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HomeMy WebLinkAbout0638 OLD STAGE ROAD o/d ,c� f i k Town of Barnstable *Permit# ev JS Building Department Services "res6moVehsehorrtissae Brian Florence,CBO 163g6 Building Commissio r '0h�o 200 Main Street,Hyannis,l Q k- www.town.barnstable.ma.us .. Office: 508-862-4038 OCT 6 Z�,l Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - Aftfl&AMgm, Not VaUd without Red X-Press Imprint Map/parcel Number `1 241 &10 Property Address 62,2 (Old S`f«L� Qcj. Cv tery t'rle MA OZ6 S 2 [Residential Value of Work 43 0 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address a"I u e-0-I f- 13$ (9/c4 �'f�i . � Ce�.t�evvale � �-6 3.Z Contractor's Name A"J a►d ,P"J-ka t''1 ;�6 .. Telephone Number '7 7 t/ -9 3 6-6 65 y Home Improvement Contractor License#(if applicable) ��6 3 7 Email: �-i cttavd 1O i bh wp''-1, Construction Supervisor's License#(if applicable) CS — V q 1q3 Eg} orkman's Compensation Insurance q k one: [� I am a sole proprietor ❑ I am the Homeowner Ur have Worker's Compensation Insurance Insurance Company Name .7�►, �, r7 / wt� Workman's Comp.Policy# AW C - Yoo- 703 201-oW17A Copy of Insurance Compliance Certificate must accompany each permit. Permit Re st(check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be'taken to )Gj�,'O.. ❑Re-roof(hurricane nailed)(not stripping. Going over' existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: *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 equired. SIGNATURE: r„ QAWPFIL.ESTORMSIbuildingpernit forms\EXPRESS.doc 08/16/17 f 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 JJ Please Print Legibly Name (Business/Organization/Individual): �F f_2 r i y 4f OIr e- Address: 3a 3uakwooct Dr. Z7 City/State/Zip: H t,S MA 0260 r Phone #: `77V-J36 -66,< Are you an employer? Check the'appropriate box: Type of project(required): 1. 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. New construction ?working I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. Demolition for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. We are a corporation and its 10. Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions 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. lContractors 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: A t ly' t -t Policy#or Self-ins. Lic.#: A fie=Ll 00—70?,;1 7� ��/7 Expiration Date: D5-"U6�8 Job Site Address: 0 f J. C3i2 G 2 Jo City/State/Zip: (eC-IA,e) 0 C Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi r the pains and penalties of perjury that the information provided above,is true and correct r",Si re: Date: �� �� 17 Phone#: '7711-8.3 ",66S�l 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#: U/7,e 0�I79/J72QOZCIIG'CP.L�/Z- s Office of Consumer Affairs&Bu mess Regulation License or registration valid for individual.use only HOME IMPROVEMENT CONTRACTOR i before the expiration date. If found return to: Registration;u ,,166334 Type: Office of Consumer Affairs and Business Regulation Expiration-"'---T. -2018 DBA I 10 Park Plaza=Suite 5170 Boston,MA 02116 I INTEGRITY HOMET!- OLf ION + i RICHARD PECKHAl!M JEf t ? 32 BUG OOD DR I HYANNIS,MA 02601 e ! Undersecretary Cdlid w• out signature p Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Const\gc:tMii-lS`bpe,rvisor ,j CS-094193 W,.y I � 41pires: 07/29/2019 RICHARD J PECKHAM` JR� , y 32 BUCKWOOb DRIVES , HYANNIS MA 02601? Commissioner ��e (pai�vnarnu ��cr�oac�c�eC�- z Office of Consumer Affairs&Business Regulation License or registration valid for individual,use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: <,:166334 Type: Office of Consumer Affairs and Business Regulation �,.-. Expirations=5/-13/2018 DBA I 10 Park Plaza-Suite 5170 I ' _ ��' Boston,MA 02116 INTEGRITY HOME .DL=,TIO:NS I'lTa l 1 RICHARD PECKHAIVI Jf�, �. 