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HomeMy WebLinkAbout0098 TOWER HILL ROAD � o . � � � e o a a �� , � a o ry �� �' � u a ' 1 � � �. � r D'. � e � �� r r e e �� ., o �. � - � p i 15-�Assessor's office (1st floor): 0 �, e THE C , ssessor's map and lot number ..........0 .. � T `✓� .......... ........ 916Board of Health (3rd floor): d� o" Sewage Permit number ............l l`�.... - .��` 1� ...1!7!<► ' !} -�( j�-� j:hl'R !• C Z BARB 9TOBLE. Engineering Department (3rd floor): \ 'oo MAO& House number? \0� �'�o v d 639- Definitive Plon `Approved by Planning Board ---------------------------------19________,. APPLICATION PROCESSED 8:30-9:30 A.M'. and 1:00-2:00 P.M. only T-OWN O�F 13ARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ... .u.!.�..�........4 G.A...!ol°.�r:....................................................................... TYPE OF CONSTRUCTION ...........�. ...........i..y?.mo..P....:......................................................................... a ........... ...........1........19.X-.��_ . TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ......7 .9...... .B.W.. %.r........�!L. . .... �hr.............(IS .�f.V!Ik �n................................. .. Proposed Use !.1n..g... e............d. ..... � ra.t:.i'..LI^f.�^.A........... ���,7��!.a....... . - Zoning District ...... ......1...........................................................Fire District ....:-.G'..Yl....�...........,.Q..........:.......�'..........�:��::...... i Name of Ownerl!..1. '..�Y!1.9.1!..5:.....3 �.r('..........Address .......l...P..... .G�(!. !":..�i�t.!.I....'1� ...... �.C�i.fiil/g fit. Nameof Builder ..S.e.�f...............................................Address .................................................................................... Nameof Architect ..................................................................Address ........................................................ Number of Rooms ..............,,...'1'1.. ........................................Foundation r A Exterior ......... .`.1..W..... � P..S........................................... Roof`ng .... �.5�1?... Z t....:` .......::....�.. .. 77 Floors .......... ....................................................Interior ....9. P P..o..T t.o. ..................................................... Heating .... u.z...�. Tg...............................................Plumbing ..:. .......? .2.)1��!.:� Fireplace ..\ ..(.......•...................................................................Approximate Cost ........(.... `,•�... :..G...U. �....�......................... Area . .. ...:../.. �. .;�:. .. Diagram of Lot and Building with Dimensions Fee ? :........... .... .......................... GL( S OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of'the.•Towrt' of..Barnstable- regarding the above construction. ...:..`........ Construction Supervisor's License ..C ¢2% L............... g WHITE, RAYMOND J. A=141-030 . No ..3.187.4.. Permit for ..$u.ild...Addition . .......S .ngle...F.am�..].y...Aw..o.� �.xl ........ Location .....:f9.8. .TOWQ.r..Tji.U.-R.Q.a.d.......... ........................0 S.-to.x.V.;U.1o...........................:. Owner Raymond J. White Type of Construction ......Frame Plot .....................:...... Lot...............•................... Permit Granted .....MaY.,...9......................19 88 Date of Inspection ....................................19 Date Completed ...................:..................19 U � • 1 .1 a /Assesso"s office (1st floor): ssessor's map and lot number ....... .!�'�.1..- 00. IRE ".. ........ "Pric a Board of Health Ord floor): ,n - IIV$TA�..,.c . : < tq Sewage Permit number �.. .C4.51Y��1. ✓L� Sd (il �� Engineering partment (3rd floor): -I-- ` ENV;poop ft-�� Housenum ............................:...... ......................... —J TOWN REGU �cr+ay Definitive Plan Approved by Planning Board ________________________________19------- . LAl r�e � APPLICATION PROCESSED 8:30-9:30 A.M. and 1:00.2:00 P.M. only TOWN M BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO. .. . ........4. ... .: .c?. ...............:........................................................ TYPEOF CONSTRUCTION ........... . .. '. '... ........: .....:.:...................................................................... ........... ...........4........19. . TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: - Location .....r..�......./...!.6. ..�'r.� :.......11l.. .1....✓?J.................. 1.\ K b'! ��C ............................................. Proposed Use ... !.J t.. ..