Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0052 SOUNDVIEW ROAD
4 , y Town of Barnstable *Permit# Regulatory Services Fee35 die 9 { I i h Richard V.Scab,Interim Director X-PRESSA PERMIT Building Division Tom Perry,CBO,Building Commissioner JUL 2.5 2014 N 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 _ RESIDEN � t EXPRESS PERMIT APPLICATION MVP Not Valid without Red X-Press Imprint Map/parcel Number-- �X. 7/0-51 Property Address59 � — de Residential Value of Work$q 6- ©� _ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address b • V/ Q�t �a SO uu� V er o e oz6 Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) AR 6 k f3 Email: Construction Supervisor's License#(if applicable) Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner 1 have Worker's Compensation Insurance co Insurance Company Name ��� Q Sy-/pr- 1A S ' Workman's Comp.Policy# W ®-1/4? 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 ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side d Replacement Windows/doors/sliders.U-Value d (maximum.35)#of window l #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.c_Historic,Conservation,etc. ***Note: Property eIRESS.dopn sign roperty Owner Letter of Permission. A copy of Improvement Contractors License&Construction Supervisors License is. required. SIGNATURE: T:\IIVIN D\Building Changes\E}P S Revised 061313 ,,, 4;' THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) IMA F DATA oS'fi 9Ug'Bustm"i<' -Umx f,:Skowsbary,,;MA_�1545,•- ��f S Ton fkw 8`�7 903-37b8 Federal ID#`75.26984G0:ME'.Lie#C o2439:P.1 Coat.11016427 ' tr'i Lie#tIbC.U56552Z;MA Home at ConvaLAor lVil It Q"' cg.#17�893 vi State ' 0 6, tir _P work Phone: Aame Pltonet Cen hhoaet Room Addi!ess: (If different from Ins,. ' Address) sty State TAP' E-mait Addresa(to receive project communications and Home Depot updates): p T I DO NOT wish to receive any marketing enails fin Tire Home Depot ' Project lnfano atiou: Undcisigned("Comer"),the owners of the property located at the above inUallation adder;agrees 6liiiy; and THE) t-�Serviow,Inc.(`The Rome Depot")agrees to f amish,deliver and arrange for the installation ('hwW iat1W of all mato-Ws-Aescribed.on the below apd on the refermced Spec Sheet(s), al)'of vAich are,incorporated into this Comraet by•this ref=we,41WZ.with any appl cable State,SutWemeot:and Fayrnetut Summary atLacW berelcs And;any.Change'.Orders(ci Uc=v"e1y,- ' Job#: amtcmd radiact Shows)#: ' ' Amaoiat. -ORoofing Sidin Windows bsv„lotion 'MGutters f Cin°ers ❑ptft y iDoors p _ $ 104W [IsUng E3 Windows 0 wlatiaa � OGuftip t Covers.QEntry Doors rl ROOng USOns 0 Windows Ll insulation ❑t.,utM i Coveys'OEntry Doors❑ Rooting Siding Windows 0 htsulation ❑Guucxs/Covers pEnu'y Doors 1'1 $ " M,aimum 25 tl�eposli of Aev due upoa n of f3�caotratt.. _ 7WW CaMrad Amo unt M�Psnrbn�s�y nut deposk mta+etlmn otne�d of tln Ca�x Amaaut+ ' Cnstomer.agrees that, immediately upon completion,of the wcark for each.Product, Cugtc mar will execute a.Cosnpletic►n Ceifii~ie�tie (one for eitch Pr6duct'is defined by an indivii�iial Spec Shectj and pay any balance due. As applicable,`eich Custtmner'utidci this Contract agrees,tci he jniriily and severally obligated-and liable hereundix. The Hme Dgot reserves the right to is-sue a Chop t:Order or terminate this Comtr ct or any individual Prod=W included here=at ita discretion,if The Home.lpat or its tm tli ri7od servic:epnwider de tmnines that it cannot ptr6ortn its tsbligataians w to a-structural psobletn with.the home,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing emmi.or because work reguirgd to complete the job was not included in the Contract Payment Summary: The Payment Summary # 05 included as part of-this Contract,'sets frxt h the.-total Contract amount and payments required for the deposits and final payments by Product(as applicable). .. ,. NOTICE TO CUSTOMER ,V,1 u are$ntiltled to,a c oetd Wed4n .copy of Ellie Contred at ft tie you islgn.'Do'oW tea a- (aft-. there is one Completions f4r4=ch noted Product as defer by-WdividuM Spec ts)before`work'on-that Product is complete. In the event of tertnination of this Contract,Customer agrees to pay The Hone Depot the casts of materials,labor,expenses and servlifts provided by Tito Home Depot or A,utiuoarlUd Servloe Provider the date of termiimti pglI o% urs any other m a oun&set forth In this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWZD 10 MONE-M"T MtM TW DV:DTI' PA."IE T OR OT11M 2&"JEEN2S-Na kV UHDUT LIMITING Tlx:HOME DEP(YM OTHER xEaODM FOR RECOVERY OF SUCH AMOUN & Aece ecc and Audwhadw: Customer agrees and unda-standis that this,Agreement is the entire agreement between Customer and The Home Depot with regard to the Products and Installation services and a4wsedes all prior discussions and agreements,either oral or written, relating to said Products and InsWlaticat_This Agreement cannot be assigned or amended except by a writing signed by Customer and The Home Depot. Customer acknowledges said agrees that Customer has read,uaders=ds,voluntarily accepts the term.,of and has received a copy of this Agreement. a by.-. R t X r, An, Cu oWar's Signature Date Sales Con. list's Si Custcmler's Signatuf CJSales Consultant iicrtse No: ('.ANf'lH'3J A1T1t1Aie'['11W. i't31 1WR MAV VATW-Ft. TMN. (aRvoicahld;) r Massachusetts - Department of Public Safety Board of Building Regulations and Standards fcanse: CSS1.400-M ERICSSON TORRES P.O.Box 373 South Yarmouth MA Ex cos tsseonec ra 3 I 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): 1 ]C j son A)me- 1q:nmeneli Address:- _QJ City/State/Zip: P'AC5f:L"' •inA- Phone#: 5 6 T 33 3(—(©9. Are you an employer?Check khe appropria-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 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. employees and have workers' [No workers'comp.insurance comp.insurance.: 9. []Building addition 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 l LE]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#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 emWloyees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify der the pains a enaides of pc.jury that the information provided above is true and correct. Signature: Date: q I/ I I ?