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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
007
Map Q Parcel v v Application#
Health Division �ID q
Conservation Division 10100, Permit#
Tax Collector Date Issued
Treasurer Application Fee fl oa o a' 67
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis W eo
Project Street Address (
Village -AU
Owner e44o � > Address ��3 0 ge.T
Telephone �;DT_ ?a G .�
Permit Request tis ��9��'6 ¢ 5��.�, '� W i ac J
Square feet: 1 st floor:existing Q5Y6 proposed 2nd floor:existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation 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 tove: des 53 No
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑ec,ing ❑r w size
Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
ca r-
Commercial ❑Yes O No If yes,site plan review# Cr'
Current Use Proposed Use
BUILDER INFORMATION
Name�� � 1'� 3 Telephone Number �V�� `/c �-9
Address L( License#
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
If
SIGNATURE DATE f-ld- 7
FOR OFFICIAL USE ONLY
t
PERMIT NO.
DATE ISSUED
MAP/PARCEL-NO.
r
ADDRESS - VILLAGE
OWNER -
DATE OF INSPECTION: {
FOUNDATION
FRAME
INSULATION '
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH - FINAL
GAS: ROUGH F FINAL
FINAL BUILDING '
DATE CLOSED OUT
ASSOCIIIATION PLAN NO.
F w.
• •Yy • Sh-N• i/YV VV//I/.rV.I/rVY-YY.- 11
Department of Industrial Accidents
' , ^ Office of Investigations
d 600 Washington Street
Boston,M-4 02111
www.mass.gov/dia '
Workers' Compensation Iapsurance Affidavit: Builders/Contractors/Electricians/Plumbers
A • licaut Information Please Print Le lbl
Name(Business/Orgenization/Indivi(ival): . �oyr w c
Address: _ �`JC
� I-'s Sr '
tate/Zi 4� 0 hone:#: O •U
City/S p: y
Are yo employer? Check the'appropriate box: 'Type of project(required):. .
i. I am a em#loyer with 4. ❑ I am a general contractor and I
employees(fall and/or part,time).* have hired the sub-contractms 6.. New construction .
2.[] I am&'sole proprietor or partaer- listed on the-attached sheet. 7. ❑Remodeling
These sub-contractors have t
ship andhave no employees 8. ❑Demolition'
working for me in any capacity. employees and have workers'
•$• . 9.••❑Building addition
[Na workeis' comp,insurance comp.insurance.
re q wired 5. ❑ 'We are a corporation and its 10.❑Electrical repairs or additions
j ' officers have exercised their .
'3.❑ I am&homeowner doing work 11.❑Plumbing repairs or additions .•
myself [No workers'com9. right cf exemption per MGL` 12.❑Roof repairs
insurance requited.]t c. 152,§1(4),and we have no
employees. [No workers' 13:❑Other
comp,msurance requured.]
*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 affidavitiudicating such.
tContractors that check this box must attached an additional sheet showing the name of the'sub7contractars and state whether ornot those entities have
employees: If the sub-contractors have employees,they mustprovidt their workers'comp.polidynumber.
I am an employer that is providing workers'compensation insurance for my employees.-Below is.the paFicy and job.site
information.
Insurance Company Name:A
Policy#'or Self-ins.Lic.#: [20 Expiration Date:
;ob Site Address: CitylState/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 05ce of -- -
Investigations of the 1IA•for insurance coverage verification.
I�do hereby certify under the pal .•and penalties of perjury that the information prgvided above,is tru-e and,correct.'
Si -tare: Date:
Phone#:
F.�.Board
only..•Do not write.tn this area, to be completed by city or town officiaL
n: PermitT€ficense#
hority(circle one):
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
rson: Phone#:
Inform a ion And Instfucti®ns
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hiie,
express or implied, oral or written
es
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a-deceased employer, or the
r 6MM nr t ruster-of an individual,partner-sb association or other Iegal'entity eiiiploying employees, However the
owner of a dwelling house having not more than three apartments and who resides therein;or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on snrlk-dw.elling•house
or on the grounds or building eppurtenantthereto shallnotbecause of such-employment bedeemed to be an employer."
