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HomeMy WebLinkAbout0016 COASTAL LANE t C.o Co�.s�� � �.����.. o � --.--_:.. N 91 5, Lsf:)T 83 co 0 2'} F L z 33 .7Z 2l S r CERTIFIED PLOT PLAN I CERTIFY THAT THE FOUNDATION FOR SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON AND LOT 83 COASTAL LANE, HYANNIS, MA. THAT IT CONFORMS TO THE MINIMUM BUILDING SETBACK REQUIREMENTS OF THE TOWN OF BARNSTABLE. PREPARED FOR BAYSIDE BUILDING INC. �R � STEVEN% \ SCALE: V = 30' OCTOBER 5, 1998 RUMBA y ESs . Weller & Associates 1645 Falmouth Rd. —Suite 4C Centerville, Ma. 02632 (508) 775-0735 Town of Barnstable *Permit Regulatory Services F Ex�gyerese 6 mo jrom issue date s44n�►ss. Richard V.Scali,Director ' Building Division Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barmtable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERNUT APPLICATION - RESIDENTIAL ONLY _') f Dt Valid without Red X-Press Imprint 1.,a Map/parcel Numb DD Property Address 10 WAt5TAt— A-NL A.4."Qts Residential Value of Work$ 3 ?00 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address <u }4 9LQ V e�2 Contractor's Name &•--L3-'1 , t Telephone Number Home Improvement Contractor License#(if applicable) Email: k,—Ly-i 40.avy, C.Lou 10 Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor AUG 0.7 2017 ❑ I am the Homeowner 2I have Worker's Compensation Insurance np Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Req st(check box) K Re-roof(hurricane nailed)(stripping old shingles) All construction debris will,be taken to lamu ❑Re=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: *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,.Conservation,etc. 'Note: Property Owner must sign Property O er Letter of Permission. , A gapy of the Home Improvem ont ctors License&Construction Supervisors License is equdi d. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doC 01/25/17 I Massachusetts Department bf Public.94ety Board of Building Regulations and Standards License--CSSL-099167 _ Construction Supervisor Specialty_ OLIVER M KELLY- y _ - ` 8 RFIfNE:ROAD • f YARNt(3lTlH.FOf • r Expiration: Coh"'n 0I1281fOt7 n n fG—Xe Q� Er Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home ImprovemenQC-ontractor Registration r Type: Individual OLIVER KELLY ' Registration: 128957 8 RHINE RD .: Expiration: 06/13/2019 YARMOUTHPORT,MA 02675 �- Update Address and return card. Mark reason for change. sca, zonn-osn' _ _- fOLAddre_ss nftne al_1-1.Fmployment_D_L,ost Card V/te�a��rmaoauaerc�l�a�C�/j�ctaac�u�el� _ _ Office of Consumer'Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only 'fa TYPE:Individual before the expiration date. If found return to: :Registration Expiration Office of Consumer Affairs and Business Reguladon 12895? 06/13/2019 10 Park Plaza-Suite 5170 O IVEr LLY j stb ,MA 02116 i OLIVER M.IELLY ;Q C � rL 8 RHINE RD. ;: YARMOLITHPORT,MA`02675 Not valid without signature Undersecmtary r Ac a CERTIFICATE OF LIABILITY INSURANCE 0DATE 5-150-2017 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: DOWLING&O'NEIL INS PHONE _FAX, 973 IYANNOUGH RD A/c o CNo): HYANNIS,MA 02601 E-MAIL INSURER(S)AFFORDING COVERAGE NAIL# INSURER A:ACE AMERICAN INSURANCE CO INSURED INSURER B: KELLY ROOFING INC 8 RHINE RD INSURER C YARMOUTHPORT,MA 02675 INSURER D: INSURER E: INSURER F: COVERAGES ERTIFl TE NUMBER: 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 MAYBE 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 SUB POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR [NSA WVD ( D/YYYY) MM/DD GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES Ea occurrence CLAIMS-MADE❑ OCCUR MED EXP(Any one person) S PERSONAL&ADV INJURY $ . GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY JEa El LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO Ea accident) _ ALL OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED �.iOPER-9 WAGE $ AUTOS Per ap de $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LU1B CLAIMS-MADE AGGREGATE $ r DIED I RETENTION$ $ WORKERS COMPENSATION X WC STATU- an, AND EMPLOYERS'LIABILnY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTI N/A E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? N UB 05-10-2017 05-10-2018 (Mandatory in under If yes,describe under 8HO85809 E.L.DISEASE-EA EMPLOYEE $500,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION TOWN OF YARMOUTH BUILDING DEPT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE 534 WINSLOW GREY RD CANCELLED BEFORE THE EXPIRATION DATE THEREOF, SOUTH YARMOUTH,MA 02664 NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATNE - JOHN J.LUPICA,President ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD c a KELLY ROOFING INC. MA CSL #99167 PH 508 ,509 4540 5 RHINE ROAD® MA RIC #128957 YARMOUTHPORT A 02675 kellyeoofing@icloud.com June 23' 2017 Proposal submitted to Sally Glover of 16 Coastal Lane, Hyannis MA We propose to supply all materials and labor necessary to remove and replace the existing asphalt-roof at the address above. --All debris-to be removed to town.transfer. Install 8" White Aluminum Drip edge on all eaves. Ice and water damage protection membrane to be installed on the first six feet of eaves, over complete lower pitched roof areas in all valley areas and around all protrusions. Remainder of deck to be covered with #15 Felt Paper. Lifetime limited warranty Architect style shingle to be installed, (Color to be Specified) All shingles to be storm nailed. (6) Bathroom vent pipe.boots to be replaced with new. Repair/Replace all flashings as.necessary. Install Shingle Vent II Ridge vent on all ridges with Hand Nailed Caps. Protect all walls, windows, decks, plants, shrubs, etc. during roof strip. Complete cleanup of area during and after procedure including all nails and cleaning of gutters. Obtaining of Town Permit. At a Total Cost of $8,700. Payment schedule: 50% at project Start, balance upon completion. Respectfully Submitted, Oliver Kelly. Proposal accepted by; �L� -/ G Date y ! 3 /2017 If acceptable please sign and remit one copy to the address above, keeping a copy for your records, this proposal is valid fog 45 days from date above, please call to verify thereafter. �t TOWN OF BARNSTA.BLE CERTIFICATE OF, OCCUPANCY PARCEL ID 272 004 010 GEOBASE ID 37575 ADDRESS 16 COASTAL. LANE PHONE HYANNIS ZIP - LOT 83 BLOCK LOT SIZE DBA ',y \ DEVELOPMENT DISTRICT HY Y PERMIT 37879 DESCRIPTION CERTIFICATE OF OCCUPANCY PERMIT, TYPE BCOO '`� TITLE CERTIFICATE OF OCCUPANCY CONTRACTORS: Department of Health, Safety ARCHITECTS: and Environmental Services TOTAL FEES: BOND $.00 CONSTRUCTION COSTS $.00 756 CERTIFICATE OF OCCUPANCY 1 PRIVATE P:.t+'ts:? .� <. * 3TABIsE. # MASS. i639. A� BUILDf D IO h BY DATE ISSUED 04/16/1999 EXPIRATION DATE '1 Y ^• :APERMIT BUILDING RCEL x 27 . Ot) 03 t1 GEU13A� 3.D :3'�6i75 -.�)DRESS • 16 'COASTAL I.jkNE � �?IiG�1E �HYANNI S IP _- )T S;3\/ BLOCK LOT 1 Z.F D13A ` ''.