32 BUCKWOOD DRY;;:. _ HYANNIS,MA 02601 ` Undersecretary o lid 3* 0ut signature 't Construction Supervisor Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license - Call(617)727-3200 or visit www.mass.gov/dpl I _ l Integrity 91fome SoCutions P.O.Box 1269 774-836-6654 Centerville MA 02632 RichardCihsbuildu>g.com IHS avvw.ihsbuilduig.com Building&Remodeling- Signatures The signatures that follow constitute confirmation by those signing that they have examined and understand the Contract Documents and agree to be bound by the terms of these documents. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM ent is entered into as of the date written below. Paul Queale , Owner (Signature) (Date) LL L� t (Printed N e) l 1 Richard Pecl r, actor _ 2/7 1 a ) (Date) �UY �� v (Printed Name and Title) 7 Town of Barnstable *Permit# Expires 6 inoorGa/'rows issue sate Regulatory Services Fee iniuvsrt+aia, 4 �® �`�, MAWA�' Richard V.Semi,Interim ITirector m Mld Building Division I I� (.0. Tom Perry,CBO,Building Commissioner N 200 Main Street,Hyannis,MA 02601 gg,t_ TABLE www.town.bamstable.ma.us TOWN OF F,��a�S Office: 508-862-4038 i!V Fax EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address a nL6 ST � - &ff5pu/uz- Residential Value of Work$ 3 76t? Minimum fee of$35.00 for work under$6000.00 yy�� Owner's Name&Address a U L-- l: b 3g" 014 StA ePO*erv/lk 44 ©a"z- Contractor's Name F/N4)0t t,Z Telephone Number 401-7®'�`4 3 1 Home Improvement Contractor License#(if applicable)�� /�.� Email: Construction Supervisor's License#(if applicable) 3�5 Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ 1 am the Homeowner I have Worker's�Compensation Insurance Co Insurance Company Name /�/�� Q����� Y�. . Workman's Comp.Policy# &dam V 0 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to cane nailed)(not stripping. Going over existing layers of roof) Z;;;acemenit de 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 oilier town department regulations,i.e.Historic,Conservation,etc. ***Note: Property, er sign Property Owner Letter of Permission. A copy of H Improvement Contractors License&Construction Supervisors License is required.. SIGNATURE: TACEVIN D\Building ChangesUT S i;ZXPRESS.doc Revised 061313 Jun 28 14 12:53a Chris Read 1-508-681-8800 p,1 Sold, Furnished and Installed by. Bra ch Name: Boston Date: [ �y//t�/ THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free.(800)657-5182;Fax(508)845-6017 Branch Number:3I �/� Federal ID#75-2698460;ME Lic#C 02439;Rl Cont.Uc#16427 CT Lic#HCC.0565522:MA Home Improvement Contractor Rcg.#12689.1 Installation Address: City State �i Pnrchaser(s): Work Phone: Home Phone: ' Cell Phone: Home Address: I - 0`e• e_ c ` t (If different from Installation Address) C�-- City take _ Zip E 70ali Address(to receive project communications and Home Depot updates): >4 6.� Ole DO NOT wish to receive any marketing emails from The Home Depot Proiect Information: Undersigned("Customer"),the owners of the property located at the alcove installation address,agrees to buy, and THD At-Home Services,Inc.("The Home Depot")agrees to furnish,deliver and arrango.for the installation ("Installation")of all materials described on the below and on the referenced Spec Sheet(s), all of which are i)ioorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary attached hereto#and any Change Orders(collectively, "Contract"): job#: anleenw Rehrenee) Products: ec sheet( , # Project Amount Roofing Ziding M Windows LJ Insulation w n ) " ❑Cutters/Covers ❑Entry Doors [I3 t- $4 � ^ 1 6 Roofing LJSiding F1 Windows Ll Insulation ❑Gutters/Covers []Entry Doors ❑ $ _CTRoofing 118iding Windows D Insulation 1 $ ❑Gutters/Covers ❑Entry Doors El Roofing OSiding Windows Insulation $ ❑Gutters/Covers []Entry Doors El Nfimmum2g°lo Deposit of Contract Ammotdae upon macution of this contract, Total ContractAfrnotmt $ '7 mfaare Poichasers may not olepodt more than n d 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 under this Contract agrees to be jointly and severally obligated and liable hereunder. i The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at