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HomeMy WebLinkAbout0027 HIGH STREET 4j^ 5 N 5MEADR No. 53LOR UPC 12543 smead.com • Made in USA io I FMER USED N TMS PROdkT Ul* S FI MEETS THE SOUROM REGUREMM OF THE SFI PPOGRAM ozWWWWROGRAWORG i ,y. Town of Barnstable Building ��� ; Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept EMPMN. ,�$ I.Posted Until Final Inspection Has Been Made. Permit Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made _- Permit No. B-20-372 Applicant Name: Dean Fraser Approvals Date Issued: 02/10/2020 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 08/10/2020 Foundation: Location: 27 HIGH STREET,WEST BARNSTABLE Map/Lot: 133-031 Zoning District: RF Sheathing: Owner on Record: MERRITT, ELLEN C Contractor Name: Fraser Construction Company Inc. Framing: 1 Address: PO BOX 576 Contractor License: 194747 2 WEST BARNSTABLE, MA 02668 Est. Project Cost: $5,100.00 Chimney: Description: partial reroof Permit Fee: $35.00 Insulation: Project Review Req: Fee Paid: $35.00 Date: 2/10/2020 Final: _ Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. d r L.------------ --r'' f Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work:+ y' Service: 1.Foundation or Footing r Rough: 2.Sheathing Inspection _ 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Pers contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site � $ Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT t n,e Town of Barnstable *Permit 49-1 �?l7 Expires 6 months from issue date Regulatory Services Fee 16 9. Al Richard V.Scali,Director e 00 / /k r a - 1 F�Mp'l ansI^�`°�' �T Building Division SEP 2 6 D� Tom Perry,CBO,Building Commissioper 2016 200 Main Street,Hyannis,MA 02601 UVVN OF 8A R V www.town.barnstable.ma.us ���BLLC Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X--Press Imprint Map/parcel Number 1,??� _O 3� I Property Address Residential Value Value of Work$ r. C� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address /l.L ( �'�-��✓, r; Contractor's Name C / 'e;(� • Telephone Number y a-3 O 2T 3 7 Home Improvement Contractor License#(if applicable) -31 Email:A?11,S4 loinne I✓�"YJm Construction Supervisor's License#(if applicable) 0 6 0 S t ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ Jarn the Homeowner ET I have Worker's Compensation Insurance Insurance Company Name �A- C 4-01L Gl L ✓1 S UJ'G rv- Workman's Comp.Policy# C-p 710 Copy of Insurance Compliance Certificatel must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof ) -side Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows 4 #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. copy of the Home Improvement Contractors License&Construction Supervisors License is equired. SIGNAT L'i•f— C:\Users\Decollik\A ata\L,ocal\Microsoft\Windows\Temporary Internet Files\Content.Oudook\2PI0IDHR\EXPRESS.doc Revised 040215 f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 fvwru mass.gov/dia Workers' Compensation Insurance Affidavit: Buildei-s/Contractors/Electricians/Plumbers Applicant Information Please Print Lexibly Name(Basins organizationgndividuaq: Address:-3' O City/State/Zip: C-em 1 e Cyl(� M)q -;4), Phone#: 7 AFiam u an employer?Check the appropriate box: Type of project(required): 1. a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time)-* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees Thy sub-contractors have g_ ❑Demolition working for me in any capacity. employees and have workers" 9. ❑Building addition [No workers'comp.insurance comp.insurance required.] 5. ❑ We are a corporation and its ME]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]Y c. 152,§i(4),and we have no employees-(No workers' 13.0 Other comp.insurance required.] •Airy applic�t that checks boa#1 mmu also fill out the section below showing their workers'compensation policy information. 