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HomeMy WebLinkAbout0150 LOMBARD AVENUEF-/57C> , t x O T 0 Z c 1 , Cape Save Inc. 7-1) Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fag: 508-398-0399 8/30/18 0 ZE Brian Florence CBO o Town of Barnstable CD Building Division 200 Main St. =� Hyannis,MA 02601 w Cn RE: Insulation Permit 18-1678 Dear Mr. Florence: This affidavit is to certify that all work completed for 150 Lombard Ave,West Barnstable has been inspected by a third party Certified Building Performance Institute(BPI)Inspector. All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey -Commonwealth of Massachusetts . Sheet Metal Permit Map_��Parcel Date: Permit#'A 0� Estimated Job Cost: $ UJA U (29 Permit Fee: $ Plans Submitted: YES NO Plans Reviewed: YES NO Business License# Applicant License# aC)0 Business Information: Property Owner/Job Location Information: e Name: N6tn aar Pl wn br n" Name: Street: 1 S�e-n Jeh r%ftc4 n n';1 �(-� Street: I So L ory) Cf r� V 5 City/Town: :")n,Qd,( 1)1 r City/Town: LU , g ,ram .S fab Le Telephone: 5 CfS Telephone:�0 I::I `7 0 2.3 S Photo I.D.required/Copy of Photo I.D. attached: YES_2 NO Staff Ionia! J-1/M-1-unrestricted license J-2/,M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. 1/2-stories or less Residential: 1-2 family Multi-family Condo/Townhouses Other i Commercial: Office Retail Industrial Educational Fire Dept.Approval Institutional_ Other Square Footage: under 10,000 sq. f. over 10,000 sq. Number of Stories: Sheet metal work t be completed: New Work: Renovation: HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing ! I Provide detailed description of work to be done: See accu u&.�, Cj- (S'1 4 ZVt ct ;jn S+�.11aij�l c0S 2'vaY►ab(Q c2_f rV C Qi r "andlerS l v( Z f ( hews r - t i A 1 INSURANCE COVERAGE: i • t' I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L Ch.112 Y No E] If you have checked Xf&indicate th a of coverage by checking the appropriate box below: A liability insurance pdficy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the iMassachusetts General Laws,and that my signature on this permit application graives this requirement. Check One Only Owner ❑ Agent ❑ . i Signature of Owner or Owners Agent I By checking this bo �Ihereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation:YES NO Progress Inspections Date Comments i Final Inspection Date Comments i Type of Ucense: 3Y Q Master ripe t4aster-Restricted 'ityrrown QJoumeyperson ignature of Licensee Dermit# . QJoumeyperson-Restricted License Number. ( -ee$. Q Check at www.mass.dovldnl nspector,Signature of Permit Approval . i The Commonwealth of Massachuselft Department oflndusind accidents Office oflnvestdgadons 600 Washington Street Boston,MA 02111 www.mass gouldia ' Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leolly Name(Business/Orgwiafion1hxUvidi4:. C&,nhf Pc4- •Address: .S n ar i �rk 4S+}Ge.`1 J)V', U V'La i- k9S . city/staxe/ziN �Iw1. (6� p OZS b 3 Phone.#: Are ou an employer?Check the appropriate box: -Type of project(required):.- LJA I am a employer with 4• ❑ I am a general contractor and I employees(full and/or part-time).s. have hired the sub-•contractors 6. Q New construction . 2.❑ I am a'sole proprietor or partner- listed on ihe'attached sheet 7. emodelirug ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. Q Betiding addition [No woikm'comp.insurance comp,mstrance.t required.] 5. ❑ We are a corporation and its 10.❑El cal repairs or additions 3.❑ I am a homeowner do' all work officers have exercised their I1.=lambing repairs or additions ' er MGL tIIyself[No worlcrs'comp. right 'of exemption P 12.❑Roof repairs ' insurance required.]t c.152,§1(4),and we have no employees.(No workers' 13.❑Other comp.insurance regidred.] *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 arm doing all work and then hum outside contractors must submit a new affidavit indicating such. tContractors that check this box must eriached an additional sheet showing the name of the sub contractors and state wheflrer or not those entities have employees. If the sub-contractors have employees,they most provide their workers'comp.policy number. ram an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site . information. ktInsurance Company Name: y pr Policy#or Self-ins.Lie.