`� DEVELOPMENT DISTRICT HY P,ERMIT 3, 152 DESCRIPTION SINGLE FAMILY DC+J a�L1 NG (t ONN1±,C`(' TO TOWN SEMI - PERMIT TYPE BUILD TITLE NEW RESIDENTIAL BLDG PMT :' CONTRACTORS: B `' , BUILDING, Department of Health, Safety" and Environmental Services,,, 't1TAL S71-?S; $ 122 02 BOND � �.00 THE CONSTRUCTION COSTS $100,650.00 102 SINGLE FAN HOME DE`IA.GHET3 1 PRIVATE P' . * BAANSTABM MASS.039. ED 11AA'� . BUDDING 1VISION DATE ISSUED 09/08/1.998 EXPIRA1 TaN-t DATE - THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY,OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY. EN- CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND WHERE APPLICABLE, SEPARATE 1.FOUNDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION 2. PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU- PERMITS ARE REQUIRED FOR (READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ELECTRICAL,PLUMBING AND MECH- 3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. ANICAL INSTALLATIONS. 4.FINAL INSPECTION BEFORE OCCUPANCY. BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ;ELECTRICAL INSPECTION APPROVALS 2 2 r f q vok Gam 2 3 1 HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT �wIII, CK 2 B A D OF HEALTH 1� OTHER: SITE PLAN REVIEW APPROVAL 1' 009 `f WORK SHALL NOT ROCEED UNTIL PERMIT WILL BECOME NULL AND VOIA`IF CON- INSPECTIONS INDICATED ON THIS LHE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR. BY V,. ARIOUS STAGES OF CONSTRUC- MONTHS OF F .DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA- ION. NOTED ABOVE. TION. BUILDING PERMIT , 1.70 � bd� Q 99 4-4 - eL LIU C4,4 CD , k (4- L 6-7q Engineering Dept. (3rd floor) Map ?� Parcel 06'`1, 0/0 P�t# 3 3 I 'S :2— House# Date Issued Board of Health(3rd floor)(8:15 '79:30/1:00-4:30) ee, ( 3/ot Conservation Office(4th floor)(8:30-9:30/1:00-.2:00) -��'. APPLICANT MUST OBTAIN'A SEWER ° CONNECTION PE FROM THE Planning Dept.(1st floor/School Admin.Bldg.) * $NGINEE 60"URIIJ 0$TO � _ CTI De ' e Plan Approved by Planning Board 19 ! d _ 2 BARNSTABLE. P MASS. TOWN OF;BARNSTABL Ile\-:- 'E 9- �' Building Permit Application t Project,Street Address 1 f (fQ/1 S 74 L L 6NE (i PF U L-OT S 3. Village /q 'I JAI t/l S Owner 6- 4`1,S/br B L D c Address CFA17f�2 ✓/U-4E :Telephone 771 - /p'/0 - Permit Request 7U r oAl 7 T 2 UC T /t SIA10 L �'ft�/L�/ !f 00f f First Floor /2(4 D square feet Second Floor square feet Construction Type IV 0,6 D /�' AME Estimated Project Cost $ VML 100, Zoning District Flood Plain Ic Water Protection �'o� Lot Size y q� Grandfathered fffes ❑No Dwelling Type: Single Family Y"' Two Family ❑ Multi-Family(#units) Age of Existing Structure Ng y Historic House ❑Yes p'No On Old King's Highway ❑Yes UI&O Basement Type: &'Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) 25M7 la Number of Baths: Full: Existing New_� Half: Existing New l No.of Bedrooms: Existing New 3 Total Room Count(not including baths): Existing New First Floor Room Count y Heat Type and Fuel: eGGas ❑Oil ❑Electric ❑Other Central Air 'W4s ❑No Fireplaces: Existing New. Existing wood/coal stove ❑Yes p_<o Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) - ❑Attached(size) 9 Cg/Z as X ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes Q<O If yes, site plan review# Current Use V AC&IT 1-0 7- Proposed Use I z6ucc Builder Information Name ,3 19 Y51b /3L_jS6 /AJC Telephone Number 771- /0 y0 Address &V QS License# 01�) 56 qS C'Ei(IR-29-Y/C F 1)a G 3 A Home Improvement Contractor# Worker's Compensation# 7C Q QIJ J NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO aiVDF6Z-�- SIGNATURE DATE BUILDING PER ��i FOLLOWING REASON(S) 1. � i,`. , ~ - FOR OFFICIAL USE ONLY _ PERMIT NO. l 52, DATE ISSUED MAP/PARCEL NO. ADDRESS '' + VILLAGE OWNER DATE OF INSPECTION:, FOUNDATION - - FRAME ' INSULATION FIREPLACE ELECTRICAL: ROUGH - FINAL PLUMBING: \ ROUGH FINAL GAS: ��aROUGH' " +FINAL' FINAL BUILT} f-�s!