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HomeMy WebLinkAbout0101 PINE GROVE AVENUE r/O/ 't�ir1� �2a vE �1/� �..� a)61-3 0 c Town of Barnstable ¢Permit# E>rphvs 6 mm*s f wn ire date Regulatory Services Fee .3 S_, • YSNS7'A�Ii. • 'A' Thomas F.Geller,Director � Building Division _ Tom Perry,CBO, Building Commissioner ����� ����'� 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us APR - 8 2013 Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDEaIAL.ONLY Map/parcel Number ago el �j/ Not Valid without Red X-Press Imprint AHNSTABLE PropertyAddress U J n `7 I o l Residential Value of Wor(k� j� 00 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address J Cr y�{� ���� �C7, \}�P 9 01��L Vl:rAoJ� S / Contractor's Name C� �l C�c c l i Telephone Number —IN ?22 0 S 2 2� Home Improvement Contractor License#(if applicable) �� Z Construction Supervisor's License#(if applicable) I® ) ❑Workman's Compensation Insurance Cheeone: I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insu nce Compliance Certificate must accompany each permit. Permit Req st(check box) - 1 l Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to t l J0 ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders:U-Value (maximum.35)#of windows ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire'Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: C:\Users\decollik\Appbata\Local\Microsoft\Windo s\Temporary Internet Files\Content.Outlook\QRE6ZUBMEXPRESS.doc Revised 053012 Town of Barnstable 4 Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 ,fax: 508-790-6230 � Property Owner Must T Complete and Sign This Section If Using A Builder I, as Owner of the ro subject property l p p t3' . hereby authorize C nreu� Lae ntSJ D Q) to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) - Signature of Owner Date t.Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the. reverse side. " C:\Users\decollik\AppData\Local\v icrosoMWindows\Teinpoiary Intert►et Files\Content.Outlook\QRE6ZUBN\EXPRESS.doc ` Revised 053012 t The Commorir mkit of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Sheet Boston,MA 02111 rahvtumass gov/dia ` Workers' Compensation Insurance Affidavit: Builders/Contractors/Electzicians/Plumbers Applicant Information Please Print Let+ibly Name Rasmessogm Co(el Ciyt1 Cu r e y LY15 r 4nyi Address: City/State/Zip: \ 02 G Phone#: Aree you an employer?Check the appropriate Type of project(required)_ 1.❑ I am a employer with 4_ M1 am a general contractor and I employees(full and/or pact-time).: have hued the sub-contractors 6- ❑New construction 2.❑ I am a sole proprietor or partner- wed on the attached sheet. 7. ❑Remodeling ship and have no employees , • - These sub-contractors have S. ❑Demolition wailcing for me in anycapacity. employees and line worms' 9. ❑Building addition [No wodcers'comp.insurance comp.insurance-4 wed-] 5.❑ We are a corporation and its 10.❑Electrical repairs or additions 3_❑ I am a homeowner doing all work officers hate exercised their 11.®PI yr&ing repairs or additions myself[No workers'camp_ right of exemption per MGL 12 f repairs insurance r Y c. 152,§1(4X and we have no ] employees-[No workers' 13-❑Other comp.insurance required.] *Any applicant that checks box#1 liar also fill out the section below showing their wotlters'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mar submit a new affidavit indicating such. ICoat rotors that cbeck this boor must attached au additional sheet showing the name of the sub-comaKtors and stare whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I ant an entpioy:sr that u proriding ttaorkers'codtpensation tnsaorance for my entplo}ess &etoty as the policy and job site information. Insurance Company Name: Y Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/3tategip: Attach a copy of