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0018 HEMEON ROAD
Town of Barnstable Building ,r^ . „ `ly:•croue�arfirSo�ThstVisyblW omth eSteet-i M ; e onJob�andn,�th is;Catea.rd ecM*, us4ft be�Kp t F � � _ .s � �� N `� � �� v � s Y s x °" •` ., `' �J se � Permit �+' Where a Certificate of Occ paneYs�Requ�red�3su�ch Building shall Notccupied unt�l�a F��al lnspectrt has been matle �;� Permit No. B-19-1036 Applicant Name: Lloyd R Smith Vivint Solar LLC Approvals Date issued: 04/04/2019 Current Use: Structure Permit Type: Building-Solar Panel-Residential Expiration Date: 10/04/2019 Foundation: Location: ' 18 HEMEON ROAD, HYANNIS r Map/Lot: 268-089 Zoning District: RB Sheathing: a , Owner on Record: DUNBAR,ELIZABETH B Contractor Name: BRIEN LANGILL Framing: 1 Address: PO BOX 746 - tractor;License CS 106675 2 WEST HYANNISPORT,MA 02672 h Est Pr�oject Cost: $8,866.00 Chimney: Description: Installation of roof mounted photovoltaiv sold'(,systems 4.03kw 13 Permit Fee: $95,22 Panels Insulation: 1Fee Paid , $95.22 Project Review Req: Date 4/4/2019 Final: yze a Plumbing/Gas ' Rough Plumbing: t5upoin fficial This permit shall be deemed abandoned and invalid unless the work authoraeci by,this permit is commenced within six months after issuance Final Plumbing: All work authorized by this permit shall conform to the approved application and the:approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zonings,. laws and codes. Rough Gas: This permit shall be displayed in a location clearly visible from access street or road'a:nd shall be maintained open for public inspection for the entire duration of the work until the completion of the same. I' Final Gas: The Certificate of Occupancy will not be issued until all applicable signatures bythe Bwldmg and Fire Officials are provided onthispe mit. Electrical Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing .- .'� Service: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Rough: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Final: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Rough: Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Health "Person7,egisteredcting with unr contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: ,. Town of Barnstable Building erTos RAIMST►= PPote Whtdh�s Card So That it t's;UisibleFrom the S treet Approved`Plans Must be;ftetaiGned` on Job�and this CadMust"be Kept h 1eliy e Permit No. B-18-2225 Applicant Name: Elwell Perry Approvals Date Issued: 08/06/2018 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 02/06/2019 Foundation: Location: 18 HEMEON ROAD,HYANNIS Map/Lot: 268-089 Zoning District: RB Sheathing: � Try,Contractor Name:' Elwell H Per Jr. Framing: 1 Owner on Record: DUNBAR,ELIZABETH B gT . 3 s j . Contractor License CS 104088 Address: PO BOX 746 2 WEST HYANNISPORT, MA 0267241`1 Est,,, Pr, Cost: $2,658.00 Chimney: Description: Install 9"of R-30 fiberglass to 922'attic flat. Aall 74 prop-r-vents. Permit Fee: $85.00 Insulation: 3 hrs.Air Sealing. Install 2. rigid ins board tor-commonwvall. 4 Fee Paid $85.00 Project Review Req: Date 8/6/2018 Final: Plumbing/Gas ,u Rough Plumbing: �m ;Building Official z Final Plumbing: s Rough Gas: This permit shall be deemed abandoned and invalid unless the work aathnz oed`by this permit is commenced within six mgnths after'issuance. All work authorized by this permit shall conform to the approved application and the�approved construction documents-for which this permit has been granted. Final Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zonmgi'by laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open,for public inspection for the entire duration of the Electrical work until the completion of the same. ` Dl- Service: The Certificate of Occupancy will not be issued until all applicable signatures bythe Bui ding and Fire Qffieials are provided on this^permit. Minimum of Five Call Inspections Required for All Construction Work - Rough: 1.Foundation or Footing 2.Sheathing Inspection. Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final: Work shall not proceed until the Inspector has approved the various stages of construction. "Pers s on ing with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department c : Building plans are to be available on site Final: ��� All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT _1114 141'1'_",�, Town of:Barnstable .:r • =ul B din - �'- 9 - , : f i. _" , P : .. .; . ,. ., .on�ob and thrs, , ., � .-:bc;�C� t �.r.... .•:�..,..,, .: ,,. �„ �.. ,. , t �>1'Iarrs�Must he i2etamed t T it d. Tfi t i rble:, r$ h Kea -, ,. : p r Z. ,.Ca.0 .., .,.it, s v's ->F � e-� ee `Pp� � � �,.. � f ... ,.,p. ._., Y i _ , r..k.. ..K 3 „ <.:.. 5.r i 7YIA,S37:.: .- ..3,,; ✓, .,✓ In tion.-Has�Been. ade.,. ,., _\ �., �. . .Posted Unt _as l sec �.N.l ,.�� z � :�-. , I � :: des . alda VshallsNot�be�Occu led ntr!a,Frnalrins eetron,kra�s teen me'de, - . -., , �Ilhere,a.Certrficate��o#&Qceu anC.�rsriRe. mire r eh�l�xr rag p, p 3 �, , - Applicant Name: DUNBAR, ELIZABETH B Permit iVo . 947-3060 Ap provals Date Issued:` 09/21%2017 CurrenbUse ruc e St tur P.ermit,Type:'.Building Sh Foundation. ed, Residential-.200 sf and under ,` "Expiration Date: 03/21/201$ Location: 18 HEMEON ROAD,HYANNIS J. Map/Lot 268-089 Zoning District: . RB Sheathing: Owner on Record: DUNBAR,ELIZABETH Bk. . .Contracor Name Framing:AN 1 Address: PO BOX 746 Cont actor License g 2 - �.; WEST HYANNISPORT,MA 02672 Est Protect Cost: $0.00 Chimney: Pe Description: 8x12 rm�itFee: $35.00 Insulation: t' FeeL P ai $35.00 Project Review Req: 8x12 o Final: 9/21/2017 z _k, Plumbing/Gas L Rough Plumbing: Buildin Official . g Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after:issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and the;approved construction documents4for�whicfthis permit has been granted:All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by laws and codes. Final Gas: �; This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. \ Electrical The Certificate of occupancy will not be issued until all a licable si natures the Suildin land Fire dificialsaare rovidetl on this ermit. p Y PP g byg P P Service: Minimum of Five Call-Inspections Required for All Construction Work 1.Foundation or Footing R Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation - 7..Final Inspection before Occupancy Low Voltage Final: Where.applicable,separate permits are required for Electrical,Plumbing,and Mechanical installations. Health Work shall.not,proceed until the Inspector.has approved the Various stages of.construction - ,. Feria . . .