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0025 MAYWOOD AVENUE
i Sull ,'Van Engineerifl&N OF BARNSTABLE C o nsulting, 10', , " PH I; (508)428-3344 • P.O. Box 659 • 711 Main Street, Osterville, MA 02655 seci@sullivanengin.com • www.sullivanengin.com 'JVJ,SjO#aannu 020 Brian Florence Building Commissioner, Building Dept. Town of Barnstable 200 Main Street Hyannis, MA 02601 RE: Chapter 91 Waterways License Application Kerr Family Trust, 25 Maywood Avenue, Hyannis Port Dear Mr. Florence, Please find enclosed a Municipal Zoning Certificate along with a copy of pages 1-5 of the Department of Environmental Protection Chapter 91 Waterways License Application and copy of the plans for the above referenced project. Would you please review and sign the Municipal Zoning Certificate and return it to me in the enclosed self-addressed stamped envelope at your earliest convenience? Thank you for your assistance. If you have any questions,please contact the office. Very truly yo rs, LekO' Sullivan Engineering& Consulting, Inc. Attachments f f Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program X284841 Transmittal No. Chapter 91 Waterways License Application -310 CMR 9.00 Water-Dependent,Nonwater-Dependent,Amendment Important:When A. Application Information (Check one) filling out forms on the computer, NOTE: For Chapter 91 Simplified License application form and information see the Self Licensing use only the tab P P � PP g key to move your Package for BRP WW06. cursor-do not use the return Name(Complete Application Sections) Check One Fee Application# key. WATER-DEPENDENT- General (A-H) ® Residential with<4 units $215.00 BRP WW01a ❑ Other $330.00. BRP WW01b For assistance ❑ Extended Term $31-350.00 BRP WW01c incompleting this --...................--.._........----........_.._........-.._..-.._.._........-.--.._.............._.._..-..........._.._..-..----.......—.._.._..-......-- application,please Amendment(A-H) ❑ Residential with< 4 units $100.00 BRP WW03a seethe "Instructions". ❑ Other $125.00 BRP WW03b NONWATER-DEPENDENT- Full (A-H) ❑ Residential with<4 units $665.00 BRP WW15a ❑ Other $2,005.00 BRP WW15b ❑ Extended Term $3,350.00 BRP WW15c Partial (A-H) ❑ Residential with <4 units $665:00 BRP WW14a ❑ Other $2,005.00 BRP WW14b ❑ Extended Term $3,350.00 BRP WW14c Municipal Harbor Plan (A-H) ❑ Residential with <4 units $665.00 BRP WW16a ❑ Other $2,005.00 BRP WW16b ❑ Extended Term $3,350.00 BRP WW16c Joint MEPA/EIR(A-H) ❑ Residential with< 4 units $665.00 BRP WW17a ❑ Other $2,005.00 BRP WW17b ❑ Extended Term $3,350.00 . BRP.WW17c . Amendment(A-H). ❑ Residential with<4 units .$530.00 BRP WW03c ❑ Other $11000.00 BRP WW03d ❑ Extended Term $1,335.00 BRP WW03e CH91App.doc•Rev.03/17 Page 1 of 13 ` 3 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program x284841 Transmittal No. Chapter 91 Waterways License Application -310 CMR 9.00 Water-Dependent, Nonwater-Dependent,Amendment B. Applicant Information Proposed Project/Use Information 1. Applicant: Margaret& Michael Kerr Name E-mail Address 1017 Ridgedale Drive Mailing Address Note:Please refer Beverly Hills CA 90210 to the"Instructions" City/Town State Zip Code Telephone Number Fax Number 2. Authorized Agent(if any): Sullivan Engineering &Consulting, Inc. chuck@sullivanengin.com Name E-mail Address 711 Main Street, P.O. Box 659 Mailing Address Osterville MA 02655 Cityrrown State Zip Code 5084283344 5084289617 Telephone Number Fax Number C. Proposed Project/Use Information 1. Property Information(all information must be provided): Kerr Family Trust Owner Name(if different from applicant) 287 156 Tax Assessor's Map and Parcel Numbers Latitude Longitude 25 Maywood Avenue, Hyannis MA 02601 Street Address and City/Town State Zip Code 2. Registered Land ®Yes ❑ No 3. Name of the water body where the project site is located: Hyannis Harbor 4. Description of the water body in which the project site is located (check all that apply): Type Nature Designation ❑ Nontidal river/stream ® Natural ❑ Area of Critical Environmental Concern ® Flowed tidelands ❑ Enlarged/dammed ❑ Designated Port Area ❑ Filled tidelands ❑ Uncertain ❑ Ocean Sanctuary ❑ Great Pond ❑ Uncertain ❑ Uncertain CH91App.doc•Rev.03/17 Page 2 of 13 " s Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program x284841 Transmittal No. Chapter 91 Waterways License Application -310 CMR 9.00 Water-Dependent, Nonwater-Dependent,Amendment C. Proposed Project/Use Information (cont.) Select use(s)from Project Type Table 5. Proposed Use/Activity description on pg.2 of the "Instructions" To construct and maintain a 4'wide x 45' long timber boardwalk, 44'timber pier, 10' ramp and 16' float. 6. What is the estimated total cost of proposed work(including materials &labor)? $25,000 7. List the name&complete mailing address of each abutter(attach additional sheets, if necessary).An abutter is defined as the owner of land that shares a common boundary with the project site, as well as the owner of land that lies within 50' across a waterbody from the project. Wendy Garthwaite 318 South Beach Road, Hobe Sound, FL 33455 Name Address Joseph &Susan Fallon 124 Wellesly Road, Belmont, MA 02478 Name Address Name Address D. Project Plans 1. 