its discretion,if The Home Depot or its authorized service provider determines that it cannot pejfform its obligations due to a structural problem with the home,environmental hazards such as moo asbestos or lead paint,other safety concerns pricing errors or because work required to complete the job was not included in the Contract. Payment Summary: The Payment Summary # 111C, /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 filled-in copy of the Contract at the time you sign. Do notfsign a Completion Certificate(note: there is one Completion Certificate for each listed Product as defined by individual Spec$heats)before work on that Product_ r is complete. I In the event of termination of this Contract,Customer agrees to pay The Home Depot tk.e costs of materials,labor, expenses E, and services provided by The Home Depot or Authorized Service Provider through the date of terminadon, plus any other amounts set forth in this Agreement or allowed tinder applicable law. THE HOME DEP()T MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER:PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOTS OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees and understands that this Agreement is 0 entire agreement between Customer and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,either oral or written,relating to said Products and Installation.This Agreement cannot be assigned i*amended except by a writing signed by Customer and The Home Depot. Customer acknowledges and agrees that Customer has rea(I, understands, voluntarily accepts the' terms o-add has received a copy of this Agreement. r ' Acc pteri b_ _Submitted by: OD a O R1 I 0 O J • O • tD tF5'a»ronoouuerz off+ License or registr valid for individu4 use only ►ee of onsumer Affairs si ess Regelstion before the expi lion d te. If found return • to OME i PROVEMEW t)NT CTOR Office of C Sumer A. airs and Dusines egu atioa Ct Registr lion: 15087 T o: tU DBA 10 Park axa-Suite 170 '7 Expira on: .5/4l20 4 Bosto A 02116 N W E'S SIDIN 'GO. N AI.DEMAR P FtA11N^ JCZ U r L GL ' 11 MAIN ST. ::•• .� __ ___ _ .._ _._.__.•__ - _ • t� � AUBURN,MA 0 501 ' ,. ` adersecretary • Not valid out signature tb _..._. _...._.. O • _ E N - Massachusetts • Department of Public Safety Board of Building Regulations and Standards . Cunztrueti+>n Super►ieur SPccialt� r- rn License:CSSL-101316 co ,► ►�. ,, i WALDENIAR PARkMQ CZ''. o 246 iyp t,i BUIitY$T 4l to Auburn MA 011501, to 1 J.�.•+ ' 11 INA Expiration m. 1012912015 a y 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 Legibly Name(Business/Organization/Individual): Id J QLKWT jZ PA-FA r//Uo(,U t Z- Address: Z V t 11Ltat-(� S7/ City/State/Zip: A V8 U_PZ , A4 O/So/ Phone#: S 0 8- 96Z' Are you an employer?Check the appropria-box: Type of project(required): 1.El am a employer with 4. ❑ I am a.general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction IN 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g• ❑ Demolition working for me in any capacity. employees and have workers' comp.insurance.: 9. ❑Building addition [No workers' comp.insurance p' 10.❑Electrical repairs or additions required.] 5. ❑ .We are a corporation and its 3.❑ I am a homeowner doing all work officers have exercised their 11:❑ Plumbing repairs or additions myself. o workers' com right of exemption per MGL y � p• 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#I 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 thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address:' City/State/Zip: Attach a copy of the workers'compensation policy declaration page.