Loading...
HomeMy WebLinkAbout0155 WINTERGREEN CIRCLE �.5 � 'n -���'� ��� 0 4'-z,5: -"P Town of Barnstable *Permit# �(o-- 7 V1 i Pr ti Tres 6 months from issue date Regulatory Services / MAss. Richard V.Scali,Director J �' ;'� ��0 201Ci T p Building Division O !<Y Paul Roma,Building Commissioner OF BARNS I��L� 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number � �.� � V Property Address w l w44p_k9NA�A C„ �Srl�iQiV L��,Q ' Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address �2A� Contractor's Name u 1WLr��Vwvl Telephone Number t�o.'-Ik0 2 2Y� 07elnn Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) 102G �Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ Larn the Homeowner have Worker's Compensation Insurance Insurance Company Name _Am� u� Workman's Comp.Policy# Q UvCGs�4 s 22 Copy of Insurance Compliance Certificate must accompany each permit. . Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑ roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum .32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is re 'red. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\E SS.doc 06/20/16 The Commomreakh cejfMawadrrtsetts Mr Department&frnd-us&ud Acddex& Office of£m adores. 600 Wpashiiiom&reet Boston,MA 02111 ' wevt�n:a��vfdia War•lcers' Compensafian Insm-xnce avid$nAder Centracturs/FlechicianslPlumbers APPUcant lufmmiatzan PleasenPrin 01/U e Acl&ess-- W t0Sfow I�-9 CityfStati--t 'Lk), r IOUS� wi( — sae- 60, �(36- 27/gq Are ya an employer?.Checkthe appropriate has: Type of project(required): am a employer Wift4. I am a general comfractor and I I employees(fish.and/or art limed* ❑have Hiredthe sub-contractors 6_ ❑ldew oomos 2.❑ I am a sole proprietor orgartner- Tisted on the attached sheet 7. ❑Remodeling. ship and have no employees These sub-contractors have 9- ❑Demolition woddng for me in any rapacity. employees andhave wodoers' 9..❑Building addition [No 'camp.insmo ce comp-m¢+trarrrn 1 • r -] 5. ❑ We are a coipozatiaa and its 16-❑Electacal repairs or adcS ioms 3-❑ I am a homeowner doing all work officers have esescised their 1 L❑Plumbing repairs or adclitioms myself[No wo&='Door- ho§I ememp�dwe have lry-❑Roof repairs is n-asace r��d`]7 employees.[No woAmrs' IJ-❑Other cam-kXMMace nquinAl 'Any apg&a=1hst chedsbas#1 must alsa Moatthe sectionbalowshorcmg felt wodseW co®pmzmfiaupa&T=dvcrosaoa lmmeovmem who sabanit fl&sfEdata imXreiag 8iey summit a new affid2zit iMM—i"Bach. IC rb3CtUxs that check ibis box xa=wed as additi®al sheet showing the—of the snb� and state wheshec or not tease euhties hntp emplayees.Iftbesnbtautradexs have mnpIafea%thepzmastpmvidetheir vmdm 'c=xp.poHumm3bez_ I am an uasurazce,for my em pfuyees: Belviv is the paticy and job site inflormatron. -- - _ ---. Insarance Company Nam: &C� Porky 4 or Self-ists-I-ic- R, /WC 6"p?1L r=pimtian Date-_ 2. �/_ Job Address= �/Vl 1 ,�.Lh C(-- Cityl5tatelzip:. '(1S'I- g Vt 66 , Attach 2-copy of the workers'campensation p olicy declaration page(showing the policy number and expiration date). Failnm to secure coverage as required under Section 25A of 1ldGL m 157 can lead to the imposition of criminal penalties of a fine up to S1, O Oa and/or oiie—y&irimiprism=aeui,as we11 as civil penalties in Hie fours of a STOP WORK 01MERand a lime of up to$250_OD a dap agRaimst the violator_ Be adi ised that a copy of this statement=ay,be forwarded to the Office of Iavestsgations of the MA for i stirance•coverage verification Iri`a kerBlry cer* dliepars andpenahtfiu af pediuy thattlts iiiforwsatim>arm dtd a ig ue/ and correct �_atnnR- Ilate: � �b PhD=ik L dfiTziaL use awly. Do not awrRe in this area,to be campleted by carp artncVm a1j'rerAl My or Town: PermiitUcense S Lnuing Audmirity(circk one): L Board of Health 1 BTdmg Department 3.Brown Clerk 4.Electrical Iuspeetor S.Plumbing Emspecter 6.Oflier Coact Person Phone#- - --- — 6 ormation and Ins coons ' Maccar] se s GebeaalLaws chapter M req=m all=ploy=to presvrde WorlMs'=:UPeasattan fur then =Playees- pUrSa=±-tD this sty,an EZTIoyee is defined as"_.evecy person in ffie seavicc of anotheruadcrEnycontcact of hurt express or i MPUCCL oral or wr>fteo." Aa emTkym-is defined as"an m&TidnA per,assomfion;corporation or other legal earthy,or nay two or mole of the faregoing engaged in a joint eUtEaprisa,and inclndmg the legal=presentatives of a deceased mipIoyer,or ffic receiver or trustee:of an individual,partnership,association or ofherlegal entity,employing=nployees. However tha owner of a.dvmIling house having not more than tbree apartments and who resides fherem,or the occupant of the - &Feffmg house of another who employs pmsans to do naaa�ce,cmsftuz' ous on or repair wcak on such dwelling he or on the g m m:ds or bm7dmg appurten lh=to shall not because of such employment be deemed to be an eanploym." MG'L Chapter 152,§25C(6)also stems that¢every sf f or local Ticensing agenrcy sha.II withhoId fhe issuance ar renewal of a Tcense or permit to operate a business or to construct buildings in the commonwealth for any applicant•who has notproduced acmptable evidence of compTnance with the insurance cOyetagerequixed" Additionally,MGT_chapter 152,§25C(7)sues-Nm fherthe cc =anwealthnor any of its political subdivisions shall eater e perfbmance ofpnbhr,wotic uMEamiable evidence of compIi�nce with$ne insm�ce. into any contract for th requirements of this cheptrr have lean presented to the eo—La�+�m3tiozity:1 Applicants ' Please fill out tine workers'compensation affidavit completely,by Checkmg the boxes!hat apply to your sitnatiOn and,if necessary,SMPPlyy sob�dur(s)name(s)• addrass(es)and phMm_T_ ez(s) along with their drat*) of ins azanCC- LimitedLiabMtyCompames(LLC)or Limited LiabUjtyParfneasbips(LIP)widino employers otherthanthe m_e=bers or partners�are not mqui ed to caIrY workCre compensation insurance If an LLC or LLP does have employees,a policy is required. Be advised that this a$dayrt maybe sabmitte:d fn the Deparfnent of Industrial Accidents for confamation of insarmoe coverage. Also be sure in sign and dais the afudavif; The affidavit should be returned to ffie city or town that the application for the permit or license is being requested,not the Department of L,aa a A caiden_s- Should you have any questions regarding the law or ifyou Mir,requi rd t3 obtain a work=' compensation policy,please call the Departme�at the n=ber listed below. Self-insured cmmpanies should ea,'ur their s elf insurance license number on the line. City or Town Officials f Please be sore that tale affidavit is complete and prhtt-,dlegibly_ The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of investigations s has too cordact you.rcgz ding the applicant_ Please be sure to Ell in the prn�itllicense mxmber which will be used as a mfience number. In-addition,an applicant that must submit multiple pe=WIicense applitations m any given year,need only submit one affidavit indicating current p olicv information Cif necessary)and tinder"Job Site Address"the applicant should write"all loons in (may or town)-"A copy of fhe.affidavit that has been officially stamped or mm3o--d by the city