_0 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#: r aM O ice o onsumer ai�and usiness Regulation ` s g 10Park-- - Plaza - Suite 5170 m , F Boston,.Massachusetts 0211fi { Home Improvement Contractor Registration= Registration: _126893 Type: Supplement'Card p 3/Ex iration:. 8/ 2014 w The Home Depot At�Home Servi6es . .,.._. `ANDREW SWEET , ., 2690 Ct1MBERLANp (PARKWAY SUITE 3U04 ATLANTA GA 30339 r , Update Address and return card:Mark reason for change. - 3 -� Address Renewal M Lmployment' E Lost Card DPS-CAI 0 50M-W04-GG110-121.6p •` µ $ Office oY sY�$ r a►"'r's�i us e � p ah 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 126893 Type: 10 Park Plaza-Suite 517Q Expiration'. g/3J2014 Supplement Card - Boston,MA 021116 T . Home Depot Atotnle Ser+ices ANDREW SWEET ` x 2690 CUMBERLAtD Wi�IiKWAY S � -- - AAN�`A,GA 30339 Undersecretary ai rt ou signature ¢ r.. achuSe`o The Commonwealth of a • Department of Industrial Accidents Oiee of Investigations 600 Washington Street ,Boston,AM07111 www.massgov/dia Builders/Contractors/E1 shp t� Workers compensation Insurance Affdavit: Pa b A licant Inf n rmati Idatne(sue r_essloromization/ladividual): Address: � �?�Jr`" ,�,/•3 (�1 303 Phone#: City/SWe,/Zip: Type of project(required): Are you an employer?Check the appropriate x' 4. I am a general contractor and I 6. Q New construction 1.❑ I am a employer with have hired the sub-contractors '• Q Remodel employees(full and/or part time). listed on the attached.sheet. rietor or Demolition . 2,❑ I am a sole prop Per- •��sub-contractors have $. ❑ ship and have no employees employees and have workels' 9. Q Building addition working for me in any capacity. comp.insurance) 10.[]Electrical repairs or additions [No workers'comp.insurance S. Q We are a corporation and its r airs or additions �1 all work officers,have Exem;�"d their 11.Q Plumbing ep 3.Q I am a homeowner doing right of exemption per MGL 12,0 Roof repairs myself.[No workers'comp. c.152,§1(4),and we have no 1 . O insurance required-]t employees.[No workers' comp.insurance required.] co tion policy inIMY f ticant drat checks box#1 swat also fu out the section below showing dais ww'mo mpea� t meowners who auba,this affidavit in�ting they are loins all work and den hire outside contr wwn must submit a new affidavit indicating arch atesehad an additional sleet showins the name of the subcontractors and state whedstr or not thou entities have =Contractors am eheck#his box must •cmrip,policy number• �>oy�• tithe sub-c�rteractora have ernployeea,t�5'TM�Pf°"' or my einplayees. Below is the policy and job site I ane an employer that is providing workers conepensation insurance for q� ® � jonnation. !Y /7.+ •111 5ft�1'� 5 hmu nce Company Name' I 1 S �� t�� :�on Date: Policy#or Self-ins-Lic.#• Vet te! t tQ� V I l;U.) Cal city/state/zip:Zap.. Job Site Address: V�� number and expiration date). Attach a copy of the workers'compensation policy declaration page(showing the policy penalties of a d under Section 25A of MGL c. 152 can lead to the imposition of criminal pens Failure to secure coverage as regtaire fine up to$I,500.00 and/or�-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fm of up to$250.00 a day against lator. Be advised that a ropy of this statement may be forwarded to the Office of Imes ' ations f DIA for e c very a verification. I do hereby certify under t a allies of perjury that the information provided above true nd coned D use on y. Do not write to area,to a contP e y c or town 00kiaL City or Town:Vkla Permit/License# Issuing Authority(circle one): 1.Board of Health .2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Itaspector 6.Other Phone#: Contact Person: Ac rCERTIFICATE OF LIABILITY DAY ri rrzrI 12rrl4Y; 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 BE'iWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ® _ . 1 > 1"'�1 '�1T: �#td's =a is ricafe Tildar Ls ar;ALDITI INAL SUP fl V, t� .,w� W'' O+.f'.� ON !r- '_j G`. .:d v -..v, ,. v�.,.lY'gi. .,r,:rd25t'.�.._ - rah`!, -1,- v�R- ,�,r .a Y' .-. ; aGet,.-.� L'he rr:;3 and cDndr:ons.orli z pohcy,reg ill P10 Qi6s r ay-r qu4,-2;a�-e idc;rsehent:.A,.state,rient-an#t;u. e�fiticate' +c s"no&'cOi;s 'r' lets u�1� certficate holler in lieu of"such"endorsement(s). PRODUCER CONTACT MARSH USA,INC. NAME: __ _ TWO ALLIANCE CENT ER PHONE M —'i Ax No- 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS ----— _-- - _ INSURER(S)AFFORDING COVERAGE ._NAICA 3^A9�<fG ttJ G•",6"y-1d 1� INSURER A-. 1�?CI ast im-urame.-amparey 12G397 INSURED INSURERS,Zurich'Amencan insurance`o +16535' THDAT-HOME SERVICES,INC. hBA THE HOME DEPOT AT-HOME SERVICES INSURER C:New Hampshire Ins Co — 123841 2455 PACES FERRY ROAD 'Illintus National Insurance C an 23817 ATLANTA,GA 30339 INSURER D: Y INSURER E: INSURER F: COVERAGES �IERiIFF,ATE NUMBER: ATL: 4268601 IREVISION NLIMISER:3 I 111S IS TO CERTIFY THAT THE POIL,ICIES OF iNSURANCE IS TIED BELOW RAVE BEEN ISSUED R; TO T:i�111SLREL..t,1JiED t1GG„� {}rz T,.E€•%LICY FEr;;00 INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE.MAY BE 1SSUED.OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBRI POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVQ POLICY NUMBER MMIDDNYYY) (MMIDDNYYYI LIMITS A GENERAL LIABILITY GL 8877%04 0310I2014 03/012015 EACH OCCURRENCE $ 9-000,000 X COMMERCIAL GENERAL LIABILITY ( DA TO ENT D $ 1000000 IE'__ `CLAiMS•rv1A(3'c i X OCCUR - r 1 ?IIS vI- L_-YXv PREMISES- _.`.;.. I� M -", f 1 i i i `Mtu Exr(Any one person) i$ �C OF SIR:$41%PER OCC- PERSONAL&AD1!INJURY $ 9,iXJ0;0tXi GENERAL AGGREGATE $ 9,000,000 GEN%AGGREGATE LIMIT APPLIES PER:- PRODUCTS-COMP/OP AGG $ 9.000,000 X POLICY JE PRO- LOC $ B" AUTOMOBILE LIABILITY BAP 2938863-11 03/01/2014 103101/2015 OMBI dED SINGLE LIMIT $ 1,0m,� X I ANY AUTO { ill & ry;LY INJUR/F -person) $ _...