- l i ' t� r DATE CLOSE&Q.Ll I' ASSOCIATIONr1L N NO. * Y N L-oT 83 ' -t>w SEn 0 � "J� IZ 1 JAI 0 ,A Lz 33.7 2 C PROPOSED PLOT PLAN FOR '0 LOT 83 COASTAL LANE HYANNIS, MA. `O+�E{��p OF STEM PREPARED FOR DUMB H 57 BAYSIDE BUILDING INC. '►v�rv�r+.� SCALE: 1"=30' SEPTEMBER 3, 1998 Weller & Associates 1645 Falmouth Rd. —Suite 4C Centerville, Ma. 02632 (508) 775-0735 6 G G U U 6 U 6 Western ure o m an g y A r G LICENSE AND PERMIT BOND F For County, City,Town or Village Only-Not Valid for Bonds Required by the State.Not Valid for Contract, ; Performance,Maintenance, Subdivision,Agent to Sell Hunting and Fishing Licenses or Utility Guarantee Bond. , G 9 KNOW ALL MEN BY THESE PRESENTS: BOND No. L&P• 4 2 8 8 4 8 4 7 That we, Bayside Building, Inc. of the Village of Centerville , State of Q22GhtIottA , as Principal, and WESTERN SURETY COMPANY, a corporation duly licensed to do business in the State of Massachusetts , as Surety, are held and firmly bound unto the Town of Barnstahl e , State of Obligee, in the amount (Valid only when a County,City,Town or Village is named as Obligee) of Two Hundred Eighty and 00/100*************************DOLLARS ($ (NOT VALID FOR MORE THAN$25,000) lawful money of the United States, to be paid to the said Obligee, for which payment well and truly to be made, we bind ourselves and our legal representatives, jointly and severally. THE CONDITION OF -THIS OBLIGATION IS SUCH, That whereas, the Principal has been licensed _to construct a.. single family rl Tual l ing at Ih Coastal Lane,, JJ3 70 feet frontage by the Obligee. N- ' fR FORE, if the Principal shall faithfully perform the duties and comply with the laws and or gr all amendments), pertaining to the license or permit, then this obligation to be void, o sept e n full force and effect for a period commencing on the 14 th day of _-�• IRt ► ;. , l998 , and ending on the��. �day fin.�?� th AT1gust *..—!w i Ua , unless renewed by continuation certificate. •hisbi�ayberminated at any time by the Surety upon sending notice in writing to the Obligee and to tl �s ,�3 the Obligee or at such other address as the Surety deems reasonable, and at the expira- ti days from the mailing of notice or as soon thereafter as permitted by applicable law, which�e8 �'this bond shall terminate and the Surety shall be relieved from any liability for any subsequent acts or omissions of the Principal. Dated this 14th day of August- , 11998 Principal Principal Co to igned WESTERN SURETY COM NY c r• 6 G By J A f A e­i Rest ent Agent By President r c ACKNOWLEDGMENT OF SURETY STATE OF SOUTH DAKOTA l (Corporate Officer) r f ss F County of Minnehaha fi On this day of ,before me,the undersigned officer,personally G appeared Stephen T.Pate ,who acknowledged himself to be the aforesaid officer of WESTERN SURETY COMPANY,a corporation,and that he as such officer,being authorized so to do,executed the foregoing ; F instrument for the purpose therein contained,by signing the name of the torpor ' n by himself as such officer. ; R IN WITNESS WHEREOF, I have hereunto set my hand and official se G , J. RHONE ^ �� NOTARY PUBLIC ;c ns$AL SOUTH DAKOTA SFL .0 otary Public, South Dakota n My Commission Expires 6-12-2004 