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HomeMy WebLinkAbout0099 CAMP STREET CAPE COD INSULATION c� imB GtA 9s"aat sWeArwu� aYaPSNow �r�.e OIIiTfllt INSUTA}ION CUUMos 1-800-696-6611 Job Location. 9 CA eve 2 T Builderinro -y- & L�,,ra,�c- L6 ., arm MrM Co pan Name Ph a Number Date SPRAY POLYURE?HAN"eFOAM ( ` DUYQW,200 Applicator Name Applicator Sign ure installedInsulation Lacat�on'o#Insulab�on . Thukness Total R-Value:per ESR 3210 Approximate S46 Ft:` Walls Attic 200 -3 Q Cathedral Ceiling/ i Intumescent Coating>Used locafion' Thicknes s/Coverage Rate R-Value=7.4 @ 1" Tensile Strength=45.4 psi Density=2.1 Ib/ft3 Compressive Strength=20.6 psi Demilec-Batch# 1 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel v�/ Application # � 5 S �o / Health Division Date Issued ( �— Conservation Division Application Fee Planning Dept. Permit Fee �Lt P Date Definitive Plan Approved by Planning Board Historic - OKH _Preservation / Hyannis ! Project Street Address 9 4 Ca°m® S k e44 Village #9Q-A/'A✓13 Owner Cat-OR sU/ 1 Q 1n Address /7 1i ri l k M ®ri�ATeloV 61A Telephoned�78'y�y aC a ZrY/ Permit Request Rewtave +RfP(A c'e as&lt Vn!6 ke C&I 2,ep1ace AA -e Cedar A A/lS lV e i d? ,l�NJ �U��f ' U®C� CMS fU+PLtI 4 Pti (�c�in��' r ke G/ - �it�`P Sq Aele :�1 s(floor existing WAO ` proposed 2nd floor: existing proposed If Total new Zoning District Y Flood Plain Groundwater Overlay Project Valuati S UD Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure /, /S Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑.No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other aY3 Cr'cavi r!'Lcc I/ Cra w/ Z3 C Basement Finished Area (sq.ft.) Basement Unfinished Area Wft) ;`-- r.rrry Number of Baths: Full: existing new Half: existing d; -"new , Number of Bedrooms: existing Onew Total Room Count (not including baths): existing new First Floor Room Counti. �- Heat Type and Fuel: gGas ❑ Oil ❑ Electric ❑ Other aa� I Central Air: ❑Yes )d.No Fireplaces: Existing New Existing wood/coal stove: ❑Yes N0 Detached garage:4existing ❑ 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 )dLNo If yes, site plan review# Current Use R t 5 ' tD eyA—aX Proposed Use 'e's, ��'�✓ u i' APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Nam rk4Xir1A) DB leAtl #41e /fit° e`lephone Number 36 Address� r&)C _14t' P6111F License # CS �� 3 C U i)0 f �a da Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO /JlM SIGNATURE DATE i 1 ` FOR OFFICIAL USE ONLY ( '1 APPLICATION# DATE ISSUED MAP/.PARCEL NO. ADDRESS VILLAGE j OWNER DATE OF INSPECTION: " FOUNDATION t FRAME INSULATION !`. FIREPLACE is ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT , 4 ASSOCIATION PLAN NO. f. R {t i r ��.y S lIi{i VVl/L(fiV/L IY LLLiLIi VJ 111 Mn)UWI./LLLU LLLV. ' Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 ww =� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Organizadon/Individu i): ` ~ Address: OQ Dl�y City/State/Zip: (✓Y OVIA P(A k. Phone.#: �3(+ 7 ��7oZ Are you an employer? Check the appropriate box: Type of project(required):• 1.04 am a employer with �4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New constriction . 2.❑ I am a sole proprietor or partner- listed on the-attached sheet 7. '®Remodeling ship and have no employees These sub-contractors have '8. ❑Demolition - working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance. �� -9. Building addition required.] 5• ❑ We are a coiporation'and its WE] Electrical repairs or additions 3.❑ officers have exercised their I am a homeowner doing all work 11.❑Plumbing repairs or additions'. myself. [No workers' comp. - right of exemption per MGL 12.❑.Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp.insurance required-] *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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. #contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees- If the sub-contractors have employees,they must provide their workers'•comp.policy number. 