1 have attached-plans for my project in accordance with the instructions contained in(check one): ® Appendix A(License plan) ❑ Appendix B (Permit plan) 2. Other State and Local Approvals/Certifications ❑ 401 Water Quality Certificate Date of Issuance ® Wetlands SE3-5655 File Number ❑ Jurisdictional Determination JD- File Number ❑ MEPA File Number ❑ EOEA Secretary Certificate Date ❑ 21 E Waste Site Cleanup _ � RTN Number CH91App.doc•Rev.03/1, Page 3 of 13 J Massachusetts Department of Environmental Protection X2t3asal Bureau of Resource Protection -Waterways Regulation Program Transmittal No. Chapter 91 Waterways License Application -310 CMR 9.00 Water-Dependent,Honwater-Dependent,Amendment E. Certification All applicants, property owners and authorized agents must sign this page.All future application correspondence may be signed by the authorized agent alone. "I hereby make application for a permit or license to authorize the activities I have described herein. Upon my signature, I agree to allow the duly authorized representatives of the Massachusetts Department of Environmental Protection and the Massachusetts Coastal Zone Management Program to enter upon the premises of the project site at reasonable times for the purpose of inspection." "I hereby certify that the information submitted in this application is true and accurate to the best of my knowledge." ) /2 ApplicarWss stature bde Property Owner's signature(If different than applicant) Ag Ys 5. nature(rf applicable) D e r CH91App.doc•Rev.03/17 Page 4 of 13 s Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program X284841 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment F. Waterways Dredging Addendum , 1` 1. Provide a description of the dredging project �I ❑ Maintenance Dredging(include last dredge date& permit no.) ❑ Improvement Dredging Purpose of Dredging 2. What is the volume(cubic yards)of material to be dredged? 3. What method will be used to dredge? ❑ Hydraulic ❑ Mechanical ❑ Other 4. Describe disposal method and provide disposal location(include separate disposal site location map) 5. Provide copy of grain size analysis. If grain size is compatible for beach nourishment purposes, the Department recommends that the dredged material be used as beach nourishment for public beaches. Note: In the event beach nourishment is proposed for private property, pursuant to 310 CMR 9.40(4)(a)1, public access easements below the existing high water mark shall be secured by applicant and submitted to the Department. CH91App.doc•Rev.03/17 Page 5 of 13 ,J nY• • e � .� � s �,., , $ �' ; �� 9. Fire '�� '�. # `� H •:.. � _� 3 "' f � Rom. � a. • 3o r 4 n i •` f E Gr Cr °� c d arbo :!alBa�• ;..� ..a c � '.• ! ,y`'. _�s a §S r � 0 � �,. '-� awff r' ,• x ••, `�' °' z ,sr *sox �> Me on �� Y •! .. ;e � ,��• � �w �., Park � �c •. _ s` r tZ,t` ya °d2Ta*�,t $4 �jr !. •'."' • 4 '• F.-aa 0 r ;at.y,Y yw 3�71E.'�'�S)y a ,� 'n`,�• � -�;: HYANNIS {, . WkK XA � x ..as• � y � 'u xR*,'A, ip�"..7*L ate, �a :.fr c - �'�. � w� 2. n� v -. i ,4' � � .�a'� - � �fi�"� ��� ��.,��.€ '*� � �� ,;'n+� �$•���;� ,� E �#'� a ....��S.fir %� `�' i �a�G�:�,T� ,. ?�,�� r�{ n v 6� +�'r 3"'ui'3 p� •r£*� �� —�'—��'�a� 1� ''•'-`„T� ,fig� ��, 'p t ., mod'.T �•.S , n �_ � y .k- .+ � C sic Woods oRoek r �yf .. ,,� n.. a s wYi.4 fAd' �P-..., �! .�.` 'a`� 'f.•y ,,,, "c k...a. � - �t 4�. 14i#sx. ,� t, rir$ �`.� '�:�a»''. '" - V s�4'�'" � y .Ff'i t��". r a x:s. � � t • �;�,� , irit If 4�r . '` sy •, c * +x ;.1:! n•u•a t r. t�T�-.�� c s r' � �7 �. ? ��:�a, '. �, a �k SCALE tsG 0�, ls; Vry( to '' ¢ f�3��,� -;�ur , C CF'�'�j�"�'`w� ' 1 r aD � apa.e "s• i7Y I -`• ,i! ft�$a. � r Ck 200b0 (`SF M� siS �`�' '�'�S.r �. ,e•'��'+s. ,'�^#�' #,y'.. � 3�0'',;�s � �#`�'A ,,.rk'&i.;_ r- y`'� a x �y Y,.Yx ' F4fa^e,�rr:i'rT'$�xy�;i �' ,y*i -zi a,sr a 'q -�`r'' I b T•.,".y !`. ii " yM'_' a � ``'. `°�G NIT DIRECTIONS. T- � DIRECTIONS: FROM HYANNIS - FOLLOW MAIN STREET TO THE SHEET 1 OF 4 WEST END ROTARY,• TAKE THIRD EXIT ONTO SCUDDER AVE. TURN MARGARET & MICHAEL KERR TRUSTEES LEFT ONTO MARSTON AVENUE AND RIGHT ONTO HYANNIS AVENUE. KERB FAMILY TRUST TURN RIGHT ONTO MAYWOOD AVENUE. #25 IS ON THE RIGHT. TO CONSTRUCT & MAINTAIN A TIMBER BOARDWALK, PIER, RAMP AND FLOAT BY ASSESSORS: MAP 287 PARCEL 156 IN HYANNIS PORT, MA DECEMBER 17, 2019 LATITUDE: 41'38'3" SULLIVAN ENGINEERING LONGITUDE: 70'17'52" & CONSULTING INC. UTM: 391919E 4610806N OSTERVILLE, MA i MA o � AVEjV(/E , � REFERENCES: DEED C215534 PLAN LCP 14065—C LOT 4 7 W cg/ a F i #25 2 DWELLING F o° GPR i i � N G -50 SS��Epo' �R0P0 R - 305E P�pR R 5( Z i i X (MIN FLOOD HAZ.) 8- i 5� FEMA ZONE ° gP� i` VE ELEV--14- of , �r I� �, � i R �E � PROPOSED 4' P SN OF ASS OW p u CI 1 x-1.7 No. 269 '^ x 1.7 0 4i x 0:4 or STERN- � - FSS/ONA x x 0.7 x-1 9 OVERALL PLAN VIEW x-2 SCALE: 1 ' = 50 x-1.7 50 0 25 50 100 x-2.8 -2.8 PROPOSED SHEET 2 OF 4 BOARDWALK, PIER, MARGARET & MICHAEL KERR TRUSTEES RAMP & FLOAT x-2.8 KERR FAMILY TRUST x—2.8 TO CONSTRUCT & MAINTAIN A TIMBER BOARDWALK, PIER, RAMP AND FLOAT IN HYANNIS PORT, MA DECEMBER 17, 2019 SULLIVAN ENGINEERING & CONSULTING INC. OSTERVILLE, MA n F� x 4 00 v x-1. x 0.4� x .g <o �S x-1.8 W 31' <� a x-1.9 moo �p W x 0.7 o G x-1.7 v2 0 • ,o 'o. 41 �L.. `'P 0 \9 R o s N OF q E T. cy G c„ Z for FGIS x-2.8 o ASS/ONAI N O HYANNIS HARBOR x-2.8 SHEET 3 OF 4 PLAN VIEW MARGARET & MICHAEL KERR TRUSTEES SCALE: 1" = 20' KERR FAMILY TRUST TO CONSTRUCT & MAINTAIN A TIMBER 20 0 10 20 40 BOARDWALK, PIER, RAMP AND FLOAT IN HYANNIS PORT, MA DECEMBER 17, 2019 SULLIVAN ENGINEERING & CONSULTING INC. OSTERVILLE, MA 115' LENGTH OVERALL ' 45' 70' COASTAL BEACH LAND UNDER OCEAN 45' 44' 10' 16' PROPOSED BOARDWALK PROPOSED PROPOSED PROPOSED FLOAT PIER RAMP T=l F L-- MHW EL. 2.8 MLW EL. 0.0 LATERAL ACCESS FLOAT STOPS REQUIRED STAIRS TO PROVIDE 18" SEPARATION PIER PROFILE 10-10" 0 FLOAT PILE "OF qSs. SCALE: 1» = 10' (TYP.) 4 REQUIRED 4�+ LES T. ti 10 0 5 10 20 o w Nn IL 4'-0" 9 � y Rz _ _ EL. 9 �a,�f"hol ERE 00 � CCA-TREATED PILING AND STRUCTURAL TIMBER 2" X 4.. SS,ONALEN��� C) C) (GREATER THAN THREE [3] INCHES THICK) ARE HANDRAIL O ), ALLOWED. OTHERWISE, NO CCA-TREATED OR _p z 5 CREOSOTE-TREATED MATERAILS SHALL BE USED. Cpz�-{>�- 6 3" X 8" FOR O [n= Crn ot ALL STRUCTURAL mO 2314 6 MIN. SPACINING G DRYYP.), MEMBERS mZ z- ,l-m co Rl n M �'1Z�7�n2—i y Z N WATER AND ELECTRIC TYP. PIER SECTION M.H.W. 2.8 r�l Z Z v 0�z'< 0 CROSS BRACING �l y �l SCALE: 1" = 4' FOR PIER ONLY Ti 4 0 2 4 8 M.L.W._.