. INSURERA:Steadfast Ins Co 26387 The Home Depot, Inc. INSURERB:Zurich American Ins Co 16535 2455 Paces Ferry Road Building C-8 INSURER C:Illinois Natl Ins Cc 23817 Atlanta, GA 30339 INSURER D:American Home Assur Co 19380 INSURERE:New Hampshire Ins Co 23841 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 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' POLICY EFFECTIVE POLICY EXPIRATION " LTR NSRD PE FINSURANCE POLICY NUMBER DATE MM/DDYY DATE MMIDD/YY LIMITS A GENERAL LIABILITY IPR 3757 608-02 03/01/08 63/01/09 EACH OCCURRENCE $4,000,000 X COMMERCIAL GENERAL LIABILITY LIMITS OF POLICY ARE EXCESS - DAMAGE TO RENTED 1,000,000 PREMISES Ea occurence $ _ CLAIMS MADE ]OCCUR "OF SIR: $1,000,000 PER 3CC11 MED EXP(Any one person) $EXCLUDEDs PERSONAL BADVINJURY $.4,000,000 GENERALAGGREGATE $41000,000 GEN•L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG" $4,000,000 X POLICY PRO- J CT LOC _ . . H AUTOMOBILE LIABILITY BAP 2938863-05 03/01/08 03/01/09 COMBINED SINGLE LIMIT 1,000,000 X ANYAUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY,; $ .. SCHEDULEDAUTOS (Per person) HIREDAUTOS BODILY INJURY ,,. $ NON-OWNEDAUTOS - (Peraccident) X SELF INSURED AUTO PHYSICAL DAMAGE (Perry cident)DAMAGE $ GARAGE LIABILITY AUTO ONLY-EAACCIDENT $ ANYAUTO - - OTHERTHAN EAACC $ AUTO ONLY: `..AGG $ A EXCESSIUMBRELLA LIABILITY IPR 3757 608-02 03/01/08 03/01/09 EACH OCCURRENCE $5,000,000 X OCCUR CLAIMS MADE AGGREGATE $5,000,000 DEDUCTIBLE $ RETENTION $ $ C WORKERS COMPENSATION AND 1928757 (FL) 03/O1/08 03/O1/09 X ORYTAITS OTR D ANIPLOYERIETOR/LITYART 1928756 (CA) 03/01/08 03/01/09 $1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT E OFFICER/MEMBEREXCLUDED? 1928755(AOS) 03/01/08 03/01/09 E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 OTHER F TX Employers Excess TNS-C45197967 (TX) 03/01/08 03/01/09 Occurrence/SIR 25M/2M D Workers Compensation 1928759 (QSI) 03/01/08 03/01/09 E Workers Compensation 1928758 (KY, MO, NY, WI) 03/01/08 03/01/09 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS *FOR EVIDENCE ONLY 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 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 2455 PACES FERRY RD., N.W. BUILDING C-8 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. ATLANTA, GA 3Q339 AUTHORIZED REPRESENTATIVE USA ACORD 25(2001/08)datkinson ©ACORD CORPORATION 1988 8213215 i Town of Ba"rnstable *Permit#92 oC� C> -PR Expires 6 neonths fr�t issue date RPAIT Regulatory Services JAN 2 9 2D08 Thomas F.Geiler,Director Tows OF Building Division ARNS TABLEom Perry,CBO, Building Commissioner 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 witliew Red X-Press Imprint Map/parcel Number lj 1tiJ - Property Address ✓ 4 L Cl'G 'e If 11 1z 14Residential Value of Work 1 D 0 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address f5�"+ t e<G t 9 e �4c44t' �r7r � . Contractor's Name p 140,me OeACT 41, th ,reerzit: f Telephone Number s� Q�r;I-�1 t{ t/W Home Improvement Contractor License#(if applicable)- /a 6 8 y-?' Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor - ❑ I am the Homeownei (w'I have Worker's Compensation Insurance Insurance Company Name `Uc tv` /T Q Yrf✓J t t P 1,45 C o Workman's Comp..Policy,# 17a r. o Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders. U-Value �3(maximum.44) *Where required Issuance of this permit does not.exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Pernussion'. A copy of the Home Improvement Contractors License is required.- SIGNATURE: Q:Fomis:expmtrg ltevise061306 t - } The Commonwealth of Massachusetts Department of Industrial Accidents ` { u r Office of investigations R. + 600 Washington Street Boston,MA 02111 iwww.mass.gov/dia Workers' Compensation Insurance davit: Builde>i s/Contractors/Electricians/Plumbers A licant Information - Please Print Le ibl Name(Business/Organization/Individual) Address a ci 5-S City/State/Zip:l4 �4%4 -?p 3 _Phone#. Are you an employer?Check the - 4 - yappropriate bozo - Type of pro,ect(required): e.