# (�C\ )1�I O 361�a 11 Expiration Date: i0 Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page'(sbowing the policy number and expiration date). Failure.tD secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip 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 under thepains•andpenalties ofpedury that the information provided above is true and correct. Signature: Date;: l Phone k — Offrcial use only. Do not write in this area,tb be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): ; 1.Bbard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other j Contact Person: .Phone#: i oTMF Town of Barnstable Regulatory Services Thomas F.Geller,Director s639. � Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www-town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 - Pro e e Must o let and Sign This Section Using A Builder L ,as Owner of the subject property hereby authorize to act on my behalf, in all-matters relative to work authorized by this building pexmit (Address of Job) I **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled before fence is installed and pools are not to be utilized until all final inspections are performed and accepted. I Signature of Owner Signature of Applicant Print Name Print Name Date Q:FORM&OWNERPERMMSIONPOOLS f Page 1 Residential Heat Loss and Heat Gain Calculation 8/1/2018 In accordance with ACCA Manual J Report Prepared By: Jack O'Connor Plumbing $ Heating For: Malkani, Heather 150 Lombard West Barnstable, Ma Total CFM: 1,200 Room Cooling CFM Heating CFM Both First Floor CFM: 600 Family Room 198 226 226 Bathroom 29 32 32 Kitchen 173 139 173 Dining Room 173 156 173 Entry Foyer 27 47 47 Second Floor CFM: 600 Bedroom: rear left 121 128 128 Bedroom: rear right 105 122 122 Bathroom 58 40 58 Bedroom: 3 playroom 138 142 142 Hall 46 44 46 Office 132 125 132 HVAC-Calc Residential 4.0 by HVAC Computer Systems Ltd. 888 736-1101 Load calculations are estimates only,actual loads may vary due to weather and construction differences. Page 1 Residential Heat Loss and Heat Gain Calculation 8/1/2018 In accordance with ACCA Manual J Report Prepared By: Jack O'Connor Plumbing & Heating For: Malkani, Heather 150 Lombard West Barnstable,Ma Design Conditions: West Barnstable Indoor: Outdoor. Summer temperature: 70 Summer temperature: 95 Winter temperature: 72 Winter temperature: -15 Relative humidity: 50 Summer grains of moisture: 88 Daily temperature range: High Building Component Sensible Latent Total Total Gain Gain Heat Gain Heat Loss (BTUH) (BTUH) (BTUH) (BTUH) Whole House 982 sq.ft. 28,995 4,919 33,914 52,011 (3 tons) First Floor 14,534 2,644 17,178 26,380 Family Room 392 sq.ft. 4,794 726 5,520 9,948 Infiltration 325 266 591 2,430 -Tightness:Avg.;Winter ACH: 1.07 ;Summer ACH: .5 Duct 0 0 0 474 -Supply above 120; Enclosed in unheated space; R-8 People 2 600 460 1,060 0 Floor 392 sq.ft. 0 0 0 887 -Over unheated basement; Hardwood or tile;R-19(4-6.5 inch) W Wall 202 sq.ft. 429 0 429 1,582 -Wood frame,with sheathing,siding or brick; R-113 1/2 in.; none Window 22 sq.ft. 1,628 0 1,628 1,055 -Double pane;Wood frame; Clear glass -No inside shading;Coating: None(clear glass); No outside shading. N Wall 90 sq.ft. 191 0 191 705 -Wood frame,with sheathing,siding or brick; R-113 1/2 in.; none Window 22 sq.ft. 550 0 550 1,055 -Double pane;Wood frame; Clear glass -No inside shading;Coating:None(clear glass); No outside shading. S Wall 90 sq.ft. 191 0 191 705 -Wood frame,with sheathing,siding or brick; R-113 1/2 in.; none Window 22 sq.ft. 880 0 880 1,055 -Double pane;Wood frame;Clear glass -No inside shading;Coating:None(clear glass); No outside shading. Bathroom 54 sq.ft. 708 274 982 1,411 Page 2 Malkani, Heather 8/1/2018 Building Component Sensible Latent Total Total Gain Gain Heat Gain Heat Loss (BTUH) (BTUH) (BTUH) (BTUH) Infiltration 54 44 98 405 -Tightness:Avg.;Winter ACH: 1.07 ;Summer ACH: .5 Duct 0 0 0 67 -Supply above 120;Enclosed in unheated space; R-8 People 1 300 230 530 0 Floor 54 sq.ft. 0 0 0 122 -Over