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HomeMy WebLinkAbout0065 BUCKWOOD DRIVE ��uG� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION _m-A ` ' TIOIN OF S� RNSTA� Map � Parcel Oq � � LE Application# Health Division %"? n � Date Issued Conservation Division Application Fee Planning Dept. Perm'ifFee -� L 1 : "C Date Definitive Plan Approved by Planning Board„ Historic - OKH _ Preservation/ Hyannis Project Street Address A fl� `'9 W r0 e2 �,u Village�4i�111' Owneri°l�'L� �/a✓il�/ Address Telephone J-Pr Z Permit Request 1PY212 f/ / ,G,9yee Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type ��U Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family U"' Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes d"N-o On Old King's Highway: ❑Yes It-Mo 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) NameA iivd Telephone Number ,:rO '7L Address 0 Cj12 License # c v9d�fGl4/il` Home Improvement Contractor# /J3S Email 414 Gd �i� Worker's Compensation #4) ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE �/j� //� FOR OFFICIAL USE ONLY •APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE r ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. r f t \ Town of Barnstable Regulatory Services tuussrear.8,tg i) Richard V.Scali,Directur -0;u,' Building Divisioa 'four Perry,Building i:urrunissiuuer '100 Maw Street,liy;auus,NUN U601 ��•��•«•.ro rr•n.h�r ns i a h i c.m a.u s oflic:c.: s48_F 2--10'- Fxx: 508-7-90-62.30 17roperty Owner Must Complete and Sign This Section 1f Using A Builder Lavigne as Owner of the suhit'cF L,f;rc:h} sutl)o:v� Co -- Ult�cfJto::ct c:n r:yaehaif; in a1J maErc:r. r• :su:is•i:to :��o;k at:thc:rzed b;tni�ht_1cit)g�pernn:;r:,plic:._:;•:; 65 Buckwood Drive Hyannis MA 02601 (Address-of job) I)oc)1 fences and aLums are the rusponsiaility of the appi.cart. lochs itre not to Ix.filled or u.tilcced before fence is iastalled.mi(l b fima l l inspecrons are peiforzved am) accepted. i i L; urc of�lppr wwrt trim Name P11I3L Name I i y i3 zo�G f Tlae Co»tmonwerclllt of Mressrtehusetts ' Deprcrtm.enl of Inrlccstrtrcl Aceirlents 1 Congress Street, Suite 100 Boston MA 0211 A-2017 4 1 )v}VW.mress,go v/rllrc �;• Ww-kers' Compensation Insurance Affidavit: Builders/Contractors/Electricions/Plumb TO BE FILED WITH THE PERMITTING AUTHORITY, ers, Ilcant Information Name(Business/Or enization/individual)' l Please Print Le ibty Address. :- ', City/State/Zi 1:2 Phone, FAre you an employer? CA�eck (Z appropriate box, _ �amaemployer with � ..�omployeos(full and/or part-time).' Type of protect(required)I am a sole proprietor or partnership and have no employees working for me in any capacity,(No workers'comp, insuranco required,) 8' Q Remodeling delin�tel(on 3.(]l am a homeowner doing all work m self, $'"(] Remodeling a 01 am a homeowner and will be hiring contractors to conductcomp. insurance required.)t 9• Q Demolition ensure that all contraclors either have workers'compenset on insurance or or arark on my rsolo I will 10 Building addition proprielors with no employees. l l,(�] Electrical repairs or addir,c„>�, S.Q I am a general contractor and I have hirod the sub,contraetors lisled on the attached These sub•oonlraot,prs have employees and have workers'comp, insurance) sheet, 12,[�Plumbing repairs or add ItI,,•,. ,, : 6 We are a corporellon and its ofi�cers have exercised their right of exemption per MGL o, 13.