-. ::. . ._ �� .... . 1. , - 2 , - . Pers9ns contra Ln wrth;,unre I teredycontractors;do.not,6ve..access tQ,#he'guaranty fund (as,setforth In.IVIG'L`c:142A)>--,_- . . �- g .. . . . g .. i .._ ..,. Fme':.Depai lment .. - -: Building plans are to be available on site Final: :'.:All Permit:Cards are the property of the APPLICANT=ISSUED RECIPIENT JZJ -7 Town of Barnstable - Regulatory Services /to f"'p=_L_ Thoums F.Gam,Nr+eenr Building Division Tom Perry,Building Commtsswner 2M Main Stmet, Hymmak MA MMI www.town barn#able ma= . 508-8624038 Fax 309-7304M 30Le 0 . - Fes.$ - SHED RBGL9nunON 200 square feet or,less Lwatim of shed(address)Liza)Km z Property owner's name Telone mmiber -71 sheofShed Map/Par�t# W - _5 CD Y Daft �-- M- Hyamms Maier Shvd Wacerfivnt Hubmc Dmft2 t<t £+ Old Sing's Highway Ebtwic District Commission ju dsdicop? If over 120 square feet,you must file with Old Mug's Highway Conservation Coam"an(sig s� aired) Sign off hours for Conservatln 8: O`9:30&3:30-4:30. PLEASE NOTE: IF YOU ARE WITTY TEM JURISDICTION OF ANY OF TBE ABOVE COA'IlVIISSIONS,MMM MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE TBE APPROPRIATE CON MIISSION FOR DBTAIM e TMS FORM MUST BE ACCOWAN ED BY A PLOT P) Al 'fl 9j •Q-forrm-shedreg REV:05201 326 Yarmouth Rd. I Hyannis,MA 02601 1508 5007 I Fax 508.771.7070 1 hyannis@pineharbor com Schedule Date PINE,f I1 "f-,%R 259 Queen Anne Rd. I Harwich,MA 02645 1 508.430.2800 1 Fax 508.A30.1115 I info@pirieharimrcom WOOD PRODUCTS IAM.368.SHED I Customer Service1.866.SHEDKrr I wwrw.pinebarborcom Invoice# Sold By . Branch \ Date &Ok Name" Ema �Om+ pmffi - con 4ddress �� Ca \ 1coo � f� � Phone city M, State Zip Phone Size&.Style Foundation $pedal Instructions RE' . FloorIn Doors Windows - I Siding Trim Roof Shingles Cupola Cu la&Weathervane MAN G Other t/L.Jnt by4_s,$, i A� aN, N3 Sub Total � ft r� �. Tax ,r Installation Delivery , TOTAL ryl Deposit y y 'xg Check Cash Credit Card BALANCEy ❑ ❑ c 326 Yarmouth Rd. I Hyannis,MA 02601 1 508.771.5007 1 Fax 508.771.7070 1 hyannis@pineharbor.com Schedule Date PIMP, 1 1L�it1>Vit 259 Queen Anne Rd. I Harwich,MA 02645 1 508.430.2800 1 Fax 508.430.1115 1 info@pineharbor.com WOOD PRODUCTS 1.800.368.SHED I Customer Service1.866.SHEDKIT I www.pineharbor.com Invoice# Sold By 1 _. a ' _ Branch ��� , - �'' Date h� ti< '•�� �'-! Name +� ""+ _a ri�t Email a' '.y W Address £ {. i �._ .}1i I Phone City State Z ¢ � zip PhoneDESCRIPTION AMOUNT Size&Style Foundation ��'; ,- t1° Special Instructions <� A 1 Floor � �� Z�t.i �`t�.�. i"-,_{ Doors . Windows 4 LA k 14,"J � w Siding 4-r Trim .�C Roof Shingles Cupola&Weathervane �••• i t Other 01 C1 Sub Total ' j Tax Installation Delivery . TOTAL } Deposit t_- Check Cash Credit Card BALANCE r �rw4 ❑ ❑ LEFT GABLE RIGHT GABLE s FRONT BACK •If you change,postpone or cancel a delivery we require at least a 5 day notice prior to installation. •Finance charges will apply on overdue invoices at 1.5%per month,18%annum. •By executing this Contract,Buyer acknowledges that Buyer is exclusively responsible for obtaining all permits,including any required by the building and conservation departments,to allow for the installation of the shed. Buyer further agrees to hold Pine Harbor Wood Products harmless and indemnify them against any and all liability with regard to said permits.Further,Buyer shall be solely responsible for determining any front,rear or sideline setbacks applicable to the property on which the shed shall be placed. Customer Signature Date By signing this agreement the customer acknowledges having read and understands the terms and conditions of this agreement. IN8G058501E 9G.22' O C] Q— 0° p O 0 / — Ou�rn> W0 Ai l p - o /No. 18 p i STY. n WD. FRM. 71 i i % 03 Fn O o O O 0 0 � o _ - �l z o APN 2 G8 089 (� Ui Q rn 1 4,5 1 0±5F 70 O _ 86. 13' 58504513011W CURRENT OWNER: PRANCI5 J. 5HEA, JR., EXECUTOR LEGAL REF.: BOOK 1 1439 PAGE 2G I I hereby certify to Mortgage Master, Inc.,Elizabeth B. Dunbar that to the best of my knowledge and in my professional opinion, the structures as shown hereon were in conformance with local horizontal set-back requirements when constructed, or are now exempt from set-back requirements per mgl Title VII Ch. 40A, Section 7; that the structure is not located in a Special Flood Hazard Zone a-s shown on F.E.M.A. Community Panel number 250001-0008-D, dated JULY 02, 1992. This plan is NOT the result of an on-the-ground instrument survey; is NOT to be Used to determine property line locations; is NOT valid without an --01'15inal signature; is NOT to be used for construction of any kind. MORTGAGE LOAN INSPECTION JOB No.: 09168 I N DATE: 285EP09 BARNSTABLE MA55ACNUHTT5 SCALE: I" = 30'_ PREPARED FOR DUBIN � REARDON r.j. hood * son, Inc. land surveyors - engineers 18 route GA, sandwich, ma 025G3 Ph: (508) 888-1090 Fax: (508) 833-8212 ' ?l7 f l? �pTME 1 'Town of Barnstable *Perm,9 w �V Regulatory Services fee'G,nnuths i�fnr is�uraj V 1 VV BARNSTABLE, y MASS. � Richard V.Scali,Director �p i63q. �� rF039. Building Division Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS�PERMIT APPLICATION - RESIDENTIAL ONLY �� —Not Valid without Red X-Press Imprint Map/parcel Number�� , �/ � Property Address /$ Ne-im mac)r) f rt e _(,.14Y_a_17_y_LSLp C)Jr�I—M—n o Z4G'(Z Residential Value of Work$44 a —___ Minimum fee of$35.00 for work under$6000.00 Owner's Name& Address E a k ei _ Vi� l8 Hem n ay nn i por±, MA oz67r� `_ c ears Contractor's Namt;;... Qrs T" VVICTIAIP ' elephone Numbe ',1S 3 y Z Home Improvement Contractor License#(if applicable) 14.8 9 O1 Email y�CU 83 l@ L7wlO��t 1 `Co N'. Construction Supervisor's License#(if applicable)_ XWorkman's Compensation Insurance Check one: JUL Q 52017 ❑ I am a sole proprietor I am the Homeowner y'OINN O� HARNSTABLE l have Worker's Compensation Insurance 9 !�J! 1`! I` f1® Insurance Company Name ACea A wie r ( e a n 7 ns u ra ki C eCo.. Workman's Comp. Policy# W L R C 4_8 G 0�1 Z4-1 Copy of Insurance Compliance Certificate must accompany each permit. Pen-nit Request(check.box) AJA — ❑ Re-root(hurricane nailed)(stripping old shingles) Ali construction debris will be taken to 14 At — ❑.Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) AJ A — ❑ Re-side Replacement Window. door sliders. U-Value (maximum .32)#of windows #of doors: *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation;etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License& Construction Supervisors License is re fired. SIGNATURE: �,r,5A.q.