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Home My WebLink About0075 BUMPUS ROAD Cl/?") USG x Y6 -h OrN �� TA -��- 0 r� t °6 i I Date:. June 27, 2018 To: Building File RE: Basement Apartment Address: 75 Bumpus Road, Hyannis Originator: Unknown Complaint: "People in and out at all hours of the day& night"—basement apt. Enforcement Process Steps ® 1. Initiate local investigation: RA ® 2. Document/enter into system Yes ® 3. Contact ® 4. Property Owner Jennifer Cappabianca & Pasquale,Jr. 11�'." ;,53 -3593 . ® 5. Seek access,to subject property 6. Seek administrative warrant(if necessary) NA ® 7. Notify state authorities of findings fy NA ® 8. Document conclusion OPEN ® 9. Referred Building/Bob Property—310-438 Property is developed with a 1%2 story single-family dwelling (1988) containing 3 bedrooms and 2 baths on 0.28 acre in the RB zoning district. 06/28/2018 Caller advised Lindsay that there appears to be an apartment in the basement due to the sheer volume of people entering and exiting the lower level all day and night. Dispatching Bob to check site. ;r Date: June 27, 2018 To: Building File RE: Basement Apartment Address: 75 Bumpus Road, Hyannis Originator: Unknown Complaint: "People in and out at all hours of the day& night"—basement apt. Enforcement Process Steps ® 1. Initiate local investigation: RA ® 2. Document/enter into system Yes ® 3. Contact ® 4. Property Owner Jennifer Cappabianca & Pasquale,Jr. 5. Seek access to subject property 6. Seek administrative warrant(if necessary) NA 7. Notify state authorities of findings NA ® 8. Document conclusion OPEN ® 9. Referred Building/Bob Property—310-438 Property is developed with a 1 Y2 story single-family dwelling(1988)containing 3 bedrooms and 2 baths on 0.28 acre in the RB zoning district. 06/28/2018 Caller advised Lindsay that there appears to be an apartment in the basement due to the sheer volume of people entering and exiting the lower level all day and night. Dispatching Bob to check site. Assessor's office (1st floor): �D ; u ?ME Assessor's•map and lot number ............�........................ e�F rod♦� Board of Health (3rd floor): \ WQ o Sewage Permit number ..�.^.�.S.. ....9 �. ..................... Z HARIISTAKE.MAD i Engineering Department (3rd floor): 'oo 039& . e0� kiouse number ........................:.......; ......................:..... 0 Na Y a. Definitive Plan Approved by Planning B'tl(6rd --------------------------------19--------- . APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only TOWN �'OF BARNSTABLE BUILDING INSPECTOR a APPLICATION FOR PERMIT TO .......................! ��..�� ... ..............................................::.:..:.............................................. / Wr'G/3 �q TYPE OF CONSTRUCTION .......GOf1?....... ^..��C..............!!tn;�;1. ......... ..�r' . i,�'............. . .........�.. .................... . .. .L.........19.. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: ! !.....V(�5.... .Y.'. . / � ' 2 1 Location 0 `7 t` //Yr f..��+.!................................................ s �Proposed Use !.�J.1.f�.. ...f?/?A ... .............. ... ..... W-x .................................................................. ZoningDistrict ........ .... ....................................................Fire District ......... .............................................................. Name of Owner �` ''��'�''i S� �: q�......tr7.Q.,1!(s.........................Address ......................................................•............. .... .......... 'Name of Builder ....1..! O..9...VP,4.—�............ .............Address ! <.... ��r�t...s L�lome of Architect ..................................................................Address ..................................................................................... Number of Rooms ......4.........................................................Foundation �6 v/+r.d........