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Home My WebLink About0014 OCEAN AVENUE 4 Oc�.r� Oa �e — — i TOTYII Barnstable, *Permit# Expires 6 months from issue date . Regulatory Services Fee Thomas F. Geiler,Director Building Division ._ Tom Per ` CBO, Buildin Commissioner ry g 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us. Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint ,an/parcel Number /w�` - - ------ --- - ---- Property Address tesidential Value of Work Q Minimum fee of S25.00 for work under$6000.00 Owner's Name&Address J INN, D •/�!'� 0UkL bcuLcs Contractor's Name •'�1 .� Q l Telephone Number C � J Home Improvement Contractor License#(if applicable) I 0 [O 0 Construction Supervisor's License#(if applicable) . rkman' kz- s Compensation�Insurance Check one: G ❑ I am a sole proprietor ❑ I am the Homeownerki 94 have Worker's Compensation Insurance / Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must,be on file. ' Permit Request(check box) ❑ Re-roof(strippingold shingles) All construction debris.will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side W1bQZ '&A/ . A S6v6 Replacement Windows/doors/sliders. U-Value (maximum.44) *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. Qpy of the Home Improvement Contractors License is required. SIGNATURE: Q:Forrns:expmtrg Revise061306 I 1 ACC ®® CERTIFICATE OF LIABILITY INSURANCE °A03107712011 ' 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 INSURERS), 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 endomement(s). PRODUCER =,TCT Erica H.O'Connor HART INSURANCE AGENCY,INC. PHONE (508)759 7326 No:(508)759-7366 243 MAIN STREET PO BOX 700 ADDRESS: BUZZARDS BAY,MA 025320700 NSURE S RFFORDINO COVERAGE NAIC 0 INSURER A: ARBELLA PROTECTION INS CO - 41360 `INSURED EJ JaAimer Builder,Inc - INSURER e: ARBELLA PROTECTION INS CO - 41360 48 Rosary Lane °��c ARBELLA PROTECTION INS CO, 41360 Hyannis,MA 02601 _ NSURER D. ARBELLA INDEMNITY INSURANCE COMPANY 10017 INSURER E: . - I 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. INS TYPE OF INSURANCE ADDL SUER POLICY NUM13ER .POLICY DIYYY (POLICY EXP' -LIMITS LTRA GENEALIJABftm 8500042039 01/01/2011 01/01/2012 EACH OCCURRENCE s 1000000 DAMAGOR COMMERCIAL GENERAL LIABILITY - - - - E E - o u NTIED n S 300000 CLAIMS-MADE ®OCCUR MED EXP(Any one person) $ 50Od PERSONAL a ADV INJURY S 10DOON GENERAL AGGREGATE S 2000000 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO S 20MOM POLICYF—IJECT PRO- LOC - - - - S B AuTOAROBRELIABItm ILE MIT 2 0 / / 10000 ANY AUTO- - BODILY INJURY(Per person) S ALL OWNED -- SCHEDULED - - AUTOS � AUTOS - BODILY INJURY(Per accident) S NON-OWNED' - - - PROPERTY DAMAGE $ - HIREDAUTOS - AUTOS r CNil UMBRELLAL1A6 OCCUR 46DO042040 D1/01/2011. 01/01/2012 EACH OCCURRENCE S 2,000,000 EXCESS LIAR CLAIMS-MADE - AGGREGATE S 2,000,000 DIED RETENTIONS S . D tNORIERSCOMPENSATION 0053890111 01/01/2011 D1/01/2012 WCSTATU- oTH- AND EMPLOYERABLLFTY -S'U . ANY PROPRIETORIPARTNERIEXECUTIVE. Y NIA - E.L EACH ACCIDENT S 500,000 OFFICERIME MBER EXCLUDED? EJ(Mandatory In NH) .E.L.DISEASE-EA EMPLOYEE S - 500,000 If yyeeaa describe under . DESL�RIPTION OF OPERATIONS below. EL DISEASE-POLICY LIMIT $ 500,000 DESCR"ON OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional RemarM SctrdWs,N more apace is required) CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ZOO MAIN STREET ' THE EXPIRATION DATE THEREOF, NOTICE,WILL BE DELIVERED IN HYANNIS,MA 02661 ACCORDANCE WITH THE POLICY PROVISIONS. - AUTHORIZED REPRESENT/• 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010106) The ACORD name and logo are registered marks Of ACORD " 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/OrganizatiorAndividuai): r•v Ja K f/j71, C Address: g f�OsQ,r2/ City/State/Zip: G(•!I.tV S /n6 0260 ( Phone#: (60.2 '?19 .4� Are you an employer? eck'.the appropriate box: Type of project(required): 1.[DI am a employer with aW 4. E).I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction listed on the attached sheet. . Remodelin 2.El I am a sole proprietor or partner- 7 ❑ g ship and have no employees These sub-contractors have 8. 'Q Demolition . working for me in any capacity.. employees and have workers' 9. Building addition [No workers'comp. insurance comp.insurance.$ required.] 5. 0 We are a corporation and its 10.❑ Electrical repairs or additions q ] 3.0 I am a homeowner doing all work officers have exercised their 11.0 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 comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If.the sub-contractors have.employees,they must provide their 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: ltr,6�� P47�0K 1 AI E Co . Policy#or Self--ins.Lie.