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0335 CRAIGVILLE BEACH ROAD
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map_- Parcel (o Application Health Division Date Issued Z 11— N POE! Conservation Division Application Fee(f Planning Dept. Permit Fee L. Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address 3 5 Village 1JyQn n%S Owner M#Q ft r lnl(,c Lb='6- Address !Z� Telephone J�RS�7 71 - Permit Request Inkr7dr &l U IL't eel, Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation i-o) 000 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attac7'n orting currgtation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) . C'� Age of Existing Structure Historic House: ❑Yes ❑ No On Old King': ighway:!❑Yew' ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other ' Basement Finished Area (sq.ft.) Basement Unfinished Area(sq. ) j Number of Baths: Full: existing new Half: existing new in Number of Bedrooms: existing —new Total Room Count (not including bathe): 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 V (BUILDER OR HOMEOWNER) Name 1_�QJAYTIMEX, 13UIL4W, JAA�:. Telephone Number ' Yq� Address 10 License# Do 3aS I GO Home Improvement Contractor# /J 0640.1 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE J/-Soft L- FOR OFFICIAL USE ONLY 4 APPLICATION# DATE ISSUED MAP PARCEL NO. 6. «. ADDRESS VILLAGE OWNER- s DATE OF INSPECTION: - 1' _ -,FOUNDATION, FRAME �t INSULATION ' s T FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL f GAS: ROUGH FINAL FINAL BUILDING e: . Z'2 F . DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Af assachusetts Department of Industrial Accidents W ®face of Investigations d 600 Washington Street Boston,MA 02111 www.mass.gov1dia ff*davit: Builder's/Con>tiracto>rs/lElect>ricnaiis/Plu>� hers Workers' Co pensati®»fnsuarance'A Applicant Information Tease Print ILeeibly NaMe(Business/Organization/Individual): �� ,I�'r/ M e—x Address: : Cl//Lf7i S 1 �( City/State/Zip: Phone.#: Are you an employer?Check the appropriate box: Type of project(required): 1. am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction / employees(full and/or part-time).* have hired the sub-contractors 2:❑ partner- listed on the attached sheet. I am a sole proprietor or 7.. Remodeling. ship and have no employees 'These sub-contractors have . g, ❑Demolition workingfor mein an capacity. employees and have workers' Y P ty 9. ❑Building addition [No workers'comp.insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 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. tContractors 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 is providing workers'compensation insurance for racy employees. Below is the policy anal job site information. Insurance Company Name: �LG`�/T ��f INS Policy#or Self-ins.Lic. A&63 Q q D I 113 Expiration Date: " J Job Site Address: 335 ce4 g /lu O City/State/Zip: ` 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 DIA for insurance coverage verification. I do,hereby certi d r the pains and penalties of perjury that the information provided Bove is true and correct Signature: Date: Phone#• Official use only. Do not write in 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#: e f %� , _— , ✓� _: - iJ Jam' J_ .. 't/i//J•'% i�% �' /� / /�% .. I Office of Consumer Affairs and 'usiness 1egulation MIAM !'' 10 Park Plaza - Suite 5 170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 110609 Type: Private Corporation Expiration: 11/3/2014 Tr# 233027 E J JAX T IMER, BUILDER, INC.- ERNEST JAX T IMER 48 ROSARY LN HYANNIS, MA 02601 Update Address and return card.Mark reason for change. Address R Renewal! n Employment ]Lost Card OPS-CAI 50M-04/04-G 101216 �a�trr.,a�art-a.:cZ ny I�ClJ>�cc. u 3 t ]License or registration istration valid for individul use onl T Office of Consumer Affairs fie usiness Regulation � y ,—:HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: - '' Registration: 110609 Type: Office of Consumer Affairs and Business Regulation Expiration: 11/3/2014 Private Corporation IlO Park]Plaza-Suite 5Il70 ]Boston,IV[i A 02116 E J—JJAY.TIMER,BUILDER,INC: ERNEST JAXTIMER 48 ROSARY LN HYANNIS,MA 02601 Undersecretary Not valid without signature hs Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor License: OS-003251 f 1L'll61`HJGSTJJA1611Dk-R •• IY. 48 ROSARY < HYANNIS MA �601 !:; " ''` Expiration Commissioner 01/14/2016 Aco O CERTIFICATE OF LIABILITY INSURANCE °A 2/31"013 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 E: Erica H O'Connor HART INSURANCE AGENCY,INC. PHONE 508-759-7326 x205 FAX 508-759-7366 243 MAIN STREET ' AIC No): PO BOX 700 AADDRLE : BUZZARDS BAY,MA 025320700 INSURE 8 AFFORDING COVERAGE NA1C# INSURERA: ARBELLA PROTECTION INS CO 41360 INSURED EJ Jaxtimer Builder,Inc INSURER B: ARBELLA INDEMNITY INSURANCE COMPANY 10017 48 Rosary Lane Hyannis,MA 02601 wsuRER c ` - 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 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 INSR WVn SUER POLICY NUMBER POLICYEXP EFF POLICY DD YYY UMITS LTR A GENERALUAB0.nY 8500042039. 