or town may be providedth to e applicant as#ooYthat a valid affidavit is on file for frrtnre permits or licenses Anew affidavit must be filled out each W me Year- here a homier owner or citizen is obtaining a license or permit not related to any business or commercial veaxtare (ie. a dog license or peamit to bum leaves eta_)said person.is NOT requited to complete this affidavit: The Office of Investigations would Ir7oe to thank you i a advance for yom coapea d and should you have any qurs ons, please do not hesitate to give us a call. The Department's address,telephone and fax rurmbea: Dqpa�ent cif Accidents COU=of Xnvedkft=% BWbM2 MA Ed111 Ted.#617-727-4900 wt 406 or 1-977 MA MATE Fax 9 617 727 7749 Revised 4-24-07 1 BBB . CA ;apse :,emu, 68 Winslow Gray Rd West Yarmouth, MA 02673 508-360-2749 e-mail: rsocc(cr�yahoo.com HIC REG #170787; LIC# 102600 Job Address: Name: Matthew Kozma Town:- Address: 155 Wintergreen Circle Job Phone: 774-487-2361 City: Osterviller Other Phone: State: Ma E-mail: matthewkozma@comcast.net ZIP: Estimator: Dmitry Labkovich _ 07/26/16 We hereby submit specifications and estimates to furnish and install new white cedar shingles on the following areas: Left,Right and Back Walls Specifications as follows: 1. Remove existing siding and dispose of debris; 2. Inspect sheathing for rot or other deterioration and advise homeowner of any additional work; 3. Inspect existing waterways at window,door and comer boards and notify homeowner of any additional work; 4. Install Typar breathable house wrap. 5. Install new window and door drip cap flashing; 6. Install double first course of siding. Install new siding using approximate 5 " exposure hitting tops and bottoms of windows and door openings as allowed(may not be possible at all). 7. Siding to be secured using rust-resistant fasteners '/2 inch to 1 inch above next course line; 1 d date Accepted by / THIS PAGE IS PAR'r OF AND IN CONFORMANCE WITH PROPOSAL No 1 1 2 8. Shingle joints to beat least'/4"away from fasteners and 1"away from previous course joints(to minimize exposed fasteners when siding shingles). 9. Clean yard of all debris and utilize magnet to minimize exposure to property or personal damage from nails left behind; 10. Remove and re-install electrical fixtures; 11. Last course to be hand nailed using#5 box stainless steel nails; 12. Replace Two Gable Vents LABOR AND MATERIALS: $10,960.00(White Cedar Shingles A Grade) If acceptable, initial here: / / We hereby submit specifications and estimates to furnish and install new Primed Pine Trim on the following areas: Four Corner-boards 1. Remove existing trim and dispose of it. 2. Install new trim using Primed Pine. 3. All fasteners will be stainless steel. LABOR AND MATERIALS: $44884V. 5.00 If acceptable, in here: ` Job is estimated to commence approximately _4_ weeks after deposit received unless otherwise noted here: Work is scheduled to be substantially completed in approximately: days If acceptable, (both) initial here: Start and completion times are approximate and subject to change due to, but not limited to, the following circumstances: weather delays, additional work on previous jobs, permitting delays,etc. This is the entire agreement. Any discussions or verbal agreements are superseded by this agreement. Such agreements, even those of the smallest nature, must be in writing to be recognized. Accepted by date l e)� THIS PAGE IS PART OF A14D IN CONFORMANCE WITH PROPOSAL No i 1 3 Aunv work above and beyond the specifications "outlined in this proposal will