�:. ....... �l� C 10-12" p� y PILE (TYP.) rr FOR PIER J Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program x284841 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment G. Municipal Zoning Certificate Margaret& Michael Kerr, Kerr Family Trust Name of Applicant 25 Maywood Avenue Hyannis Harbor Hyannis Project street address Waterway Cityrrown Description of use or change in use: To construct and maintain a 4'wide x 45' long timber boardwalk, 44'timber pier, 10'ramp and 16' float. To be completed by municipal clerk or appropriate municipal official: "I hereby certify that the project described above and more fully detailed in the applicant's waterways license application and plans is not in violation of local zoning ordinances and bylaws.", ��� Printed Name of Municipal Official Date.' signature of Mu icip Official Title City/Town CH91App.doc•Rev.03/17 Page 6 of 13 . M Town of Barnstable Building FWe (TisCacd So That it is'Uisible From the Street& A` lroved,P,lans"Must beReta�ned>on Job and this;Card Must be Ke t ABIJ:. r` �6s � :^ y a.. y `?_ ,'pf'% 'a `� k# ` .tr<-af r8 .'� i >' $ y _{L -4.1. P u •3NAM6 9. ed Until Final I spection Has Been Made x� y;# �Kr ceka CertificateofOccupancyas Required,sucfi Buldi ng shall Not be Occupedauntd a Ftnal InspeciorrFhas been made Permit NO. B-18-728 Applicant Name: Gene A Cormier Approvals Date Issued: 04/04/2018 Current Use: Structure Permit Type: Building-Smoke Detector-Fire Alarm Dection Expiration Date: 10/04/2018 Foundation: System Map/Lot 287 156 Zoning District: RF-1 Sheathing: Location: 25 MAYWOOD AVENUE, HYANNIS Contractor Narne 4..Gene A Cormier Framing: 1 41 Owner on Record: GRAFF, KATHLEEN ANTHONY HORNE,TRS ET Contractor'.License 1592 t a 2 Address: 2905 NSTREET, NW. �. 7 �A" Est Project Cost: $0.00 Chimney: WASHINGTON, DC 20007 3 Pdrmit3,ee: $35.00 Description: Install wireless fire alarm devices-smokes, heatsiand CO Insulation: k Fee Paid:1 $35.00 3; Project Review Req: Date 4/4/2018 Final: s Plumbing/Gas 1 Rough Plumbing: g g ;- k Building Official Final Plumbing`. .This permit shall be deemed abandoned and invalid unless the work authori ear 1'his permit is commenced withinsix months after issuance. All work authorized by this permit shall conform to the approved application-and theapproved construction documents"for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoriirgbla codes. Final Gas: � z This permit shall be displayed in a location clearly visible from access stret�or toad nd shall be maintained open for public,inspection for the entire duration of the work until the completion of the same. Electrical The Certificate of occupancy will not be issued until all applicable signatures by,the Building andFire Offic Is are pro�u�ed on this,permit. Minimum of Five Call Inspections Required for All Construction Work: Service: a�' 1.Foundation or Footing g 2.Sheathing Inspection �; • Rou h: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT U Appi_icadon Pjumber.... Permit Fee........ ...:.........................Ot11er t-ee........................ 1639. •� Pam. �-, _ ®� _ N� To Paid..............................................................I...... TOWN Off+" ]�.�I�I�TS'1I�" ,� ��ZOB I uu/y s AAA Permit Approval by... On....d...... .... B❑LDING PERMIT "Vs. P -if r C r TO tiT Map.......... . .....................Parerl................................................ sL s cod- El�yilueyrs Ilritfor-1- a.-filoE el idl IN-r°oject Locaflovio �t taco Project Address t five Village dq Ya mit Sjporg, Owners Name LM-i V-le �e e(-r Owners Legal Address City geVe -Y State Ci9 Zip Owners Cell E-mail Section Z —Structural Use Single/Two Family Dwelling ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet Section 3 —Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty Fire Alarm Rebuild ❑ Deck Apartment - Sprinkler System ❑ Addition ❑ Retaining wall ❑ Solar ❑ Renovation ❑ Pool ❑ Insulation Qther-Specify Section 4—Detail • ab Cost of Proposed Construction 000 o Square Footage of Project r Age of Structure Dig Safe Number # Of Bedrooms Existing Total# Of Bedrooms (proposed) 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Last updated:11/7/2017 I - i -- i J 1 Q- w;feLes C,re o.lar ra C® i I I r Section C Fn oPect Speeffncs , ❑ Wiring ❑ Oil Tank Storage ( Smoke Detectors ❑ Plumbing ❑ Gas E] Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑Add/relocate bedroom Water Supply ❑ Public ❑ Private Sewage Disposal ❑ Municipal ❑ On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: I am using a crane ❑ Yes ❑ No Section 7—Flood Zone ' Flood Zone Designation Within or adjacent to a wetland, coastal bank? Yes ❑ No ❑ Section 8 m Zoning Information Zoning District Proposed Use Lot Area Sq. Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard. Required Proposed Rear Yard Required Proposed Side Yard Required Proposed I-ias this property had relief from the Zoning Board in the past? ❑ Yes ❑ No Last updated: 11/7/2017 e 'kis Name C5ev1e Cnrm'Ner Telephone Number 50o �QS - GD)G Address -RUY %rYr0LA;T'W State,k/1 zip 0 License Number LicenspType6 ern e�qim-r WirationDff'Le F. Contactors Email 2 F V e aczaj oeco GL'r M,(OAcelIb J understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code, I understand the construction'inspection procedures,specific inspections and documentation requirDdaby 780 CMR d the Town of Barnstable,Attach a copy of your license, 'V1" Signature Date Section 10 —Home Improvement Contractor Name Telephone Number Address city State zip Registration Number Expiration Date I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code.. I understand the,construction inspection procedures,specific inspections and documentation required by 780 CMR and the To-,Am ofBarnstable,Attach a copy of your H.I.C... Signature Date Section 11 —Home Owners License Exemption- Home 0-wmers Name: e e Telephone Number Cell or Work Number I understand my responsibilities under the rules and regulations f4rr Licensed Construction Supervisor in accordance with 780 CYa the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the,Town of Barnstable. Signature Date "PLICANT SIGNATURE Signature Date Print Name Telephone Number E-mail peimit to: Last updated: 11/7/2017 i _ A d, T-YeaEth epartmexr. 