[D Roof repairs I52,¢I(4),and we have no employees (No workers'comp, insurance required,) Any applicant that subm' box NI must also fill oul the section below showing their workers'compensali Homeown¢,s who check this b box must indicating they are doing all work and Then hire outside contractors must Y Contractors Ihal chock this box muss attached on additional sheet showing the name of the is °s Policy information. employees. If the sub contraclors have employees,they must provide their workers'comp.policy number, submit a now aftldavit indicating such. ` (ant«n entployer t/tat is prov(r(1�:� workers'coin art b contractors and state whether or not those amities have infornmtton, p Batton lirsur«�tce for my employees, Below is the poltcy«nil vb sit Jnsurance Company Name• , �-- / e Policy#or Self ins. Lic. Job Site-Address: Expiration Date: Attach a copy of the workers' compr,nsatlo�Policy y P y dec oration a City/State/Zip; �� � Fatlu�e to secure coverage as required under MOL c, 152, §2SA is a criminal violet( P ge (showing the poltcy number�and expiration cJalc:. and/or on'e-year imprisonment, as.�vell as civil penalties in the form of a STOP WO day agalrisl the violator. A co of,tl;is statement may °n punishable by a fine up to$1,500 0rl coverage verification, l y Y be forwarded to the Office of investigations of the pi f up to x250 Uti �� A forinsurance /r!o hereby certify tattler the petits rrnr(pennitles ofper�lyO,that ljre It err "In atur . %�; tf noon provlrled above is true awl correct, Plion #. D 73 G. Official use only, Do�IcoI wrtte In t/tls area, to be completed by cl ty or town offlcla4 City or Town: ;l IssuinL6h,c=r Authority (circle one): Permlt2lceQse p^-- -� !I I. d o�f Health Z, BuildingDepartment 3, Ci P tY/Towa Clerk 4, Electricalg, piuntb(nt Person; g Inspector Phone p: I Massachusetts 0epartmenl of Public Safety �ltvjf Board of Bullding Regulatlons and Standards license; CS•100988 Constru0tlon Supervisor• SHED ROW'SIpY. vy t3 WEST YARMOU,�N n 2' I'I ''� ' ' 1 )I'111 0 '�•�- Explratlont COMMIssloner 111111201T _) Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite S 170 Boston, Massachusetts 02116 Home Improvement Cb �tractor Registration Reglslrallonc 153507 •..m^„ , ,f';. Type; Prlvale Corporation Explrallon; 121151201$ Tra 259188 CAPE COD INSULATION, INC HENRY CASSIDY ' 18 REARDON CIRCLE --- SO. YARMOUTH, MA 02Oe4 .r' Vpdata,Address and return card, Mark reason for chnnge. scA) 4'1 soM•osr): Address Q R8118WRI (] Employment L� (.,cst Cal V/60 C9)'�17tWltlUBrllG7�L C��GGCWd�!•C�4W4�T0 ate\ Ofncc,OfCOnstlnial'Affnlrs c� puslncss Regulnkn Llconss or raglstrntlon valid for Indlvldul use only QME IMPROVEMENVUNTRACTOR before the expiration date,' If found return tot egistratlon: "I'M07 Type: Office of Consumer Affalrs and Business RegulRtlon xplratlon;c;1;'1.:q.51'20:1.8 Private Corporation 10 PRrk PI RzR •Suite $170 CAPE COO INSUTATa'QIJ':,IN '`•'°''�'"• Roston,MA 02116 HENRY CASSIDY 18 REAROONCIRCIE' . ':"„' �TT�� • $0; YARMOUTH,MA02004 Undersccrelnry '� ARL Nut sign e I �., CAPECOD-27 CLEDDUKE ACORO° CERTIFICATE OF LIABILITY INSURANCE DATE/Mf�I1DD1YYYY) 711/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER NAAMEAOT Barbara De Lawrence Rogers&Gray Insurance Agency,Inc. PHONE t ac No 434 Rte 134 EMAIL South Dennis,MA 02660 ADDREss:bdolawrence@rogersgray.com INSURERS AFFORDING COVERAGE NAIC a INSURER A:Peerless Insurance Company INSURED INSURERS:Safety Insurance Company 39464 INSURER C:Endurance American Specialty Insurance Company 41718 Cape Cod Insulation,Inca 18 Reardon:.C:(�cle - INSURER 6:Atlantic Charter Insurance