01/01/2014 01/01/2015 EACHOCCURRENCE $ 1;000,000 DAM; E O RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 300,000 CLAIMS-MADE FV OCCUR MED EXP(Any oneperson) $ - .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 $ B AUTOMOBILEUABILITY 1020011547 01/01/2014 01/01/2015 COMBINED SINGLE LIMIT 1,000,000 E acci nt ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Per accident $ A UMBRELLALUIB OCCUR 4600042040 01/01/2014 01/01/2015 EACH OCCURRENCE $ 2,000,000 EXCESSLUIB HCLAIMS-MADE AGGREGATE $ 2,000,000 DED RETENTION$ 10,000 - -_ $ B WORKERS COMPENSATION 0053890113 01/01/2014 01/01/2015 N4 wcsTATU- OTH- AND EMPLOYERS'LIABILnY Y I N FR ANY PROPRIETORMARTNER/EXECUTIVE NIA .. - E.L.EACH ACCIDENT $ - 500.000 OFFICERIMEMBER EXCLUDED? (Mandatory in NH) l - E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(;Hach ACORD 101,Addrdonal Remarks Schedule,B more space Is required) CERTIFICATE HOLDER CANCELLATION Fax#:(508)862-4717 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF BARNSTABLE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 230 SOUTH STREET ACCORDANCE WITH THE POLICY PROVISIONS. HYANNIS,MA 02601 y ' AUTHORIZED REPRESENTATIVE ©198 -20400ID&C24POZ:TION..All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD • BARNUM= • A ,Town of Barnstable Regulatory Services Thomas F.Geller,Director Building Division. Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder 1 %1fE as Owner of the subject property }-t y/W//i.0 470Rr.e/-Us hereby authorize �. �� %//Vlf� to act on my behalf, r in all matters relative to work authorized by this building permit application for: 33 CVZq16'(&&6 96ACK (g& "-nrNrSr (Address of Job) tune of Owner Date A. SCNN6�&6e6T- ' Print Name If Property'Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C.\Usets\dccollik\AppData\Local\Microsoit\Windows\Temporary lntemetFiles\Content.0utlook\DDV87AAZ\EXPRESS.doc Revised 072110 x.; � 37W I It ��, Town of Barnstable *Permit# j ® E artment Services Expires 6 moVeefrom issue date ria'�Florence F 2017 Building Commissioner -71' OF 200 Main Street,Hyannis,MA 02601 8A RNST. town.barnstable.ma.us ^' Office: 508-862-4038 Fax: 508-790-6230 EXPUSS PERMIT APPLICATION - RESIDENTIAL ONLY �alid without Red X-Press Imprint Map/parcel Number // . a � Property Address S P q� .�' (6 ❑Residential Value of Work$ l5 . v_ Minimum fee of$35.00 for work under$6000.00"1'1/. Owner's Name&Address Cm n. p Jed' 69 dl 4 G I�•l' Contractor's Name Telephone Number fD B Home Improvement Contractor License#(if applicable) �� 1-7 Y Email: `�d 1-C o G IDrl ��`rJC� ,,®Con:5iro(A-ttn — Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ Lam the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# 5__t3 o,5--b i I y S2 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 Replacement..Windows/doors/sliders.U-Value j 1 J (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 Owner Letter of Permission. . (:� A copy of the Home Improvement Contractors License&Construction Supervisors License is quired. SIGNATURE: Q:IWPFII.ES\FORMSIbuilding permit forms\EXPRESS.doc 08/16/17 ?lie Coinutompeaith ofMassar.lirrsetts Departwmt aflnduslriat Accident - far O,,ice of rmw igatiew 600 WashhIgIOn Sttmet Boston,MA 02111 monmasmgovfdia Workers' GQmpensatianInsuxance Affidavit Budlder /ContractarsMecticians/Plambers Applicant Infiarmation Please Print Named Amress:. L( (� Y-A city/State- - S�S / 1'1 O S Phone g Are}o employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 4. ❑ I am a general contractor and I employees(fu11 afscpor part-time)-* Have hired the sub-contractors 6_ ❑New cxaasfruction .❑ I am a sole pmprietor orpartaw- listed aathe attached sheet. 7_ E.Rtmrodeling soup and have no employees These sub-caafractars have 9..❑Demolition working for me in any capacity- employees and hmewaticess'[NoWorlmrs. comp.insurance Comp_snsm-MMI 9. ❑Building addition reTired-] 5. ❑ We are a corporation and its 14.