+ C::\Users\decolIik\AppData\Local\Microsoft\WindowsUNetCache\Content.OUtlook\L7UCi9LF21ExPIZESS(2).doc 01/25/17 i FtME l� BARNSfABLE, 9 MASS Town of Barnstable QjA i63q. aim rfD MA'S Regulatory Services Richard V. Scali,Director Building Division Paul Roma Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder �VLIn IJQ V— as Owner of the subject property hereby- authoriz f�i I WI (�t7OS �C C— to act on my behalf, Sears PA aZVI in all matters relative to work authorized by this building permit application for: ia Heme- on (Address of Job) Al 4' aa�O.d (cfYiTaC _ e320017 Signature of Owner UDate �D- Print Na If Property Owner is applying for permit,please complete the Homeowners License Exemption,Form on the reverse side. C\Users\decollik\AtipDataALocal\Microsoft\Windows\INetCacheAContent.Outlook\I.,7U69LF2\EXP,RESS(2).doc 01/25/17 I , The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 021.14-2017 wM 0`'es www.mass.govldia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING Au'r1-IORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):Sears Home Improvement Products Incorporated Address: 1024 Florida Central Parkway City/State/Zip: Longwood, FL 32750 Phone #: 860-753-0452 Are you an employer?Check the appropriate box: Type of project(required): I.®I am a empto)eer with employees(full and/or part-time).* 7. ❑New construction 2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.®I am a homeowner doing all work myself.[No workers'comp. insurance required.]' ❑4.E]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 1 I ❑ Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.®I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs "These sub-contractors have employees and have workers'comp.insurance. 6.®We are a corporation and its officers have exercised their right ofexemption per MGL C. 14.X 0ther10,_-% 152.§1(4),and we have no employees.[No workers'comp.insurance required.] .1 Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicatine 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. /am an emplover that is providing workers'compensation insurance for my emplovees. Below is the policy and job site information. Insurance Company Name: Ace American Insurance Company / Phone : 866-283-7122 Policy#or Self-ins. Lic. #: WLRC48609247 Expiration Date: 08/01/2017 n Job Site Address:1 W eo n ay City/State/Zip a"n I5 OY�Mry 0Z67Z Attach a copy of the workers' compensation policy declaratio paging the policy nulniber and expiration date). Failure to secure coverage as required under MGL c. 152,525A is a criminal violation punishable by 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. /do hereby ceru un er the pain and penalties of perjury that the in formation provided above is true and correct. Si nature S f en+ Date_ l.me_ 30. Z01- _ • Phone.#: 0-753-0452 Official use only. Do not write in this area,to be completed by city or town official. City or Town:_ Permit/Lice rise Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: RESET FORM i CERTIFICATE OF LIABILITY INSURANCE DATEO(M$/2016YYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT N Aon Risk Services Central, Inc. NAME: Chicago IL Office A/CN No.Ext:HOE (866) 283-7122 FAX (800) 363-0105 m 200 East Randolph E-MAIL o Chicago IL 60601 USA ADDRESS: _ INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: ACE American Insurance Company 22667 Sears Home Improvement Products Inc. INSURERB: ACE Fire Underwriters Insurance Co. 20702 1024 Florida Central Parkway Longwood FL 32750 USA INSURER C: INSURER D: INSURER E: . INSURER F: COVERAGES CERTIFICATE NUMBER: 570063227480 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED,HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as requested NSR TYPE OF INSURANCE ADD SUBR POLICY NUMBER POLICY EFF POLICY EXP LTR INSD WVD MM/DD/YYYY MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY HDOG27853717 08/01/2016 08 Ol 2017 EACH OCCURRENCE $S,000,000 CLAIMS-MADE X❑OCCUR DAMAGE TO RENT ED $S,OOO,OOO PREMISES(Ea occurrence MED EXP(Any one person) Excluded PERSONAL B ADV INJURY $S,000,000 0 GEN•L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $5,000,000 N X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG S5,000,000 OTHER: o 0 n A AUTOMOBILE LIABILITY ISA H0904419A 08/01/2016 08/01/2017 COMBINED SINGLE LIMIT $5,000,000 A ISA H09044188 08/01/2016 08/01/2017 Ea accident _ A ANYAUTO ISA H09044176 08/01/2016 08/01/2017 BODILY INJURY(Per person) Z X OWNED SCHEDULED BODILY INJURY(Per accident) q1 AUTOS ONLY AUTOS PROPERTY DAMAGE N X HIRED AUTOS X NON-OWNED U ONLY AUTOS ONLY Per accident N UMBRELLALIAB HOCCUR EACH OCCURRENCE U EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION A WORKERS COMPENSATION AND wcuc486092S9 08/01/2016 08/01/2017 X PER STATUTE OTH- EMPLOYERS'LIABILITY Y/N OH, WA, WV _ ER (� ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $2,000,000 A OFFICER/MEMBER EXCLUDED? N/A WLRC48609247 08/01/2016 08/01/2017 (Mandatory in NH) �JI All other States E.L.DISEASE-EA EMPLOYEE $2,000,000 Jf yes,describe under oESCRIPTION OF OPERATIONS belowI E.L.DISEA3 0LiCY LIMIT $2,000,00c J-q- DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OI' THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ~ EXPIRATION DATE THEREOF, NOTICE_ WILL. BE DELIVERED IN ACCORDANCE WITH THE JL•^ POLICY PROVISIONS. da Sears Home Improvement Products AUTHORIZED REPRESENTATIVE 1024 Florida Central Parkway Longwood FL 32750 USA ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000034159 LOC#: A ADDITIONAL REMARKS SCHEDULE �---'' Page _ of _ AGENCY NAMED INSURED < Aon Risk services Central , Inc. Sears Home Improvement Products Inc. POLICY NUMBER See Certificate Number: S70063227480 1 'CARRIER NAIC CODE s See Certificate Number,: 570063227480 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance INSURER(S) AFFORDING COVERAGE NAIC# INSURER INSURER INSURER INSURER " ADDITIONAL POLICIES I(a policy below does not include limit information.refer,to the corresponding policy on the ACORD certificate form for policy limits. INSR AUUL SUBR POLICY NUMBER POLICY POLICY LIMITS LTR TYPE OF INSURANCE INSO WVU EFFF.CI'IVF. EXPIRATION ON DATE UA"I'E WORKERS COMPENSATION B N/A SCFC48609260 08/01/2016 08/01/2017 WI r I . i ACORD 101(2008/01) ©2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD i __........ i r Office of C o.nst:imer nfi rs 6n.d Blasiness Regulation 10 Park Plaza - Suite 51.70 Boston, :Ma.ssa.ch.usetts 021. 