1 Homeowners wbo submit this affidsrtt iatiicsting they are doing all woA and then hire outside contractors most submit a new af&darit im&catn;such. ;contmcmrs that check this boar must attached an additional sheet showing the name of the sub-contractors and stare wbether or not those entities have employees. If the subtonmaurs have employees,they m=provide their workers'comp.Policy number. 1 am au employer t)tat is providing workers'compensation insurance for my enrplo3rees. Below is the policy and job site information. Insurance Company Name:UlC Gr. '�+CAL l0 so rQ► c, Policy#or Self-ins.Lic.#:Mo c `) Expiration Date: r Job Site Address:2-2 I.At(l �,t`Ul 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 2.5A 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. 1 do hereby cr under the pains d p es of perjnry that the information provided above is true and correct Si gnat.(,. Date: PhoneL 7? V 2Z 7 Official use only. Do not write in this area,to be completed by city or tmvn 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 9: ACORO® DATE(MMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCEF 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: Ashley Clark LEONARD INSURANCE AGENCY A N Et: (508)428-6921 1C.No: AooRIFSs: Ashley@Leonardagency.Com 683 MAIN STREET SUITE B INSURERS AFFORDING COVERAGE NAICtt i OSTERVILLE MA 02655 INSURER A: ACADIA INS CO 31325 INSURED INSURER B HERBST HOME IMPROVEMENTS LLC INSURERC: INSURER D: 35 PEEP TOAD RD INSURER E: CENTERVILLE MA 02632 INSURERF: COVERAGES CERTIFICATE NUMBER: 59747 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 ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER (MMA) MM/DD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence $ i MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑ PRO JECT ❑ LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS CPer accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION /� STER ATUTE ERH AND EMPLOYERS'LIABILI Y Y/" ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? WA WA WA MAARP300898 11/18/2015 11/18/2016 (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/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached If more 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.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Ytlffno h`��t(i't5�j� ACCORDANCE WITH THE POLICY PROVISIONS. -446-Recta-28 AUTHORIZED REPRESENTATIVE -pC,S -Southumaath MA 02664 Daniel M.Cr ey,CPCU,Vice President—Residual Market—WCRIBMA @ 1988-2014 ACORD CORPORATION. All rights reserved. Herbst Home Improvements LLC 35 PEEP TOAD ROAD CENTERVILLE MA 02632 508-420-6216/774-238-2937, www.markherbst.com PROPOSAL SUBMITTED TO: WORK PERFORMED AT: Ellen merriff 27 high st bamsatble Install 4 new windows with no change to header height or dimensions Remove existing Install new Anderson windows Insulate and trim interior Install new exterior trim cutting or replacing shingles around opening We herby propose to furnish the materials and perform the labor necessary for the completion of: All material is guaranteed to be as specified. The above work will be performed in accordance with the specifications submitted And completed in a substantial workmanlike manner for the sum of: one thousand two hundred dollars Dollars($1,200.00)with payments as follows: full amount due upon completion *Any alterations from above proposal involving extra costs will be added under a separate written agreement and become an extra charge over and above said proposal. RES CTFULY SUB 2123/2016 son Herbst ACCEPTANCE OF PROPOSAL The above price,specifications and conditions are satisfactory.I herby accept this proposal. You are authorized to do the work anc payments will be as specified above. SIGNATURE: L"_ C_ t( *This proposal may be withdrawn by said company if not accepted within 30 days. Massachusetts Department of Public Standards Board of Building Regulations License CSSL-106051 ; Construction Supervisor Specialty JASON HERBST 35 PEEP TOAD ROADt; •� CENTERVILLE MA 02632� Expiration: Commissioner 10/0112018 '. Uhe �earrvaxa�aeueczCC�a��/�aaoac Office of Consumer Affairs&Business Regulation UHOME IMPROVEMENT CONTRACTOR Registration:.; '17t33f Type: Expiration;:c•:=SM20:'18 LLC HERBST HOME IMPRO ME L LE JASON HERBST : .=_= 35 PEEP TOAD RD ........ I CENTERVILLE,MA 02632'-' Undersecretary i ' I Construction Supervisor Specialty Restricted to: CSSL-RF-Roofing CSSL-WS-Windows and Siding Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. DPS Licensing information visit:'WWW.MASS.GOV/DPS ' License or registration valid for individual use only before the expiration date. If found return to: �{ Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 i Not valid 4witout4signatu - ' •.tom`-- --`-=y',_ _.. - -:-- -- - -- TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION ., TOWN O► BARINSTABLE Map t�j� Parcel Application #Fr �� JiaN 14 P11 3. 07 1 Health Division Date Issued 1 4 I(_O Ig Conservation Division Application Planning Dept. DIVISM" Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address )--7 #7 V 0-S Village r Owner Address -• z— Telephone 3(e - /0;IL 7") Permit Request r r,-c; Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation aS�U Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family O Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ 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) Name Telephone Number `7�"5--62 5�3 Address �� a / License # CS S 1,' /'J Am as r Home Improvement Contractor# /(0041 Email Worker's Compensation # V ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO_ f'4 l I JLI✓� SIGNATURE DATE ' FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP%PARCEL NO. ADDRESS VILLAGE ' OWNER DATE OF INSPECTION: {Y FOUNDATION y�y FRAME C INSULATION FIREPLACE s ELECTRICAL: ROUGH FINAL r PLUMBING: ROUGH FINAL s� GAS: ROUGH FINAL y , FINAL BUILDING DATE CLOSED OUT s } ASSOCIATION PLAN NO. f .._ T[1'e Commoraveuith of Massadwsefts Digp lTtlnent i7fhuhatrial Accidents e Of I71'VFStigadons 600 Washington Street Boston,MA 02L1I wnnv.rnassgovldia Workers' CampensatianInsuranceAffidavit Buildens/Cantractors/ElecfricianslPlumbers . Apply ant Information ]] f Please Print,Legibly Name eStisme�ld ni on/Individnan: �-1�iJ 1 ,�S I r Ad&ess: CityfstatrMp: S.,e ku n one 4- .�`� I 5— L( 3 Are you an employer?'check the appropriate box: T of o jest (r 3'� �' 3 ('eqairetl}: L❑ I am a employer with_ �1- _ 4. ❑ I am a general contractor and 1 6- ❑New c onstrwtioa employees(full and/or part4ime)* have hired the sub-contr&dDs. 2:❑ I am a sole propfietor or partner- listed on the attached sheet y- ❑Remodeling ship and have no employees These mb-contractors have g- ❑Demalitioa ` wonting for mein any capacity. employees and have worklers' 9. ❑Building a ddition [go-work fs'comp_fnurrance comp.insurance, � ] 5. ❑ aFe are a corporaticnand its 10_C]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers hate exercised their 1 Y..Q'Plumbing repairs or additions myself[No workers'comp- right.ofe zroptionperMGL 12 0 Roofregaifs insurance required.]F c.152, §l(4),and we h"T na employees_[No workless' 13_�§Outer comp.msnrance required:1- *Any sppli anttbztchar sbox#1mastalsof1outthesectionb9 wshnwiu4cOi&waaien�'mmpensauouporLLTanfornndm Homeowners who sabmit this s�dav B industineg daey ate doing alI wo�c and then lyre GniSide conizactn[5 rffiSS sohazit a new affidavit ia�r�mr!3 tcwtmcrors that rhe&this bax must attached sa additional sheet sha mg the name of the WIF-Omdrmcb0a and state whether ornottbnse entries have erVlayees. Ifthe snbtoutmdors have EW10 ees,dreg must provide their workers'comp.policy number. I am an employer thatisprmdding workers'compensation irmwaace for my employees. Belau is Ste policy and job site information. Insurance Company Name: A- C2 naL,-r� / Policy g or Self-ins_Tim y 1 U 5- P(p I S— °3 Expiration Date: - 2- - `1 Job Site Address c2--7 C7 t S� !i citylstaw2l p: Je4 lit tr n l�� 1� " Attach a copy of the vrorkers'compensation policy declaration page(showing the policy number and expiration date). tJoZ 6,(�p6 Failure to securecoverage as requiredunder Section25A of MGL c. 152 can lead to the imposition of criminal pettalties of a fine up to$1,500.00 and/or one pearimpri'sofment,as well as