Company44326 South YafrttOVth,MA 02664' INSURER E INSURER F. COVERAGES CERTIFICAtE.!NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF JOURANCE U.STED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,•1 EhM 01Z;CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY.j?ER FAIN, THL.INSUIQANGE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SU,PH POLICIES.LIMIT$`SHOWW AY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE D POLICY'NUMBER MMIODIYYYY MMIDD I LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE a OCCUR CBP8263.063 04101/2016 04/0112017 PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1-000,000 GEN'L AGGREGATE LIMIT.0'41. PeFt- GENERAL AGGREGATE $ 2,000,000 X POLICY a:PR OT LOC PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY n $ 1,000,000 COMBINED SINGLE LIMIT"• Ee eccidenl B ANY AUTO 6232707 COM 01` 04(0.1%2016 '04/.0:112017 BODILY INJURY(Per person) $ AUTOS `X AC�j7QSULED BODILY INJURY(Per accident) $ L X HIRED AUTOS X 'qtl OS ED (Per accident)TY AGE $ $ X UMBRELLA LIAB X OCCUR'' BFGF{0000RRENCE $ 2,000,000 C EXCESS LIAR CLAIMS.MADE EXC10006635001 04/01/20'16 04/0112017'::AGGREGATE $ DEO I X I RETENTION$ t01000 Aggregate-•.• $ 2,000,000 WORKERS COMPENSATION STATUTE PER H_ER AND EMPLOYERS'LIABILITY Y 1'N D ANY PROPRIETORIPARTNER/EXECUTIVE ❑ N 1 A CEOQ431902 0613012016 0613012017 fi I,,EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE A,, $ 1,000,000 It es describe under 1,000,000 DESCRI, PTION OF OPERATIONS below E.L.DISEA.8-pQLICY LIMIT:: $' DESCRIPTION of OPERATIONS I LOCATIONS I VEHICLE$ (ACORD 101,Additional Remarks Schedule;:may be:attedh@d'it'more space Is required) Workers Compensation includes Officers or Proprietors, Additional Insured status is provided under the General Liability and Auto LIA I1ItV4hbn required by written contract or agl°et31ri2nt'wlth the Certificate Holder, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE VaTh-"I u)Iders THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 4- ACCORDANCE WITH THE POLICY PROVISIONS. 94A Co erce Park�bttth Sou hatham,MA 0265t',,.,• AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD tfl1 sli t -)1"'- CAPE COD INSULATION 71two 51 IS F9 1151R 0{AIS 11AM011 SPRAT 10AM SVSPIN010 SAlif OVIf191 IHSUl AlION CII{INOS �� . 1-800-696-6611 � - - Town of Barnstable Regulatory Services Building 1S1011 Div' ' �- � 200 Main St Hyannis,MA 02601 co Date: (� +� Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed.& completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance .Institute '(BPI) inspector, All work preformed meets or exceeds Federal & State Requirements, Property Owner Property Address Village �eAj Uvl nt (�S AoD DV A-AA6 Insulation Installed: .Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings ( ) (�4) Slopes ( ) ( ) ( ) ( ) ( ) Floors R� Walls ( ) ( ) ( ) ( ) ( ) N r / GVO r k J7,9 r ro r c?ear Sincerely H ry E ssi r, President pe C lns ation, Inc. AWE Town of Barnstable *Permit# (A (P' IS I ) -.Regulatory Services gee 6 months om issue date '""S& 1639. Richard V.Scati,Director Al MA'1 Building Division �1� Tom Perry,CBO,Building Commissioner MAY 2 3 2016 200 Main Street,Hyannis,MA 02601 0VVN QF www.town.barnstable.ma.us Office: 508-862-4038 Fax: 59- kO-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Z�Z J Not Valid without Red X-Press Imprint Map/parcel Number``__ 1 Property Address El"Residential Value of Work$ /0 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 5714r�ltq yL4- W o J Contractor's Name 1 k�, J 6L4`h u6/,bt A iT W U. Telephone Number .gT!