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HomeMy WebLinkAbout0532 WIANNO AVENUE Ave TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel l Application S 6 Health Division 2/ Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board 9l �q Q Historic - OKH Preservation/Hyannis Project Street Address �U awtJ�_ Village LL-6 Owner 1-i6h° ¢-ij/L Address Telephone— - Permit Request `f ��D -7 �/,) le-, � /cw� . (//0 �bZlk-OD Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning Dis Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family, ❑ Two ❑ Multi-Family (# units) Age of Existing Structure Historic e: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Ot Basement Finished Area (sq.ft.) Basem t Unfinished Area (Qq: ) Number of Baths: Full: existing new Ha existing PAW -v o Number of Bedrooms: existing _new o Total Room Count (not including baths): existing new First F r Room Count, 2 Heat Type and Fuel: ❑ Gas . ❑ Oil ❑ Electric ❑Other w Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood co st g: ❑rs U No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) L,- Name &1156n 11 r�n1T 49 7ASW Telephone Number 'Address fy �d ��-� �`�d License # �� Home Improvement Contractor# v�•ro�� Worker's Compensation # V l 9l l ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO IVI,# SIGNATURE DATE ' FOR OFFICIAL USE ONLY `APPLICATION# DATE ISSUED I . MAP/PARCEL NO. I i ADDRESS VILLAGE OWNER _ DATE OF .. _ 0 INSPECTION: i FOUNDATION FRAME 'INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: _ ROUGH FINAL FINAL BUILDING r r DATE CLOSED OUT . Y ASSOCIATION.PLAN NO: J The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumb ers Applicant Information Please Print L dbl y Name(Business/Organizationlindividual): 1� 1 L�� ���y T r Address:_ City/State/Zip: nk�5VO-S Phone.#: Are you an employer? Check the appropriate bog: Type of project(required): 4. ❑ I am a general contractor and I 1.�am a employer with 6. El New construction . employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet 7. ❑Remodeling 2.❑ I am a sole proprietor or partner-ship and have These sub-contractors have no employees S. ❑Demolition working for me in any capacity. employees and have,workers' 9 ❑Building addition t [No workers' comp.insurance comp. insurance. 10. Electrical repairs or additions required.] officers ❑ We are a corporation and its �Elt p - officers have exercised their 11.❑Plumbing repairs or additions 3.❑ I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs c. 152, §1(4), and we have no insurance required.]t 13.�er employees. [No workers' comp.insurance required.] "Any applicant that checks box#I 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 employms,they must provide their workers'comp.policy number. Iam an employer that is providing workers'compensation insurance for my employees Below is the policy andjob site information. r ® Insurance Company Name: �1 � Policy#or Self-ins. Lic.