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0911 PITCHER'S WAY
�, g1j�i�� hers � � i f YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$�0.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (whictf perate.) Business Certificates are available at the Town Clerk's Office, 1"FL., 367 you must do by M.G.L.-it does not give you permission to o Main Street, Hyannis, MA 02601 (Town Fall) DATE: ( Fill in please: APPLICANT'S YOUR NAME/S: �i//%cf L) a ' YOUR HOME ADDRESS: pia;+: F,� BUSINESS �i;a c�Fi6 }T4.!aTt)I� t �'•'f r'a"' 1714 2— �O yi L4/t2 i S /�'1/Y G'-'G TELEPHONE # Home Telephone Number 5 SS 0P- NAME OF CORPORATION: NAME OF NEW BUSINESS v G-r'�P Cape 1~ kS-or,r TYPE OF BUSINESS C�Sc i �/?fra o� IS THIS A HOME OCCUPATION? YES' _NO ; M NO - — ! O Assessin ADDRESS OF BUSINESS v;rs L✓ itir�1s o -601 AP/PARCEL NUMBER ( g) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you'may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to mare sure you hive the appropriate permits.and licenses required to legally operate your business in this town. 1. BUILDING Col ISSI NER'S cE MUST COMPLY WITH HOME OCCUPATION This individ al h an,-inf r of y rmit req irements that pertain to this type of businessRULES AND REGULATIONS. FAILURE TO COMPLY MAY RESULT IN FINES. �A hor' ed q`Lg a e** i OMMENT l l �� Cn rX 2. BOARD OF HEALTH N u9 This individual has,�/ep infor ed of�the p r i�requ' e ents that pertain to this type of business. Authorized ._nature** � 'YW�l1ALL COMMENTS: A 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: Town of Barnstable Regulatory Services OFTFIE Richard V. Scali,Director Building Division • BARNSTABM 9 MAM $ Tom Perry,Building Commissioner .9 3 i 6 ♦0 1°rE °i 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Approved: Fee: Permit#: HOME OCCUPATION REGISTRATI Date- Name: � d 11 Uf—y Phone#: '�F -,?--7Z F Address: 7`� Pd% (�,+.(� S I/" Village: pyelt?n4-Y Name of Business: /l U l b �' �C `�� O'S 6 h VLF Type of Business: C-5 0-0 h't I C DY Map/Lot: INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the . following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter, odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There are no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary,Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. , • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. I,the undersigned,have and agre th e restrictions for my home occupation I am registering. Applicant Date Homeoc.doc Rev.103113 i TOWN OF BARNSTABLE Date:66 TOXIC AND HAZARDOUS MATERIALS O-N—SIT --IN/-EENT0RY� NAME OF BUSINESS: lJ D 6t,��5 zc Jr (Nis 6 0 r I BUSINESS LOCATION: 3i11 �; -�,�,p rS ��)t��yr , IV11� 021001 INVENTORY MAILING ADDRESS: SA vy& TOTAL AMOUNT: TELEPHONE NUMBER: 5o $ -2-172 &1 I� CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: SOS Zhb LJU?Y MSDS ON SITE? TYPE OF BUSINESS: lASa r ovi4-r INFORMATION/RECOM MEN DATIO S: Fire District: Waste Transportation: Last shipment of hazardous waste: Name'of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum .Y Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite). Hydraulic fluid (including brake fluid) I Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes I Fertilizers Asphalt& roofing tar PCBs Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be to is or.hazardous (please list): Metal polishes - Laundry soil &stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials TOWN OF BARNSTABLE Permit No. ________- Building Inspector I JAUnaai Cash _-- rua -- �° OCCUPANCY PERMIT Bond No building nor structure shall be.erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to C & F Builders Address lot #12 911 Pitchers lay. HrBr1L iss Wiring Inspector „ Cam, l f,//'�/ Inspection date Plumbing Inspector`( Inspection date kr t Gas Inspector Lf Inspection date Engineering Department Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. 