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1000 PHINNEY'S LANE
/ oc O IT fit.r f1 n&-L(S L.a-n c?. Application number... ��...13 Date Issued ........ . ' SAMSUBLF- .......... .�....... g Building Inspectors initials.......'., Map/Parcel.......2.'i 2....... ................................... TOWN OF BARNSTABLE EXPEDITED PE UV11I'APPLICATION: ROOF/SIDING/WINDOWS/DOOR'%TENTS/STOVESMEATHERIZATION PROPERTY W®RmATION Address of Project: 00 >,,,,,e Vf NUMBER STREET VILLAGE Name; �1 Phone Number �of2� Email Address: 61 Cell Phone Number Project cost Check one Residential ✓ Commercial ®"'1'�+�9�AIJ LJL71.®A`31lLtL'1Tt01`V As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CYa Owner Signature: _wee A-11 — Date: TYPE OF WOYK Siding tJ Windows (no header change)# g Z � Insulatxon/Weatherization Doors(no header change)# Commercial Doors require an inspector's review Roof(not applying more than I layer of shingles) Construction Debris will be going to Wzs4e o�fi CONTRACTOWS INFORMATION Contractor's name Aazr i ,,,� == VS Home Improvement Contractors Registration(if applicable)# //z 7 (attach copy) Construction Supervisor's License#_�'C�p 5 416o (attach copy) Email of Contractor Swiea S @ m a,' - C� Phone number Flo/- 7 IV- (3�9 AHL PROpERHISTORIC DIES TICA7'F/AVE STRdl�'d"d OVER DS YEARS OLD OR IF THE S� iJ—E DPI —P—E�T 1IS 11 A�IISD®RIC®ISTRIC'T, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (if yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one:this event is a:for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health(Department approval between the hours of 8e 00am-9:30 am or 3.30 pm-4.34pm.. Commercial events may require.Fire Department approval *WOOD/COON ./1rELLET STOVES Y Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE E n m'NLY TI[ON Homeowner's Na me: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 9$0 CMR the Massachusetts State Building Code. I understand the construction inspection procedurbs,specific inspections and documentation required by 980 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature Date All permit applicatio are subject to a building official's approval prior to issuance. Home Improvement Agreement: Page2 Finance Charges: *Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement, to which The Home Depot is NOT a party, and will be in addition to Customer's payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service Provider may collect Customer's payment(s) made payable to The Home Depot. Insurance proceeds will will not be used to pay some or all of the total amount of sale. Description of Work to be Performed: Installation of lWindows A more detailed description of the work to be performed is included in the section entitled Scope o Work which appears on page 0 of this Agreement. Anticipated Delivery Date/Installation Schedule Approximate Start Date: 11/21/2019 Approximate Finish Date: 12/19/2019 All dates are approximate and subject to change based on unforeseen events including inclement weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if applicable. Electronic Records Authorization: You are entitled to a paper copy of this Agreement if you choose. If you consent to an e-mailed copy, your consent ap ies to this Agreement and all subsequent documents and written communications related to this a t. By contacting your Service Provider, you may update your email address, withdraw your cons r tain a paper copy of the Agreement or related documents at no charge. By providing your cons and erifying your email address above, you confirm that you have access to a computer that can rece and o n e ails and PDF documents. r By * itialin aragraph, I consent to receive only electronic records related to this transaction. I ial tance and Authorization: By signing below, you authorize Home Depot to (a) arrange for Service Provider to perform Installation and/or (b) order and arrange for the delivery of special order merchandise, including special order merchandise that may be custom made, as specified in this Agreement. Do not sign if blank or incomplete. (Service Provider's/permitting information may need to be provided to You later.) By signing, you acknowled p4at you have read, understand, and accept this Agreement in its entirety, including the General r and Conditi sad State Supplement, if any. You further acknowledge receiving a complete of this Agre nt. Ke p it t ote(ut your legal rights. X 09/26/2019 The Home Depot stom .' at Date Service Provider Name X 09/26/2019 908 Boston Turnpike Unit 1 Co-Signer (if applicable) Date Service Provider Address X 09/26/2019 Shrewsbury MA 01545 Sig ture Behalf om Depot Date City State Zip R-1-073-13-00016 Service Prov er Phone um r Service Provider License Number The Home Depot-2455 Paces Ferry Road, N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care: 1-800-4664337 4601`I HDE Customer Agreement(24 Jul.18) v 0.1.8 f Home Improvement Agreement: Pagel Home Depot License #'s - For the most current listing www.Homedepot.com/LicenseNumbers MA: 107774, 112785 Janice Campbell Salesperson Name: Registration No. (if applicable): Home Depot U.S.A., Inc. ("Home Depot") or Service Provider named below will furnish, install and/ or service the equipment listed below at the price, terms and conditions as outlined on this form. Oberlander Scott New England South 