MoL chapter 152, §25C(6)also states that"every state or.local•licensing agency shall withhold the issuance or
renewal.of a license or permit to'operate a business or to construct buildings in the commonwealth for any
applicaut•who has not produced-acceptable evidence of compliance with the insurance coverage required:"
A.dditionany,MGL chapter 152,•§25C(7)states`Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for.they erformance of public work until-acceptable evidence•cf oomplizriee with the insurance
requirements of this chapter have been presented'to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, it
necessary,supply sub-contractor(s)name(s),address(d)and phone number(s)along with their certificates)of
insurance, Limited Liability Companies'(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or-partners,are not required to carry workers' compensationinsurance. If an LLGor LLP does have
employees,a policy is required, R. advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit.or licensels being requested,not the Department of
Industrial Accidents.; Should you have any questions regarding the law•orif you.are require.to obtain a workers'.
compensation policy,please call the Deparhnent at the number listed below, Self-insured companies should der their
self-insurance license number on the appropriate-line.
City or Town Officials.
Please be sure that the affidavit is complete'and printed legibly. The-Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact'you regarding the applicant,
-Please be acne to fillin the pennitllicense number which will be used as a reference number. In addition, an applicant.
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy-information(ifnecessary)and under"Job Site Address"the applicant should write"LU.locations'in (city-or
town),"A•cbpy of the affidavit that has been officially stamped or marked by tlhe city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses, A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not relat ed io any business or commercial ventute
(i.e.a dog license or permit to bum leaves•etc,)said person is NOT requited to.complete this affidavit,
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questiqW,_,--
please do not hesitate tri-give-ds.a call, y -
The Deparnent's address,telephone-and fax number;
az �n 4 of Massaqb setts
qgat £ � Act '
MCC of In afigations
Robtan,Mk(t2111
TeL 4 617-727-490.0 ext 406 ar 1-077 MASSAFE
Fax 0' 617-727-7?49..
Revised 11-22.06 w.w.w,MaSs.gavI6
°FINE ram, 'Town of Barnstable.
ti
Regulatory Services
-
,� Thomas F.Geiler,Director
4'AIF0
;9�°�� Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
www.to wn.b arnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
hereby authorize ro , ��.�. C to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Address of Job)
e Ai�
Signature of er ate
rint Name
Q 10PUM S:OWNERPERMIS S ION
CO
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4� Licen.`se CONSSTRlIC�TION, F,RV,1'0R,;
Number�GS 065318 :f
5 R,„ t Bin�i�£e 4�28�197.1
�, 5 }6i��sir� 01128/2008 Tr.no: T43'89
Comm7ssi6i r
f
i
DATE(iNIR10GJYYYY)
CERTIFICATE OF LIABILITY INSURANCE o3I26/2007
08)394-7848 FAX (508)750-1223 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Grath !nsuran a Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
MOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
U`e 134 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
fBox 1500
Dennis, IRA 02560 INSURERS AFFORDING COVERAGE P1AIC>I'
Apcon Inc. INSUP,ER A: Nat i ona I Grange Mut-ua I 14788
4B30 P.te 28 taURE-R B: American I nternat i cn I +;soup
Cotu i t, AAA 02635 I``uRZER�
INSURER D: -
1NSURES E.
AGES
DUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PERIOD INDICA T ED.NOT%WTHSTANDING
EOUIREMENT.TERM.OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT VMH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
ERTAIN,THE I NSURANCE AFFORDED BY THE POLI"IES DESCRIBED HEREIN!S SUBJECT TO ALL 7riE TERMS,EXCLUSIONS AND CONDIMONS.OF SUCH
IES.AGGREGATE LIMITS SHOY+M MAY HAW BEEN.REDUCED BY PAID CLAWS.
