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Home My WebLink About0016 SHUBAEL GORHAM ROAD a . � ��, . � n ,_ _ - - E 7�nth Cam_ \ TOWN OF BARNSTABLE Permit No. -------- 21112 a Bzwding Inspector _--_�---- i swst.0 _ Cash 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 BuildinrInspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." , Issued to Alan E. Small Address Centerville lot #286 16 Shubael Gorham Road, Centerville ^'^ Wiring Inspector Inspection date + Plumbing mspcto Inspection date r _ Gas Inspector Lit l' Inspection date /Engineering Department f Inspection date Zf) r 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. t jBuilding Inspector Assessor's map and lot number . .../.�./ /// .� 9 '.k: OF THE C t ' Sewage Permit number ��......................f �.... `/ l t22'. ., .1 Z BABBSTABLE i House 'number ....................c:................................................ '°o rasa t639. O NAY a TOWN OF BARN STABLE " BUILDING INSPECTOR: , APPLICATION FOR PERMIT TOE `.... ar7 u TYPE OF CONSTRUCTION ............./C ��J ! .......................................... ........................ ................... ................19.4.?�.�. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: n Location ./.............................. . , . '.. ., J....rQ.� ......'}i� Y....[.1..�� ...... .. . ..... . ..... ProposedUse ....... tl:.. ✓.........:...........................................................:............................................................................... Zoning District ............... c.................................................Fire District ............. .''..4r�.............................................. A Name of Owner .... 4.: ...: Address ...�G%� .... ^.. .......... Name of Builder' ....... ....... ..`. ... ... ..........Address .... . d;/.',c....... ................................../� +� I a 3L Name of Architect .. ? ...........................................Address .............. Number` of 'Rooms .............................................Foundation Exterior ....... P ..... 1.! Roofing .......... ... ............................................ :... Floors ../z I.. ....f /...:. ...........:..Interior ..... �.......................................................... . Heatingj .. �..............Plumbin :........:. ......... ................................ g .................. ......�. Fireplace .............................Approximate Cost ........�.�fl•�...r'�......................� "..!.! .... ...... Definitive Plan Approved by Planning Board -----------______-----------19_______. Area " ' .... ........................ ....... . '76 ,Diagram of Lot and Building with Dimensions Fee �• SUBJECT TO APPROVAL OF BOARD OF HEALTH 71 AN A\ , 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 . .........d........ :.. .. ..y HE.6LEY, JAMES • t 1 24528 ADDITION t No ................. Permit for .................................... Single Family Dwelling ..................................................... ...................... Location .1.6 Shubael„Gorham Road �. Cnrl f ............................................................ ' ......... + ' '..'�.• �Owner".. James He •y...............................Type,of Construction. ,Frame.......................... u .... .. ......................... Plot ......................... Lot.. .... ................. ..r r•t y `{�', f ; "r Novemb 9 82 r ., . Permit 'Granted ........... .... er l... 1*9 r ; Dateof lnsp n�r✓!�rz'...t ...�/� ` .....&19Y T,- Date Completed ............................. ... .19 , 'a h r Assessor's map and lot numbeOW ........ 3- 7 �f E TOE r' Q� g J�~ -i SEPTIC SYSTEM MU `�B °" Sewage Permit number ........................................................ �:� , / INSTALLED IN COM TAME, i House number ... `��.......................................................... . `- WITH ARTICLE.II ST�r � ."639. SANITARY CODE AND aYa� .TOWN OF BA"RNST1 BLE - BUILDING , ;nl•NSPECTOR APPLICATION FOR PERMIT TO .............. .........r...... .......................................................................................... . ... .. .......................:........................................................................................ TYPE OF CONSTRUCTION ........... .4z...........;9)-C- TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .... . . .. ... .. . . ........ . . ......... ........................................... . Proposed Use .... .�.s _19: . ..................... ......�....................................................................:........................ .... . . .. ..... Zoning District .......... ............................... . ...........................Fire District .,,.. Nameof Owner ... ......... .Address ...... ................................... Nameof-Builder ..................................................................Address .................................................................................... Nameof Architect ...Address............................................................... .................................................................................... Number of Rooms ..............7...............................................Foundation ..... ". ....................... Exterior ..............................................Roofing ...... ... .......................... 2.0 Floors .........................................................Interior ........... . , ..:d�{,... ............................................... Heating ........ .........................`................Plumbing ............ . : Fireplace ..: ..... ... .. .......... ....................................Approximate Cost ........... ..... .....�... `................ ..... tT / Definitive Plan Approved by Planning Board ---------------_---------------19________, Area Y.9 .F.0.................. Diagram of Lot and Building with Dimensions Fee •....... (.... .......................... SUBJECT TO APPROVAL OF BOARD OF HEALTH 76 _ rFIT E I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable garding the above construction. Name ................. .... .: ............... Allan E. Small A=171-139 N, .�nj2........ Permit for$.V-Ud..,Ungla.......... family dwelling ........................ ....................................................... scat of Shurbael Gorham Rd a ................................................................ Centerville ............................................................................... Owner allan E. Small .................................................................. Type of Construction Wo.o.d..F.r.ame...................... .. . .. .. . ...... ................................................ .............................. 286 Plot .......................... Lot ................................ Permit Granted ........M...a,.r..c..h......21, 19 79 Date of inspection .......... .....:...................19 ib Date Completed ...... ....... .............19 PERMIT REFUSED ........ ......... ....0.r r.................... 19 ..................................................................... ............................................................................. ............................................................................... . ............................................................................... Approved ................................................. 19 ................................................................................ ............................................................................... 79. Assessor's map and lot number ^i.... ...� THE t Sewage,, Permit number �S EIHHSTADLE, i House .number .... `t� .................................... : MACS. �F0 MAI a\ f „ ==y TOWN OF BARNSTABLE. BUILDING INSPECTOR ,�._. .. / APPLICATION FOR PERMIT TO ..........