thee workers'compensation policy declaration page(showing the policy number and expiration date). Failure to sure covuage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 cevtiJsy under doe ios and oy that due information provided above is true and correct Sienaflare: Date: Phone#: Official use only. Do not write in this area,to be completed by city or Mvit official City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityllown Cleric 4.Electrical Inspector 3.Plumbing Inspector 6.Other Contact Person: Phone#: - - - 6 . Y G. c, ACORQ CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDWYYY) O1/24/2013 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 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:. Joanne Bretton Southeastern Insurance Agency, Inc. Py"C°N : 508-775-5154 a "e:508-790-0557 641 Main Street UNRLE ADD SS: Hyannis, MA 02601 PRODUCER CUSTOMER ID INSURERS)AFFORDING COVERAGE NAIC S INSURED INSURER A: Arbel l a Mutual Ins Co 17000 All Cape Exterior Remodeling LLC INSURERB: AEIC Insurance INSURER C: +� 67 SEA STREET APT A4 INSURER D: Hyannis, MA 02601 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 2013 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADS- UBR - POLICY EFF POLICY EXP LIMBS LTR INSR WVD POLICY NUMBER MMID MMIDDJYYYY ' GENERAL LIABILITY 850004193 01/14/2013 01/14/2014 EACH OCCURRENCE Is 1,000,00 X COMMERCIAL GENERAL LIABILITY DAMAG TO RENTS PRISES Ea w wrr ence $ 100,00 CLAIMS-MADE T OCCUR MED EXP(Any one person) $ 5,00 A PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE UMR APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,001 POLICY jEo- LOC $ AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) b ALL OWNED AUTOS ' BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS - $ S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY WCC500789601201 01714/201301/14/2014 X WC STATU- OTH-I TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN N E.L.EACH ACCIDENT $ 1,000,000 B OFFICERIMEMBER EXCLUDED? N 1 A ' (Mandatory in NH) E.L.DISEASE-EA EMPLOYEq$ 1,000,000 R yes,describe under DESCRIPTIONN OF OPERATIONS below OWNER INCLUDED E.L.DISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(Attach ACORD 101,Additional Remarks Schedule,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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE di play purposes only Joanne Bretton ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 26(2009109) The ACORD name and logo are registered marks of ACORD ACORQ. AGENCY CUSTOMER ID: LOC#: ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED Southeastern Insurance Agency, Inc. All Cape Exterior Remodeling LLC POLICY NUMBER 67 SEA STREET APT A4 Hyannis, MA 02601 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 2S FORM TITLE: ACORD Certificate of Liability Insurance Garage Liability INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD POLICY NUMBER DATE(MMIDDIYY) DATE(MWDDf/Y) LIMITS AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ Automobile Liability ION NSR NSRD POLICY NUMBER DATE DD/� DATE @A�MIIDD/DIY) Excess/Umbrella Liability INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD POLICY NUMBER DATE(MMIDD/YY) DATE(MMIDDIYY) LIMITS . $ Other Liability INSR POLICY EFFECTIVE POLICY EXPIRATION LTR POLICY NUMBER DATE(MMIDDIYY) DATE(MMIDDf/Y) LIMITS ACORD 101(2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 1 ��ie rpor��meoazeuecclCl a���oraac�ier�e ;. Office of Consumer.Affairs&Business Re ulation License or registration valid foi individul use only. OM E IMPROVEMENT'CONTRACTOR before the expiration date:. If found return to: egistration ,i73,192 Type. Office of Consumer Affairs and Business Regulation xpiration: 9/11[2014 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 COREY AND GORE Y CONSTRUCTION PATRICK CLIFFORD � 12 BALDWIN RD C� DENNIS, MA 02638 Undersecretary No valid witho signature . Massachusetts Departrnent'of Public Safet Board of Building y .T Regulations and Standards Construction Supervisor Spocialtv - License:CSSL-105951 PATRICK CLIFFQ'RD 12 BALDWIN ROAD Dennis MA 02639: f Expiration Commissioner 06/02/2016 rl -D oF�ftrr Town of Barnstable * rmit�3 '�� o RegulatoryServices E.Perees6�t elks ronrissuedare i r #.ass. 1619- %0 Thomas F. Geiler, Director Building Division Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.bamstabie.