10 Zoning board (ifrequirecl) Q Historic District . .F—I Site Plan Review(if required) Fire Department ® Conservation r-IOr corEarnercial TPoFk,,p ease jsake yom-plans directly to t%e faxe dep&, wag p�€�r qppp aml Owner's Authmlzab�rr� as Owner of the subject-property hereby authorize to act on my behalf, in all matters relative to-work authorized by this building permit application for; (Address of job) Signature of Owner date Print Name 1 I Last updated; 11/7/2017 r� 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 Please Print Legibly Name (Business/Organization/Individual): CAPE COD ALARM CO., INC. Address: 204 OLD TOWNHOUSE ROAD City/State/Zip:WEST YARMOUTH, MA 02673 phone #: (508) 398-6316 Are you an employer? Check the appropriate box: Type of project(required): 1. ✓D I am a employer with 30 4. ❑ I am a general contractor and I 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 shipand have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' insurance.* 9. ❑ Building addition comp.[No workers' comp. insurance P• required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I 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' 13.0 Other t Vl S AeL ,G W; ae comp. insurance required.] ire aLacyr) w) V *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Associated Employers Ins., Co. Policy# or Self-ins. Lic. #: WCC-500-5006433-2017A Expiration Date: September 1, 2018 Act Wood 11 Job Site Address: ) ��'d� City/State/Zip: OLV`Y1: 01)P� 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 certify under th ppaains�ndpenalties of perjury that the information provided above is true and correct Signalure: Q Date: Phone#: —c�6 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#: Q '.EOMiiAOfViNEALTH OF MAAGHIJSE�S Commonwealth of Massachusetts e ® Department of Public Safety. BOARQ License: SSCO-000248 ELECTRfCIANS.:::...;: <:ISSUES THE:;FOLLOWING LICENSE AS A .,[ .; .< Security Systems -S-License RE'G[STI=RED SYSTEM, TRACTOR_ IQ GENE CORMIER ~ ;GENE A CORMIER `' >``''' i� Employer: 3;CAFE COR.,ALARM`CO INC ?# :>:> CAPE COD ALARM"=` 204 OLEYTQ:INWHOJUSE RQ. Iw . .WEST,YARMOUTH, M* : :U2673-1531;;;,..,. l. o .ra dn'Ex Pi 9592 a7/31/2019:: :.:,<: 123442 Commissioner 11/07/2018 ti e 0 D� ..... ... ......... ®nnl1�®N] f AI,T'FI ®F-MASS.AGwuSETfS> a ELECTRCIANS::;::..:<.> ::;'`> "' # IrfCENS ISSUES..TRE FOLLOWING ;:REGISTERED SYSTEM TECHNICIAN r GENE A CORMIER z c� SOUTH.pENMtS, MA ,Q2f 60'r26&7 w 21 0.7 1507 2805 i Cape Cod Alarm Co. Inc. Systems Contractor License#1592C All employees bonded and insured tA 204 Old Townhouse Road ' Protection System West Yarmouth, MA 02673 PI'OpOSdI W W W.Capecodalarm.com Telephone: 1(800)468-8300 Fax: 1(508)398-5666 M�S�CA' �B��`t� no �.::� Email:info@capecodalatm.com gg Client Information —T— WFFW MIKE KERR MtkISP MAYWOOD AVENUE (25 NEWTON AVE) Proposal Number 10123 HYANNISPORT MA 02647 Date 3/1/2018 Phone 1(508)778-2219 EXt, Account Rep. C036 Joshua Ledger Email SOCCERKERR(a)AOL.COM PROTECTIVE SIGNALING SYSTEM MONITORING AGREEMENT THIS AGREEMENT made and entered into this day of acceptance of this proposal by and between CAPE COD ALARM CO.INC.hereinafter called the"Company",and CUSTOMER hereinafter called the"Subscriber". 1.Company agrees to provide or cause to be provided at the address above indicated the service and/or connection specified in Paragraph 4 hereof below. 2.Subscriber agrees to pay Company,its successors and assigns,for ongoing monitoring the annual charge as stated on this proposal and payable by customer as also stated on this proposal,in advance commencing the first day of the month following the date of installation completion and/or connection payable throughout the term of this Agreement. 3.Telephone line installation charges and monthly charges for the leased lines used in connection with services rendered under this Agreement shall be paid directly to the Telephone Company by the Subscriber. 4.The schedule of monitoring is as follows:PROTECTIVE SIGNALING SYSTEM MONITORING. 4a.If Cape Cod Alarm shall be required to place any sums outstanding in the hands of another for collection,I agree to pay all cost of collection,including,but not limited to attorneys fees(not to exceed 33 1/3%)and court costs. FINANCE CHARGES: I have the right to pay the sums due within the credit term granted without incurring a finance charge.If I do not pay within said terms,I agree to pay,in addition to the sums due,a finance charge of one and one half percent per month(which is an annual percentage rate of 18%)on the next monthly balance: 5.If any agency or bureau having jurisdiction,or Subscriber by his own act requests to make any changes in the system as originally proposed,Subscriber agrees to pay for the cost of such changes.The Subscriber also agrees to pay any City,State or Federal taxes,fees or charges now in force or hereafter imposed,applying to this installation and service. 