� -, AI LOWNED 1. "--�SCHE LIVED SELF INS- FD AU70 PH If 1).101C P.J:JS AUTOS I tJiLY iNjU ,,rPz*ac" arr)iI 5 r 14 NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ UMBRELLALIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WOR92R$COMPENSATION + W0049?0262(A05). ii.;-�i/?Op4 f13. 11E015 kVCSTAs r p ..:�IOTH-i... Ar1D ...r.f Y R8 it .Ll^ i i !.TQPY L!1h!ITS i I ER t _ 1 'C s N(.. WC049;0p�ir.'."�K A7 Vr i r ANY PROPRiETORiPARTNER/DCECUT}VE t t 03 ti2014" Ooiiitr'201d r 1,0u.000 OFFICERIIAEMBER EXCLUDt=b?" N NIA �"Et.EACH ACCIDENT $ _ 0 (Mandatory In NH) WC049101883(FL) 03/012014 03/0112015 E.L DISEASE-EA EMPLOYE $ i,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.C.DISEASE-POLICY LIMIT $ C WORKERS COMPENSATION WC049101885(KY,NC,NH,VT) 03/012014 03/0'2015 I(EL)LIMIT 6 1,000,000 .... C WC049101886(NJ) 03/012014 03/012015 ?L'ESCRIt'TION OF OPERATIONS I LQCATIOr:S t VF1IIC1_13 (_trkch ACORD 1014 Addirlonal R mn�rk,;Schedule•Ir„ore spate N r€;,sired) .. .. 1 VIDENCE OF INSURANCE CERTIFICATE HOLDER _. ._.._,_ . .__...._ CANCELLATION- THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 r AUTHORIZED REPRESENT&?!!!E t 1 f Marsh USA Inc. 1,ManashiMukherjee ILaa.aao'Iti ©1988 2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD C6) iohoaj*- Town, of Barnstable �oFtHt rok *Permit# ti �r O - Expires 6 mont/rsjrom issue date - Regulatory Services Fee 5 awxvsn.Br,E. : 16 doss. . a1lb� Thomas F. Ceiler, Director �ES�a�� PERMIT . . . Building Division 0�T � � �OiC Tom Perry, CBO,' Building Commissioner 200 Main Street, Hyannis;'NIA 02601 TOWN OF BARNSTASLE www.town.barnstabie.ma.us Office: 508-862-403 8 Fax: 508-790-62301,` ' EXPRESS PERMIT APPLICATION' - RESIDENTIAL ONLY Nol I1a&1 tvithou1 Rest X-Press hnprint Map/parcel Number p�Q? O Pro rty Address�S %U rPJ Cej Residential Value of Work 93 Minimum fee of$35y1or work under$6000.00 Owner's Name Address 0/?'1 'ed"' S '�+Qsk 1c Contractor's Name n ' ' 'rN ©rre Telephone Number �(j09'��� Home Improvement Contractor License#(if app)i ble) . Cons coon Supervisor's License#(if applicable) �Q__�'1 Workman's Compensation Insurance Check one: ❑ m a sole proprietor I am the Homeowner I have Worker's Compensatioin nsurance" Insurance Company Name 0, Workman's Comp, Policy# � Copy of Insurance Compliance Certificate must acco mpany each permit. Permit Request(check box) ❑ Re-roof(hurricanenailed)(stripping old shingles) All construction debris will be taken to ❑ R/eplacement roof(hurricane nailed) (not stripping.: Going over existing layers of roof) #of doors Windows%doors/sliders. U Value_ _(maximum .35)#of windows *Where required: Issuance of this permit does not exempt compliance%vith 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 req uir SIGNATURE: >:1WPFILEST0RMSIbuildingpermit forms\EX PRESS.doo .evised 072-1 1:0 Y'- The Commonwealth of l I(IsRichusetts Department of Indust;•iril Accidents 1�- ®fftce of Invectig"tioits 1 'f � 1 �fl�1_ �itsliatagtoti st,evi -ton,MA- 02111 y a WIM.M.ri5s.70VAi!tt Workers' Compensation Insttrartce Affidavit, Builders/Cot<itractors/Eleclfas Prim l }'cease Print i�eIIii?l�v An lieat3t lniormation Name(Btuines;/Urganizatiun/lndividusl): - y Address: �" � f ''-C _ City/State/Zip: ( �C1 � a Phone#: ' M �'�> — Are you an employer?Check e a propriate b : a ype of projec equired): 4 1 am a general contracto ❑N conction 1. 1 am a employer with—�V have hired the sub contremployees(full and/or part-time). listed on the attached sh . emode2.❑ I am a sole proprietor or partner These sub-contractors h . ❑Demolition ship and have no employees em to ees and have wop Y .�❑Building addition working for me in any capacity. -- comp.insurance.[No workers'comp.insurance 0:❑Electrical repairs or additions required.] 5. ❑ We are a corporation anofficers have exercised I l.❑Plumbing tepairs or additions 3.❑ I am a homeowner doing all work rightofexemption per 12.❑ Roof repairs myself[No workers'comp. c. 152,§l(4),and we hinsurance required.] 13.❑Otheremployees.[No workercomp.insurance requir *Any applicant that checks box Hl 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 naiiie`Qf 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. v am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ' rZat) �� Insurance Company Name: n ✓� Ex iration Date: Policy#or Self-ins.Lic.#; a'© 3 - , p �� JI/�/✓JJ 1^B� City/State/Zip: Job Site Address: C /'�► rf Attach a copy of the workers'compensation policy declaration page(showing the policy number and exp ration date). ies of a Failure to secure coverage as required under Section 25A of Mc e imposition of crim vile penalties i2 can 1n the foead to rm o a STOP WORK ORDER inal tand.a tine tine up to$1.500.00 and/or one-year imprisonment,as well p 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. airs and era perjury that'ilie infirmation provided above is tru and correct. 1 do hereby certify u p p Date: �� V Phone# F[Offficialy. Do not write in this area,to be completed by city or,town offieinLPermit/License# rity(circle one): L6.Other rd of Health 2.Building Department 3.CityrTown,Clerk 4.Electrical Inspector 5.Plumbing]]Inspector ct Person: Phone N: G �irrsr��yoyyuIra !J ///(,lL04Gu�1-tcde� Office of Cunsumcr Affairs&t3usmess Regulation License or registration valid for indivitlul use Wily before the expiration date. If found return to: {OME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Rtegulatio' '. Registration T26893 Type: 10 Park Plaza-Suite 5170 Expiration 8/3/2012 Supplement Card Boston,MA 0211.6 The Home Depot'At-;lome'Servi6es i DARREN DEERS 2690 CUMBERLAND PARKWAY Sv.�.- i Not valid without signature GA 30339 Undersecretary _ 7 M1 ' � ® .DATE(MPAIDDIYYYY) . �c®R® CERTIFICATE OF LIABILITY INSURANCE �.. 02/19/10 PRODUCER �- 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A. MATTER OF INFORMATIOj Marsh USA, Znc. ONLY .AND CONFERS NO RIGHTS UPON Tii ' CERTIFICATEi HOLDER. THIS CERTIFICATE DOES NOT A1'iEi 10, EXTEND OR hoaedepot.certrscuest�ma-sh.cct: L E D: B'_i I G PC C r.p• ALT' iZ THE COVERAGE AFFORDED f{ LI 'iEJ Two A'_lisnce Center, 3560 Lenox Road, Suite 2400 - r,. Atlanta, GA 30324 !,NISURERS AFFORDING CO`IEFU: GE Nt`•IC 4 Fe.Y 212) 948-0902 ------ INSURED . INSUi?ER A.Steadfast Ins 2638? Co ; _ The Home Depot, Inc. r- - ------- - ----- - --- --- --- .:.,, Home Depot U.S.A., Inc. INSURER3:Zurich American Ins Co 15535 2455 Paces Ferry Road NA INSURERC:New Hampshire Ins Co _ __- 23841.