#: �U f � Expiration Date: / O Job Site Address: ��� �Q'� () /`rL- City/State/Zip:D Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration ate}: Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the ains-and penalties of perjury that the information provided--above is true and correct. Signature: Date: 10 o� — Phone#: dcc j Official use only. Don write in this area, to be completed by city or town offtciaL 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#: 610537 5/8/2009 10:27:38 AN PAGE 2/003 Fax Server eRT£parBOtitl ACOBI. CERTIFICATE OF LIABILITY INSURANCE per, i PaoauIR Tam CEIrl "'M as ISSUED AS A MTER OF MFORw►I USI Rolm spwmmn OILY AID COMM NO RXMM UIMM TM CEIMFICATE P.O.Box 53310 HOLMR TIN CITE DOER MDT A9E11% a7TBiD OR kvh*,CA 02619 ALTER TIE COVERACE AFFCRD'BR IM POLMMS BELOW. � am 8s"m MOURERS AFPORDM COVERAM r�A: St Pali FIM and No**bmwaooe Co AraarMarl TTsrd t TsWe ha. mmm a Tiraysiees Fwapeft Csa Ca.ofAnmd P O Bo:13/8 r Marston IIf,MA 02M i OfStR6t E COVERAGES THE KMCESCWMXVXM Uff D MOW HAVE SM SSU®TD THE sM NAMED AMW FORTHEPOtalfMGM="lM riDINRIHSMCM ANY MSMEMMW. Mod OR COMMM OF MW COIN MCT OR UMM=U MU f MM IZESFECr TD WMH TM CB VM%"TE MY BE MMED OR MAY MUAM,THE BfSUlN M AFFDUXM BY THE POLICES OMMM MUM M SUSI=TO ALL THE MMA%S=UMMS MW CMDrnM OF SUCH Poucm&AO am"m ums smm MAY smvE m1 vamum 8Y mm cutm . mm TYPE0Fe611RAMCE POLIL7rAAr� Pauff Pwwwa TMY PM tsPb t A ammuma nr CK00ZWM 01mm otm m0 mm S`1004000 X C0MMEACIALB0=3WLY1 &" 1 FIREoUMM anr.l M N CLAMMME QOCCUt 1 MEDEWVWCM { t PeRsm ILammmm IRY 41 COMMLPA REGME rGEWAGGREGAFEUU fAPPLEBiEt PRMUC15-00WMPAGG it X m= Lac { AOIOYOR r-LM9L fY I wla®sw16u1� s MY AM ALL OWNED AUM BODLyINAM SCIEDULEDAULOB QWr§Mg S CUR®RUMS BOOLV aLtm NON-OIrAED AUM V--W"Q i F1 � UMr%aE s GABAGEMBLM MMONLY-BLACCIDENr S ANTAUIO 01tERTNAP 6110000 f MMOILY: EXCEMuMMM EACHOCCURRENCES OCCUR ❑CIABSYADE AfIIIE s s x DEDUCTIBLE s t B womm3m ►noltME xjuE 819Y97=9 0imm flume X f EMPLOVEMLIABI M ELEACHAC4METf i1 OQ fEL ne�J►s6-MERLAPL swum FL -FaLww"wrissum A C1QI0220040 omm 0umc Ffoaber �000 umill Form Dadudfie DESCROMOKOFOPERNI ADD®BY mrMIBSB TMs ce4fika0s Is issued sls a nlafr of proof audy.+ExcW 10 days nafte of rancagadon for nonlwyme t CAWMBJAIM 8809>1D.AWr B8QE1fE� DATE TEMM,THE nt MM� ML�VOUNLW _Ir IlanaeTOTBe raLr�reLrlr� ■uuwQ��oDaooawsL �PosE rta oTauAerisrrcF Ar+rl®Laanatx A oR I�A�ES. ACORD 2"(1197H of 2 14 A AXLdG a AOORD CORPORATION 1988 Certitcate o Flame Resistance.f i REGISTERED FABRIC ISSUED BY Date of Manufacture NUMBER JOHNSON OUTDOORS INC. i BINGHAMTON, NEW YORK 13902 NOVEMBER 2006 F-140.01 Manufacturers of the Finest Tent Products Described Herein This is to certify that the products herein have been manufactured from material inherently flame retardant as here after specified by the material supplier. NAME: AMERICAN TENT AND TABLE i CITY: MARSTON MILLS, MA Certification is hereby made that: The articles described on this certificate have been manufactured with an approved flame retardant chemical in compliance with I California State Fire Marshal Code, NFPA-701", Underwriters Laboratory of Canada, and have been tested in accordance with the Federal Test Method Specifications and meet or exceed the Military Flame Specifications of MIL-C-43006G. Type,color and weight of material 14 OZ vinyl WHITE BLOCK OUT Description of item certified: GENESIS 40X40 2 PC Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric Snyder Manufacturing, Inc. ZZA,;�� I Manufacturer of Flame Retardant Vinvl Laminates TENT DEPARTMENT,JOHNSON OUT ORS IN 'Large Scale . 