�,,:..... ,N;:�...................................................................................:.. TYPE OF CONSTRUCTION f-»� * - �rA.A+ f y ~ 1 .. ....,y.........?..... .:... ............19........ TO .THE INSPECTOR OF BUILDINGS: The.undersigned hereby applies for a permit.according to the-,following information: Location .... `+..+.`.. { .. ... .......... i.........................................::` ::°� .........t� : f............... ProposedUse .. .... .. ................................................................................................................................. ZQning'. .District +d �.. .^ F .Fire District .................................. ...... ..... ..................... ... ...... . .: ,l �r. Name of Owner .........................................it-, �.m ... L� .{'`';�� 4�), - ( . 4f r;............................Address ................ .. Naameof Builder ....................................................................Address .................................................................................... Name of Architect ' ...............................Address ................................................ Number of Rooms .............................................:Foundation .......................................... Exterior j..n . a r* . 1 t Lv ........... ..................................................Roofing ......... Floors ..........r./ r,, � _......Interior .............. ✓ l� .................................. Heating ... .�. ... . ..............:.............................Plumbing ........................ ................................. Fireplace ... r -t.. ..o.^:1.. ...................................Approximate Cost ....... .............. L .� .............. . i �finiiti�ve Plan Approved by Planning Board ________________________________19________, Area .. .... �.................- Did Fee gram of Lot and Building with Dimensions 7 ......�'.f . ....................... SUBJECT TO. APPROVAL OF BOARD OF HEALTH . 76)... a I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding garding the above construction. Name ................t......:........................................: .............. Allan E. S'fa-al*. —1 n--'c 171-139 No .... PerrAit for ......... ..........f.W i 1,y..dweain&................................... Location 1hurbaial-Goxiliam..Rd.................... S ................... . ................................. Owner ........... ......................... Type of Construction ..Wo.od..Fx,.ame.................. .................................................... .......................... Plot ............................ of ....286 ............. Permit Granted .......... (rcb...2.1............19 79 ...... ............Date of Inspection ............ .......................19 Date Completed ..................... ................19 PERMIT P iVUVI'S FUSED ..................................... ...................I........ ................................ . ....................................................... .. ......... ................................ ......................................... ............................................................................... Approved ................................................ 19 ............................................................................... .............. ............................................................. j p �f/fi. � .:. `........... Assessor's ma and lot number y ! r CF THE Sewage Permit- number ../... .�:� .. Af ....... Z $ASBSTADLB i House number ...............:................................. ......... 'oo rae9 ; . ........... i6 iOlEp YPY&- TOWN ' OF BARNSTABLE BUILDING- INSPECTOR APPLICATION FOR PERMIT TO ...uJ............... .........: .... 