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0115 LAFRANCE AVENUE
1 I -S At,/e-, i I I� k it r; Town of Barnstable Final Inspection Affidavit f Date: i Building Division 200 Main-Street Hyannis, MA 02601 RE: Insulation Permits Dear;' This affidavi=istortifythatallw kcompletedat: Street: C.� Village: has been in'sp cted by a certified Building Performance Institute (BPI) Inspector. All work performed meets or exceeds federal and state requirements. Permit application nu bed—_) Issue date: Sincerely, Francis Sheehan President Frontier Energy Solutions, Inc. 502 Harwich Road Brewster, MA 02631 Office: 774-237-0410 Email: fssfrontierenergy@gmail.com ,• yj TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 1^ I r Map T0W,1 OF B AVI TAB E ParceI ANNlication # Health Division 9- 2 4 Date Issued. Conservation Division Application Fee Planning Dept. „Tw , a„:,�� �t Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Addresst= � 61 — Village tAS OwnerjWJA1� }� �`� Address c;Z /tXW Telephone �-°�7�--•�� � `� S � Permit Request -� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 5000 a 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 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 .ft (sq ) 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 If yes, site plan review# n Current Userczj Proposed Use 4N) nAivorf P APPLICANT INFORMATION - (BUILDER OR HOMEOWNER) - - q Nam f Telephone Number �� 'C Address License # p�✓ c Home Improvement Contractor# vvmrker's Compensation XLy,"1CbC605Z ALL CONSTRUCTION DEBRIS RESU TING FROM THIS ROJECT WILL BE TAKEN TO LI&C, SIGNATURE a x DATE FOR OFFICIAL USE ONLY s y APPLICATION # ybATE ISSUED ti•- MAP/ PARCEL NO. ADDRESS VILLAGE OWNER ,T DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE --, ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING r DATE CLOSED OUT ` ASSOCIATION PLAN NO. r 14. The Parties acknowledge that this Agreement is under seal. It is intended by the Parties that the Tenant or any successor Tenant is the intended beneficiary of the Agreement and shall have a right of enforcement. ., ,t Property Owner's Signature: ` Date Phone: Address: -� -- �irJ GSl o�L) PrI ,C m. Tenant Signature Date Agency Approved Weatherization Company an Y _ / Adam T. Incorporated / All Cape Energy Alternative Weatherization Ca dl�sulation / Cape Save / Cazeault Frontier Energy Solutions Lohr Home Improvement I Tupper Construction Agency Signature Date u 14. The Parties acknowledge that this Agreement is under seal. It is intended by the Parties that the Tenant or any successor Tenant is the intended beneficiary of the Agreement and shall have a right of enforcement. Property Owner's Signature: Date Phone: Address: Tenant Si natureL—�-_-- ~"`' 'r�"� � bate Agency Approved Weatherization Company Adam T. Incorporated / All Cape Energy / Alternative Weatherization Cape Cod Insulation I Cape Save I Cazeault jFroLntiernergy Solutions / Lohr Home Improvement / Tupper Construction Agency Signature Date =?., The C:•ommotrivettlth of'Masserchusetts Department of11iditstrial ACc2dctta, 1 I Congress Street, Suite 100 a hoston,MA 92Y4-10.17 lopm.ftiss:.g o v/rtia \porkers' ("ompensn.fion Insurance Affidavit: .[3uidUcrs/C isntractors/Eler.friciarts/f lumbers. TO I3t:FILED NN7.ITH THE PER\41•T••hIM.;AUTHORITY. ..1.pp(icvnt Information �f'Icase. Print L egibly N11MC (Busincss/Organizationilnctividual): ) A Address: / C7. -— P JS_IL�. [ _--l_--�_�— --G c� S l ( h<)nf: J! 1�� ? _{ U-- -- - - -- - Are you an cmplover?Cbec.k the.auprnpriak hors f Type of project (requ.ire(l): I. I am a employer with !_© employees(.full and/or pnrntinrc).' 7. ❑ New construction 2111 am o sole proprietor or Imi-tnrrshi,p and have no employees working Ivor mc.in $. lZCfnodeling' any capacity.LNo work-ors'corni)..insuranee required.) t.❑I nm a homcowmr.r doing all work myself'.INo w•orkers'.comp.insurance required.)' ❑L)errlUlitlUn CD []�I am a Itmneowne,r and will be hiring contractors to conduct all work.on my lre,perly. twill ' 10 Building addition ensure that all contractors either have w»rkr.rs'compensation insurance or r,re.sole f::Iectrieal repairs or additions proprietors with nn employees: I?.❑Plumbing repairs or additions i.❑I am a general contractor and I have hired dos subcontractors listed on the attached sheet. These sob-contractors have erirployecs and havcworkers'comp,insurance.: 13.17Roof repiirs yy 6. Wc.orr,:a co onli'.on and its olhlc:ers.have ckt:rcised thbir'd. tt of exem ion a MGL c. 14. �)thef�Cll l Vh .n L�,t<�Or1 i ❑ m � � p' p' Lit,§1(4);and w-c hnvc net employees.