1-MPZ609Y Customer Last Name Customer First Name Store #/ Branch Name Customer Lead/ PO# 1000 Phinneys Lane Centerville MA 02632 Customer Address City State Zip I Igo2jesu 777@gmaii.com Home Phone# Work Phone# Cell Phone# Customer Email Address NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 908 Boston Turnpike Unit 1 Shrewsbury MA 01545 Address City State Zip Or Email: I customercancellationnortheast@homedepot.com Service Provider Email Address BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT THE HOM POT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL' AND WRITTEN NOTICE OF YOY5W9,HT TO CA Acknowledged by: 09/26/2019 mer' gna �,- Date Contract Price and Payment Schedule : Payment of the Contract Price is due upon signing unless a different payment schedule is required by law, specified below or in a payment addendum. Contract Price: $ 11682.00, Includes all applicable taxes. Excludes finance charges.* Sales Tax: $ 10.00 (If applicable) *Maximum deposit ONLY applicable in MD, MA, ME(33%), NJ,. WI(99%) Dep. 1 25.0 % Deposit Amount $ 420.5 1 Remaining Balance $ 1261.50 The Home Depot=2455 Paces Ferry Road, N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1-800-466-3337 4601`I HDE Customer Agreement(24 Jul.18) v 0.1.8 Commonwealth of Massachusetts = f Division 4i Professional t_icensure Board of Building Regulations and Standards Consstrucbprv-t�p� rvtsor SDecia€tv CSSL-100546lres: 0611812020 { N ERICSSON TQR1RES '- ; P.O.BOX 673 SOUTH YARM A26 4 y . N'+1 Commissioner C'L .. - -- ,�..�sa 'z �'�-�.�.s:.+.��:.,av� ._*'rr�`r.�..a.. ...>r.�..�'a�y�'wx.�`�-�s��-.�,�•._",«"�u'�-'��a .' oj ON_Ic®of.Consumer Affairs& Bus�ne s Regutat�on HOME IMPROVEMENT CONTRACTOR TaY . Corca�a�on - r ; n _ �30J2021 _ r k �a ERiCSSON HOtTINC ERCCSSONA 'OR r+.i ' assr�1y 47SEAST R /ER, t1tA�02151� 70 k " s,. s` t � t' 3" ,z- .t YrF Y 1 a '1 'k� et"G s m '�: The CZMNWMWAMcyf r nYs 600 WadfiV x&rmt M4 021ZI - Inimata Pease Prhit Deily .N� Addrem • ����SOa`� Q�rlh �A 6ldd Pha�� ��'f"-46Z-b yyZ Areym a gffi lver?Cftecktlb.-,&W agriatcba= L❑ I aat a mfh. 4 I am a Type of pzaject freed}: euiplaycr ❑ g�cal ca�sch�and I Ioyaw(full andbr ga ime * 1om Immd-ffze SUTIP o rs 6` Q Now amnaTcam 2. I a;u a sole prop ieficf orputaer- Fisted amthe dMched she& 7- ❑Re, deliag and haveno emplagees s�ab-ca�raatosslsa� $- El Demalifmg for mein aaay rapactfg a aadhave worl=e 9 El ia� [No wad'camp. t< comp. $ required-1 S[] We are a•xporafimf and is ice❑E[ ddcd sepaiEs osadc s 3.❑ Iam.a fia ==er&L6.allvmt orc?zslm m cxmcised emw 11-❑Bnmbmgrep;tim ar adMaas , mysdf END=Zbni?C=P- r*1af em=P5=perMGL ME]��_ Umursae�er � l c.132,§1Maudwe have� epiks euaplayees:(No' 13_❑other �-immmm ] °ter��enca RM �sM 111 secffcrzLb dmkwaffmocd*� y; � ��arners�mr sthtm'i r�s sf�da�+� �m�aaia�age a�ddiealrce aatiidece�crosmmst sah�taaems�d�t sncb_ ICan=Cftvalimtcb-+Wsb=mnta# =sdnifia¢ dmdAWMEOgtLe—Ofthe sffa<nd=cftwsxadstgtmwhefimacaMgme sh ' eag�1'eyees.7f'@tesv�rctsbave ,ffieY'�"P��ems'�.parcgm�bet . Fan[mae tpFayarSuaispruurriirrgu�rk¢rs'ao er�sakarticesrcraffca€vr emFfa�+ees $efn�4isfitaPvr&GyandfD6my €a,�arnrabnra,- . I eCompanyName: , 'P-o&cy 4 or SW-im-Ur- Job Site Addtew CifglStat Af tach atr copy of the work am,m,camp ens afionpahcy decBu-Atom page(sltapmg the poficy agmI er and�pn atioa date. Fair to serum cauecage as requiredus&rSec€ian 25A of MGL c.I`r7 cam lead to Sie imposifion of csinginai peaaliixs of a f m nP to$L O D aadfar one-yaar impfisoamtt as weIl as civA penaifics is the fa=of a STM WOM 4MERand a i-me, Of Bp to MM a&F Wimt the violafat: Be advised fm#a co3'afft zbhmcmtmay.ba£arwardedfo the Office of: IfL4+CS' �3t10flS Offtie 1} r fOC inenranrm Ftfa Itetrafry airdsr the pains �F oaf f7ae t oreaaiiaupematTe d abvm b bm and meet SIffi3f Date- PbowA- 529k--Q4Z-69y1i flffliod uwwk'y, Da urrt mite in ihfis=4&Fie empi Lated by dty artow qffidal tty or Town: cease# Ax&9i*y(drde one): L]3cwd 4f$eaIth jcdyjrmmC3,crk 4.Ekectricaty s 3'gam I r d.der: , 60abet Person: pk 6 i The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114.2017 www mass;gov/dia Workers'Compensation.Insurance Affidavit Builders/ContractorslEleeWeianslPlumbers. TO BE FILED WITH THE PERNIlTTJNG AUTHORITY, Applicantinformation Please Print Ledbly Name(Business/OrPnizationdhdividual):___ 14nrn cz_, _L'!�o,Ci2o Address: q 0 -�'�n T,r•., K e City/State/ZP= S w/' M Ot S4 S— Phone#: -7-1 L4 -fi Are youan employer?Check the appropriate boa: Type of project(required): L 5` 1 am a employer witk_ employees(full and/or part-time).; 7. ❑New construction' 2.❑lam a sole proprietor or partnership and have no employees vaoddng.for me in S. Remodeling any oapaeity.[No workers'comp.insraanae required]- 3.®I am a homeowner doing auworkmsel£ 9. ❑DemoHon y L+�O WOI'10e19 camp.inmvanA�r� �d,�t' 4.oram a homeowner10 Building addition and wr71 be kiting contractors to conduct all wodt on my property.I wr11 easora that all contractors either himeworkers!compensation insurance or are sole 11.0 Electrical repairs or additions propdetorswith no employees. 12.aFlumbing repairs or additions S•®I am a general contractor and I have hired the sub-conhaotors listed on the attached sheet 13.❑Roof icpairs These sutrcoahactors have employees and have workers'comp.insurance.; 6. We are a corporation and its oi$cers have exercised their ' l4.B&er r v ❑ rP right o£exemption per o. 157,§1(41 and we have no employees.