____ .__-__ Building C-20 Atlanta, GA 30339 INSURERD:NATIONAL UNION FIRE INS CO.OF PITTS--__i 19445 INSURERE:Z1linoi.s Union Ins Co 27960 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY 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 ADDI - POLICY EFFECTIVE POLICY EXPIRATION- TR POLICY NUMBER A MMID /YYY D TE M /D /YY LIMITS A GENERAL LIABILITY GL04887714-00 03/01/10 03/01/11 EACH OCCURRENCE Is 4,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY. PREMISES LEa occurrence Is 1,000,000 CLAIMS MADE ❑X -OCCUR MED EXP(Any one person) $EXCLUDED PERSONAL 8 ADV INJURY _' $ 4,000,000 GENERAL AGGREGATE $4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ... PRODUCTS-COMP/OP AGG $-4,000,000 _,.: PRO- . ._<._ - :_....._.a._.,.--'--_.�-..�.._ _--_- X' POLICY : T LOC B AUTOMOBILE LIABILITY BAP 293B863-07 03/01/10 03/01/1.1 COMBINED SINGLE LIMIT (Ea accident) $ 11 000,000 X ANY AUTO ALL OWNED AUTOS BODILY INJURY $ ' SCHEDULED AUTOS -(Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) _-- - X SELF INSURED AUTO PROPERTY DAMAGE $ (Per accident) PHYSICAL DAMAGE t GARAGE LIABILITY _ AUTO ONLY-EA ACCIDENT $ _ ANY AUTO OTHER THAN EA ACC $ - - AUTO ONLY: - AGG $ A EXCESS I UMBRELLA LIABILITY GL04887714-00 03/01/10 03/01/11 EACH OCCURRENCE $ 5,000,000__ - X OCCUR, CLAIMS MADE AGGREGATE $ 5,000_000__-_ - g DEDUCTIBLE - $ RETENTION $ $ C WORKERS COMPENSATION • WCO20342355 (AOS) 03/O1/,10 03/01/11 X WCSTATU-' OTH- --- — — - AND EMPLOYERS'LIABILITY Y/N D ANY PROPRIETOR/PARTNER/EXECUTIVE WCO20342356 (CA) 03/01/10 03/01/11 E.L.EACH ACCIDENT -_ $ 1,000,000 OFFICER/MEMBER EXCLUDED) E (Mandatory in NH) WCO20342357 (FL) 03/01/10 03/01/11 E.L.DISEASE-EnErvPLOY_[ 's'1,000,000 It yes,describe under SPECIAL PROVISIONS below E.L.DISEASE•POLICY LIMIT $ i,000,000 OTHER - E TX Employers Excess TNSC46242373 (TX) 03/01/10 03/01/11 Occurrence/SIR 30M/2M D Workers Compensation WC0910566 (QSI) 0.3/01/10 03/01/11 C Workers Compensation WCO20342358(XY,MO,NY,WI, ) 03/01/10 03/01/11 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BV ENDORSEMENT/SPECIAL PROVISIONS RE: EVIDENCE OF.COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION - DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN THE HOME DEPOT, INC. HOME DEPOT U.S.A., INC. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 2455 PACES FERRY ROAD NW REPRESENTATIVES. BUILDING C-20 ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE USA ACORD 25(2009/01)Jthornton_hd ©1988-2009 ACORD CORPORATION. All rights reserved. 14481889 The ACORD.name and logo are registered marks of ACORD L 49 The Commonwealth ofMassachusetts - Department of Industrial Accidents a r V ;tom Office of Investigations 600 Washington Street - c+� Boston, MA.02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): r� SCVV Q eS Address: tiM/' City/State/Zip: mal`h I Phorie#: Are you an employer? feck,the appropriate bog: Type of project(required): 1:.❑ �mpoioyees a employer with 4. ❑ I am a general contractor and I * have hired the.sub-contractors 6. ❑ N construction (full and"/or part-time). _ � . . listed on the attached sheet 7. Remodelin 2. I am a soleproprietor r g . o .partner- . ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9.. ❑Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.❑ Electrical:repairs or additions q l officers.have exercised.their 3.❑ I am a homeowner doing all work 11`.❑ Plumbing repairs or additions myself. [No workers'comp right of exemption per MGL 12 ❑ Roof repairs insurance required].at c. 152,.§l(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 anew 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 in _ ranee for my employees Below is the policy and job site information. y Insurance Company Name:. 'P V V Policy#or Self-ins.Lic.#: �1°n/� Expiration Date: :Job Site Address: - � l �A Wit?/ City/State/Zip: 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 ofMGL c. 152 can lead to the imposition of criminal penalties o f 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 certify e;pa• .penalties ofperjury that,the information provided/a''�bove is true and correct. Si nature: Date V t 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 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 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 licensior perinif 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 ihe_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 (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. " I 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. I 4 The Department's"address,telephone and fax number: ! i The Commonwealth of Massachusetts_ . fx_ Department of Industrial Accidents I Office of Investigations Y E 600 Washington Street. . Boston,.MA 02111 i i Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia I OP 0 DS DATE IMWDD:YYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE TORRE-1 11/02/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Bryden & Sullivan Ins Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 88 Falmouth Road Hyannis MA. 02601 NAIC# t Phone: 508-775-6060 Fax: 508-790-1414 INSURERS AFFORDING COVERAGE INSURED InsrR= A Western,World N.;L _ Ericsson Torres 16 Hoover Rd -NS EZ West Yarmouth MA 02673 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 15 SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1 SR ti I POLICY EFFECTIVE POLICY EXPIRATION ( - Ltmffs LTR NSRD TYPE OF INSURANCE POLICY NUMBER I DATE(MMtDD/YY _ ( DATE(MM/DDIYYI EAC4 OCCUR PENCE $ 1000000 GENERAL LIABILITY i j - c _ -- I + 11/02/09 ' 11/02/10 I PREMISES(Ea occurence) $50000 A i ;7 COMMERCIAL GENERAL UABILITV� BINDER MEDE)O(Any One Person) £ 5000 CLAIMS nv�0e n OCCUR I PERSONAL 2 AOV INIUP.Y $ 1000000 GENERAL AGGREGATE S 2000000 fIII, PRODUCTS-COMPIOPAGG E 1000000 i; GENT AGGREGATE L'MiT APPLIES PER: PRO- t POLICY jECT LCC AUTOMOBILE LIABILITY COMBINED SINGLE UMIT i$ (Ea accinn.0 ANY AUTO - -. BODtY1 ALL OWNED AUTOS i - (P--Pe an) g I pppl (P�r,oersor.) I I SCHEDULED AUTOS I , . H ` I i l BODILY RUUP.Y IRED AUTOS y I I I (Pet a•.cldEnt) NON-OWNEDAUTCS I 4 PPOPEP?