09/22/2009 15:42 5064202795 ur4ERICAH TEe1T PAGE 02 d q Town of Barnstable \\10, Regulatory Services Thomas F.Geiser,Director Building Division Tom Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.tnw o,barestable.m a.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder l rP�as Owner of the subicct property herehy auth,,my _ �10E'C -�� �i� /C� to act on my behalf, to all matter:r.lanre to work authonzed by dus building permit apocaoon for: (Address of Job) ('AaV1 Sign tore of Owner arc Print Namc V►orms.eapmog Ncv=071416 oE1HE, , Town of Barnstable *Permit# � �P�- '{•� Expires 6monthsfrom issue date % BAgriSTABLE, t Regulatory Services Fee �S 9 Thomas F. Geiler,Director i6 3.9• � �l(l1lOS� - lED MP RESS PERMIT Building Division v DEC 2 7 2007 Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508- MOF BARNSTABLE Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address V r 04"V1 ne:J [[Z/Residential Value of Work A6 Owner's Name&Address C J ` 1 Ce- f9 Contractor's Name Telephone NumberI '-Home Improvement Contractor License#(if applicable) �6$ Construction Supervisor's License#(if applicable) 054orl®an's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# (oq el -?6 - 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 roofl ❑ Re-side @/Replacement Windows. U-Value o (maxin+um.44) ❑ Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signature Q:Forms:expmtrg Rzvised121901 .AI r oardofi Bu�lding Regulations and'Standaras Construction Supervisor License�, � +LlceeCS 43556 i b i!B,it,hdate�1�13/1`962 _ 1 plratf Tr# 6886 : I i / -ffliffin — s t } - r I �SC TTtECROSB i_ i j >SOSTERVILLE sMA',02655.��` -'Commi"ssioner" TXae �om�reonaea o�✓, aclucaelta 4 Board'of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before.the expiration date. If found return to: Board of Building Regulation§grid Standards Registration \51882 One Ashburton Place Rm 1301. Expiration•'J..,13/2008 Boston,Ma.02108 �t==Lypea_Pna`te�Corporation. )- --� . I SCOTT E CROSBY�BQLEMWI:N:C 17 SCOTT CROSBY — 11?2 MAIN ST UNIT#.7, _____ --_—_.-..._...._._._.._..._... ... ��- Not valid without signatur OSTERVILLE,MA 02655 Deputy Administrator t The Commonwealth of Massachusetts Department of Industrial Accidents �( Office oflnvesdgadons 600 Washington Street Boston MA 02111 ✓� www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Organization/I Pact, ndividua b A Address: i i rz— G f �C° 1' Vl l`�"-j City/State/Zip: -6 - —Phone#: —U 1 a Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with_ (a 4. ❑ I am a general contractor and I 6. �remodeling construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 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'comp.insurance comp.insurance.t required] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑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' 13.0 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. Insurance Company Name: f ►— ' l� Policy#or Self-ins.Lic.