1!./. ............................... I TYPE OF CONSTRUCTION ............. ...................:................................................... i J ................... ..9.......... ..19.4 TO THE INSPECTOR OF BUILDINGS: i The undersigned hereby applies for .a permit according to the following infor at* on; Location ...!..J;�............................. . ................. ......... ... .... .......'�.... ..... ................... , .�..� a 3 �..... .... . . ProposedUse ....... ................................................................................................................................................... ZoningDistrict ............ �a ..................... ........................Fire District ............. .......................................... Name of Owner ................. . r.'...... .. ............. ........Address f'!��!/� .. .... 4'4 - .....:...........:.......... j Name of Builder` ................... .. .......,..... ........................Address 1•,••••,••••••••••••••••••• ........................................ .....•. .. Name of Architect .. ............................................Address ? .,.......... .............................. .............. Number of Rooms ...C!.. 'L... :::...........................................Foundation ..... r... Exierior .........o ... ........ ..... .............................Roofing .... �� ..................................................... u�� Floors �!d�+.•..... /............ .............Interior .....•/• u!..:. ...-...'........................ ....................... - -Heating -...-.... f� ,.<:.......:...........................................Plumbing �'f.... .. Fireplace .......... ................................................Approximate Cost ....... .1� ... .. ....... . ..........fY�'.... .... Definitive Plan Approved by Planning Board -----------_______-----------19_______: 1 Area "``'..' .. Diagram of Lot and Building with Dimensions Fee ' ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH t . �y ., �r ,i 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. V 9 ` Name ��_,.t <.....1:.�:...6. ................ � � HEALEY, JAMES A-171-139 24528 ADDITION No ................. Permit for .................................... .......$. g Ig .Mily..jl?�Kqjjing.. ... ..... ..... ............ Location 16 Shubael Gorham Road................................................................ ................. ........................................... Owner ....J4Weg...PPAIIPY.............................. Type of Construction ....F. 404P......................... It ............................................................................... Plot ............................ Lot ................................ Permit Granted ...November 9 ,.....................................19 82 Date of Inspection ....................I................19 Date Completed ..................19 0o la ►_ �^ T�>��1G1� bQ.TA t..lo T>4 t t_:14 F t._Aw = I I O -4 S t SS O G•Pti• SEF.rt C TA+J K = -Sso, 15 O % = A-9 5 usue- ko00 6AL-. .t15Pos,&L PIT uSE loco (GA.t_ i STTcu/A _L Av-P A = lSo G.P. 7 r ISo S� Z.S = 3 is '8O't-10,1A AtZM.r =-4> Sr-- SD Ste. )c 1 .o - =50 G,.9.D. TOTAL l::>ESIGFJ = d25 \0 'T-oTA t- 'D4t Lam( FLr--)w = 330 6 pv. �/ Fv� MfZGDL&,T10L1 tZeTE t"ICJ SM I u orc L16,. u��P CA R t'� t -Z S - s _ T�sT 12 !r rg F G - qq' Top rw = luv� m.o G"P.ve �- 4' 'Sox q�.4 S�rlc to 2 fZ IWV. T"A�IK GAL. qGw q(o Z LEAr,N A v./I A STOW 4 /b� �o � �I LOGATIO" l=L=85 12 W o ScAL�- SC.AL it-Z 0 17A'T�F= I G r tZ T t F-j T 14 A T- T t4 t= Fcu ODATJ o W s to wu t l -- tom! TZ►,[::E tZE tit CE✓ I 4-1>r.T= tS1�l G«NIPL�(S WIT" TOG: 51DE- LIt-4G (rvT ,. AWt> SETOALIC VC-QU►cZEME:uTS C)F TE"tE- TowL olr= C&WTE V/LLZ 0 fl�blLA �5 3 13 1 T141S PL.At--! o s-TE2v►L-t�= o MfiSS. I Kbr E3 U4C� T"o i�r'TC��✓tIw(E- 1_c�'C_ t_It. , _ fZ1.A1� G J y�1tt U,-- - _ _ .