19 116- P/ Building/Inspector . I s Y e - - .F Ile a �•r'• Y d# '.:, . • - ,•.r<-. 1':: rw3.. i '> t A P - ,.•;, i •r ^+�. "ate. -Yw ♦w-a," .� u r�r' 7-���i,• ,� r-4 .r__'�s� ! Y - , .: F r+� � ..� � ,} /, s ;V' � a.K,�' '• �°..�.`< r�tx+,, r .✓_�.� a#�'.F' r •* aAr �i.l�, .� a ��. Y t r d r a, • , ;CXas ,. .r u •,, �' .�,,��.t:r*a� .}xaG'� 'V .. 1,. �. �.,t. � r�4.'+,'"�� '; �. �u�•a ,'i:� •�, � ��..,.,.k..,� ,v•: ,a�' �a y �1• .. - e .`�.'.; ,yc�4 ` :,'!�• (�:..t','*-:j'.. c,'-.•' `, s. - .`. '_�' �{ „a '��F�' {:- L:� R� �,K� f M•e,1�b `��.� k ' _ a.. ..,�#; e; 'Y.> - .,;.-e•r..,. ,�„� .�" XA �Y 2` � ar �e ri ,�;-S`,..e i. 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SEPTIC SySTEMl4 `7 /' 'NSTe�LE® IN Co House number ....................,...,.. .a.. �V f...-�i WITH TITLE °° 053 EIV"RONMENT a MAX a` TOWN OF BARNSTA Cl EGULAT; BUILDING INSPECTOR APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION .................... 1� ............ �1 f �1,• ...:............................................ ........................./......... .......19... � TO THE INSPECTOR OF BUILDINGS: The.undersigned hereby applies for a permit ac a d ng to the following information: Location '-'!. �—�............`;!✓„' ........:................................................... ............................................................. Proposed Use .........................-57X� /le...:........./.. .. ..............................................I......................... ... Zoning District ` Fire District ..........��'Y' /r ....................................... . .. Name of Owner ......e7-lz:::.. ' Gl ....................Address 3-7 ..... Nameof Builder ....................��.... ....................Address .................................................................................... .Name of Architect ..............� . ........ .................................Address..................................................................................... Number of Rooms .......................0......................................Foundation . ... ..... Exierior ......... ...... GCGII�... �/�f ..Roofing .................. 5 ���........../ ......................... .... ..... Floors .G'/r' �f '� .Interior..................... . . ............................. ........................ ........ ........................ ,r4 Heating ................ '^ .. G/ ...............Plumbing /j 7................................................................................. Fireplace ............................SJi.rJ. ..........................Approximate Cost .............. .00' ........................ Definitive Plan Approved by Planning Board ------------- _'__ _----19__ Area : Diagram of Lot and Building with Dimensions Fee l SUBJECT TO APPROVAL OF BOARD OF HEALTHTJ� , I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name o° C' & F BUILDERS A � �8 Ooe --. Permit for ----.��g��.--- ' x ____S.iogl�,Ipaod'lv..l}���l] ' _-- ^ Location —.Lmt—#l2...9l1...Pitchers'Wary ^ ------ -------------- ' ' Owner ..C��_.6_]�_Buijd�r�________ Type of Construction —.���am�......................... , , / " . --.------------------~----- ' ^ Plot ............................ Lot ----------' ' Permit Granted ........... 11 ------]gOI / Dote of Inspection -----. A,s>/ . , uun, Com . � PERMIT REFUSED - / .......... ^----------' lV � wv [ --7 � ' ---------------' . . -- . ^ - ` --- .— ------' .. --. --. . . . ..�--.�..�'��... .��--------...----.. ' ' ' � -----.-..—..�--.—..------...---.— ' -----------.—.------.. . . --------------'^^^^^^^^' At5j��!ffe Assessor's map and lot number .GC.>S,,....`..