(No workers'comp.insurance«squired.) 'Any applicant that.chccirs box 111 must also till our the section below showing their workers'rompensntion policy infnrmntinn. — t Honmovncrs who submit this affidavit.indicating they are doing a'I work-rod.then hire outside cimtracturs must submit it new affidavit indicating.ouch. ;Contractors!hat check this box muss attached an additional sheet shoving the.name,of the sub-contractors and star.whether or not those,entities have employees. If the sub=eontructorshave employees,that'muxr..provcde their workers'comp.policy number. t a.tn an entp.loyer that iv.provitlinl workers'compensation insurance for my elingloyees, 'lielow is the policy and job site i in(ormrition (( .I Insurance Company Nalne: � Policy N or Sctf-.ins. Lic. fl• i '. L, ,� � - --------/ •---- a / { 017 f Job Site A.ddrt City/statt:/lip ,Attach a copy oPthe worker9' c.om sensation olicv;declaration aloe(showing the olio nuni a nc ex irat { (? I h ( fi policy � p a n d A— failure to secure'Coverage as retluired under MGL c• 152,§25A is a criminal violation punishable by a fine up to$1,500. and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK C.)RDER and a fine of up to$?50.O0 a day.against the violator'. A copy of this statement may he fonvardi:d to the Office o.f Investigations of the DIA for irtsurance I coverage.verification. t Ao hereby certify u.ntler flee pdiats a _��ties njperjury that the i.nlornration prowled have G true ant!correct - Signature_.__ \ Late: ......1 _ �_._..................----- 1'Iton�s1-L,_2 `❑,_ O fficial use only, i'>o trot write in this area, to he completer!h}:city or town offteinL i a y or'T'own:_� Permit/License H. I Authae'ty(circle omn ): I 1 1. Board.of Heaft:h 2, l3.uil.ding,Department 3. Cityfrawn Clerk 4; Electrical hus.pector 5. Plumbing Inspector l 6. Other Contact Person: . Phone N: • ft..Z`:{i.Ntr</it<Cu�(dt.-[j ��.r[-:3ldr�U Ca�J ! License or registration vihd'for individual nse.only +� Office of Cousumer Affairs&Rusint s Re�ulation befor.:e the expir ikon date If:found return to: 9MW"�r HOME IMPROVEMENT CONTRACTOR Office of Consumer Affurs and Business Regulation HEn i. Registration: 160854 Type: - 10 Part.Plaza-Suite;5:170 t Expiration 9/8i2018 ` LLC Boston,KA 02116 FRONTIER ENERGY SOLUTIbNS FRANCIS SHEEHAN 502 HARWICH RD _....._.� BREWSTER,MA 02631 Undersecretary` N t val' ithou sign'tture , Construction Supervisor Specialty Massachusetts Department of Public Safety Restricted to: CSSL-IC-Insuiation Contractor Board of"Rutid'ing Regul..ajons and Standards q. License CSSLAO5-4.1 Construetron Superviscir Specialty Eli ` FRANCIS S SHEEHAN ° 502 HARWICH RD • X BRE•WSTER,MA,02631 Failure tq possessa c_urcent edition offFie Massachusetfsr State Building Code is cause.forrevocation of this license. l"J1` E tplfatlon, DPS Licensing information visit: WWY4I:MASS.GOV/DPS �CirntTilssioter 02/1Tf:2018 j• - i j • ® DATE(MMIDDIYYYY) ;aw'Ro CERTIFICATE OF LIABILITY INSURANCE 04/05/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER _ CONTACT NAME: Krystal Doyle ROGERS&GRAY INSURANCE AGENCY, INC. A/coNly Ext: (508)398-7980 ac No: E-MAIL kd0 le f0 erS ra com ' - - ADDRESS: Y � g g Y• 434 RT.134 ' INSURERS AFFORDING COVERAGE NAIC# SOUTH DENNIS MA 02660 wsURERA: AIM MUTUAL INS CO 33758 INSURED INSURERB: , FRONTIER ENERGY SOLUTIONS INC INSURERC: INSURER D: ' 502 HARWICH ROAD INSURERE: BREWSTER MA 02631 INSURER F: COVERAGES CERTIFICATE NUMBER: 42389 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 ADDLTYPE OF INSURANCE INSD SUER LTR POLICY NUMBER MMIDONYYY MMIDDfYYYY LIMITS COMMERCIAL GENERAL LIABILITY - EACH OCCURRENCE $ DAMAGE RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ NIA - PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT ❑LOC PRODUCTS-COMP/OP AGG $ OTHER: - $ - AUTOMOBILE LIABILITY i COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS - N/A BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE . $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR ' _ EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE N/A AGGREGATE. $ DED I RETENTION$ $ WORKERS COMPENSATION X 'STATUTE OERH AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE YIN— IN E.L.EACH ACCIDENT s 1,000,000 A OFFICER/MEMBEREXCLUDED? NIA NIA NIA VWC10060153152016A 03/14/2016 03/14/2017 - (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEE $ 1,000,000 , If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) , Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant.to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govAwd/workers-compensationAnvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Frontier Energy Solutions IncACCORDANCE WITH THE POLICY PROVISIONS. 