6.The initial term of this Agreement is THREE YEARS from the date each system is installed or connected and becomes operative and thereafter for consecutive terms of one(1)year until such time as either party upon thirty(30)days written notice,advises the other party of its intent to terminate the Agreement at the end of the then current term.It is further agreed that after one(1)year from the date of this Agreement,the Company may periodically adjust the service charge.Within thirty(30)days of receipt of notice of such adjustment, the Subscriber may terminate this Agreement by thirty(30)days written notice to the Company,provided Subscriber is not in default of any terms or conditions in the Agreement 7.It is understood and agreed by the parties.that Company is not an insurer and that insurance,if any,covering personal injury and property loss or damage on Subscriber's premises shall be obtained by the Subscriber;that the Company is being paid for the connecting and/or monitoring of a system designed to reduce certain risk of loss and that the amounts being charged by the Company are not sufficient to guarantee that no loss will occur;that the Company is not assuming responsibility for any losses which may occur even if due to Company's negligent performance or failure to perform any obligation under this Agreement. THE COMPANY DOES NOT MAKE ANY REPRESENTATION OR WARRANTY,INCLUDING ANY IMPLIED WARRANTY OF MERCHANTABILITY OR FITNESS,THAT THE SYSTEM OR SERVICE SUPPLIED MAY NOT BE COMPROMISED,OR THAT THE SYSTEM OR SERVICES WILL IN ALL CASES PROVIDE THE PROTECTION FOR WHICH I-T Is INTENDED. Since it is impractical and extremely difficult to fix actual damages,if any,which may arise due to the faulty operation of the system or failure of services provided,if,notwithstanding the above provisions,there should arise any liability on the part of the Company,such liability shall be limited to an amount equal to one half the annual service charge provided herein or$250 whichever is greater.This sum shall be complete and exclusive and shall be paid and received as liquidated damages and not as a penalty.In the event that the Subscriber wishes to increase the maximum amount of such liquidated damages.Subscriber may,as a matter or right,obtain from Company a higher limit by paying an additional amount proportioned to the increase in liquidated damages. Subscriber agrees to and shall indemnify and save harmless the Company,its employees and agents,for and against all third party claims,lawsuits and losses alleged to be caused by Company's performance,negligent performance or failure to perform its obligations under this Agreement. 8.Subscriber hereby authorizes the Company to make installation and/or connection at Company's convenience.If Subscriber desires installation or connection to be done at a time other than normal working hours or on weekends,added cost will be paid for by the Subscriber at Company's standard rates.Any installation or connection charge quoted in this Agreement is based upon Company performing the installation or connection with it's own personnel.If,for any reason this installation or connection or any part thereof must be performed by outside contractors,said installation or connection is subject to revision. 9.This agreement does not cover repairs due to abuse,misuse,construction/renovations/upgrades,and/or acts of nature. 10.It is understood and agreed by the parries that this Agreement constitutes the entire Agreement between the parties,and there is no verbal understanding changing or modifying any of the terms of this Agreement.This contract may not be changed,modified or varied except by writing and signed by an authorized representative of the Company.This Agreement shall not become binding on the Company until approved by Company's Management as provided below.SUBSCRIBER HEREBY ACKNOWLEDGES THAT HE HAS READ AND UNDERSTANDS THIS ENTIRE AGREEMENT.IF THIS IS A HOME SOLICITATION SALE,YOU,THE BUYER,MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER DATE OF THIS TRANSACTION. CCA recommends wireless monitoring.If you use telephone lines then we recommend using a standard P.O.T.S.telephone line(Plain Old Telephone Service)far all Digital Monitoring. If you have Cable/V.O.I.P phone service,or DSL please contact your Account Manager. ***Permits Are Extra We Propose:hereby to furnish this Protection System including material and labor-complete in accordance with above specifications,for the Total Amount Shown.All material Is guaranteed to be as specified. All work to be completed during normal business hours In a workmanlike manner according to standard practices.Any alteration or deviation from the above specifications involving extra costs will be done only 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 other necessary Insurance.All parts&labor guaranteed for one year. Additional Terms: ' 36 month monitoring contract required unless othwise noted.If system Is not monitored add$200.00 to Installation amount.We recommend a daily test$4.00 per month.Any 110VAC work is not part of this proposal.You will need to contract a licensed elctrician for any 110VAC work. ***Carbon Monoxide detectors are required by law to be replaced every FIVE(5)years.(CONTACT US)*** Deposit Required: 1/2 Down&Balance Due On Day Of Installation. A late fee of$5.00 or 1.5%per month,whichever is greater, will be charged. All major credit cards accepted. ***PLEASE SIGN OR INITIAL x Proposal 10123 www.Cape6o A arm,com 2 �© Cf�R H [IFE�JA @ E OF LLL-�l1 B UT, Lr [INSC-1iRAL,KECE DATE(MM/DD/YYYY) THIS CERTIFICATE IS I17 SSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS, UPON THE CERTIFICATE3 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 17 this certificate does not confer rights to the Certificate holder in lieu of such endorsements. PRODUCER CONTACT Rogers&Gray Ins.