16 IIo�Tae Irnl auvemen:l t_'ontractor Registration Registration: 148607 Type: Supplement Card Expiration: 1 011 11201 7 SEARS HOME IMPROVEMENT PRODUuTx LUBOS SVEC 1024 FLORIDA CENTRAL PKWY LONGWOOD, FL 32750 Update Address and return earn Mark reason for cflAnlgn. En r°;f Address Renewal I"Im xloyntent t,ost Card � tAlic of(:onsumer a.lfairs� Business Regulation 1�eeu5e or't tf r trzttkara stand for intlivrdat<ai'nSe uralk c HOME IMPROVEMENT CONTRACTOR before the etlau<ation due, If found<return to: r Office ofCousurner Affair-s and Business Regulation "F Registration: 143507� Type: 10 Palk Plaza-Suite 51,70 Expiration 10/111201.7 Supplement Carer Boston,A4A 02116 SPARS HOME IMPROVEMENT PRODUCTS INC. I LOIBOS SVEC 1024 FLORIDA CENTRAL_PKWY �.. .. ..-_ LONGWOOD,Ft_32750 _ . Undersicretan� Not valid without si�uafur'e 't I dl;assachusetts Cepar went of Public Safety Board of Butl.d ng Regulations nt1 Standards License: CS-097519 LOBOS SUEC $27 THOMPSON ROAD THOMPSON CT 06277t Corrt'missroner 08/31I2018 3 i 4 Job:22308636 Page 1 of 6 II11111111III III Office Location: HARTFORD Proposal Date 06/20/2017 JJobNumber 22308636 Sears Home Improvement Products,Inc. Customer Name 59eaarrs P.0 BOX 522290 ELIZABETH B DUNBAR 1024 FLORIDA CENTRAL PARKWAY Customer's Home Phone Customer's Work Phone t.ONGWOOD,FL 32750-7579 (774) 454-2098 Home Improvement Products PHONE(800)469-4663 Street Address Contractor License/Registration Number 18 HEMEON WAY ESTIMATE AND PROPOSAL City State JZip Code WEST HYANNISPORT MA 02672 Is installation within city limits? Installation Address County BARNSTABLE (Yes/No): YES Billing Address(if different from above) City State Zip Code Project Consultant Name&License No.(if applicable) GIL RABINOVSKY Description of the Project and Description of the Significant Materials to be Used and Equipment to be installed Interior Products / Exterior Products Home Warranty ❑Vinyl Siding ❑Roofing ❑1VAC ❑Kitchen Remodeling ❑Countertop ❑Whole House ❑Coating ❑Windows ❑Attic Insulation ❑Cabinet Refacing ❑Flooring ❑System ❑Painting ❑✓Doors ❑Garage Doors ❑Bathroom ❑Appliance SPECIAL INSTRUCTIONS: PLEASE KEEP DOORS CLOSE CATS IN THE HOUSE MOLD REMEDIATION: This Estimate and Proposal assumes that no mold remediation will be needed during installation work. If, upon inspection by the contractor or others, it is learned that mold remediation is necessary then Customer must arrange and pay for such remediation by a qualified person prior to the start or continuation of work. If Customer fails to arrange for necessary mold remediation within thirty(30)days, Sears may cancel this contract upon written notice to Customer. ASBESTOS ABATEMENT: This Estimate and Proposal assumes that there are no asbestos containing materials ("ACMs") that would be disturbed in the performance of the installation work. If upon further inspection by the contractor or others it is learned that ACMs have to be disturbed to perform work,then Customer must arrange and pay for abatement of asbestos by a qualified person prior to the start or continuation of work. If Customer fails to arrange for necessary asbestos abatement within thirty(30)days,Sears may cancel this contract upon written notice to Customer. The TOTAL PRICE including all labor,material,taxes and any applicable discount is$ 4,988.83 Contract Price $4,988.83 Initial Payment(not to exceed 30%of Total Price unless Special Order)$ 1,500.00 State Sales Tax $ 0.00 Final Payment(balance payable upon completion of job)$ 3,488.83 Local Sales Tax $ 0.00 The Initial Payment is due prior to Sears ordering products. Total Amount Due $4,988.83 Financing: The form and method by which the Customer(s) will pay is described in a separate Cash/Credit Card Payment Addendum made a part of and incorporated into this contract by reference. All of the above check boxes(and associated Product Addendum(s)),"Work NOT to be done:","Additional work to be done:","Special Instructions:", "Mold Remediation","Asbestos Abatement,"and"Financing:"sections have been reviewed by and explained to me. Product Addendum(s)is/are made a part of and incorporated into this contract by reference. Customer(s)initials NOTICE TO BUYER: YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD(3) BUSINESS DAY, FIVE (5) BUSINESS DAYS IN MARYLAND, (FIVE (5) BUSINESS DAYS IN ALASKA, SEVEN (7) BUSINESS DAYS IN MARYLAND, FIFTEEN(15) BUSINESS DAYS IN NORTH DAKOTA IF YOU ARE 65 OR OLDER) AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT, SKI-(Dig.) Rev 08/01/16 Job:22308636 Page 2 of 6 STATE NOTIFICATIONS NOTICE TO MASSACHUSETTS RESIDENTS ONLY In addition to the Notice to Buyer shown above, Massachusetts law requires that contracts for home improvement work state that all home improvement contractors and subcontractors shall be registered and that any inquiries about a contractor or subcontractor relating to a registration should be directed to'. Office of Consumer Affairs and Business Regulation Ten Park Plaza, Suite 5170 Boston, MA. 02116 _ w Telephone: (617) 973-8700 Please note that owners who secure their own construction-related permits or deal with unregistered contractors shall be excluded from access to the Guarantee Fund. Notwithstanding any other language in the contract or associated documents, Sears will not remove, replace, or install any heating or air conditioning system, or any portion thereof, if asbestos or asbestos-containingmaterial is known or like) .to be resent in that heating or air conditioning system, Y p 9 9 Y or any portion thereof. If it is determined or reasonably,suspected that asbestos is present, either before commencement or during performance of the work, it shall be the customer's responsibility to select, retain and pay all costs of a Division of Occupational Safety("DOS") licensed Asbestos Contractor to remove all asbestos or verify that none is present in the components involved in the job. If the determination or reasonable suspicion of the presence of asbestos arises after Sears has started the work, Sears will immediately cease performing the work until a DOS licensed Asbestos Contractor, hired by the customer, removes all asbestos from the components scheduled for repair or replacement in accordance with 310 C.M.R. 7.00 and 453 C.M.R. 6.00 or verifi es that none is present. By signing the contract the customer agrees that it understands the above. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES i Job:22308636 Page 3 of 6 Door Addendum Consultation Info Lead Number: 22308636 Date: 06/20/2017 Sales Rep: GIL RABINOVSKY Customer Name: ELIZABETH B DUNBAR Phone: 7744542098 Address: 18 HEMEON WAY City: WEST HYANNISPORT $tat@; MA Z i p c 0 e: 026 22 Descriptionof • and Desc riptionof • to •- Used and Equipment to •' Installed The work to be done under this contract includes the following: 1. Remove existing door(s)to be replaced. (PLEASE NOTE: The removed door(s) are likely to be damaged.) 2. Prepare openings as necessary to receive door. (No finish work other than normal installation is to be done unless otherwise noted below.) 3. Installation includes the clean-up of all job-related debris upon completion of the job. 4. Install the products as described in Addendum. PLEASE NOTE: Contractor is not liable for the condition of operation of rehung storm doors. APPROXIMATE START DATE and APPROXIMATE COMPLETION DATE: The work will start approximately TBD (Approximate Start Date) It will be substantially completed by approximately TBD (Approximate Completion Date) These dates are subject to change at the time the contract is accepted by Sears Home Improvement Products, Inc.("Sears")or at any other y time by mutual written agreement.Customer understands that the Approximate Start Date is only an estimated date and the Customer will be contacted prior to this date to schedule the actual start date. The TOTAL PRICE including all labor,material, taxes and any discount is $ 4,988.83 Contract Price $ 4,988.83 Initial Payment(not to exceed 30%of Total Price unless Special Order) $ 1'500.°° State Sales Tax ( 0.0 0 %)$ 0.00 Final Payment(balance payable upon completion of job) $ 3,488.83 Local Sales Tax ( 0.00 %)$ 0.00 The Initial Payment is due prior to Sears ordering products. Total Amount Due $ 4,988.83 Additional work to be done: R & D OLD STORM DOOR Work NOT to be done: Removal or moving or any walls; flooring, painting, wallpaper work; repairs of water or termite damage to sub-floors or walls; electrical or plumbing work outside of this kitchen or bath project. NOT DOING ANY ATHER DOORS AND WINDOWS Job:22308636 Page 4 of 6 SEARS'LIMITED WARRANTY ON INSTALLATION In addition to any manufacturer warranty extended to you on the product(s)used(which warranty becomes effective the date the merchandise is installed),if the workmanship(or application)of any Sears'arranged installation proves faulty within one year after the completion of installation, then upon notice from you Sears will cause such faults to be corrected by repair at no additional cost to you. If Sears determines that repair is not commercially practicable or cannot be timely made,then,at Sears'sole discretion,Sears may elect to provide replacement or refund.Service under this Limited Warranty is available by calling Sears Home Improvement Products at 1-800-222-5030,Option 4.This warranty gives you specific legal rights,and you may also have other rights that vary from State to State. ti Job:22308636 Page 5 of 6 1024 Florida Central Pkwy ORDER: 223086360001 Longwood, FL ORDER DATE: 6/20/2017 EST. DELIVERY DATE: 7/3/2017 ORDER CONTACT: Gil Rabinsysky DOOR ORDER ADDENDUM INVOICE INFORMATION SHIPPING INFORMATION (HARTFORD] SHIP VIA: 22308636000 6/20/2017 E 22308636 0 F ' 1 1 2 Panel 3/4 Oval Elite Smooth Door 1 y 3068 PAINT INSIDE AND OUTSIDE DIFFERENT COLORS COLOR INSIDE=[White] COLOR OUTSIDE=[Black] HANDING(OSLI){INSWING RIGHT HANDED} NON-DECORATIVE GLASS OPTIONS NO GRIDS CLEAR NO GRIDS(PRIVACY 1) BRIGHT BRASS GEORGIAN KNOB BOTH SIDES SINGLE KEYED DEADBOLT STANDARD HINGE MATCH HARDWARE FINISH DOOR FRAME=[4 9/161 THRESHOLD=[MILL] 2 INCH BRICKMOULD MATCH FRAME FINISH COLONIAL 2 1/2 IN. (356)=[POPLAR] MATCH DOOR FINISH ACTUAL DOOR SIZE=[37 11/16 X 82 11/16) BM TO BM ACTUAL SIZE=[40 3/16 X 83 7/8] I RABBET OPENING=[36 3/16 X 81 15/16] ROUGH OPENING=[38 7/16 X 83 7/161 2 Easy Vent Retractable Screen Storm Door 1 36 X 81 . WHITE CLEAR/CLEAR BRIGHT BRASS EXPANDER MATCHES HARDWARE i TOTALS: 2. vSUBTOTAL: TOTAL: COMMENT: Job:22308636 Page 6 of 6 IIIII II II"II III Job Number: 22308636 . NOTICE TO BUYER 1. DO NOT SIGN THE AGREEMENT IF ANY OF THE SPACES INTENDED FOR THE AGREED TERMS TO THE EXTENT OF THEAVAILABLE INFORMATION ARE LEFT BLANK. 2. YOU ARE ENTITLED TO A COPY OF THIS AGREEMENT AT THE TIME YOU SIGN IT.KEEP IT TO PROTECT YOUR LEGAL RIGHTS. 3. YOU MAY PAY OFF THE FULL UNPAID BALANCE DUE UNDER THE AGREEMENT AT ANY TIME,AND IN SO DOING YOU SHALL BE ENTITLED TO A FULL REBATE OF THE UNEARNED FINANCE AND INSURANCE CHARGES 4. YOU MAY CANCEL THIS TRANSACTION,WITHOUT ANY PENALTY OR OBLIGATION,WITHIN THREE(3)BUSINESS DAYS,FIVE(5)BUSINESS DAYS IN MARYLAND, (FIVE (5) BUSINESS DAYS IN ALASKA, SEVEN (7)BUSINESS DAYS IN MARYLAND, FIFTEEN(15)BUSINESS DAYS IN NORTH DAKOTA IF YOU ARE 65 OR OLDER)FROM THE ABOVE DATE. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. FAILURE TO EXERCISE THIS OPTION, HOWEVER, WILL NOT INTERFERE WITH ANY OTHER REMEDIES AGAINST THE RETAIL SELLER YOU MAY POSSESS. IF YOU WISH,YOU MAY USE THIS PAGE AS NOTIFICATION BY WRITING"I HEREBY RESCIND"ANDADDING YOUR NAMEANDADDRESS.A DUPLICATEOFTHIS RECEIPT IS PROVIDED BYTHE SELLERFORYOUR RECORDS. 5. IT SHALL NOT BE LEGAL FOR THE SELLER TO ENTER YOUR PREMISES UNLAWFULLY OR COMMIT ANY BREACH OF THE PEACE TO REPOSSESS GOODS PURCHASED UNDER THIS AGREEMENT. ADDITIONAL PROVISIONS Proposal and Approval.Sears offers to furnish the materials and arrange for their delivery and installation as specified on the first page and/or the attached sketches and specification sheets for the TOTAL PRICE shown. This offer must be approved by the Installation Department. If this is a credit sale or a payment on completion sale, it must be approved by the Credit Sales Department. If this proposal is not approved or the installation cannot be made in accordance with the law,this offer will be withdrawn and any payments you have made will be refunded to you. Any materials left over after the installation has been completed are Sears property and will be removed by Sears. Installation. I understand that Sears will not install the materials but will arrange for the installation. Sears is not responsible for materials or installation NOT furnished or arranged by Sears. Sears' installation contractor(s)will obtain all building permits required by local law. For homes located in historic or landmark zoning districts, Customer will be responsible for obtaining required approvals and related permits prior to the commencement of work on this contract. Authorization. I authorize Sears to: (1) arrange for a contractor (licensed where required by law) to make the installation of materials; (2) issue a