- _ - -" 7 D3�ih1�12 L oFtHE> Town of Barnstable *Permit�?oi ill ' Expires 6 montk o u Regulatory Services Fee ' + AAAARI'fAi.F. # - 9 sr 9. Thomas F. Geiler,.Director, pTFfl MA'1� • Building Division .Tom Perry, CBO, Building Commissioner 4 200 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 without Red X-Press Imprint Map/parcel Number 0)_�q lReery Address �i (� /�'� 2 A)8I"sidential Value of Work Min' um fee of$35.00 for work under$6000.00 Owner's Name&AddressEel 1 e Contractor's Name �rl ie V)Q Telephone Number Home Improvement Contractor License#(if.applicabl e)- / 9/ 3 92 7kWormarlcticn Supervisor's License#(if applicable) , ®'s Compensation Insurance X�®RESS PER-MIT . Check one: -PRESS 1��YIIT ❑ Iam a sole proprietor ❑ am the Homeowner MAR 4 20�2 I have Worker's Compensation Ins ante Insurance Company Name e UU i�lre �/I/ yTOM OF BARNSeT/ABLE Workman's Camp. Policy#_ 00� 7 C A Copy of Insurance Compliance Certificate must accompany each permit Permit Req st(check box) ' Re-roof(stripping,old shingles) All construction debris will be taken to P/,moU Re-roof(not stripping. Going-over existing layers of roof) ❑ Re-side p #of doors ❑' Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. t `' A copy of the Home Improvement Contractors License& Construction Supervisors License is requir , .GNATUR,: NPFUSIFORMS%uilding permit formslEXPRESS.doe ' ise Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR Registration F"126893 Type:. Expiration -$131212 Supplement{ e At No eu sThe Home De of ce f DARREN DEMERS ' 2690 CUM BERLANDAR W- S g� A" 5A TX, 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 'lard Boston,MA 02116 Not valid without signature - Jlte } -- --- Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Registration: 140993 1 Type: Individual t" j = Expiration: 12/17/2013 Tr# 219072 MICHAEL J. VIOLA MICHAEL VIOLA � m 8 HADASSAH WAY j- ---- - -- ----. HULL, MA 02045 -- --- ---- - -- ----- - Update Address and return card.Mark reason.for change. f.:. I Address 1-1 Renewal r- Employment r Lost Card UPS-CAt it 50M-04104-G10:1216 i i�a»zrizzooza�e��l� E- Office of Consumer Affairs.&11usiness Regulation r License.or registration valid for,individul use only � I before theexpiration date. If found return to: �lYRD J HOMEIMPROVEMENTCONTRACTOR . `I t Registration- Expiration- 140993 Type: k Office of Consumer Affairs and Business Regulation / L - 10 Park.Plaza-Suite 5170 `. / 12/17/2013 Individual f Sy Boston,MA 02116 MICHAEL J.VIOLA. MICHAEL VIOLA ' 8 HADASSAH WAY*` } HULL, MA 02045 Undersecretary Not valid without signature I • • j • I ^� 'Massachusetts - Department o/ Public Safety Board of Building Regulations and Standards Cc,rast I'll iatiir SuperT isor Spec.ia(tNVm License, CSSL-09940T MICHAEL;J VIOLA S HADASSAff.:.WAY ti a r ti, •' HULL MA 0304592, { Expiration Commissioner Expiration 9 ,L,Y I Clx 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 Name(Business/Organization/Individual) ,:—.)J 0 At 2-U04- Address: G2 5 eerrvD City/State/Zip: Law4rz, Phone#: Are you an employer? Check-the_ppropriate b . Type of project(required): I am a employer with 4• MI am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling shipand have no em to ees These sub-contractors have g p �y E]Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp. insurance comp. insurance.t g required.] 5. ,We are a corporation and its 10.❑ El cal repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L umbing 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' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homedwners 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: �J&A) AAA Policy#or Self-ins.Lic.#: C 0 3 Expiration Date: Job Site Address: b S (� OP6 ..P CA Ci /State/ ty Zip e -� 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 a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and se pains and pen ' s of perjury that the information provided above is True and correct Signature: Date: Phone#• Offlcial use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#:' !