�'&Le 9VW Home Improvement Contractor License#(if applicable) 1691 � Email: 4tA-e0 ( et-tl, V el�"L' Construction Supervisor's License#(if applicable) C Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner 31-have Worker's Compensation tInsurance + Insurance Company Name Workman's Comp.Policy# (� E_ZZZ Q 00 W 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 ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side(Old-f ': is je 0 r Jtj-) f Q Replacement Windows/doors/sliders.U-Value a (maximum.32)#of windows 1 #of doors: PC ❑ 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 Own�Smust sign Property Owner Letter of Permisjon. A copy of theTiome Improvement Contractors License&Construction Supervisors License is SIGNATURE: C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\2PIOlDHR\EXPRESS.doc Revised 040215 r Town of Barnstable t639. . p" Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 20O Main Street, Hyannis,MA 02601 www.town.barnstable.uta.us Office: 50&8624038 Fax: 508-790-623.0 Property Owner Must. Complete and Sign.This Section If Using A Builder 1q, a j'- , as Owner of the subject property t hereby authorize Eft riS r/ic61A1i// d'e- h _J l��sJ_to act on my behalf,Ce in all matters relative to work authorized by this building permit application for: (Address of Job) I Signatur f Owner ` ate j Print Nam I If Property Owner is applying for permit,please complete the Homeowners License Exemption Form.on the f reverse side. s o C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporarylnternet Files\ContenLOutlook\2PIOIDHR\FXPRESS.doc Revised 040215 i ��,;� � spa •� AL NS �r- il, 44 e k t..sp `. s �i�r x 3 Sh 14 t k ilk 3 a ° ` cat n as 9 #. F Lice' ' 5 04 INB Y _ ff d S Pe 41 10 L 3 p►i h _ tQ� 0 $ , IV N Y i SAE F � j p { t `aly�'�r„ar �"5' �� rx �'�zrt`f '-. r � �• s Y.. 1���� "' h p,'�`. �.�*,1 E�> t - K. $j `£ka A -S fiw�• � 'S� x^Y `E( n-� � � Z �, � q y, gy' $ �• 5' Office of Consumer Affairs and Business Regulation --- 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement 06ntfdctor Registration - Registration: 169134 ice _ s Type: Corporation 3ri1i i Expiration: 5/19/2017 Tr# 265051 THE UGLY DUCKLING HOUSE COMPANM,;- : � CHRISTIANE CALDWELL �9 - 194-MAIN ST 4 ; W. BARNSTALBE, MA 02668 � 7 --- `••` U date Address and return card.Mark reason for change. ---'` F� Address [—,I Renewal Employment 17 Lost Card SCA 1 0 20M-05111 c�J!'e�i�rrzrrcarcufecc�l�o/��/J/rrc:�eac�ciaeC/t • Office of Consumer Affairs&Business Regulation License or registration valid for individul use only rOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 169134 Type: Office of Consumer Affairs and Business Regulation Expiration •5/19/2017 Corporation 10 Park Plaza-Suite 5170 �� j Boston,MA 02116 LIN THE UGLY DUCKG HOUSE COMPANY a t CHRISTIANE CALDWELL z ,: „••"1 � r 194 MAIN ST W. BARNSTALBE MA 02668 "'y Undersecretary Not valid without signature - Client#:763109 2UGLYDU ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDNYYY) 05/23/2016 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 CON C NAME: Dowling&O'Neil Insurance Ag PHONE 508 775-1620 FAX 5087781218 973 lyannough Rd,PO Box 1990 E-MAIL NE Ext: AIC,No ADDRESS: 508 775-1620 Hyannis, 02601 INSURER(S)AFFORDING COVERAGE NAIC# 62 INSURER A:National Grange Mutual Insuranc INSURED INSURER B: Ugly Duckling House Company LLC INSURER C:Safety Indemnity 194 Main Street West Barnstable,MA 02668 