[No workers'comp.iaganince require ] t°���r C-^.er "rS *Any applicantthat checks box#1 mast also fill out the section below showing their workers compensation policy information. t Hcmcovm=who submit this a$4davh indicating they are doing V work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that ehecktHs box must attached an additional sheet showing the name of the sub-contractors and state whether or notthose entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am au employer that is providing workers'compensation insurance for my employees Balm is the policy and job site informadom / InsuranceCompaayName� /walla( Policy#or Self-ins.Lic.#r S &5 5 '1 -7 Expiration Date:-3-- I -2 c Job Site Address: &00 ii�L�ih�y� City/State/Zip: �'�ii�u✓i!/ems Attach a copy of the workers'compensation policy declaration page(showing the policy number and espiratign,date). Failure to secure coverage as required under MGL b.152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonm as ell'as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. py; this statement may be.forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify yng an enalties o information provided above is true and correct. Signature:.: ate: 1Z- L Q Phone A Official rise only. Do not write h2 this area,to be completed by chy or town official City or Town: PermitUcense# issuing Authority(circle one): L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improveme _:Contractor Registration Type: Supplement Card Registration: 112785 HOME DEPOT USA INCi, ,. Expiration: 04/22/2021 P O BOX 105451 ATTN: LICENSE MGMT TEAM =- ATLANTA, GA 30348 Update Address and Return C--- ard. P SCA 1 20M-0507 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE;;Suoolement Card before the expiration date. If found return to: RegisEfation Expiration Office of Consumer Affairs and Business Regulation ' ... 04/22/2021 1000 Washington Street Su' 10 'F —�rF—HOME DEPOT Boston,MA 02118 _ ANDREW SW EEt. --� 2455 PACES FERRI F-&G=Y1 HSC ATLANTA,GA 30339 - Undersecretary Nob4alid It ut SI nature A�6P DATE(MMIDDIYY'(Y) CERTIFICATE OF LIABILITY INSURANCE 1210612619 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. 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). PRODUCERCONTACT MARSH USA,INC. NAME: PNO,ALLIANCE CENTER (A o = • AAC No: 3560 LENOX ROAD,SUITE 2400 _-MAIL ATLANTA.GA 30326 ADDRESS: --- INSURER(S)AFFORDING COVERAGE NAIC 4 CN101642069-HomeO-GAW-19-20 INSURER A:Old Republic Insurance Co 24147 INSURED THE HOME DEPOT,INC. INSURER a:New Hampshire Ins Co 23841 :o HOME DEPOT U.S.A.,INC. INSURER C:HomeRisk Captive Insurance Company 2455 PACES FERRY ROAD BUILDING C-20 INSURER 0: A rLANTA.GA 30339 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: ATL-004353439-28 REVISION NUMBER: 21 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 'BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN SIR TYPE OF INSURANCE 'ADDLjSUBR POLICY EFF POLICY EXP LIMITS L rR' POLICY NUMBER I MMIDDIYYYY MMIDDIYYYY A X :COMMERCIAL GENERAL LIABILITY MWZY 114574 103/0112019 :03101/2022 FACHOCCURRENCE 3 1.000,000 CLAIMS-MADE OCCUR RENTED DREMISESAMAGE TOEa occurrence) ! i 1.000,000 X iSIR:51,000A00 EXCLUDED _ MED EXP(Any one person) S PERSONAL 3 ADV INJURY S 1.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE I S 1,JOO.000 X POLICY J jE° LOC PRODUCTS-COMP/OP AGG S 1,000.000 OTHER: S A .AUTOMOBILE LIABILITY MINTB314573 03101/2019 03101/2022 'OMBINEO TINGLE LIMIT accident) S 1.000.000 (Ea X i ANY AUTO SODILY INJURY(Per person) S OWNED SCHEDULED SELF INSURED AUTO PHY DMG .AUTOS ONL'! AUTOS SOCILY INJURY(Per accident): i HIRED NON-OWNED PROPERTY DAMAGE i AUTOS ONLY `AUTOS ONLY i "Per accident S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAR —'CLAIMS-MADE; :AGGREGATE i DED RETENTION S b B 'WORKERS COMPENSATION ;'NC 012717099(AK,NHAJ.t/T) J 03/0Q01 9 i 0310112020 X ;PER TRTUTE i ! ERH ;AND EMPLOYERS'LIABILITY YIN INC 012717100"INI 03I0112019 '03I01/2020 :ANYPROPRIETOR/PARTNER/EXECUTIVE ( ) E.L.EACH ACCIDENT I b 5.000,000 'OFFICERIMEMBEREXCLUDED? N (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE 3 5,000,000 If yes,describe under Continued on Additional Pa a S,W0,000 DESCRIPTION OF OPERATIONS below g E.L.DISEASE-POLICY LIMIT 3 C :Excess Auto1 .297110011002019 03/0112019 03101/2020 Limit: 4,000.000 A Excess General Liability MWZX 314580 03101/2019 03/01/2022 'Limit: 8,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) EVIDENCE CF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING C-20 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. I Manashi Nlukherjee _MeLuao ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 4 AGENCY CUSTOMER 10: CN 1016a2G69 LOC#: Ailanta -- - - ACC)DO ADDITIONAL REMARKS SCHEDULE Page 2 of - 3_ AGENCY NAMED INSURED ,MARSH USA.INC. ME HOME DEPOT.INC. - ----__--- -- HOME CEPOT U.S.A..INC. POLICY,vuMaER 2455 PACES FERRY ROAD 3UILDING C-20 —.------- _— ArLANTA,GA 10339 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Compensation Continued: Carrier:Indemnity Insurance Company of:Noah.America Policy Number:'NLR C65890549(AL..ARFL,ID.IA.i(SAY LA,MS..H0.NE,NM.ND.OK,SC.30.iN,'M/.'NY) Effective Date:03101 20 1 9 Expiration Date:0310112020 (EL)Limit:55,000.000 Carder New Hampshire Insurance Company Policy Number'NC 012717098 (DC.0E.HI.IN.NO..NN.,b1TAY.,3O Effective Dale:031012019 Expiralfon Date:03101/2020 (EL)Limit:55,0001700 Carrier:ACE American Insurance Company Policy Number:'NCU C55890586(OSI) (AZ.CA.IL.NC.OR.