�CORD CERTIFICATE OF LIABILITY INSURANCE mill :Iiilrcl III:irwil 1" _jr_f8fJtjFD Ar 1 1 ' �' ' I I w-m-aarl i5p aam�cy ONLV AND CONFERS NO RIGHTS UPON THE HOLDER, THIS CERTIFICATE DO-28 NOT AMEND, 9ATEND OR ALTER THE CVIERACE AFFORMO BY THE PoLII BIRLOW, 04ZIBWERS AFFORDING COVEIRACE Bdr,PO 0 INSURER A; a Ziidaasah way Xiohmel VlolsINQdYtETtD: MMZTE STATE =8 CO INSURER a. Roll, NA 02045 THE POLICIES OF iN_ URMtE WSfE_D BELDYv kA�Nfi� PSEEN lg$Ur;D TO THE INSURED NAMED ABM FOR THE POLICY PERIOD iNVICA760, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY C04TRACT OR OTHER DOCIATENT WITH RESPECT TO WilCH THIS CERTIFICATE MAY 2E ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY T"E POLICIES OESCRISED HEREIN 16 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES.AGGREGATE LIMITS SHOWN MAY mAvr_!BEEN REDUCED SY PAID cLAims, TgwmuYVN al . p"loy utmMER EACH OCCURRENCE -0V4W9M REWED 6 =9491ACAAL OlI UANUTY - Im(FA owf w MED EXP(AAY 01119 t=!� I CLAMS PI Li OCCUR PeRWNAI�6 ADV INJURY 4 td-iNEFIIAL AGGREOATE W9LAsaRE4ATFiUMITAPP"SFVt PROVt.=G-GOMPf9FA03 POLICY D 619Lla2C� _ AUT01I MAI UNGILF LIMIT A ANY AUTO ALL OWNCO AUrOS WILY ttAjukvl pemw) IlEll UAlu'y OC; Lj OCCOR HIRWALMW I MILY Owny 1 6 Me MI PROM"I DAMAOU (PW�daTg) AUTO ONLY-�A"10ff.. .!�ARAGf UABI ANYAUTO OTHER THAN 9AACC 4 AUrO MY; AGO 3 RXCE S"mA- K"O EACH OCG(WENCE CLN OCCUR AGORETAATe r ------- FP VftWERS COW014ATION ANO TOAY LIMITS ER 5126/1 2011 5/26120-12 15.1-WPIACOMeNT 1100000 ANY PA0ftETQ4`VARrNt!PVr-CUTfV9 QFFICMM9mftR lVWLjjDkw RLDISRAL59-P-AEWLIDI 500000 RIL DAW6-PQUGY UMIT ID0000 ro EIPW_AL PlIlMISION4 b4W OTHER - Of 0PARI I J.00AAVOM I FWdLUDIOND ADDED BY EMVf,0MfiNT I SPIECM PROI THD AT-NO= MVIC410, XNC. AM THE E<= DEPOT ARE lKCWM9t) AS ADD ITIONiV,INSURED WITH RESPECT TO GENZPAL LIA.91,11TY INSINIIiANCE. :ERTIFICATE HOLDIMIR CANCEU-ATION 9"ouW ANY *p yHt AV4VE Mc#nm pWomd ar uAwEtkAo SaVORS THE ExVIVATM THD AT,gka DAYS YHM01. nW ISIBUIR0 IMUN04 t%LL 20DRAVCM TO MAIL IMV8 WRIYIEN ==PdA-IM PARKWAY .191,11m. 300 NOTICE tO 'r"g CHATIMAI'K "OkOliq NAMED TO M WI BUT rAIII TO DO SO SHALL IMPOSE NO091 OR LIAEI Of TO RAURFA, ITS A01IIIII OR ATLANTA, GA0*GXA O JR�m iaw� vila on:QT (IT(t7iTtl/01) CERTIFICATE OF UABILITY NSURAINCE 0 2/2.7/?10 1.2 F'"l-HIS 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 BJELOW. TPiS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESEWATWE 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 1-866-966-4664 CONTACT Marsh USA Inc. NAME: PHONE FAX (A/C,Na.Extl: homedepot.certrequest@3narsh.com E-MAIL Two Alliance Center, 3560 Lenox Road, Suite 2400 ADDRESS: Atlanta, GA 30326 INSURER(S)AFFORDING COVERAGE — NAIC#......... Fax (212) 948-0902 INSURER A: steadfast Ins Co 26387 INSURED INSURER B: Zurich American Ins Co 16535 The Home Depot, Inc. Home Depot U.S.A., Inc. INSURERC: New Hampkhire Ins Co 23841 2455 Paces Ferry Road NW -INSURER D: Illinois Nati Ins Co 23817 Building C-20 Atlanta, GA 30339 INSURER E: NATIONAL UNION FIRE INS CO OF PITTS 19445 INSURER F: Illinois Union Ins Co 127960 COVERAGES CERTIFICATE NUMBER: 25776028 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR POLICY EFF POLICY EXP LTR PE OF INSURANCE WVD POLICY NUMBER (MM/DDIYYYY) JMMIDDIYYYY) LIMITS A GENERAL LIABILITY GL04887714-02 03/01/12 03/01/13 EACH OCCURRENCE $ 9,000,000 X DAMCOMMERCIAL GENERAL LIABILITY AGE TO RENTED $ 1,000,000 PREMISES(Ea occurrence) CLAIMS-MADE ITI OCCUR MED EXP(Any one person) $EXCLUDED X LIMITS OF POLICY XS PERSONAL&ADV INJURY $ 9,000,000 X OF SIR: $lM PER OCC GENERAL AGGREGATE $ 9,000,000 GENI AGGREGATE LIMIT APPLIES PER: -PRODUCTS-COMP/OP AGG $ 9,000,000 POLICY PRO- �jECT F-]LOC $ [ B AUTOMOBILE LIABILITY BAP 2938863-09 03/01/12 03/01/13 COMBINED SINGLE LIMIT (Ea accident) s 1,ODO,000 X ANY AUTO BODILY INJURY(Per person) $ .ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ — AUTOS AUTOS NON-OWNED PROPERTY DAMAGE(P $ — HIRED AUTOS AUTOS a,accident) x SELF INSURED PHY D14G $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION WC019736915 (ACS) 03/01/1, 03/01/13 X I TNC STATI1 DRY LIM T- I JITH AND EMPLOYERS'LIABILITY YIN . ER D ANY PROPRIETORIPARTNER1EX.."m N N/A WC019736917 (FL) 03/01/1 03/01/13 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? E (Mandatory In NH) WC019736916 (CA) 03/01/1 03/01/13 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 Workers Wor s Compensation WC1192494 (QSI) 03/01/1 03/01/13 SIR (ADS)/SIR (GA) 1M/750,000 C 9 Compensation WC019736918 (WI) 03/01/1 03/01/13 F F [Worker TX p TX Employers XS Indemnity TNSC46566397 (TX) 03/01/1 03/01/13,occurrence/SIR 30M/lM DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HOME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C-20 ATLANTA, GA 30339 USA @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Jthornton—hd Mar 12 12 03:04p Michael--Bedard" 1-401-246-2868 p. 1 Mar 07 12 04:41p Chris Read 1-508.681-8800 p.1' HUSiE IMPROVEMENT CONTRACT PLEASE.RRAD THIS t• Snld,Furnished rid Inctall d b}t i .., Branch Naas: Boston Date:.?� 7 f THD At-Home Service•& 1-1e d/Wa The}hula&Depot A Flinn:Service, 345A Greenwond Sttrx:t,Unit 2,Wor%xstc,MA 03607 J�, Till Free(860)651.5182:Fax(509)756-3833 (Branch Number:31 federal ID 4 75-269F t(i(t ME I.te 9 C il2$39,ItS Cont.Lie#16427 Cl' .1.ic-9 HHIC.0,9 65�22:MA Hoene Imp.-oventent Contractor �Reg.f{.26593 Inst`illattou Address: 'City State. 7.ip, Trurhaset(sG Work Phone: (tome Phone: (all Phnne Home Address: (Ifdiffercnt from Instulk•:tion Address( City Sta:c Zip E-mail Address(in receive project communication,and Home Depot updams': /91 DO NOT wish to-cceive•any marketing emails frolic The H(xnc Depot Pro cr Information. Undersigacd(."Customer')_.the owners.of the property kx:ated al ttrc al:tw'o installalitrn atldVe;;s.affdt+tn hny. mil THl)r\l-Hanle Services.Inc.("The Home Deptit-)ug=,;to furni,,h•rielieer and arrange for-he ittsiallatio:i('installation•I of all matcrials de:;,:rity d on the below and oil the-relermced Spec Shw,(s).all of which are incorritm e I into this C'ontr el by this refcrcttcc.along with ray applicable State Supplcntynt and payment Strnnu ry attached ht:reti)and any Chung&O,das(rullcttivelY: "Contract"): ; Job it: ran,nuct Pro'ect Amount Rcxi ing []Siding Wintlows Q Insula:ioa +� f Canters(Covers I ntry Dow, ❑ S t � 0 - .. - QRailine Sidiap \Yindotes ❑Inszdntion ,� 5 • i QGutuxslCoycrs ❑L'rirylltxii> [] 12nntin� Siding W'iudttw•s ❑hts�lnlir.n # []Crulteis I Covers ❑Flory Dtxirs ':'�, [jRntHia; Siding[]Winchnvs intulatinu ` $ • . QGuoers/Covers Q Entry Dalrs 0-.-._ �tinimurn25:$1)e)wsituft.:tintraad.Amounts►rrcup�nttecttBarioCthiscnnirna't. Talr1 Coninrct Amount $,.� � 417(52. �� Maine tlunitasem,ntry nat deposit mar than ooc-third arlhe CuntractAtnnmu Cantmncr u_rucs than,inuncdiatcly upon annplcriun of tl:c'iarotk for each`Noeticl,C:u;tptnei Will czccuh•a Completion Certifrcale (t)ve for each Product as delined by r:n'individti:d 51),^v Sheef)and Pay any butanee dtic. As applicable.each Costumer order this Contract ligr e,to Ix jointly and wvcn.1 ly ahligated and liable hereunder. The Noma f) put raucecs the right to isStte a Chant Ordci'or wrininate his Contraci or:toy individual 1'rndtU00 included herein at its(Sis rolitnl,iCTh¢f lent&1)�l of air,its:tuthuiictid s::rcicc'ptrtvidcr detemnno ttmt it cannot perlornl its ohh�ttfiuns tfuc 10 a ti:ntcturul problem will)the'home.ctiviroontartial heir ,ads such as mold,w%hcsi or lead paint,u'.lu t solely t uncerlte,pricing dnt)is or hecanse work ruiuired to cuiupleie the job t6s nut)netadcJ.in the COlItr•u 'paYrttent Suruayin•yi_ The Paym..nt Summary 'H_� �, iuclude(I a�'p.trt n1'this C'unn-ttti sets fiu-th 411c trt:a Cori( gel aillowlt anti payn)cilislct iur::d for the depasixs and final pnytnenr,by Panda [;:supplieablc). Nn'flCl:TO CUSTUMI,x You are entitled to a coutpinteh rll)ed•in copy or the Contract at the time yuu sign.I)o not sign o Completion Certificate tau e• • there is rnie.Crnnplchtin C