civil penalties in the form of a STOP WORK ORDER and a f= of up to$250-00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of fe DIA for insarance coverage-verification- I do hereby pains andpenalfias ofpet ury tftatthe irrfotmtdionprmddRd ah//oy a i/s/tr�uw and.correct Simatore: Date: Phone o fsial irm only. Da trot write in this area,to be completed by city or town officiaL City-or Town: Pernz tUcense# Iss1La Authority(circle one): 1.Board of Health 2.BuiTdiag.Deparhnent 3.CitylTown Clerk 4.Electrical Inspector 5.P'htmtbingInspector 6.Other Contact Person: Phone 9: 6 Information and bi-structions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto this statute,an employee is defined as"_..every person in the service of another under any contract ofhire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer;or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)withno employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance Coverage.- Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permitAcense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submif one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file fur future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address;telephone and fax number: The CommmwwWffi of Massachusetts Department of 7ndustdal Accidents office of kvestlgatfaus 600 Washington Street Boston,MA 02111 Tel.#617,727-4900 at 406 or 1-977 MASS.E4FE Revised 4-24-07 Fax# 617-727-7749 WwW.Mas.S1gov/dia 1` PAassachusetts -Department of.Public Safety '. �✓ Board of Building Regulations and Standards. r Comtruction Supen i+or Speciatt% License: CSSL-102771 JOSEPH J REILLY- ^E } "- 8 BELMONT.. = •'`r Fall 02 River MA '120 'a2-1 ,I- vr, Expica#ion _ - ''-Commis'sioner o Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 " Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 160461 Type: Private Corporation Expiration: 7/29/2014 Tr# 227004 RETROFIT INSULATION, INC. JOSEPH REILLY P.O. BOX 105 ____............................. ....._-__.......... .............____...------........_ . .. ...... SEEKONK, MA 02771 ................. ---- -..__. .. _.._.._....... ...-............._..... ................._..........................._...__............................. Update Address and return card.R1ark reason for change. Address Renewal i Employment i Lost Card A Office of Consumer Affairs&Business Regulation License or registration valid for indivictul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation �-5r481}2egistration: 160461 Type' 10 Park Plaza-Suite 5170 Expiration: 7/,2 912 0 1 4 Private Corporation -; ? Boston,ti1A OZ 116 RETROFIT INSULATION;INC. JOSEPH REILLY 644 RODMAN ST .._.... _...... .._..-....... ... . FALLRIVER,MA 02721 Undersecretary Not valid without signature r �Rightfax N2-1 8/8/2013 5:59: 25 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) TWL&PERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICAT HOLD S 11- 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 THIS OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to he terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to he certificate holder in lieu of such endorsement(s). I PRODUCER CONTACT NAME: VIVEIROS IN'S AGCY INC PHONE FAX 140 PLYMOUTH AVE (A/C,No,Ext): (A/C,No): E-MAIL FALL RIVER,MA 02723 ADDRESS: 759RC INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: ACE AM6RICAN INSURANCE COMPANY RETROFIT INSULATION CORP INSURER B: INSURER C: INSURER D: PO BOX 105 INSURER E: SEEKONK,MA 02771 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THISIS10 CERTIFY THE POLICIESOF INSURANCE LISTED 13ELOPU HAVESEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NOICATED. 