-Dennis Branch NAME' 434 Rte 134 PHONE .508-398-7980 FAX a.877-816-2156 South Dennis MA 02660 E-MAIL mail@rogersgray.com INSURERS AFFORDING COVERAGE NAIC# INSURERA:Allied World Surplus Lines Insurance Com an 24319 INSURED CAPECOD-54 INSURERB:Arbella IndemnityInsurance Com an , Inc. 10017 Cape Cod Alarm Co., Inc. INSURER c:Associated Employers Insurance Com an 11104 204 Old Townhouse Road West Yarmouth MA 02673 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1330374015 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 A L POL LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF ICY EXPMMIDDlYYYY MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y 5200178001 9/1/2017 9/1/2018 EACH OCCURRENCE $1,000,000 CLAIMS-MADE F_x1 OCCUR DAMAGE TO RENTED - PREMISES Eaoccunence $100,000 MED EXP(Any one person) $10,000 PERSONAL&ADVINJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $5,000,000 POLICY[_X]PRO- LOC PRODUCTS-COMPlOPAGG .$5,000,D00 OTHER: g AUTOMOBILE $LIABILITY Y Y 1020005044 9/1/2017 9/1/2018 C MBINED IN LE LIMIT ANY AUTO Ea accident $1,000,000 OWNED X SCHEDULED BODILY INJURY(Per person) $ AUTOS ONLY AUTOS HIRED NON-0WNED BODILY INJURY(Per accident) $ X AUTOS ONLY X AUTOS ONLY PROPERTY DAMAGE Per accident $ $ A UMBRELLA LIAB X OCCUR Y Y 5201058601 9/1/2017 9/1/2018 EACH OCCURRENCE $3,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $3, DED X RETENTION$0 000,000 C WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY N WCC50050064332017A 9/1/2017 - 9/1/2018 X SPER TATUTE ORH Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? ❑N N/A(Mandatory in NH) E.L.EACH ACCIDENT $1,000,000 If yes,describe under E.L.DISEASE-EA EMPLOYE $1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000.000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Certificate holder is provided additional insured status for ongoing and Completed operations, primary/non-contributory including waiver of subrogation with respect to general liability when required in a written contract or agreement. Certificate holder is provided additional insured status with respect to auto liability when required in a written contract or agreement. i i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES.BE CANCELLED BEFORE 200 Main Street of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 00 ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis MA 02601 AUTH RgED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ���CTRCALCLOSEI'_... BATHROOM '�.Up - O DOWN O TA KITCHEN \ TA D O GARAGE ST BEDROOM IV BED O O co UNFI SHED 3: LIVIN ROO 0 DINING.ROOM O BEDROOM O LIBRARY C CAPE . • , ALARM • • 1 • • 300 FIRST FLOOR BASEMENT LEGEND: 25 id€'bfl 995N AVENUE BACP BUGR &FIRE ALARM CONTROL PANEL HYANNISPORT, MA 02647 INDOOR SIREN HEAT DETECTOR SMOKE DETECTORS REVIEWED <: ' SMOKE DETECTOR "Old Townhouse Road co CARBON MONOXIDE D DATE ` .WestYa"0iith`NfA02671 AR A I DEPT. DOOR CONTACT = CA:PE COD ALARM Tel (80U) 468=8300.. WATER DETECTOR FIRE DEPARTMENT DATE O LOW TEMPERATURE D 7 MT..O'RTURES ARE REQUIRED FOR PERMITTING IOSh LCdgOC (508)39,8=63i6 TA Account Representative Fax (508)398 5666 jledger@capecodalarm;com WWW CapeGOClalaI111 COIN` Commonwealth of Massachusetts Sheet fetal Permit M1apZ2a Parcel '*R 11 Date: -2� Permit AUG 2 9 2014 Estimated Job Cost: $ Permit Fee: A Plans Submitted: YES y I� ®F�A�� � Reviewed: �'I�S N® S --- Business License 0�\. Applicant License i#'-_L-A Business Inforrnation; Property Owner/Job Location Information: Name:( \\ �� . 'Name:����PQ ewl�v Street: m zQO�— �(L City/Town; City/Town: �A\Ar'x\rN\j—> :'elephone: Sl�' �o"� Telephone. 5 j) Photo I.D. required,%Copy of Photo I.D. attached: YES NO Staff initial .il-.l /M-l-unrestricted license J-2/M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. /2-stories or less Residential: I-2. family Multi-family Condo/` 'ownliouses Other Commercial: Office Retail Industrial Educational Fire Dept. Approval Institutional Other Square Footage:,under 10,000 sq. ft. over.10,000 sq. ft. Number of Stories: Sheet metal work be completed: New Work-: ' Renovation: 14VAC Metal Watershed Roofing: Kitchen Exhaust System Metal Chimney/Vents Air Balancing Prov' detailed description of work.to be done: Alf w _ INSURANCE COVERAGE: -- - I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes y'No ❑ If you have checked YS indicate the type of coverage by checking the appropriate box below: A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application&&y3&this requirement. Check One Only. Owner ❑ Agent ❑ i Signature of Owner or Owner's Agent s By checking this bo ,1 hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Progress W51jections Date Comments Final ins ection i Date Cornunents Type of License: 3y Master ritfe k� ❑ Master-Restricted amity/Town Fliourneyperson Signature of Licensee 'errnit# ❑Jourrteyperson-Restricted License Number: gee ❑ Check at nspector Signature of Permit Approval The Coarxmoymea of Massrtchas - - Office Of Amlestiga ians Boston,.MA0-7111 f rmf ii nass.gr,*iMia workers' Compensation Insurance Affidavit:Builders/CentractorsMectriciansfNumhers ApAk-ant Infaxrmation / Please Print 1&6bly Name(Busine�- OrganimtionlJndividnal): Adriress G WStatzfZip: & Phone Are you au employer?'Check the appropriate bow: T , 4-_ ❑ I atrt a ctmfractor and I 3'l�of P4 ofect(r��'�- 1.