`/A.'NA) Effective Date:03101,2019 Expiration Oats:03101 020 (EL)Limit:34.000,000 SIR:31.000.000 SIR Tor the Mates of AZ.CA,IL,NC.OR.`/A.WA Carrier:National Union Fire Insurance Company Policy Number XWC 3565596(0S0(CO.CT,GA,ME,MI,NV.OH,PA.UT) Effective Date:13/0112019 Expiration Date:03/01/2020 (EL)Limit:S4,000,000 S1.000,000 SIR for the;tales of CO.MENVAI.OKP.A.!JT 3750,000 SIR for the;fate of GA S350,000 SIR for:he;tale of CT Carrier:National Union Fire Insurance Company Policy Number XWC i565597(OSII(MA) Effective Date:03101/2019 Expiration Date:0 310 1/20 20 (ELi Limit:34,500.000 SIR:3500,000 rX Employers XS Indemnity: Carder:lllinios Union Insurance Company Policy Number.rNS C65221019ITX) Effective Date:03101r2019 Expiration Dale:0310112020 (EL)Dmd:S10.000,000 .. SIR:S1A00,000 ACORD 101 (2008/01) Oc 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD a Application number................................................3 " I Date issued........... ........`.. .........................V. 0 �nss. �� ® r � �1 Building Inspectors Initials...�4.• oS b ......... map/parcel.......�.........................I................ TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING[WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION . PROPERTY EX]FORMATION Address of Project: Z/7• NUMBER STREET VILLAGE Owner's Name: Sc o-N Phone Number Email Address: LT sus 771 �' tir�a:I .c Cell Phone Number Project cost$ 1 N 30 — Check one Residential ✓ Commercial OWNEWS AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance f with 7g0 CMR owner Signature: o �-t t���Q �n.�,rac—t Date: TYPIE OT±WORK L] Siding ZWindows (no header change)# ' 10 ❑ Insulation/Weatherization ❑ Doors (no header change)# Commercial Doors require an inspector's review 1� Roof(not applying more than 1 layer of shingles) Construction Debris will be going to �a S-��mc�A4��'"` e "� CONTRACTOR'S INF®RMATION Contractor's name l' K(yY✓t Home improvement Contractors Registration(if applicable) (attach copy) Construction Supervisor's License# /D 5 attach copy) Email of Contractor 5-,/e e q 5 C' r"ti` YEARS®Lphone ®�snumber bSU6PROPERTY IS N ALL PROpERTIE5 THAT HAVE STRUCTURES® R TS A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATIONNUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one:this event is a:for profit non-profit event Check one:Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent pf food is being served at your event please obtain a Health.Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles:front back left side right side HOMEOWNER'S NER'S LICENSE EXEMPTION ION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date F- _,,� �PPLJCANT9S SIGNATURE Date / - 3 o- 1 9 Signature All permit applications are subject to a building official's approval prior to issuance I Page 1 of 13 MA Reg#146589 CT Reg#0605216 mom Federal ID# 20-2625129 Window / Door Contract Customer Information Scott & Kim•0berlander (508) 663-8084 (Primary Mobile) Date: 01/15/2019 1000 Phinneys Ln go2jesus777@gmail.com. Rep: Michael Castiglioni Centerville MA 02632 Office# 800-242-9974 Location Agreement NE.WPRO hereby agrees that it will, for the consideration hereinafter mentioned, furnish all labor and.material necessary to install the goods purchased by Owner in accordance with the terms described on the following pages of this agreement (collectively,this "Agreement") at the premises located at: 1000 Phinneys Ln Centerville MA 02632 Windows Being Installed: 10 Doors Being Installed: 0 Window Details ---- Location: Living Room Series: Supermax Double Hung Interior Color: White Screen Type: 1/2 Exterior Color: White Grid Pattern: None Hardware Finish: White Grid Type: None Additional Labor: None Glass Options: None Location: Living Room Series: Supermax Picture Interior Color: White Screen Type: N/A Exterior Color: White Grid Patterns None .Hardware Finish: N/A Grid Type: None Additional Labor: None Glass Options: None - Location: Living Room Series: Supermax Double Hung Interior Color: White Screen Type: 1/2 Exterior Color: White Grid Pattern: None Hardware Finish: White Grid Type: None Additional Labor: None Glass Options: None Location: Master Bedroom Series: Supermax Double Hung 0 Interior Color: White Screen Type: 1/2 Exterior Color: White Grid Pattern: None Hardware Finish: : . White Grid Type None. Additional Labor: None Glass Options: None Location: Living Room Series: Supermax Picture Interior Color: White Screen Type: N/A Exterior Color: White Grid Pattern: None Hardware Finish: N/A Grid Type: None Additional Labor: None Glass Options: None LeapTo4igitaixom 1.4.21 QI l "1"/ f i _ _ .Page_2,of 13 Location: Master Bedroom Series: Supermax Double Hung Interior Color: White Screen Type: 1/2 Exterior Color: White Grid Pattern: None Hardware Finish: White Grid Type: None Additional Labor: None Glass Options: None s- Location: Master Bedroom ~ Series: Supermax Double Hung Interior Color: White Screen Type: 1/2 Exterior Color: White Grid Pattern: None Hardware Finish: White Grid Type: None Additional Labor: None Glass Options: r None -- - _ Location: Master Bedroom Series: Supermax Double Hung f Interior Color: White