502 Harwich Rd AUTHORIZED REPRESENTATIVE Brewster MA 02631 Daniel M.Crow'ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 711411 4 �t Town of Barnstable *Permit# 6/�a_ 7 Expires 6 months from issue date Regulatory Services Fee as, • s BAmsrABIX • mass.16g9. Richard V.Scali,Director � �EDN1P�A Building Division BUILDING DEPT. Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 JUN 28 2016 www.town.barnstable.ma.us Office: 508-862-4038 TOWN OF951B &6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X--Press Imprint Map/parcel Number 2-'70 j 7 —T Property Address ms t g-A,&&u 4�m_5 dResidential Value of Work$ S L.®.J Minimum fee of$35.00 for work under$6000A0 Owner's Name&Address �IU B �► ��t�t I✓�I 1 15 �(;2 Akw &5 T-t5 u 1%)90 &uvi,-5 44 02 h:F�Iw Contractor's Name Di,i,Ljr--V ` &w j Telephone Number ScS 9-7eoq �t� Home Improvement Contractor License#(if applicable) Email: y z.L�,�29a't�1 d®Lo. 7 Construction Supervisor's License#(if applicable) 691 9 3 07, ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor 2 Elam the Homeowner have Worker's Co pensation Insurance Insurance Company Name k12. Workman's Comp.Policy (o 2-V � �j?j l ` 6 Copy of Insurance Compliance Certificate must accompany each permit. 4` Permit Requ (check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to V4anoo�r ❑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: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is r fired. SIGNATURE: C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Fi s\Content.0utlook\2PIOIDHR\EXPRESS.doe Revised 040215 oFtr� • snaxsrABM MASS.: , Town of Barnstable QED MA'I A Regulatory Services Richard V.Scati,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 l-Z�i , as Owner of the subject 1 property hereby authorize- _04—%'0eA- to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) 2'1 '24 ignature.of Owner Date 1 � t Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\2PIOlDHR\EXPRESS.doc Revised 040215 _ _ rj r The Coninionsvealth of Massachusetts Depart►nent of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 *vmt,.nrass.gov/dia Workers' Compensation Insurance Affidavit: Bvdlders/Conh actors/Electricians/Plumbers Applicant Information \ Please Print 1,egibly Name(Business/Organization/Individal): A U, CC,, - Addrress:% City/State/Zip.4KQ01-X(P®&'q- -',1' 021015 Phone#: 60% 60q C4 bW A,r�e/you an employer?Check the.appropriate bog: Type of project(required): 1.L'7 I am a employer uath I , 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6- ❑New construction 2.El 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 wormers' 9. ❑Building addition [No workers'comp.insurance comp.insurance, required.] 5. ❑ We are a corporation and its 101-1 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I LE]]numbing repairs or additions myself [No workers'comp- -right.of exemption per MGL 12_ Roof repairs insurance required.]b c. 152,§1(4),and use have:no employees-[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 also fill our the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such FContractors that check this box must attached on addiuoaal sheet shouting the time of the sub-conunctors and state whether or not those entities have employees. If the mb-contmaors bare employees,they must provide their workers'camp.policy number. I am an employer that is pr os idng workers'cotrpensation insurance for my eirWh4wa& Belotv is the policy and job site inforinaliom Insurance Company Name: � Policy*or Se}f-ins.Inc.4: Expiration DatZ`6,201 / Job Site Address:16 City/State/Zip:. "ivd * 0260 Attach a dopy 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 citril 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,cet Jffiqj,,nder the pains andpenaJkes of ped ry that the information provided abmw is 6ntee and correct Si Bate: Phone#: --so y® Official use only. Do not write in this area,to be completed by city or loin 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#: ,aco o® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 05/27/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate,does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Christine Davies DOWLING & O'NEIL INSURANCE AGENCY PHONE 508 775-1620 FAX No: E-MAIL ADDRESS: cdavies@doins.com 973IYANNOUGH RD. INSURERS AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B KELLY ROOFING INC INSURERC: INSURER D 8 RHINE ROAD INSURER E: YARMOUTHPORT MA 02675 [INSURER F: COVERAGES CERTIFICATE NUMBER: 56798 