`!DAMAGE' g I I I - LAliTO ONLY•EA ACG'OENT �. I GARAGE LIABILITY EAACC S ANY AU i C I OTHER THAN I AUTO ONLY A- S i EACH OCCURRENCE $ I .EXC6SSfUMSRELLA LIABILITY 1-7l AGGREGATE I I OCCUR CLAIMS MADE g I DEDUCTIBLE l I RETENTION- S NICSTATU- OTH- . 1 TORY LIMITS I ER WORKERS COMPENSATION AND EMPLOYERS'LIABILITY i E L.EACH ACCIDENT i g ANY PRCPRIETOP,lPARTNEkF>�CUTNE I E.L.DISEASE-EA EMPLOYEE S 1 OFFICER/MEMBER EXCLUDED? E L DISEASE-POLICY LIMIT {S If yes,de�:nbe.under ) _ SPECIAL PROVSIONS Delay: _ I - j OTHER 1 11111 1 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS Carpentry/Painting/Drywall-*Certificate Holder is included as an additional insured with respect to general liability if required by"a written contract. CANCELLATION CERTIFICATE HOLDER TFIDATHO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN r NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL THD AT-HOME SERVICES INC IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR and The Home Depot LH ESENTATTVES- 2690 Cumberland Pkwy,Ste 300 ROED REPRESENTATIVE Atlanta GA 30339 nnis Office _-- - ------- ---- - Jul• 2J. 2009 9 , NAIVl GharIe a Jr,, 110. 4111 r. j 075 ai�Nsa nu e u a iononsumer � � g 10 park plaza - Suite 5170 Boston, Massachus-tts 02116 Hone Improvement 00"htractor.Registration Registration: 163528 Type: DBA Expiration: 7/7/2011 Tr# 285903 ERICSSON HOME IMPROVEMENT ERICSSON TORRES 16 HOOVER RD ----- WEST YARMOUTH, MA 02673 Update Address and return card.Mark reason for change. Address [3 Renowal n Employment [] Lost Card !PS-CAI 0 d0M•0ei0e•0 GG8SLIQF.0 paMCA10e21200e�i/ _B Office�t2'by(4's�S'i � 'fPbfrl�& t `g�Uon 1,1cense or roglstratlon valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: Office of Consumer Affairs and Business Regulation Reglstrafil'on: 163528 10 park plaza-Suite 5170 Expiration: .7/712011 Tr# 285903 Boston,MA 02116 ERICSSON HOME'IMPROVEMENT ERICSSON TORRES 16 HOOVER RD. _ WEST YARMOUTH'.MA 02673 Undersecretary Not valid without signature Ju1. 23. 2009 9: 20AM Charles C. Case Jr, No. 4717 P. 6 + Restricted to:;b,o. �= Nlasxachtomts- Dcpartmem ot•Public Safm 1A Masonr)"o,nly' Bo:irll of Biiildin� Retulations and Suindartls RF- Roof.Coveting Construction Supervisor Specialty License. WS-Windo14s s►ni!Siding License: CS SL 100546 + SF- Solid Fuel Burning:Devices Restricted co:. W.S DM-Demolltlon only ERIGS50.N; TORRES Failure to possess a current edition of the Massachusetts State Building Code 16 HOOVER ROAD is cause for revocation of this license. WES�TIYARMOUTH, MA 02673 Refer to:' VVVVW:Mass,Gov/DpS E-xpiration: B ia=2 Y i,ntnJ3rl it•r Trn: 100546 09-20—'10 12:18 FROM—THD PRODUCTION 5087569009 T-927 P001/006 F-251 Sold.R mished and Installed by ,f�, - THD At-Home Services,Inc. Branch Name: Boston Dates y�rt-� diWa The Home Depot At-Dome Sctvices 345A Orcenwood Street,unit 2,'Worcester,MA 01607 Branch Number:31 Toll Free(NO)657-5182; Fax(508)756-8823 F6de7al m#75-2698460;ME l is#C 02439;RI Cont.rice 16427 p Cr Lic(ir 565 11 MA Horne rn e lirw4veent Contractor Reg-s 126893 Installation Address: )I'i�1 1�f�r r 1 1C f�/? 1 A �? i1 f t��_�f✓� �'�--= City State Zip Purchaser(s): IfOr Phon " cell Phone:- - Rome Address: State Zip (If different from Installation address) 0 ity E-maill Address(to receive project communications and Home Depot updates): i ❑1 DO NOT wish to receive any marketing emails from The Home Depot Protect Information: Undersigned("Customer'),the owners of the properly located at the above installation address,agrees to buy, and TffD At-Home SerVice�.,Inc.C"fhe Hamt Depot")::gzi s to hnroixh,deliver and ea,'sngc for the installation{"Installationi of all materials described an the below and On the referenced Spec Shect(s), all of which nre iucOrpOr'ated into ibis Contract by this refort:nce,along with any applicable State Supp!cment and Payment Summary attached hereto and aiiy Charge Ordcrs(coNcc:;rely, "Contract"): job#: ammal ikdemon ucts: S Sheet(s)#: Project Amount ORoofng Siding indows 0Insulation /p, f lff OQaners/Covers OEntry Doors 0 - ✓�..•' !1 — W'ndOwS 'In9ulalioa - gitoofing❑Siding t —---- _ - - C]Ouners/Covers QEntryDoor ❑- Raoting []Siding(Windows IusuiaGon_ _ $ QCrvttcrs/COvers DEnty Doors Roofing Siding❑Windows lwulatioa $ ❑GuttersICovers OLcnuyDoors❑NJhjmmn 25%De it of C4,,ttraci Amount due upon exemaon Of this e0ntt'ad. Total Contract Amount $ /`7//11 Maim Pmrhasm may rmt deposit More than on&Wrd of the Contract Amount. r J Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion Certificate (one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer under this Contract agrees to be jointly and severally Obligated and liable hereunder. The Home Depot r"erves the right to issue a Change Order or terminate this Contract or any Individual Product included herein,at 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,otfier safety concerns.pricing errors or because work required to complete the job was not included in the Ca rats. Payment.Su nmarv: The Payment Summary# 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 not sign a Completion Certificate(note: isted Product as defined by individual Spec Sheets)before work on that Product. there is one Completion Certificate for each 3 is complete. t the costs of rne De In the event of termination Of this Contract,Depo Costaor Authorizeenses mer d Serees ve Providy The Hothr ugltothe date of ter rtinatlon,Iplust any other Ind services provided by amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAXMAY WI'X'HFIOLl)AMOUNTS OWED TO THE CIOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHFR PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUC)4 AMOUNTS. . Acceptance and.4uthortzation: 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 