❑Electrical repairs cr additions officers have exorcised thew 3_❑ I ama hnmeouner doing all u�a�rk I❑Plumbing repairs or additions . rota€ a workers' right of exemption per MGL �17. Roof fep� . ce ewe&]f c.152,§1(41 andwehaveno employees.[No wa&iem' aElother cow insurance mquired_] *Any ap &rut&ztebedcsbos91—st also fla out the swdonbeImvshasentbekwodere compensation periieyiffamuioa I Romeoatuers who submit this af5dnft inffrat ng they am chino nn vat and then ham outsW cunt mcma ym submit anew affidavit indicating sacb- kA'nnactuts tt rhea this boat mm attached sa additional skeet sbeuing the name of the sab-coutzcm¢s and state whether or not tbose eatttin bane employees.If the snb-caaxactnes have tapIvpees,they intsrpmuidedw&workers'rnmp.polkynumber- lam an e)tfpfnyer tliatisprmaduig ivarke.s'compensatiati hwirance for my*employees Below is tfte pa cy anti job sde €nfortnatiom Insurance Company Name: i r' Policy�tx Self--ins.Lit_�_ I/�/L G ,S�0� oI��7�Z• • � F-kpiratiou Date: 2 v I ' v i ` Job Site Address- t'q vi ` ,V— city/Stawzio: Attach a copy of the workers'compensation policy declaration page(shov dog the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MGL a 152 can lead to the impositkm of criminal penalties of a fine up to$150QOU anifor one-year imprisormenk as well as cif penalties in the form of a STOP WORK ORDER and a floe of up to$250-DO a day against the violator- Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage uerificatioa I rla lietaa c fy�as the pains and pens es of perjury thatffte informadmrpm idedabotra is bare and correct ;sie�raivre IJate: 3 J 3'd 1-7 Phone i1 7 Ojol iff am only. Do ftot wrke an this area,to be campletead by c4 ortolan oficiat City or Town: PermiflLicense# Issuing Authority(circle one): L Board of Health Z.Building Department 3.CRyfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector . 6.Other C'aatect Person: Phone#: 6 laformation, and Instructions M.as& reef:s General Laws chapter 152 requires all employers fn provide waz 'compensation for their eanpIayees, . PmMMM3tto this state,an empkyee is defined as.",..every person in the service of another Under airy c032tract of hire, express or implied,oral or writ�u." An.employer is defined as'an individual,partner,association,corporation or other legal ent ,or any two or more of the foregoing engaged is a joint Vie,and including the legal=presenatives of a deceased employer,or the Iec✓iV=or trustee of an individual,partnership,association or other Iegal entity,employing employees. However the owner of a dwelling house having not more than.three apartments and who resides therein,or the occupant of the - dwmffi g house of ano&er who employs pmsans tD do maintrnan c,construction or repair work on such dwelling house or on the grounds or budding thereto shall not becanse of such employment be deemed to be an employer." MCL chapter 152,§25C(6)also sf es that'every state or local liiceasing agency shall withhold$ire issuance or renewal of a license or permit to opematr.a business or to construct bufldings in the commonwealth for any applicant who It's not produced acceptable evidence of compfiancewith the bmmxance covexagerequxed." Additionally,MCsL chapter 152,§2SdM states'Neither the c=n=weahh nor igy of its political subdivisions shall eMter into any contract for the perfmmaaw ofpubho wow u atil acceptable evidence of compliance with the msm-a ce. eq=euients of this chapter r have been presented to the eont ;dng a ffi0i ity." Applicants , Please till out the workers'compensation affidavit completely,by checking ife boxes that apply to your situation and,if necessary,supply sub-.contractor(s)nanze(s), addresses)and phone numbers)along with their certificate(s)of msraance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not rtqaired to cant'wolicers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affrdayrt maybe submitted to the Department of Industrial Accidents for confsmation of msui zace coverage. Also be sure to sign and date the affidavit. The affidavit should be-re-muied to the city or town that the application for the pe anit or license is being requester not the Department of . In.dr—strial A..cci rats. Shouldyou have any questions regarding the lave or ifyou are required to obtain a workers' compensation,policy,please call the Department at tine number listed below. Self-insured companies should ear their self—insurance,license number on the appropriate at. City or Town Of r _ Please be sore that time affidavit is complete and pried.