'I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy, and job site information Insurance Company Name: Policy#or Self-ins.Lic• #: Expiration Date: / �3 Job Site Address: l / (_ LIWO City/State/Zip: NA4✓ Inc, Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine. .. of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the WA for insurance coverage verification. I do hereby certi under thepairs•andpenaldes ofperjury that the information provided above is true and correct Si afore: ; Date: Phone#: Q Official use only: Do not write hi this area, to be completed by city or town official- City or Town: Permit/License# Issuing Authority(circle one): .1..Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: . i Rightfax N2-2 9/12/2012 7:01:49 AM PAGE 2/008 Fax Server CERTIFICATE OF LIABILITY INSURANCE 9S/12SUE/2012/2012 E 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 INSVRER(S),AUTHORTLED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed.if SUBROGATION IS WANED,subject to the terns and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements. PRODUCER CONTACT OLDE CAPE COD INSURANCE NAME: 296 WINTER STREET PHONE FAX (A(C,No,Ext): ANC,No): HYANNIS,MA 02601 EMAIL ADDRESS: INSURED INSURE S AFFORDING COVERAGE NAIC# WARREN,WALTER DBA NORTHSIDE INSURER A TRAVELERS PROPERTY CASUALTY HOME IMPROVEMENT COMPANY OF AMERICA 40 ALEXANDER DRIVE INSURER B YARMOUTHPORT,MA 02675 INSURER C INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THESIS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE 1N5URR NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWTI'HSTANDDIO 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 POLICY EFF POLICY EXP LIMITS LTR INSR WVD GENERAL LLIBB,PIY - EACH OCCURRE SCE S .DAMAGE TO RENTED S 0 COMI ffd2CIAI OENERAI.L1ABIIdTY PREMISES OE%ch occurrence) 0 CLAIMS MADE 0 OCCUR NEED.EXPENSE(Anyone S person 0 PERSONAL&ADV. S INJURY O GENERALAGGREGATE $ GENT,AGGREGATE T A9T APPIJU PM 0 POLICY O PR07 Cf O IAC PRODUCIS-COMP/OP 1 S AGO AUTOMOBILE LIABILITY COMBINED STNOLE S Laar . eecident 0 ANY AUTO BODILY INJURY S (Pyrpersoro O ALL OWNED AUTOS BODILY idecdINJURY S - O SCFIEDUL D AUTOS. PROPERTY DAMAGE S . ertccident O HIRED AUTOS - S O NOW-OWNED AUTOS S 0 O UMBRM ALIAB 0 OCCUR - -- .. EACH OCCURRENCE S O EXCESSLNAB 0CLAIMS-MADE AGGREGATE S O DEDUCTIBLE S O RETENTION S - S WOREERS'COMPENSATION Wc. A AND EMPLOYERS LIABILITY X STATUTORY Y/N LIMITS ANY PROPRIFTOR/PARTNEZt/ - - EXECUTIVEOFFICERWEMBER Y L EACH ACCIDENT $500,000 EXCLUDED? NIA 7PIUB-5B580645 09/01/12 09/01/13 (KMATORYINNM E.L DISEASE—EACH $500,000 EMPLOYEE Ifyes,descrlbe under DESCRnMONOF LDISFAMPOLICY $500,000 OPERATIONSbelow tam DESCRIPTION OF OPERATIONS/LOCATIONS NE3311CM(Attach ACORD 101,Additional Remarks Schedule,if more space is required) - - CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE 230 SOUTH ST SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN HYANNIS,MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. AMOK=RFPREFMATIVE Sr6a4v MA.C.LeA.ry ACCORD 25 2010/0 01988-2009 ACORD CORPORATION.All rights reserved. Office of Consumer.Affairs and usiness Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: '145832 _ - Type: DBA Expiration: 3/4/2013 Tr# 210315 NORTH SIDE HOME IMPROVEMENT_=� WALTER WARREN JR. . 40 ALEXANDER DR. - YARMOUTHPORT, MA 02675 Update Address and return card:Mark reason for change. --- Address Renewal E] Employment ❑ Lost Card DPS-CA1 v 5OM-04I04-G701216 J Consumer A °�` License or registration valid for individul use only Office of Consnmer Affairs&B siness Regulation y - HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: _f-ag5832 Type: Office of Consumer Affairs and Business Regulation Expiration V4/2013 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 NORTH SIDE HOME1MPROUFMENT WALTER WARREN_JR 40 ALEXANDER DR­.-, LU YARMOIIfHPORT,MAcI)2675: Undersecretary Not valid without signature :11a,r tnenl of Public.SA��t� Bt rd o Rttilili:n�g Reg-plat o s anti StapdaM vo L1ceMe CS 91653 WALTER R WARREN JR 40 ALEXANDER DR vARIViiOUTH PORT,MA_02675 iration: 9/30/2012 E •si�its.