agtccmcnrs,tither oral or written,r Depot latin to said regard tothProducts 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. Sub rt cep by: Gusto 's Signature Date Sales CO�Isultant s Signature ate > X Telcphorie No. Customer's Signature Date Sales Consultant License No. CANCF:i,I.AT[QN: CUSTOMER MAY CANCEJ THIS - -{ec apPiitahle) AGREEMENT WITHOUT PENALTY Oft OBLIGATION BY DEI.I'VIBRING WRITTEN NOTICE TO THE ROME DIVOT BY MIDNIGHT ON THS THIRD BUSINESS DAY AFTER SIGNING TMS AGREEMENT. THE STATE SUPPLEMENT ArrACHRD HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW. IN CUSTOMER'S STATE. NOTICE:ADDTfIONAL TERM$AND CONDITIONSXRE STATED ON TIM REV"5R4£SIDF AND ARE PART OF TRIS CONTP-JLCT 11•30-09 C-5C White—BranchFlle YEllov;r—Cusiomer Pink—Uw;Consuitard Town of Barnstable � E.rpirrs 6 nro�rrks ror t issue re Regulatory Services Fee 3t3.A7RVSNBLE. Thomas F. Geiler, Director.Al�MAYa � Building Division Cl�/ Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office_ 508-80-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY N01 Valid without Red X--Press Irnprini Map/parcel Number Prop Address �J04/?3 �/rlf) Residential Value of Work / inimum fee of$35.00 for work rider$6000.00. M t Owner's Name & Address l+ ' ttl ' g r/y©/ iAl A Contractor's Name /Y► L0/Yl Tele one Number Home Improvement Contractor License #(if applicable) :T/J 12 Con ruction Supervisor's License#(if applicable) �/�"9/ Workman's Compensation Insurance — p� Q� Check one: -PRESS PERMIT ❑❑ I am a sole proprietor s�P � � ��fi� am the Homeowner have Worker's Compdnsation.ipsurance A G TOWN OF BARNSTABL Insurance Company Name New S Workman's Comp, Policy#{ 0,3 Copy of Insurance Compliance Certi v e must accompany each permit. Permit 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 roof) ❑ -side #of doors ' Replacement Windows/doors/sliders. U-Value (maximum .35)# of windows -Where required: issuance of this permit does not exempt compliance with other t P P r town department regulations,i.e.Htstorrc,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission, m A copy of the Home Improvement Contractors License & Constructian Supervisors License is re d. .`IGNATURE: ':1WPFILESVORMSNjildingpermit formslEX PRESS.doc evised 072110 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ff 600 Washingtoaz Street Boston,/>'1i4 02111 www,Ma s .g o ldi a Workers' Compensation Insurance Affidavit: Iluilders/Contractors/E lee trieians/Plumbers A phcant Information ] Please Print Leciltly Name(B Lis iness/Organization/Ind'ividual): ;`( ✓"?% - = *: �— Address: City/State/Zip:. If'� Phone#: ' � Are you an employer?Check the a propriate b Type of.pro' t(required): I. f am a employer with_I1Q 4 I am a general cone actor and l 6 ❑N consh uction employees(full and/or part-time). have hired the sub-contractors listed on the attached sheet. 7. Remodeling 2.❑ [ship a sole proprietor or employees partner- These sub-contractors have g. ❑Demolition ship and have no employees employees and have workers' working for me in any capacity. 9. ❑Building addition comp.insurance? [No workers'comp.insurance 10.❑Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3.❑ 1 a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGI. 12.0 Roof repairs c. 152,§1(4),and we have no insurance required.]t 13.❑Other .employees. [No workers' comp.insurance required.] *Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. . t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Co i d ' Expiration Date: Policy#or.Self-ins.Lic.#: - V V 1 Ghl/ City/State/Zip:CCs� °/e Job Site Address: 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 tine 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 tine 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 un pains and penalti of perjury that the information provided ve is true al cor ect. Date: 1.— Y Signature: 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): Lardf Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector erson. Phone#: 1 The Commonwealth of Massachusetts ✓ Department of Industrial Accidents OfJlice of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Le ibl Name(Business/OrganizatioNlndividual): bl ie S Address: In City/State/Zip:i&L�, Phone#: Are you a employer?Check the appropriate bo Type o[proj '(required): 1.❑ a employer with 4 - am a general contractor and I employees(fu11 and/or part-time). have hired the sub-contractors 6• ❑Ne construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. emodeling ship and have no employees These sub-contractors have g, ❑Demolition d working for me in any capacity. employees and have workers' [No workers'comp. insurance comp.insurance. t 9. ❑Building addition 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 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 We outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that Is providing workers'compensation Insurance for my employeex Below Is the policy and fob site information.Insurance Company Name: luc� �� '�'P/l e�5 Policy#or Self-ins. Lic. #: — 3-s 7-3/ — / 0 Expiration Date: Job Site Address: VA/8 l w City/State/Zip:C�'�U/�l (l �,�, �0 3� 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 S 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 Investi ations of the DIA for insurance coverage verification. I do hereby cerfo under the p ins a penalties of perjury that the information provide e ve Is t and corre ct Signature: Date: CV V _ Phone #: Offlcial use only. Do not write in this area,to a completed by city or town offlclaL 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 employdrs 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 withho ld 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 with the insurance requirements of this chapter have been presented to the contracting authority." Applicants b checking the boxes that apply to your situation and,if Please fill out the workers compensation affidavit completely, y g PP Y necessary,supply sub-contractors)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 dlicense 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. # 617-7274900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 11-22-06 www.mass.gov/dia L1 Office of Consumer Affairs&Business Regulation 1 License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expihation date. If found return to: i - Office of Consumer Affairs and Business Regulation i Registration 426893 TYPe 10 Park Plaza-Suite 5170 Expiration Bt3/2012 Supplement Card Boston,MA 02116 The Home Depof.;At Home Services 3 hf I 1 .