-Y 4 I am a general contractor and I -1.9 I am employer with l0 g . 6 ❑New construction employees(full and/or part-tune).* have hired the sub-contractors - 4 2.❑ I am a sole proprietor or partner- listed on the attached sheet.` ' 7 ;D aReinodelmg shi :and have no em to ees `" `" These sub-contractors have a "" P P y 8 ❑ Demohhon working forme in any capacity. employees and have workers' com insurance.$ 9. ❑Building addition [No workers' comp.insurance _ p required.] 5• ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.El officers have exercised their I am a homeowner doing all work 11.❑Plumbing repairs or additions ` myself. [No workers'comp right of exemption per:MGL M 12.❑Roof repass: insurance required.]t c. 152, §1:(4),and we have no Oth"� employees. [No workers' 13 er comp. insurance required.] *Any applicant that:checks box#.1 must also fill out the section below showing their workers'compensation policy infom�a 10, t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such n< . tcontractors that check this box must attached an additional sheet showing the name of the sub-condraetots and state whether oi.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. N4f Insurance Company Name: W ca.0, y t✓e .�� S• . C a Policy#.or Self iis:tic Expiration Date J U S lob Site Address: �P C:`: City/State/Zip ft/ A g P. . 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 maybe.for to the Office of Investigations of the DIA for insurance coverage verification I do herebycerti u er th ains.and realties o er'u that the information provided above is true and correct, fy P P fP J ►Y f Si ature: Date: _40 e Phone#: �.� 6J— �0 (�,Z Official use only. Do not write in this area,to be completed by,city.or town officiaG 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#• Inf ` ®rmaton andF Instructions ...... A. Massachusetts General.Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written. An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a.joint enterprise,and including the legal representatives of a deceased employer,or the zeaeiver or tLustee of an individual,_pa1b ership,association or other legal entity,employing employees. However the owner of a dwelling house having not mole 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 to shall not because�of such employment bed eemed to be an employer." . or on the grounds or building appurtenant.there , MGL chapter 152, §25C(6)also"states that"every state or local licensing:agency shall withhold the ssuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced;acceptable evidence of compliance with the insurance coverage required." Additionally;MGL chapter 152, §25C(7)states."Neither the commonwealth nor any of its political subdivisions shall ' enter into any contract for.the performance of public work until-acceptable evidence of compliance with the insurance requirements bf this chapter have been presented to the.contracting authority.7, Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if -contiactor s names ,address(es)and.phone number(s) along with their certificate(s)of sub ( ) necessary,supply ( ) LLP with no employees other than the 'li Partnerships insurance. Limited Liability Companies(LLC)or Limited Liability p ( ) 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. Als n o be sure to sign and date the affidavit. The affidavit should be returned to the city or to that the application for the.permit.or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' at the number listed.below. Self-insured companies should enter their compensation policy,please call the Department 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 All 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 peimit/license applications in any given year,need only submit one affidavit indicating current Site Address"the applicant should write"all locations in ` (city or policy information(if necessary)and under"Job town)."A`copy of the affidavit that has