Western Surety Company r Form 849-A—12.96 1 '`'`'"'`'�`' �`'"'+ 1-605-336-0850 ' f n F n u ACKNOWLEDGMENT OF PRINCIPAL (Individual or Partners) y fi STATE OF F ss Y n County of v n ti On this day of ,before me personally appeared F n 6 e F n r F r' a known to me to be the individual_ described in and who executed the foregoing instrument and y a u Y acknowledged to me that_he_executed the same. y f I . Y F My commission expires f y i, Notary Public k V `r ACKNOWLEDGMENT OF PRINCIPAL (Corporate Officer) STATE OF ss County of y On this day of ,before me, g personally appeared , who acknowledged himself to be the of , a corporation, and that he as such officer being authorized so to do, executed the foregoing instrument for the pur- poses therein contained by signing the name of the corporation by himself as such officer. My commission expires Notary Public F u F F E n F 1 F � a c F F e d a { P � C' a n U n 4 n ~ n a ZZ u ce C �. z Z n ' `i e �orruuonrnerr�/� r/.. �f r�.r�rr•�ri�r/(i DEPARTNEHT OF PUBIIC SAFETY r� CONSTRUCTION SUPERVISOR LICENSE Number: Expires: Restricted To: 11 BRIAN T DACEY 62 FERNBROOK IN CENTERVILLE, NA 02632 i III :17.1050 i Restricted To: 11 88 - 35,101 cf enclosed space (N6t C.112 S.61t) 1A - Nasonry only 16 - 1 6 2 Family Homes Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. 'I COMMONWEALTH OF NLASSACHUSETTS -- DErAKrN ff-NT OF INDUSTRIAL ACCIDENTS 3RP 600 WASHINGTON STREET -ames Car-,aoeu BOSTON, MASSACHUSFM 02111 Cor-'n:ss,cne• WORKERS' COMMNSATION INSURANCE AFFIDAVIT I, /?>R -' T -D c�F Y (licensee/permirtec) with a principal place of business/residence ac (Gry/S catdz:p) do hereby terrify, under the pains and penalties of perjury, than. [q/�am an employer providing the following workers' compensarion coverage for my emplovccs working on this . job. ' Tc r ors /q1 loll Insurance Company Policy Number O 1 am a sole proprietor and have no one working for mrw [ ) 1 am a sole proprietor, general contractor or homeowner (circle one) and have'hired the contractors listed b::cw who have the following workers' compensation insurance polio /3 0 ff NA16 IA)4C T C. cr DO Name of Contractor Innirnee Company/Policy Number Name of Contractor Insurance CompanyTolieyNumbe: Name of Contaactor In=.nc: Company/Policy Number Q 1 am a hOmcownc.performing all the work myself. NOTE: Plcasc be aware that while homeowners who employ persons to do tnaintenancc,construction or repair work on a dwciling of not more than three units in which the homeowner also resider or on the grounds appurtenant thereto arc not gencrJ1 v considered to be emplovers under the Workers' Compensation Act(GL C 152,sect.,10)), application by a homeowner for a lice:sc or permit may evidence the legal stirus of an employer under the Workers'Compensation Act I undcrst:.nd that a copy of this statcmenr wiU be forwarded to the Depar- cr:of lndustrial Aeddena'Ofnce of lnsuranee for eovra,: vc ;ic::•ion and th;, failure to secure coverage as required undo Sccdon 25A ol-.MGL 152 ern lead to the imposition of c 7=iminal pe --cs consisong of a fine of up to S1500.00 and/or imprisonment of up to oncyc=and civlq pcnaltiu in the form of a Stop Work Order arse fine of 5100.00 a d:v 2g2ins: Me. Sicned this dry of . 19 Liccnscc'PcrminCt Lic:.isor/Pcrmicror SUBCONTRACTOR'S INSURANCE ENGINEEER: BAXTER & NYE ENG: (L) FIREMENS FUND - S30MXX80564866 (W) LIBERTY MUTUAL - WC1312595563023 WELLER & ASSOC: (L) NAT'L GRANGE MUT.