Screen Type: 1/2 Exterior Color: White Grid Pattern: None Hardware Finish: White Grid Type: None Additional Labor: None Glass Options: None - Location: Master Bedroom Series: Supermax Double Hung Interior Color: White Screen Type: 1/2 Exterior Color: White Grid Pattern: None Hardware Finish: White Grid Type: None Additional Labor: None Glass Options: None m M I Location: Master Bath Series: �~ a _ Supermax Double Hung Interior Color: White Screen Type: 1/2 ' Exterior Color: White Grid Pattern: None Hardware Finish: White Grid Type: None Additional Labor: None Glass Options: None Window Capping Type Standard Capping Capping Texture PVC Capping Color Aspen White 28321 Additional Details Newpro will remove any demoed or installation debris from the property in relation to this contract. All promotions were applied at the time of purchase and cannot be combined with any future offers. Payment Total Price: $14,306 Deposit $0 Due Upon Completion $14,306 Payment Method finance Estimated Start &Completion Dates Estimated Start Date 04/08/2019 Estimated Completion Date 04/0 /2019 (�, 7 Customer understands that these are estimated dates and will be contacted to schedule actual date. I s .� This`sp�ee int�enti onally`eft blank LeapToDigitalxom 1.4.21 T Terms and Conditions Page 12of13 Owner has read and agrees to the terms and conditions of this Agreement. Owner specifically agrees to the (1) Total Cash Price; (2) work being performed; and (3) work not being performed. Owner understands that this Agreement and any attachments contain all of the promises made by NEWPRO. Owner has been orally advised of his right to cancel this transaction at any time prior to midnight of the third business day after the date of this transaction and Owner was provided with two (2) copies of a cancellation form explaining this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. YOU THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY OF THIS TRANSACTION. SEE THE ACCOMPANYING NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. The undersigned gives NEWPRO permission to debit their checking/savings account, or process a credit card transaction, for the deposit amount indicated on or after the contract date. Subsequent payments, such as start payments, or completion payments will remain in effect until I cancel it in writing, and agree to notify NEWPRO of alternate payment intentions. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that NEWPRO may at its discretion attempt to process the charge again within 30 days. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute the scheduled transactions with my bank or credit card company; provided the transactions correspond to the terms indicated in this authorization form. Scott & Kim Oberlander 01/15/2019 Date Michael Castiglioni 01/15/2019 Date i This space'ntenti-bnally Ieftgblan,k LeapToDigital.com 1.4.21 f Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstrAxli n'Supervisor CS-105188 pires: 11/01/2019 _ f VLADIMIR KRUCHYNs-YY, 1 PAVILLION ROAD AMHERST NH 03031 Commissioner C L , -— --- - - Jle Ccc�rzr�nr•zztaerc�(.��f`G'T�tcelcrc%welt• . office of Consumer Affairs&Business Regulation ; — HOME IMPROVEMENT CONTRACTOR TYPE:LLC "on Expiration > 5 03/23/2019• ALL WORK COT3S�-�055-�ikr VLADIMIR KRUCHYMS YM R� CGr 1 PAVILLION RD. AMHERST,NH 03031 Undersecretary I , The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Auplicant Information Please Print Legibly Name (Business/Organization/Individual): _/✓2tJDr,) C Address:_a (,2 L'&d Sfi City/State/Zip: 4//6 b vo-tn t't'( � 019a I Phone#: /- ?00 -3'1Z-L 2- 1 1 Are you an employer?Check the appropriate box: Type of project(required): I.dI am a employerwith S O f employees(full and/orpatt-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in an capacity. o workers'comp.insurance required.] S• Remodeling Y P tY•IN 3Q I am a homeowrer doing all work myself.[tdo workers'comp.insurance required.]t 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my Property. I will 10 O Building addition ensure that all contractors either have workers'compensation insurance or are sole I I.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.r7 I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.4' 13. of repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other_0 r i►d4,,,) 152,§1(4),and we have no employees_[No workers'comp.insurance required.] rerl a ce- -—4—S *Any applicant that checks box#]must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:U 6(QJ Policy#or Self-ins.Lie.#: ,,/�,,f/� ,Q 74f OWL) Expiration Date: 5 Job Site Address: Z00 0 // `A''I►-ie y/S � 7 City/State/Zip: r.,4rzy,"l Attach a copy of the workers' compensation policy declaration page(showing the policy number Ind expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment s 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 copy statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verifieatio . I do hereby c rtify un er a pa' and penalties of perjury that t ormation provided above is true and correct Signature: Date: Phone#: /- Y0 6- 3 q2- 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#: J Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement:Contractor Registration Type: Supplement Card NEWPRO OPERATING,LLC. = Registration: 146589 26 CEDAR ST, - Expiration: 05/04/2019 WOBURN,MA 01801 Update Address and Return Card. SCA i ,. 