�i,>nt:i': Tt;?: 4121 �` 1 Kitchen Cabinets: Cabinets $4,000,00, Laminated Counter Top $640.00, Installation $1400.00 Arbitration; The contractor and Homeowner herby mutually agree in advance that in the event the Contractor has a dispute concerning this agreement, the contractor may submit to a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business regulations and the consumer shall be required to submit to such service as provided in MGL c. 142A Building Permit; The following Building Permits are required. • Building Permit • Historic Permit • Electrical Permit • Plumbing Permit It is the obligation of the Contractor to secure such permits as the Homeowners agent. The homeowner's signature, (Roy M.and Carol P. Sorblom), on this contract allows Contractor to secure permits as the Homeowner's Agent for 99 Camp Street Hyannis Ma. 02601. S / PUR6HASER DAfE CONTRACTOR DATE Walter Warren Northside Home Impr ement a . r� URCHASER DATE 1 P a e VIA, S .. -dow 5 r. C� Cp r e e C-S PIN t . a Fill f e s� y a 1 ° ! = A i f Y ry F fig (- P ` f,M / z i 1 Yx 31 � f 6�`F -f a; :� a .. [...�...r-•. F . r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION . Map `" CJ Parcel . Application # 06. -3� 1 JI Health'Division Date Issued Conservation Division . Application Fee Planning Dept. Permit Fee' °� Date Definitive Plan Approved by Planning Board Historic - OKH Preservation /Hyannis Project Street Address q cl C/-N ky, p Village 14 prt,J N 15 Owner 0 1 S 0 R 13L 0 yki Address�_� CA ^0 S7— 11/ ",Vis- Telephone —7 Permit Request 01 EA,,J 1,V 3'e,1;0W_ SS6�,?e. ( .403cg�Lj /2_eA7o i,a, T-o A,1 J) W/trf•1_ /D4_A'71,W 0 C-0 Al 7 2,1 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation'&-1-5'0v 4 Construction Type Lot Size Grandfathered: .0 Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: 'J 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`'O;existing`=0 new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other;"` Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ R`W �, =' Commercial ❑Yes ❑ No If yes, site plan review# .; Current Use Proposed Use g ` >�_ APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name R o Ni C.-G t Telephone Number Address �"� �'�i (2r� License # C S� ��/7 e /L.q Home Improvement Contractor# 1-7 0 y Worker's Compensation # EC F K23Co ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 7 t SIGNATURE e DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. M -' ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH -FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. H p� ? J The Commonwealth of Massachusetts Department of Industrial Accidents ; : . Office of Investigations 600 Washington Street xe t Boston, MA 02111, www.imass.gov/dia Workers',Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1,7t' ..Please Print Lezibly Name (Business/Organization/Individual): qL.,71 JReSY� 0't 4_r c I' LL,y— Address: v�- `I� t � City/State/Zip: Pee 0�k��S' ' Phone�#: Are you an employer?Check the appropriate box- A Type of project(required): 1.� 1 am a employer with�� 4, I am a general contractor and I� ❑ 3.-- * have hired the sub-contractors = 6. New construction p p and/or part-time). employees(full 2.❑ I am a sole ro r etor.or partner liT.sted on the attached sheet. {7: ❑Remodeling ship and have no employees These sub-contractors have ,g,. ®Demolition` e ' working for me in any capacity. employes and'. workers_ • 9. ❑ Building addition comp.insurance.) _ No workers comp. insurance tl 10.0 Electrical repairs or additions required.] .5.❑ We are a corporation and its el 3.0 I am a homeowner doing all work officers have exercised their I I E Plumbing repairs or additions myself [No workers. comp. right of.exemption per MGL 12.0 Roof repairs insurance re uired. t c. 152, §1(4), and we have no q ] employees. [No workers' 13.❑ Other' ` y; comp.insurance required.] ,t `Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information,,. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and'state whether or not thosebntities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. - I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name- r`I pret t-V !R-0'`C P y ". Policy#or Self-ins.Lic:#: d 3 l / Expiration Date: Job Site Address: C'/ �'/� '� °4 Ajd Ad`S.' City/State/Zip: li-/�t'��iOAFiS• F, Attach a copy of the workers'.compensation'policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required'tinder Section 25A of MGL e 152 can lead to the imposition of criminal penalties of a fine up to$1,500:00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER'and a fine of up to$250.00 a day against the violator:`Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA foi insurance-coverage verification. , 1 do hereby certify un er`the pains aiid penalties ofperjury that the information provided,above is true and correct. 1 Si ature: . Date: f Phone# + Official use only. 'Do not write in this area,'to b'e completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: information arid_. Xnstructi®ris Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an e7nplo))ee is defined as"...every person'in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal.representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,.or the occupant of the dwelling house of another who employs persons to do maintenance, constniction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employmentbe deemed to be an employer." MGL chapter 152,§25C(6)also slates that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." •Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public-work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary,supply sub-coniractor(s)name(s), address(es)and phone numbers)along with their certificate(s) of imited Liability Partnerships(LLP)with no employees other than the insurance, Limited Liability Companies (LLC) or L members or partners,are not required to carry workers' compensation insurance. if an LLC or LLP does have emloees, � is required. Be advised that this affidavit may be submitted to the Department of Industrial py aolicy Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents: Shouldyou have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permi0license number which will be used as a.reference number. In addition, an applicant that must submit multiple permitflicense applications in any given year, need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicant should write"all locations in (city or town)."-A copy of the affidavit that has been officially stamped or maiked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or Commercial venture (i,e. a dog license or permit to bum leave$etc.)said person is NOT required to complete this affidavit. The office of Investigations would like to thank you in advance'for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. 17-727-49 D0 ext 406 or ]-87.7 MASSAFE _ # 6 Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia Office of Consumer Affairs and usiness Regulation, 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration ' Registration: ,140427 Type: Corporation Expiration: .10/15/2013 Tr# 217009 MULTI-STATE RESTORATION, INC CAPE :-- ROY RICCI P. O. Box 2210 MASPHEE, MA 02649 Update Address and return card.Mark reason for change. Address 0 Renewal C Employment ,O'Lost Card PS-CAJ %r 50M-W04G101216 0ffice�6&AWr1 t i�`/A84els WWO-0 License or registration valid for individu,l use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: -,140427 Type: Office of Consumer Affairs and Business Regulation V-ST Expiration: 1A/15/2013 Corporation , : 10 Park Plaza Suite 5170Boston,MA 02116 ATE RESTORATION }NE;CAPE COD ROY RICCI 21 PEQUOT RD. Y g SEh;w 000— MASPHEE;MA 02649: ry Undersecreta .Not g lid without signature F Massachusetts- Department of Pubiic'Sat`ets Board of Buildin, Regulations and Standard Construction Supervisor License One-and.Two-Family Dwellings License CS 51784 RICHARDYD- LAURIA ; 1 LEAH DR.4 ROCKLAND, MA 02370 Expiration:'4/1/2013 '. Commissioner . Tr#: 12672 e + MULTI-STATE RESTORATION, INC. _ FIRE* FLOOD*WIND* SMOKE*HURRICANE*VANDALISM Fed ID#050515889 CONTRACTORS REGISTRATION#140427 AUTHORIZATION TO PERFORM SERVICES AND DIRECTION OF PAYMENT , a n. 57dR916tl herein referred to as "Customer",authorizes Mufti-STATE RESTORATION,INC.,herein referred to