been.officially stamped or marked by the city or town may be provided to the applicant as proof that.a valid affidavit is on file for future permits or licenses...A new.affidavit must 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 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.y 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 Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-977-11tiASSAFE Fax#f 17-727-774 9 Revised 11-22-06 www.mass.gov/dia r; ,hF hs I G , I RL F'r■ ._ I CERTIFICATE NUMBER. PRODUCER ^--.,xac•. '�. .?: *.. ;.:." ' 10-01 �aTL-aa�234a 1 TN18 A MATTER OF INFORMATION ONLY AND CONFERS CERYIFICATfi IS ISSUED At' - MARSH USA INC ,.z i I NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE ham edepat.certrequestQmarsh cam POLICY,THIS CERTIFICATE GOES NOT AMEN,EXTEND OR ALTER THH COVERAGE FAX(212)948-0902 AFFORDED BY THE POLICIES DESCRIBED HEREIN 3475 PIEDMONT ROAD,SUITE 1200 ATLANTA,GA 30305 COMPANIES AFFORDING COVERAGE , COMPANY . 00492-THD-IPUSA-07-08 IPUSA A STEADFAST INSURANCE COMPANY INSURED COMPANY HOME DEPOT USA,INC. A. ZURICH AMERICAN INSURANCE COMPANY 2455 PACES FERRY ROAD NW --— BUILDING C-8 COMPANY ATLANTA,GA 30339 C AMERICAN HOME ASSURANCE COMPANY COMPANY I A� -Q NEW HAMPSHIRE INS COMPANY �i�V�t�R1 E^y.sS >� aT••ylsg '. a q�k'-• . "x `-Y: r...," s� €.;`'a a"�r.ri;+.' 'n'[+ s� :'`'.(.k ;r:n k' +r 1t, x,u ..mw - _: _ rz¢ fl_. : .. 11d� . Of1iII0� � sse' Certle2['e�ora1PlO �ote. R19, T . r9, Q THIS IS'TO CERTIFY THAT PQLIbIES:OF;-INSURANCE.DESCRIBED HEREIN HAVE_BEEN'ISSUED TO THEINSUREO NAMED.HEREIN FOR TtEE"POLICY."PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT,'TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO.'ALL THE TERMS,CONDITIONS AND EXCLUSIONS.OF SUCH POLICIES.AGGREGATE LIMBS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. '. . `" •` "' CD '-TYPE POLICY EFFEC�E POLICY EXPIRATION PE OF INSURANCE POLICY NUMBER'. L LTR - DATE(MMIDD ) DATE(MMfD01YY) LIMITS q • t315NERALuaealTY IPR 3757 608-02 . 03/01/07 03/01/08 GENERAL AGGREGATE $ 4,000,000 X COMMERCIAL GENERAL LIABILITY 'LIMITS OF POLICY ARE EXCESS' PRODUCTS•COMP/OP AGG $ 4,000,000 CLAIMS MADE a OCCUR 'OF SIR:$1,000,000 PER OCC' PERSONAL Ei AOV INJURY $ 4,000,000 OWNER'S 3 CONTRACTOR'S PROT EACH OCCURRENCE $ ' 4,000,000 FIRE DAMAGE(An one fire $ 1,000,000 MED EXP' n ane person) $ EXCLUDED B AUTOMosafivaelurr BAR2938863=04 03/01/07 03I01/08 COMBINED SINGLE LIMIT' $ 1.000,000 X ANY AUTO F. . . ALL OWNED ALTOS BODILY INJURY SCHEDULED AUTOS .. (Per parson) $ .. HIREDAl1TOS., BODILY INJURY NON-OWNED AUTOS (Peraeddenq $ X ELF-INSURED AUTO HYSICAL DAMAGE PROPERTYDAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY .", ass ' EACH ACCIDENT $ . .EXCESS LIABILITY AGGREGATE $ A IPR 3757 608-02 03/01/07 03/01/08 EACH OCCURRENCE $ 5;000,000 N UMBRELLA FORM AGGREGATE $ 5,000,000 OTHER THAN UMBRELLA FORM ' $ C YVRKERS cOM ABILITY oN-AND - 02921209(CA) 03/01/07 03101/08 X A 0T EMPLOYERS'LIABILITY TORY LIMITS E � 2921210(FL) 03/01/07 :. .03101108':; EL EACH ACCIDENT $ 1.000,000 F. PARTNETHE PRIETOR/ X INCL 2921211(AZ;ID,MD,VA) 03/01/07. 03/01/08 EL DISEASE-POLICY LIMIT $ 1,000.000' D PARTNERS/EXECUTNE . OFFICERS ARE: EXCL 2921208(AIDS) 03/01107' 03/01/08 . EL DISEASE-EACH EMPLOYEE $ 1.000,000 C oT a 2921213(QSI) 03/01/07 03/01108 E . WORKERS'COMPENSATION' ' 2921212(KY,MO,NY,WI) 03/01/07 03/01/68 TEXAS EMPLOYERS TNS-C44642086(TX) 03/01/07•' 03/01/0.8 EACH OCCURENCE 25,000,000 .. EXCESS LWBILITY � SIR 2.000.000 �DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESISPECIAL ITEMS w. {E T46tG � fyltil. E � [ c S , S t ;y4� r �'c�,,.„3%: y..i �`� M�"^ ': �R. � � � r n 4��»x "' �'Sf�i✓��Nt{��s� ,�iaa��'��F•`;�n� wa��"'*re'��+kr't�.r'"'":3,`i` �' ' .. •..T'i:'.u- .r.y.�.' .ram„ :3h.