TYPE Of WSURIANCE POLICY NUNBBR POL Y EFFECTIVE P I Y XPBEATI N URIITS
I GENERALLJAIMUTY IA9M17301 10/22/2006 10/22/2007 EACHOCCURRENcE # i•OC�O,00
�X COLIMERCU.LGENEP.ALUABILITY DAIlACoE?CREh7ED S •I� oo
CLA"MIADE .�000.1R N'cDEXP(ArtyOrppersenj E_ 5,00
- PERSONAL&ADV IliL URY Is 1,OQO,00
i CENERAL AGGREL-`.7E S 2,DOD,0017
GEM AGGREGATE LIMIT APPLIES PER:I PRODUCTS-COMP/OP AGG S 2,000,00C
POLICY JEC.. 7 LOC
AUTDMO&L[LIABILITY
ALL SINGLE L:N,IT S
(Ea accieerW
ANf AL40 --
ALL OWNED AUTOS BODILY INJURY S
(Perpowfl)
SCHEDULED AUTOS --
HIREDAUTOS BODILY INJURY S
{Per amlderM)
NON•DWNED AUTOS I
PROPERTY DAMAGE S
[Flat a;des t)
AUTO ONLY-EA ACCIDENT S
GPRAGE LIADILrrY --
ANY AUTO I OTNERTNAN EA ACC s
A'-'TO ONLY: ADS F
Imc SSIUMBRULA LIAIN CtlIJ117301 05/26/2008 05I26/2007 mm occuFRENCE s 3,000,00
X OCCUR rL AINE Id°OE ! AGGREGATE i
�S
DEDUCn8'.E - S
s
RETENTION S
OIatER6txnnPsagAnONAND We 00895360500 03/26/2007 03/26/2008 ACg7ATiA X cTK
MIPLOYERS'LIABILITY E.L.EACH ACCIDENT s 1 ,000,00
01
NY pROPR1ETOPJPARTNERAP(ECUTIVE E.L.DISEASE-EA EMPLOY $ 1 OD91
FFICER MUSTER EXCLUDED? I
yyea,C®""'o'Q r E_L.CIS
•POLICY LIMIT s 1 ,000,0
FECIAL PROVIS110%Wow
THU
L
IPTION OF OPERATIONS I LOCATIONS I YENICLES 1 EXCLUftONS ADDED BY ENOMSEMENT/SPECIAL PROVISION!
'rATE N
FrOLDER v CANC) LUTIO ���
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE LMUI NG INSURER WILL ENDEAVOR TO MAIL
DAYS WRITTEN NOTICE TO THE CERTIFICATE NOLOEP NAMEDTO THE LJSPT, 1
Town Of Barnstab i e BUT FAILURE TO MAIL SUCN NOTICS SMALL IMPOSE NO CDUOAnGN OR LIABILITY
Attn: Bu I I d i ng Dept. OF ANY KIN��-Em�k
N THE INS ITS AGENTS OR R IEPREBEWATIVES, I
200 Main Street
Hya>,n 1 s, MA 02601 Au?No y
FAX: (508)T78-105' OACORD CORPORATION 1936
!RED 25(2001.+08) .
t -d £Zp-I-09L "e09 oul aoueinsul W){ WdG�-al L,OQa 92 Jew J
- i n
r
f TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
ti C
Map Parcel 1 �� Application#
Health Division
Conservation Division °� Permit#
Tax Collector Date Issued
Treasurer Application Fee 00
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board -'
Historic-OKH Preservation/Hyannis
Project Street Address
Village ��y✓A/l Tr /���
Owner 14 57�,.—'¢'S Address eo 3 y ie tea-
Telephone b��1Oi `j a° y
Permit Request vv�-- .S' a VeJr
)��
Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation 0 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 Za,_ new
Number of Bedrooms: existing new
Total Room Count(not including baths):existing new First Floor Room Count
c`
Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other -
Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal-stove: LJ 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 p-,/ Proposed Use
BUILDER INFORMATION
Name 2 , /G�'1 � J Telephone Number ?! �Za 01 y
Address �3 �' License#
/ : �"Lt9 •,/1�i® Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE' DATE
s-
• FOR OFFICIAL USE ONLY
PERMIT NO. _
DA
TE ISSUED - .f
MAP/PARCEL NO.