unheated basement; Hardwood or tile; R-19(4-6.5 inch) N Wall 37 sq.ft. 79 0 79 290 -Wood frame,with sheathing, siding or brick; R-113 1/2 in.;none Window 11 sq.ft. 275 0 275 527 -Double pane;Wood frame; Clear glass -No inside shading; Coating:None(clear glass); No outside shading. Kitchen 182 sq.ft. 4,184 661 4,845 6,114 Infiltration 247 201 448 1,841 -Tightness:Avg.;Winter ACH: 1.07; Summer ACH: .5 Duct 0 0 0 291 -Supply above 120; Enclosed in unheated space; R-8 People 2 600 460 1,060 0 Miscellaneous 1,200 0 1,200 0 Floor 182 sq.ft. 0 0 0 412 -Over unheated basement; Hardwood or tile;R-19(4-6.5 inch) N Wall 96 sq.ft. ' 204 0 204 752 -Wood frame,with sheathing,siding or brick; R-113 1/2 in.; none Window 16 sq.ft. 400 0 400 767 -Double pane;Wood frame; Clear glass -No inside shading; Coating: None(clear glass); No outside shading. E Wall 70 sq.ft. 149 0 149 548 -Wood frame,with sheathing,siding or brick; R-113 1/2 in.;none Window 16 sq.ft. 1,184 0 1,184 767 -Double pane;Wood frame; Clear glass -No inside shading; Coating: None(clear glass); No outside shading. Door 18 sq.ft. 200 0 200 736 -Metal; Polystyrene; No storm Dining Room 210 sq.ft. 4,195 681 4,876 6,849 Infiltration 271 221 492 2,025 -Tightness:Avg.;Winter ACH: 1.07 ; Summer ACH: .5 Duct 0 0 0 326 -Supply above 120; Enclosed in unheated space; R-8 People 2 600 460 1,060 0 Floor 210 sq.ft. 0 0 0 475 -Over unheated basement; Hardwood or tile; R-19(4-6.5 inch) E Wall 98 sq.ft. 208 0 208 767 Page 3 Malkani, Heather 8/1/2018 Building Component Sensible Latent Total Total Gain Gain Heat Gain Heat Loss (BTUH) (BTUH) (BTUH) (BTUH) -Wood frame,with sheathing,siding or brick; R-113 1/2 in.;none Window 22 sq.ft. 1,628 0 1,628 1,055 -Double pane;Wood frame;Clear glass -No inside shading;Coating:None(clear glass); No outside shading. S Wall 79 sq.ft. 168 0 168 619 -Wood frame,with sheathing,siding or brick; R-113 1/2 in.; none Window 33 sq.ft. 1,320 0 1,320 1,582 -Double pane;Wood frame; Clear glass -No inside shading;Coating:None(clear glass);No outside shading. Entry Foyer 144 sq.ft. 653 302 955 2,058 Infiltration 89 72 161 663 -Tightness:Avg.;Winter ACH: 1.07;Summer ACH: .5 Duct 0 0 0 98 -Supply above 120; Enclosed in unheated space; R-8 People 1 300 230 530 0 Floor 144 sq.ft. 0 0 0 326 -Over unheated basement; Hardwood or tile; R-19(4-6.5 inch) S Wall 30 sq.ft. 64 0 64 235 -Wood frame,with sheathing, siding or brick; R-113 1/2 in.;none Door 18 sq.ft. 200 0 200 736 -Metal; Polystyrene; No storm Second Floor 14,461 2,274 16,735 25,629 Bedroom: rear left 0 sq.ft. 2,907 593 3,500 5,457 Infiltration 163 133 296 1,215 -Tightness:Avg.;Winter ACH: 1.07 ; Summer ACH: .5 Duct 0 0 0 260 -Supply above 120; Enclosed in unheated space; R-8 People 2 600 460 1,060 0 W Wall 101 sq.ft. 215 0 215 791 -Wood frame,with sheathing,siding or brick; R-113 1/2 in.; none Window 11 sq.ft. 814 0 814 527 -Double pane;Wood frame; Clear glass -No inside shading; Coating:None(clear glass); No outside shading. N Wall 90 sq.ft. 191 0 191 705 -Wood frame,with sheathing,siding or brick; R-113 1/2 in.; none Window 22 sq.ft. 550 0 550 1,055 -Double pane;Wood frame; Clear glass -No inside shading;Coating:None(clear glass); No outside shading. Ceiling 196 sq.ft. 374 0 374 904 -Under ventilated attic; R-19(4-6.5 inch); Light Bedroom:rear right 0 sq.ft. 2,520 363 2,883 5,190 Infiltration 163 133 296 1,215 Page 4 Malkani, Heather 8/1/2018 Building Component Sensible Latent Total Total Gain Gain Heat Gain Heat Loss (BTUH) (BTUH) (BTUH) (BTUH) -Tightness:Avg.;Winter ACH: 1.07 ;Summer ACH: .5 Duct 0 0 0 247 -Supply above 120; Enclosed in unheated space;R-8 People 1 300 230 530 0 N Wall 90 sq.ft. 191 0 191 705 -Wood frame,with sheathing,siding or brick; R-113 1/2 in.; none Window 22 sq.ft. 550 0 550 1,055 -Double pane;Wood frame; Clear glass -No inside shading;Coating:None(clear glass); No outside shading. E Wall 85 sq.ft. 181 0 181 666 -Wood frame,with sheathing,siding or brick; R-113 1/2 in.; none Window 11 sq.ft. 814 0 814 527 -Double pane;Wood frame; Clear glass -No inside shading;Coating: None(clear glass); No outside shading. Ceiling 168 sq.ft. 321 0 321 775 -Under