(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.60 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 forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of pc.jury that the information provided above is true and correct. Si nature: Date: Phone#: 7 aq Official use only. Do not write in this drea,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#: i Information and Instr' ctions Massachusetts General Laws chapter 152 requires all employers to provide w rkers' compensation for their employees. Pursuant to thjs statute,an employee is defined as"...every person in the sery ce of another under any contract of hire, express or implied,oral or written." An employer is d�fined as"an individual,partnership,association,corpor tion or other legal entity,or any two or more of the foregoing en aged in a joint enterprise,and including the legal re esentatives of a deceased employer,or the receiver or trustee o n individual,partnership,association or other leg.1 entity,employing employees. However the owner of a dwelling h fuse having not more than three apartments and ho resides therein,or the occupant of the dwelling house of anoth" who employs persons to do maintenance,c nstruction or repair work on such dwelling house or on the grounds or build'\been enant thereto shall not because o such employment be deemed to be an employer." MGL chapter 152, §25C(6es that"every state or local lic using agency shall withhold the issuance or- renewal of a license or pperate a business or to constr ct buildings in the commonwealth for any applicant who has not prceptable evidence of compli ce with the insurance coverage required." Additionally,MGL chapte 7)states"Neither the com onwealth nor any of its political subdivisions shall enter into any contract forrm e of public work until ac eptable evidence of compliance with the insurance requirements of this chapten pre nted to the contractin authority." Applicants Please fill out the workers' compensation affidavit ompletely, checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address s)and ph e number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limi d Liab' ity Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' c mpen ation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affida 't y be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be a to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the perm or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding t e law or if you are required to obtain a workers' compensation policy,please call the Department at the number is d 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 legibl . The Dep ment has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Inv stigations ha to contact you regarding the applicant. Please be sure to fill in the permit/license number which will e used as a ref ence number. In addition,an applicant that must submit multiple permit/license applications in any given year,need o y submit one affidavit indicating current policy information(if necessary)and under"Job Site Address'the applicant sho Id write"all locations in. (city or town)."A copy of the affidavit that has been officially stampel or marked by the 'ty or town may be provided to the. applicant as proof that a valid affidavit is on file for future pe its or licenses. A ne affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or ermit not related to an business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is OT required to complet this affidavit: The Office of Investigations would like to thank you in advanc for your cooperation and s ould you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth o Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www,mass.gov/dia J(Ne cl-)w O ice o onsumeerr%ai and usiness Re ulatio 10 Park Plaza - Suite 5170 Boston, Massachusetts 0211 b : Y Home Improvement;Contractor Registration Registration: 126893 ' y,r Type: Supplement Card { Expiration: 8/3/2014 The Home Depot At-Home Selvlos ', r ,• ANDREW SWEET *. 