�.ui c/e t� Jl It ( �.......). . ................................... Exterior ..... ..P..P.... ! ./�1.... !% .[�U�9��.....�.✓. 1. ...04!��fFo fing r .. �,�i�.A �....... ........................................................... i � S1„NS cs Floors _/ .T`.5.....!..n..... ......... �.e...�./.� ............ ....Interior ........... '.(. 5�.. .......... ............................. er- Heating � ..`...............:. _....Phimbing ......... .......... �i-Aj . g 6V OFireplace .....,�� ........................................ Approximate Cost ...... ... Area ................... .. Diagram of Lot and Building with Dimensions Fee _. OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .................................................................................. M Construction Supervisor's License .....0. ............. '*-'HORAN, MARK A=%i0-438 t 'No t,323....... Permit for ....z.4Story . Single..,'amily Dwelling.......... Location .Lot .... 75...AgTp s,,,RgAd .....................Hyanns>S....................................... Owner ...Mark Horan . ..................I.......................... Type of Construction ..Frame.... ............................ ............................................................................... Plot ............................ Lot ................................ Permit Granted ....OCtober...1.2.........i q 88 Date of Inspection ....................................19 Date Completed ......................................19 I i ;•..^. : e-:tt r;, ...f.: �, "'�`�. :'�r" •�3 ..-.; r a '.. � dh�:s�.... ..}s,.:�,.:�,,ti.. ��-+a:-,....iaj.y.,»_ «+y MY.......r,,,..�x�•[.:..r .,.. ...- x.+P... ».. .._.... -- of ? a TOWN OF BARNSTABLE Permit No. .......32348 BUILDING DEPARTMENT TOWN OFFICE BUILDING Cash ......... '►,ate uY. HYANNIS,MASS.02601 Bond ........... CERTIFICATE OF USE AND OCCUPANCY Issued to MARK HORAN Address lot: 41/42 75 Bumpus Road, Hyannis USE GROUP FIRE GRADING OCCUPANCY LOAD THIS PERMIT WILL NOT BE-VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. December 12 88 t� �� /� G•�.-�--�.__ 19................. 1a...�/' .... Building Inspector •'�y�•�'. TOWN OF BARNSTABLE BUILDING DEPARTMENT _ »a°T ' TOWN OFFICE BUILDING nua i639' �� HYANNIS, MASS. 02601 �o r�r►• MEMO TO: Town Clerk FROM: Building Department DATE: An Occupancy Permit has been issued for the building authorized by BuildingPermit $ ....... ... a'.5.1 ................................�.........................................................._............................ .............. issued to r1 ........................ 5 r,'%U� r ��.�. ..... C ------.------... /_.... Please release the performance bond. TOWN OF BARNSTABLE, MASSACHUSETTS BUILDING PERMIl DATE j ii 19 PERMIT NO,'- 2 13 4 8 APPLICANTfh: vi: C, T J" , v k' 017538 . ...... ADDRESS IN 0.) (STREET) (CONTR'S LICENSE) PERMIT TO I3 u-,--Q -I i k /S iainll'i — NUMBER OF 1ITORY DWELLING U• NITS I (TYPE OF IMPROVEMENT) (PrOPOSE'D USE) AT (LOCATION) —lot ZONING (NO.) (STREET) DISTRICT* BETWEEN AND (CROSS STREET) (CROSS STREET) SUBDIVISION LOT LOT—BLOCK—SIZE BUILDING IS TO BE —FT. WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CO.NSTRUCTI TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION (TYPE) REMARKS: 87 B 0"ND AREA OR VOLUME L ESTIMATED COST $ PERMIT $ 5 5 0 FEE (CUBIC/SQUARE FEET) OWNER V ADDRESS ZIP) I":.':j..!'! S L Y,:t r--ao tj.t: I BUILDING DEPT. BY THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF. EITHER TEMPORARILY C PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE A PROVED BY THE JURISDICTION. STREET OR ALLEY GRADES As WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINE FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIOI OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF THREE CALL APPROVED PLANS MUST �E RETAINED ON JOB AND THIS WHERE INSPECTIONS REQUIRED FOR APPLICABLE SEPARATE ALL CONSTRUCTION WORK: CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR I. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANELECTRICAL,, PLMBIG CAL NSTAULLANTIONS.AND 2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL MEMBERS(READY TO LATH). FINAL INSPECTION HAS BEEN MADE. 3. FINAL INSPECTION BEFORE OCCUPANCY. v POST THIS CARD SO IT IS VISIBLE FROM STREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 10 c"'�Z�, <�7 -/ 1 Al 2 2 2 'q HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT OTHER BOARD OF HEALTH WORK SHALL NOT PROCEED UNTIL THE )NSPEC- PERMIT ',V!LL BECOME NULL AND VOID IF CONSTRUCTION INSPECTIONS INDICATED ON THIS CARD CAN TOR HAS APPROVED THE VARIOUUS STAGES OF WORK 15 NOT STARTED WITHIN SIX MONTHS OF DATE THE CONSTRUCTION, p ARRANGED FOR BY TELEPHONE OR WRITT PERMIT ;S ISSUED AS NOTED ABOVE. NOTIFICATION. Lors41)42. N • O Q /�o4i✓nNr�O�✓ o � N V) All 14-- 50"w � U MPus I� o� � I CERTIFY THAT THE FOUNDATION SHOWN DOES NOT VIOLATE ANY. EXISTING ZONING REGULATION OF, t3A.Q nJ ETA B L 2 MASS, THE-TOWN OF 2A FL N S't�.t3L. .. i=r'ov N O�Tt or�J CERT LrA-rIO&) T VEEzDE., irl c Ilk Of � YAR M o vo4 l MAC a S. W aLTR {—��S E N�1Z,. ASSOG . IN e. . Q,A`I Kl t OLDHAM r1 - 2a 1- o7 su - .� STEM MUST BE Assessor's office (1st floor): . k � t� PL,�,%sCE F THE T A� s lessor' mop and "lot number 14.." ..7 3 CA- . 3 TITLE � Quo Board of Health (3rd floor): E TAl `iODE'AND Sewage Permit number ., ^. .`6.7.. , ..................T4WNAEGU4,gTIpNg i eAHd9T11DLE. : Engineering Department (3rd floor): r �oc,,�163}9- : \0� House number .....:....................... . �. ............................ `.` Y a. �. D YA Definitive Plan Approved by Planning edd6rd ____________________ __________19-------- . APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only - TOWN OF BARNSTABLE 'BUILDING INSPECTOR t4744 401,IfAf APPLICATIONFOR PERMIT TO ........................... ...........................................:..............:......................:............... TYPE OF CONSTRUCTION n 2 �^�% / ,f /J ��4 .. 19.,�� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby pplies for a .permit according'to the following inform lion: Location ....-........... `l ...T..2............ / ?�l/ ....(.``J<.................. 5........ ProposedUse ...........5.� � .e�........... .. ...`1.............................:.................. .................................:.................................. Zoning District ........ ....................................................Fire District �AlY.I`!.l.. - ......... .. . . ............................................ Name of Owner .......!�t...... �.� ^........................Address � � �/�� . .....t... � . ... ..................................... ... ... ... . . Name of Builder .... .'.c:Q F.9:......./U.........F......!L.................Address ............�. .................�..:...5. ._...............�!.. .... Name of Architect ..................................................................Address ........................................... Number of Rooms ............................I............................. Foundation ....:. ..6!!r�'.a........Cfi ... . ........... f f l I� , Q J Exterior ..... C.a....�.C�d/��....�1.!��t?�l1r�.. .�./h1. ...CC',��f� o fing ...........Cf... hf7:. ................................................... r s ,�tvs Ps . s�, ,. Floors c . ....��...../...:C .��Q. ...//.�!.. .f..................Interior ~'" ............��}`W ( v.:............................. / 7 Heating !�f"� �.•^ ..Plumbing ®A n ... ................. 6 VFireplace ......Approximate Cost ...g .�r ................................ . ........ Area .... �. ....s ............. Diagram of Lot and Building with Dimensions Fee OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. 14 v Name .............2.................................................................. Construction Supervisor's License .... .`.?.-!0v.............. r HORAN, MARK t.