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. ILTR TYPE OF INSURANCE ADDL SUER POLICPOLICY NUMBER MM/DDY EFF POLICYMMMDI EXP LIMITS COMMERCIAL GENERAL LIABILITY �: EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO-' POLICY DJECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT , $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- ANDEMPLOYERS'LIABILITY Y/N X STATUTE ER ANYPROPRIETOWPARTNER/EXECUIIVE E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? WA WA N/A 6S62UB2E90137116 05/06/2016 05/06/2017 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500.000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached ff more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hastings Meadow Condominiums ACCORDANCE WITH THE POLICY PROVISIONS. 135 West Main Street AUTHORIZED REPRESENTATIVE `TH Hyannis MA 02601 ` j C Daniel M.Cro ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Massachusetts Department of Public Safety Board of Building Regulations and Standards = License: CSSL-099167 Construction Supervisor Specialty . OLNER M KELLY- 8 RHINE ROAD YARMOUTH POKY -� Expiration: Commissioner 09=4017 . dXXe (oom4'J?iowwPiI riNa i . �i i2/j�.1.��il;�l/�Q/� Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston;Massachusetts 02116 Home Improvement Contractor Registration Registration: 128957 _ Type: Individual _- - Expiration: 6/1412017 Trk 266M6 Oliver Kelly - - Oliver Kelly 8 Rhine Rd Yarmouthport, MA 02675 = Update Address and return card.Mark reason for change. sca , -1 Address j� RenewaI C Employment Q Lost Card .Office of ConsumerAffairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: 1tegistration: .:_12gg57 Type: Office of Consumer Affairs and Business Regulation Expiration: -6A4i2Q1W Individual 10 Park Plaza-Suite 5170. Boston,MA 02116 Oliver Kelly Oliver Kelly -- _ 8 Rhine Rd_ _- -- LOGO Yarmouthport MA02675 : : Undersecretary Not valid without signature q I TOWN OF BARNSTABLE BUILDING.PERMIT APPLICATION Map Parcel Application # Z4—If - Health Division �� � �P�� Date Issued ' Conservation Division `� P Application Fee Planning Dept. �0�� Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis **died Project Street Address //Y� �,c'}/� OWCG I� Village Ate N! S Owner t LEW 11-pe-0 M 4 n t S Address Telephone 5-09 -71 Permit Request 11 ov e- S h ee-T /to R a zT7.4,*L 4!�/-e6,,.,y r N Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay . Project Valuation J"10 3?&V A 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 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 # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 4 A-,J L 14,4 M, ;4 Telephone Number � � (` a 6 ``- S--6 "T- Address 1- LE-A-ft t 2 License # Cs FA - OS'/`7 $ c G 4- A114 0 Z 3 7d Home Improvement Contractor# /7 Email a-�-7��SN'0&Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO P ST fi Qe - ) 0 A 57--,0-2 a/►� z , re SIGNATURE DATE S i FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. • ADDRESS VILLAGE it r OWNER f DATE OF INSPECTION: R' FOUNDATION FRAME INSULATION f FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL _. FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 5 y :v/teanvnw�uuea �CJvura� cca°Ct. t ulation License or registration valid for individul use only fice of consumer Affairs&Business Reg before the expiration date. If found return to: E IMPROVEMENT CONTRACTOR office of Consumer Affairs and Business Regulation I " Type:. 10 ParkPlaza-Suite 5170 'Wegistration 4 Supplement C7'd Boston,MA 02116 xpiration.=--- ^ I� l- �; -- a y,, MULTI-s RES bra-z =~k O ,CAPE COD � b� RICHARD LAURIA V, _' /lll i 21 PEQUOT RD. i=`" ' No alid t ut signature MASPHEE,MA 02649 Undersecretary I Massachusetts -Department of.Public Safety k Board of Building Regulations and Standards r._-_.—_ n-_-_—___-� o r. -i__ ♦uiiiu uC`uGT o--pe riso� i a 2 r arnfly License: CSFA-051784 fi� nri CA�HDIR �LE Rockland MA 02370 Expiration Commissioner 04I01/2017,. ' 6 Restricted-One-'and two-family]eanyany accessory building thereto,irrespe S , Failure to possess a current edition of the State Building Code is cause for revocation .For DPS Licensinginformation visit: www-Mas ' ne ConsrlrorrTrealah of Massachusetts De p arhner t of Industrial Accidews n _.. . l ,ffrre o f 1rni�s'tigations 600 FPashingtort,S -eet Boston,41A 02111 M!ftmi.niasmgovldia Warkers' Cumpensatian Insurance Affidavit:$ui1der7slCuntractcirslEIect ricians/Plumbers Applicant Infaiiration Please Print Lm. 