�r / THE �oF Tod / (J/ P f Sewage Permit number .` .... �................................... y t BJHH9TABLE, i House number ................U,�..(../.....................:.. ....... .... 9O 11ne6 O i639• \e0 TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION ....................4�e ............ ............................................................ ....................... .!=:... .......,9... � TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location �•..�U ./C ,//�h5 ............................................................... ProposedUse ....................... a/�!U a�✓..�'�............. �........ .!..le ...................................................................... Zoning. District / Fire District ...........�`r�?� ���_ Name of Owner ...... ......,j �E,.,15....................Address ......? �. . �'��. ...... !�? � /�;�/., '........ Nameof Builder ..................��. i.',✓.� ....................Address .................................................................................... .Name of Architect ..............""�,.. .......................Address .................................................................................... �t —7- Number of Rooms ...................... ......................................Foundation ... Exterior �i//�//(' ...... ' '4/'���.....,`�>�l/ � ..Roofing ....................;?.......;5 Floors f!��' G� /� ..........Interior ................................. Heating ....Plumbing / � J............................ �...........( ........ ............................... Fireplace ..:.........................;... ... .........................Approximate Cost ..............�.�0620.... .................... Definitive Plan Approved by Planning Board ---------- ' ______19___ Area ....` ..... ... Diagram of Lot and Building with Dimensions Fee ../........................... T SUBJECT TO APPROVAL OF BOARD OF HEALTH t I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. �2 Name ...... �al..� �k%..��. . � .1.. ................ �. � C & F BUILDERS =272-1 23098 One Story ry No ................. Permit for .................................... ,K Single Family Dwelling ............................................................................... Location ,Lot #12...91.1. . ....Pitchers. . . . ...Way... .. . .... .... .. .... .. ..... . Hyannis ............................................................................... Owner C & F Builders .................................................... Type of Construction Fr.ame .... ................................. ................................................................................ Plot ............................ Lot ................................ 4 ' Permit Granted .....! !ay.y. ..11. .................19 81 Date of Inspection 19 Date Completed ......................................19 PERMIT REFUSED ................................................... .. 19 ........................................... .................................. .................................. ........................................... ..... _ ......................... .......... '• Approved ................................................ 19 ............................................................................... ............................................................................... °Fz r Town of Barnstable *Permit# Expires 6 niontlis f on,issae date Regulatory Services , Fee 1ARNSTABLE, i v MAC Thomas F. Geiler,Director i639. pTED Mpi A Building Division - RE'Si PE RP IT' Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 D C C 2 3 2009 www.town.bamstable.ma.us OWN Office: 508-862-4038 a + 9(� A . EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Prop rty Address L , � �' o'`� At, 1 Residential Value of Work C b J Minimum fee of$25.00 for work under$6000.00 0,41 Owner's Name&Address Contractor's Name . Telephone Number LSD Home Improvement Contractor License#(if applicable) q �lT i Construction Supervisor's License#(if applicable) 700 / 7 ❑Workman's Compensation Insurance Check one: ❑ I aga sole proprietor ❑.14m the Homeowner . I have Worker's Compensation Insurance Insurance Company Name W " Workman's Comp.Policy# Copy of Insurance Compliance Certificate mus accompany each permit. 