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Nol Valid tvtlhouf Red X-Press Imprint Map/parcel Number ® 67 Pro erty Address -Ne. t� -e /I/L /�N ' " _ Residential Value of Work 1 d ' l ©�7 Minimum fee of$35.00 for work under S6000.00 A Owner's Name & Address IIVA Contractor's Narne n/o ��5�� g " Telephone Number Home Improvement Contractor License #(if applicable) / Con coo n Supervisor's sLicense#(if applicable) =Workman's Compensation Insurance Check one: ,�, ,Rim ❑❑ I am a sole proprietor h '76 j1am the Homeowner _ I have Worker's Compensation Insurance I CJ�f OF BI AR S I A5� E Insurance Company Name New /n "kTA/S Workman's Comp.Policy# - 67 1 )�, Copy of Insurance Compliance Certificate must acc piny each permit. Permit Request(check box) ❑ Re-roof(h urricane nailed) (stripping old shingles) All construction debris will be taken to ❑ReZdc rricane nailed) (not stripping. Going over existing layers of roof) ❑ Re n #of doors Replacement Windows/doors/sliders, U-Value (maximum .35) #of windows *where required: Issuance of this permit does p not exempt compliance with other town department regulations,i.e. Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License & Construction Supervisors License is re , :NATURE: ---g--�� "�A --� 'PFILESIFORMSIbuilding pennii formslEXPRESS.doc The Commonwealth of 1Mlassachusetts Department of Industrial Accidents Office of Investigations kF---1 i ti F•if 604 Washington Street . 'T1` , "' Boston, MA 02111 I www mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I Please Print Legibly Name.(Business/Organization/Individual): H C-M(E c Address: 3L1�� pe":Ie-5 6&pq City/State/Zip: (G fu� �' 10.431 Phone#: Are you an employer? Check the appropriate b Type of project(required): 1 ! I am a with employer 4. I am a general contractor and I -- — have hired the sub-contractors 6 ❑N construction employees(full and/or part-time).,� ,7 Remodelin 2.❑ I am a sole proprietor or partner- listed on the attached sheet. g ship and have no employees These sub-contractors have g. ® Demolition working for me in any capacity. employees and have workers' 9 Building addition No workers' com insurance comp.insurance.# [ F 5. [] We are a corporation and its 10.❑ Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work officers have exercised their 1 I. 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#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. c.�v� ^ CC)Insurance Company Name: Policy#or Self-ins.Lic.#: © � I 3 S Expiration Date: ! I j Cit /State/ZiP Job Site Address: /d PA � N Y F Attach a copy of the workers' compensation policy declaration page(showing the policy number and xpiration 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 cer"undepains and penalties of perjury that the information provided above is true and correct Date: Signature: Phone#: Official use only. Do not write in this area,to be completed by city or town official, ,City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#• .r . The Commt wealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, ALL 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Infor mation Please Print Le6ibly Name (Business/organization/Individual): n. cam Address. aJ, h- City/State/Zip: Phone#: �o'.