�. 1. .�'l r.1.J�j........�.Oct..P..�.l.t.?n. ................ .. ............................. Zoning District ...... .......................................................Fire District a,l 4 / V! ' ....... Name of Owner 1C`{..: V!l�.'y�.. .....J.�LU.`7.! .�..4'.........Address ..... .i7.... '.? .r..I ......!n5 C )24i. Nameof Builder ..S'.0.7rf...............................................Address .................................................................................... Nameof Architect ..................................................................Address .............................. Number of Rooms ............ ........................................Foundation ..................... J. .Q.. ...................................... Exterior .......... . .......:Roofin ..:. :So��..... �..5. ►.!-r... .J..P...S...................................... g /�`.. A?. ............................................. Floors . ..........�-.�.!' .Q...E Interior ... .�.?.p.ThU.`.!.�.............. ..... ................ Heating + .�... ....0 ?..1 f'.�...........................................Plumbing 2 I l+•r �.:�.... J .... ..... ................................................. Fireplace ...1..P-:5.:...................................................................Approximate Cost .......1...9 . =:..U..U.w......o...0 Are : . ­77. ..... Diagram of Lot and Building with Dimensions Fee qs OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. .. .. ..` . .................... Name GJ ,... � - :. Construction,Supervisor's License ... ..... .......................... WHITE, RAYMOND J. No .3 1.8 7 4.. Permit for ...Bui.ld...Ad.d.i.t.ion .... ....... ....... .... ..... .. . .. .... ' Single Family Dwelling ......................................................................... Location -....!V--Fo.we.r...Hill. . ....Ro.a.d............ ............. .... .. .. .. .... .... .. .. Osterville ... ............. ................................................................. Owner ..,,Raymond J.......W.h.i.t.e.................... Type of Construction ,Frame .................................... ............................................................................... Plot ............................. Lot ................................. Permit Granted .....May... ...................19 88 Date of Inspection ....................................19 Date Completed ............:nf.............19 J - 1 T l 414SF v i f . s I I i f I E I / 1 BROTHERS, INC. :ril5 IS A TAPE SURVEY, NOT AN INSTRUMENT Va-uVEY. DO NOT USE THIS PLOT PLAN TO ERECT R2ENE FENCES, SHRUBBERY OR ANCILLARY STRUCTURES. FOR BANK M TGAGE PURPOSES ONLY ENGINEEtS 8� SURVEYORS I ! i ..• ��-/- v i� ✓ ----------------------------- P.O. BOX 434 NAME ------------ ---�- WORCESTER, MASS. 01613 P Toy-✓G i' -sC LOCATION . - ------ -'--- -- ----- ------------ --- 1-617-852-5203 --- i REGISTRYzi, rfz 6� SCALE ------ �,-- `----------------- DATE .._Y '` 1d ----- �. - - fl, � WE, HEREBY, CER'11=Y Y}iAT TI-IDS PROPE'R[Y IS NOT IN THE SPECIAL FLOOD HAZARD O AREA AS SHOWN ON THE HUD FEDERAL; INSURANCE MAP- i3 DATED z, 7,76 • i �0 ;U 0 r i >'9B _ r , 1 -" tl3 I: L' n Cy e 1 C �° ► l i � -� 6 i sTs a. X C a v, D u b e i' I gyres / Zi STN ds "may i _ . .... .. . :.. a .::: P-r Id o r J o �ts l S, �- k I a f G ► n.C.• . S (J2`Y1 C) L4 stie I' / 2' �.c.�►'d e /G ' �. o-h 9 Mier 11r3u12 1ov1 3 'tvat1s eotCO- --� °Erne The Town of Barnstable MASS •, ■naxsTaecE. • Department of Health Safety and Environmental Services 'OrEo► ' Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 t Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: LIIU c Tc o- Est.Cost 1 D r Address of Work: l C�Gv ►- ��� ( C �� ( S p� v i��oT !/f1� Owner's Nam c,�, �, Le.."c -To Date of Permit Application: a I c( (Ri 7 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED.UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date, Contractor Name Registration No. OR �7 ` 17 L� /9 Date Owner's me i� The Canlnlonlf'ealth of.4fas achusen a:rl --===1•:.:, Deparinz nr of Indttsrrtal.4ccidems •4 ;;,, office OfI'MeSV9,71/offs \ ;" _r �, 600 !1'ashin-tun Srrcc�r Busrorr. MUSS. 02111 Workers' Compensation Insurance Affidavit �lpnlic�in�t information'• _ _ _Please PRIlVT lebi�t i , namc ( l 1 2\I erw ki M Incatian Q �I © l�1 C� t' �f ctt� C) nhcme c��0' 7�a- I4VZ 1 am a homeowner performing all work myself. FI I am a sole proprietor and have no one workina in any capacity .�•w,. �.�...� _._w.�.�.,..�ws.•wr.w.ncs..wwn+AT+!"�'....w�+!h!r7�..�f.+�.w.�.�..�Y'��'!"�'..^..'�...•.�.�..��....