'b y Name�uSIIfe�,'�lgaII�Eir�nlfndis�erina��= M,u,Ln" Qj()crT-e-121�5 ' V 12A-77 0A1 .. - Address: A)IC O LeT 7—A City,/StateMp M A-ry� Pee mane-'tk wog q 77—3 3 33 Are you an employer?Check the appropriate box- Type of project(requiied),- L&I am a employer with `t 4. ❑I am a general contractor and I employees(full andlorport-time). * leave hired the sub-contractors 6_ ❑New comsfiuction 2-_❑ I am a sole propneetor orpartner- listed on the attached sheet. ?'- ❑Remodeling ship and have no.employees. . "I These sub-contractors have 8. gDemolition wod ing for roe is any capacity employees and have woADers' [No Workers, coMp_insurance comp.insurant # �_ ❑Building addition required-]ed_ 5_ ❑ We are a corporation and its 10.E]Electrical repairs or additions 3.❑ I am.a homeoumer doing all work, officers have exercised their 1L0 Plumbingrepairs or additions . myself- o workers' right of exemption per MGL �' � �OTF- 12.01ioofrepairs inm ancerequired"I i 7c.152,§l(4k andwe have no, employees.[go workers' 13_❑Other comp_insurance required_] OAny app€icwr that checks box R mast also fill out the section below shmeing Their watlteis'compensatiou policy informaiieaL Homeowners who submit dais affidmif indicating ttwy are doing all wa&anti then hire outsidecontractors-r- submit a new affidavit indicating rnrfi FCantractors tEW ebea this box mast attached air additiauel sheet showing the name of the sub-coutwdars and state whether or not rbmse entities have employees.ifthesub-contmctors have empIoyee%they nnutpravUether workers'comp.palicynmober_ I ana aia errtplo}vzr flnrrt is pratzdriig workers'canrp¢rasrrfr'oan iirsirrance f or nriy*¢nrploy�ees. Betoav is th¢policy rend jab situ it formadom Insurance Company Name: 'Policy-or Self--ins_Lic.49: I\,a- W C 6 3 '7 S 3 t Expiration Date: 7—/4 -/4 Job Site.Aadrzss:_//S L� ��2A-1VeE /��/ ' CitylStaWZip: Attach a copy of the workers'compensation p olicy declaration page(showing the policy number and respiration date). Failure to secure:coverage as requiredunder Section 25A of MGL c 15I can lead to the imposition.of criminal penalties of a fine up to$1,5a0_00 and'ar one-year imprisonment,as well as civil penaalties.in the form of a STOP WORK OBDEAand.aa fine of up to$250-00 a day against the violator. Be advised that a copy ofthis statement maybe forwarded to the Office of Investigations ofthe DFA.far insurance coverage verification. I do hereby cerlifi�rierd¢r f rums andperraltces ofpedwy diatthe innfonraationpraazrledabam is barb and correct Simature_ Date: Phone g -- 5j-6 .7 7 Official use only. �Uo ntat esrrte int this area,tit be crriarplete�d b}'city arfaivar a;;f�czat City or T'own.: RerraitU.cense# Issuing Antherity(ci r.Ie one): 1.Board of Health 2.Buffffing Depai-iment 3.f ity/rown.Clerk 4.Electrical Inspector rr.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto ibis sfAata,an enplayee is defined as---.every person in the service of another under any contract ofhim, express or implied,oral or writie:m" An employer is defined as"an individnai,partner-J:dp,association,corporation or other legal entity,or any two or more of the foregoing engaged in a Joint enterprise,and including the Iegal representatives of a deceased employer,or the receiver or trnsstee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more fan three apartments and who resides therein,or the ocaTant of the - dwelIing house of another who employs persons to do maintenance,construction or reps work on such dwDIEug house or on the grounds or building appurtenant thereto shallnotbmause of such employment be deemed to be.an employer." MGL chapter 152,§25C(6 also starts,that"every state or local licensing agency shall withhold fhe issuance or renewal of a license or permit to operate a business or to construct bwldiags in the coT,nvnonwealfh for any applicant who has not produced acceptable evidence of c' liar, with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)st&z"Neither the commonwealth nor any of its political subdivisions shall enter intro any contract for the perform ame ofpublic work until acceptable evidence of compliance with the insui-a ce._ reguirenients of this chapter have been presented to the contracting authoity." AppHcasrts Please fill out the worker'compensation affidavit completely,by checking the boxes that apply to your situation and,if c s of umbe s .Ion with certffi necessary,supply sub-:ontractor(s)name(s), addresses)and phonen r() g �() insurance. Lio:iited Liability Companies(LLC)or Limited LiabrlityPartamships(LLP)with no employees other than.the members or partners,are not regLm ed to cauy woikers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitf-d to the Department of Industrial Accidents