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) ❑ ReXse #of doors Replacement Windows/doors/sliders.U-Value �. S (maximum.44)#of windows *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: Q:\WPFILESTORMSUilding permit formsEXPRESS.doc Revised 090809 The Commonwealth of Yfassacltusetts Department of Industrial accidents Office Of Investigtations 600 Washington Street Boston, ! 4 0�111 ic�aw,r,.ass.govr''diai. �'iurnbers `Workers' Compensation Itisrrance Affidavit: Builders/Contractorsi l lease Prink Legibly Applicant Information ' - I,r/L' Name (Business/organizat,)nlIndividuai): Address: v _ Jam— .�T C� ' Phone#: - , ti - 3531 City/State/Zip: T � � ,�. �G Type of project(required): you an employer? Check the appropriate box: 6 ®Remodeling construction 4. [] I am a general contractor and I[A�re . 1 am a employer with have hired the sub-contractors employees(full and/or part-time)_* 7. listed on the attached sheet. 2.❑ 1 am a sole proprietor or partner- These sub=contractors have 8. ❑Demolition ship and have no employees employees and have workers' 9 Building addition working for me in any capacity. comp.insurance.x [No workers' comp.insurance 5 We are a corporation and its I0.❑Electrical repairs or additions required.] officers have exercised their 11.❑plumbing repairs or additions 3.Q I am a homeowner doing all work right of exemption per Iv1GL 12.0 Roof repairs myself. [No workers' comp. c. 152, §1(4),and we have no 13 Other . insurance required.]t employees.[No workers' comp.insurance required.] °Any applicant that checks box#l must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are additional doing sho all wing thrk e name o then 'f the sre ub contractors and state whether or de Contractors notsubmit a new ahosetent ties havech. Contractors that check this box must attached an add 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: 3 / l 0 `%J / �/l S Expiration Date: -�/�,� Policy#or Self-ins.Lic.#: �7 �� 1O l 0)-co 4 City/State/Zip: � I Job Site Address: Lite Attach a copy of the workers' compensation policy claration page(showingto the im osttion of criminal penalties ofa Failure to secure coverage as required under Section 25A of s civil c. 15a can lead p e u to S1 500.00 and/or one-year imprisonment,as well as civil fthisjes in the form of a STOP WORK statement may be forwarded to the IOffffice of a a fine fin p of this of up to$250.00 a day against the violator. Be advised that a copy Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided bove is true and correc 3 Phone#: — F6. O se only. Do not write in this area, to be completed by city or town officiaC Permit/License# own: uthority (circle one): of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Phone#: Person: �J/ LJ/ LUVJ .VJ JJIVL 1 MVL 4.I1 P ' �l:u�;tchu>ctt� - Drp:u•tnt�nt 111'I'uhlir �;tlrt� 1 Rwir l lot'Buildin. Rc%ulaliun. antl st;uld,31'l, Construction Supervisor License License: CS 70077 Restricted to: 00 JOSEPH C OUARTE 15 FALL ST WAREHAM, MA 02571 Expiration: 12/30/2010 r Imuni..illnrr Tra: 7662 \ Bo ard of BuildiOg 1"90A'i0n5 pnd jhnrlarJs a HOME IMPROVEMENT CONTRACTOR r , Registration: 132349 Expiration: 1/11/201.1 TrO 278918 Type: Partnership. J &J Remodeling Joseph Duarte 15 Fall St. Wareham. ma 02571 Auministratur _ y I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigailons 600 Washington Street -- Boston,MA 02111 _ www mass gov/dw Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Avylicant Information Please Print Le i Name(Business/orguantion/Individual): Address: W s City/StateMp: Aodag at Cam- Phone#: e©_ Are you an employer?Check the appropriate box: Type of project(required): .. 1.01�am mployer with 4. Q I am a general contractor and I 6 ❑N construction ees{full:and/or part-time).* have hued.the sub-contractors 2. I a sole proprietor or partner- listed on the attached sheet. 7. URemodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurances 9. ❑Building addition required.] 5.-❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' .com ' right of exemption per MGL p 12:0 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 wdoing all work and then hire outside contractors must submits new affidavit indicating such. *Contractors that check this box must attached.an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp..policy number. I am an a to er that is providing workers'co ensadon insurance or a to ee& Below is the o and job site mP Y P g mP I my mP Y P �' 1 information. Insurance Company Name: Policy#or.Self-ins.Lic.#: Expiration Date. Job Site Address: I ?;. City/Sta dzip: P Attach a copy of the workers'compensation policy d laration page(showing the policy nu r 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 thin statement may W.forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify rider, a its an enahUs of perjury that the information provided above is true and correct Si afore: Date: 3 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#: Informtxon an;d Instructions M 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; J express or implied,oral or written." An emWlover is defiped as',an individual,.partnership,also.ciation,corporation or other legal entity,,or any two or more of the foregoing engaged inr8 joint enterprise,and including the legal representatives of a`deceased employer,or the receiver or tnistee 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 1d'o 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." II MGL chapter`152,§25C(6)also states that"every statte.ox.local licensing agency shall withhold"the issuance or "renewal of a license or permit'to'operate'a business or to constract baildings'in the commonwealth for any applicant*h'o has-not produced acceptable evidence of compliance with lth&`tnsuranee 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 untit acceptable evidence of compliance with the insurance requirements of this chapter live been presented to the contractuig authority" Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if tiftessary;supply sub-contractor(s)name(s),address(eq-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 siga and date the affidavit. The affiidavit should be returned to the city or,town that:the application for the perirtit or license ja being requesteti;:got the Department of Industhal Ad.cident% Should'you ha*- any questions regardingtlie law or tif'you are required to.'obtain a workers' compensation policy,please call file Department at the nur fiber listed below. Self-insuredepmpam,es should enter their' a- -::self insurance.license number.on the ate lime . ; 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/l!&'nse tiumber which will be used as a.reference number... ln.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.'"a111ocations'm_ (eity;or towii)Y A�copy o`f�the affidavit that leas beQa vffiicially stWnped or.marked by,theteity.or town y be prov-ided xo the applicaiitasi roof that a>valideffidavit•is oitfile.for future percpits or.licenswA.