—d Are you employer?Check the appropriate box: L❑ I a employer with 4. ❑ I am a general contractor and I Type of project(required): - mployees(full and/or part-time).*. have hired the sub-contractors 6 ❑New construction 2. 1 am a sole proprietor or partner- listed on the attached sheet. 7. [�emodeling. ship and have no employees These sub-contractors have working for me in,an capacity. g• O Demolition b y p ty, employees and have workers' [No workers'comp. insurance comp, insurance.: 9. 0 Building addition required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their myself. 11-F Plumbing repairs or additions y [No workers comp. right of exemption per IvIGL insurance required.]t c. 152, §1(4);and we have no- 12.0 Roof repairs employees:[No workers' 13.:[] Other COMP.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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 inf my eiployees. Below is the policy and job site information. Insurance Company Name: ;' Policy#or Self--insI. & 73 p / Expiration Date: Job Site Address: (aj City/State/Zip: / ) l7' Attach a copy of the workers'compensation policy declaration page(showing the policy number and iration date). P te). Failure to secure coverage as required under Section 25A ofMGL 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 Investibations of the DIA for insurance coverage verification. I do hereby certryunder the pains aft enalties of perjury that the information provided above is true and c erect. Signature: � Phone#: 71coonly. Do not write in this area,to be completed by city or town offcciaz n: Permit/License# Issuing Authority(circle one): I. Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical In ect or 6. Other P 5. Inspector ns ec t or 5 P 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 ev�dence of,compliance with the insurance requirements of this chapter have been presented to the contracting authority, Applicants Please fi11 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have' employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' ease call the Department at the number listed below. Self insured companies should enter thei compensation policy,pl r 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 crrent policy information(if necessary)and under"Job Site Address the applicant should write"all locations o _(city e town)."A copy of the affidavit that has been officially stamped or marked by the city a town maybe 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 Washmaton Street Boston, MA 02111 Tel. 9 617-727-4900 ext 406 or 1-877-MASSAFE Fax 4 617-727-7749 Revised 11-22-06 www.mass_gov/dia 'f,4e fc-;rrarreec-xuaealG� ��s_��saca�ia�se�s �,. office of Consumer Affairs&iassesess Regomatios 1iOME IMPROVEMENT CONTRACTOR Registration: 126893 Type: _ Supplement t _ Expira +: 8r3I2012 The Home Depot At44ome Sor,00es DARREN DEMERS 2690 CUMBERLAND RAPAWAY S � - — q'(3`At'1 ,GA 30339 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10.Park Plaza-Suite 5170 'arc) Boston,MA 02116 Not valid without signature Cg, DATE(MMIDDIyYI'Y) A66� CERTIFICATE OF LIABILITY INSURANCE 02/21/2011 THI�RTIFICATE 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 be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 1-404-995-3000 CONTACT NAME: - - Marsh USA, Inc. PHONE homede ot.certre uest@marsh.com E-MAIL P 4 ADDRESS: ---'-------- Two Alliance Center, 3560 Lenox Road, Suite 2400 NAIC# INSURER(SI AFFORDING COVERAG Atlanta, GA 30326 Fax (212) 948-0902 INSURER A: Steadfast ins Co 26387 INSURED INSURER B: Zurich American Ins Co 16535 The Home Depot, Inc. New Hampshire Ins Co 23841 Home Depot U.S.A., Inc. I NSURERC: P -__._..._.__.._.._. 2455 Paces Ferry Road NW INSUI3ER0: Illinois Natl Ins Co 23817 ------------------------ Building C-20 INSURERE: NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanta, GA 30339 _._,.....