ADDRESS ` VILLAGE,'
OWNER i
DATE OF INSPECTION:
FOUNDATION
FRAME '0(C _� 7 O �JZ-.
INSULATION'
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
The Commonwealth of'Massachusetts
Department of Industrial Accidents
Office of Investigations
1 a 600 Washington Street
Boston, AM 02111
\ V
www.mass.gov/dia
Workers' Cotlapensation•Insurance Affidavit., Builders/Contractors/Electricians/Plumbers
A licant Information Please Print LelKibly
Name (Business/organizatiowIndividual): .
Address: t(Y3 e
City/State/Zip: - 041 Phone#:
Are ou an employer? Check e-appropriate box: Type of project(required):
1• I 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
listed on the attached sheet $ ❑ Remodeling
2.❑ I am a sole proprietor arpar tner- ._ � , _ .
ship and have no employees These sub-contractors have 8•. ❑ Demolition
working for me in any capacity.' workers' comp.insurance. 9. ❑ Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
officers have exercised their 10.❑ Electrical repairs or additions
required-]
3.❑ I am a homeowner doing all work, right of exemption per MGL 11.7 Plumbing repairs or additions
myself.[No workers' comp. c. 152, §1(4),and we have no 12T.-I Roof repairs
insurance required.] t 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 af}ids4indicating such.-
1contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Comp any Name:
Policy#or Self-ins.Lic. #: Expiration Date:
Job Site Address: 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. 15.2 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 certify under t,"Ins andpenalties ofperjury that the information provided above is true and correcz
Si atvre: Date: � O
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 Denartment 3_City/Town Cleric e.Electrical Inspector 5.Plumbing Inspector- �
6. Other j
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as "an individual,partnership, association, corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the s'
receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the ti
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the `
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall witbbold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line. -
City or Town Officials .
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fi11 out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write "all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Depmtrnent of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. _617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 5-26-05
w+Nw.mass.aoviaia
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r_� s. �1`e �arrr,uv�evea�L�./l2446a44ru,�a; �
er �`
' SOARQ Or'lsul DI G RECiULA
` License CONSTRUCTION:SURERVISOR
,, N'umbe�?#CS 06531t8
' 1971
n 81rt�id�ter
01IOW ,
1f28�10'OS Tr.no: 1,4389`F
� p1[es 0 ,
5 `�C'M",
`A'. h t t
f..
MICHAEL
t 4830 FUT 28' . ,'263 ` 7.r<✓-' �J'�°A , /�, -.
COTT UI IM/A Q_ Commissioner `'
i
. CERTIFICATE OF LIABILITY INSURANCE -� o3/s i 07
'rtODIICER (508)3S4-7848 FAX (508)760-1223 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Kevin McGrath Insurance Agency ONLY AND CONFERS NO RIRHTS UPON THE CERTIFICATE
420 Route 134 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
- ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 1600
South Denn I s. MA 02560 INSURERS AFFORDING COVERAGE MAIC#
NsuRem Apcon Inc, - INSURER A; National Grange mutual � 14788
4830 P.te 28 INSURER B; American I nternat i on I Group
Cotuit, MA 02635 iusuReRc:
INSURER D:
INSURE4 E: ---__�
KOYg(�GES
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 INSUP.ANiCEAFFORDED BY THE POLICIES DESCRIBED HEREIN!S SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAW BEEN REDUCED BY PAID CLAIMSJEL . _
NBR TYPE OF INSURANCE POLICY NUNBER Y Ef VE P I P T N UN$TS
OENERALUAWLITY M017301 10/22/2006 10/22/2007 EACHOCCURRENCE $ i,000,
�X-�CCOOMMERCIAL.GENERAL LIABILITY DAMAGE TO RENTED $ 100,00
HCLAIMS MADE �OCC!R MED EXP(Any om Person) $ 5,
A � PERSONAL R ADV ISL URY $ 1.000,
GENERAL AGGREGATE S 2,000,
GEN'L AGGREGATE LIMIT APPLIES PER: I PROD UCT6•OOMPIOP AOG S 21000,001
POLICY "� LOC
AUTOM081LE UABILnrf COMBINED SINGLE LNIr
ANY AUTO (Ee al sift R) S
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per Person) $
MREDAUTOS BODILY INJURY $
NCN•OWNEC AUTOS (PeraocderM)
PROPERTY DAMAGE $
. (Fetacdderhj
GARAGE LIABILITY ALM ONLY-EAAXIOENr $
ANY AUTO OTHER THAN � $
� _
i A000NLY: AGO $
I
GXCESBJUMMRELLALIABILITY CUM17301 05/26/2006 05/26/2CO7 EACHOCCURRENCE I s 3,000 00
x OCCUR '.AAINIS MADE AGGREGATE 1,i
A
DEDUCT13lE _ '