� — ✓ DARREtJ DEMERS \ I 2690 CUMBERLANQ.PAI�KWAY GA 30339 Undersecretary `' Not valid without signature '�'�-� -=� i Office of Consumer Affairs and�usiness Regulation 10 Park Plaza- Suite 5170 Boston,Massachusetts 02116 .Nome Improvement CQpt-�etor Registration Registration: 149128 Type: IndiaMdual Y'", � 6mirati0n: 11l2812011 Tr# 290244 TIMOTHY HANSCOM TIMOTHY HANSCOM 4 CIRCLE DR. WAREHAM, MA 02579 ='r• - :"- -•----.____.�_. __ -- - t ''.::, Update Address sad return card.Mack reason for change. Address i—) Renewal E Employ at :__;.J.ast Card Ob6a of Consam Affairs t+u.v�es,et�'taso$ License or registration valid for individul use only before the expiratioa date. Iffound return to: HOME IMPROVEMENT CONTRACTORpCke of.Consumer ABafrs and Business ReguJadeft Regis4atton:. 1A9128 10 Park Plaza-5utte 5179 Exprragam 1:.1-2E12011 Tr# 290244 Boston,MA 021,16 Type=:.-":��ndivitivat'•.. TIMOTHY HAXSCOAd..: :i-. TIMOTHY HANSCON: Val 4 CIRCLE CR. WAREHAM.MA 025-t 1-.^ Umd�csecretarr � 1Vot . a '::' }fa+,arhtr•ctt - Dep:r1'trnr:it ni'F'ulzlii �ritit� ' , , Hoard ref Puildi;t Reg 10ati lin s aild 1t.rnfl:Irct. ` - Construction Supervisor Specialty License License: CS SL 99162 , Restricted to: WS TIMOTHY HANSOM sx 4 CIRCLE DRIVE WAREHAM, MA 02571 MIA me Expiration: 6;4/2011 ! r 'I FROM :jamgad FAX NO. :5083622271 Mar. 1 2007 11:51RM P1 HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold,burnished and Installed by; fj THD At-Home Services,Inc: Branch Name: Boston Date: / ->+� - d/b/a The Horne Depot At-Home Services 345A Greenwood street,Unit 2,Worcester,MA 0160.7 31 Toll Free(800)657-5 t 82; Fax(508)756-8823 Branch Number Fcdctat ID#75-2698450;ME Lic#C 02439;RI Cnnt.t P#16427 Cr Lia 565 ;MA Home Imp vemmt Contrwior Reg.#126893 '� i�n�fir, �l�'_ ��l-�� G oa63�--. Installation Address: state Z1p City Pro chaser(s): Work Phone Home Phone: r Cell Phone: Home Address: t� 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 emails from The Home Depot Aa(pvn proiCCtlnfnrmation: Undersigned("Customer'),the owners of the property located at the above installation address,agrees to buy and THll At-Home Services,Inc.("L'he Home Depot")agrees to furnish,delivea and arrange for the installation("Installation")of all materials described on the below and on the referenced Spec Sheet(s),all of which arc incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(colleetivelY, "Contract")' S Sheets #: ProjectAnrount Job#: (nar�9ererrm) do - ❑Roofing Siding indaws ❑insulation ❑ Gutters/Covets ❑ try Roofing Siding ❑Windows ❑Insulation $ ❑Gutters/Covcrs ❑Entry Doors ❑ RoofingElsiding ❑Windows ❑Insulation $ ❑Gutters/Covers C]Envy D,v rs n ❑Roofing [!Siding WindnwS ❑Insulation $ [3Gvuem/Covers ❑Entry Doors ❑7NMfin.hn= sit of Contract At oust die upon execn�of this conhtacL Total Contract AmounE $ay pat deposit more than one-third of the Contract Awoant. J ('usto ner agrees that,immediately upon completion of the work,for each Product,Customer will execute a Completion Cnderi this (one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at.. its discretion,if The Horne 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 c•oncerrts,pricing errors or because work rcgerired to complete the job was not included in the Co act Payment Summary: The Payment Summary # included as part of this Contract, sets forth the total Contract amountt 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 not sign a Completion Certificute(note: there is one Completion Certificate for each listed Product as defivaed by individual Spec Sheets)before work on that ProduL 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 Rome 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 HoMp I)EpOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEP05TT PAYMENT OR OTT�[EIt PAYMENTS MADE, WITHOUT LIMITCNG 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. e- d by p by: o X o Custor 's Signature Date Sales C sultant's Sigaatu G � Telepho `No. sc-- Customer's Signature Date Sales Consultant License No: (as applicable) CANCELLATION: CUSTOMER MAY CANCEL,THIS 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 SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE::ADDITIONAL TERMS AND COMMONS ARE STATED ON TILE REVEM SIDE AND ARE PART OF THIS CONTRACT Pink—Sales C ftSvbnt r-��1_ _:_ . -- '_�_�.-� � t r ' f � i � � il� � ue� G� i, �� � � I � � i �� � � _ � � 1 . . . Parcel �� f Permit# Conservation Office(4th floor)(8:30- 9:30/ 1:00=2:00) to Issued 9 Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) �]�. ;01. Fee Engineering Dept.(3rd floor) House# 6c - of ENE rq P ng ept.(1st floor c 4 ` �:� RARNSfARLE MA ✓y, Fn .� TOWN OF BARNSTAB � � '� �� ©� � ;��; T .S Building PermitAp li ion � Project Street Address" Village Owner"J/- f t'j�hl �',�j"�/D.S Address li OU/d0 G G� fib'/S Telephone Z so 01/ Permit Request 4iUa'a z--z T//l/C&tom 4,W --5 First square feet SeeeRd-F48or square feet Estimated Project Cost $ Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use /Z& ,,Z C ,6 //s/ Proposed Use Construction Type d/'h7 f/r.°O2 V/.w//� Residential X Dwelling Type: Single Family ( o,� TWI FaffMy Age of Existing Structure /0 Basement Type: Historic Housej nfinished� Old King's Highway //,Ll Number of Baths No.of Bedrooms Total Room Count(not including baths) `� First Floor Heat Type and Fuel Central Air Fireplaces og!