2690 CUMBERLAND PARKWAY St_JITOfl f - :` ATLANTA GA 30339 t 1' Update Address and return card.Mark reason for change. r - - Address Renewal Employment r ", ❑ ❑ ❑ anent P y ❑ Lost Card DPS-CA1 0 50M-(W04-G101216 �� Office o�Ls�i�er�ns(ess egq� 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:<"1 93 Type: 10 Park Plaza-Suite 517Q �' Expiration: g/3j94 Supplement Card Boston,MA 02116 ` T , •Home Depo# AtxEomg Zer"vlces ANDREW SWEET 2690 CUMBERLAND PAR M, AY.AY:S — AA'N` ,GA 30339 Undersecretary al it ou signature i The Commonwealth of Vassaehusetts Department of Industrial Accidents office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Compensation Insurance Affidavit: Builders/Contractors/El p Workers' omlease Print Le bl C p A I licant Information Name(Business/Orgatti zationlindividual):, Address: S 3o3 Phone City/State/Zip: 3 Type of project(required): Are you an employer?Check the appropriate*4. EI am a general contractor and I 6 New construction 1.0 I am a employer with � have hired the sub-contractors employees(full anor part-time)-* 7. Remodeling d/ listed on the attached sheet. 2. I am a sole proprietor or partner- These sub-contractors have g• n Demolition ship and have no employees employees and have workers' 9. Building addition working for me in any capacity. comp.insuranceJ 10,❑Electrical repairs or additions ' .insurance [No workers comp 5. 0 We are a corporation and its airs or additions required.] officers have exercised their I I.C]Plumbing repairs 3.❑ I am a homeowner doing all work right of exemption per MGL • 12.n Roof repairs myself.[No workers'comp. c. 152,§1(4),and we have no 13 �j other�f S('& insurance required.]t employees.[No workers' !°t insurance required-] comp. � their workers'compensation policy information. such. x#1 must also fin out the section below showing contractors must submit a new affidavit indicating su t li applicant that checks box 1 work and then hire outside co does have Y ap t Homeowners who submit this affidavit indicating they are doing the name of the sub-contractors and state whether or not those en tConttactors that check this box must attached an additionaln s heel iho theigr workers'comp.policy number. employees. 1f the sub-contractoTS have employees, Y p employees 1 am an employer that is Providing . Below is the policy and job site workers'compensation insura�nee•for my information. /,� #am Sh* " :LN—Y Insurance Company Name: "�l1 �� / � Date: � f 1 Policy#or Self-ins.Lic.#• W f✓ 7 Q g a Expiration Q �i OL'U � � City/State/Zip- Job Site Address: 3b f the workers'compensation policy declaration page(showing the policy number and expiration date). Attach a copy o Failure to secure coverage as red theimposition of criminal penalties of a quired under Section 25A of MGL c. 152 can lea top penalties in the form of a STOP WORK fine up to$I,50o.00 and/or one-Year imprisotune well as civil of this statement may be forwarded to the Office ORDER ' a fine of up to$250.00 a day against vi tor. Be advisee d that a copy Investi ations of the DIA for' coves a verification under the n pe ties perjury that the information provided ab ve is true and correct I do hereby certify 7 Date: — Si afore• Phone# Offuial use only. Do not write in this area,to a completed by city or town offeciaL City_or Town: Permit/License# issuing Authority(circle one): nt 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 1.Board of health 2.Building Departme 6.Other Phone#: Contact Person• CERTIFICATE OF LI I�.lTY INSU E D02 IeiI�tOD,ry, v' '12o+.4 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.NY..ORT a._ it?If- e--fiticate hok'-er is In iI9j -N1 1 1 S!R ;`3.. the p licy( )"T3:st be PwG ra ed. ..it SU BROG Z 7•ON as "AiVE0 Sub, c. 6 :1lc 0 eraay:`:he terms aDd Ponaifto. oic � .1S �-en�dli;ear��,275dOrsE73a�rlt..:A':S(as'£�'iscSla".0�]:ifS3S.iCi�ITIt r7ere•{1i3e3.f3Gi GDi31el ��1iib-IU 1t�8 certil'leate holder in lieu of such endorsement(s). PRODUCER CONTACT MARSH USA,INC. NAME: --- — TWO ALLIANCE CENTER PHONE FAX E —1- — -- 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS: ------------- -_----_ __ _ INSURER(S)AFFORDING COVERAGE _ NAIC� IW4FJ2— vr. —-": —thrt5 Y I'INSURER aL.. :, v hr :�^,�}• 1, .� —...... .. - .. .,._. (INSURED, I 114SURER B:Zurich American Insurance':;rr 065351 THD AT-HOME SERVICES,INC. -- ----— -: — DBA THE HOME DEPOT AT-HOME SERVICES INSURER C:New Hampshire Ins Co .23841 2455 PACES FERRY ROAD INSURER D:Illinois National Insurance Company 23817 ATLANTA,GA 30339 INSURER E' . 1N.SURER F: GOVERAGES CERTIFICATE NUIyaBER: ATL-I 24-�e1i-i;1 REVISION NUMBER:3 l THIS IS TO'CERTIFY THAT THE POLICIES OF INSURANCE LISTED=_=LOIN}HAVE BEE& ISSUED TO THE INSURED NANIIED ABOVE FOR THE POLICY P—1101) "1NDICA7ED. -NOTWITHSTANDING ANY-REQUIREMENT,TERM`Oil CONDITION OF:ANY.CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE.MAY BE ISSUED.OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE DOLSUBR ` POLICY NUMBER OLICY EXP MMND� lPN DIYYYY LIMITS A GENERAL LIABILITY GL04887114-04 03/01/2014 03/01IM15 EACH OCCURRENCE S 9.000,0W X COMMERCIAL GENERAL LIABILITY PREM DES rya o c E��C)_ S 1,000.0w. ( j ]CLAIMS-MADEI`�' i OCCUR i ? tU? fI f 5 P. Llr Y A', i � �iNEt�tXP tAnu one oetsom �S OFS1R $IM: ER OW PERSONAL&ADV INJURY $ �1 GENERAL AGGREGATE S $000.0W GEN'L AGGREGATE LIMIT APPLIES PER:. PRODUCTS-COMPIOPAGG $ 9,000,000 X POLICY j Ca F-ILOC '- .,Is B. AUTOMOBILE LIABILITY BAP 2938863.11 03/0112014 �03/01/2015 1 COMBINED SINGLE LIMIT 1 r{t3+hUT4] ODICY ll IjURY tPer peror i$ _ ALL OWNED I SCHEDULED !. (SELF lNSURF0Akrrr)Rp(DIN1G 1 =NL,INjU.,.,Fe,acc,e,,:);s .(AUTOS ;AUTQS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident) $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONSis r j WORKERS COAPONSAT?ON W i 491J+ao7(ti S) .0i't,_>, ^'.- J+,01/9-1-iI5 ..�1- ,. �-STA11 �. �31:i-1 I I AND EMPLOY s S 4AB+CITY E t I I--_136RYCIMUg t ER .1 1 ( YIN 1 .�C0+310c . C.J:VF' a01120i4,. 00112011�,. ANY PROPRIETORI ARTNEWEXECUTIVE` { II_EL EACH ACCIDENT S D OFFiCERIMEMBER EXCLUDED?_ N f A WC049101883 FL 03/01/2014 03/01/2015 --- - 1,000,000 (Mandatory In NH) ( ) E.L.DISEASE-EA EMPLOY $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C WORKERS COMPENSATION WC049101885(KY,NC,NH,VT) 03101/2014 03/01/2015 (EL)LIMIT 1,000,000 C WC049101886(NJ) 03/01/2014 03/010015 , 1 i { E;CR.I?TtON OF OPERATIONS I LOCATIONS f VEtiiC L>:S(Attach ACORD 101,Air,{ticna;Rrr:ar...1 xned,rt-,1,star-apace? l�rjcl?tez?) . EVIDENCE OF INSURANCE CEIRTIACA CANCELLATIO THD AT-HOME SERVCES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AuTHORtzED REPRESEhTAT?4'E of Marsh USA Inc. I Manashi Mukherjee ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Assessor's office(1st Floor): Assessor's map and lot numberV0 ,1nt J1iyyi.ci ,• 0`TN[�0 Conservation } �'�� ♦w Board of Health(3rd floor): t zieasITUtt Sewage Permit number Engineering Department(3rd floor): ra3q. House number Ito asr►. Definitive Plan Approved by Planning Board 19 APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION ZO,,C 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: / Location C 5 C, Tim [ ` �� h L/e v Proposed Use Zoning District Fire District Name of Owner ` 0 I,-i S Ci? u t u 1)Y e Address Name of Builder -t��t� .9��/2 i^av c 66 Address Name of Architect Address Number of Rooms Foundation Exterior Roofing Floors Interior Heating Plumbing Fireplace Approximate Cost 2 7 OG_a Area Diagram of Lot and Building with Dimensions Fee ©--^� OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name Construction Supervisor's License D 3 /l U ,( �� io�3sq QUEALY, DORIS No 35291 - Permit For ReSHINGLE/ROOF 6 r Sinale Family Dwelling , . r Location 638 Old Stage Road w ^ r Centerville �r A n Owner Doris Ouealy Type of Construction Frame 41 - Plot Lot ^ Permit Granted August 17 , `' 19 ! 92 Date of Inspection 19 ` Date Completed `o% 19 w } " n q 1! � 07 ���+9xosueev�0��✓uamaaerueclld �•!' r NONE. IMPROVEMENT: CONTRACTOR 5 7. Registration• 102359 .' ,t a Type - INDIVIDUAL Ezp`iration 01/01/94 Peter G. Mandravelis 5 Fairview Avenue. Al Dennis MA 02638 ^ ADMINISTRATOR • . � ly y � ti W i y {� U ; j, k i i s. is w