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. UMRS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAWS. NSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MM1MDIYYYY) (MMMD1YYYY) LIMITS GENERAL LIABILITY ACH OCCURRENCE is COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED Is CLAIMS MADE =OCCUR. EMISES(Ea occurrence) ED EXP(Arty one person) $ ERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $ POLICY PROJECT LOC RODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) BODILY INJURY $ HIRED AUTOS (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE Is DEDUCTIBLE is RETENTION $ $ A WORKER'S COMPENSATION AND X WC STATUTORY OTHER EMPLOYER'S LIABILITY Y/N UB-4705P615.13 08/02/2013 08/0212014 LIMITS ANY PROPERROFJPARTNER/EXECUTNE N/A E.L.EACH ACCIDENT $ 1,000.000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 r yes,describe under E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATION SILO CATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION CONSERVATION SERVICES GROUP SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED ATTN:WII LIAM JULIO BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL B DELNE9ED IN ACCORDANCE WITH THE POLICY PRO �,..•^^'��/ 50.WASHINGTON ST AUTHORIZED REPRESENTATIVE WESTBOROUGH,MA 01581 ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORP�2!�r ed. RETRINS-02 CANA i4�Ran CERTIFICATE OF LIABILITY INSURANCE 1 DATE 7/19120113) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 'CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). ACT PRODUCER (508)676-0309 NAME, Viveiros Insurance Agency,Inc. PHONE IFAX AIC No Ext: I A/C No): 375 Airport Road E-MAIL Fall River,MA 02720 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# I INSURERA:Arbella Protection Insurance Company INSURED Retrofit Insulation, Inc. INSURER B: P.O. Box 105 INSURER C: Seekonk,MA 02771 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE PCLICIES 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. IITR TYPE OF INSURANCE ADDL SUER POLICY NUMBER ': MMIDDY/YYYY MN EFF LDDffYYYY LIMITS GENERALLIABWTY EACH OCCURRENCE $ 1,000,00 MA A X COMMERCIAL GENERAL LIABILITY X. I8500040668 i 7/1512013 ! 7115/2014 PREMISES Ea occurrence $ 10,00 CLAIMS-MADE LJ OCCUR I i MED EXP(Any one person) !$ 5,00 i I I PERSONAL 8 ADV INJURY $ 1,000,00 GENERALAGGREGATE S 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: I I PRODUCTS-COMP/OP AGG $ 2,000,00 X CT POLICY PRO- LOG $ ;AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY I i Ea accident $ ANY AUTO , BODILY INJURY(Per person) 1$ ALLOWNED SCHEDULED I AUTOS AUTOS BODILY INJURY(Per accident) $ i NON-OWNED I PROPERTY DAMAGE $ HIRED AUTOS AUTOS i i Per accident i I $ UMBRELLA LIAB OCCUR ` EACH OCCURRENCE Is 2,000,00 A EXCESS LIAO CLAIMS-MADE!. 4600040816 I 7/11/2013 1/11/2014 AGGREGATE ;$ DED RETENTION$ I i $ WORKERS COMPENSATION I I I WC STATU- iOTH- FIR AND EMPLOYERS'LIABILITY YIN ' 1 1 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑11 N I A E.L.EACH ACCIDENT $ (Mandatory in NH) I E.L.DISEASE-EA EMPLOYE $ If yes,describe under I I DESCRIPTION OF OPERATIONS below ! E.L.DISEASE-POLICY LIMIT $ I 1 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Additional Insured with respect to General Liability. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Thielsch Engineering ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave Cranston,RI 02910- AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD r' OWNER AUTHORIZATION FORM (Owner's Name) owner of the property located at rty Address) &-M�4(rTj 4. 69 a7 (Property Address) hereby authorize �--�0`�, -4 'T,.VI-,--NV (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. L-w Owner's Signature ll � zZ , l3 Date �� �', + U S ^n M� � ! �� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 3 j Parcel 133 3 ' Application # Health Division 01C Date Issued Conservation Division Application Fee Planning Dept. Permit Fee ' �J Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis ! Project Street Address Z-1 4:R _(sie-T- Village \4,6s-r1 Owner 5i1 �-- � '[[" Address PO Bo < Telephone 7 7 4 . `19 i • W o 573 '.Permit Request S4fesl> 'D doz- ibo0y - .462- w w�+►�rt OO'� - MA.lAA T.W_r ct ,6_ SI��� S t Sbk��C+-�� "moo CMG_.V.A* t �Jl W41 few G�aoacUs 4e.a5 K'" _+av s&Aft**W Po�� Square feet: 1 st floor: existing tsS��' proposed 2nd floor: existing S0(- proposed Total new -Zoning