work order for this installation to a contractor; (3) inspect the installation; and (4)pay the contractor when the installation is complete if I have signed a certificate that the installation has been completed to my satisfaction. Delays in Installation. I agree that Sears is not responsible for delays in delivery or installation due to weather,fire,strikes, war, government regulations or any causes beyond Sears'control. Oral Agreements and Changes in Contract. I understand that there are no oral agreements between Sears and me. Everything I expect Sears to do has been included in writing in this contract. Nothing can be changed in this contract unless it is in writing on a separate form accepted by me and Sears. Responsibility of Buyer. I agree that any information or measurements that I give to Sears are correct and complete. I am responsible for any special work described in this contract. Electrical & Plumbing Service. I will provide adequate electrical and/or plumbing service(s) to run any newly installed appliances or other furnishings. If the electrical and/or plumbing service(s) do not meet the standards of the utility company or electrical and/or plumbing codes, I will make the necessary changes at my expense unless Sears has agreed in this contract to make the changes. Payment.Twill pay Sears the cash price that covers the price of material and installation as shown on the first page. Warranty Information_Appropriate product warranty documents will be given to me by Sears. h� �( M14Q9t� 06/20/2017 06/20/2017 EiiZAeEiv B OVRe+R Customer's signature Date Customer's signature Date � Accepted by Sears Home Improvement Products, Inc.("Sears")on 06/20/2017 by: Date Management Representative SK1-(Dig.)Rev 08/01/16 T _.. ----- .. _ . - -= _- Let me know if the information provided below is not sufficient enough, thanks. RPM �w.Color'RdI;"17. - 1 1.5.,ill , .7S -iq t cy it•I Mob*it+i G lemfilar I huS OW 111-lLimbwrn Deaiubolt QI fql r L 3amt )1J i 7,7 r u iWWcl,_!PAW talk l ao.1-10 5c o j.l ie Dc I Cladding 66,00 33 to bh - - - _h8fh Et nae 111+e ) r_dr_ 27.0U 7 6` antF ;yl':e as. er. )isciun t. 5cf ' ' lLfl-rie Dih._QU11 tea,46 7S 51 Pr•oduct optrons - s Entry Do,Viidei mil! :'2.':i;WWfr?i-);-dt't=N:idy r,,1J4t sr iC§ Ll tEe1 lab .. Egon^e wyciec Ri.lik Er: me 055e r.rIN Bass Lifetime F'W Fir'rm �c}:Set ,''1./Gi crgia,':Kn6L,t'•r.I"t Sleet- ?"hialnhf'ur De-aclbdt. P;0 t-'e_epsite SC.CBQ We C_,r,;,Irt i Prcxla:rr_t6an(c�niplet;e I t nergy P, rfornian-c Ratings- U-r-n.ct_rt.-0.L p OWE Tra t rS11ItIi7(ry 41 _ Ensly Star Ad Rega,,s ywMes Br Zo i_, 0 Tax dt: YES g d ti . TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 6� Parcel O" Application # 2oI 1 Health Division Date Issued ZJ , Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _Preservation/ Hyannis Project Street Address I hnEDAI 4D, Village wrvr JiANU15 Rogr Owner r_a.1Z_1qt�1J IDWE49 Address PD. BOX '7Y6 id7 dyAiyW5YW Telephone )h l -q: q—mg g Permit Request �'}d 2T1110AI 12 OF 58-50IF/E ARFA , 10P9W IQO/ 106110 E paL4 W&IS 4- DRYW AIC , I DOOK TD tANVIAM60 APFA : I DooR FDA Nwy. POM 110k o,W1 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Construction Type w v Lot Size 33 A Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 6 Two Family ❑ Multi-Family (# units) // Age of Existing Structure i� yam, Historic House: ❑Yes C/No On Old King's Highway: ❑ ®Yes No ®Basement Type: Full 0 Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) 00 CNe�� Basement Unfinished Area(sq.ft) 600 Number of Baths: Full: existing a1 new Half: existing new Number of Bedrooms: a existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: I,VN s ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes o Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: ._-; Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ ' Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name MM VOILLMEZ Telephone Number Address ®� ��k 6�1 License# CS y66 a L w , M A , C)a.6 KS- Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 9p,wi-t-A m `r2a 1,F-C--R SIGNATURE V4,14 V& DATE 60/0 ► FOR OFFICIAL USE ONLY APPLICATION# DATE,ISSUED MAP/PARCEL NO. ADDRESS VILLAGE r OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION f 1 FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING P" • DATE CLOSED OUT- - f' ASSOCIATION PLAN NO. f__ I y u The Commonwealth of Massachusetts I Department of Industrial Accidents Office of Investigations t1 _fit i 600 Washington Street Boston, MA 02111 r www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Con.tractors/Electricians/Plumbers Applicant Information Please Print Les;ibly Name (Business/Organization/Individual): MARK IIauME�R Address: ���• �D�C �� City/State/Zip: dMIT AIA , W695' Phone #: JW_W_51 q Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction ,/employees(full and/or part-time).* have hired the sub-contractors 2.LJ I am a sole proprietor or partner- listed on the attached sheet. t . ❑ Remodeling 11 These sub-contractors have 8. ❑ Demolition ship and have no employees working for me in any capacity. workers' comp, insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs insurance required.].t employees. [No workers' 13.0 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. tContractors that check this box,must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I arm an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the.form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Y I do hereby certify under/the ains and penalties of perjury that the information provided above is true and correct. Signature: 041/v V 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 Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual,partnership,association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL'chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or.permit to operate a business or to construct buildings in the commonwealth for any Applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter.152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)naine(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,:please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of.Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant . that must submit multiple permit/license applications in.any given year, need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town).'