-inaw afi'idavit,mustbe filled out each ,.year.Where.a home owner.or citizen isi abtoining a license or perm t riot related.to any business:or:commercial venture, (i.e.a dog licensor pern it,to burtrleaves.etc)saUperson is NOT required.to-complefte:this a dayit. Tlie>Office-of Investigations;would like to thank you imadvance.for your:caoperatioa and.shou d you Uvp.any questions, please do not fiesitate to give us a WE M The Department's address,telephone and fax—number: The Commonwealth of Massachusetts D ent of Industrial Accidents ' Office of Investigations 600 Washington Street Boston, MA 02111 ek4o ASAETel.#617727-4900 f � - Fax# 617-727-7749 kevised 4-24-07 _ www.mass.gov/dla DEC-07-2009 12:57 HOME DEPOT HYANNIS P.001 HOME IMPROVEMENT CONTRACT IILEASE,R3;A',D;rTHLS " _ Sold,Furnished and'Installed by �JJ( Branch`nine.cSost Flu Datr f�]JJ—el .. - TkLp AL Home Servic .lnC d/b/a The Home QLpotAt-Home Scr ices 345A GreeawoQd Street Untt 2 Worcester.lvl�S O1607. Brunch Number 31 Toll Free(800)657 5182. F&x(508)756-8823 "Fcitcnil lD#75=2698460,ME 1rc4t CO2439;'MT ni,1 mil 164n- t, - % GTl ic#S65S22;'ISIP:'Ho c Improveuie'trC ntractor Rzg_'#126893 Installation Address; . . _•... �.; ,.,.0 State, lip. Purchwr(s): I: Work Phone: Flume Phone. -Phone:: n Home Address: (If different from.lnstt l]alioa kid—revs.• . City. State, Zip E-mail Adttress(zo're eeive.projcct:wmmunicauonc•and Home Depot updates) •= []•I DO;NOT swish to reeeiye any.•mark4ng'emarls from:The Howse-Depot :. Pri4ect':TiirirrtnatTo6 Th&rsigned('Cte"mer');thc-6wners;6f•the prdperry ktcated at-the;above•'mstallation address;ggrecs to hay, and THD At-Home Sirvice,,,-lnc.("The Home Depot")agrees tafuxrtish:dehver•aridarrgrtge,tor tttc Installatian{`'Installation")of all.materials describe!i on the.below and on the referenced,Spcc•Shcet(s).-all•of which are.iaeorpo-ratea into•this Contract by,this referencc.,.alon with my applicable Sfaie Supplement ai'd'Payment Sumittaiy atttchcd hertitn and.any Change Orders(collectively, "Contract"):' .. - .., _ :_. ... ..... r Job fii ta«��t>ua > .:f. .:::..-. ucK.¢. ,. ' � ,�'•- ;,y._. Sheet s'tfc,. , :• .•: Piro'edAtriount'.. i •RpotSxrg• = Sidi :. Windows •In4ulitli0ri, ,; :.�•. ":. ,, , $....: (]Gut&�ICovcrS�OEntiyDooc�c`:�• ' '�i:. .('}_�• Roofing Siding Windov+5' Insulating'_" ... _.: .. .,.,�Cititrcts•'/'Covets.DE»uy Doors�Q_•.��.:.�'. ., . . ... .- .. . 12ooflng. •Siding windows. Insul�uon,.. . j..$ .-DOuutrs/:Covets lE]Etttty Doors;E3 • .. .. RooCmc Siding..• Windows' �,'.lrisulatioia: '; � .• ., •. ���i ` i ©Crttttcrs/Corers'[]EntryU(xira �: s. .. Mini 25 0 +lf Contract Amotmt due u eautavtton o£this CO2n CaLti•, mum pun � . . , . .•...:• .. , .;Total Coittrsct Amount; Maine Purchase ma)not deposit more than one4hird of the Conti-Act Amount Customer agines that.i4tuntdiately tp6n cotnpietiom of the work'fbr ettcti l'toi3rict;Gristamei w;tlJ:axecute,a Completion Cerifcate (uric for reels' 'iocIuct `s efitied by au_indiVidtialfSpec Siieet)sand`:pay ally"balance'due.' As appliczlile;reels Customer under thi's Compact agree;to be j iintly and severally obligated and liable here The Iiomc Depot reset ives•dte•ngtx tojc,uc•a Change Order or terminate tht,Contrhu or any,individual products)included herein,.at its.discretion,if The fl>mc DcJxx or its authorized service providl i•dctermines that it cannot perform it's 6bgauons due_to a structural problem with the hum environmental,lies u ds such m as old;asbestos or Iced paint other safety concerns pricing errors or because worn rcqutrc d to cozu fete the lob was not inetu4c-d ia'thc ConoQact'Q Parntent:Summary:' The Paymcnt:,SuxOinaty..# !