�_�.. I m an emplover providing workers* compensation for my employees working on this job. ennrnny name: addrevs- tiff nhnnc fi- incurince co nniicv!! �M I am a sole proprietor. general contractor, or homeowner(circle ale) and have hired the contractors listed below who ha% the following workers' compensation polices: cmmMrnv n•trnc• •rtlrires�• tiff nhnnc 0• incur-ince co nniicv _ _ , .:•�.::•-..�-•-.. _ �,.;t.. --_- -- __�---:_-,�;�••,-..ems,.... —�.•:•-_- _-�.r.`' ..-__ conman• n•trnc• - addre-c- riff• nhnnc Itc incur-tnce co nolicv a __ Attach additional She if necessary^'i?_•r_- di t^,ry y,��:�:;_•'; i�• � - +�" +•�_� ^LL+'•' �� ��";;, •���y Failure to secure ctrvcrnt!c as required under Section 25A of I11GL 152 can lead to the imposition of criminal penalties of a lineup to S1S00.00 andiur one wears*imprisonment ar%well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a cope of this statement may be forwarded to the Office of Investigations of the D1A for coverage verification. 1(10 hereby cerrfft•under t/tc pains and penalrics of pe)jure•Char the information provided above is true and correct. Sianatur� Date SL/9 1 2-7 Print name �XlQ,"O nn .T_ .i 1 Li l ['' Phone# CS QR r�d-0 �a'UL— ' official use unl_v do not write in this area to be completed by city or town official city or town: permit/llcense 11 rrtiuilding Department IC3ucensing Board C C C3 check if immediate response is required C3Selcetmen s Office ►•• �. (:]ticaith Department hone N: rI phone s. �. contact persnn• - • ' .Af I' information and Instructions r I ' - Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers''compensation fo employees. As quoted from the an entplitree is dcfincd as every person in the service of another under ar contract of hire, express or implied. oral or written. An exnplurcr is defined as an individual. partnership, association. corporation or other legal entity. or any two or the foregoing engaged in a,joint enterprise,and including the legal representatives of a deceased employer, or tilt receiver or tntstee of an individual , partnership. association or other legal entity, employing employees. Howe,- owner of a dwelling house having not more than three apartments and who resides therein. or the occupant of the d%%°elling house of another who employs persons to do maintenance , constntction or repair work on such dweliin or oil the :grounds or building appurtenant thereto shall not because of such employment be deemed to be an emp MGL chapter 152 section 25 also states that ever-•state or local licensing agency small witlthold the issuance � 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. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the pertormance of public work until acceptable evidence of compliance with the insurance requirements of this chat been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation supplying company names. address and phone numbers as all affidavits 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 regi to obtain a workers' compensation policy. please call the Department at the number listed below. City or Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the boat the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be return the Department by mail or FAX unless other arrangements have been made. The Office of Investi=ations would like to thank ou in advance for you cooperation and should you have an,% que: please do not hesitate to give us a =11. ' 1!..' .v.�l••�..� ...��.� �...Tw.}L1V.�A�-�1�.�...I w.��T..TA.��I�� h4. _ TY���M The Department's address. telephone and fax number. The Commonwealth Of Massachusetts - Department of Industrial Accidents Office st lnvesugations 600 «'ashington Street Boston,Ma. 02111 fax #: (617) 727--7749 y TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE I g 7­ / 17 JOB LOCATION Number Street address Section of town "HOMEOWNER" y -mil t U2 Namd Home phone Work phone - - PRESENT MAILING ADDRESS City town State Zip code The current exemption for "homeowners" was extended to include owner-occupied dwellings of six units or less and to allow such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Person(s)' who owns a parcel of land on which he/she resides or intends to re- side, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"- shall submit to the Building Officia on a form acQp-ptable to the Building Official, that he/she shall be responsibl for all such work performed under the building permit. (Section 109. 1. 