be priced on r,-quest. All additional work, including travel time and lumberyard runs, will be subject to extra charge. In the event of rot repairs, roof repairs or any related work requiring immediate attention,we will proceed without customer approval. We look forward to working with you;please call if you have any questions. Sincerely, ROOFING AND SIDING OF CAPE COD,LLC ROOFING AND SIDING OF CAPE COD,LLC will provide cleanup on a continuing basis and all debris will be removed from site. All products installed by ROOFING AND SIDING OF CAPE COD,LLC will be to manufacturer specifications. All work will be performed by insured professionals. All material is guaranteed to be as specified and the above work to be performed in accordance with the drawings and/or specifications submitted for above work and completed in a substantial workmanlike manner. There will be no refund for special-order windows, doors or any other non-stocked materials after three days from approved proposal. All warranties will be null and void if account is not current and paid in full. Owner to move all personal objects, furniture, etc., from work areas. All items against walls should be considered for removal during any exterior siding jobs, additions,etc. to guard against damage.In the case of any roofing and ridge venting, dust and debris should be expected and any items in the attic should be removed. ROOFING AND SIDING OF CAPE COD, LLC is not responsible for any damages if said items remain in place. Curtains, drapes and window and door treatments may need proper reinstallation or replacement by customer due to sizing on any window or door replacements and is not included in jobs contracted with ROOFING AND SIDING OF CAPE COD,LLC Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance upon above work. Workmen's Compensation and Public Liability Insurance on above work to be taken out by ROOFING AND SIDING OF CAPE COD, LLC. No lien or security interest will be placed on the residence as a consequence of the contract. Owners who secure their own construction-related permits or deal with uriregistered contractors will be excluded from access to the guaranty fund. This Contract not valid unless signed by Corporate Officer: �nptk�x� Acceptance of Estimat9e q Accepted by ,/�/ date 1 � /Z THIS PAGE IS PART C) 1b IN CONFORMANCE WITH PR POSAL No i 4 The above prices, specifications and conditions are satisfactory and are hereby accepted. ROOFING AND SIDING OF CAPE COD,LLC is authorized to do the work as specified. Payment will be made as such: �) Deposit o . CsZ� >�- � 1/3 Depo �GocCo � . C LC 1/3 Beginning of work 1/3 upon completion Date: /l d2�!.t Signatures: d a I Note: No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract. You, the buyer may cancel this transaction at any time prior to midnight of the third business day after the day of this transaction. Accepted by date THIS PAGE IS PART OF AND IN CONFORMANCE WITH PROPOSAL No Board of Building Regulations and Standards c Office of Consumer�Affairs�&Business Regulation nJc/rJ Construction Supervisor f ME IMPROVEMENT CONTRACTOR License: CS-102600 egistration: 170787 `11:'i rS Type: : DZNIITRY LABK9`VI ''-- •.� '-h I � xpiration:� :12/9g/2017 LLC � 68 Winslow Gray Rd ROOFING AND SIDIN.G:.OF CAFECOD, LLC. i West Yarmouth ' DZMITRY LABKOVICH i 68 WIN SLOW GRAY RD �• Expiration � W.YARMOUTH, MA 02673 Commissioner 03/27/2017 i Undersecretary V j;. r I - , ACO 0 CERTIFICATE OF UABIUTY INSURANCE THIS CERTIFICATE 15 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 eertHicah holder Is an ADDITIONAL INSURED,the poBey(les)must be&Waded. R SUBROGATION 15 WAIVED,subject to • the terms wd Conditions of tht policy,certain policies may requka an endoraernertt A statement on this certificate does not carrier rights to the eertlHute'holder In lieu at such endomemwd(s). 