`8.1.Lti:;s - SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, AFFORDING THE INSURER - COVERAGE WILL ENDEAVOR TD MAIL�a DAYS WRITTEN NOTICE fO THE FOR EVIDENCE ONLY - I 1 CERTIFICATE HOLDER NAMED HEREIN.BUT FAILURE TO MAR SUCH NOTICE SHALL REPOSE ON _ NO OBLIGATI OR D SURER AFFORDING COVERAGE ITS AGENTS OR REPRESENTATIVES OR THE LIABILITY OF ANY KIN UPON THE UV , ISSUER OF THIS CERTIFICATE MARSH US INC Ma . I ry Radaszewskl - �� ` � x LID AS OF02/28/OT . • «z Y Y.b ..I��?!.�e.Aw �'� s ,�,.�.. ,.-... .. .-N•s E wwi�w-- �w.,A'x�-,,.+, a"^-r..�•r�5,�i� DATE INMIDWYI e' , D i 2I28/07�� -x � «* COMPANIES AFFORDING COVERAQE - _ PRODUCER MARSH USA INC ,` caMPANY . hamedepot.certrequest®marsh Cam `E ILLINOIS NATIONAL INSURANCE COMPANY FAX(212)9.48-0902: 3475 PIEDMONT ROAD,SUITE 1200 ATLANTA,GA 30305 CaMPANY NATIONAL UNION FIRE INS CO •„ `' 100492-THD-IP USA-07-08 IP,USA INSURED COMPANY. HOME DEPOT USA;INC. G . iLLIN0IS UNION INSURANCE CO 2455 PACES FERRY ROAD NW BUI WING.C-8 ATLANTA,GA 30339 COMPANY' i`H tv' ' �• �._ ,� �� t i e ,µ`` fir'+. l I � s. t .. 1 � y I 7 t, .. .. .: x y�,Z •xs�-" s'Lrs'a "?�t�'U•�w . .. w'�at.x }�--,�•,,, Ka "'4:• '°' s -.` 9, vt,i. `Fs a3 yam" `+rs � t ...•:'.7. •s!sa .�iF..l¢Ci xfiv'a.:.:::735'3�vf:E-.sY'.:3.« �i'.5i CERTfFICATE3H'QLOER�' c� '^ �' 3� ems.:. �� .{rwv.a�^,F.-trt.,.,.+...i..,rs;. FOR EVIDENCE ONLY r FII I } IMARSNUSAINC BY w Ma Radasiewskl .I l.!nth wli,; I ry s,20�fft 1 , NFRC The Horne Depot ka6500-Series Double Hung Vinyl Window National Fenestration Architectural-grade, Soft Coat Low E and Rating Council® Argon Gas-filled Insulating Glass Unit ENERGY PERFORMANCE RATINGS U Factor(U.SJI-P) Solar Heat Gain Coefficient Visible Transmittance I 0.33 0.29 0.48 Manufacturer stipulates that these ratings conform to applicable NFRC procedures for determining Whole product performance.NFRC ratings are determined for a fixed set of environmental conditions and a specific product size.NFRC does not recommend any product and does not warrant the . sultabillty of any product for any specific use.ENERGY STAR�` Qualified in all i I e i Northern. South/Central Monty Heeling Hosting&Cooling ® North/Central Southern Hsating a cooling Mostly Cooling OP:25 Test Size:48 x 80 Test Number:05.30307.01 ✓T TOGyhZ2tdy0p[(/� 6�i.i��ZGGG�[l0e�d _ Board of Building Regulations and Standards License or registration valid for Individul use only HOME IMP,#OVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards ' Registratiorn _�26893 g g XPR5tlan 8/312008 One Ashburton Place Rm 1301 1- 7 a NO Boston,Ma.02108 j yR upplement Card Home De THE (.�k�� 1%,: po Arne etyfc DANIEL PELOQiJIN 3200 COBB GALLERhi�ZV1fY'#20 _ ..._ Atlantic,GA 30339 . Administrator Not valid without signature DEC-08-2007 01:53PM FROM-HOME DEPOT ' T-484 P.004/006 F-931 tiulvlr,11VIrAv v irlivi r IV l MAY I mal.1 Sold,Furnished and Installed by; Branch Name: 2 Date: J ((a__/S1 / THD At-Home Services,Inc. � 7 d/b/a The Home Depot At-1-Iome services j 345A Greenwood Street,Worcester,MA 01607 Branch Number: Z Job#: r� Z3� Toll Free(800)657-5182; Fax:508-756-2859 I•'cdcml ID N 75-2698460 ME Lic#C 02439 Pd Cont.Lie#16427 y CT Lic#565522; MA Home Impruvcmcnt Cunuacror Reg.9126993 Installation Address: J A II j;C I `-'tl d 2-G 3 Z... City- State Zip Last 4 DigiLc of Driver's Purchaser(s): Lie.#&Exp.Mo/Yr: Work Phone: Home Phone: ( ) F( 4E-77-76- Home Address: (If different from Installation Address} City State Zip E-mail Address(to receive updates and promotions from The Home Depot): Project Information: I/We/You("Purchaser"),the owners of the property located at the above installation address,offer to contract with THD At-Home Services,Inc.