#: 1AJ E, ��'"l D U Expiration Date: " 9 - Job Site Address: i ��� Aftle _ City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi nder the pains andivenaldes of perjury that the information provided above is true and correct. Signature: 6zT Date: b�� Phone#• &(S_1' O C1© l) Official use only. Do not write in this area,to be completed by city or town official, City or Town: Permit/.License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 08/08/2007 18:84 PA% 5084283068 GERMANI INSURANCE �1001 � In 1 N ti I ` 1 DATE(MAWDIYY) ,. F I 8/8/2007 PRODUCER ' ' 7AILTER, HIS CERTIFICATE• Ig 1 3 8 •D A MATTER O 1 F RMATION NLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE GERMANI INSURANCE AGENCY OLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 908 MAIN STREETED 19Y THE P LI OSTERVILLE,MA 02686 __, „_ COMPANIES AFFORDING COVERAGE•__ COMPANY. SAFETY INSURANCE __.. `. _. INSURED OONTANY SC07T E.CROSBY BUILDER,INC. g A(4-AMERICAN INTERNACIONAL GROUP 1112 MAIN ST.UNIT 7 - .. ..... . ....- �_.. .. .. .---_-�... . COMPANYOSTERVILLE,AAA 02656 COMPANY D THIa IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 46LOW HAVESEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,.NOfW"STANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE`AFFOROED B Y THE POLICIES DESCRIBED HEREIN IS SUBJECT'TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. co TYPE OF INSURANCE POLICY NUMBER POLICY EPPEOTTYe POLICY WRATHM LI MIIT$ LTR DATEPYMWO" DATE(MMID01YY) A a'N> ALLuaslLrrY CP00001153 07/08/07 07/0S/08 oENeRALAaaReL3Are s 2,000000 �( OMOURCIALOENHRALULBIUTY PRODUCTS-COMP/OP AGO : -J CLAIMS MADE U OCCUR PERSONAL A ADV INJURY i _ OWNER'S i CONTRACTOR'S PROT EACH OCCURRENCE s_ 1,0001000 FIRE DAMAGE(My wm f1m) t MED EXP ane pseon) 0. AUTOMOBILE LIABILITY COMBINED SINGLE LJIAPT i ANY AUTO _.... _ ALL OWNED AUTOS (Pa ILY I nINJURY SCHEDULEDAUTOS HIRED AUTOS 600I4Y INJURY NON-"ED AUTOS (Por°celdWU) i - _... ... ... . PROPERYY OAMADE' _. G ARAGB LIABBJTY AUTO ONLY-EA ACCIDENT • ANYAUTD OTI1gR7TIANAtlTOOI�Y _.___ _ HAeN AccroeNr s' - AQOREOATB EXCESS LIABILITY EACH OCCURRENCE _ �...._•._._..._. UMBRELLA FORM AGGREGATE i OTHER THAN UM0REIJA FORM B WORKE"COMrEIMMONAND WC 687-79-W 08R2/07 O6/22/08 EMRAYmw LUURLFTY BLEACH ACCIDENT i _1 QQOOO,. Tm aARTlcrA16rm '' INCL eL DISEASE-POLICY LUff s 500.000 oFF"mm urrv¢ 9XCL QDISEASS-EA EMPLOYEE I 5 100.000 OTHER OE:8CRIPTION OF OPE;RATIONS/LOCATIONSIVENCLE&SPECUIL ffEMS . � , . _, v r I II sh i i " I mll Jwi0011 Nmll lillmis, I SHOULD ANY OF IM ABOYS DESCRIBM POUCIES K CANCELLED DEFORM THE OPMATION DAYS TN£RSOP, THB WUING COMPANY WILL ENDEAVOR 70 MAIL 100 DAYS WRIMN N OWZ TO THE CERTIFICATE HOLDER MAIMED TO THE LEFT, BUT rA1LURE TO MAL SUDH WMC1'SHALL IMPOSE NO OBLIGATION OR LJIULIIJTY rm O BP AUTHO REPRESENTATIVjbRA i i . Town of Barnstable • e�axsree�. "'"= 639. �' Regulatory Services �� Thomas F.Geiler,Director Building Division Tom 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 Complete and Sign This Section If Using A Builder I � .n as Owner of the subject property y e VS � LL to act on m behalf, . hereby authorize y I in all matters relative to work authorized by this building permit application for: I Po P— (Address of Job) } 161 Signature of Owner Date Print Name • i Q:Foims:expmtrg Revise071405 s I � �� ����� �� ..F 1 ' ,. '1 i" , 1 - i Town of Barnstable *Permit it �G���� Expires 6 months om issue date Regulatory Services Fee o V MAM Thomas F.Geiler,Director12(��Q�L 639. p�� / (� ������� �� ����Building Division om Perry,CBO, Building Commissioner SdV 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: ��508-. ..., : :`��" o:�,� �; � Fax: 508-790-6230 EXPRESS PERAHT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number /0 i 0 ;Zential Address 7 J a U1 t d o i/�a A U e n u 'e Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address C 1 a,m h11 m V nbb i C v i w� � ��ee5 ¢1U 13 Contractor's Name G l; �1 �.