1,1100 ar HwE, Anne Sonzo HOB INTERNATIONAL NEW ENGLAND LLC PMKE (SDB)945-7863 AwRE� ameearrm@habfrAsmotional.Dom 265 ORLEANS RD. IMuraii4ei AmoftdwoCOV&A a IWCr NORTH CHATHAM MA 02650. aTstwER Ae AMGUARD INSURANCE CO 423W V6tinEb WSUREne: ROOFING&SIDING OF CAPE COD LLC wsrwatc. • wwRenoe ' 68 W114SLOW GRAY ROAD wauaa E• WEST YARMOUTH MA 02673 wlHwEaP: COVERAGES CERTIFICATE NUMBER:36338 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF-INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAvEO ABOVE FOR THE POLICY PERIOD INDICATED. NOTVNTHS.TANOING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO LVHICH THIS CERTIFICATE MAY DE ISSUED OR MAY PERTAN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, I7ICLUSIONS AND COMMONS OF SUCH POLICIES.LIMITS SHOWN IAAY HAVE BEEN REDUCED BY PAID CLAIMS. L�jTtR TYOFNw WANCE ►OLOYNUMSER IUO­DTTtY• MLIOrry PE I LeRf7 COMMERCMLGENOUILLIABIUTY EACHaCLuRAErrCa I1 mskoz❑ocCLM PRELIISrd Env._,) 'l ME0 EXP µTr ar P.nal I. WA PERSONAL A AOV MAW- f Wirt.ACIOREGATS LNIT APPLIES PER OENEtALAGGREGATE I PRO. LOG Plio0UCTe-COW10PAGG f . On1a R COMBINED-'WCAE LIAOT f AUTOS➢BLEl1ABRtA 4Ena[eltrq____,N EOORY NJ[RV(Pr p.[m1J t ANr Atlie .ALL""IN"' 60C1AED. NIA BODILY FULW If-. dd..t) f AIMS AUTOS — HREDAUR.n HSA�KM - • t UNERELLALIAS (OCCUR EACH OCLUPAENC' L EXCESS LLAS CI.VN&MAoe NIA AtAREaATE f aso IirETealoJE X ppEE f RKEASCOLPIMATON /� STLnlTs 'EAR I• rmoPRemFwARTKEanxECuirVF WA WA WA R2WC654822 12/20R015 12110r20t6 E.T_EACLIACcmt?Ir f 100.000 A actacmAu i NEHnExcu�E➢r EL bls'sstE•PA Er.'PLOtE t 100,OOD 1 PJLS eY�A Qiaies�i. E016s.POLICY LI I, 1 500,000 bESCRU4IUJ6aPERATIOHS DeL-x i NIA ➢EHCRPTM"oFOrEA mmS/LDCATDIWVBOMES I(I.00RD iel,AQ4UalW Rrrb 6c11NW,IryWdOtll.tl eA,nn.yrMb nyulndj Workars'Campensation benefits wi be paid to Massachusetts employees a*.Pursuant to Endorsement WC 20 0306 B,no wtherization Is given to pay Bairns for benefits toemployges in stales other than Massadwaete ITthe insured him or has hired th➢u&amployass outside Of Masssactwsahs. This certificate Of insurance shows One policy in farce onthe date M this certificate was issued(unless the w0nLtion data on the above policy precedes the issue data of this certficate of brsurence). The Shaba of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool atwnw.mass.govriwdrwarkerecompahsadwJi ves5getionrr. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HUB International NE LLC ACCORDANCE WITH THE POLICY PROVISIONS. 265 Orleans Read AUTHORIZED fEDRESORATLVE f.�t . N Chatham 11A 02650 DanM M.C .CPCU,'A.President—Residual Market—WCRIBMA 01988.2014 ACORO CORPORAnCFL AN rights reserved. ACCRD 25(201=1) i nti ACORD name end logo are registered marks of ACoRO I I I I °FI T Town of Barnstable b Expires 6 months from issue date Regulatory Services Fee �� snFtxsrnsr�, Thomas F. Geiler,Director Building Division reb Mai Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www:town.barnstable.ma.us Office: 508-862-4038 Fax: 5087790-6230' EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY F Not Valid without Red X-Press Imprint Map/parcel Number Property Address J ►eVl/'►f�f'QD Residential Value of Work 9©C7( Minimumfee of$25.00 for work under$6000.00 Owner's Name&Address 0 S Uel Contractor's