1) The undersigned "homeowner" assumes .responsibility for compliance with the Sta Building Code -and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands ..the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE ' APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings: 35, 000 cubic feet, or larger, will be required to comply with State Building ..Co�de Section 127. 01 Construction Control. HOME OWNER'S EXEMPTION The code state that: "Any Home Owner performing work for which a building permit is required shall be exempt from the provisions of this section (Section 109.1. 1 - Licensing of Construction Supervisors) ; provided that if Home Owner engages a person(s) for hire to do such work, that such Home Owner shall act as supervisor. " Many Home Owners -who 'use , this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for , licensing Construction' Supervisors, Section 2. 15) . This lack of awarenes often results in' serious , roblems r unlicensed persons: In this case'ourrBoarda cannot rly eproceed oagainst me rthe res inlicensed person as it would with licensed Supervisor. The Home ''4wner' actin as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his/her responsibilities, man communities require, as part of the permit application, that the Home Owner certify that he/she understands the responsibilities of a supervisor. On the last page of this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. n Engineering Dept.(3rd floor) Map;. 141 " Parcel d� Permit# „C 62S 7 0 House# Date Issued Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) 8 —/I`� b(�" Fee Conservation Office(4th floor)(8:30-9:30/1:00-2:00) P"="g4) TNE 19 - 4 e BARNSTABLE. Z 7 MASS. I t4 TOWN OF BSTABLE Building Pere it`Application Projec reet Address Village © &R ►� Owner . 2i Address I c�wp;— ��� �� QcITt•v,l�� Telephone ArlI 6`Z-- Permit Request L �v1 ` First Floor / ? square feet Second Floor D square feet Construction Type Estimated Project Cost $ 10 , 6e� , Zoning District Flood Plain Water Protection Lot Size 7,P1 arGrandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure L: —6 `!r-S Historic House ❑Yes XNo On Old King's Highway ❑Yes JdNo Basement Type �)O Full Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing _ New U Half: Existing 0 New No.of Bedrooms: Existing 2_New Cl Total Room Count(not including baths): Existing s' New First Floor Room Count Heat Type and Fuel: )1 Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes '4 No Fireplaces: Existing , New Existing wood/coal stove ❑Yes 4 No - � Garage: ?A Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ • Commercial ❑Yes WNo If yes, site plan review# - Current Use Proposed Use Builder Information Name 6UAa�/, Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE BUILDING PERMIT D IED FOR E FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. . r ��'I / r DATE ISSUED MAP/PARCEL NO. i k i- �, , . ,try • . , ADDRESS ' VILLAGE ' OWNER DATE OF INSPECTION: t FOUNDATION �S 7 FRAME i O?' 2 , INSULATION. •ry r FIREPLACE ELECTRICAL: ROUGH FINAL :. PLUMBING: ROUGH FINAL ` .. 6 GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT f ASSOCIATION PLAN NO. 1 ALTERNATIVE WEATHERIZATION � 6 -1 E__1 k L9 Date: —4 � � s Town of Barnstable u "' 200 Main St Hyannis, MA 02601 Re:Pernnit�# "1/illage: -The insulation/weatherizatlon=work at 1 �' �� �Gi has'.been completed,,I.i.actbtdance with:789C1NR, Regards;. .': Timothy Cabral, President CSL-105454 58 DICKINSON STREET I FALL RIVER,MA 02721 1 (508) 567-4240 I ALTERNATIVEWEATHERIZAnON'OGMAIL.COM Application numb ... ............................................ �1 1 ® Date Issued................ ........ ................................... . FS, at . , Building Inspectors Initials... . ........................... Mox �A�UG ` 20181 Map/ .............r( o Parcel (( ++ - ((11 22 61481V .�...lJ TOWN OF B;Mf STABLE 6 EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDO WS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 6 awer 9 ft� ��P`c-�/I NUMBER � p�STREET VILLAGE Owner's Name: J (A Ir ed-[, _Phone Number ,6(f f- yA,'K6 - 7M. Email Address: ScLj�f1l °'tl A-A bD. Cw-m Cell Phone Number Project cost$ � Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize 4ft1/e. p� C to make application for a building permit in accordance with 780 CMR Owner Signature: �S c( Date: TYPE OF WORK ❑ Siding ❑ Windows(no header change)# Insulation/Weatherization ❑ Doors (no header change) # Commercial Doors require an�inspector's review ❑ Roof(not applying more than 1 layer of shingles) Construction Debris will be going to F- CONTRACTOR'S INFORMATION i Contractor's name t ithbf4wOXbd' a_ 'iV e, W OK Home Improvement Contractors Registration(if applicable) # (attach copy) Construction Supervisor's License# A05'Y S (attach copy) 04*rngAW-We4-0eri za: Uri ,A Email of Contractor Phone number J�yo :5?07'S'�y� ALL PROPERTIES THAT H E STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN. 