RETENTION S $
WOWERBCOMPOMTIONAND WC 00895360500 03/26/2007 03/26/2008 STATU x DTI+
EMPLOYERS'LUIBIUTY E.L.EACH ACCIDENT $ 1 1000,00
8 ANY PROPRI ETORIPARTNERJEJ[ECLRIVE.
OFFICER)MEMBER EKCLUDED] E.L.DISEASE-EA EMPLOY $ 1 ,000,00
W,owanooihniar E.L.DISEASE.POLICY LIMIT S 1 000,0
SPECIAL PROVISIONS below
OTHER L
DESCRIPTION OF OPERATIO5 8I LOCATIONBI VEHICLES I EXCLUSIONS ADDED BY ENOORSEMENT(SPECIAL PROVSONB
DER AtICELIAIJON
BHOULO ANY OF THE ABOVE DESCRIBED POLICR:B BE CANCELLED BEFORE THE
EXPIRATION GATE THEREOF,THE ISSUING INSURER WILL ENOEAVORTO MAIL
Town OP Barns-cab I e -GAYS NIRITTEN wancE TD THE CERTIFICATE HOLIER.NAMEDTO THE LEFT
n: Building Dept. BUT FAILURETO MAIL SLICHNOTIC G$HALLIMPO$ENOOBLIOATIONORUABILITY
Attn:Att Main Street OF ANY KIND N THE INSURER,rrs AGENTS OR RMOSEWATIVE200
Hyannis, MA 02601 AUTM TAITVE P
ACORD26{2001108) FAX: (508)778-1057 4 (DACORD CORPORATION 1988
T 'd 6Zal-09L-809 ouI aoueansuI W)i Wd6tl :al L00u 92 JeW —
r
03/26/2007 12:26 FAX 5004201637 FREDERICKS INSURANCE Z00411004
01-25-OT 06:57pm From-AIG +973 331 0699 T-741 P.001/002 F-216
tom. I
"'�',i"I[''•i+,::�...,e�';;;4t��I�;t•S�•.,,rt:�W4�h�!T��,�y t�"I'�i.��L.�. :�� _ { � - .�, -
�,I P,t v!i I, . nt•.n'I.• .,t h�. �_i�.�hr�wt� �r !� •'� QI. a .�y��v�„ � ,.t^ '� �`• '�,.. �-�
..��01�U�,�✓,S -rk : •r' n. 1 'r..:'-�.� Y' . I ,r,
C•Jh•7,,. , v 4 1.J,:
THIS CERTIFICATE IS ISSUED A$A NIA'I'TEF �F INFORMATION
Agr�y Inc �OL
ou
re Of rks Ineurun OPdLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
1046 Ivfah Street D�R.T3-IIS CERTIF'IGAT'E DOES NOT AMEND, EXTEND OR
P 013c)x 427 ALTER THE COVERAGE AFFORDED EY THE POLICIES BELOW
Ostervil`®,MA 02685 COMPANIES AO CE
INSURED COMPANY A GRANITE STATE INSURANCE COMPANY
LedgirrOod Manor Cora
Po Box 617
W.c^Srnsfa6le,AMA 02668.001D
�.Y L'.R�V G `.a:'Gc :'• 12,9Yy a.. ,rr; nr-y P ....
fIFY ..,. k-. ,:.'i'::::?;}<(Y u4"l i7' .,`Y., i:.i in0 1'
TN15 fri T _ ��{{,t
0..OR T-IA7 T;iE POLICIES OF INSURANCE L1sTiEp B LOW HAVE BERN ISSUED TO TnE IA151•wD NAmEu ABOVE FOR
THE POLICY PERICO INDICATED,NOT WMNSTANDiNG ANY RPOUIREMEW,TERM OR CONDITION OF ANY CONTRACT OR OTHEF!
DOCUMENT WITH RespEe'r TO WHICH THIS reRj h'1CATFE MAY flit ISSUED OR MAY PERTAIN,THE INSUPANGE AFFORppD THE
POLICIES DESCRIBED WERt IN 15 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDMON41 Of SUCH POUCiES,LIMITS SHOWN
MAY HAVE BEEN REDUCED SY PAID(,IAIkjS,
Co
L TYPE OFIN/URAN PGtlpY NUAd R Pl�t1CY 9FC$!?tINR DATE P r
A ba>__ CDM!; SATiflW OUCvE�SPIRAAGk T
t:MALDYCRS'LIApILITY
HE PRCPRtBT0p) LIMITS
a ATNExstEXCCUTrVB I
44 jai
MURS ARE!
KCI.ra�cct o 4398931 I 8f 51200i3 ATIrTORY u
�I16r+ OB7 M"
i. �Gry�rApptltte t�MA O�S(81in!`a Qt�,
AcclayeNT $ 100,000�.
tel:POLICY l.tW S 609,010
ESCRiI�TION OF OPtbRA ON 1 CCI rA5 — t00
CERTIFICATE HOLDER CANCELLATION
TOWN OF 6APINSTABLE RMOUW ANY OFTIGAOouPDESCRiBEOPOLIC(OgiE°ANCekIX-0GEFoFWT4E
BUILDINGSOUTH
DI T IIIATIONDATITHIpeciF,n+ElssuIN000mpmYv�rac,�,v0Rtawl�a•.to
HY N N i S, 5 T DAYS WM"M N07MI YO THE OEATIFICATE HOLDS a AMPM TO THE°LAPT,Rm
1 IY4N NiS, MA 026f)1 FAILM TO MAIL SUCH NOTIO9 ek4a INIPOBE NO ONUCIATION OR tW LITY OF
ANY IQND UPON THE QOWANY,Ra AGENTS OR mon6BINTA was.
AUTHORIZED REPRESENTATIVE
I -- -
03/26/2007 12.'26 FAX 5084201637 FREDERICKS INSURANCE UO3/004
IMPORTANT
I
If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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 endarsement(s),
DISCLAIMER
I
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
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7 ,!� - Install. new FRP on all wails in C c !
Remove exisitng window �c '
! I 4' — food prep area.
replace w/ new service window -------,.._
I I \ \ \ I Replace existing window w/
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new service window
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Remove exisitng wall to wall ( i 5 -0
\ I =- 5
7-1
'lamCN
carpet ` New VCT Flooring w/ sanitary r�
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cove base
\ f I I S{\Construct new walls
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Demolition Plan Floor Plan
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Cash Register �1)
2 4crylic Cone Box , L 6
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13 Refrigerated Cold Pan is ,3 jz t i W v
a Glass Guard Fruit Display
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5 -Blender I ,, i
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\ -t- ----- , C�
6 ice Machine - - {
7, 3 bay sink w/ drainboards
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a Stainless shelving \ I '/r�a� Is "
9 Wall mounted touchless hand sink Cz71 J15 5 O
(ED
:O Suspended Menu Boards i r
21 Wort: top cooler
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12 Soft serve yogurt machine MLVi�-)IUN
I to Storage Cooler
14 Storage freezer ! ;
! 15 Frozen yogurt freezer
IG Dipping well
17 Mop SiInk
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Equipment Plan
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