__.. _ INSURERF: Illinois Union Ins Co ---_27960 COVERAGES CERTIFICATE NUMBER: 19834682 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ---`----------- -- ------- ------ ----POLICY EFF POLICY EXP LIMITS ADUL SUER L� TYPE OF INSURANCE POLICY NUMBER MM/DDIYYYY NIM/DDlyYYY) — A GENERAL LIABILITY GL04887714-01 03/01/1' 03/01/12 FACHOCCURRENCE $ 9,000,000 DAMAGE TO RENTED 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Eaoccvrrence.- $_..--.---._.__._....____. X MEO EXP(Any one person) $EXCLUDED CLAIMS-MADE OCCUR ---- -------- — X LIMITS OF POLICY XS PERSONAL BADVINJURY $ 9,000,000 X OF SIR: $lM PER OCC GENERAL AGGREGATE $ 9,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 9,00 0,000 g - PRO- _ _ $ -.. POLICY E LOC g BAP 2938863-08 03 O1 1 03 O1 12 COMBINED SINGLE LIMIT 1,000,000 AUTOMOBILE LIABILITY Ea accident) _—......___.__..-. Ix ANY AUTOBODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPFRTYDAMAGE $ HIRED AUTOS AUTOS Peraccidenl SIR AUTO PRY $ UMBRELLA LIAB OCCUR EACH OCCUR-- RENCE ------ ---- H EXCESS LIAR CLAIMS-MADE AGGREGATE__._____ DED RETENTION$ $ C WORKERS COMPENSATION WC061967352 (AOS) 03/01/1 03/01/12 X JURY LIMIT ER ------ - AND EMPLOYERS'LIABILITY D ANY PROPRIETOR/PARTNERIEXECUTIVE YIN WC061967354 (FL) 03/01/1 03/01/12 E.L.EACH ACCIDENT $ 1,000,000-- OFFICERIMEMBER EXCLUDED? N❑ N/A 03/01 12 _ E (Mandatory in NH) WC061967353 (CA) 03/01/1 / E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below C Workers Compensation WC061967355(KY,M0,NY,WI, )03/01/1 03/Ol/12 F TX Employers XS Indemnity TNSC46244151 (TX) 03/01/1 03/01/12 Occurrence/SIR 30M/lM E Workers Compensation WC1192378 (QSI) 03/01/1 03/01/12 SIR 1M DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HOME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C-20 ATLANTA, GA 30339 (.- USA ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD jfiero_hd 19834682 i T^+, ? ..,.. �T'?....L- C~�. �.iV :l'i.�.1:1Y.i :.•'S AL.:c. i. =6�_- e -.5 1.� .y. -:�v.0 .Lio ER Horne. Improvement Can'tTa.Lior RegiStradoll Type.' Inctividual ... :... ...:.. . Enitat{on: 11012011 Try GSI? TWOTHY H,6,USCOM ... -. .: 4 CIRCLE DR- _ -,-.— •:-• tJpdate.Address and return card.;dark reasata for chau c. t Address i Renewal. `' Lm FAI- .w�r,.r�.e%_fJDlf.�6At..�,vine'!6--'^'^'^....°•.m.,-.-,„"""''..a."a.,".'.. � ... . .. ✓�+.8 T7>::r:,:t;::�FCf%*"i..� Cpt•'�T�Lrlr.`CG�?'FG4✓.IitC _ _-,,,�°"`.,-.-_._--__ license or registration valid for inaividtil uSc on, on tz " _ 0"fice orCoimaier:t.miirs�F Rusiae•t REP U4tioa .c .: before the es iration date, If found.return to: 4:1p`•. a.:: NWE IMPROVEMEriT CQRIRACTOR � ---�- -- Office of Consumer Affsirs and$usine�s R.egu}�cico ;n Registration: 14912a 10;Park Plsxa-Suite 51.70 wLL' EXpiretiQrl¢.:.;11129,<Q^,1 Tr# 2902C _.._..._. Bustoo,NIA 02916 Tvpe::::<1 d'i5 u31' WA7R7R::. ;✓•vti.%1A 02-571 C r crseecetar� Y 147oE v d wztGo 9�gftaCure — .bglaYrr1104 of Public `afrt 6u.u•tf {,t Buitairv-, K -waru,u. :uul 4.utt! a tl Canstruction Supervisor Specialty License License: CS SL 99162 Restricted to: WS TIMOTHY HANSCOibi 4 CIRCLE DRIVE WAREHAM, MA 02571 ExoFration: 6f4Pz013 Tr=: 16331 HOME IMPROVEMENT C0NTRACT PLEASE READ TINS '• p ( t Sold,Furnished and Installed by: Branch-Name: Boston' Date: 1,f6 t \ 'ID At-Home Services,Inc. d/b/a The Home Depot At-Home Services 345A Greenwood Street,Unit 2,Worcester,MA 01607 Toll Free(800)657-5182;Fax(508)756-8823 Federal ID#75-2698460;ME T is#C 02439t Rl Cont.Lic#16427 Branch Number:31 C r 1.ie#H1C.0565522;MA H nprovemeru Co'IZ orr Ric'g.