ventilated attic; R-19(4-6.5 inch); Light Bathroom 0 sq.ft. 1,407 274 1,681 1,689 Infiltration 54 44 98 405 -Tightness:Avg.;Winter ACH: 1.07; Summer ACH: .5 Duct 0 0 0 80 -Supply above 120; Enclosed in unheated space; R-8 People 1 300 230 530 0 E Wall 37 sq.ft. 79 0 79 290 -Wood frame,with sheathing,siding or brick; R-113 1/2 in.; none Window 11 sq.ft. 814 0 814 527 -Double pane;Wood frame; Clear glass -No inside shading; Coating: None(clear glass); No outside shading. Ceiling 84 sq.ft. 160 0 160 387 -Under ventilated attic; R-19(4-6.5 inch); Light Bedroom:3 playroom 0 sq.ft. 3,321 407 3,728 6,078 Infiltration 217 177 394 1,620 -Tightness:Avg.;Winter ACH: 1.07; Summer ACH: .5 Duct 0 0 0 289 -Supply above 120; Enclosed in unheated space; R-8 People 1 300 230 530 0 E Wall 85 sq.ft. 181 0 181 666 -Wood frame,with sheathing,siding or brick; R-113 1/2 in.;none Window 11 sq.ft. 814 0 814 527 -Double pane;Wood frame; Clear glass -No inside shading:Coating: None(clear glass); No outside shading. S Wall 79 sq.ft. 168 0 168 619 -Wood frame,with sheathing,siding or brick; R-113 1/2 in.;none i i Page 5 Malkani, Heather 8/1/2018 Building Component Sensible Latent Total Total Gain Gain Heat Gain Heat Loss (BTUH) (BTUH) (BTUH) (BTUH) Window 33 sq.ft. 1,320 0 1,320 1,582 -Double pane;Wood frame;Clear glass -No inside shading; Coating: None(clear glass); No outside shading. Ceiling 168 sq.ft. 321 0 321 775 -Under ventilated attic; R-19(4-6.5 inch);Light Hall 0 sq.ft. 1,113 274 1,387 1,893 Infiltration 54 44 98 405 -Tightness:Avg.;Winter ACH: 1.07; Summer ACH: .5 Duct 0 0 0 90 -Supply above 120; Enclosed in unheated space; R-8 People 1 300 230 530 0 S Wall 37 sq.ft. 79 0 79 290 -Wood frame,with sheathing, siding or brick; R-113 1/2 in.; none Window 11 sq.ft. 440 0 440 527 -Double pane;Wood frame; Clear glass -No inside shading; Coating:None(clear glass); No outside shading. Ceiling 126 sq.ft. 240 0 240 581 -Under ventilated attic; R-19(4-6.5 inch); Light Office 0 sq.ft. 3,193 363 3,556 5,322 Infiltration 163 133 296 1,215 -Tightness:Avg.;Winter ACH: 1.07; Summer ACH: .5 Duct 0 0 0 253 -Supply above 120; Enclosed in unheated space; R-8 People 1 300 230 530 0 Miscellaneous 300 0 300 0 S Wall 90 sq.ft. 191 0 191 705 -Wood frame,with sheathing,siding or brick; R-113 1/2 in.;none Window 22 sq.ft. 880 0 880 1,055 -Double pane;Wood frame; Clear glass -No inside shading;Coating: None(clear glass); No outside shading. W Wall 93 sq.ft. 198 0 198 728 -Wood frame,with sheathing,siding or brick; R-113 1/2 in.;none Window 11 sq.ft. 814 0 814 527 -Double pane;Wood frame; Clear glass -No inside shading;Coating: None(clear glass); No outside shading. Ceiling 182 sq.ft. 347 0 347 839 -Under ventilated attic; R-19(4-6.5 inch);Light Whole House 982 sq.ft. 28,995 4,919 33,914 52,011 (3tons) HVAC-Calc Residential 4.0 by HVAC Computer Systems Ltd. 888 736-1101 Load cabadations are estimates only,actual loads may vary due to weather and construction dfferences. 1 O O N (b tb iD 8 of c E m d n Fold.Then Dgtmctt Atong All Pmrforottons a C W LT S SOARb OF Q ' z _ PLUMBERS AND GASFITTERS X ISSUES THE FOLLOWING LICENSE MASTER PLUMBER JOHN C OCONNOR 8 PALOMINO PL , �A SANDWICH, MA 02563-2414 a. CL c a N N N f0 m N O r + sANDll�ljs MA I � T _��DRIVE SET LICENSE lilt . t111412016 . S15499531 �! !„1 e2 i 011 9 4- Pat • � �rriQM+. i�N NE�a e8!R/,ILOMINO.WAYs ` S/1NNyVWCN MA?46 O�y{kj�jl�� LT� .f�1 ��•! • fS6EX M t4GT S 10 qq �j✓,�q�ti5Dp 1�812016 Rev 07ltN201�� ®�,, ��� f - t a � �1 c 00 ;1 3 0 � � o e T 3 A 0 Z ! 1 :navwasi.� i�a^ a •�'tfk ! w Q f�hY,bjit� f � _ Rppq�gtlUy++�''pR»r=ws!H.�'t7006YS0: �41 wme.,w+.Mwr.�=Use+'few°vwR'+Ncr t p�:,.x� �• ���.,srx.:c.^ar�anc ..\ *1Q1�'i�c�:'lA�°:A3:"wP9F.4�� r�`..;""x9�' i a �s o � � d � � s • Aw 44 w s C-A - a m ACORO® DATE(MMIDD/YYYY) A� CERTIFICATE OF LIABILITY INSURANCE 6/25/2018 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 WANED,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 Anita Ahearn NAME: Eastern Insurance Group LLC PHONE (800)333-7234 FAX A No: 233 West Central St ADDRESS:aahearn@easterninsurance.com INSURE S AFFORDING COVERAGE NAIC A Natick MA 01760 INSURERANautilus Insurance Company 17370 INSURED INSURER B Jack O'Connor, DBA: Jack O'Connor Plumbing rG Heating INSURER C: 15 Jan Sebastian Way INSURER D: Bldg A, Unit 5 INSURER E: Sandwich MA 02563-2354 INSURERF: COVERAGES CERTIFICATE NUMBERCL1862530248 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 ADD S B POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD MM/D X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A CLAIMS-MADE ❑X OCCUR PREMISES Ea occurrence $ 100,000 NH954912 6/16/2018 6/16/2019 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 M'OTHER: L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑JECOT- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS paraNQt $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $_ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ B yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space Is required) RESIDENTIAL PLUMBER CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Dennis THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 685 Route 134 ACCORDANCE WITH THE POLICY PROVISIONS. South Dennis, MA 02660 AUTHORIZED REPRESENTATIVE John Koegel/AAHEAR ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 imunit i ACO®�� CERTIFICATE OF LIABILITY INSURANCE DATE(MMrDDmYY) o1/17/2016 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. N SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER NAME CT Kelly Smith EASTERN INSURANCE GROUP LLC pHIC0 . (508)620-3447 AI NO: E-MAIL kesmith EMAILDRESS: @easteminsurance.COm 233 WEST CENTRALST INSu S AFFORDING COVERAGE NAIL# NATICK MA 01760 INSURER A: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B: OCONNOR JACK DBA JACK OCONNOR PLUMBING AND HEATING INSURERC: INSURER D: 15 JAN SEBASTIAN WAY BLDG A INSURER E: SANDWICH MA 02563 INSURERF: COVERAGES CERTIFICATE NUMBER: 230496 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 AD L SUER POLICY EFF POLICY EXP LIMITS POLICY NUMBER D M DD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR PREM SES Me occurrence $ MED EXP Any oneperson) $ N/A PERSONAL BADVINJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑JET LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY CO BINED SINGLE LIMIT $ Ea acddeM ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Pet accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Parer ar ZI UMBRELLALUIB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION /� STAME ER AND EMPLOYERS'LIABILITY — TH ANYPROPRIETOR/PARTNER/EXECUTIVE YIN N E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDEDI N/A N/A NIA 6S60UB1K03678917 11/14/2017 11/14/2018 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be 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-compensationrinvestigaUons/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Jack O'Connor ACCORDANCE WITH THE POLICY PROVISIONS. 15 Jan Sebastian Way Bldg A Unit 5 AUTHORIZED REPRESENTATIVE Sandwich MA 02563 Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD Town of Barnstable Building Department Services t3UILD1iVG RARNM= ' Brian Florence, CBOT XAS& Building Commissioner : AUG G 200 Main Street,Hyannis,MA 02601 20 is www.town.barastable.ma TQns WN OF�3At;�sr��LE Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section - If Using ABuilder as Owner of the subject J property hereby authorize 'J LK �° ,^d I- to act on my bebal{ in all matters relative to work authorized by this building petmit application for. LoMbr-i2 Ave we c,.,1S/r.�A- /'/q 62�l0 (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.pre.performed and accepted. S tare of Owner Signa e of Applicant Print Name Print Name Date QTORMS:MMMERIMSIONPOOIS Rev-.08/16/17 Town of Barnstable ' }wilding I)epartment Services Brian Florence,CBO o Building Commissioner 200 Main Street, Hyannis;MA 02601 n.,N. www.town.bnmstnble.ma.us 1639. Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEM[PUON Please Print DATE: JQB.LOCATION: qr� : number sheet. village "HOMEOwl I: name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of sic 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}and on which he/she resides or intends to resi&,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"homeownee'shall submit to the Building Official on a form acceptable to the Building Officia],that he/she shall be resnonsible for all such work performed under the bin7ding permit (Section 109.1.1) The undersigned"horneowner".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 andrequirement s and that he/she will comply with said procedures and requirements. 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 Section 127.0 Construction Control. HOMEOWNER'S EIM�IMON 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,bxemption)areunaware 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 helshe understands the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. QAVVTFMES\FORK%uiilding pemrit fnrmsVDTRESS.doc 09/16/17 Town of Barnstable *Permit S Regulatory Services Yee • r3"'ItimAa14 MAM Richard V.Scali,Director 163P Building Division Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.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 �S.S " 0 1 (,l W.r I -Address /SO /Ul/V1 t)G GI hd�,A CA 6k 61646 dential Value of Work U 7S Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address / I t �r 11�16,1&CA O f ISO /()r 6(.\ d 6 �,J Contractor's Name 36,a✓\ fferb,S Telephone Number -7 Home Improvement Contractor License#(if applicable) �� 13� I Email: N�v-bS �(,W�il tMQIb�Q✓►�>7S��l�V"� Construction Supervisor's License#(if applicable) O C(�.S r `J Workman's Compensation Insurance Check one:Elw XPRF 9 I am a sole proprietor ❑ I ' the Homeowner Novi I have Worker's Compensation Insurance JUN 2 3 2016 Insurance Company Name 4r C. j<, . 51���►'� �dN^� f�k0 n I Cl 141 I �"� L E Workman's Comp.Policy# /'l1 AQ 4%�(� 3�U I Copy of Insurance Compliance Certificate must accompany each permit. Permit Requ (check box) � // Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ''ni XA ❑ Ike-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. f ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improve Contractors License&Construction Supervisors License is r uired. SIGNATURE: w`� Q:\WPFILES\FO uilding permit forms\EXPRESS.doc 06/20/16 The Coinnoirweakh c,f Manadi esdts Dapartmeut gf.l'n . t - Accidimmjtg 600 WaskhWon YS`met Boston,MA 02HI furtnstmasmg P1dia Workers' Compensa .rm Insurance Affidavit Bmlders/CnntractarsMec driansJPhunbers Apl3licant Infarmai on Please Print E Iy Addre= 3S pLe p 4-pad rd ciwstr r Phone 7-7 3 S Arl an employer?Checkthe appropriate bom Type of project(required)- I. m a employer with. 4_ ❑I am a general confrsctor and I 6. ❑New oansixuctios employees(fiz12 andfor part-time)-* have firedthe sub-co hactm 2.❑ I am a sole prqpaietor or partner- listed on the attached sheet 7. ❑Remodeling. she p and have ao employees . These sub-contractors have g- ❑Demolifioa waiing forme in any capacity- employees and have workers' 9..❑B,uiltftag addition LNo wads'comp.insurance comp- -j 5. ❑ We are a corpomfim and its 16-❑Electrical ors or additions 3_❑ I am a homeDwner doing all work officers have exercised their 11-❑PlunNagrepairs or additions myseM [N temp o workers' right of per M(M ,�, = ��]� c.152, §I(4h and we have no L-� of . employees-(No wod=s' 13_L`�Defier !Gl cam-msntance required] #Any WHo=1hatchedmbio=#1mastalsoMoutthe section below shavdngibe¢suadcers'ccmp—sati policgiaform dam. 1Fhmeoames urbo submit dos af5d2vir h-Hr &ey&m dxsm-abl walk sad,dU!n Ism anmde cUat3cims mast MIMMit a nem afiidseitmdir�ne sncFi IC===O s ff=Ak1,this bore must 9ftril au.addiliMal sheet sbon�sg rice azure of die sad state wbethec a8 mttbose emities 1 employees.Iftbesnb coa�dflshave empIoyr�s,tha}*�stpiwid &eft amabser- I am art Below is the puficy and job site informalron. Insurance Company Dame: t!(f ,��, ��ilGt�G CX� PolicyA,orSelf-iffi-Lic- A IC ���u l g t 1( 16 / Job Sit�Address: /S Q 1014,g r !cg CitylStatdz�pla WAS /tL Af€arlt aropy of the worlmrs'compensationpolicy declaration page(showing the policy amber and expiration date). Failure to sectme coverage as required under Section 25A of MGL c.15 can lead to the imposition.of criminal penalties of a fine up 10$000 00 indfor 6ni-e--ye-airimprisonmeA as well as tivil penalfie in the float of a STOP WORK ORDERand a fine of up-to 00 a day against the violator. Be advised t3rat a copy of this statement maybe forwarded to the Office of 7avestigatinas ofthe DIAL for insm:ance;coverage verificah= da ker8by =- dteppain7sand pet�trry thatthe utformafimprol-iiW abory is bus/and correct S (t�- Date: 6 Phnae ik_ -7 2 13 7 Oj%ciaE aw wily. Do toot write in dds area,to be cmnpleted by c4 artown ofjiraial City or Town: Ferndfmicense;g Lxsuing Asthority(drde one): L Board of Ht a tfi r.BmWmg Dgrmtmfnt 3.Cdyfrown Clerk 4.Electrical Inspector S.PIunbmg Fnspector 6.Other Contact Person: Phone 9: 6 o�rm�atzon and Inst ructims �. Masmch yetis C mtm-Z Laws chaps I52 requnm all=PIU=to grOVida WDEb '=:0Peasaftan far f==employees. pMSMU&{n this Vie,an enpIoywls defined&&' .eggpersoniu ffie seavicc of anofficrumder any caafxact ofhfim, cspress or i mpliact oral ar wri� An empkyg is defined as-an mdi idnal,p3r[nessb.3p,aWDCfi ban;corporation or other legal errbdy,or any two or more Of the foregoing engaged is a joint MbXpase,and inchrding fbe legal F p=c nfzfi=of a deceased employer,or the receiver or trustee of as individual,p ip,associst=or ofher legal entity-,employing employees. However ffiZ owner of a•dweIIinghome havingnotmare than 133ree apartments and who resides therein,or the octet ofthe - dwaIIing house of another who employs pmtsom to do mahtmancc,construction.or repak wo&on such dwelling bome, or on the groupds or building appurtt:mar¢tbemto shallnotbecanse of such emplaymeratbe deemed t o be an eniployar" MGL chapter 152,§25C(6)also sffB=that-every sfaf m or local licensing agency shall withhold$re issuance or renewal of a license or permit to operate a business or to construct bwIdings in the co—Gnmalth for ray applicant Who has not produced acceptable evidence of compr=ca with the insurance coverage required." Addiiionagy,M(B:.chapter 152,§25C M sial s-Neithertha nor auy of its political subdivisions shall ester into any contract for the pmfmnauc,'ofpnblic work u3til acceptable evidence of campIigncewith$ie fimmnnce. requnmmemts of this chapter have been presentedfn the contacting anihoiity." AppIicaat� Please 51 nit the worla=as' compensation affidavit completely,by chmking fbe boxes that apply to your mtoaf m and,if pIYsohnes)nme( ` wiier � ss) of n�� s), a cs(es)anpineme g � insurance. Lnited LiabrZy Companies LLC or Limited Lab7itpParneshiFs JP)wiSino Io e other the members or pmta=s,are not rued to carry workers' compensation in�ee_ If an LLC or LLY does have employees,apolicyisrequired. Be adviseedtha:tfbisafddayitmaybesnbmrtfedto the Departmentoflndvsirial Accidents for conEmmatim ofT surm=coverage. Also be sure to sign and date the affidavit The affidavit should be returned to ihe city or town that the application for the perm re it or license is being quested not the Department of Lnghjs�.A cat mta_ Should you have any question regarding the law or ifyou ate requ>redfn obtam a worms' compensation policy,please call thm Deparhnem±at the n=ber Iisted below. Self-imnr-d=panes should— their self insurance license n ober an the aggropri_ate line City or Town Officials Please be sure that the affidavit is complete and pri tcd.legibly The DepartmesrtIm provided a space at the bottom of the.affidavit for you to fill out in the event the Office oflnvesti gaiio s has to contact yom regacUm g the applicant Please be sure to f M in the pemffiWlicrose munber which will be used as a reBxmce number. In—addition.an applicant that must submit multiple pcsrnW ice se appHts ions in any given year,need only subset one affidavit indicating easent policy infb=:ation Cif necessary)and under`Job Sitm Address"the applicant should write-all locations in (may 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 lZoo-fthat a valid affidavit is on flee for B:dm a Pmn#s or ketoses. A new affidavit must be filled ovt each year.Where a home owner or cifiz=is obtaining a license or pew not related to any bnsiams or commercial Yee Cie.a dog license or permit to bun leaves et-_ -said person.is NOT regrmed to complete this affidavit t The Office of Tuvesfigsti=would him to tfi—k you in advance for your cocpeaa dam and should you have any questions, please do not hesitBl to gcve us a call. The Dgep rt mfs;4 ddress,telephone and fax member: Depaximmt of 1adustda1 Accidents (ice a Dnm&tkatio= B MA Oil11 Tel.#617' -49.W e�ft 406 car 1-8W MA�� Fax 617` 27-7M Kevised 424--07 ww gg Herbst Home Improvements LLC i 35 PEEP TOAD ROAD CENTERVILLE MA 02632 774-238-2937 ` www.herbsthomeimprovements.com PROPOSAL SUBMITTED TO: WORK PERFORMED AT Heather Malkani 150 Lombard ave,Barnstable 02668 We herby propose to furnish the materials and perform the labor necessary for the completion of: New roof faces and sidinq front and back Replace fascia board front and back ✓Replace 4 corner boards on dormer Remove one layer of shingle Ins ect roofin deck and wall I ood fob' Install 301b felt on roof a t a Ouse wrap on sidin /Install cedar breather on ro portions # ✓Install mebec H2B0 bleaching oil shingles on sidewall NG�+ IG�.dt V Install 18"red cedar taper sawn shake on roof portion ✓Install copper flashing at roof and dormer intersection All cedar installed with stainless nails Clean all debris daily 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 workman-like manner for the sum of:eleven thousand seventy five dollars Dollars($11,075.00)with payments as follows: deposit of 5,000 and remainder 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 TFULY SU IT li✓�" 6/14/2016 Jason Herbst ACCEPTANCE OF PROPOSAL The above price,sp cifica ions and conditio s are satisfactory.I herby accept this proposal. You are authorized to do the work an payments will be as 5peci abov . SIGNATURE: s � I *This proposal may be withdrawn by said company if not accepted within 30 days. ' i i AC�® DATE(MM/DD/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE 06/09/2016 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). PRODUCER CONTACT NAME: Ashley Clark LEONARD INSURANCE AGENCY P"c°N o E (508)428 6921 FAX A/C No): E-MAIL L ADDRESS: Ashle y@ eonardagency.com 683 MAIN STREET SUITE B INSURERS AFFORDING COVERAGE NAIC# OSTERVILLE MA 02655 INSURER A: ACADIA INS CO 31325 INSURED INSURERS: HERBST HOME IMPROVEMENTS LLC INSURERC: INSURER D: 35 PEEP TOAD RD INSURERE: CENTERVILLE MA 02632 INSURER F: 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 SUER POLICY NUMBER D MM POLICY POLICY EFF EXP LTR / /YYYY MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE RENTEIT_ CLAIMS-MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PRO ❑LOC PRODUCTS-COMP/OP AGG $ JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ S NON-OWNED AUTOS AUTOS PROPERTY DAMAGE Per accident $ HIRED AUTO AUUTOSTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X PER STATUTE ER AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y-" E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBER EXCLUDED? N/A N/A N/A MAARP300898 11/18/2015 11/18/2016 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under LIMIT $ 500,DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY L000 N/A Ecertificate OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) ompensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. ate 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 of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification l at www.mass,,ov/Iwd/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 Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE I1 South Yarmouth MA 02664 J_n Daniel M.Cro uey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD _............ m . ......... d72o�poarurrwruuecaLC�o�6> aac�ucaeCrd t \. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR y Registration:;P1�7,,1331 Type: _ Expiration:_3-'=*i.01,8 LLC " HERBST HOME IMP�6V�M �T=GIC JASON HERBST 35 PEEP TOAD RD \ CENTERVILLE,MA 026 " Undersecretary Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CSSL-106051 Construction Supervisor Specialty JASON HERBST ,a 35 PEEP TOAD ROAD CENTERVILLE MA 02632� - 4 i I•n Expiration: 1 Commissioner 10/01/201111 I 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 , Not valid wit out signatu Construction Supervisor Specialty Restricted to: CSSL-RF-Roofing N 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: WWVV.MASS.GOV/DPS : l