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 the4ent have sides? Yes No (If yes please attach floor plan with exits marked) 1. 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 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 LICENSE EXEMPTION 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 APPyrAJNT9S SIGNATURE 4 V Date Signature All permit applications are subject to a building official's approval prior to issuance. Permit Authorization mass-save Forma :aza-5s tN:'�rf.�.._st'R/n._.•�rc-i - Site ID: 3426055 Customer: Nancy Komenda I, A.iJ owner of the property located at: wnees Name,printed) 98 TOWER HILL RD BARNSTABLE, MA 02655 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization --- work on my property. Owner's Signature: Date: 'Z f FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: �t�e.<<1Gi�►"ye_�(Z�2a�-�C.Q�r�za ii 7m, S o/f 6 Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: For Cffice Use Cnly Rev.102015 The Commonwealth of Massachusetts Department of Industrial Accidents 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. Applicant Information Please Print Legibly Name (Business/Organization/Individual): ALTERNATIVE WEATHERIZATION, INC. Address: 2 LARK STREET City/State/Zip: FALL RIVER, MA 02721 Phone#:508-567-4240 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 16 employees(full and/or part-time).* 7. New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] 3.a 1 am a homeowner doingall work myself. 9. ❑Demolition y [No worker'comp.insurance required.]' 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole l l.E]Electrical repairs or additions proprietor with no employees. 12.❑Plumbing repairs or additions 5.0 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.' 13.❑Roof repairs 6.n We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[E]Other INSULATION 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 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. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: LIBERTY MUTUAL INSURANCE Policy#or Self-ins.Lic.#: XWO(19)58867158 Expiration Date:6/8/19 Job Site Address: Ot•t)e l� City/State/Zip: t2/� o & l Attach a copy,of a workers' compensation policy declaration page(showing the policy number and 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,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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u d ain a p lti s f perjury that the information provided above ij trile and correct. Si nature: Date: t � Phone#:508-567-4240 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#: i ACC?® DATE(MM/DD/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE 06/11/18 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). PRODUCER NAME: Anthony F.Cordeiro Insurance Agency PHONE Ext: 508-677-0407 FAA Noy 508-677-0409 Fall Pleasant Street ADDRESS; HSouza@Cordeirolnsurance.com Fall River,MA 02721 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Liberty Mutual INSURED INSURERB: Ohio Security Alternative Weatherization INSURERC: Ohio Casualty 2 Lark St INSURER D: Fall River,MA 02721 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY CY EFF MMIDD/YYYY LIMITS INSD WVD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE I--%I ISES OCCUR PREM Ea ocwrrence S 300,000 MED EXP(Any one person) S 15,000 A Y Y BKS58867158 06/08/18 06/08/19 PERSONALBADVINJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY❑PRO- ❑ JECT LOC PRODUCTS-COMP/OPAGG S 2,000,000 OTHER: S AUTOMOBILE LIABILITY Ea BIKED SINGLE LIMIT S 1,000,000 ANY AUTO BODILY INJURY(Per person) S B OWNED X SCHEDULED Y BAS58867158 06/08/18 06/08/19 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 1,000,000 A EXCESS LIAB CLAIMS-MADE Y Y US058867158 06/08/18 06/08/19 AGGREGATE S 1,000,000 DED I I RETENTIONS S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S 500,000 C OFFICERIMEMBER EXCLUDED? nI N/A XW058867158 06/08/18 06/08/19 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Action Inc and NGRID,USA its direct and indirect parents,subsidiaries and affiliates is added as an Additional Insured for General Liability on a Primary&Noncontributory basis per the terms and conditions of form CG2001 (04/13),for Ongoing Operations per the terms and conditions of form CG2010(04/13),for Completed Operations per the terms and conditions of form CG2037(04/13)and Waiver of Subrogation applies per the terms and conditions of form MEGL0241-01 (04-11) Additional Insured for Automobile Liability applies per the terms and conditions of form SCA005(02/16) Excess Liabilitv is a followinq form. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN NGRID USA ACCORDANCE WITH THE POLICY PROVISIONS. 40 Sylvan Road Waltham,MA 02451 AUTHORIZED REPRESENT / ff I @ 19.V-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD r Mgstac-bateft,DopaiU. 660otPublic ss#dy fttid O iaiWirig$fegulaticns and;ztOAd8rds LiGeh4ZS-105464r Construction Supetvtsor TIMOTHY,CABRAL 58 t?iC1GNSON S FAIL'rtttf£R r Expiration: Ct3tfsftli SiOf of 09/08/2019 �J y t Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improveme"' ontractor Registration _ Type: Corporation ALTERNATIVE WEATHERIZATION, INC. r Registration: 175683 2 LARK ST ,4._s= Expiration: 05/28/201 9 FALL RIVER,MA 02721 4h w> ^ Update Address and return card. Mark reason for change. - '. .. 2Uit A-V,r. L,Qc_f�aL. � Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only yx TYPE:Corooration before the expiration date. if found return to: r"°"r RRwistration Expiration Office of Consumer Affairs and Business Regulation J 756$3 05/28/2019 10 Park Plaza-Suite 5170 ALTERNATIVE WEATHERIZATION,INC. n,MA 02116 TIMOTHY CABRAL 2 LARK ST FALL RIVER,MA 02721 Undersecretary Ot V Out 3! 8tur@ cAppiicat<oa Number.. .................. .. .................. ` BAMSTAXX Permit Fee............... ...........Other Fee..... 0! ................... nail Total Fee Paid .. 1"69, ................... ................................................ TOWN OF BARDtRA19'I A�L� by......14�............ (�I, 5 II ee�� S Pecmit ...... On....4.�1 .!..l.1..`... BUILDIN , , iW0 I q I 0 3 APPLICATION MV........................................Pafet....... Section 1 — Owners Information and Project Location 4/0 Project Address Owners Name N l �A� Owners Legal Address q,F t--P H ( e. City. o V-p \J \ State Zip 1 Owners Cell# ��� E-mail Section 2—Stractaral Use ( Single/Two Family Dwelling ❑ Commercial Structure over 35,000 cubic feet �❑' Commercial Structure under 35,000 cubic feet Section 3—Type of Permit ❑ New Contraction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structare) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment ❑ Sprinkler System ❑ Addition_ ❑ Retaining wall ❑ Solar ❑ Renovation ❑ P 1 ❑ 'on Other—Specify Section 4—Detail Cost of Proposed Construction p Square Footage of Project Age of Structure Dig Safe Number #Of Bedrooms Existing Total#Of Bedrooms (proposed) 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design F Last updated:11/712017 Section 5 -Work Description R�P— �2 ,D-0—p kkkem) Section 6-Project Specifics ❑ Wiring OR Tank Storage . ❑ Smoke Detectors ❑ Plumbing ❑ "Gas r ❑ Fire Suppression y ❑.Heating System ❑ Masonry Chimney ❑Addhrelocate bedroom Water Supply ❑ Public ❑ Private Sewage Disposal ❑ Municipal ❑ On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: I am using a crane C Yes ❑ No Section 7—Flood Zone Flood Zone Designation J Within or adjacent to a wetland,coastal bank? Yes ❑ No ❑ Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq.Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard Required Proposed Has this properly had relief from the Zoning Board in the past? ❑ Yes El No Last updated:I V7/2017 1 Section 9—Construction Supervisor Name l C %- T.Iph...N ��' � -Address S it tate Zip �(S License Number License Type Expiration Date I — 2— Contractors EmO AZ4( �b4Af4C/-(,nQel1# �ZS� ��(' �Zed 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' on procedures,specific inspections and documentation 780 CMR and th Town of le.Attach a f your license. Signature Date Gl/U Section 10—Home Improvement Contractor Name \L Telephone umber Address__ A�,, aA✓{-�w.� • City vf,(i State Zip , ; G �►`, Registration Number 1 Expiration Date I understand my responsibilities under the rules and regulations for Home hTrovement Contractors in accordance with 786 .CMR the Massachusetts State Building Code. I understand the 'an inspection proceduues,specific inspections and w docummentation 780M nd th Town of B e. a copy of your H.I.C... Side Date Section 11 —Home Owners License Exemption Home Owners Name: Telephone Number Cell or Work Number I ` I tmderstand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 f 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 "PLIC SIGNATURE Signature Date l� A i Z7� Print Name t e-k-f-A-e� Telephone Number E-mail permit to:— qUS ke A-1 Lag updated:I Inr2017 Section 12—Department Sign-Offs Health Department ❑ Zoning Board(if required) Historic District ❑ . Site Plan Review(if required) ❑ � Fire Department ❑ ' ' ' M Conservation ❑ For con rimfid work,please take your plans diredly to the,fire department for approval Se Eft —13--Owner's:Authorization I, ,as Owner of the subject property hereby authorize d to.act on my behalf, in all matters relative to work authorized by b&ding permit application for: _rpIA1_01. PN34 (Address of job) Si e e Toe ' tN e , i S } �r IA&Wdahm&11/7/2017 The C.Onmoxeeam o,f MessrrckMWM Dept ofIn*=WdAcis �. .]m ffo#6A; MA:0294�2#1-7 , ..• . .: :: : iviv�irusssgoirl�s •' • - '• '. - • Workers'Compe iwdon 1Gasrtranee Affidavk:General Businesses. TO k9 FILM WITH TBB PERNIITTING ADTHORM A 'cant Information Please Print 'b Business/Organizadon Name: P� ( c, �-A Address: Id City/State/Zip: Phone#: .0 S Are ou an employer?' eck the appropriate box: Business Type(required): I I am a employer with _employees(full and/ 5. ❑Retail or part-time).* 6. 0 Restzu=t/B=Sating Establishment 2.❑ I.am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(mcl.real estate,auto,etc.) employees working for me in any opacity. [No workers'comp.insurance required] S. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c.152,§1(4),and we have 10.0 Manfaataring no employm.[No workers'comp.insurance rNui ed] . •11.D I•iealh Care 4.❑ We are a Ann-profit won,staffed by volt�teers, with,no cmplvyees.[No workers' P.insuranceI?eq.] 12,0 i3 'Any#*ica1t1=checis box#1•=st also M oaft scM beloaV A&WMz#t*. MW..C==Si ri*M PaC'? ++If the co�n�e o$eecs 6�e �emsetves,butte as anhas other eotployces,a ia�o�rs'eompecsutiaar PDUq is rtgviteti end such ea oW33i7n6onshoWA chwkb=#I: - I am an employer that isprnAft workers'' bong 0nat'wri fi�sur,,,�..c!efor Bdow is thepo&y hile��.' Insurance Company Name: "�/`�2 `- (�®�`'T' Insurer's Address: 6 Vdll 4-1-1-1 City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: 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 MOL c.152 oa lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisomnent,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 copy of this statement may be forwarded to the Office of Investigations of the DIA insurance coverage 'on. I do hereby ,a and allies of perju at the Wermation provided ab e' and correct/ Signature: Date: % (/ Zqa Phon �••� 6 Official use only. Do not write in this area,to b'e compIded by.cit}r town of jf�iaL City or Town: -ker333Lilmcense Issuing Authority(eircle one): . L Board of•Health 2.lh&db*DepUtneat.3.-0*ifr6wn Clerk 4.Ucensing.—Wi 6-5.,5electmeies Office 6.Other Contact Person: •Phone#: WWWM ss.gav4R Information and Instructions MassaclBrsetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an gnplc3w 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 individwd,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 decried 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 and who resides therein,or the occupant of the dwelling house of another wbo employs persons to do mamtenano: construction or repair work on such dwelling house or on the grounds or building thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,J25C(►t)also stabs that"every state.or local Ii g agency shaU withhold the iasaancu or renewal of a license or permit do epva nde i bness•bar to constract`.hmldmgs in die. mwealth for any appmMa who-has•n of awe&Weiuz bf compgsncewWthe izurance coverage mead." Adffi ionalty,MGL chapter 152,§25C(7)states-Neither thtcommoinwealth nor any of its political sudbd"rvisiems shall' . enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance mquh=ents of this chapter have been presented to the-counting ai6ority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply your insurance company's name,address and phone number along with a certificate of insurance. LimiWd Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not requite 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 fbr confirmation of insuraacce 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 Departmmt of ladustrial 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 Icense 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 foryou to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be'sure to fill In tire.pep#ojcense number;W i yp be used asi:reference number.Id addition,an applicant drat must submit mnitipie permidliceiFsa appiicatioas m arty given yeas,heed'anlg submit one affidavit:indicating ivrneat Policy infioama#iom(rf aecessari`� 1 c oftiie:affii Las beers offieiallystabnped"orrlced iiythe ciiy"or town may be provided to the applicant as proof @iaf a valid affidavit is oa:file for future'penpits�or licenses..•A new affidavit . must be filled out each year Where a'home owner or•chixeri is.owint ing.a license or permit not-related to any;business or commercial venture CU.a dog lidense or permit to buin leaves etc.)said person is NOT required to complete thi& affidavit The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-871-NIASSAFE Fax#617-727-7749 WWW.Mass.gov/dia Form Revised M-23-1$ ImC Nov. 30. 2017 12: 36PM No. 4059 P. 1/1 ei 70 DATE(MMIDDIYYY`) CERTIFICATE OF LIABILITY INSURANCE 11/30/2017 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(les)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: John McShera MARSHALL K LOVELETTE INSURANCE AGENCY INC PHc°7 E : (508)775-4559 (FAX No): DD,L ADDI�SS: john@loveletteins.com 396 MAIN ST INSURER(S)AFFORDING COVERAGE NAIC* WEST YARMOUTH MA 02673 INSURERA: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B: HEALY BROTHERS CONSTRUCTION CORP INSURERC: INSURER D: 72 OLD MAIN STREET INSURERE: SOUTH YARMOUTH MA 02664 INSURERF: COVERAGES CERTIFICATE NUMBER: 217651 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 A POLICY NUMBER PMOfLDICDI EFF PMIDICDY EXP LIMITS OL LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RF-NTEff- CLAIMS-MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ H'EN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ,ECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COEa acciMBINEDdentS INGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PRO $PERTY DAMAGE HIREDAUTOS AUTOS (per UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X STATUTE I IEROTH- AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? wA N/A NIA 6S60UB5B97516917 05/09/2017 05/09/2018 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached 11more space Is required) Workers'Compensation benefits Will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate Was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govAwd/workers-com pen sail onhnvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 367 South St AUTHORIZED REPRESENTATIVE Hyannis MA 02601 Daniel M.CroGi y,CPCU,Vice President—Residual Market—WCRIBMA O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Massachusetts Department of fziublic"Safet Board of Building Regulations.and X. !a Standards: .P License: CS-060855 "Construction Supervisor ICHAEL A HEALY 72 OLD MAIN ST tt SOUTH YARMOUTH M/4f026-' IrCornmissio � Expiration: her .. T22/2016 y Nov, 30. 2017 12: 34PM No. 4058 P. 1/1 `��® CERTIFICATE OF LIABILITY INSURANCE DA11//33020117 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(les)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 John McShera Marshall K Lovelette Insurance Agency Inc PHONE (508)775-4559 FAX No:(508)775-4577 396 Main StNO.West Yamouth,MA 02673 E-MAIL DD ASS: john@loveletteins.com INSURERS AFFORDING COVERAGE NAIC 8 INSURERA: NAUTILUS INSURANCE COMPANY 17370 INSURED Healy Brothers Construction Corp INSURER 72 Old Main Street South Yarmouth,MA 02664 INSURER C INSURER D: INSURER E: INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP LIMITS A COMMERCIAL GENERAL LIABILITY NN698732 01/09/2017 1/09/2018 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ®OCCUR PREMISES Ea occurrence LU $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO �LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT OTHER: $ AUTOMOBILE LWBILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS 1 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 Town of Barnstable Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 367 South Street Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25,(2016/03) The ACORD name and logo are registered marks of ACORD ' r , e c0aa�vr�aaruuerc . p Office of Consu `� ac�uroz` ff HOME IMPROVEMENTairs&Busines egulati on r{A<,,TYPE;CorporCDNTR TOR :. _._Re` anon LY g _._ 'on Ex iratio ROTHEp;_ : 03/24/2019 ter .11��OCyION,INC. 2 OLD 1EL HEALY;� t SOU:I MAIN ST ., H YARMOUTH, '�=-=" N.0 MA 02664 Undersecretary, Massachusetts De artnient of Fiu�lic Safe P ty:,.'= `Board of Building Regulations.and St;1j-) ds;•'' License: CS-060855 ,`' ✓`Construction Supervisor. t . � �. CHAEL A HEALY '72 OLD MAIN ST :. `SOUTH YARMOUTH IVIA•,'02,664 _ Constructidn.Supervisor..:. Restricted to: L rdOcted-Buildings of any use group which contain .t6ss than 35,000 cubic feet(991 cubic meters)of enclosed space. 1 Failure to possess a current edition of the Massachusetts.., State Building Code is-cause for revocation of-this li r:.. 9 copse. DBS,,;Licensing information visit: WWW.MASS.GOVIDPS i i i