�lo 3.23.4.8... Permit for .11-5.hO .Y.............. . x, ..... Sl.ngl.e...Eamily. ..Dwell.i.xzg......... Location Lot 41/42 75 Bum us Road H annis � - .......................X..........................................:.......... ` Mark Horan 4 Owner - - s Type of Construction ........Frame................................... .... ... r ..... ..... ................. Plot ...... ` ................. Lot ................................ - -_ Permit Granted .October. 1.2,..- .19 88 r'Da a of Inspection .........................;,:...... .19 any' �.•- Date o1hpl ted .... � �...^............1 t Ltir • J` f t f r i 41 Town of Barnstable *Permit# ufr mnt1 m o issue date X-PRESS PERMIT � Expiresti o e Regulatory Services Fee JULO it 2006 Thomas F.Geller,Director G — TOWN OF BARNSTABL E Building Division �3 V Torn Perry,CBO, 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 rs}CC Not Valid without Red X-Press Imprint Map/parcel Number 31 02T Property Address el �]Residential Value of Work 4 6-712— Min mum fee of$25.00 for work under$6000.00 Owner's Name&Address li. � 6irlcm Contractor's Name 'rHt> &�k - Won"e Se_[y1Ce_! Telephone Number 40 `HT 717.E Home Improvement Contractor License#(if applicable) 12 C-Vq_3 Construction Supervisor's License#(if applicable) E349orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I=the Homeowner I have Worker's Compensation Insurance Insurance Company Name 1%�e W F-(�Q' Shjre (ham GO Workman's Comp.Policy ®R 175 Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to VJQS e Mana e ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this pemit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise071405 t' d Rward of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR y Registration: 126893 t E 513006 Qi�lement Card. i THE Home Dep I _ iSt � rfwc 30HN ZUBA 3200 COBB GAL LE 20 r. ALTANTA,GA 30339 ' t � Administrator �1 06/d/211 16:50 5087476629 PAGE 05 Treoum 1;MRROVr.1tMNT CoXIV A.CT .< Sold,Furnished and Installed by: ame: r Date: THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services 345A Greenwood Street,Worcester,MA 01607 umber. 3/ Job Toll Free(800)657-5182; Fax:508-756-2859 Federal 10#75-2698460 ME Lic#C 02439 RI Cont.Lic#16427 CT Lic#565522: MA Home Improvement Contractor Reg.#126903 Installation Address; _:-F V Ad aoS �• UVX r. r 1-S MA, . U' ty�ir.� State Zip Paroheac Last 4 Digits of Drlveex Lie.#&Eau.Mo/Yr: o hone: Elome Phone: _Cr.0 40 1 (.. ) YD Aome Address: A it Bu -- 3T, wa ke a*4a- 0/cal- (It different from nstallation Address) City State Zip E-mail Address(to receive updates and promotions from The Home Depot): 120. Project Ini' %anon: llwe/You("Purchaser'),the owners of the property located at the above installation address,offer to contract with' h Ho�epot U.S.A.,Inc.("H a Depot") [rush,deliver and arrange for the installation of all materials as described on the attached Spec Sheet#1:r �92� ,incorporated herein by reference and made a part hereof. Home Depot reserves the right to cancel this contract if,upon re-inspection of the job,Home Depot determines that it cannot perform its obligations due to a structural problem with the home,pricing errors or because work required to complete the job was not included in the Spec Sheet or Contract. DEPOSIT PAYMENT OPTIONS (Subjeci to fund verification and/or credit approval.) A'o ��F CONTRACT AMOUNT S / i� 1, Cheek,Caa b)e t i:h�rok ur US Dupont Service Money Onto( I !7 y +� /y (Made payahl�:to 7'he]ionic Depot). � "P��^iW *LESS DEPOSIT $ F J �V 2. Credit Csrd'and/or other payment opt ions-CYrde One Below ji Visa MasterCard Discover American Expt'ess •`' BALANCE DUE ON COMPLETION The Monte lmpnrvaraeul Loan '111e Hume Depot Cruet C'.a,vl $� 0 New Account xt+drug Ap nunt (HtL&HDCC ONLY) "Wrilmram 25%of Contract Amount due upon execution _A Credit: 12 9dO 0. 4v (HiL DCC QNL f this contract. 