("Home Depot")to furnish,deliver and arrange for the installation of all materials as described on the attached Spec Sheet tt 3 7(a 2(p::7 incorporated herein by reference and made a part hereof. Home Depot reserves the right to cancel this contract if,upon re-inspection of the job,Hume Depot determines that it cannot perform its obligations due to a structural problem with the home,pricing errors or because work required'to complete the job was not included in the Spec Sheet or Contract. DEPOSIT PAYMENT OPTIONS (Subject to fund verification and/or credit approval.) - CONTRACT AMOUNT $� 1. Check',Cashiers Check or US Postal Service Money Omer (Made payable to The Home Depot). tLESS DEPOSIT S / I 3 2. Credit Card"untUur other payment options-Circle One Below BALANCE DUE �� Viva MasterCard Discover A ON COMPLETION $ The Home Depot Hone Tmprovcmcot Loan nt Credit C:vl tMinimum 25%of Contract Amount due upon ❑New Account Misting Account (H1L&HDCC ONLY) execution of this contract. Available Credit_S�0 d (HIL&HDCC ONLY) Indicate Payment Method For Accltia6@I° 6MOVDale: BALANCE DUE ON COMPLETION: p A/ platnc as it appears on card;�r'�iG./} �.r---r t o l-Z Al Un r1S l y" r"B y my/o signantre be w,1/We agree to allow Home Depot to charge th ov efer credit ca for the deposit,nd"eatcd. "when you provide a cbeck as payment,you authorize us either 1At)Y�\�`_ (i a Z_ to use Information from your check m make a one-time electronic' l.ardholders Signature Dule fund transrer from your account or to process the payment W a check transaction,when we use information from your check io H1I or HDCC Authorization Codes make an electronic fund trunsfer.funds may be withdrawn from your account as soon us the payment is received,and you will not Deposit Final Pa ment receive your check back_ # On 2,.6 # 00 6 Purchaser agrees that,immediately upon completion of the work,Purchaser will execute a Completion Certificate and pay any balance due. Purchaser also agrees to be jointly and severally obligated and liable hereunder. Entire Agreement: This agreement and its artacliments,including any financing agreement,contain the complete agreement between die parties and can not be amended or modified unless in writing in a separate agreement signed by both parties. NOTICE TO PURCHASER Do not sign this contract before you read it. You are entitled to a completely filled-in copy of the contract at the time you sign. Keep it to protect your rights. Do not sign a Completion Certificate before this project is complete. Law prohibits home repair contractors from requesting or accepting a Completion Certificate signed-by the owner prior to the actual completion of the work to be performed under the contract. You may cancel this transaction any time prior to midnight of the third business day after the date of this contract. See Notice of Cancellation for an explanation of this right. There will be a service charge equal to 10% of the contract amount ifjob is cancelled by Purchaser Af-I'LIZ the third business day,but BEFORL materials are ordered.There will be a service charge equal to 25%of the contract amount if job is cancelled by Purchaser AFTER materials are ordered. BY MY/OUR SIGNATURE BELOW,T/WE UNDERSTAND THAT THE AGREEMENT MAY BE SUBJECT TO REVIEW OF MY/OUR CREDIT HISTORY AND 1/WE AUTHORIZE HOME DEPOT TO VERIFY AND REVIEW MY/OUR CREDIT RECORD WITH AN INDEPENDENT CREDIT REPORTING AGENCY AND RELEASE THEM FROM ALL LIABTLTTY INCURRED FROM INADVERTENT OMISSIONS OR ERRORS. BY MY/OUR SIGNATURE BELOW, UWE AGREE TO BE BOUND BY THE TI-R,MS OF THIS CONTRACT. UWE ACKNOWLEDGE T OF A COPY OF THIS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE OF CANCELLA N. SUBMITTED BY: U Date: / LO 07 on I ACCEPTED BY: Date: l0 l3 Purchaser Date: Purchaser NOTICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT 6-1.07 rev 4-2-07 C-SC White—Branch File Yellow—Customer Pink—Sales Consultant TOWN OF BARNSTABLE Permit No. ----------_---------- 1 NAUnA Building Inspector A■... �; Cash --------------- -- so'r0 YPY �/��I OCCUPANCY PERMIT Bond ----—---------`�- No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Address Wiring Inspector %r _.�� Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. 19..._.__ ............................................................................................._......... Building Inspector Tewage q?% mc�p and lot number ...... . ..... /o..... .�..�............ ._ � � ?ME Permit number .". 1�.:....0/.!c.....P.. ... s rr m M!! . , INSTALLED IN COMPS MA a L Z E, i House number ......................... .......