2Jti-OfU Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Suoolement Card before the expiration date. if found return to: Registration E,xxoiration Office of Consumer Affairs and Business Regulation 146589_ 05/04/2019 10 Park Plaza-Suite 5t70 NEWPRO OPERATING;LLC:. Boston,MA 02116,,7 VLADIMIR KRUCHYNSKY_Y- "Q �Q , 26 CEDAR ST. C WOBURN,MA 01801 Undersecretary Not valid without signature I AC Ra CERTIFICATE OF LIABILITY INSURANCE DATE 0105/052D/YYY1� /2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the poiicy(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 NAME: Melissa Pflug Mackintire Insurance Agency Inc PHONE (508)366-6161 FA Ne: (508)366-5202 (PA No Ext 11 West Main Street EMAIL melissap@mackintire.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Westborough MA 01581-1931 INSURERA: Sentry Insurance INSURED - INSURER B: Guard Insurance Group Newpro Operating LLC INSURER c: Colony insurance Co 26 Cedar St. INSURER D: INSURER E: Woburn MA 01801 INSURER F: COVERAGES CERTIFICATE NUMBER: 18-19 Master 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 MAYBE 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. I�TR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD Y MMIDD/YYYY LIMITS x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 t� CLAIMS-MADE ®OCCUR PREMISES Ea occurrence S 500,000 MEDEXP(Any one person) S 15,000 A A0062403003 12/31/2017 12/31/2018 PERSONAL&ADV INJURY s 1,000.000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE S 3,000,000 X POLICY JEo- LOC PRODUCTS-COMPIOPAGG S 2,000,000 OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 Ea accident ANYAUTO BODILY INJURY(Per person) $ A OWNED Ix SCHEDULED A0092403004 12/31/2017 12/31/2018 BODILYINJURY(Peraoadent) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGEAUTOS ONLY AUTOS ONLY Per accident Uninsured motorist BI $ 250,000 X OCCUR EACH OCCURRENCE UMBRELLA LIAB OCCURRENCE S 5,000,000 H A EXCESS LIAB CLAIMS-MADE A0092403006 12/31/2017 12/31/2018 AGGREGATE s 5,000,000 DED I X1 RETENTION$ 0 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STATUTE ERA ANY PROPRIETORIPARTNERIEXECUTIVE v�N E.L.EACH ACCIDENT $ 500,000 B OFFICERIMEMBEREXCLUDED? NIA NEWC874066 05/01/2018 05/01/2019 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Limit $1,000,000 Pollution C CSP304242 12/31/2017 12/3112018 DED $5,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Boxborough Town Hall ACCORDANCE WITH THE POLICY PROVISIONS. 29 Middle Road AUTHORIZED REPRESENTATIVE Boxborough MA 01719 r� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Town of Barnstable f Building �PostThis�Ca'rd'FSo That��t.�is�U�stble;Fromthe Street-,�Approvetl Plans Must beRetamed on,.lob and�this Gard Must.be,Ke:t 16119, P �MA ,�« Posted Until�Final Ins ec ion Ha's Been M�atle � S ' Y�� � -' � � �' R Whe e a Certificate of Occu anc :is Re wiretl such Bwltlrn shall Not be Occu ied�untilta Final lns ection has be nFrnade Permit Permit No. B-18-1477 Applicant Name: RetroFit Insulation Approvals Date Issued: 06/05/2018 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 12/05/2018 Foundation: Location: 1000 PHINNEY'S LANE, HYANNIS Map/Lot 252-056 Zoning District: RC-1 Sheathing: Owner on Record: OBERLANDER,SCOTT A& KIMBERLY C Contractor Name RETROFIT INSULATION, INC. Framing: 1 Address: 1000 PHINNEY'S LANE Contractor License 160461 2 _ .. CENTERVILLE, MA 02632 "NG � Es# Profect Cost: $5,702.00 Chimney: Description: 9" layer cellulose open attic, insulate attic hatch,make temporary Permit Fee: $85.00 access through sheathing,install propa vents Insulation: insulated hose c Insulation: x Fee Paid: $85.00 and roof mounted vent to bath fan,install 8x16 soffit vents,air Final: Dated sealing,install R-19 fiberglass blockers to sills;ms�tall 10 rnlpoly over 6/5/2018 �� s open ground in designated crawlspace penmeter wall, install closed, Plumbing/Gas cell spray foam insulation to crawlspace perirneter wall y _ Building Official Rough Plumbing: Project Review Req: Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six month after issuance. Rough Gas: All work authorized by this permit shall conform to the approved application a'ndAh&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 zoningzby laws and codes. Final GaS: This permit shall be displayed in a location clearly visible from access street dt 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 applicable signt res by the�Bwldmg and fire Officials a e provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work. � � , FIN 1.Foundation or Footing g" � � 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. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department -:0 Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT t Town of Barnstable *Permit# 00� � �- X-PRESS PE ■Jt Expires 6 months from issue date Regulatory Services Fee 5 JUL �. 7. ��fls Thomas F. Geller,Director p�� � Building Division TOWN OFARfST "`7°t!m Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 50 8-862-403 8 Fax: 508-790-6230 EXPRESS PERINUT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint , Tap/parcel Number roperty Address Residential Value of Work 3 S qO-® Minimum fee of$25.00 for work under$6000.00 )wner's Name&Address A4 �•�D O 4. ,.� ,ontractor's Name OL-Wa-,Q_ � 1_� T Telephone Number 50r6 -1'1 Some Improvement Contractor License#(if applicable) d2 q� CI S�1 -onstruction Supervisor's License#(if applicable) �orlcma,n's Compensation Insurance Check one: ❑ I am a sole proprietor )I am the Homeowner have Worker's Compensation Insurance ., pA Insurance Company Name Lyvaem ►"le� $'l� W orlanan's Comp.Policy# lnD `�`� l ded ® q 02 �✓'�.. 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 � am.t9t/rMf�A� `— ❑Re-'roof(not stripping, Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (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. Home Improvement Contractors 'tense is required. SIGNATURE: Q:Forms;expmtrg Revise071405 Department of Industrial Accidents W Office of Investigations 0 600 Washington Street Boston,MA 02111 y www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/1Electricians/Plul®bers Applicant Information ]Please Print Legibly Name (Business/organization/Individual): 0,,JV 1:-, - Z-- Address: City/State/Zip: Phone#: g�p S Areu an employer? Check the-appropriate bog: Type of project(required): l.LJ I am a employer, ith 'L_ 4. ❑ I am a general contractor and I 6. ❑ 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. : 8. ❑ Remodeling ship and have no employees These sub-contractors have 8: ❑ Demolition working for me in any capacity. workers' comp.insurance. g, ❑ 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 11.❑ Plumbing repairs or additions myself.[No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.[_1 Other comp.fimmance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information t Homeowners who submit this affidavit indicating they are doing all work andthen hire outside contractors must submit anew affidavit indicating such IContractars-thatcheck.this.box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy infomwdon. I am 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.#: W&231-5 53 as� 0 V 025 Expiration Date: 1'2 2S Job Site Address: / �Kl�'�` � L � City/State/Zip: S 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 civ>7 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 the pains andpenalties of perjury that the information provided above is true and correct; 5i afore: Date: Ir1 Phone#: � Official use only. Do not write in this area,to be completed by city or town of,ficiral City or Town: Permit/License# Issuing Authority (circle one): 1.Board of stealth 2.Building Department 3.CitylTowa Clerk 4.Electrical luspector..5.f 1➢1mbina Inspector 6. Otther Contact Ferson: 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 alicense 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 ofpublic 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)name(s), address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liabr7ity Companies (LLC)or Limited Liability Partnerships(UP)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 Boston, MA 02111 Tel. 1617-727-4900 ext 406'or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 ww-w.mass.gov/cia e Town of Barnstable ]regulatory Services Thomas F.Geller,Director 'ATfD;u�'1` Building Division. Tom Perry, Building Commissioner 200 Main Street, Fjymmis,MA b2601 W"Aown.b arnstable.maxs 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Scction. If Using A Builder as.Owner of the subject property hereby authorize . O�-`-y��— �'�''� � to act on my behalf, in all matters relative to work authorized by this building permit application for. 4. (Address of Job) S gnatare of Owner ate o B�RT 1�• ���RSo ,J Print Name QTORM&OWNERPERMISSION ';4 9/te V Board of Building Regulations and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvements Contractor Registration Registration: 128957 - Typ,q: Individual Expiration: 6/14/2007 -31 Oliver Kelly Oliver Kelly --------------- 9 Peregrine lane _ �= S. Yarmouth, MA 02664 - Update Address and return card.Mark reason for change. IS-CA7 4 50M-04104-G101216 0 Address Renewal Employment Lost Card, �� Liberty Mutual Group L�iberq PO Box 7202 mutusi, Portsmouth,NH 03802-7202 Telephone(800)653-7893 Fax(603)431-5693 May 25, 2006 TOWN OF BARNSTABLE 720 MAIN ST HYANNIS,MA 02601- - RC: Certificate of Workers Compensation Insurance Insured: OLIVER KELLY 9.PEREGRINE LANE , SOUTH YARMOUTH,MA 02664 Policy Number: WC2-31S-338804-025 Effective: 12/282005 Expiration: 1228/2006 Coverage afforded under Workers Compensation Law of the following state(s): MA Employers Liability Bodily Injury By Accident: $ 100,000 Each Accident Bodily Injury by Disease: $ 100,000 Each Person Bodily Injury by Disease: $ 500,000 Policy Limits As of this date, the above-referenced policyholder is insured by Liberty Mutual Fire Insurance Co under the policy listed above. The insurance afforded by the listed policy is subject to all the terms,exclusions and conditions, and is not altered by any requirement, term or condition of any or other documents with respect to which this certificate may be issued. This certificate is issued as a matter of information only and conkers no right:upon you,the certificate holder. This certificate is not an insurance policy and does not amend,extend, or alter the coverage afforded by the policy listed above. If this policy is cancelled before the stated expiration date,Liberty Mutual will endeavor to notify you of such .cancellation: AUTHORIZED REPRESEW&LVE LIBERTY MUTUAL,INSURANCE GROUP This Certificate is executed byLB3ERTYMULUAL INSURANCE GROUP as respects such insurance as is affirded by those companies. cc: Insured::. .,Producer of Record: OLIVER KELLY SANDPIPER INSURANCE AGENCY INC 9 PEREGRINE LANE" 12 ENTERPRISE RD SOUTH YARMOUTH,MA 02664 HYANNIS,MA 02601 5/25/2006 a q • ( (/ p p T 2 T m Z Z Z Z N v � m O x c O O O O 0 S o`o n Q co 3 3 3 3 -o ° `° 0 Od ". sF4 Q Q 3 o• � co m m cQ o o. 3 = o m to fD 3 < m O o 0 p O 3 m o a�� .1 -DO v - O_ ti, Z CD y u y CA O �� D 0 :l7 0 7 EL � f D � � � .0 : CD M w CD � s O n n (� g ��< o r (� Ao co r CD b s p oo 1 .