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 cozfact you regarding the applicant Pleas a be slue to fLI in the penii tllicense rnDnber which wM be used as a reference number. In.addition,gm applicant that roust submit multiple per iylicense appliralions in any given year,need only submit one affidavit indicating current policy inlfirmation.(if necessary)and under`Job Site A_d ess"the applicant should write'all locations iu (city or town)-"A copy of the•affidavit that has beea officially stamped or madded by the city or gown may be provided to the applicant as proof that a valid affidavit is on file for foime permits or licenses A new affidavit must be filled out each year. When e a home owner or citizen is obtaining a license or permit not relaiEd to any business or commercial v&at= tie. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Of of Investigations would hke 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: tip of Mzss-achm t _ . I�egaz$rn�c�lzid A�dents_ , •' r Office of jAVM i IRti0-= . Ras 0�111 Tf,-1,4 617' -4900 Cxt 4€6 or 1--977 1v4 A SAFE Fax#617 727 7749 Revised 4-24-07 'wW ma gagIdrd i � . Town of Barnstable Building Department Services BARNMEM Brian Florence,CBO 639' ►`� Building Commissioner 200 Main Street,Hyannis,MA 02601 www-town.barnstable maxs Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section a If Using A Builder as Omer of the subject property . l P PAY hereby authorize �� / o to act on my behalf, in all matters relative to work authorized by this building permit application for. 3 3si vt14 'aac4 �?W (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are perfo ed and accepted. Sigynature of Owner S' ature of Applicant Print Name � Print Name Date Q:FORMS:OWNW Rer.08/160 Town of Barnstable Building Department Services Brian Florence,CBO Building Commissioner k 200 Main Street, Hyannis,MA 02601 MAW www.town.barnstable.ma.us Via. Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street Village, "HOMEOWNER": name home phone# work phone# CURRENT MAMING ADDRESS: City/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside;on which_there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building Rermit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. ` The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control, - I - HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFUM\FORMS\building permit fbrms\EXPRESS.doc 08/16/17 RULK;UN-Ul 1 oaTE(MnNoo/YYYY) ACORD' CERTIFICATE OF LIABILITY INSURANCE 09/21=17 THI�T1RCATE 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 have ADDITIONAL INSURED provisions or 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 endorsemen s). PRODUCER License#17OU862 CT nee.certificates@hubintemational.com HUB International New England ac°ONr o E,n; 508)945-0446 �No: 0 1)945- 1136 265 Orleans Road North Chatham,MA 02650 INSURERS AFFORDING COVERAGE -INSURER A'Selective Insurance Company of South Carolina 19259 INSURER 8:Associated Industries of Massachusetts Mutual Insumnoe ConlPan 33758 INSURED - Rolfe Construction Inc. INSURER C: 141 Bog Road INSURER D: Marston Mills,MA 0260 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 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 ADDL SUER POLICY NUMBER POLICY EFF POLICDrInnm Y EXP LIMITS TYPE OF INSURANCE 1,000,000 A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS 44ADE ❑X OCCUR S2262 330 0410=17 04103/2018 PREMISES 1 RENTED 100,000 MED EXP An one rson 5,000 PERSONAL✓1<ADVINJURY $ 1,000,000 AGGREGATE 2,000,000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL X POLICY❑j0� LOC PRODUCTS-COMPlOP AGG 42,000,OWWO OTHER COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY BODILY INJURY Perperson) $ ANY AUTO AUTOS ONLY SCHEDULED BODILY INJURY Per accident $ ��� AUTOS yNEp �OPPr.ERZDAMAGE AUTOS ONLY AUTOS ONLY UMBRELLA LIAS OCCUR EACH OCCURRENCE _ $ EXCESS UAS CLAIMS-MADE AGGREGATE DED RETENTION$ PER OTH- ER B WORKERS COMPENSATION 500,000 AND EMPLOYERS'UABIUTY CC5005017452 08102/2017 OtIR12/Z018 ANY PROPRIETORWARTNERIEXECUTIVE Y-N E.L.EACH ACCIDENT $ ��ppFlCER/ML M�F�R EXCLUDED? N/A 500,000 (Mandatory m ) E.L.DISEASE-EA EMPLOYEE S If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION holder is listed as Additional Insured f r General Additional when required by writbe ten contract space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of BT wew Ra ACCORDANCE WITH THE POLICY PROVISIONS. 