�k.i t?f� Telephone Number , Home Improvement Contractor License#(if applicable) D Constru 'on Supervisor's License#(if applicable) 5 5 orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# J'U 6— q 6 —3 t— Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) . [id/Re—roof,f(stripping old shingles) All construction debris will be taken to 190 L/I C Nif 4bV ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) 'Where requited: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: P erty Owner must sign Property Owner Letter of Permission. Ho a Improvement Contracto 'License is r uired. SIGNATURE: Q:Forms:expmtrg Revise071405 I oard-of,Building Regulations aT Standardds �i � , Con'struciion�Supervlsor Llcerse ,,�Lrlcen�e,CS�`�43556 • sh Y-Bfrthdate�.:2 3`11962 t, ay E piratW 1-2/1Q2008 N 'r1r"*"S"'•� W Sa ��I n.+P OSTERVILLE MA"62655 ' ` a'Commissloner' • I Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before.the expiration date..If found return to: Board of Building Regulations and Standards Registration -\51882 One Ashburton Place Rm 1301. Expiration��7/13/2008 Boston,Ma.02108 �K .R Type': Private�Corporation. SCOTT E CROSBY-BUILDERil- 1 SCOTT CROSBY 1112 MAIN ST UNIT#,7�_ ..—_......_...- - -----.... - OSTERVILLE,MA 02655 1 Deputy Administrator Not valid without signatur t - 11/10/•L000 14!5V YAA 5UlJ4Z5aUtftI, (iLKXAN1 .11)15lIKANt:t WO vvJ. ••• 'II 11 A...CORD„ ' i HI �� DATE(MMJODYIry) r: 1N6/2006. ' C PRODUCER- THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE' CERTIFICATE GERAAANLINSUFLANCEAGENCY HOLDER.. THIS CERT1ELCATE-DOES .NOT AMENO,.EXTEND-OR .... 908 MAIN STREET ALTER THE COVERAGE AFFORDED .BY THE POLICIES BELOW. 1 OSTERVILLE,MA 02655 COMPANIES.AFFORDING.COVERAGE COMPANY A ESSEX INSURANCE COMPANY ' INSURED ... COMPANY SCOTT E.CROSBY,BUILDER, INC. 8 AIG AMERICAN INTERNATIONAL GROUP 6-2-CROSSY-CIRCLE.. ••----- --...____..——..._.._._. _......_--._ _ OSTERVILLE,MA 02655 cbrdPAwv C ''COMPANY D �'"• ii. � �1,,.,1, '„ U �s <i 1. 11,''1 „� ) I ,a, . :1.!t. dw.Uruy;u ('r.:Y d.... ti '�.....ajl:,:aa tiff ' i1 w41�1w' .Jl;ii:a:,w„n''c.;itiir,n�lu'Vl�a»eaGi�T1u1.;M;:1:S4�o::1i94c.!cfri".tieaG i.L.E_r l: IKI `' N•xG Bpi•_.• '�111�HUnu1�.3M'�i..w'r._cl.csi9LIiU��L___.1N!,f1;4 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDWF_D_NOTWIT.HSTANDWGANY REQUIREMENT.,TERM OR CONDITION.OF ANY CONTRACT OR OTHER DOCUMENT WITH-RESPECT TO WHICH THIS CERTIFICATE MAY-BEISSUED OR MAY PERTAIN,THE INSURANCE'AFFMED 8 Y THE POLICIES DESCRIHEO HEREIN IS SUBJECT t0 ALL tHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO, ' TYPE OF INSURANCE POLICY EFFECTIVE POLICY EXPIRATION LTa l POLICY NUMBER DATE(MMIDOM) DATE(MWDD"l LIMITS A ..G•EN ERALLIABILITY' 3CU9430 07/06/06- � QTl03TOT���. N. ( t_rucnd errocC�TE,,, (... O�OOO COMMERCUIL GENERAL LIABILITY PRODUCTS•COMP/OP AOO .f —_ .. _ ... CLAIMS MADE OCCUR PER80NAL AADV INJURY.. A... ... OWNERS A CONTRACTOR'S PROT EACH OCCURRENCE ..9. 