as "MULTI-STATE",to perform any and all necessary cleaning and construction services on Customers'property at: 9 tI Gf RzO 15'�H b/ _A All Pj tM, d— Telephone: G i l G FJ /'I 9�F and with respect to items that need to be cleaned at a remote location,to remove and clean such items as necessary. _/ Customer authorizes 11/�s' &I e �LJ/1 Insurance Company,herein referred to as"Insurance Company",to directly and solely pay MULTI-STATE. If for any reason the check should come to be or be made payable to the Customer, Customer then agrees to pay MULTI-STATE immediately upon receipt of the check from the insurance company. In order to expedite payment to MULTI-STATE, Customer hereby appoints MULTI-STATE as attorney-in-fact,authorizing MULTI- STATE,to endorse Customers'name,and to deposit Insurance Company checks or drafts for MULTI-STATE services. Customer agrees to pay Customers' deductible in the' amount of$ that applies to this claim. If the loss is not covered by insurance,Customer agrees to pay, the total amount to MULTI-STATE upon receipt of the invoice. Signat-uptof Owner It is my understanding that the services to be performed by MULTI-STATE will be limited to those,which are authorized by my Insurance Company. Insurance Company Name Policy Number Customer agrees that MULTI-STATE is working for the Customer and not the Insurance Company or agent/adjuster. Additional remarks: i' I have read —this ddocume and completely understand and agree to same. Signa4& Date Printed Wame P.O.`BOX 2210•MASHPEE, MA 02649 .866-921-9111 •FAX 774-238-4422 MULTISTATE RESTORATION INC. Fire o Flood o Wind P.O. Box 2210 • Mashpee, MA 02649 • Tel: (508) 477-3333 • Toll Free: (866) 921-9111 • Fax: (401) 723-8294 CAPE COD DIVISION • roy@multi-state restoration.corn 12/28/2011 To Whom It May Concern; Richard Lauria is employed by Multi-State Restoration. He is in charge of my Construction Division. If you have any questions please feel free to call me. Roy M. Ri Ow r ulti-State Restoration (508)-922-8965 r Client#:34309 MULTISTA ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATD/YYYY) 12/27/22712011 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: Sandy Benigno Starkweather&Shepley PHONE FAX vc,No,Ext:401 435-3600 ,/c No): 401-431-9678 PO Box 549 E-MAIL sbeni no starshe ADDRESS: g p•com Providence,RI 02901-0549 INSURER(S)AFFORDING COVERAGE NAIC# 401 435-3600 INSURER A:Employers Mutual Ins INSURED INSURER B:Hartford Ins Group - 19682 Multi-State Restoration Cape Cod INSURER CBeacon Mutual Ins Co 24017 Division,Inc. 1135 Charles Street INSURER D: North Providence,RI 02904 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 SUBR MM/DDNYYY MMIDDIYYYY LIMITS A GENERAL LIABILITY 3D6630912 1/61/2011 01101/2012 EACH OCCURRENCE $9,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence) ccurrence $300,000 CLAIMS-MADE 51 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 PRO- LOC - $ . I A AUTOMOBILE LIABILITY 3E6630912 1/01/2011 01/01/201 Ea aacdeDSINGLE LIMIT $1,000,000 A X ANY AUTO 3Z6630912(MA) 1/01/2011 01/01/2012 BODILY INJURY(Per person) $,. - X ALL OWNED SCHEDULED -AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident X Drive Oth Car $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE - AGGREGATE $ DED RETENTION$ - $ B WORKERS COMPENSATION 02WECTK2360 7/16/2011 07/16/201 X WC STATU- OTH- AND EMPLOYERS'LIABILITY- ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 50845(RI) 12/01/2011 12/01/201 E.L.EACH ACCIDENT s500,000 OFFICER/MEMBER EXCLUDED? 7. N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500 OOO If yes,describe under - - DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT s500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) , RE:99 Camp Street,Hyannis,MA • r 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 - iQ L. �GVt�va�srxa kC ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S366574/M362160 SSB �g c Aron p -� O f5 C,PrPc S i Lam , �ftc;, L LL A-5eM eA-P7- L, is /�`�tt• � �j` 3 ee !`6tlx �02lt B ATI � SrA'�RS paua,� VIN 9 .o 1� � tVIN 9 ` STAIR5 cc(� l7C`Nrl � Xo7` la�r 13' i " y I Zd to