(.!� ........................ .1 39• 0� TOWN OF , BARN l"E"' BUILDING:- INSPECTOR � APPLICATION FOR PERMIT TO ............BRuild..Aingle..Namily..Duelling........................................ TYPEOF CONSTRUCTION ...................Ito ad...fram2........................................................................................ . I ' .Llgta.,=t......:................19aQ... ' TO TH& INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .............�4Ofi.... ..JAQQ.RQ1AX.e...C'r.P.l? ... `r�1t� .V. , .a. .........................................................................:... Proposed Use ..............5.ingl.e...FAMi1y..DV%jjjAg..........................................................................I......................... Zoning District . ........RUid.entr.iAl...............................Fire District ....... `.� 1 .G'xuJ. ,a.��Q. t. V.��.�,�............. Name of Owner ..........aT=u...K....2:11itt......................Address .............Barnstable............................................. Name of Builder ........JaMe.S...K....SSt1ith.......................Address. .............Barrist ble............................................. .Name of Architect ..................................................................Address .................................................................................... Number of Rooms .....................................Foundation Poured Concrete . Exierior ........................Clapboard. &...T111....... ...........Roofing ............Asphalt...Shingles............................. Floors ....:Wal ..�O...Wa�1............................Interior .............�'��Wc��1 ..:.................:............................... Heating g 1 ......................C?�.5....................................................Plumbin ...........�:a...b.4t.ha.................................................. Fireplace ......................One....................................................Approximate Cost .............$3..5.aQQQ.................... .......... . .. Definitive Plan Approved by Planning Board -----------____---------------19 . Area /t)W. s' Diagram of Lot and Building with Dimensions Fee ................ .If......................... SUBJECT TO APPROVAL OF BOARD OF HEALTH /11Y/ �j 1 . I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ... . . ............il.....�C .................. SMITH, JAMES K. No 2 2 4 7 5.... Permit for ...One 1Z?.. ..:tQry ....... ......I. Sin- g;�q... ............ Location .)�Pt....#.4......6... i/ale..r-cau r t ................ .................................. Owner ...JaWP.J ....$.Al.ith......................... Type of Construction ......Fr-Ame....................... ................................................................................ Plot ............................ Lot ................................ Permit Granted .....§�eptb emer...3.....19 80 ........... Date of Inspection ........ ...... ......19 Date Completed 19 gy 6 P. PERMIT REFUSED ......... ............................................. 19 ........... A........................................................... gn r. ........... V..'............................................................ ........... ........................................................... ......... ................................................................ Approvid ................................................ 19 ............................................................................... .............................................................. Assessor's map and lot number w'. I11 E Tpf` Sewage Permit number r%,�e�....... �1" �"�� d�P�♦� Z 33AWSTADLE, i House number ..........................�! ,,....�.............................. 9O MA66 p i639 �0 MFY Ark T TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .......... !? 3 r7 i> m1 ra zrn 3,1 r� f ,;rr, �I Y �r....................................... ..... TYPE OF CONSTRUCTION .....................+Tn n fw.ma....................................................................................... : 31aA �t.......................19Rt�... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .............7� .......... ;�� .......r�a... ' ?trt .. r9cr l?:'........................:............ Proposed Use ...............t5.!,1'1.T.le. It' 3 ct ?sit? ._i. F?'............................................... Zoning Districts ,cPr:t�3,1, C't�Yl t`P?'i] 3'!.l P--rJ�t Q r l a ............... ,.....................................Fire District ... ......._,_:..:............>..:. ..:...... ..,... �: ....... Name of Owner JATRtS X r .,a ..'k:i ......................Address Name of Builder . Pq Tf M ...h......................Address :922r.r!:tbb'1 f? Nameof Architect ..................................................................Address .................................................................................... Pourer? Concre le Numberof Rooms ..................................................................Foundation .............................................................................. Exterior ......................... .�.`ob.o r T 1 Roofing .............��?hai S. irib�' e 5.......,..................... Floors ;tall to wallInterior ........: �1.�,VWr'3,.�;�............:....................................... ................................................... ........ Heating g CrD£ Plumbing . .. .. .... 9 Fireplace ...........Pixel'...................................:................Approximate Cost ..............,%,3 ,; ..................................... Definitive Plan Approved by Planning Board ________________________________19________. Area ....................... Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH � r I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name . „t .�f?�� .... 0.........6......`............................. SMITH, JA?IES- R,--- A=21-0-169 No .... Permit for One 1/2 Story 7, ... .............................. 7 Single Family Dwelling H ........................................................... IV" _0 :'W';.�-�,;2- Lo�ation ... 6 Jacqueline Court ... .......................................... Centerville ............................................................................... Owner .. James K. Smith ................................................................ Type of Construction ....Fr... ..ame.......................... .... .. .............................................. ...................:............. Plot ............................. L I t ................................ Permit Granted ......September....3..,...I9 8 0 Date of Inspection ....... .. ..... ...................19 Date Completed .................. ..................19 PERMIT REFUS ...... .... ........ ....... .... .... 19 ............I .. ... . .................... ......... ...W.1........ .... ............................. b. .................. ................ R,.r...... ............................................................................... Approved ................................................ 19 ............................................................................... ............................................................................... S3OJ lr76 76'• 4-9cj 4.3 .�. 1 tsS - tnao 6a �� 14 4 . .1G [75At t?tT - US> toga GAS x iron. S �c 2.S 3-1`� PTD. jdl�`l FWrT'OAII AtZ=A TOTAL •'�ESIGti =;42� '�.i?D: � �tA ��'• , a \� a t�2G>5L6Tt{C,t�l QoTE iL! Lf OFL lEsS, x Ica J �► Ak Tor `9 - r -Box 99� Scnc 1 . faao 9t S buy, urv. GAL.4. 9g,7 9�9 F i T a' V rrW , y WASHED c.E(TIFICiD Ft_c)'l 1N.- NO WA�-r;E -r N A-r T(a r-- Fca t�l E3 'r, 5 U u . .�t:QL�r�eJ Gexvt�L�<; vV IT1A .T"iZ: S1VE 1-1"E p T PAT 1= t2C-.Lt��'itt,�u 1-�.1-.tG rl�2V�Ya1��i Tt-t Is P I-A W 15 u c)-r PA-Scn CA-4 P-w 4`-k?Y' f'�1.. l)�>Cr f'? f� 1�ry}_C;t- M ��-1l•:-: ' �..C>�C' 1.:14.1i:.:'_'s t.�/4��-�r. �+. ,�!'� at.T"�.