2198 Main Street Brewster,MA 02631 AUTHORIZED REPRESENTATIVE ACORD 25(2016(03) ©1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD IMass. Corporations, external master page Page 1 of 2 w r: Corporations Division Business Entity summary ID Number: 270442062 Request certificate New search Summary for: MARCHANT MILL HOUSE, INC. The exact name of the Nonprofit Corporation: MARCHANT MILL HOUSE, INC. Entity type: Nonprofit Corporation Identification Number: 270442062 Old ID Number: 001006984 Date of Organization in Massachusetts: 06-24-2009 Last date certain: Current Fiscal Month/Day: 12/31 Previous Fiscal Month/Day: 12/31 The location of the Principal Office in Massachusetts: Address: 2 IRVING AVE. City or town, State, Zip code, HYANNIS PORT, MA 02647 USA Country: The name and address of the Resident Agent: Name: UNKNOWN Address: NONE City or town, State, Zip code, NONE, MA 00000 USA Country: The Officers and Directors of the Corporation: Title Individual Name Address Term expires PRESIDENT FREDERICK P FLOYD 50 OVERLEA RD. HYANNIS PORT, MA 2016 02647 USA TREASURER ROBERT SOLOMON 83 QUAIL LN HYANNIS PORT, MA 2020 02647 USA CLERK JAMES MCEVOY 28 FOX RUN CENTERVILLE, MA 2020 02632 USA f-...................___.......... .......... ...._........ VICE NANCY GARRAGHAN 115 OCEAN ST WEST 2016 PRESIDENT HYANNISPORT, MA 02672 USA DIRECTOR ROBERT SOLOMON 83 QUAIL LN HYANNIS PORT, MA 2020 02647 USA ` http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN=270442062... 10/30/2017 f Mass. Corporations, external master page Page 2 of 2 ❑ ❑Confidential ❑Merger ❑ Consent Data Allowed Manufacturing View filings for this business entity: ALL FILINGS Annual Report Application For Revival Articles of Amendment Articles of Consolidation - Foreign and Domestic Vrewfiimgs Comments or notes associated with this business entity: New search �I http://corp.sec.state.ma.us/Corp Web/CorpSearch/CorpSummary.aspx?FEIN=270442062... 10/30/2017 Uttice of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improveme_nttGontractor Registration Type: Corporation m 1 Registration: 128174 Rolfe Construction Inc M Expiration: 03/04/2019 141 Bog Rd. , o Marstons Mills, MA 02648 w Update Address and return card. Mark reason for change. SCA 1 0 20M-05111 rl 1 wwa^w.•J � C��e TCa�u-�ira�raueal��n�C��l�ii9J�cc�[c�eC�J Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: --=R_istration x i atio Office of Consumer Affairs and Business Regulation rt �128i74-,1 03/04/2019 10 Park Plaza-Suite 5170 11)t , Boston,MA 02116 Rolfe Constructionarlc a MICHAEL ROLFE_- 141 Bog RdV Marston Mills,MA 02648 Undersecretary Not valid without signature ` Massachusetts Department of Public Safety, ; :Board:of Building Regulations and.Standarditi _� _ i4 SWei SETTS ;:DRI RUE S — License..CS-068855 ! ,f .'Construction Supervisor- p1 , ;,LICENSE .11� MICHAEL ROLFE .�� ry�i,. r /r n 6aEW. ad r+ure>Ee zx Yr 141 BOG ROAD - E.1]~ F A {15.08 1V ':NONE 'S5820035��MARSTONS MILLS MA 02648 — # as e i aA * + 494 �y 6 SIX M 1611GT-5-10 1 VOL ZC Cx riration: a 7 p d" • ,.� INN palo-S&ROAD. a^ Com�rn�ssioner- 0412912018 1 MARSTONS MILLS,MA 82#48 h` A . e v t DD OS'03161q Rev 071S2'l09 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel 0 4) TOWN OF BARN TA�!F Application # �00 � �7 Health Division '~ Date Issued tea" 2Ql3 JUL 15 Pill cl:. Q 2 Conservation Division l 11L Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board DIVJS,10g., Historic - OKH _ Preservation / Hyannis Project Street Address 3 3s Cro,P ' V+ e Village west ,SV_el / Owner ]'�y S C' S`° ��`". �` Address Telephone �^ Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation f Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. m . 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: ❑ 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 # CurrerifUse —V --- — - - Proposed Use APPLICANT INFORMATION 2 (BUILDER OR HOMEOWNER) Name / J�= Ifi � Telephone Number L2-- 6�o Address �6 �� 7�h /�Y.�KP,rC License # �s — Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO POVPt Ag SIGNATURE �� DATE S FOR OFFICIAL USE ONLY 1 APPLICATION# DATE ISSUED MAP/PARCELNO. ADDRESS VILLAGE r OWNER ,i DATE OF INSPECTION: FOUNDATION. e FRAME' INSULATION p FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL Ax l E. GAS: ROUGH FINAL FINAL BUILDING z A i DATE CLOSED OUT ASSOCIATION PLAN NO. r FW KELLEY PLUMBING&HEATING Estimate 24 FREDERICKSBURG AVE. EAST HARWICH,MA 02645 Date Estimate# (508) 430-8084 7i15i2013. 3 Name/Address TDI Development Co. 335 Craigville Beach Rd Hyannisport Ma Fax 1-781-749-7934 Project Description Qty Rate Total Check cottage and garage for any water and gas 0.00 No water and or gas was found on either building. y i Total 00 Signature �I Alassach Board of B partm setts -De Build' Re ent of P Construction S gulations a ublic Safe t i icense. CS uPer�i.sor nd Standards E -Og Tf1T DIS 8149 ; PO.B ENST Nya��port +5 MA-p26'2 Cpmmi II] I ss; �l' d Oner EXPirati 03724J2 15 &,Xe Tpol—,5r aweaN?, License or registration valid for individul use only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: k'fj'Cgistration: ME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation i ;1'55997 Type: ! 10 Park Plaza-Suite 5170 xpI'ation 5/29/2015 Private Corporatioy.' Boston,MA 02116 T D I REALTY GROUP ING %C v TATE ISENSTADT 55 LAKE AVE. Not valid without signature HYANNIS PORT,MA 02647 -' Undersecretary J DAVID W. SILVA ELECTRIC `` Cel1: (508) 737-0116 ' Residential_* Commercial • Industrial n Voice: (508) 420-2172 . 30 Years Experience Fax: (508) 428-4378 Masters License#206:08A Email: davesilva@comcastnet 55 Thistle Drive • Centerville, MA 02632 July 15;2013- To Whom It May Concern, Please be advised, I went to 335 Craigville Beach Road and surveyed the two structures that are going to be demolished. Both buildings have NO LIVE ELECTRICAL.WIRING and no electrical hazard. Sincerely, David W. Silva �l/V j of Barnstable } . Regn�atory Services' 4 - xses ' Thomas F.'Gez7er Dine ctor 1.Building Di'visioa::. ; . '. Tom Perry,BtuZding Commissioner- 200 Main . _ Shzct Hyannis,MA.Q2601 WW*.tD wn.bsr n sta ble.ma.us Office: 508-862-403 8 Fa1c 508-790-6230 - A . • - Property.p rty Owner Must - Complete and Sign Thar" •SectLon . If Usiti A.B uMer as Ownet of the mbjectptopetty ; het-by autho=a to att on 7 behalf, in aII matters reladre to work aathorized by this buildin ettait f gP- (Address of Job) • - Pool fenc and aLg=as ate ie tesponsibil% of the a lic' tY' Pp ant. Pools -- are not-to b ed-before fence 's instaIled and pools, are not to be utilised final inspectro are petfotmed and accepfed. S . 5igtiatute of Applicant Pant NatQe. Print Name I? A ate QFOKMS:Owi�Tmpm?I srONP00L3 r Town of Barnstable Regulatory, Services` • s�nvsre�s, E Thomas F.Gather,Director r.• . . MASS - Tom Perry,Bonding Commissioner 200 Maur Street; ffyaffiis,MA 02601 . www.tov nmbarnstable:ma s Office: 508-862-4038 Fax 508-790-6230 HOMEOWNER LICENSE KKEMTTOlq Please Print DATE JOB LOCATION: . . numbs street e, Pillage «HOMBOwNER": �• name home phone#'' ., work phone# CURRENT MARINE ADDRESS: pia city/town - st zip code y ' The cmTent exemption for`homeowners"was extended to include owner occ hied dweIlm s of srJ;units'or Less and to allow homeowners to engage an individual for hire who does not.Possess a license,provided that the owner acts as supervisor. t DEFINITION.OF HOMEOWNER Persons)who owns a parcel of land an which he/she resides or intends to reside;,°Il which there is, or is intended to be, a one or twow-fioamly dwelling, attached or detached structures accessory to such.use and/or flarro.structures. A person who constructs more than one home in a twb-year period shalt not be considered a•homeow=— . Suck "homeowner"shall submit to the Building Official on a fora acceptableto the Buildiag Official,that he/she shall be responsible for aIf such work performed under the burl ina permit. (Section 109.1.1)'k The undersigned"homeowner"assrmmes responsibility for compliance with the Stan;B `ilding Code and other applicable codes,bylaws,rules and regulations. The undersigned`homeowner='certifies that Wshe understands the Town ofBams�ble 3uilding Department r n==inspection procedures and n zrrrirr cuts and that he/she.will comply with said rocedxaes and. requirements. *. .. Signature of Homeowner i Approval of BuildingOficial Note: Three ply dwellings containing 3 53 000 cubic feet or larger will be regnlred to comply with the State Building-Code Section 127.0 Contraction ConiroL ! + E . HOMEOWNER'S EXEMr ION The Code states that 'Any homeowner perfmming work for which a building penrut is T=pjired skull be exempt from the provisions of this section(Section 109.1.1-Licensing of canshvction Supervisors);provided that if the homeowner uig"ges a persons)for hire to do such warts,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assurning the responsribili(ies of a.supervisor(sce Appendix Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often te%ults in serious problems,particulffi-lj+. . when the homeowner hires unlicensed persans. In this case,our Board eunmotproceed against the unlicenred person as it would with a licensed ' Supervisor. -The homeowner acting as Supervisor is ultimately responsible To ensure that the homeowner isTal]y aware m bh*er rosponsrbi6ties,many eon rmm 6=regi ire,as part of the permit application, that the.bomwwner certify beat he/she understands the responsr'br•Iities of a Supervisor. On the last page ai this issue is a farm r-Lu=tly used by - several towns. You may cars t amend and adopt such a farrn/cert>fication f6r use in your counnunity, Q:forrris:hom=:cmpt oFt Town of Barnstable �# Permit# Regulatory Service Expires 6 month s � Fee s Mass. Thomas F. Geiler,Director k l o V5Y ATED MA't� Building Division Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis, MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not valid without Red X-Press Imprint Map/parcel Number Property Address 33 S w,4 f r t � '4) 0 residential Value of Work 6200, 0 o Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Ao At Aly Contractor's NameA✓I vib fmeTelephone Number 5 /J0,P/� Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) U Zw/ orkman's Compensation Insurance - Check one: ❑ I am a sole proprietor .' ❑ I am the Homeowner S N. T I have Worker's Compensation Insurance �C�U�J OF BgRN.STAIBL Insurance Company Name Workman's Comp. Policy Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ' Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows *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 Owner Letter of Permission. A copy of the Home Improvement Contractors License& Construction Supervisors License is required. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 070110 ,1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Q Please Print Legibly Name (Business/Organization/IndividuaI): 104UC. �A_UiS Address: .5 U2? In q i,J 2�6. Ufi if 12 L City/State/Zip: Phone#: Are yo.u..an employer?Check the appropriate box: 0 I am a employer with ;�� 4. I am a general contractor and I Type of project(required): 1. ❑ employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑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 corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. 00f repairs i insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.0 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 worker;'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: 0( / t-AM c C Policy#or Self-ins,Lic.#: OD r VJ ia3s/ Expiration Date: _ /7 / 41 Job Site Address: 4-lfy� � � City/State/Zip: r /o 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. , I do hereby cenV under the pains and penalties of perjury that the information provided ab ve is true and correct Si ature: �/� Date: rJ t Phone#: ,tea' yP-Yl c-o LLOther se only. Do not write in this area, to be completed by city or town official own: Permit/License# uthority(circle one): of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector erson: Phone#: CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD"YYY) 103/02,2011 THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. T1413 CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT; holder Is an ANITIONAL IRSUKED, the po y s must be endorsed. If R WAIVED. subject o the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certlfkats holder in Hsu of such wWorssmengS). PRODUCER NAME: BLAIR AG1isfCY, INC. PHONE NeU1, 508-866-9150 C11o528-866-5334 145 SOUTH MAIN ST A-MFJI. : CARWR, WA 02330 CUSTOMER ID0. 508-866-9150 INSURERS)AFFORDING COVERAGE NAIc P INSURED INSURER AFAW FAWLY CSIIALTY IN URANCZ COMPANY 16721 JOSABEN, INC. INsuRnAROCKRILL INSURANCE COMPANY DSA PAUL DAVIS RESTORATION OF CAPE COD 6 THE ISLANDS INSUMAC; PO BOX 1382 INSURER O: SOUTH DZNNIS, MPL 02660 INSURERE: INSURER F; COVERAGES CERTIFICATE NUMBER. REVISION NUMBER! THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LI TED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS. CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LrIt TYPE POLICY EXP OF INSURANCE INSR wvo POLICY NUMBER (MMATD"VYY) IMMRN*YYYYI LIMrfd GENERAL LAASILlTY EACH OCCURRENCE S1,000,000 E COMMERCIAL GENERAL LIABILITY X R PKG E 003594-01 11/17/201 11/17/2011 PREMISES(e�oou,rrnwa $ B CLAIMS-MADE OCCUR MEOEXP(Anyonepmwn) 1 5,000 PERSONAL Q ADV INJURY S1,000,000 GENERAL AGGREGATE s2,000,000 OEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO 1 2,000,000 POLICY JPERCT LOC s . AUTOMOa1LE b1As1UTY COMBINED SINGLE LIMIT S ANY AUTO (Ea eotldenU --- 2001C38363A 11/17/201011/17/2011"BODILY INJURY(Parp.mon) S 1,000,000 A ALL OWNED AUTOS' BODILY INJURY(Per eoddenl) s 1,000,On X SCHEOULEDAUTOS PROPERTY DAMAGE 5 1,000,000 x. HIREDAUTOS (Per rrmdenl) �( NON-OWNED AUTOS 1 UMBRELLA UA13 OCCUR EACH OCCURRENCE 1 EXCMUAB CLAIM&MADE AGGREGATE4 S DEDUCTIBLE 1 RETENTION 1 1 WORKERS COMPENSATION TWC STATU, ORS LIMITS x ER AND EMPLOYERS LIABILITY Yr. fN A ANY PROPRIETORIPARTNERIEXECUTNE ❑ 2001W6351 11/17/20 11/17/2011 ,L.EACHACCIDENT 1 500,000 NIA OFFIGERVEMBER EXCLUDED? ........... ...........__..._..-.-..-.. (Muldnory In NMI DAVID RL= IS INCLUDED E.L.DISEASE-EA EMPLOYEE 1 500,000 If yea,d5wAbe Undr DESCRIPTION OF OPERATIONS below .L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS r LOCATIONS IVEHICLEO(A1MeA ACORD 101, er!_' dub,It m6ps epUq Is rpulmd) OPERATIONS PERFORtd6D By NA1UD INSURED CERTIFICATE HOLDER CANCELLATION JOSABEN, INC. , L) DSA HAUL DAVIS R$$TOR7ITION OF CAPE COD S THE ISLANDS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANE CLLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO, SOX 1382 ACCORDANCE WITH THE POLICY PROVISIONS. SO- DXNNIS, MA 02645 AUTWRItPD REPRESENTATIVE FAX$ 508-430-7800 .� 01 18$8- 8 A ORD CORPORATION, All rights reserve- ACORD 25(2008108) The ACORD name and logo vo registered marks of ORD / f PA UL DAVIS RestorationMemodeling Paul Davis Restoration of Cape Cod & The Islands P.O. Box 1382 South Dennis, MA 02660 (508) 4430-8100 • Fax.: (508) 430-7E00 MA Lic. # 055949 Registration # 117515 PROPERTY IMPROVEMJEN'T CONTRACT PROPOSAL SUBMUM D TO: / PHONE: DATE: (2,r RL iS C S�,=s) q,7 -:3?,5 f Fll- t �f JOB DAME: 3.�� C.�s�i!�/r we � >�� ��.�rj��,r5�nr•Z T" 1�11� o a��� STR EFT: STlti= CITY: CITY STATE: 'We hereby submit specifrcaLions and esrimates for: c'-6A-s5 S'514N) ff,L S{�iK}ELe �.i Y ,K'itJG- -� i� ft)UJ2K�Itir9 '( 77M��.. ............................................................................................................................... .. We hereby propose to furnish all labor and materials to complete the work in accordance with the abj%e specifications for-the sum J`{AW6I 56 C .&Ll- �' oIlars (S y: with payment to be trade as F611 cvs: 0 '1/ DOAt At �f}1/mnaz7- ( &Z66) e-, (2S- 1 `� '1 h`�i'�Cf Gyu t? f %� & 4z Al/ ;Lc=7-1 All materml suasantend to be as spe:ified. AU work to be completed in a workmanlike manner according to standard practices. An,,; a1_ter4iUon or deviation from above specifications involving extra costs, will be -xocuic"d Drily upon written orders. and will become an extra charge over and above the estimate. All agreements contingent upon strikes: accidents, or delays beyond our control. Owner to carry fire, tornado. and ocher necessary insurance.Our workers are fully covered by Workers'Compensation Insurance.Tire Terms and ConditiOns _n the back or this pace ate;,art o this contract. P_,kUL DAVIS RESTOR.ATION OF CAPE COD &TiIE ISLANDS THIS CONTRACT REPRESENTS THE r-ULL AGREEMENT BETWEEN THE PARTIES AND NO Authorized Signature —) VERBAL AGREEMENTS OR PROMISES WILL Estimated time of completion PEE BINDING ON THE CdivTT`ACTOR. / 7 - 4 LV f�Tif /C FEFl 1 I fi/tiG) (working days i >\IOTE:This proposal may be withdrawn by us if nor accepted within days. T-he above prices,specifications:and conditions are satisfactory and are he ccepted.You authorized to do the v,,ork as specified.Payment will be as oulined.as above: KSignatur XDate o�d(/ X Signatu_ra liar,_ l Q e• —�� i.ua..ou�.nu.��.a a.� - v��rui un♦.na v . ann � .tau a_a r - y Board of Buildim, Ref,ulations and Standards Construction Supervisor License k License: CS 65949 Restricted to: 00 DAVID ROME 200 GREAT WESTERN RD#5 ' S DENNIS, MA 02660 - Expiration: 10/5/2011 ('unmrissiuncr Tr#: 6033 umer OffairsL`CB 40C�'"a License or registration valid for individul use only ' Office of Consumer Affairs&B mess Regulation g. Y HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: ,A,17515 Type: Office of Consumer Affairs and Business Regulation Expiration: 1,0/1:31z012 Private Corporatioi, ,. 10 Park Plaza-Suite 5170 Boston,MA 02116 PA DAVIS SYS.T-,O&EAPE_0QQ—,'& ISLAN DAVID ROME E= ggg 108 Susan Lane Brewster, MA 02631 ",_" Undersecretary of valid thout signature