for confirmation of in Duran ce coverage. Also be sure to sign and date the,a f idavit The affidavit should be retuned to me city or town that the application for the permit or license is being requested,not the Departmenf of LndListijalAccidents. Should you have any questions regrading the law or ifyou are required to obtain a workers' compensation policy,please call the Department at the number listr d below Self-insured companies should enter their self-ir ur;,nce license number on the appropriate line. City or Town Of FaciaLs T - Please be sate that the affidavit is complete and printed.legibly. The Department has provided a space at the bottom. of the affidavit for you to Ell out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fil in the permitllicense number which will be used as.a reference number. In addition,an applicant that must submit multiple pennitllicense applications in any givenyear,need only submit one.affidavit indicating cunuat policy infomation.(if necessary)and under"lob Site Address"the applicant should•mite"all locations in (city or town)_"A copy of the affidavit that has been officially stamped or marked bythe city or town maybe provided to the applicant as proof that a valid affidavit is on file for futa re permits or licenses. A new affidavit must be filled out each year.Where a home ov-mer'or citizen is obtaining a license or permit not related to any business Or- commercial veniise (i_e. a dog license or permit to bum leaves etc.)said person is NOT regiCad to complete this affidavit The Of of Investigations would like to thank you in advance for your cooperation and should you have any gnes(ions, please do not hesitate to give us a call The Department's address,tdrphone and fax number: The CGMMmwean of MmsaGhusntts T Department of hid trial Accidea� Of of TILVesigatiom 6M Vlaw GI,5f=t BortGn,MA f1�111. ` (-,L 4 617'27-45M(�-xt 4€6 or 1-977-MAS&AFE Fax 9 617` 27 774 Revised 4-24-07 • - w .mass-gavldia - i 05.18.201.ri 15,59:38 BH Insurance MID ID 170118M 1/1 ACC> CERTIFICATE OF LIABILITY INSURANCE °ATE`MM'°°'YYY" OS 18 2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGA7IVELY 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 NAME: STARKWEATHER&SHEPLEY INSURANCE CORP OF MA PHONE FAX AIC No Ext: AIC No PO Box 549 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC i Providence RI 02901 INSURERA: AmGUARD Insurance Company 2390 INSURED INSURER B MULTI STATE RESTORATION CAPE COD DI INSURERC: 68 NICHOLETTAS WAY UNIT G INSURERD: INSURER E: MASHPEE MA 02649 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 ADDL SUER POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER _ MMIDDIYYYY MMIDDIYYYYJ LIMITS GENERAL LIABILITY _ EACH OCCURRENCE $ COM MERCIAL GENERAL LIABILITY - DAMAGE0 ENT D PREMISES Ea occurrence $ CLAIMS-MADE DOCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ ` GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPIOPAGG $ POLICY I PRO LOC $ AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT (Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OV>nVED P OPERTYDAMAGE $ HIRED AUTOS AUTOS Peraccidenl UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $' A WORKERS COMPENSATION WC L STATITSU- OTH- ANDEMPLOYERS'LIABILITY YIN R2WC639531 7/16/2015 /16/2016 TO YIM -.._ ANY PROPRIETORJPARTNER;E'X,ECUTIVE EL EACH ACCIDENT $ 500,000 OFFICEP.11IBER EXCLUDEN N❑ NIA {Mandatory in NH) 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 LOCATIONS VEHICLES (Attach ACORD 101,'Additional Remarks Schedule,if more space is required) Re: 115 LaFrance Avenue, Hyannis, MA 02601 CERTIFICATE HOLDER CANCELLATION Town Of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 200 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hyannis, MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED O 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD � e %eY AC�® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 5/18/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Beth Deschene NAME: Cross Insurance, Inc.