4� 2.02-4'y 97 �� Indicate Payment Method For Name as it appears on card:. t}44 BALANCE DUE ON COMPLETION: "By my/our signature below.I/We agree to allow Home Depot to charge the above referenmd H credit for the deport indicated,P Q-01 ' �G`�a�._ rer-9 Cardholdol's Signature Dale 603s HIL or HDCC Authorizatlori Codes Deposit Final Payment # 9� #' Purchaser agrees that,immediately upon satisfactory completion of the work,Purchaser will execute a Completion Certificate and pay any balance due. Purchaser also agrees to be jointly and severally obligated and liable hereunder. JqtIre r :This agreement and its attachments,including any financing agreement,contain the eompfete agreement e ween the parties and cannot be amended or modified unless in writing in a separate agreement signed by both patties. NOTICE TO PURCHASER Do not sign this contract before you read It. You are entitled to a completely filled-In copy of the contract at the time you sign. Keep it to protect your rights, Do not sign a Completion Certificate before this projects compplete, Law prohibits home repair contractors from requesting or accepting a Completion Certificate signed by the owner prior to the actual completion of the worK to. be performed tinder the contract. You may cancel this transaction at any time prior to mWo�IIht of the third business day after the date of this contract. See Notice of Cancellation for an explanation of this right. There will oe a service charge equal to 25%of the contract amount if the job'is cancelled by Purchaser AFTER the third business day. BY MY/OUR SIGNATURE BELOW,VWE AGREE TO BE BOUND BY TIIE TERMS OF T141S CONTRACT. I/WE ACKNOWLLDGE RECEIPT OF A COPY OF THIS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE OF CANCELLATION. BY MYIOUR SIGNATURE BELOW, I/WE UNDERSTAND THAT THE AGREEMENT IS SUBJFC'I' TO REVIEW OF MY/OUR CREDIT HISTORY AND I/WE AUTHORIZE HOME DEPOT TO VERIFY AND REVIEW MY/OUR CREDIT RECORD WITH AN INDEPENDENT CREDIT REPORTING AGENCY ANl) RC'LLASE THEM FROM ALL LIABILITY INCURRED FROM iNADVERTEN'I OMIS IONS OR ERRORS. DO NOT SIGN THIS CONTRACT 1F THERE ARE ANY BLANK SPACES. SUBMITTED BY: f Date: C ne t ACCEPTED BY: ate: Homeowner Date;_ Homeowner � NOTICE:ADDITIONAL TI;.RNS,CONDITIONS AID WARRANTIES ARK STATED ON THE REYMsR SIDE AND ARP:PART OF TM S CONTRACT Wbite Dranah8ile Yell(d CuvlOmer Fink—Selee C;eusultaal 12-6-05 C-SC CERTIFICATE NUMBER MARSH CERTIFICATE OF.INSURANCE ATL-00091 590 7-1 1 PRCDq_ZR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS MARSH USA,INC. NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE ATTN: BRENDA BOOKER (404)995-2594 POLICY.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE MAYA MCCLURE(404)995-3206 CR AFFORDED BY THE POLICIES DESCRIBED HEREIN. TAMI ROUSE(404)995-3430 FAX(404)760-5663 COMPANIES AFFORCING COVERAGE 3475 PIEDMONT ROAD,SUITE 1200 i ATLANTA.GA 30305 CCNIPANY CC492dP'JSA-GWA-03/04 A STEADF,°,T INSURANCE COMPAN" T:-ID AT-HCIV1E b.`:'.VICES IN'. H 7Ur7i:Cr1 A.?:i;'cF.;CA..`i I?•• IJRANCE ra:;'?P,\Pi`• LEA THE HONIE _=POT AT-rLi,l=SERViCES,IN0. - --�— — — ! FICINIE D PCT US.''.. INC. i CCm--;..., 245`PAC_'S ;,.':'READ IV`:/ C I iC',I. :'ANIFSHIP�: It,;' CP Ir:S.�IY ATLAINTA.GA — U ---AME_R!CAN HClvir ASSURANCE C0.:t1AINY------- L. _.- .---.-.--- i (,VcR.^•.GES This certi;".:ate supersedes and replace:.any preJ!WSly issued c,.r,ificate`c: the pclicy'period rn:;•:::i below. 3- THI:; .S TO CERT;FY THAT 'CLICIES OF NSLRANCE DESCRIBED HEREIN HAVE BEEN ISSLED TO THE II•,SI:REO NAME HEREIN FOR THE P!A.. 'e PERIOD INGICATE" NC-,'d:THSTANDING ANY RE.'JIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICAT_.MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,CONDITIONS AND EXCLUSIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MMIDDIYY) ':DATE(MWDDIYY) A GENERAL LIABILITY IPR 3757 608-01 03/01/06 03/01/07 GENERAL AGGREGATE $ 4,000,000 X COMMERCIAL GENERAL LIABILITY 'LIMITS OF POLICY ARE EXCESS' PRODUCTS-COMP/OP AGG $ 4,000,000 CLAIMS MADE OCCUR 'OF SIR:$1,000,000 PER OCC' PERSONAL 6 ADV INJURY $ 4,000,000 OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 4,000.000 FIRE DAMAGE(Any one fire) $ 1,000.000 MED EXP(Any one person) $ EXCLUDED B AUTOMOBILE LIABILITY BAP 2938863-03 AIDS 03/01/06 03/01/07 COMBINED SINGLE LIMIT $ 1,000,000 X ANY AUTO ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ ( NON-OWNED AUTOS Per accident) X ELF-INSURED AUTO PROPERTY DAMAGE $ HYSICAL DAMAGE GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ 1 ANY AUTO OTHER THAN AUTO ONLY ` x, EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ G WORKER!COMPENSATION AND 6610998(AZ,ID,MD,VA) 03/01/06 03/01/07 X TORY L MRS ER hr" EMPLOYERS`LIABILITY C 6610995(AOS) 03/01/06 03/01J07 EL EACH ACCIDENT $ 1,000,000 G THE PROPRIETOR/ 1771 X INCL 6611326(OR) -- 03/01/06 03/01/07 EL DISEASE-POLICY LIMIT $ 1,000,000 TIVE PARTNERS/EX.FCU 6610999 NY,WI E OFFICERSARE: -_ EXCL ( ) 03/01/06 03/01/07 EL DISEASE-EACH EMPLOYEE $ 1,000,000 0 RER WORKERS E COMPENSATION CONTINUED 6610997(FL) 03/01/06 03/01/07 D. 6610996(CA) 03/01/06 _ 03/01/07 DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESISPECIALII'EMS - CERTIFICATE HOLDE(t ?CgNCELLATION F r _,...,, . .. SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL__M DAYS WRITTEN NOTICE TO THE FOR INSURANCE PURPOSES ONLY CERTIFICATE HOLDER NAMED HEREIN,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE,ITS AGENTS OR REPRESENTATIVES,OR THE ISSUER OF THIS CERTIFICATE. MARSH USA INC. BY: WalterGilstrap ?L7afiLl�.` MM1(3►OY) ,'s VALID AS OF 02127/06` I �\ dY18 L011llllt7/iYYCl11tR vJ 1uuc�uc:iauJccsu . Department oflndustrial Accidents N Office of Investigations 600 Washington Street Boston, MA 02111 ' wwev.mass.gov1dia, Workers' Com�en.sation Insurance Affidavit: Puf.ders/Contractors/Electricians/Plumbers Applicant Information Please Print lic Legibly Name (Business/Organizationllndividua.�: Address: City/Statelip • \ C _ Phase M Are you an employer? Check the-appropriate boa: Type of project(require ci): 1,D I am a employer with 100 4. 111 am a general contractor and I 6. ❑New construction employees(fall and/or part-time).* have hired The sub-contractors 7. Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet t ❑ ship and have no emgloyees These sub-contractors bane 8a El Demolition working for mein any capacity. workers' comp,insurance. 9. ❑ Building addition o workers' comp,insurance' S. ❑ We are a corporation and ns , [N 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL. 11.0 Plambmg repairs c r additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs itssazance required.]t . employees.[No workers'insurance Other cap.insurance required.] *Any applicant that checks box#f 1 nanat also fill out the section below showing thair workcu'compensation policy ini:'on=tion: ' t Aorneowncn who submit this affidavit indicating they am doing eM work==.than hire outside contraeters mast submit anew KM&Yit indicating such :Contractors Ut check this box must attached an additional cheat showing the name of the sub-contractors sad their workers'cramp.policy iaforaoation. F am an employer that is providing workers'compensation insurance for.my employees. Below is the policy andiob site informadion, IMkMEcd comp any Name: lob Site Address: F3V MOM 5 City/State/Zip: 4-lvat)n. MA ®26v I Attach a copy of the workers' compensation p.oiiey declaratfou page(showing the policy number and expiration date). Failure to secaro•coverage as required undet Section 25A of MGL c. 152 cirri lead to the imposition of criminal penalties cf a fine up to$1,500.40 and/or one-year imprisonment,as well as civ-ilpenalties is 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 DLA for insurance coverage verification. I do hereby cell O er e palffl a penalties of pedury that the information provided above is true and correct Si tore: Date: Phone#: )I t^ Gf c►u6,wit: thy. Do orft M feet:tress,to be eaMptdei by city or t e cud City or Town: P ermi+JLt cease# l Issuing Authority(circle one): I 11.Board of Health 2.Building Depautmeut 3.City/1 own Clerk a.Electrical Inspector 5.Plumbing Inspector 6. Other Cozrt�act Person: Phone#: