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0021 MEGAN ROAD
a� r /oFLN.i, Town of Barnstable _ �� TPerritti� -- 4Y AiS �q _ `\�T ;0*�� �`'4/•/ _ -' hu;il2� F. Cc3!er, Dir eci-or Building Div-Iislon Tc< a Pcrry, CDO, B;ti1dir,a CemlriissiQner _U+i %tail S `.eC q C PRESS i' t{11Il'A.PPLIC'A 'T0\ - R-E IDENT- i-L of L`x Xor Yal;t!!:r7:.c;ttR�tf,-?.ess fr,:�r�l .�Gi•nerGG� �lilii!��r .A.c d res. L_ Me ✓V 11t, N n S e;ILI_.:' V?,_ c 7rV Ci,( �-_f- - 1?3iitl cr's Nary e t oriiiraCGr s Nan eTmJJ e���i�- �l i� (7N IL7&6 _Te S� f[_9 5 -n j�:tGA� °llT1 �r� / V9�2 erne I; prov�7 eni i_..-_CaCi'r (i7 a-,I iC2:v.v)— 7 Y0 /2 6 SD_ C';�,.tml rion uperY;sJf'_ !Cel5 fi.'?r i'.•20iZ�— -- i /:•>'':�.vlildI'.•.S Ci!?Ce: i.^!3 ;S:i;?:3Ce s s -- _ %;i? SOie�rCDF Cl^r /V 2 v 20, J I have, VvorCe .,. C or?epnsatic„ ira :ra, e W/Vo 8 +=ri '0f AIt$ULdIICC CGTr^1'JiZCC CPL?E:C2ie muss acco 11nany e ch pe l-nit i a.tq: Jst'check, boy. `-rOG? ilu"ricane naitea) $L t ctr IiC i?ei'ri$ Wlti i `17Uin. Qi0 s'iingie_cj (CU7 I L'C pB iEaerl i0 ?e-:�;}r th rr, Inc ;i 1ilfSd� ;101 i[iirrQ;n�" v:iPl� OVe; vl$i!P.� :?,yPrc Qi r00i`� _J rQtcoxs (G i3 vreieni /Md, wVs doors,''$i:C i J-V2i!i �i 3�. ?iZ2Xim + 1>j iP 3I w1;ndo'ISS `y.%j„• y^U tiC'u: (S�J3n��Oi LC:;�ii D:ii..a CX"T•0:::0 f;2r�i8.,.._ .�.f;�� ,;C(P,:�;l.'vo L._iiG�S,Lam. �351�Ca', .,7RSC(1'flid0`!,cif,. vl','rer L_aer ui'l'errlissi, 2, ....�'p'.E:: i CI':r ���....;...- .T.i iiSI ii�rt >'i i7 e^;�: " rr CQoy OI i.i 2:1')1 C T7, r 'G'r'c e11 L4..3 rj to F !CE nse c CcnstrLlc ior, uperyiso S iICCl1Se 1 required. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations -t n 600 Washington ISireet Boston, MA 02111 www.mass gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AAppul�icant Information Please Prinf Le jbly NaMe (Business/Orgairization/Individual): 0 Address eof r City/State/Zip: 64-[n, - 3c)-;J4 Phone#: 91-7D ' 15"7— 57' g.P` Are you an employer? Check the Appropriate bo . Type of project(required): LJWI am a employer with 4. I am a general contractor and I 5. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition workingfor in an capacity. employees and have workers' Y P ty 9. ❑Building addition [No workers' comp.insurance camp• insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.[] I am a homeowner doing all work officers have exercised their 11.0 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 trust also fill out the section below showing their workers'.compensation policy information. t Homedwners who submit this affidavit indicating they are doing all work and then hire outside.contractors must submit-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 isproviding workers compensation insurance for my employees. Below Is thepolky and job site -: information. Insurance Company Name: Jaw S o . •." Policy#or Self-ins.Lic.MWC, 00736916 Expiration Date: 3 Job Site Address: 1 ± City/State/Zip: /7Z471WV15 _ Oak 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 under pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#• orcial 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#:� ` 4�f�Q ,. t9ffiee of Consumer Affairs for Business�e��}atime� Registration: Type Re s Expiration,� _4f3/1012 Supplement C The home Depot PAC_ arri®Sp-Mces DARREN 2694 CUMSERt A 90 P RKWA`f S A NIrA, GA 30339 . Underseeretarg License or registration valid for iudividul Use uolY before the expiration date. If found return to:Office of Consumer Affairs and Business Regulation to Park Pizza-Suite 5170 ,ard Boston,MA 021.16 Not valid without signature Pp- i f 1U04 v a z' b r'�v:r ::...;;....:.:.:...... . . . . . . . . . . . . . ...:. .........:.....:.:.:....::..........: :.:.:.:.: >::;::`::::: Is sUE DATE --- :.:<::< >::>:>::>:><: >:>:>> WA: t`gT '... ... ... ..:.:::...::.:..:...::.::.................. llrlor�oll .......... ::.:;::.:;.:::.:.:::.:::.:::.::...:::.:::.:::.:::.::.::::.::...... . . ........ ........................ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORISED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu Of such endorsement(s). PRODUCER CONTACT NAME: BRYDEN&SULLIVAN INS AG PHONE FAX 88 FALMOUTH ROAD AaG No,Ed): A!G No): HYANNIS,MA 02601 EMAIL ADDRE88: PRODUCER CUSTOMER IDIl: IN INS S AFFORDING COVERAGE NAIC# TORRES,ERICSSON DBA INSURER A TRAVELERS PROPERTY CASUALTY ERICSSON HOME IMPROVEMENT COMPANY OF AMEiiICA 16 HOOVER ROAD INSURER B WEST YARMOUTH,MA 02673 INSURER C INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HERE N IS SUBJECT T 0 ALL THE TERMS, EXICLUSIONS AND CONDITIONS OF SUCH P OLICDES.LIMIT S SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADIU I SUBR POLICY NUMBER POLICY EFF POLICY EXP LOUTS LTR INSR WVD D D GENERAL LIABILITY EKcaoccIIaaEReEI $ DAMAGEI0MIND $ 0 COMMESCIALGIUMALLTABILITY PSMM MS(EmL oGawnwo EMEMMSE(Amyom $ 0 CLKDIBMADE 0 CCCIIR VONOM PELSWALaa ADV. $ 0 DUOKY GM113ALAGGREGAIE $ D GMrLAGGIMP61EIJWIAPPLIFBPEL' • pEDDIICI9•COMP00F $ ❑ Y D PB1 z l D I= K'r AUTOMOBILE LIABILITY COPS $ LZM<I E kacciia BDDOI.YDTIU&Y $ 0 ARYAIIIO �:R>ro BD07IIynmmY $ D ALLOWN XU108 Pai Ka6laY ncPFAIYDAEfA 11 $ 0 9CHMDUI.FDAU1OS Pocacciia D RMIMAIII08 D WN-OWMAIIIOS D EACEOCCUSIME $ 0 III®3FLK11AB D OCCUL AGCAEGAIE $ 0 E3CE88LTAB 0 CLKMS-MADE 0 DMDTJCIMZ 0 BFIENIEVI WC WORKERS'COMPENSATION NrA SIAIIIIOB-Y A AND EMPLOYERS LIABILITY Lnutt YIN ANYPE7PRDIIC3RAB.INFBI EL.EACEACCIDMil $100,000 EXDCIIIIVE00'xELz0M& Y N/A 7PJUB-4433P248 11/09/11 11/09/12 EYCLUEMDT - EL.ffi9fAIz-vxR $500,000 (MABDATORY IITRE) EMPLOYEE Itya,,ao«za.�:DICIDIMITOF EL.DI8EA8E-POLICY $10.1000 LIMIT OpF8AIE7N8lobw McR=OE OF OPIRATIOMILOCA710B8AMCIM(MULACOYD101.Adaiti=1314 *Sa1•aab,Fmom'Peao s m0ma) IBM WCO:MS CO mMIAT101T P=YD0E8 BOI PBDVSF COVEDZE ICLI=SON TCERES DBAFP,IC 8809 W3211MOVEEtFbTI IBEDISUI.PO8MAWDI,I wCCwv0L13CvPOLMYABDIfSLmIEDOIBMLSIAIESDTSRBAECEmmmjmaNzAIIIEDIT"SIBMPAYMElTIOOTBFlTFI'II1MLCLJkM9MKDMBYI1MnT9nFD' EM)IC1MSUTSIAIESOIBMS.IEADTMA.IMAIIIBD8IZA1IO9ISGr"t0PAYCLKDMP0&BmMffI8D8ABYSIAIE01ME IEAEMAIFIBMDISURFDBIKE&CILRKS—MEMPIAII'FL80III TM1 R01,ACD MY PRIOR CEQTII4C ATE IS8UI9T0 TI E CERTDHC AT'IR0L—MM AFFECTING WORSTRS C 0 R C0V=GI qj •: ?:::::::::::::•:;::;:::::•:;:•:::: ;::•:;?: :;>:;;;::;:•:::::::::•:; C$R IFiC,A1 ;Hf la$tt' t :::.:`. .. :::: THD-AT-HOME SERVICES INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED ATTN:INSTALLER RELATIONS DEPT BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED 2690 CUMBERLAND PKWY SUITE300 IN ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 A7TlDORZrD2MWMITAIIUK BrtaW Ma&eaw / S •traBtriGtaOtt®:.Va.a• • • . . . •t:itent of Public Safet% j 1A- lvfosontj�'oa1Y' •� d°lBEZEL :►ssachusctt.- Delta: RF. Roof Covcdng tLuions and Standards B t' tl'tt Rt t 'n•t :1' t tl t Sid: .Windo�4s»nil g Licen se sa • -Ws Supervisor Specialty vices Gonstructton Supe P Y SF- Solid BurncuB'De License: CS'SL 1wi4 DM-BemolttlOnOnly Restricted W. WS Failure to possess a current edition of the ERICSSON:•TO RRES Massachusetts State Building Code . , is cause for revocation Of"this license. "16 HOOV E) ROAD Refer to: ov/DP S� y .V . WES7YARMOUTH,MA 02673 � Expiration: iebD12 ('nnlml�tjon r Tra: 1O 0 i License or rogistratton valid for individul use only � • ,� oIDceotCoarnmaAtt+los&B es�BegulsKon - •before the expiration date. 1f found return to: ofac E rcoaover (joUTRACTt1R Office of Consumer Affairs and Business Regulation tiegietrattoe• 4-ts352t1' TYpa 10 Park Plaza-Suite 5170 _ ExpiMOonc '*;xk13 DeA Boston,MA 02116 !� SSOW HO e t �,Pa-11 : � t=; i gy ERICSSQN TOR r WEST YARMOIlTH.'Ntl4tF Osdenscretaq Not valid without signature HOME nomovlldl'IENT CONTRACT PUKA.SM BEA0 THIS-. coid,FurisbLd and Installed by. '1"Hl)At-'Rome Services,Inc: Brash Name: Boston Da j dtb/a The Home Depot At-Home Servit-xs —/- 909 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Fret:(800)657-5182;Fax(508),W-6017 Broach Number 3X Fcdend ID#75-2698460;ME Lie#C 02439,RI Cont.Uc#16427. #H1C.0565522;MA Honle bup/r7ovetnettt Contractor 1(eg ti.126893 installation Addre ` p��: R lit gAy! city State Zip Pur er(s): WtxikPlwux: How Phone, (:dl Photo' [ J � 1 [ 1 [ l 1 l Home Adttress: cif, State Zap + ,J (If different from Installation Address) E-mail Addrekti(it)receive pmjctt-t communications and Home Depot updates): P ❑.I DO NOT wish to receive any marketing cmarrls fiom The Home Depot reev to hu Project Information: Undersigned(-Customer),the owners of the property located at the above installation address,ag Y. and THD nt-Home Services,Inc.(`:`The Home Depot')agrees to famish,deliver and arrange for the installation("lrastsllation")of all materia:s describcAi on ale below and on the nfercncod Spec:Sheei(s),all of which are incorporated into this Contract by.thiS reftvcnec,.:lung with any applicable State Supplement and payment Summary attached hereto and any Change Ordc s(collectively, "Contract'): Job#;:P e...:a e.rrr<M.) P utcts S Sbeet s # Pro Let Amount W OD 1 Roofing Siding Windows insulation $ .`� ' / �C)J i�� ❑cuu�.r�/comer,.prnt=y T ❑ �]Roolinf'_. Siding Windows insulation � DUutters/Covers DEntry Doors ❑ Rtxtfin Siding Windows Insulation ['jCiutrea�/Covers ❑Entry Doors❑ 'I�Kuutic:U Siding Window% ' Tnwlati' $ ©Gutters/Covets ❑>.ntry Doors 0 Nunimunt25%I>r,xnifofCtr,tract.arnazttitdiMevpodexeai6on4otdi'coatrat. Total ContractAtnount $ 1�itine Yu.islusels nc,y n,A d.yxr it.uwre thm one4 grd of ft Contract ArntMuaL Cusigmei'.::grccs ijat,';n;i,,t di::tel.y upo(i.completion of the work for each Product,Customer Will execulca Con.3pletion.6".liticatt;_. . (one for.e ch Product,lue:t a d.i i ned by an individual Spec Shect)and pay any balance due. As applicable,each Cit:tcmiimer.under.This Contmct.ai;rccs to tx:joiiuly and severally obligattx}and liable hereunder_ The Nome.Deliitt r 5cr.;,the,ight to issue a Change Order or terminate this Cohtrrlct or any individual Product(s).included herein,at CLu!11 if"11,c i iome 1),-poi or its authorized scrvlw provider determinec that u cannot perform its obligations due to a sttvcMal its disci s or because. :problern w:q,tlxe hu,ne,cnvirouuncntal haGards such as mold,asbestos Or lead paint other safety conceals.pricing trrur. , wt#requit 4y?*complete the job was not included in the Con tract- Summary tt J� ' included as part of this Contract, sets font the total EotrtTa t;+i ux:i;<:n;1{':Y c.nt,r(cluired for doe deposits and final payments by Product(as applicable). NOTICE TO.CUSTOMER You a.re c�.titi-1 to a Chet plc.tcly rilled-ire cirpy of the Contractat the time you sigh. Do not sign a CotnpletAon Ccttificate(note, . there is n„t•Cuinl;lt•tivn('rrtif,cate for each listed Product as deftned by indivi"Spec Sheets)before work on that Product is compici e. In the ecc;tt ut t,rn:;,,:,601; :if,his Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses and scrvic.�s pro,idml 1,.° ':'a Houle Depot or Authorized Service Provider through the date of termination,plus any other atnouni-s,.t forth.in(i,i,Al OTJT recnx:nt or allowed under appGcabk'1aw. TIM HOME DEPOT MAY WITHHOLD AMOUNTS OWED 'l.) °I'ttt_: 5it�ntl:: tDILPQ'r FROM THE DEPOSIT PA'YMMT OR OTHER PAYMENTS MADE, LINEMIN(:7'II?•:I IOaIF.IDl'1'OT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Accept!40w__,;,.i :d:::?g:r:..::!;:.::: Customer ag,tccs and understands-that this Agreement is the entire agreement between Customer an 'rhe lf„u,c U,.pot\Viiii-3:11d to die Products and Tnstallation serviccS and supersedes all prior discussions and agreements,either oral or mvrmeu,rc htin,,�to ti i;i 1'r(xiucts and installation.This Agreement cannot be assigned or amended except by a writing signed by Custi,ut.:r:,:,! ;1,, 1 i.>tnc; .'c ix,L GlsWnu:r acknowledges and agrees that Customer has read.undtxstands,voluntarily accepts the terms of Fit'..1 ha,s::sic:,f a io;» c&this A,iooncnt. Accepted t:, l �u�bby: t o,,, :;i ,, ,,,,<: I}arc S0ltaut's S" amre Daze Telephone No. C ocr; +ace I):,tc Sales ConsnitazltLiccnseNo. (as applirahlc) MAY CANCEL TFUS AGREh:�i.{!�"l' <<I"ilttii'=':' ^ttAl:tY OR OBLIGATION BY DLI,I`.'iti Ni. 's=;;.'..'; r4(o't`lcr. l'J THE HOME DEPOT by 1'11UN1(AIT ON TnE 1111RD BU.SINF.SS DAY A),i'I K tilC:tits;(: 'I'I11S AGR1iEMFNT. THE STATE A'1`l�A01E D HERETO CONT ,_ ; tq>,cNt 3'U USE ]E ONE IS SPECIFICALLb' 1"ltI•:SCRIREP IlY LAW IN CUS1`(;tI;;1t'S I'X1I- : :,1,1,1e10:NA CON wrIONSA-RESTATEDONTHEREVERSE$MEANDAREPA,RTOF-THI$CONTRACT 03-30.12 ;; C, ld;die-Branch File Yellow-Custtinivi' pp6wp[; WOa� ..,_i 1 ': -; ,.; -aril T2-FEE BOG: 'ON WJ ' Y °FjME T Town of Barnstable *Permit# k �4/ Expires 6 mo thsfro tissue date °s Regulatory Services Fee Thomas F. Geiler,Director MASS, SS 9�A 039• ♦m � �T Building Division TEn �a UN 17 2008 Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 TOWN OF BARNSTABLE www.town.bamstable.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 i Me 0t_jq �� �� t ter, S Residential Value of Work G Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address_ Y\i", S I9 Qct h 2C Contractor's Name Hb(ll,e )-e p* T 1-6m e S'.zr y;Cz T Telephone Number Home Improvement Contractor License#(if applicable) / 7 .J ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's /Compensation Insurance � Insurance Company Name t 6/L �° ,TA �l S C6 Workman's Comp. Policy# ' / D Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side 3 Replacement Windows/doors/sliders. U-Value V ' �� (maximum .44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATURE: C, G Q:\WPFILES\FORMS\building permit forms\EXP SS.doc Revise020108 ACORDTM CERTIFICATE OF LIABILITY INSURANCE D 04/18/ATE(MMIDDIYYYY) 08 PRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A MA'i�R QF INFORMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON fPjE CERTIFICATE HOLDER. THIS CERTIFICATE DOES O'T t(As"-qD, EXTEND OR homedeiedmont Rd NE, Suireh 200 ALTER THE COVERAGE AFFORDED I Y THE POLICIES BELOW. 3475 Piedmont Rd NE, Suites 1200. .._._� Atlanta, GA 30305 Fax (212) 948-0902 INSURERS AFFORDING COVERAGE I NAIC## _ INSURED INSURERA:Steadfast Ins Co Home Depot U.S.A., Inc. — 26387 d/b/a The Home Depot INSURERB:Illinois Natl Ins Cc 23817 2455 Paces Ferry Road American Home Assur Cc _ - INSURER C: Building C-8 19380 Atlanta, GA 30339 INSURERD:New Hampshire Ins Co 23841 INSURER E:Illinois union Ins Co 27960 �_� COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NO rWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.. INSR DD' POLICYEFFECTIVE POLICY EXPATE IRATION DIYYI LIMITS LTR N POLICY NUMBER A GENERAL LIABILITY IPR 3757 608-02 03/01/08 03/O1/09 EACH OCCURRENCE g'i,U00,000 I X COMMERCIAL GENERAL LIABILITY LIMITS OF POLICY ARE EXC SS 6Af�A TToIYEF)T-€� -� PREMISES TaoccurenceJ g1,000,000 X❑ "OF SIR: $1,000,000 PER CC" CLAIMS MADE OCCUR LIED EXP(Any ono peson) $EXCLUDED -.- I PERSONAL&ALYV:NJURY '• 000,000 - GENE-RALAGGREGArE $•I,000,000 I--------- -- GEN'L AGGREGATE LIMIT APPLIES PER: �PR!>DUCrs-CGMP/OP.t6G I$4,000,000 ' X oOLICY PRO- LOC AUTOMOBILE LIABILITY - — "-"--'-"'--" ANY AUTO I COMBINED SINGI.E LIMIT � (Ea accldeW) I$ ALLOWNEDAUTOS I Y I SCHEDULED AUTOS BODIL Y INJUF.Y(Per person) _ HIRED AUTOS BODILY INJURY -�NON-OWNEDAUT'OS (Peraccidenq I$ IPROPERTYDAMAGE GARAGE LIABILITY — ! '- I i_--- �WTOONLY-i:AACCIUENT 5 ANYAUTO ; ------..-..---- -� OTHER THAN JEAMICIL...... AUTO ONLY: PGr' I$ 1--- _I ' EXCESSNMBRELLA LIABILITY $ i EACH OC_CUft,1F.N_CE OCCUR, CLAIMS MADE - - 11 --- ---_' GREGATF. �.__.-..-.S--— I I - -.I DEDUCTIBLE --- ----.._..,c_..------------- RETENTION $ B WORKERS COMPENSATION AND 1928757 (FL) —03/01/08 03/01/09 X WCSTATU-T C O;!'y EMPLOYERS'LIABILITY 19-RY.l-I A�1I;c' �� I -• _-y-_-- A-----�.��L• ---- -----._—_._. ANY PROPPIETOR/PARTNER/EXECUTIVE 1928756 (CA) 03/01/08 03/01/09 E.L_EACHACC6),�N;� Sa.`-00,900 D OFFICER/MEMBER EXCLUDED? 1928755(AOS) 03/01/08 03/01/09 ) FLL.DISEAST•CAh'PLOYE[If yes,describe under -_. _ _ _ SPECIAL.PROVISIONS below ISLih:YLlMII !$1,,OOU,Olif,• OTHER - - ��--.....__.._._.__ .. PTX Employers Excess TNS-C45197967 (TX) 03/01/0803/O1/09 Ocnurrence/sIR 25H/2M Workers Compensation 1928759 (QSI) 03/01/08 03/01/09Workers Compensation 1928158 (XY, MO_NY, WI) 03/01/08 03/01/09 RIPTION OFOPERATIONSILOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS --- CERTIFICATE HOLDER CANCELLATION i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXP IRA7 TOWN OF CHATHAM DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 U.SYS WR' NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE T"DU SO r 263. GEORGE RYDER ROAD - IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, TF.AGf / o REPRESENTATIVES. CHATHAM. MA 02633 AUTHORIZED REPRESENTATIVE _ USA ' ACORD 25(2001108)datkinson 8556605 ©ACORD CORi','0R/ I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information '(_ �p / Jn Please Print Le 1 NaMe(Business/organizarionfindividuan: / �� AAE D-t I 0 ( Iy' 1, 1`�•4 ti Address:_ Y p14C s r�e--r r,/ City/State/Zip: i--64-r� Cc, . �Qq Phone.#: Are you an employer? Check the appropriate bow Type of piroject(required): 4. I am a general contractor and I 1.�I am a employer with�_ � 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2.ElI am a-sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition loyees and have workers' working for me in any capacity. emp 9. ❑Building addition [No workers' comp.-insurance comp.insurance,$ • required.] 5. We.are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 LQ Plumbing repairs or additions myselL[No workers' comp. right df exemption per MGL 12.[]Roof repairs insurance required.]t e. 152, §1(4),and we have no .y 13.�Other employees. [No workers' comp,insurance required.] [nI E/l j d *Any applicant dat checl^r box#1 must also Moot the section below showing their workers'compens4on policy information. t Homeowners who subunit this affidavit indicating they am doing all work and dim hire outside contractors=A submit a new affidavit indicating such. =Corrtrectors that check this box nnrst attached an additional sheet showing the name of the sub-contractara and state whether or not tfiosd entities have =,ployees. If the subcontractors have errrploycm they must pumdt their workers'comp.policy nranber. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. A/ ` Insurance Company Name: /U w /�J � �Q lr Is C o z c Policy#or Self-ins.Lie.#: (7 o s5 Expiration Date: 3- — I Job Site Address: Ir +)--e- b Y City/State/74: 11 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to srcure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of erimirial penalties of a fine tip 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 thq violator. Be advised that a copy of this st =3it may be forwarded to the Office of Investigations of the bIA for insuremcr coverage verification. I do hereby cerCtifft under the pains-and penalties of perjury that the information provided above is true and correct Si e• "v l//�IL ��„ Date• Phone#` l� 1 2 % �a Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitlLicense# 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 wi&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)name(s),addresses)and phone number(s),along with their certificates)of insurance. Limited Liability Companies'(LLC)or Limited Liability Partnerships(LLP)with no employees other than the meunbers 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 Towu Officials Please be sure that the affidavit is complete and printed legibly. The Deparinomt has provided a space at the bottom of the affidavit fbr 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 mrnber which will be used as a reference number. In addition, an applicant that must submit multiple pmm it/license applications in any given year,need only submit onF 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 a ff davit 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 pem2its or licenses. A new affidavit must be filled out reach year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (ie.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit: The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Depaoment's address,tzlephone•and fax number. The Ummonwealth of Massachusetts Dgmtnent of Industrial Accidtrnts Office of Investigations 600 Washington Street Boston,MA 02111 Ter. #617-727-4900 ext 406 4r I 477 MASSAFE Revised 11-22-06 Fax#617-727-774R www.mass.gov/dia j If2� Tk 7,. .,la Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration _126893 Ex irat�on 873L2008 s Type Supplement Card d � • THE Home Depot;.At Home Servic FifARK NIADA 3200 COBB GALLEPIA PK1NYy#20 A ANTA, GA 30339 Administrator , I I valid for individul use only 1J License or registration j before the expiration date. If found return to: rd of Building Regulations and Standards Boa place Rm 1301 One Asbburt ' I ill 1 on 'i Boston .,I L 0A.-IL A Not valid with ut signature y i JI i I I K1 °FtHETp�� Town of Barnstable Regulatory Services �swxxS&st'Eg` Thomas F.Geiler,Director .9 i63 �� rFn� Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnsta ble.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder PC • q 141 , as Owner of the subject property hereby authorize ! "� to act on my behalf, in all.matters relative to work authorized by this building permit application for: (Address of Job) e C,,k Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Town of Barnstable �oFSHE Regulatory Services ` Thomas F.Geiler Director MAM saruyszwar.�, � � ��� Building Division PjED I��a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS- city/town state zip code The 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 license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)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 constructs 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 uermit. (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 undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum 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. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner perforating work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor.., Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness 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 Supervisor. The homeowner acting as Supervisor is uNmatcly 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 form/certification for use in your community. MAY-31-2008 18:35 HOME DEPOT HYANNIS P.005 y ! a mmaa•P/07 ....____ � - _ gOME"IlVIPROVtE�'I'CON•TRiACT 's -_ Sold,Furnished and Installed by: Branch i .me: .Date: �-31.=4�:' THD At-Homc Services,Inc. -d/b/a The:Home=Dcpot.At=Home Services ` 345A Greenwood-Street,Worcester,MA 01.607 Branch Nurriber MO:` � `'fib'#::.38'�3G.�a.;� ;;:•j,.:.._ Toll Free(800)657-5IS2•Fax:508-756-2859 Federal ID 4 75-2698460;Ml;Lic*RC 02439.IUZoat..Lic#16427 CT Lic#-565522; MA Homc Improvement Contractor acx,ir126893 Installation Address mM[- � CtWL N m�S YY1 A ttc c_;. S �J St lip :. ,.- :: Last4'Dipjts.of,1)rlverts: •...�'.,. : ''.. ... ' Purchascr(s)i.' ;,Lin#&.Ex .MolXr: ..Work Phone:.. dome Phone: Home•Addresis:• �� (Lfdiffeieatfrorriin allatiori'Address)..... r: ...city..'. Z'p . E=1nail Address(fo receive updates and promotions froro The Home Depot)` Project'information:. T/we7you("Purchas(x');the owners of the.property located at:.the above installation address,offs to contract with THD At-Home Services,:Inc_(Home•Depot")to-fumisb,deliver and arrange.for the installation of all materials as descubcd on the"attached Spec Sheet# O 1C 63tCC incorporated herein by refference'.andwadc.apart•hereof Home Depoc.reserves:tbe cight:to.•cancel this•contract.contract..if,'upon re-inspection of the job;Homc Depot determines that it cannot�perforinjts.obligations-due to..a.structara).,problew'wi'tlt the-borne;,pricinezrrors or-because work required to complete ioh waaMot,jicluded in the Spec Sheet or Contras:::.. 'DEPOSIT PAYMEN OP I fONS ... ... .... . .. .....•...,.:.:-. -:-. : �� ,' : :`:'.($abject.totundtrcrificationmd/orcreditaPProval'-).:. CONTRACTAMOUAIT' `$ '341 . 1,., Check!;,CasbimChmkorUSpwtalSetviceMonry,Order - - (Nude payable to Tho'Home Depop. t �S.DEPOSIT;:: $ _ 2, credit Card"and/oro her paymoni options•-Clydle Oae Rclow . . $ALANCE.D17)E (??' Visa M4wterCaid Discover Amen .ON COMPLETION -$ 'h The,HomcDcpotHomeImprovemcntLoanThellonteDepotCerditCani �Mitiimum25%'OfContrrict'Amaaatdue,upotl �1VewAccoenr .'QLx;stingAtrnuot, (lTtr&IIDCCOPIIX) &.UPCC ONL cxccotloa oYlhis contract Available-CreAtC$' (� ., Y) Indicate.Payment Method For .. Aeetll;(aQ35 Szot-853023,92-. Exp.Datr. BALANCE IDUE ON COMPLETION::"j Namo,u ii appe�on card' t nC �9 sae S_ By our signature below,I/We agree to.allow H e Depot c e above rcfere ced r d the deposit' dicated_ 'whctt;you provide a cbeck as paymrnt You authorize us either Da Idcr s Si to.tiac.infarmetion from your chock to mak'c-u oao-timc electrotnc fund trims cr from your.aceoud of.to procoss the payment as a . 'check•tronsutlion:•whan•wc'tiac informatiatt from.your cbcck.to kTIL Or 'utllot'ization Codes- . make aaeleetroaie flatdttnndct'faadsm�ybe witbdrawn..fram:... . your Accoum.m Teen as thc:paymont ia,ecciv°d,_and you willnot.. Ae Daft ... Final ravirtient mooivc your check t nck �$ -3•-60_ . Purchaser.agrres that,immediately;upon-completion'of the-work,Purebaser will execute a'Complction Certificate and pay any balance due: Purchaseralso agrmisto be joiMlyand sevcrtlly:obligated and'liablelterc,inder. :Entire:APrecment 1his;.agmementand;its,attacheseats,•,tndTudingaay,flnancflag:agd'�em..contain,tlie;CotYipleteagreemcnt. `tietwceu tlie:psttics and cannot lie auit:iulcd or modifed unY`ess'in writing 1n a separatea�cmcnt sighed by liotb parties: NOTICE TO PURCHASER . ","'Do-not signA.hisiontract.before ynu>read:k You,are•cntitled to.acompletcly-filled in:copy,•of the cootract,atthe time . Yon-sign. Keep,it.to protect:your.rights.!•,Do not sign a Completion Certificate before.this project is complete. Law prohibits;homampiir'i{orttr•actors,from:requcsting or accepting a Completion.Cerfd"icatc signed by the'owner prior to the actual comipletion of the work'to be perforuieil:underthe contract. You may cancel this transaction any-time•prior to midnight-of the-third.business day.after the date of this contract. See Notice:of Qmceliatios•for as explanation of this right There'will-be a.service charge.equal to 10%of the contract amount if job.is•caneclled'by Purchaser AFTER the third•business day;-but BEFORE.materials are ordered.There will be a service cLargc cqual,to•25%of the contract amount if job is.cancelled by Purchaser AFTER m aterials.are ordered. BY MY/OUR SIGNATURE BELOW.T/WE UNDERSTAND TRAT THE AGREEMENT MAY BE SUBJECT TO REVIEW OF..MYlOUR CREDIT HISTORY AND I/WEAUTROR ZE 130ME'DEPOT.TO VERIFY AND REVIEW'MY/OUR CREDIT'RECORD WITH AN:INDEPENDENT CREDIT REPORTING AGENCY AND RELEASE THEM FROM ALL -LIABILITY INCURRED FROMTNADVERTENT OMISSIONS OR ERRORS, BY MY/OUR'SIGNATURE BELOW,1/WE AGREE'TO BE BOUND BY,THE'TERMS.OF THIS CONTRACT. IIWE ACKNOWI:EDCrE'RECEIPT•OF A COPY OF-THIS CONTRACT AND TWO"COMPLETED'COPIES-OF THE NOTICE OF CANCELLATION. SUBMED BY:- Date: i iT ACCEPTED BY: Date: S�3/ O R*<cltycer- . :Date: I'urchascr - N CE:ADDPT'IONAL TERMS AND CONDITIONS ARE.STATED•ON THE REVERSE.SIDE AND-ARE PART-OF THISCONTRACi•. 9-21-07 rev 4-2-07",;CSC VJh1te—Branch Filo •Yellow;--Customer;:Pink�:Seles Consultant i TOTAL. P.onF n-i ...a.-.- - ° , .mow ,.R-`,-..t ,vsn-- �?'°Yu €.. e--° - :-4-`r t =- �� art "x4:=.r.. ;`r_.: f Y._- s- : - fie., �� `�qa r e �� Y rX€ _ n4 x = s s,a3 �e> -Itd> �vs ^.t '�`�,"�T`,,---'`'��"�c'e,e-i. .1 r •�,_ ,t,. ,!ke.n �o'�Or�=3 °�'.. u, � w,- ,fy. �C -� , 'r,� `-.�. k ;ei ��.��•5.,� .r ,A Yi Y- 3 sate'* . ' `@nn.-vim ``� -". -- .;r, :.` ..".; ,£ ,1'i -v ,k"� }- ,775 y - - -et.-..-, _ .. < - _- .. 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". 3� _ 4 -'S F +y - _ _ .. THE- TOWN OF 'BARNSTABLE NAM 11639. 0 M BUILDING INSPECTOR TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ....lle�......../YC)......... ...... Name of Owner .................................. Name of �� * ~' ....---------- ---'^ William E. Jr. v / 7A��� ` �~ �~�~` �zm� . ~ No Permit ~����. � v�^ .- -----.. . .... .~ -----.------. � ..................... ' » ' ^ Location it)A ..%eA--3�ed............................. � ............................. ...... Owner --___.Will .1��.. ............ � Type of Construction ---- _----_. ^x�/ ' ................................................. | �n \ Plot --------_. Lot ----.��*���--- ` � � MayI ' Permit Granted ---' ------'lP '~�9 � | ' ' \ / ! Dote of |n ..... ..._ lg | Date o| . . � PERMIT REFUSED . -----_--------------.. lq ` ' � .-------------------.------- \ � � ^-------....--.---------------. � � ' | � / '-----^--'-----------'—^---'—'' ( � } ` ` '--------------~--^^—^-----'' . . � ' . \ ` Approved ................................................ lQ ^ ' -------'-------'—'~'^------'-- / ----------------------'--'—''' | � . t. ISTMM TOWN OF BARNSTABLE -� i saa 1$q. �P MASSACHUSETTS Solid Fuel Stove Permit DATE OF APPLICATION .... .......T.. ........V�...1l..g-............... FIRE DEPT. ISSUING PERMIT ............................................................ L - ?9®°�q.13 NAME (owner) .q1v .. .A�...L&a.1h..s................... NAME (Installer) ...................................................................................................... ADDRESS .d/.../.1..1456. eV..4 .I-110/.l J_ ............ ADDRESS ........................................................................................................................... STOVE TYPE ... ......�rl".��� II�i. ............................... ................... CHIMNEY: NEW ........................ EXISTING ........................ ti Manufacturer .........:........................................................................................................... CHIMNEY: Masonry ............................................................................................. Mass. Approval ............................................................................................................... CHIMNEY: Metal ................................................................................................... This is to certify that the above installer has permission to install a solid fuel burning appliance at the listed address in accordance with an application on file with the ................................................................................................... Fire Department, and subject to the provisions of the Commonwealth of Massachusetts State Building Code and regulations made under the authority thereof. IssuedBy: ........................................ ..........Title ............................................... Date " Permit to install expires 60 days after issue --date Stove ............................................................................................................................................................................................................................................................................................................. StoveClearance .........................................................:........................................................................................................................................................................................................................ Floor ............................................................................................................................................................................................................................................................................................................. SmokePipe .............................................................................................................................................................................................................................................................................................. SmokePipe Clearance ...............................................................................................................................................................................................:................................................................ Chimney .................................................................................................................................................................................................................................................................................................... SmokeDetector .................................................................................................................................................................................................................................................................................. The undersigned hereby certifies that the installation of solid fuel burning stove and equipment made under au- thority of permit dated ...................................................... has been made in accordance with provisions of the Commonwealth of Massachusetts State Building Code now currently in effect and pertaining thereto ........................................................................ Installer INSTALLATIONAPPROVED ............................................................ By:.......................................................................................... Title: ................................................ date WHITE: FIRE DEPARTMENT — CANARY: BUILDING INSPECTOR — PINK: APPLICANT TOW ',OF BARNSTABLE -� 000 639 MASSACHUSETTS f D - 0 . �0 MAY M• / �� Solid Fuel Stove Permit DATE OF APPLICATION .. T�:.. '. ...�t FIRE DEPT. ISSUING PERMIT ......................... T��u .�/u.�r A,� �710 �9a NAME (owner) .*..y..................................................... .. ....... ......... ......... NAME (Installer) ..............:........................................:................................ y � � A'D ...DRESS .... ..................................... ..,...................... ............. ADDRESS ........................................:.....................................:.......:.................................... STOVETYPE ................................................................................................................. CHIMNEY: . NEW ..........:............. EXISTING ........................ r Manufacturer .........................................................:.......................................................... CHIMNEY: Masonry ............................................................................................. Mass. Approval ...............................................::..................................: CHIMNEY: Metal ................................................................................................... This is to certify that the above installer has permission to install a solid fuel burning .appliance at the listed address in accordance with an application on file .with the ......................................................:...........:...................:........:... Fire. Department, and-subject to the provisions of the Commonwealth of Massachusetts State Building Code and regulations made under the authority thereof. �. r v Issued By: ................................. Title ....:...............................:.............................................:. Date ........................:.....,..........: . .................................. Permit to install expires 60 days after issue date Y Stove ..................................:................................ e -:.......................................................... ! StoveClearance .. .... ......... ........................... ........................................................................... Floor ............................................................................................................................................:...............................:................................................................................................................................ SmokePipe ..................................................:.....................:...................................:....:............................................................................................................................................................................ SmokePipe Clearance ..........................................................................................................................:.................................................................................................................................... Chimney ............................................................................................................................................................................................................................ SmokeDetector ......................................................:::................................ ...........:.................: .............. .....................:.............................................................................................:.......... The undersigned hereby certifies that the installation of solid fuel burning stove and equipment made under au- thority of permit dated ...................................................... has been made in accordance With provisions of the Commonwealth of Massachusetts State Building Code now currently in effect and pertaining thereto ........................................................................ Installer INSTALLATION APPROVED .................. By:.......................................: ...... Title•. .....:.................................... ............................................. ................................................ date WHITE: FIRE DEPARTMENT —.CANARY: BUILDING INSPECTOR -PINK: APPLICANT ri a ��yofTxrro�`e� TOWN OF BARNSTABLE Z D11Dd9TL 'oo 139. MASSACHUSETTS f( 4 Solid Fuel Stove Permit DATE OF APPLICATION ...:.................................... ..' FIRE DEPT. ISSUING PERMIT ............................................................ ....................ry....p.......... NAME (owner) :., Jf?f/11....I.f............................................ ...........'........: NAME (Installer) ..........................................ADDRESS I T�"' 11J� tr L !11yVAN S ADDRESS ........................................................................................................................... STOVE TYPE ............. ........... ......... ........ ......... .... ..... ..... .... CHIMNEY NEW EXISTING Manufacturer .........................................................................................................:........... CHIMNEY: Masonry .............................................................................................. Mass. Approval ............................................................................................................... CHIMNEY: Metal ..............................................................:......................_............ This is to certify that the above installer has permission to install a solid fuel burning appliance at the listed address in accordance with an application on file with the ................................................................................................... Fire Department, and subject to the provisions of the Commonwealth of Massachusetts State Building Code and regulations made under the authority thereof. IssuedBy: ........................ .........................................Title Date Permit to install expires 60 days after issue date Stove ...............................:............................................................................................................................................................................................................................................................................. StoveClearance ........................................................................................................................................................................................................... .................................................................... Floor .................................................................................:.......................................................................................................................................................................................................................... SmokePipe ......................................................................................:...................................................................................................................................................................:................................... SmokePipe Clearance ....................................................................................................................................................................................................... Chimney .................................................................................................................................................................................................................................................................................................... SmokeDetector ......:..............................................................................................................................................'::....................................................................................................................... The undersigned hereby certifies that the installation of solid fuel burning stove and equipment made under au- thority of permit dated ...................................................... has been made in accordance with provisions of the Commonwealth of Massachusetts State Building Code now currently in effect and pertaining thereto ........................................................................ Installer INSTALLATIONAPPROVED ........:.................................................. By:.......................................................................................... Title: ................................................ date WHITE: FIRE DEPARTMENT — CANARY: BUILDING INSPECTOR — PINK: APPLICANT i t Mr— j- uut&_LoI FIGURE 3409-4 ' CLEARANCES FOR SOLID FUEL BURNING APPLIANCES I/f1f"1•Wllt t"Ilw1. e...11L •m w.w.1 ' I n..rf r"•t•/t . alp -.••f w.rl•1/1/ll I - 1W1 r1011i1 N. �� n".nelrw wr1 ' � A s1.. twr•• ' . A lr• ' �•11..