- MSP45246 EXCAVATION & SEPTIC: ROBERT J. OUR (L) U S F & G - 1MP30109550901 11 (W) U S F & G - 771521695 DECO CONSTRUCTION (L) TRAVELERS - 660364IC8342 (W) LIBERTY MUTUAL - 312446298044 FOUNDATION: BAYSIDE FOUNDATIONS: (L) COMMERCIAL UNION - ABR406267 (W) LIBERTY MUTUAL - WC1312201785044 WELLS: DENNIS SCANNELL (L) TRAVELERS - 660873E5627COF92 (W) WAUSAU - 151300062926 CELLAR/GARAGE FLOORS: MICHAEL BROWN: (L) AETNA - MP0023672849 FRAMERS: ROBERT DORRER: (L) TRAVELERS - W680526K991TIA9 (W) AETNA - 006C0023972416C MICHAEL DUFFLEY: (L) COMMERCIAL UNION - NBF821356 (W) LIBERTY MUTUAL - WC1312492127024 MASON: SHERMAN, WAYNE: (L) COMMERCE INS CO - N60689 (W) WAUSAU INS - TO BE ASSIGNED ELECTRICIAN: CHAVES ELECTRIC: (L) HANOVER INS. - LHN2964649 (W) MISCELLANEOUS INS CO. - 0708878 91 1 PLUMB & HEAT: WHITELY PLUMBING: (L) TRAVELERS - 660365K1782COF9 (W) EASTERN CASUALTY - POLICY IN MAIL ALARM SYSTEM: BALTTC SECURITY: (L) FTRST FINANCIAL - FF0131 G400831 (W) COMMERCIAL UNION - CB0743379 CENTRAL VAC: VACUUM HOUSE: MERRIMACK MUTUAL - SBP1608045 INSULATION: MAP INSULATION: (L) AMERICAN STATES - 02CC326435-3 (W) U S F & G - 7711099932 SHEETROCK: MEL REED: (L) WORCESTER INS - CB817530 (W) COMMERCIAL UNION - CBH557387 INTERIOR TRIM: DAVID'S REMODELING: (L) COMMERCIAL UNION - NB F821442 M & R CARPENTRY (L) MARYLAND INS. GRP- SCP30235965 (W) CIGNA PROP & CAS.- C80049997 OAK INSTALLER: ROBERT BUDDEN: (L) NORTHERN ASSUR. - NBF528652 PAINTING,: CAMPBELL PAINTING: (L) TRAVELERS - 1680251K4083COF (W) AMERICAN POLICY - WCC 186604 GARAGE DOORS: ALL CAPE GARAGE DOOR: (L) U S F & G - BSC14667590301 (W) COMMERCIAL UNION - CBH573757 STORMS & GUTTERS: ALUMINUM PRODUCTS: (L) AETNA - MPOO21014146 (W) AETNA - JC89258880 OAK FINISHER: AMERICAN FLOORS: (L) TRAVELERS - 680 342W754-0 CARPET, VINYL & TILE: CARPET BARN: (L) VERMONT MUTUAL - SBP6507393 (W) PHOENIX INS. - 6NUB476J652794 TILE INSTALLER: TONY AVERINOS : (L) ASSURRANCE CO. - CFP26528977 (W) HARTFORD FIRE - 77WZCY2409 WIRE SHELVING: CAPE COD CLOSETS: (L) U S F & G - BSC146983441 APPLIANCES: KITCHEN APPL MART: (L) FIREMENS FUND - AZC80453098 (W) HARTFORD INS CO - 77WZNB1603 MIRRORS & SHOWER DOORS: L & M GLASS : (L) COMMERCIAL UNION - CBR409003 (W) U S F & G - 0071439933 LANDSCAPE & SPRINKLER: COY'S BROOK: (L) COMMERCIAL UNION - ABR345850 (W) CIGNA COMPANIES - C41138178 DRIVEWAYS: NORTHERN SEALCOAT: (L) MARYLAND CASUALTY- EPA18716945 (W) THE PHOENIX - UB387K530 i s II I i � I o � I 1 3 ; ate i I c' -- --n , � I 1 9MMURl I II I ' r / II r ffl-LJ It 0 o v i h 1J ,I I !III i I �III II i' �i • fill Illi i i lil � i 4 I� I. s 1 r C-i-i O IL J _ a r Q ' � I ii ;ii li i i x� �or •i 1�rlill .I I I 7r --- r-1 LL-u q j i -C i - I 5, 6" 12•_o '9••G. to•o•' Iw— OL �j r i J� J•' 7 o , g �'N it C p; n I { � i -- _ — ��_"• =-- -- �I •Lf I ! �_ ^Z C_ I _ PG372HL ok I Fl , o Gdtl r _� u I 2159 N LP c EE I cTD SS62 AccN i FF � I (� I p P i . i Z' �IA �J �C :r 9� I P J J � I , Q I PIo 29<7 b � A I 0 A PTA 2953-2 I p / a > i v� i Z N m I (o CI P pp I J IO > PTO 2953-2 ' � !� 5B�•4 r 59{4 i II + i 0 ' ll C Ln — a ,,VIW w,w +if3 s'�D was 3 0'.o•• 13H � C W' C b u� ie YI y r s o1xL II I L¢I i �+ I � r iI -� .- �..L-,L ..L-.L � .t•,L .•t•,L 1 •.%;4 ' I UI C,rr a�tvwl.-rvreouSj 1 � � .. ol _ I I I III I I L L, I Oh I J i i l a 0 ca I o in 1 0 I- -- ` •� .L L ri 1Wb , , t al i 7�r A' N VAI Ir _ rpr:� rh p }r ti 1, s k li 1 I � L L ' r o II I i -- --f1 �I�L► TJ I I � I ti �iJ I — I o � [TIN ff ffJ . z u 0 � �PY a Ill ' ;ail III � f ! 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