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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. LTR TYPE OF INSURANCE NSRL WVD POLICY NUMBER MM/DDY� MM/DDmYY LIMITS A GENERAL LIABILITY MPT7001 W 5/06/2016 05/06/2017 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $50 OOO CLAIMS-MADE F7X OCCUR MED EXP(Any one person) $5 000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY 7 PRO- JEC LOC $ C AUTOMOBILE LIABILITY 6238304 5/06/2016 05/06/201 COMBINED SINGLE LIMIT Ea accident 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED (BODILY INJURY Per accident AUTOS. AUTOS ) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE - $ DED I I RETENTION$ $ WORKERS COMPENSATION WC IMIjS I OTH- AND EMPLOYERS'LIABILITY YIN ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? NIA $ (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Workers compensation certificate to be issued by carrier:ACE American Insurance Co.policy#2E222000-16 effective 5/20/2016 to 5/20/2017. Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S170318/M170300 CBD ?'Fie Commyrwceah*ofMassadliuselfs ��n�ofrutrial ArriaTe� r Offce ofrmcsfigadaus 600 WasfihVt=Jtreet Basttint MA 02M tort►V.MM gVV1d a Workers' C apensafion Ins> nce Affidavit:Buflders/Confractur5,1 ecE7it-ean s/P ushers APPEcant Informatian Please Print Name Address: cis W. s 1, Pha=9: Are you an employer?Check the appropriat7pm Type of projectam(r : 1.El am a employer ua�it.h 4. a general caairsctor and I 6. ❑New coastracii= employees(fall andfor part-time).* have hired.tbe tzd= 2.❑ I am a sole pmgfietas orpartner- ' listed on the attached sheet MacernD deligg ship and hn a no employees These sub-c riftwIo:s have $ E]Demolifioa f Nadi :For is any capacity. worm andl�e wlodce s , 9. ❑Buitdiagaddifiast [No wp�,g'�-iravxa„r-a camp-�+,erxa.u�•� . d-] 5_ ❑ We are a cmporation.and is 10:❑Electrical repairsor ads reTtire 3.❑ I am a bameouuer doing all track o$'eers have eaeressed their 1L❑Plumbing MIS of adcrdons Mysdf[No vadm s'gyp- riot of esemptim per MGL ❑Roofrepaim irsuu e reqaiLrAj f C.M§1{4�andwebaveno empb9em[No wadne& 131:1 Other cam-inszrsace reqairectj �$ary ML app£t®t Boat sheds hire 1 tayst elan oa¢thz sectFea berme shosog5 dieazva�ced Pa 9adacmati t 1£ameaarne<saha snfmrt dos a$dat$ they am damg slf vad t5eahue aaisidreaatcacros�st sohmrt a ae�affid b�di�g sadi =CdntMCt=jhC chpe*this boa Est&=r%ed sir additumal,sheet d=zimg the nz=of fife and state ar notthase eotibesbxm employees If the m b-caalzadas b—eaipSo,-%fiLeg =m.P•PQRF I nut urn eatPlo�r flttrt>is prauidr'sfg tvorlcers'eoarPerrsati¢n i�xsBrance,fer m}'earpla,}� Beia:F is flee p�ie9 Qad jab s>�a irrfatvrtahDrL � TRSUM CoMpaay Name: Aci Ay -ez AL — Portcy of seFf lira.Lis.¢ 2 F_ 2ZZ C)o o ariDa�e: Jab Site Address_ JC.��W UL { AYLIItiI S CitylStatieM=: ✓4 �k Attach a copy of the world rs'compensafioapolicy decTarafion page(showing the pofiry,number and expo atioa date). Failure to secure coverage as required under Section 25A of MGL c-1572 can lead to the imposition of criminal petitflties of a fine up to 5U00 00 aadror one-pearimgaseument as well as civil penalties is&e farm of a STOP WORK ORDER and a fine of tap to$250-M a day against the violator. Be sdviwd that a copy of this.statement may be f awarded to this Office of Itrvesfig fliaas ofthe DIA fbrfiw=w coverage verfficati= I de lterebp and aWm rM afgeruP fltafflfs axfocia>Fgrm►ided above is titre and correct Date: J r Phone rr Wee Qcitd ass sw[y. 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