#126893 Installation Address: O City re- Zip Purchaser(s):`n`n G Work Phone: Home Phone: Cell Ptwne: Home Address: State Zip 'w (If different from Installation Address) City E-mail Address(to receive project communications and Home Depot updates): ----------- ----- ❑I DO NOT wish to receive any marketing emails from The Home Depot A F ProSect Information: Undersigned("(:ustorner"),the owners of the property located at the above installation addrass,agrees to buy, and THD At-Home Services,inc.("I41e Home Depot')8grtxs fo ftanrsh deliver and arnmge for the installation("installation'') is. this all materials described on the below and on the referenced Spec Slaeet(s),all of which are incorporated into tlti;Contract b y. t reference,along with any applit:ablc State Supplement and Payment Summary attached hereto and any ChemKc Orders(collectively, H41 JV ti) "Contract"); Job#: trot+w aerate) rooducts: Spec Sheet(s)#: Pro-ect Amount ❑Roofing ❑Siding mdows' Insulation $ ❑Gutter/Covers ❑rmtry Doors [] - ❑Roofing [ Siding ❑WindowsW❑InsulalionTT $ t ❑Gutters/Covers ❑Entry Doors ❑___._ _ / O ❑Roofing ❑Siding VAndows Insulation $ (`J, ❑Gutters/Covers ❑Entry Doors❑._... .._.. ❑hoofing ❑Siding ❑Windows_❑insulaiirio_---- $-- ❑Cuuers I Covers ❑Entry Doors f_l Mioam=25%DepositofCmaadArmuntdneup--told-OFtk&cMract Total Contract Amount $ Maine Pun twy�ns may nut depowt rrats than one-third of the Couttad Amount Customer agrees that immediately upon completion of the work for each_Product,Customer will execute a Cuurpleliou Certificate (one for each Product as defined by an individual Spec Sheet)and pay any balance Aue. A.s applicable,each Customer wider this Contract agrees to be jointly and severally obligated and liable hereunder. The Home.Depot reserves the right to issue a Chance Order or terminate this Contract or any individual Product(s)included herein,at its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to.a structural problem with the home,environmental hazards such as mold,asbestos or.lead paint,other safety concerns,pricing errors or because work required to complete the job was not included in the Contract. 91- Payment Summary The Payment Summary# included as part of this Contract, sets forth the total Contract amount and payments required for the deposits and final payments by Product(as applicable). NOTICE TO CUSTOMER Lefton CertiGcatc(note: You are entitled to a completely filled-in copy of the Contract at the time you sign. Du not Sign a Comp there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product is complete. In the event of terminatioD of this Contract,Customer agrees to pay The dome Depot the casts of materials,labor,expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination,plug any other amounts set Forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE. HOME DEPOT FROM THE DEPOSiT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT I.iMTI'ING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees and understands that this Agreement!s the entire agrccmi tit t>ztween Customer and The Home Depot with regard to the Products and Installation services and superstxics all prior discussions and agrcetnents,either oral or written,relating to said Products and installation.This Agreement cannot be assigned or amended except by a writing signed by Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily ar;cepts the terms of and has received a copy of this Agreement. ce by: q Ault.' by: t's Si nature Date Cost mer s Signature arc X Telephone No. Cu is Signature Date Sales Consultant License No. (as applicable)_ CANCELLATI )N: CUSTOMER MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT .13Y MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT- THE STATE SUPPi EMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE, NOTICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE ItFVERSB SIDL+AND AR>s PART Ot'TIIIS CUN't'ltACT 1229-10 GSC White-.Branch File Yellow-Custtaner r;...;. . as ILZZZ9T_60S: "ON Xtid pp6we[' W063 id Wti6I:8 L00Z bZ Q