Name CG=r e FY A+6r111 2S �-4 Telephone Number '�Q8 2,V Home Improvement Contractor License# (if applicable) /oa�SD3 leorkman's Compensation Insurance Check one: ®PRESS PERMIT ❑ I am a sole proprietor ❑ I am the Homeowner have Worker's Compensation Insurance �U� 1 2008 Insurance Company Name 5fc",, TOWN OF BARNSTABL Workm'an's Comp.Policy# W o / DS Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) . Re-roof(stripping old shingles) All constructiondebris will be taken to Kil_°w 9,J64 IW C ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum:44) *Where required: Issuance of this permit does not exempt compliance with other town department regu:lati¢Ms h&L nc,Conservation,etc. ***Note: Property Owner must sign.Property Owner Letter of Permission. A copy of the Home Improvement Contractors License�nlis{,regquired. 1 l: I G �`,C� III"s �`iiEtG SIGNATURE: QAWMLESTORMS\building permit forms\EXPRESS.doc R-.vi cPn?n I nR .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/ElectTicians/Plumbers. Applicant Information C (� Please Print LeEibly Name(Business/organization/Indmiival): air 1 �'ee 1 rl�V✓leS CD Address eZ 3 a tfH-�eSf avi City/State/Zip: /'!A . 0 2 7/g Phone.#:_ SO 7`�� rat/ Are,you an employer? Check the appropriate box: Type of prof ect(required):- 1.{ am a cinploycr.with_- 4. ❑ I am a general contractor and I 6. ❑New construction employees(full andlor part_time).* have hired the sbb-contractors 2-El I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me employees and have workers'in any capacity. 9. ❑Building addition . [No workers' cozzrp.msurrance comp.insrrranco.$ 5. ❑ We arc a corporation and its 10.0 Electrical repairs or additions requred] officers have exercised their 11.0 Plumbing repairs or additions 3.❑ I am a homeowner doing all work myself [No workers'comp. right of exemption per MGL 12 �oof repairs insurance r t c. 152, §1(4), and we have no �] employees. [No workers' 13.0 Other camp,insrnanm required] Any applicant that chmlz box#1 roust also fip'out the section below showing their workers'compmsalion policy infor=tion. t Homeowners who sub®t this affidavit indicating 6rcy are doing all work and then hire outside contractors must submit snow affidavit indicating such. tCantractor•s that check this box nn=st attached an additional sheet showing thc frame of the sub-cautractors and state whctha or not those entities have cmployccs. If thc sub{ontracturs have em ployees,.they must pravidt their workers'MTT.policy numbs. I am an employer that is providing workers'camp ensadDn insurance for my employees. Below is the policy and job site information. II _ Insurance-Company Name: [GrT �[7SW-av►e Policy#or Self-ins.Lic_#: [/t/ �7g® � Expiration Date: Job Site Address: 'J I�l/ L l/ City/Stati/Zip:(.b✓NP l''l Attach a copy of the workers' compensa 'on 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 crina-tial pcnaltics-of a fine tip to$1;•500.00 and/or one-year.imprisonment, as well as civil pcnalti'es in the form of a STOP WORK ORDER and a fine ofup'to$250.00 a day against the violator. Be advised that a copy of this stat=iit may be forwarded to the Office of Investi lions of the bIA for insurance cov a verification. I do hereby certify under the pains•and penalties of perjury that the information provided above is true and correct Si c: Date: -- Phone# O Rin!e use only. Do not write in this area,to be completed by city or lows offcciaL City or Town: Permit/License# Tsndng Authority(circle one): 1.Board of Health 2.Building Department 3.City/Tovwn Clerk .4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person:. . Phone#: ArWii RE FREE mes 239 Huttleston Avenue Fairhaven,Mass 02719 Telephone 508-997-1111 Fax 508-997-1297 Website: www.carefreehomescompany.com To the Town of: ZI&W5 r7W Job Address: 156 '�fj/ V City, State,Zip: 0 2l°&5 I, R/?"Y77x-ow L� � ''� , owner of the home at the above Customer name location, authorize Care Free Homes,Inc. as my agent to obtain all necessary permits and to perform all home improvements to my home as stated in the accompanying contract and application. Customers 4me Date i • •vidwl use pniy valid foY in d return to• . se or registrt�n date• If fo nd Standards Licen the expiry Regulations a Woods before wilding m�301 da R tan of B ace p nd S t Board shbnrton yl eg°1at�coNTF�`GTpR• pne P' Ma p2108 Board of Bnl1ding R pvEMENS Boston, pM pR H Ap0503 9 X jT;atjon'= element Card. ESuP, ti t°re Type_ :.- d without sig 1:1 Not vaii CPRE F 1GKUP = % istYator 1... F ol3e?- F n eve �= P, 11 _ 239 HuWestO Fairhaven ,MA 02719 i c .. �v �v.... . �.�, , , ,�v. I v•1 JtJIJ I JCJI'Jf_JCJ f-.1' 1 ACORD� CERTIFICATE OF LIABILITY INSURANCE DATE(MW0D"'"") 09/18/2007 PRODUCER (508) 679-6418 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Frank X. Perron Insurance Agency, Inc: ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND. OR 1311 Bedford Street - ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. O. Box 4158 Fall .River MA 02723-0402 INSURERS AFFORDING COVERAGE NAIC INSURED INSURERA: National Grange Mutual CARE FREE HOiffiS IKC 114SURER9; star Insurance 239 HUTTLESTON AVE INSURER INSURER D: FAIRHAVEN MA 02719— INSURER E: 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. INSR DD'L POLICY EFFEGIIVE POLICY EXPIRATION LTR NSRD TYPE OF INSURANCE POLICY NUMBER DATE MM/DD DATE MWDD/YY LIMITS A GENERAL LIABILITY. ME077983Q 09/01/2007 09/01/2008 EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES(Ea occurrence S 50,000 CLAIMS MADE FXI OCCUR / / / / MED EXP(Any one on Is 5,000 PERSONALBADVINJURY IS 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 X POLICY ElJELQT' LOC AUTOMOBILE LIABILITY / / / COMBINED SINGLE LIMB ANY AUTO (En aerJdonl) 3 ALL OVVNED AUTOS / / / BODILY INJURY f SCHEDULED AUTOS (Per persoh) HIRED AUTOS / '/ / BODILY INJURY NON-OMED AUTOS (Per aoddent) _ .. PROPERTY DAMAGE $ (Par acddenl) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO / / / / OTHER THAN EA ACC S AUTO ONLY: AGG S EXCESSAJMBRELLA LIABILITY EACH OCCURRENCE S OCCUR CLAIMS MADE AGGREGATE f S DEDUCTIBLE RETENTION f TTqqTT f B WORKERS COMPENSATION AND WC0378035 09/01/2007 09/01/2000 TORYLIMITS X OER� EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT 3 1,000,000 OFFICER/MEMBER EXCLUDED? / / / / E.L.DISEASE-EA EMPLOYE 3 1,000,000 If yes,desoAbe under SPECIAL PROVISIONS bolow E.L.DISEASE-POLICY LIMIT S 1,000,000 OTHER DESCRIPTION OF OPERATIbNS/LOCATIONSIVEMCLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS Officers Included for Workers Compensation CERTIFICATE HOLDER CANCELLATION SHOULD ANY. OF THE ABOVE DESCRIBED POLICIES.BE CANCELLED BEFORE THE .S EXPIRATION DATE THEREOF, THE ISSUING ,INSURER WILL ENDEAVOR TO MAIL OS 10 , DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT Town of Barns table - FAILURE TO 00 80 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE Building Department INSURER,ITS AGENTS OR REPRESENTATIVES. 367 Main Street AUTHORIZED REPRESENTATIVE Barnstable MA 02601- 1CORD 25(2001/08) ©ACORD CORPORATION 1988 ]$TM INS025(=Bps ELECTRONIC LASER FORMS,INC.-(800)327-0545 Page 1 of 2