.'A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The-Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street r Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-977-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia n 'THETA. Town of Barnstable Regulatory Services uttxsrAs[.s, Thomas F. Geiler,Director Eo► '`�� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.6s Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I'. , as Owner of the subject property hereby authorize llAR.l� to act on my behalf, is all matters relative to work authorized by this building permit application for. OA (Address of Jo — �o Sign _ of Owner Date L- IzA8 7�4 LJ�6IgP Pnnt Name .If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FO RMS.0 PAWERPERMISSION of Yt+e Town of Barnstable • H ray � - �� o Regulatory Services sr" t Thomas F. Geiler, Director BAmLF- Building Division PrED raj� Tom Perry, Building Commissioner , 200 Maili.Street, Hyannis,MA 02601 ww w.town.barnstable_ma.us ' Office: 508-962-403 8 Fax: 508-790-6230 HOMF-OWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village" "HOMEOWNER": name home phone# work phone# CURRENT MAfLING ADDRESS: city/town state zip code Tj1 e current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess.a lic*&9se,�p16vidt d_bet the owner acts as supervisor_ DEFT IMON OF HOMEONWER " Persons) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who contras more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. `The tmdersigned"homeowner"certifies that.be/she understands the Town of Barnstable Building Department mimmum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building.Code Section 127.0 Construction Control. HOMEO WNER'S EXEMPTION The Code states that"Any homeowner performing work far which a building perrnit is required shall be exempt from the provisions Of this section,(Seetion 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a parson(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they an:assurning the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awarrness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a. licensed Supervisar. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a formlccrtifi cation for use in your community. Q:fot7ru:homccxcmpt SMOKE DETECTORS REVIEI�/ED LIBIOTH NST BLE BUILDING DEPT. DATE FIRE DEPARTMENT DATE IGNATURES ARE REQUIRED FOR PERMITTING 6'4 finished area a 3 i Unfinished Area L SVA/�-. Mechanichal 1 v M r ls'-3h' c IMPORTANT \ ANY CONSTRUCTION THAT INCREASES LIVIN SPACE BEYOND 1200 So. FT. PER LEVEL MA REQUIRE INSTALLATION OF ADDITIONAL SMOKI DE ECTORSE NOTE: A SEPARATE PERMIT IS REQUIRED FOR THE INSTALLATION OF SMOKE DETECTORS-THE ELECTRICAL 6'-4 PERMIT DOES NOT SATISFY THIS REQUIREMENT. . y I Q L-J LnJa., L_J _J L-J L_J b ro m.w�ccu�a R mm "la N FOUNDATION PLAN - - sue.v,•_,'-0- . .corcrwcus mq vcxr - - v 1 w . esrwur eoor ymc�y �� vz"Y6et1fIV2.b ReRMS AT W S �>: ATTIC BATH e.. MTCMEN :DMMG ROOq W can.sa+n wnJ BEDROOM BEDROOM nn,mn a..w.rz an+. �,K o LMNG QOM .„ BEDROOM BEDROOM T^ o � GROSS SECTION fn� d� FIRST FLOOR PLAN Public Health Division c Town of Barnstable 4 H Box 534 I t Hyannis, Massaro � Q .. .. rrTl LLLJ00 IN Z;0 5N oa o.� . FRONT ELEVATION LEFT 51DE ELEVATION z s JaI 4 rV—�1 w w ® ® ® 9 ® 0 0 w REAR ELEVATION RIGHT SIDE ELEVATION ewc v. .ro• - C==7 r--ti C==7 L_J a m mw. s _ FOUNDATION PLAN v.'. -0' O� A ROOTDD�JMCl£5/ .y,R yy I r BATH ATTIC LLKITCHEN .' DMMG ROOtj u. „e..w. v.eeeru».nw L----- rtcr. AT BEDROOM BEDROOM "fO•"<' ,.<.,eu y MASTER LNMGjRPOM `s�-„ - .BEDROOM LBEV) ROOM E—' � W 7 ^ � gapLLI z w $m GRO55 5EGTION FIR5T FLOOR PLAN Public Health Division Towne ofBamsMIe P0.Box 534 Hyannis$ Massachuft �-vim TOWN OF BARNSTABLE CERTIFICATE OF OCCUPANCY PARCEL ID 268 089 GEOBASE ID 1.7101 ADDRESS 3.8 HEMEON ROAD PHONE (508)775-6150 HYANNIS ZIP - LOT BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT HY PERMIT 30894 DESCRIPTION BUILDING PERMIT #24620 PERMIT. TYPE BCOO TITLE CERTIFICATE OF OCCUPANCY CONTRACTORS: Department of Health, Safety ARCHITECTS: and Environmental Services TOTAL FEES: BONSTRUCTION COSTS OND $C .00 �TNE Qi► 753 MISC. NOT CODED ELSEWHERE ; * RAR MBM + MAM 039. A� Ep�l BUILDI VI ON BY DATE ISSUED 05/13/1998 EXPIRATION DATE -- - --- -- - - - - - - ----------------------- -------- TOWN OF BARNSTABLE .;� BUILDING PERMIT. ' PARCI.,L' .ID '268 089 GEOFASE ID " 17101 ADDRESS 18HEMEON-:ROAD =` .. y , PHONE ,.(50B)775-(31 Hyakrals ZIP 02160-- ,'LOT BLOCK. LOT,'SIZE _ DBA " DEVELOPMENT DISTRICT HY PERMIT 24620 , DESCRIPTION. SINGLE FAMILY DWELLING (SEW.PMT.087--512 PERMIT TYPE BUILD TITLE NEW RESIDENTIAL BLDG PMT. £WNTRACTORS: PIRES, DONALD J w Department of Health, Safety ARCHITECTS; and Environmental Services T&AL EiL`S; 205.62 BOND ` . $.0c3 Tt1E ti CONSTRUCTION COSTS 466,330:00 101 • SING.LE PAY HOME 'DETACHED 1 PRIVATE; P14). .� * BARNS�PpAQBLE, •' . MAW. OWNER w PIRES, NALD. W ,� �1639. ADDRESS 15 CA��'§OtN" LANE MARSTONS MILLS, MA BY DATE ISSUED 07/24/1997 EXPIRATION DATE THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY. EN- CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OFTHIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND 'WHERE APPLICABLE, SEPARATE 1.FOUNDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION PERMITS ARE REQUIRED FOR 2. PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU- ELECTRICAL,PLUMBING AND MECH- (READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ANICAL INSTALLATIONS. 3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. 4.FINAL INSPECTION BEFORE OCCUPANCY. ' 11 BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS LOA fib� L) 1 -� �7 APB 2 2 �, .,,� lam, • � 3 1 EATING INSPECTION APPROVALS ENGINEERING DEPARTMENT 2 8 g BOARD OF HEALTH OTHER: �� SITE PLAN REVIEW APPROVAL WORK SHALL NOT PROCEED UNTIL PERMIT WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS. TELEPHONE OR WRITTEN NOTIFICA- TION. NOTED ABOVE. TION. 3nddV 38V SONISM MAI 7 'Q39WOld UNV 83WWIHS 38V SSWdr I t UOP894dS wojj sqwor s -nes)l ode 1 DING 2 a3., w I "Engineering Dept.Ord floor) Map Parcel / ��f �� Permit# ?V&42 r House# ''tr"VS, Date Issued and of Health(3rd floor)-(8:15 - 9:30/1:00-4:30) /ge k�n s•(,Z Conservation Office(4th floor)(8:30'- 9:30/1:00-2. 00) 5 n(- F&fMSTEM MUST BE Planning Dept.(1st floor/School Admin. Bldg.) D IN ' 1ANCE (;Ject* e Plan Ann roved by Planning Board 19 ONME AND � J� 6 �e'-,),Z t TOWN R S TOWN OF BARNSTABLE Building PermitApplic t'on tree Address Village S X— A1- m Owner _ L c S Address Telephone "77r (olS-D t Permit Request /mEf,,/ First Floor l�® square feet Second Floor are feet Construction Type 9-1 Estimated Project Cost $ 6� e�3o ZoningDistrict ,�� Flood Plain � Water Protection Lot Size G Grandfathered es ❑No Dwelling Type: Single Family Two Fa mil ❑ Multi-Family(#units) yO< Fou a Age of Existing Structure�j� } �istoric House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: ull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing �� New No. of Bedrooms: Existing New Total Room Count(not including baths): Existing New First Floor Room Count --A Heat Type and Fuel: ras ❑Oil ❑Electric ❑Other Central Air ❑Yes &rKo Fireplaces: Existing New --'-----ixisting wood/coal stove ❑Yes Er Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) 2 one ❑Shed(size). • ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ { Commercial ❑Yes fa'No_ If yes, site plan review# - Current Use Proposed Use �Jr^ Builder Information �^ Name1,111VN-6 I /� Telephone Number �J Address /� �?� � Z41LI License# 6!Zq 3F3 of-rc'tT Z?�C�S, &A Z 90 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 SIGNATURE DATE— BUILDING PERMIT D IED FOR E FOLLOWING REASON(S) t FOR OFFICIAL USE ONLY - 'PERMIT NO. el DATE ISSUED - �^ MAP/PARCEL NO. f* •�" '. ^. ADDRESS VILLAGE >` OWNER DATE OF INSPECTION: FOUNDATION FRAME i INSULATION ✓ y� r N C . , FIREPLACE , ELECTRICAL: ;-ROUGH ' FINAL i d.V PLUMBING: 'a SRO%t!:, FINAL GAS: " H FINAL r FINAL BUIL f DATE CLOSED D:VT ASSOCIATION PLAN NO, ", lil: Del arts ent of IndustrialAccidents Ma 011 11 ashing;tnn Street ovii workers, Compensation insurance A>Tdavit c�t�Piic•i`t informatirin= -- Please PRiNT'le�+ jv . name, C n cin. nhnnc'd 7 1 am a homeowner performing all work myself. I am a volt proprietor and have no one tivori:in__ in amp capacity I am an employer providing workers• compensation form}•employees work-in; on this job. enmimni• nnmr• atlrlrccc• • cite•• nhnnc!!• incur-vnre rn Holier!! am sole proprietor. et!neral contractor, or homeowner(circle one) and have hired the contractors listed beiow who the following workers olices. = rl.ers compensation p cnmmim• n-tine- :ttitlrrcc- cin•• nhnnc�• wmrnncr rn Holier cnnm.inc• n-itnr- addrrcc• -ire• phone p• nsurattre rn Holier•if lttachadditi0naisheetifnecessarv•. $.:_'i-� �_• , -r:-:••�Z-- •,••• ••• •• ••• �• �•:•••••�•,��+n ... �._ r...• rilurc to;eeurr cocr ce sa sts required under section 3A of A1GL 152 can lead to the imposition of criminal penalties of a line up to SIS00.u0 andiur nc c cars imprisonment ns cs•cil as cisil penalties in the form of a STOP WORK ORDER and a fine ofS100.00 a day against me. I understand that a opt of this atasemcnt mar be furirarded to the olfce of Investigations of the DIA for coverage verification. do herchr cc • •ruiner /e p1 'is aitd penalties of perjury Mar the infornsarion pros7ded above is rme�and correm ^aturc `, Date l ""��`—�� 'riRl RaIRC J c. S Prone 0 l�rLV official use unls do not write in this area to be completed by city or tons.official ciri•or town: lot -nitilicense d rilluilding Department ❑l.fcensing Board . 0 check if immediate response is required QSeleetmen's OfQcr C311calth Department contact pera=rt: phone tt: M01her�_ Information and Instructions Vassauhu.setts General Uws chapter 152 section '5 requires all employers to provide workers' compCtisatiUt employees. As quoted from the "taw".an empluree is defined as every person in the scr%,ice 6i'410111cr undr: contract of hire, express or implied. oral or written. An emplurer is defined as an individual. partnership, association. corporation or other legal entity. or an/ two • •• representatives of a descried employer. or • includtns, the-legal re assert ., .. ., rise.and P . fife Cort.�otn�cn�a`s.d to a joint enterprise. _ P reccivar_or trustee of an individual . partnership. association or other legal entity, employing employees. Ho« owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of dwelling house of another who employs persons to do maintenance, construction or repair work on such dwel' or nn the;,_rounds or building appurtenant thereto shall not because of such employment be deemed to be ame MGL cltater 152 section =5 also states that et•en•state or local licensing agency shall withhold the issuanc renewal cif a license or permit to operate a business or to construct buildings in the commonwealth for st applicant who has not Produced acceptable fn•idence of compliance with the insurance coverabe requires Additionally. neither the commonwealth nor any of its political subdivisions shall enter into any contract for th performance of public work until acceptable evidence of compliance with the insurance requirements of this ch. been presented to the contracting authority- ll A > )li ca nt s Please 611 in the workers' compensation affidavit completely, by checking the box that applies to your.situatior supplying company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance covemae. Also be sure to sibs and date the affidavit. Ti) affidavit should be,retunied 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 "saw'or if you are -e: to obtain a workers' compensation policy- please call the Department at the number listed below. City ar Towns Pie--se be sure that the affidavit is complete and printed legibly. Tile Department has provided a space at the boa tite affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant be sure to fill in the perm it/license number which will be used as a reference number. The affidavits may be retu the Department by mail or FAX unless other arrangements have been made. The Office of would like to thank you in advance for you cooperation and should you have any qu Investigations please do not hesitate to,__ive us a c:11_ 7777 Tile Department's address. telephone and fax number. _ The Commonwealth Of Massachusetts Department of Industrial Accidents ... office of lnves99ations 600 Washington Street Boston,Ma. 02111 fax #: (617) 727-7749 .�s CAN R -9 It b0 b O y 00 =3 Uyd CA >ZS O 41 [n 1b , .. C y ,. t✓� O _ ' y m N W �'17 • , C7 r� N L- H h0 tm y. N N " � .�:'h:,��i.;Yb'�"Ndfiar?t7e'�_;$6Mro•' Y:��. .a .,.,•. _ .. . I 78.10 80.1l0 LOT 32A �� 0 LOT 0 r10 3 . _ 5¢ s 32B 9 S .9 r 3 Q` vi o 0 0 0 -4a 80.00 go.00 HEMEON ROAD Z0 A/C 2;C3 _ DLO OD FOUNDATLON CERTZFSCATION TO W N 3112AJ.s TA 64-E PLAN REF. DATE /o//3/8 7 SCALE `=3a E.L SVAT I ON I HEREBY CFRTIFY THAT THE AOOVE FOUNDATION IS LOCATED ON \�N OF dfq yQ[�j,LEE '9� Su.RVE L3 THE GROUND AS SHOWN, AND �P' ss9� PAuu �� dorlGuLTd-ylTS ITS P05ITION DOES CONFORM TO THE ZONING i l rr,''7PgMEW N ?�l*RASP9ERR Lam. LAW SETBACK REQUIREMENT OF 1xt�RSToN S MILLS MA PAUL A. MERITHE.w R•P.L.S. /5¢6