{Y{111t1 I/Ml 0.6t1f 111" STOVE INSTALLATION CLEARANCES Combustible 114" asbestos Concrete/Masonry 4" brick veneer Stove components Material millboard spaced foundation wall spaced out 1" out 1"3 Radiant stove - ' 36" - - - front Circulating stove' 24" - - front A radiant stove' 36" 18" 6" IS, - sidc/back A circulating 12" 6" 6" 6" stove -side/back' C B.single wall = 18" 12" 6" 8" connector pipe B.insulated 2" 2" 2" 2" connector pipe C. Chimney height Three (3) feet above adjacent roof and (metal or masonry) two (2) feet above any roof ridge withjn 10 feet D. Damper If a damper is not included in the stove construction, it must be installed Irk. the connector pipe Ote IOnI: Ue Of asI access slue. Note 2. Thimble required for passage through combustible construction: Note 3. Non-combustible spacers required. Note 4. Clearances on each side of a radiant stove with a heat shoe d�y,shall be measured as if a'circulating type. l 780 CMR - Fifth Edition 34-109 ' &""NFr Sandwich Chimney Sweep Date: �'-�- �'a Time: � • °i� �0 P.O. Box 90 No Flues,to Clean: Last Sept:w If Z " Sandwich, MA 02563 House Age: !4 7�, No.of Stories:�— �' Stove Make: Tel. (508) 888-5114 Inst Meas: Paint Stove:.. �j Stove Inst: Replace Pipe: Customer i!'h ����2 Fireplace: Top Damper Address d � Fireplace Insert: Water Seal City State I,q Zip Fireplace Stove: Chim-Scan: Box#. - Flue Stove: Pictures Ins.Co.: Phone •` 7gG — 3 Oil E.1 Blocked Gas U Blocked U m -DANGER SIGNS N a YES. NO a. c o Has Had Chimney Fire SAFETY INSPECTION . A D Z • 3rd Degree Glazed Creosote FIREPLACE Is Chimney a Fire H rd 1. Hearth Sb. Comments: fiR[(lAY �� 2. Firebox/Grate NE0. 3. Glazed Creosote 4. Damper �le 6 �� 5. Smoke Chamber 6. Spark Screen/Doors A SERHf@E6HC: 7. Tools 5r'fOfh! • 31rt=CHG: �S SMCLf ? CHIMNEY PAMPER TAX: 8. Brickwork TOTAL 7 j as 9. Glazed Creosote 10. Flue Tiles `f"'r` rc,o _' CUSTOMER VERIFICATION PIRE6RIGN O 11. Animals in Flue Date ASf1 PUMP 12. Crown/Wash I have read this form and now understand which areas of woodbumIng 13. Chimney Cover/Cap system appear'to be satisfactory and which areas are not satisfactory. 1 y p m have also made a visual inspection of the area and find it to be soot free 114. Heiand I acknowledge the satisfactory completion of the above described work. ght WOOD'STOVE Signed 15. Stove Pipe Condition&Screws NEXT SWEEPING RECOMMENDED 16. Stove Condition&Gaskets 17. Installation&Measurements i Xoff 3 OTHER'FIRE SAFETY Fireplace and chimney should be inspected yearly for any 18. Fire,Extinguisher structural faults, and all wood bu Wing o fl es should be swept at least,.once a year . 19. Smoke Detectors 20. Fire,�Escape Plan Sweep or.Msc aYs Signature i� s, Note: This sheet is the result of a visual Inspection done at the time of cleaning.It is Intended as a convenlence to our customer,not as a certification of lire worthiness or safety. Since conditions of use are beyond our control,we make no warrantee of the safety of function of any appliance and none is to be implied. S c ja Ad PZ �or l4 �GZ �veL �e per�w i" &,e C'G ,� 4re d� �- 4'�07 t N[,A. . : The Town- of Barnstable •,2L Inspection Department '�a Na► 367 Main Street, Hyannis, MA 02601 508-790-6227 Joseph D. DaLuz Building Commissioner February 16, 1993 Mr. Jack Williams 21 Megan Road Hyannis, MA 02601 Re: Stove permit A=292.260 Dear Mr. Williams: Please contact this office regarding an application for a solid fuel stove permit, dated September 8, 1992, on file with this office. Very truly yours, X Richard R. �rt Building Inspector RRB/km cc: Hyannis Fire Department L930216B _ o � e THEro�♦ TOWN OF BARNSTABLE - 1. STADLE. i "6 O rraY BUILDING INSPECTOR � a' � APPLICATION FOR PERMIT TO "— e ��� �``��� TYPE OF CONSTRUCTION .���............................................................ ��� .. ........ ............................................. ... ......................... ........................ ........... �4.19 z ' TO THE INSPECTOR OF BUILDINGS: The undersigned hereby /applies for a .permit according tom the following information: /11 Location .....` � t' / � �i .�'d��',� !e•'d" z0�c� ............................. ................................... Proposed Use ... �. ... . ...... `'o?/41..... .......................... .............I......................... Zoning District ... ................... Fire District � �� .............. .................... /.................................................................. Name of Owner( Li� ® ................ ..... ..........Address .. ..f �^... �® J JI Name of Builder .............::.......................................................Address Name of Architect ' f ... Number of Rooms �" (!S/ .....�.........._....................................'Foundation .._ Exterior .�.. ...`l%................:.._.. ..........................................Roofing ...... ... ................. .............................. . Floors ..... Akh............. ........Interior Heating . . .. : f... /t ......Plumbing..... ... ......................................................................................... Fireplace .............�..................................................................Approximate Cost .......� 4 f............................... , Definitive Plan Approved by .Planning Board _a/ --a-1------19.7� 6 Diagram of Lot and Building with Dimensions SUBJECT TO APPROVAL OF .BOARD OF HEALTH 1� wsa I hereby agree .to, conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction.' � Nam .......................... ......................... Dac ey, i iliam E. Jr. 16073 Me story No .................. Permit for .......... single family dwelling ............................................................................... Location2 / Hagan Road ............................................................ Hyannis ............................................................................... Owner ............................................Will William E Da c ey Jr..... Type of Construction ...........frame.................... ........... ............................................................................... Plot ............................ Lot ............43?........... April 5 73 Permit Granted ........................................19 Date of In spection ....... .......................19 Date Completed .... ... ... .......19 C6 I%PL,aw, PERMIT REFUSED ................................................................ 19 ............................................................................... ............................................................................... 14 ............................................................................... ............................................................................... Approved ................................................. 19 ............................................................I.................. ................. .............................................................