�Q6 Garage: Deta hed Other Detached Structures: P I Att ched Ba n N ne S ds O er Builder Information Name Telephone Number SO g' gf z�G Addddress License# Z 7— ZW. _�z�3/ Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ✓/✓v/v/�f ' U � i SIGNATURE DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY � PL MIT NO. D;TE ISSUED _ Mv►P/PARCEL NO + ADDRESS VILLAGE OWNER ' + DATE OF INSPECTION: ; FOUNDATION FRAME INSULATION E FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL t c GAS: ROUGH FINAL FINAL BUILDING ' r DATE CLOSED OUT ASSOCIATION PLAN NO. — J ' The Town of Barnstable KAM.Jim ;� Department of Health Safety and Environmental Sernces Building Division 367 Main Street,Hyannis MA 02601 Ralph Crosses Offi= 508-790-6227 Building Commis F= 508 775-33" For office use only Permit no. Date • • AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,.removal, demoliti= or construction of an addition to any pre"cdsti n t building containing at least one but not more than four dwelling units or to structures to such residence or building be done by registered contractors,with certain exceptions, along with other requirements Type of Work• o - 0 e - Address of Work: _ Ow•aer.Name• Date of Permitircati _ on: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law ob under S1,000 Building not owner-ooeupied Qtvrter pulling own permit Notice is hereby given that: CON[RACMRS OWNERS PULLING THEIR OWN PERMIT OR DEALING W i1�UNREGl5TEf1ED FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the ow.n Date -tractor name Registration No. OR n,,,, Owner's name The Coninionfrealth of Massachusetts •� - +y f ��•- t== Department of Industrial Accidents 1 i;� =i•,a' 611011 ashington Street Boston.Afars. 02111 � Workers' Compensation Insurance Affidavit ,eRR1 cant nfot•rrtation= n name• // IlZa ogol' —LoV s sift• /'N aJ �.�►- �/�_�6�� Phone# I am a homeowner performing all work myself. II!�am aa.ssole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. company nnme! - address: sift•• nhone#t inct�r�nr�r_n nolicv# - - .r.. I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: commov name! address- phone#: incurnnce co _- - policy# L:�_ N--:-r:_-•- - ;_.-4""✓:..�;..•.,�.-a y-••-�•.ts-Msl?+,�FrY' = - -- ="'s!tF+,?vq►e�9''�}�r',v=+W:r, ��:--�-'�'_�"JSe'r3_*a!'�?�••�_y campan•name• address: city: phone :Attach additional'sheet if necessary` _••7.:-'i%�: :+''^ "''a r :'"�' " ':+srna Failure to secure coverage as required under Section 25A of DIGL 152 can lead to the imposition of criminal pennitin of s fine up to$1.500.00 and/or one rears'imprisonment as w If as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a cop)•of this statement be two to the Once of Investigations of the DIA for coverage verification. l do heretr certij' under 1 an an pens perjury that the information provided above is tr/uee and correct / Signature Due `S p i b Print name d��A ZZrL_����/� Phone# official use only do not write in this area to be completed by city or tows official city or town: pertoitAicense# rZBuilding Department C31 Icensing Board D check if immediate response is required (3Seleetmen's Office (3flealth Department contact person. Information and Instructions Massachusctis,Gencral Laws chapter 152 section 25 requires all employers to provide workers' compensation for their fined as every person in the service of another under any emplo,%ces. .As quoted from the "law", an empint►eg is de contract of-hire. express or implied, oral or written. An empinrer is defined as an individual, partnership,association. corporation or other :,gal entity, or any two or more of the ford=oink 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 tite owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwellin-, house of another wito 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. a • MGL chapter 1.52"section 25 also states that every state or local licensing agency'shall withhold the issuance or renewal of a license or per to operate a business or to construct buildings in the commonV•calth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally.neither tie 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., wr!'!��•!�.••�•�`.•"^�`��•:�:•a. ,. '.�j,;.g.,ii:..'.1� ��:•'�•'a.Y��Y...+� �+t{. .h�.f�•1'p : �'•�� VSAr.^�ti`;'tr•:.�,.,:'..i`.fr• •.i .a. applicants 'lease fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying•company names, address and phone numbers as all affidavits may be submitted to the Department of ndustriai 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 tite application for the permit or license is being requested, got the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required :o obtain a workers compensation policy, please call the Department at the number listed below. •�+•7�•M�npP/A1'!4!'�Cn-w.a.+ .. L 1w { j i Lti�'��•• '.i,...,.�:,�' - « ',7L-/±�5�'. .', _. .. .'t..�.«,.ui.,irw, r"'�.s. .«�w.�:.a:�SrlM�t. •T r.4i7i�a.�.tc-{�T� •rirs�'•:r:..:a�v City or Towns 'lease be sure that the affidavit is complete and printed legibly. 77te Department has provided a space at the bottom of he affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please )e sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to he Department by mail or FAX unless other arrangements have been made. 'he Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, )lease do not hesitate to give us a call. ..ra. �. .•.: :ter.+:'-_ _ '�:Ys'• ::a• .... . . �c�..::nn..r 7te Department's address, telephone and fax number. The Commonwealth Of Massachusetts s.,• Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 ext. 406, 409 or 375 0 DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE Nu�berM Expires: } Restricted'To;e ' 00 8"` ",.AVID G Vf}IALEN 275 QUASOWS PATH BREWSTER, NA 02631 nn 9`Jrr NONE IMPROVEMENT CONTRACTOR Re$ stratim 415105 { , � > �*} , , ��YPe�.�INDIVIDUAl� � .�.�;�s�r Etpi`TetlQn01/©6/98, z d � �;DAYIb MWEN CONTRALTI , 2 5 0UA AS:PATH •> , �� ADMINISTRATOR EHSTER Ni 02631f W a a f �IrI i0<1 s r i a 1/S Ll Z X f Zo C/ DAVID WHALEN (;ONITpgCT810 ^N 275 QUASON8 PATH ,`�' °" 5 t X SREW8TER. NA OM t • i �! mil., ��� � �i � ��+�o♦� 7- � �►.',,tea � cv=,o+ �1 I ,� � x ,I �.. of � , .�� ♦ �� � �► ^ -�� ! ♦'�, . � III ♦ � ' rA p MINN