District Flood Plain Groundwater Overlay `Project Valuation 's a 0 0,00 Construction Type -S Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) _ i Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: Yes ❑ No Basement Type: EllFull ❑ Crawl �11 Walkout ❑ Other 21 co IC Basement Finished Area(sq.ft.) Basement Unfinished Area (sq ft Z-4 o Number of Baths: Full: existing .7- new Half: existing new-) Number of Bedrooms: 73 existing _new N � Total Room Count (not including baths): existing new First Floor Room ount _ w Heat Type and Fuel: ❑ Gas Oil ❑ Electric ❑ Other Central Air: ❑Yes '�H No Fireplaces: Existing New Existing wood/coal stove: ❑Yes 9b 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) Name is �! M��az6 ,= Telephone Number 7 `f' Address 0. 30'?1z _5'74 License # �A-IMASWAX.G Le Home Improvement Contractor# Einail: .. 6c.. ►'G'e c- c 9&A-Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE V�` DATE FOR OFFICIAL USE ONLY APPLICATION# ° DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE DATE OF INSPECTION: -FOUNDATION, FRAME `j INSULATION FIREPLACE t, • ELECTRICAL: ROUGH FINAL s PLUMBING: ROUGH FINAL t GAS: ROUGH FINAL a FINAL BUILDING ' ` DATE CLOSED OUT 4 y, ASSOCIATION PLAN NO. " r The Commonwealth of Massachusetts rA Department of Industrial Accidents Office of Investigations 600 WaskhWon Street Boston,MA 02111 iwm vtassgmldia Workers' Compensation Insurance Affidavit:Builders/Co 'cianMumbers Applicant Information Please Pry Lejdbly Name co : �«.Y' C. Addre,w. 2-7 t+i &,6t- CitylSta&Zip: �3P4"srAg c.., oZ(P phmm j#- 7 7 4 . 4 4 4-. Os•7 3 Are you an employer?Check the appropriate box: Type of project(required): 1_❑ I am a employer with 4. I am a general contractor and I 6. ❑New construction employees(fell anNorput-time)_* have hired the sub-camtractors. 2_❑ I am a sole proprietor orpartner- listed an the attached sheet 7- ❑Remodeling strip and have no employees These nab-contractors Lave 8. ❑Demolition wig for mein any capacitT employees and have wod=s' g_ ❑Building addition [No workers'comp-inaxanre comp.msmraace l ❑ We are a corporation and its 10-❑Electrical repairs or additions rEgnired j 5. I am a homem aer doing all work officers have exercised heir 11_❑Plumbing repairs or additions myself[No workers'comp right ofexemptioaper MGL 12_�']Roof repairs/Vi insutrance d. t c.152.§1(4�and we have no ,..,�X'Urf� required.] 13_®Other OB ✓��°'eLl� employees.[No workers' comp.insurance required.j 'Any rppfic=d But chedu boat 01 mnsta w IM out the sectionbelow sharing tbek wa keie compensatiom policy infnrmatic- 1 Hameownen xho submit this affidsvIt m&czong they are doing all gook and then hoe outside comuactors must submit a new afidnit indicating sudL tra"I actors tbst check this box mnst attached as additional sheet shoaft the name of ft sub-cm=acton and stue whether m not these entities have employees. Ifthe sub-cmtmctoabave employees,theym=yn vide their warkets'comp.policy m®ber. " I am air erttptnyer thrrtisproviding nrorkers'cottrpeusrrtion inessrtudce for mp eerpl�nyees. Ifeiotr is Siepalicy rind job sits information Insurance Company Name: Policy 4 or Self-ins.Lic.# Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(shoving 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 andlor one-year imprisottmeat,as well as civil penalties in 1he fb m ofa STOP WORK ORDEEtand 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 insttrance coverage verification_ I do hereby eerfi under thepain atndpenalfies ofpetjnry tliettLa intforeiatime pratRded abouais hue Hued correct Sit�atYe �- V Date: ,l0 2 ( 2-o l Phone# . -7 -1 - , ':1 9 4 o Si r 3 0jFR d use asiy Do not write in this area,to be campletM by diY ar m"M a W&L City or Town. PertuitUcense# Issuing Authority(circle one): L Board of Health 2.BuRdiag Department 3.QgfTown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phones - 6 Town of Barnstable Regulatory Services Thomas F.Geller,Director a61 ��� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION DATE: l b Z -ZO l Please Print JOB LOCATION: number street village �HOMEOWNER7: �� l' 7 7 4.