&am a employer with ti_ n New won employees{full and/or part-#*me}* havehireithe sub-00ntra-CtDrS. listed on the attached sheet y- � o 2_El am a sore propr%etar or partner- These bvh-contractors have ship and have no employees These ❑Demolition working for mein any capacity_ employees and have workers' $_ ❑Building addition [Nonworkers' conlp_.iasur=.e cornp_mcnranml 5_❑ [ire are a corporation 1 on and its tI_�]Electrical repairs or additions refit ] officers nm exercised fheff 1 _ umn �_❑ I am a a h h omeowner doing all work. h 1 ❑Plbi g repairs or additions mil€ [No wcrS m'comp_ right of exemption per MGL 12 0 hoof repairs in�xs,nre required_]F c_1.52, §1(4},and we have no employees_[No workers' 13_0 Other comp_msarante,required]; *11uy apptf�t that checks box r1 nmst also fill out the section below shooing 4heir wmicers�co�ensatioaE goli�iufnrsnairras Enmeowners who submit this affidavit i„dmItmg they are rinuig an vrwk and then hag outside cou actors mast smbmitanL-waffjd3v-JtintF1ntm sudi =C antmcturs that check this bmc must sttad d as additional sheet sbowiag the name a ilte sub-cantx1ais and state vrhether Ornot ihose mitt ies have aW iayees- If the soli-contaacfars hace emiployeeas,they must pmvAe their works'coma policy number. lam art smpi'ayer that,is prmi&kg rt orkerm'cony Lvatio.n inrrtnrnce for my ewp&yem Belau is thePQVC artd,job ante Insur-ance ConapmyName: Pbltcy N or Self'.-tom Lim; ExpixatloaDate: Job Site Address: Ctfy,'Statel : Attach a cop} of the workers'compensation policy] declaration page(showing the polite number and expiration date). Failure to secare co-mrage as requiredunder Section 25A of MGL c,152 can lead to the imposititm of criminal penalties of a fine up to$1,50D_6(}and/or one-yearimp s t,as well as cavil penalties in fhe form of a STOP WORK ORDER-and a fine of up.to S250-00 a day against the violator_ Be advised that a copy of this statement maybe forwarded to the Office of ImTe*ptions of the DIA fpr irvtrance,coverage verification I da hereby cerli t thy paps and a vfpedaly that the in orrrurtion proli&z i^bone is and correct Silrnatune: Bate_ [U oG Phone#: Offrciol use alily. D1 v n:ot write to this area,to ba cawpleted by ciV ar town q ieraL Cite or Town: . PerriritUcense# Issuing AKithoritlt(circle one): 1.$oaf of Health 2.Building Department 3�Citylrown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone 9- 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto this statute,an errrployee is defined as"...every person in the service of another-under any contract of hire; express or implied, oral or written_" An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer;or the receiver or trustee of an individual;partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the - dweIling 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 withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perfo_imance of public work until acceptable evidence of compliance,with the insurancerequirements 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 numbers)along with their ceri:ficate(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_ De advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affid2vit 11e affidavit should be returned to the city or town that thtapplication 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-insi=ce license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to.fill out in the event the Office of Investigations has to contact.you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple pernitllimase 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 oa file for f ftLze permits or licenses. A new affidavit must be idled ouft each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (Le.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 and questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: ti Tb(-1CommnnwffaIth of Massachusetts Depaztment cif Industrial AoGidents a ofkve'stzgatxaas 640 Washi astern Se BastQn=IAA 02111 Tel.A 617,727-49-00 ext 406 or 1-9 MASW. E Revised 4-24-07 Fax#617-`27-7749 . w_nras�gav/dia Ai'lawco o® CERTIFICATE OF LIABILITY INSURANCE ' ATEP05/0612014�' 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). IRODUCER. CON CT Erica H O'Connor.. HART INSURANCE AGENCY,INC. NAME` 243 MAIN STREET PHONE 508-759-7326 x205 ,x FAXc No508-759-7633 PO BOX 700 ADDRESS: BUZZARDS BAY,MA 025320700 INSURERS AFFORDING COVERAGE NAIC p INSURER A: ARBELLA PROTECTION INS CO 41350 NSURED Carl F Riedel[&Son Inc INsuRERa: ARBELLA INDEMNITY INSURANCE COMPANY 10017 778 Main St OStervllle,MA 02655, INSURER C 7 t INSURER D: '. INSURER E:r INSURER F: _ OVERAGES 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.D000MENT 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, XP VSR TYPE OF INSURANCE - ADDL SUER _ pOLICI,NUMBER POLICY EFF MDDtY LIMITS _TR A GENERAL LIABILITY 8500033836 05/01/2014 05/01/2015 1,000,00 EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY DAMAGE ES Es occurrence) $ 300,00 CLAIMS-MADE OCCUR MED EXP(An one person) $ 5,00 PERSONAL&ADV INJURY $'. 1,000,00 "- GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S 2,000,000 POLICY PRO- LOC $ A AUTOMOBILE LIABILITY 1020018223 05/01/2014 05/01/2015; COMBINEDSINGLELIMIT 1,000,00 - Ea ecadenl ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED ' AUTOS AUTOS BODILY INJURY(Per accident) 3 NON-OWNED• PROPERTY DAMAGE $ HIREDAUTOS AUTOS Perac'den $ A UMBRELLA LIAB OCCUR 4600033837 05/01/2014, 05/01/2015 EACH OCCURRENCE $: 1,000,00 EXCESS LiAB HCLAIMS-MADE AGGREGATE $ DIED RETENTION$ 10,000 _ $ _ .B WORKERS COMPENSATION Q054000514 05/01/2014 05/01/2015 WCSTATU; OTH AND EMPLOYERS'LIABILITY (Mandatory NH)EXCLUDED? YIN E.L.DI EACH ACCIDENT $ 500,00 ANY PROPRIETOR/PARTNER/EXECUTIVE N N I A E.L.EA DISEASE-EA EMPLOYEE $ 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I.LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,B more space is required) - • - CERTIFICATE HOLDER CANCELLATION PROOF OF INSURANCE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE: EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. " AUTHORIZED REPRESENTATIVE" 41 *4/��14 - I ©.1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo.are registered marks of ACORD COMMONWEALTH OF MASSACHUSETTS BRAR;D OF SHEET :A tAL WORK:E SSUE T:H 5....>:..::. E FOLLOW NG> L`f CENSE.::< AS !A MASTER U;NR�:STR I CTED cc GARL .A RI 'DELL CARL F RI EDELL AN:D. Sbl`IS W 778;> ki N ST OSTERVILLE : MA 02655-2011 41 09/28/15 92897 r \ 1 �p RfEDEL�•�.