— RI PHONE (401)431-9200 FAX (401)431-9201 A/C No Ext: A/C No 376 Newport Avenue E-MAIL bdeschene@crossagency.com ADDRESS: P. 0. BOX 4830 INSURERS AFFORDING COVERAGE NAIC# East Providence RI 02916 INSURERA:Selective Insurance Co. of SC 19259 INSURED INSURER B MULTI—STATE RESTORATION CAPE COD DIV, INC. -INSURER C: 68 NICOLLETTES WAY INSURERD: INSURER E: MASHPEE MA 02649 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1651772535 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 SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE WVDPOLICY NUMBER MM/DD/YYYY MM/DDNYYY LIMITS X COMMERCIAL GENERAL LIABILITY - EACH OCCURRENCE - $ 1,000,000 A CLAIMS-MADE ❑X PREMISESS OCCUR DAMAGE OCCUR100,000 Ea occurrence $ S 2139645 1/2/2016 1/2/2017 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ 3,000,000 X POLICY PRO PRODUCTS-COMP/OP AGG $JECT ❑LOG 3,000,000 OTHER: - $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LAB OCCUR - EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DIED RETENTION$ $ WORKERS COMPENSATION PER OTH Y/N - AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ . DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE: 115 Lafrance Ave., Hyannis, MA 02601 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE -t Beth Deschene/BDXk ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) MULTI-STATE RESTORATION, INC: FIRE* FLOOD*WIND* SMOKE*HURRICANE*VANDALISM Fed ID#050515889 CONTRACTORS REGISTRATION#140427 AUTHORIZATION TO PERFORM SERVICES AND DIRECTION OF PAYMENT herein referred to as "Customer",authorizes �t � rG cda°i• , MULTI-STATE RESTORATION,INC.,herein referred to as "MULTI-STATE",to perform any and all necessary cleaning and construction services on Customers'property at: ' ,1"` Telephone: and with respect to items that need to be cleaned at a remote location,to remove ands--z,)]�`�, clean such items as necessary. Customer authorizes 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. /f11 Signature of 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: Y' Dav 14ihN r 3T0 1 ?r_( I have read this document and completely understand and agree to same. Signature 1 / Date L&11.1 Printed Name P.O. BOX 2210•MASHPEE, MA 02649.866-921-9111 •FAX 774-238-4422 Tc- MUD ROOM x 15 I x � � 2 t 15 V V' a " w n 5_ T - ,� Ir( /t-io N l 5. , w x v . x v ' n h e� s r + M—.E,.. - ._.. 2' ._v _ s--.3. _ ._..-sr.-s-_.:r_._._._:_._.._ _..:.-.-.. >.__'-_:..........._. _. .._�"i,-_ �„i.... :s.c_'{��3i� _ •_ - a . .> ._ ..-'�... __ -..>Si:...,-. _...__i .:._. ....:.. ...... ... .. .. .. .__ram. .r.._ ,:-:.... .. .€--_ .1.. _..._. ...__... __._._.......... ._:...._....,. I� �� ___ _....._.. �—.a. _. .. .: .. ....... . ... . ,. ... .. U , - =:A c gq- .�-.,$�' _ ,a Ow , a c ' 2 r - � I — Lauren Elliott-Grunes of Brewster takes advantage of the warm weather on WAonday to need her plot at the town community garden on tower Road in Brewster.MERRILY CASSIDY/CAPE COD TIMES I TEEKLOG � f The damage was mostly to the Truro brush Are ,� �: ,�:� ,.. �� ��j�� �„ exterior of the house,which was t r scorches about an acre t� - a r F assessed at 5170;100 in 2015,but ;r �l there was smoke damage inside, TRURO=A brush fire burned ? r — according to Ruth and Melanson. through about an acre of land x '§ �F a —Haven oreechio-Egresitz off Longnook Road on Monday afternoon. � e� s ar E Driver injured when truck Multiple fire departments hits car in Sandwich responded to the site at around noon,Wellfleet fire Lt George { _ y r ., SANDWICH—A driver had minor injuries after his car was White said. broadsided by a pickup truck Firefighters from Provinc- I etown,Wellfleet,Truro,Eastham ? i at the intersection of Route 6A and Orleans battled the blaze for and Tupper Road on Monday about an hour before extinguish- afternoon. ing it,he said.The state Bureau _tom ° rig '.- Firefighters responded to the ,a of.Forest Fire Control and the Firefighters spray an area burning off Longnook Road in wro on Monday intersection at 1 p.m.and took National Parks Service also the driver of the Chrysler sedan responded,he said. afternoon. MERRILY CASSIDY/CAPE COD TIMES to Falmouth Hospital,Sandwich —Madeleine List according to Hyannis Deputy Fire said. fire Capt Timothy McMahon said. _ _ Chief Dean Melanson. When Barnstable police officer The car was crossing Route 6A is-house fire The fire started in a bucket Dan Ruth arrived,a tenant at when it was Hyann hit by the truck,he blamed on cigarette placed outside the front door and the house was extinguishing the said.There were no passengers in it spread up the shingled exterior blaze. the car,he said,and the driver of YANNIS—A improperly of the house into the attic,accord H -6 "He had the hose going,the the truck was uninjured. , disposed cigarette is most likely ing to Melanson. flames out,"Ruth said,adding that Sandwich police are investigat the cause of afire at 115 LaF-. The bucket was regularly used the man told him he had been out- ing the crash,he said. dance Ave.on Monday afternoon, to dispose of cigarettes,Melanson side smoking 20 minutes earlier. —Madeleine List + PUL ITZER PRIZE l TOVAJ OF BARNSTABLE Police: Yarmouth man injured during fight I CapeCodOnlinexom a ri Page 1 of 2 Friday September 10,2010- - CAPE COD ONLINE CLASSIFIEDS I CONTACT US I SUBSCRIBER TOOLS I MOB;LE"NEWS-I EMAIL NEWSLETTERS. 