�`� Os7 3 nano home phone# work phone# CURRENT MAILING ADDRESS: �+ r �•Asza�.ST�3L E �c(� O Z(,6 c 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 homeowners to engage an individual 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 reside,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 Official on a form acceptable to the Building Official,that he/she shall be responsible for all'such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility°for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requir ents and that he/she will comply with said procedures and requirements. e L Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code i Section 127.0 Construction Control. , HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner 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 the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This-lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner 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 t amend and adopt such a form/certification for use in your community. C:\Users\decoUflc\AppData\LomIMcrosoft\Wmdows\Tempamry Internet Files\Content.Outlook\QRE6ZUBN\MRESS.doc Revised 053012 r- �VE Town of Barnstable Regulatory Services $ � Thomas F.Geiler,Director 619. ►��. Building Division Tom Perry,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, r ��� ,as et of the subject property hereby authorize to act on my behalf, in all matters relative to work au d by this building petwit (Address of Job) **Pool fences and alarms are the responsibility of the.applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date Q:F0RW:0W4ERPE MBSI0NPoo1S 62012 i Acc o CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYY() 10/21/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DO ES N OT AF FIRMATIVELY 0 R N EGATIVELY AM END, E XTEND 0 R ALTER T HE C OVERAGE AF FORDED B Y T HE P OLICIES BELOW.THIS CERTIFICATE OF I NSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING I NSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER CONTACT Leonard Insurance Agency Inc NAME: Berkley Assigned Risk Services PHONE F I 683 Main St B c.No.Ext: 800 634-4589 c.No.: 866 215-8118 ADOREss: PolievServices@berkleyrisk.com Osterville,MA 02655 INSURER 8 AFFORDING COVERAGE NAIC a INSURER A INSURED Herbst Home Improvement LLC INSURER 8: INSURER C: 35 Peep Toad Rd INSURER D: ' INSURER E: Centerville MA 02632 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. --! INSR TYPE OF INSURANCE ADDLISUBRI POLICY NUMBER v LIMITS LTR INSR WVD MM1DDlYYYPOLICY EXP Y MMIDDIYYYY GENERAL LIABILITY EACH OCCU ReN E $ .� DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea.acdrrence $ ❑ CLAIMS-MADE ❑ OCCUR ❑ ❑ MED EXP An o etenon $ PERSONAL 8 i_UO INJURY $ GENERAL AGGRE TE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS—COM OP AGO Z5 [f) PRO- POLICY ❑JECT ❑ LOC COMBINED $ •T> SINULlhJuVIII AUTOMOBILE LIABILITY ❑ ❑ $ •� m (Ea aecidenl ANY AUTO BODILY INJURY Pe ernon $ ALL OWNED ❑SCHEDULED AUTOS $ AUTOS BODILY INJURY Peraccidenl HIRED AUTOS NON PROPERTY DAMAGE $ AUTOS Par ecc;dent ❑ $ UMBRELLA LIAR ❑OCCUR EACH OCCURRENCE $ EXCESS LIAR ❑CLAIMS-MADE AGGREGATE $ DED RETENTION S $ WORKERS COMPENSATION zWC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY A OFFICEIMEMBER EXCLUDED? ❑ NIA E] WC-20-20-004798-00 6/29/2013 5/29/2014 E.L EACH ACCIDENT $ 100000.00 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100000.00 II yea,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000.00 ❑ ❑ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Allech ACORO 101,Additional Remarks Schedule,If more apace is required) Election Category Election Status Name All Entities/Insureds: Other Exclude Jason Herbst Herbst Home Improvement LLC CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Ellen Merritt EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 27 High St, AUTHORIZED REPRESENTATIVE Bamstable MA 02668 27 1'j�o��-ru fl+use x 2���1 Fc7R1-1 1J(r?oS / oc4c,rc, sq-