� .. pro) I _ 0' L E I SH , THREE GENERATIONS STRONG PLUMBING•HEATING•AIR CONDITIONING ; DATE: PHONE: j PROPOSED BY: 778 Main Street ! 7/2/14 508-775-1383 j Dick Mohre OSrERVILLE,MA 02655 i (508)428-6365 FAX(508)420-0180 WWW.CARLRIEDELL.COM T� Kathl-een Graff I JOB NAME/LOCATION: I i 4 Ton attic AC system: 2905 N Street North West 25 Maywood Ave Washington, DC 20007 Hyannisport, MA 02647 f l _........_........__............................................................................_.:........_......_........_..:................._........................_:............................._.:..........:.........................._........:...................................._........_..._...................................... Riedell will install an "American Standard" 4 ton attic instaiied ajc system that v�iil provide total coelirg cemfcrt in year i home. An "American Standard" 4 ton air handler along with insulated duct work will be installed in attic area supplying 3 a/c to living area via ceiling diffusers. Riedell will install a 4 ton 13 seer"American Standard" condenser outside of home on a supplied precast pad. Refrigerant lines will be piped from air handler to condenser to complete system. Riedell will conceal exposed refrigerant lines with attractive slim duct cover. System will be wired by Riedell. Riedell will charge, start, and test system for proper operation. System Components American Standard -Condenser 4 ton attic installed -Air handler split AC system -Line set #4A7A3048 condenser -Pad #TAM7AOC48H air handler -Aux pan 13 seer -Drain R-410A refrigerant -Insulated duct cover -Slim duct cover -Wiring *10 year-warranty on compressor and parts after equipment is registered within 60 days of installation.* *Homeowner responsible for any electrical upgrades if needed. *If new sub panel is needed, add $400.00 ._... ._............. ..__ m:...�_._ _...._.....__..._.._....._._. We propose hereby to furnish material and labor—complete in accordance with the above specification,for the sum of: ................................................................................................._....._..., $13,995.00 ..._....................................................._........................................................................................................_......................_........ . . Payment to be made as follows: A deposit of$6,997.50 with signed proposal is requested. Payments due as work progresses and balance due upon completion. ..................................................:.............................:.......................................................................................................................................................................................................... Authorized Riedell Signature All material is guaranteed to be as specified. All work to be completed in .a professional manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders and will become an extra charge over and above the estimate. All agreements.contingent upon Acceptance of Proposal — the above prices, specifications are accepted. You are authorized to do n rol. Owner to car satisfactory and are hereby strikes, accidents or delays beyond our cot N satlsfd ry P adequate home and fire insurance. Our company and our workers are the work as specified. Payment will be made as outlined above. fully covered by Worker's Compensation and Liability Insurance. Signature r Note: This proposal may be withdrawn by us if not accepted within 30 days. Signature WebbConnect - Online Ordering System for customers of F. W. Webb Company Page 1 of 1 JT'�jY��r �.3 `( ,q(x !' Welcome Cart A Rledell 0Items I Cart Checkout LOGOUT . WORIKOHNUT Search by Keyword or Part Number HOME MY ACCOUNT TOOLS RESOURCES MY CARTS HELP Product Manufacturers Heat Loss/Gain Calculator Product Categories 4�} " The heat loss/gain Calculation uses the IBR method to determine the heating needs for a home.It estimates: Chemicals&Solder 'bbt 't The maximum heat loss in BTUihr for a coldest day(helpful for furnace sizing) The total yearly heat loss in millions of BTU Controls h The total yearly cost for fuel Electrical Fire Protection HEAT LOSS/GAIN HOME PRINT THESE RESULTS Fittings Gas Products Building Input Calculation Results HV.AC Name Graff residence -Building Healing Equipment Location 25 Maywood Ave Hyannisport Gain BTU 46473 Summer design temp.91 Healing Parrs loss BTU 59863 Winter design temp. -10 - Gain CMF 1549 /� t Hoses Room temp. 71 1 Indoor Air Quality Leeway as% 10 Loss CFM 131 Measurement&Instrumentation Number of people 5@400 BaseBoardT104 ,Motors&Circulators Ground temp. 50 Tonnage�3.9 Pipe&Tube Cooling air 50 Piping Specialties Warming air 120 - Calculation Results. Room Plumbing CHANGE INFORMATION Label Zone Gain BTU Gain CFM Loss BTU Loss CFM Base Board Pumps first floor living area 44473 .1482 59863 1131 104 Refrigeration Room input ' Safely Label Ext Wall height floor sq.ft. first floor living area 190 8 .1873 Sanitary Steam Specialties ADD A NEW ROOM Test Equipment&Gauges - Tools Valves - Venting Products Water Systems - My Account - Tools Resources My Carts Help Edit Account Heal LossfGain Calculator Online Catalogs Curren[Cart Using WebbConnect S-ed Carl, Product Cross Reference Line Cards Saved Cans FAO J - Peuding O"lers Product Specification New Cad Product Codes (lydmsfeids. 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Webb Wnler Systems ` Copyright 1999-2013,F.W.Webb Company•All Rights Reserved.I Terms of Access I Warranty I Privacy Policy - Kit]Q s / http://webbconnect4.fwwebb.com/bin/fwk?wc4.hc.next 8/28/2014 i gR,qFf --------- 4, 46 e r ' BOOM yTy r�T�C 141.5; r lfffiN HU r r lit LAIVOW g R ` - IWASTER 5 g 4 ,� Nv�t �T hE� iTri� B�tT/f Tf{ Ac�� R-y16A 1,