630 # Forecast I Radar + ` l NEWS BUSINESS SPORTS OPINION ENTERTAINMENT•'LIFESTYLE <MULTIMEDIA COMMUNITY NEWS REPORTS VISITOR GUIDE, MARKETPLACE Police: Yarmouth man injured during fight NEW, CALENDAR HOMES'AUTOS`JOBS cEassir By Patrick Cassidy ----- ——- - EOS STAFF WRITER Text Size.A I A I A Search Stones.Videos and more ! FIND�.ITI- Sep tember 10,2010 Print this Article 09i Email this Article -' -The M0 s HYANNIS—A West Yarmouth man was taken to the hospital after a � allegedly being struck in the head during a fight on La,France. ShareThis '`ai"vtl°T ' yy Avenue last night. eThi_ p y V►dA �- Police were first called to 115 La France Avenue for a"reported`fight at about 8:40 p.m.,according to BarnSstable ... Police Sgt.Sean Sweeney. They were called back to the area again shortly after 9 p.m.for i another fight and found a large group of people yelling at each other, More Times Breaking News { Sweeney said. , - Police Yarmouth man injured during fight s 2s nrtr " s ` While the group was being separated,a 39-year old man from West Yarmouth fell'to the round and started to have seizures he said,A Sen Brown showing a more moderaie, LOOK s � , Nissan livers police officer at the scene reported seeing a large jump on the mans face s is am'. .NOW,union,"seek hospital execs vdldc" " head and bleeding from his ear,Sweeney said. p _ _ - -dismissal'-.s:n am - HOMES j JOBS: RENTALS Another man at the scene said the alleged victim was struck during Cape's WiFi hubs?Tell us about them! — —— — the fight,Sweeney said: 9:10 ani a $52 i,000. See All Breaking News Stories» East Dennis,MA The man was taken to Cape Cod Hospital where he was treated and Bayside Realty released,according to a hospital spokeswoman.. Consultants More Details.. HOME 4. � $329,600 l East Dennis,MA Ads by Google Today's most viewed articles McDevitt REALTORS i More Details... l Mother raises seat belt awareness m Criminal Records � ' � sriazolo Check Criminal Records History On Anyone-Get Court Records&More. Cape thief creates diversion to steal, $163,000 r "$4,000-anor2olo Dennis,MA USSearch.com/Criminal-Records > .• ` Third man indicted for Hyannis murder' Steele Associates R E r Free Sex offender Report sr1612010 More Details... Where do Sex Offenders live in Your Cape Top 10 fish markets-s,9rzolo,- Neighborhood?Find out in 60 secs! — NeighborhoodScan.com Chatham police warn of counterfeit bills. 9:10.'2p10 View all Featured Properties - _ - Police Records Free? NOW union,seek hospital exec's What are these)) I. Check Anyone's Police Record. Process dismissal.-s;/orzoio Takes Less Than 5 Seconds!` www.GovPoliceRecords.org Ads by Goggle' M,-T?x�'ljetvhl- DEAL OF THE WEEK i 38 DEALS ONLINE.TODAY MORE 3 Course Dinners$25 ! !The Red Pheasant Inn Cotuit Center for the Arts 10%discount on single membership " Cotuit Center For the Arts try us for 14 days no cost or obligation~".. The'Woman's Workout Company " TAKE$2 OFF ANY-$10 PURCHASE! Painted Daisies $10}Off Dinner for Two 1586 Bistro a Bar j $50 FuIt Body Massage OR Facial r I Cosmetique Salon " LOCAL REVIEW Jake Rooney's ****# l The place is definately bigger than it looks from the outside.My family and I enjoyed our whole evening,... http://www.capecodonline.com/apps/pbcs.dll/article?AID=/20100910/NEWS11/100919987 9/10/2010 Town of Barnstable *Permit# 651777 hP p Expires 6 months-from issue date BA grABLE, ± Regulatory Services Fee v J,�' �� Thomas F.Geiler,Director . '°rF°MA�a Building Division Tom Perry, Building Commissioner ®P IT 200 Main Street, Hyannis,MA 02601 OCT 2 3 200 Office: 508-8624038 - Fax: 508-790-6230 TOWN OF BARNST LE EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY �jr� .7 Not Valid without Red X Press Imprint Map/parcel Number sC l� Property Address dt CQ s _P Residential Value of Work Owner's Name&Address 11 2- e2t95Z'2;z Contractor's Name l w!d u c 16 :n`2 Le al 3 Telephone Number_ Home Improvement Contractor License#(if applicable) ' S ow Z/ Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner , ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Permit Request(check box) I��KT a C'oD�[ Re-roof(stripping old shingles) All construction debris will be taken to loin�z n?'Xi/S' ❑Re-roof(not stripping. Going over existing layers of roo fl ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) ❑ Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signature 114. Q:Forms:expmtrg Revised121901