�- �- N: M to ®CD Q c 3 o D D DS �! Q fl n -0 c 0 0 a a a =r Q a to 0 to 10 A Z el 0 �b d— CA :� Q m i � � rj � . THE c :G PROPOS \;.a Q _SANITARY WATERS [DING FOR (' ;� NYASUPPLY, SEWAGE Q D DRAIN E DISPOS d . A . AGES H @�A7 APPROVED s 0 A—TOWN OF BARNSTABLE, ° ' BOARD OF HEALTH o -LIC �'. pERMI4TNED INSTALLER MUS C. V . AND thSTAI L'. SySTEM, DETAIN SEWAGE And-araoo^ Mr. 8 Mrs. Robert �15388 add to single No ................. Permit for..................................... family dwelling � .—.---_~—_--...----~—...-..----. .- \ ~ IOOO �a�� ^ Location --..---.—_���������.�----____ ' - ` . Centerville ^ ..............................----'.----------. Mr. ` Mr. '� D�~^ RobertW. Anderson ^^== -----.------.—.—.--.-----. 'frame ' Type of Construction .......................................... . . ~ ' - -- '--_-- --^~--^'—'—'`'--`^^----'--'—'----, Plot Lot .----~_--.. ................................ � Auu . . � 72 Permit Granted -.—..�.����.�_—.=—'—]g Date of Inspection ...................... 19 Date Completed 19 � _— . ' 1 PERMIT REFUSED ^'~~—''~----..—.....�.---,.—. 19 | - ----.'.--_----...------.---.—,. ' ^---.,..—.--.---...----.—.,.:....--.,.... -` .^.--._.....----.....,...—�.—..,...~—. .----'—..-.--.-,.....—._.....,^.--..... �' � ' � . . ^''~`~~ l� '' -------~---.'—_—'' . . ^ -------'----------^'-^^--^—'~—' ----.---..------.-----...,..../^.. ` | ' d s 9 Assessor's office 1st Floor): (n Assessor's map and lot number Q ' �`� NS �aT-E *THE t Tam Conservation(4th Floor): `�� — '"� �Ei�� ®PUIP��MCE v� Board of Health(3rd floor): / pp sF ��� LLt 5 ♦; seaaSranci Sewage Permit number a ! �- ^l3 ` ® ��L 0,0 39. Engineering Department(3rd floor):' _ ! a TO ne�U jV® MASKo House number LA�'��61g ao Definitive Plari Approved by Planning Board 19 APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only . ' I TOWN OF BARNSTABLE s IBUIf ING ; IHSPECTOA APPLICATION,FOR PERMIT TO ��/ J Cf TYPE OF CONSTRUCTION //V��.t✓ /t'ILL� ���L Ll/V { 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the followiin information: Location �AJV Proposed Use Zoning District Fire District Name of Owner IJIZ06�i` f /7`�-✓C-S GGt/ Address /U G U Name of Builder /�/� C�i'' ��/•c 7L 4A,- Address 37 Name of Architect Address Number of Rooms Foundation Exterior Roofing �� Floors Interior Heating Plumbing <� 6et�/2�ah,, Fireplace Approximate Cost Area b 0p Diagram of Lot and Building with Dimensions Fee OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable r rding he above construction. Name Construction Supervisor's License 44 5 7 7 ANDERSON, ROBERT c* 4-- � ty` No Permit For REPAIR FIRE DAMAGE Single Family Dwelling Location 1000 Phinney' s Lane Hyannis:i Owner Robert Anderson Type of Construction Frame y - . Plot Lot Permit Granted nPr-Pmher 3'a 19__a3 j• Date of Inspection: Frame 19 Insu7c"ition 19 zFireil'ae 19 Date�Completed 19 C SLR 6A � , ! • � � � � 1. - I f } f i /^! COMMONWEALTH OF MA.� ACHUJ 'ET-- S E� JFJhIr:1� T OF 1.NTDUSTRiALjACCIDFN`iS . t 600 WASHrNGTON STk3!tT James Gam0ae� liOSTON, M�LSSACHUSI=VT`I�S 02111 WORKERS'COMT'ENSATION INSURANCE AFFIDAVIT 1, �'��✓ �/�/%�y�✓ - (liccnscc/perm;acc) .with a principal placc of business/residcncc at: (Gry/Stacc/Zip) do hereby ccrtifj; undcr the pains and penalties of pc that: j ) 1 am an employer providing the following workcrs' compcnsation coverage for my employees-orking on this job. lnsurancc Company Policy Number UA-2M 2 sole proprictor and havc no onc working for mc. () 1 am a sole proprietor,gcncrzl eontnaor or homeowner(circle one) and havc hired the eontraaors luted bclow who havc the followingworkcrs'compcnsation insurance politics: Name of Contmaor Insurance Company/Policy Numba Name ofContraaor Insunnee Company/Policy,Numba N7mc of Contmaor Insunncc Company/Policy Numba 0 1 am a horneotitincr performing all the work myself NOTE: Plcasc be a.+•arc that v+bilc borzcowacrs vrbo employ persons to do raaiatcaaacc.coostructioa or repair work on a crwclling of not resort tbaa tbrcc uaiu is wb;cb the boracowacr also resides or oa the grounds appumaaat thereto uc not generally eonsidcrcd to be employers under the r✓or1-cri Cornpeasat;oa Act(GL C.152.sect. 1(5)).applicat;oo by a boraeowoer for a ""DSc or perrm ra:y CY;deaCe the lcgd st:tut of:s er_ployer uoder the Workers*Cornpeasat;on Act i undcrscanc that a copy of ties st:tcmcnt wiii oc forts rdcd to Ehc Dcpa:t::cnt of Industrial Aecidmu'Ortsee of lnscrancc for.eoveraTc ---crifseauon and that failure to secure eovcrzgc as rcSu;rcd under Sceuon 25A of MGL 152 can kad to the impos;uon cf rziminal penaluu consisting of a fine of up to S 1500.00 an&cr imprisonment of up to onc year and civil penalties in the form of:Stop Work Order and a I fsnc of S100.00 a day against mc. Signcd this D d2yof Lice sec/ rmittce Licensor/Permittor 0 sac- c vR � c � a p c ----�1 a 10 :D U 1