ert'ific.tte for eurh listed Product as dclincd by individual Spec Sliects))afore work tin that Prndiu't is complete. E. In(trot&vent of ternlmtrtitn)of this Canlruc CusWrllcr agrees to puy'rhe Hnnte Depot the costs or inateriulc labor,cvpcusrs and services provide/by The Home Depot or Authorized Service Provider through the dote of termination,PIuS ttly other nmomrtS tit turtle in this lgrccment or allowed undter ap�i-2bl a bw. THE WME DEPOT MAY b ITI)EI01.0 AMO N•rs H()M1IF; I)hP()9' VRONI THE. I)EPOSIT,FAY\1ENT OR ()7HF.It PAYMENTS R9 LDb, \NITH+7111'- LIMITING THE HOME DEPOT'S O'rHTR RrltilrAll?S FOR RECOVERY OF SUCH (&cent tote nod Aeithurvatiiin: AMOUNTS.- Customer ugru :aud undcn lands th rot this \fat alctit in tile&olio izilenu:nt Ix wtx n Cus:niix r once Tlx leant tkyxn u tilt Irgard to(lire Pntdurt aitd I rstullaugn sc rvices and super sedos all poor Ji;uisinns and n�rceltte rot+ &ills r oral or wrilWii,rugllting it'said Prtxliici,:xulInstallation-This Agrecnntnl Cannot he assigmxt or ainemlzd except•t.a w'rhne ,irncd e by Cnshrmer arA The llanu:Dc(wt_Cusiamer-nekntnvledges and ugrecti that Cwtiomer haz rU,ld,undclsuindS,vui trtar:;y a_cep:s du. tarns of and h:ir'rcccivcd ti copy of:lira•r�ut,cnicnt. • j Aceepted by- G. Suhm1 � -- vMincr' i+ntrt7tt;re xte, Sale,Cnrmiltimt's Signature X Tclepltnnc l I(+. CUsit)lner's5 nature Date,. _ o Sale%Consultaril icenw:No: _ iac:yiph.hfll u , t 1NCF.I.f 1TiOyc C.USTOM1iER MAY CANCE'l, TH[S r 4GRP.Li\irN f 1Vi'1'HC)LIT PENALTY OR OBLIGATION By DIil.yVI;.R1N(; WRITTE N NOTI(I?TO TIIP_}I(M'IG 'DEPO'i' BY MIDNIGHT ON THE THIRD IIUSiNULS 'DAY, a\1'[91:1t Sit;NIi�G 'I HIS':WRE,FAVIU,N T. THE; ST.A'IY: tiLt'!'C.n:M1IKNT ATTACHUM HER171'(D C:OfsiTAINNS A FORM, TO list, IF ONE Is SpI CIV ALLY PRESCRIBED Ill' "[JAW IN C t1STCNM'I ER STAT E. hU71S.fis r1l11)I t tot\,ifs'i l!ttNi,\f�II t1ONbl'I'l(IN1,ARB.171.\TED ON TIk4'111{t•Iattif[MW AND ARK VAR.1't1P"t'tl)4('AN'i'Rht"1'. i. .10•tYt-17•CSC,... 'White-enutch';le Yellow-Custwner ? - 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 A 4 Please Print Le gib `C p NaT118(Business/Organization/Individual) Address: City/ tate/Zip: 0�0 Phone.#: 509"J(o - Are ou an employer?Check appropriate box: Type of project(required) I am a general contractor and I 1. I am a employer with 4. � g 6. El 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. 7. ❑Remodeling . ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑.Building addition [No workers'comp.insurance comp,insurance.$ required.] 5• ❑ We area corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. ' co right of exemption per MGL y �o workers �•. 12.❑Roof repairs insurance required.]t c. 152, §1(4), and we have no 13.❑ Other employees. [No workers' comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: &N Policy#or Self.-ins.Lic.#: Expiration Date: Job Site Address: SLAITr Wm City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expi ation 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 statemerit may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thins,and enaltie perjury that the information provided above is true and correct. Si afore: 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#: Information and Insttuctions ' 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 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 withthe 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-contiactor(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"I:he 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 bum leaves-etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any.questions, please do not hesitate to give us a call., a The Department's address,telephone-and fax number:. The Commouweaith of Massachusetts Department of Industrial Aeei&iats Office of lnvestigatims 600 Washington Street Boston,MA 02111 Teel.#617-727-4900 ext 406 or 1477,MASSAFE Revised 11-22-06 Fax## 617-727-7749 www.mass.gov/dia