� ^' ` =tncluded.ac:paxt of.,this.Contxat�,.sc:ts Corth-the-total Contract amoi ntund.r lyateutsrequired for,:the:dcpoaiLs)andfin31•psymeri&.by:Pmduct{as•applicable). NOTICE TO-CUSTOMr12'" You are:entities•xa'a'•briiplctelyfiWdd&,copvor the Contract-'a the bnci you'sign 'DaTiofsignaC�mpletionCertificate{notr. there-is Oise-Completi bn Certificate for each listed Productats deftcd,.by-individuat-,Spec Sheet,;..before'work:owthat•Y'rodu'et is complete. In the event of terms;iation of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses and services provide!I by The Home Depot or Authorized Service Provider through the date or-termination,plus any other amounts set forth in,his Agreement or allowed under applicable law. THE HOME DEPOT MAY WITti<H6LD AMOUNTS OWED TO THE IIDME DF,POT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HO VIE DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Autl.nrization; Customer agrees and understands that this Agreement is the entire agreement between Customer and The Home Depot:vith regard to the Products and Installation services and supersedes all prior discussions and agreements.either oral or written,relatin:'to said Products and Installation.This Agreement cannot be assigned or amended cxccpt by a writing signed by Customer and The dome Depot.Customer acknowledges and agrees that Customer has read,understands,voluntariI accepts the terms of aad seem�d a copy of this Agreement. _I �c�►tcd y: ! Suomi by: �! X us 1 e ! Datc Sales C o sultant'; "gnature Date _ O Telephone No. � � Customer's S4 a Sales Consultant License No. C:ANC LLA_TT_ON: :CUSTOMER MAY CANCEL THIS (aa tipntc) AGREEMENT WIT]LOUT.PENALTY OR OBLIGATION By DET.YvERING WRITTEN NOTICE TO THE. HOME DEPOT BY MIDNI GHT.ON THE THIRD BUSINESS DAY AFTER SIGP iING THIS AGREEMENT, THE STATE SUPPLE i DENT ATTACIIED HERETO CONTAINS A f ORM TO USE, W ONE IS SPECIFICALLY PRESCRIBED BY . LAW IN CUSTOMER'S STA,`F,. J NOTlCF.A00jT nNA't;TFRNIS AND CONDITIONS ARE STATED ON TILE REVERSIE SW,ANV ARV PART Ole THIS CONTRACT 6-10-09 C-SC ! whftou7.&LrnmFile Yellow-•CuStiaiec_,t•Pink.7.SalOS4DC) UI%QU.,- : ..- r P,,+ard of Suddin ite_uiateuus nud Standard HOME iiN1PROVEMENT CONTRACTOR Registration: ^,M93: Expiration: a, 2C'C TVW: e L-?ome Depot t•iam�Se+b e kRREht OEMERS 32oo CCBB GAL ERiA.PK&Y#24 -:,ANTA.GA 30339 AdminiStrawr License or registration valid for indiv-idul use oe4 before the expiration date. 1f found return to: Board of Building Regulations and Standards One Ashburton Place Rm 130t Boston,412.02108 vaot valid w•ithotAt sk.nature ATE ACOR®,M CERTIFICATE OF LIABILITY INSURANCE 1 O 0 2/202/20 lDD/YYYY). /09 PRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Mars4 USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR homedepot.certrequestQmarsh.com ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 3475 Piedmont Rd NE, Suite 1200 Atlanta, GA 30305 Fax (212) 948-0902 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Steadfast Ins Co 26387 THD At-Home Services, Inc. INSURERB:Zurich American Ins Co 16535 2690 Cumberland Parkway INSURER C:NATIONAL UNION FIRE INS CO OF PITTS 19445 Suite 300 Atlanta , GA 30339 INSURERD:New Hampshire Ins Co 23141 INSURER E:Illinois Natl Ins Co 23817 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. rINSR DD' - POLICYEFFECTIVE POLICYEXPIRATIONN R POLICY NUMBER DAT MM OD DATE MM/OD LIMITS GENERAL LIABILITY IPR 3757 608-02 03/01/09 03/01/10 EACH OCCURRENCE $4,000,000 DAMAGX LIMITS OF POLICY ARE EXCESS PREMISES ES(RENTED 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea ocdurence $ CLAIMS MADE aOCCUR "OF SIR: $1,000,000 PER CC" MED EXP(Any one person) $EXCLUDED PERSONAL B ADV INJURY $4,000,000 GENERAL AGGREGATE $4,000,000 GENI AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $4,000,000 X POLICY PRO- LOC B AUTOMOBILE LIABILITY BAP 2938863-06 03/01/09 03/01/10 COMBINED SINGLE LIMIT $1,000,000 X ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY (Perperson) $ SCHEDULED AUTOS _ HIREDAUTOS BODILYINJURY (Peraccident) $ NON•OWNEDAUTOS X SELF INSURED AUTO PROPERTYOAMAGE $ PHYSICAL DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY-EAACCIDENT $ ANY AUTO EA ACC $ OTHERTHAN AUTO ONLY: AGG $ A EXCESS/UMBRELLALIABILITY IPR 3757 608-02 03/01/09 03/01/10 EACH OCCURRENCE $5,000,000 X OCCUR CLAIMS MADE AGGREGATE $5,000,000 $ DEDUCTIBLE $ RETENTION $ $ WC STATU- OTH- C WORKERS COMPENSATION AND 3566916 (CA) 03/01/09 03/01/10 X RYLIMITS R D EMPLOYER$'LIABIUTY 3566915(AOS) 03/01/09 03/01/10 E.L.EACH ACCIDENT $110001000 ANY PROPRIETOR/PARTNER/EXECUTIVE E OFFICER/MEMBEREXCLUDED? 3566917 (FL) 03/01/09 03/01/10 E.L.OISEASE•EAEMPLOYEE $1,000,000 If SPECIAL E.L.DISEASE-POLICY LIMIT $1,000,000 under SPECIAL PROVISIONS below. OTHER D Workers Compensation 3566918 (KY, MO, NY, WI, ) 03/01/09 03/01/10 F TX Employers Excess TNSC45694422 (TX) 03/01/09 03/01/10 ccurrence/SIR 25M/2M C Workers Compensation 4801323(QSI) 03/01/09 03/01/10 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS RE: EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION TITD AT-HOME.SERVICES, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 2690 CUMBERLA4D PARKWAY IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR SUITE 300 REPRESENTATIVES. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE USA ACORD 25(2001/08)ckomraus hd ©ACORD CORPORATION 1988 11172180 A �, CERTIFICATE OF LIABILITY INSURANCE 03/`19/zoos' PRODucER (508)295-4440 FAX (SO8)295-S864 THIS CERTIFICATE.IS ISSUED AS A MATTER OF INFORMATION Paul B. Sullivan Insurance Agency Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 2870 Cranberry Highway HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P. 0. Box 551 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. East Wareham, MA 02S38 INSURERS AFFORDING COVERAGE NAIC# INSURED 7 & 7 Remo eIing INSURERA: Vermont Mutual Insurance Co. 26018 1S Wilson Way iNSURERB; Commerce Insurance Conpany 34754 Middleborough, MA 02346 INSURERC: INSURER0: INSURER E: --OVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DO' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION D LIMBS GENERAL LIABILITY BP11020S20 03/22/2009 03/22/2010 EACH OCCURRENCE E 1,0001000 X COMMERCIAL GENERA_LIABILITY DAMAGE TO RENTED f 50,000 CLAIMS MADE Q OCCUR - - MED EXP(Anyone Person) S S,00 A PERSONAL&ADV INJURY b 11000,000 GENERAL AGGREGATE b 2,00 0,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG S 2,000,OOO PJLICv JECT JEGT LOC AUTOMOBILEUABILITY QVZ276 11/26/20.08 11/26/2009 COMBINE)SIN I GLE LIMIT ANY AUTO (Ea accident's $ ALL OWNED AUTOS - X SCHEDULED AUTOS 0 INJURY S B (Peerr peiason) 100,000 HIRED AUTOS BODILY INJURY S - NON-0WNEDAUTOS (Peraccidentl 300,000 - PROPERTY DAMAGE b (Per student) .100,000 GARAGE LIABILITY - - AUTO ONLY-EA ACCIDENT S ANYAUTO EA ACC $ OTHERTHAN AUTO ONLY: AGG S EXCESSIUMBRFILA LIABILITY - EACH OCCURRENCE $ OCCUR ❑CLAMS MADE AGGREGATE 3 S DEDUCTIBLE $ RETENTION S S WORKERS COMPENSATION AND - WC STATU- OTH EMPLOYERS LIABIUTY ANY PROPRIETOR/PARTNERVEXECUT:VE E.L.EACH ACCIDENT S. OFFICERlMEM8ER EXCLUDED? E.L.DISEASE-EA EMPLOYE S 'Dyes-,Oesai)e Under SPECIAL PROVISIONS below E.L.DISEASE•POLICY LIMIT b OTHER DESCRIATION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS HID At Home Services, Inc are included as additional .insureds ith respects to general liability linsurance CERTIFICATE LD R LATI N SHOULD ANY.OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NA MED TOTHELEFT, THD At Home Services, Inc. BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 2690 Cumberland Parkway Ste300 OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Atlanta, CA 30339 AUTHORIZED REPRESENTATIVE J Edward Sullivan/HELENA ACORD 25(2001/08) FAX: (S08)791-8041 ©ACORD CORPORATION 1988