11000,OOO -FIREDAMAGE-(Myene'Ote). A. MED eXP(My one pawn) i AUT.OMOBR ELIABILMY 'cvMelNEasNccEl,Mlr. . .c'. ANY AUTO ALLOWNEO AUTOS-. . SCHEDULEO AUTOS (Per person) HIRED AUTOS -- —._ . .... ..... NON-OWNED AUTOS w0°cXc I'�^URY y OAAIABE--' GARAGE LIABILITY P TO ONLY-FAACCIDENT 4 ANY AUTO OTHER THAN AUTO ONLY; Tr EACH ACCIDENT i , AGGREOATE. t EXCESS LIABILITY EACH OCCURRENCE, a UMBRELLA FORM AOOReGATe -_...—_...._..- OTHER THAN UMBRELLA FORM d 8 WC 896-31-13 06/22/06 08/22/07 WORKER'S COMPENSATION AND TORY LIMITe — FR 1 EMPLOYERS'LIABILITY EL EACH ACCIDENT E 10 OO OOO THE PROPMEtnat MtCt '' EL OMEASE=POLICY"LIMIT PAATNtAS7d%6CUTIV6 - .....__ 0 FWAReARE: EXCL ELOIBFASE-FA EMPLOYEE i 100 QQO OTHER DESCRIPTIOPtOF-OPERATIONSILOCATIONSIVENICCESW C1AL tTEUS-•... ST:41�!l. .... . I di I1N�i 1 1u1 u5J I U:Ll1•.W.y�II 1 v �'♦ ,l RqpA !Eli vll h�.INN td rN0�a.M11' t'ir iiil i :.� Jn'IKY IA v ��:i1JId :�JIJGlI�h _ a�::::U° ., !L'U:7i• I..•u:i�:`.:3.:..eu•� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE r ....EXPIRATION-OATL-�MGRE�OF,-'T►iE-ISBWNEi-•C.OMPAN -WI►La ENDEAVOR-i0•�WL-•:... 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BDLFAMURET01dJUL ALQt_ 07tCESgiLLM6YCL4E lIQOQLtGAT10lLOR&lABK1p -- OF ANY KIND U►ON THE COMPANY ITS AGENTS OR REPRESENTATIVES. AUTHO REPRESENTATIV F_• i,..,. � };1 1 1! lu 1 !'�i (a�(Ik+l a t;'�'YJGM p1�Ppr P' •'ct. - ..��•o..,,,. ,., A��R�i ,;,�ur�� �,.' � '��{_r,.�., ,:k,4h�fi�!:r..atN;41Aq'8±, ,,�. i �;r{• "tea.,. �'s.' I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information !� der Please Print Le iblName(Business/Organization/Individual): C J C� E • G osb`► � Address: I I ( -I-. H I (Al St ' N 111 City/State/Zip: kamjt 6 U"t� Q 655 Phone#: d� ' 1UP r Are u an employer?Check t e appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time)." have hired the sub-contractors ? [�D--,'�modeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t ne ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL I LEJ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' 13.0 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 their workers'comp.policy information. 1 I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. /1 Insurance Company Name: Policy#or Self-ins.Lic.#: l h — Expiration Date: Job Site Address: 7 W 1/L0 b )�r �%`�I �(�'' City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un r the pains and penalties ofperjury that the i formation provided above is true and correct Si mature: Date: �0 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 M i 01/20/2004 20:58 0009144725919 NTDMADP PAGE 02 Hpr 18 U-i U't:33p Scott crostay-•• l�Uttiw{.a=autyu �`c i Towff uf�Burnst8W .oirc Regulat�ary,Servim Thomas F.Gclkr.Dltator 13uirelirr�►Dwiii�� Tons Pin•,CBO Building Commibeioncr 20UMnin Street, Hyannis,MA 02601 ' www.fowtLbarnstsbk.ma.n1 - Office: 508-862-4035 Fax; 508-790-6230 PropenyOwnef 1 Qet� Complete and Sign This Section _-If•Using A-Builder as<.�wtur of thes ut)j'C"ta pruhct>7• • hcrebyauthorizc�� �Q.r ? ��_to ace on my hrhalf,` its al!tttatmrs relative tv v 1*authoxjrCdbt`th�'tiait rlR'jirr9�iiC applic:ia�iii`f (Addreea of Joh) Sii ciC re of 0wocr Dats j (�d nU Print Name �1 Q:I�nmte:cxpn¢�r Roviyel171d0� _ r