#: 0.ys3 g_ o I ... 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.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-copyof this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify pains and penalties of perjury that the information provided bove i true and correct Si afore: ' Date: � 2•�0 Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Office of Consumer Affairs and Business Regulation " 10'Park Plaza - Suite 5170 i Boston, Massachusetts 02116 Home Improvement Contractor Registration m Registration: 110609 ( , Type: Private Corporation ,',< Expiration: 11/3/2012 Tr## 205399. j E J JAXTIMER, BUILDER, INC. h ` ` ERNEST JAXTIMER I , = 48 ROSARY LN HYANNIS, MA 02601 {' -4', Q 'Update Address and return card.Mark reason for change. Address 0 Renewal Employment Lost Card DPS-CA1 0 50M•04/04-G101216 ✓,o �°°v��>d✓ tee ;.. ..._...__._,.._, Office o ousumer airs mess egu attou. License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: �110609 Type: Office of Consumer Affairs and Business Regulation TET11MER, Expiration iL3/2012 Private Corporation10 Park Plaza-Suite 5170 Boston,MA 02116 1304L %-51=_-M ERNEST JAXTIMER c + - 48 ROSARY LN Q1 HYANNIS MA 02601 Undersecretary Not valid without signature - :- Massachusetts- Department of Public Safety .'Board of Building Regulations and Standards Construction.Supervisor License License: CS 3251 Restricted to: 00 l ERNESTJ_JAXTIMERs 48 ROSARY LANE HYANNIS MA 02601 1 ��— -'� ! —` Expiration: 1/14/2012 {onunisswner Tr#: 13122 Mar 25 11 12:13p Owen & Leslie O'Neil 781-749-0431 p.1 dF� • s�.*rsrAste. • KAM Town of Barnstable Regulatory ulator Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 "-w.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, �,��t� y'1'i� f ,as Owner of the subject property hereby authorize �C�,C �j' �� to act on my behalf, in all matters relative to work authorized by this building permit application for: (61 (Address of Job) T Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:iUserstdeccllik\,AppData'•,Locals[v icrosoft�WindowslTemporary lnterna NIcAContmWudooklDDV87AAZ\FAPRESS.duc R Pviv-.8 OT?11 rt I j *Permit Town of Barnstable # � Expires 6 months from isle date Regulatory Services Fee �1 a �� '7]� Thomas F.Geiler,Director Building Division mPerry,CBO, Building Commissioner m i � 00 Main Street,Hyannis,MA 02601 FEB 0 1 2007 www.town.barnstable.ma.us Office: 508-862-40 8 Fax: 508-790-6230 `OWN CWffM§§fXffl=APPLICATION - RESIDENTIAL ONLY 7 Not Valid without Red X Press Imprint rap/parcel Number 4)Z roperty Address &U4 1 f Residential Value of Work 7 700 e yv Minimum fee of$25.00 for work under$6000..00 owner's Name&Address IWA,an !ontractor's Name LT �pN�l" /�L Telephone Number Sit 776 f%1 Y come Improvement Contractor License#(if applicable) 1 �b License#{-i�aPP3iealrlej _.. W-101'rkman's Compensation Insurance Check one: - ❑ I am a sole proprietor ❑ jLam the Homeowner I have Worker's Compensation Insurance isurance Company Name Vorkman's Comp.Policy# :opy of Insurance Compliance Certificate must be on file. -ermit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris.will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) Ly'Ke-s-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission, A copy of the Home Improvement Contractors License is required. 7GNATURE: a/,— !:Forrns:exprntT9 .evise061306 .. .. ��' _M�/�/I720'IZKIJGCL4crv,,V'y �...h.•y'(.ta y '�£' { sue• 'p$Jl 4,c 8ga1 d o Blit clnle Ieg 1ta4 ns and St tndar7 y : .tcee or registration v1Ld for mitivxiW,us ns o»ly' i HOME IMP\RO.VE-MENT CONTRACTOR nWore the`exptt ation date. If fd�F>tid 1 ettt> ; l2e61stratlo gg hoard of B;u�dmg Regulations a6 Stanclar�is� ( t 1� ?�v200us As hburton P]Ace Rm;1301 ',� �3oston,b'[a 0210�3:'r T QNS I ,�� ZNS 5gT1b ING&ROOFIN t; qh NNIE TAYLOR "`Yuels ► i "' 1`:.otvli �. Island Sd' and boo ' � f� w ,may r a division of RLTconstmztion,Inc. Owen and Leslie O'Neil 14 Ocean Avenue W. Hyannisport, MA We are pleased to-submit the following specifications and estimates for residing Strip existing cedar shingles and flashings Install new.aluminum drip edge. Install Tyvek house wrap. Install grade A white cedar shingles Install Pvc trim to repair rotted rake tales. Install continuous ridge vent to all ridges. Clean up and haul away all debris to landfill t W+�hereby propose to furnish material and labor- complete in accordance with the above specification, for the sum of: SEVEN THOUSAND SEVEN HUNDRED DOLLARS $7700.00 PAYMENT TO BE MADE AS FOLLOWS: $7700.00 Upon Completion Add $1200.00 for bleached shingles All material is guaranteed to be as specified All work to be completed in a workmanlike manner according to standard practices. Any alterations or deviations from the 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 strikes,accidents,or delays beyond our control. Owners to carry fire,wind damage and other necessary insurance, RLT Construction,Inc. carries General Liability and Workman's Compensation Insurance. Certificates of Insurance provided upon request. ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are satisfactory and hereby accepted. You are authorized to do the w rk as spec' ed. Payment will be made as outlined above. Date of Acceptance: / - . `�7 Signature Start Date: S a. Signature t 31 Manni Circle Centewdle, Massachusetts 02632 Telephone 508.42a5243 and 508.833.5249 • FaX`508.420.1776" trriail caperoofer@caperoofer com . The Commonwealth ofA assachusetts �.' Department oflndustriaZAccidents - Offzce of bivesfigadons d 600 Washington Street . Boston,MA 02111' wtvw.mass gov/dia Workers"Compensation Insurance Affidaylt;Builders/Contractors/Electzicians/P1u�qbers Applicant Information ��-- PleasePriiatLe ibl Name(Business/Organization/Individual):_ /Ir/I %/�.e, /C'L- �' J•� /d� • • •Address: �� / �t�, ' � City/State/Zip: •Phone.#: _ •74 Are you an employer?-Cheek the appropriate bag: / ;Type of project(required); 1:[�!I am a employer with / 4, ❑ I am a general contractor and l employees(full and/or part time),*. have hiredthe sub-contractozs 0. ❑New construction m . 2.❑ I a a'sole.pioprietor or partner= . listed on the* sheet: 7. ❑Remodeling ship,andhave no employees These sub-contractors have g, ❑Demolition. iyorlang for me in arty capacity employees and have workers' [No workers' comp,insuuahce com ur p.insance, 9, []Building addition required.) 5. ❑ We are a:porporation and its 10,❑Electrical repairs ox additions — - .1.❑I-anx—homeowner-doing-all.wozk - ----officers-have exercised their 11:❑Plumbing repairs or additions ' myself.[No workers'comb, right bf exemption per MGL inswance.required.]t c..152, §1(4),and we ha i2, ve no ❑Roof rep s employees, [No workers' 13.❑Other-' goiap•insurance regimed.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Iromeowners,who submit this affidavit indicating they are doing all Woik and then hire outside contractors must submit a new affidavitindicating su ah, $Contractors that check this box must attached an additional•sheetshewing thename of the pub-contractors and state whether ernotthose entities have ewlcyees, If the sub-contractors have employees,they must providb their workers'comp,policy number. Tam an employer.that fs providing workers'compensatfvn insurance for my employees. Below is.the policy and job site'information. Insurance Company Name Policy#or Self-ins.Lic,#;• - ��• ExpirationDate; Job Site Address' G�/ }�,/State/Zip: Attach a copy of the workers' compensation policy dedlaration 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 weIl as civilpenalties in the form of a STOP WORK•ORDER and a fine of up to$250.00 a day against thg violatdr, Be advised that a-copy of this statement may be forwarded to the-Office Of Investi atkm of the bIA for insurance coverage verification, ' I iio hereby certify and a pains and aloes of perjury that the information prgvided above is true an:d correct. Si tt�re: • - �,7 Date; Phone#; 77 'PiV Official use only. Do not write ix this area,fo be completed by,city or town off ciaL City or Town:' Yermit/License# . Issuing Autwrity(circle one)." ,I Board of Health 2,Building Department a, City/Town Clerk 4.Electrical Inspector 5• Plumbing 6, Inspector Other Contact Person,. Phone A. Massachusetts Genefal'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." An emp layer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or mole 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 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 deegaed to be an employer." IvIGL 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 is the commonwealth for any applicant who has not produced'acce'ptable evidence of compliance with the insurance coverage required,". Additionally,MGL ohapter-152,§25C(7)states"Nejther tfie commonwealth nor any of its political subdivisions shall enter into any contract for,the perfrtmiaace of publ.cwork until acceptable Videm of compliance�zthtlie ins e' 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,Comp anies'(LLC) or Limited Liability Partnerships(LLP)with no'employees other than the members'or partners, are not required to cane workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Bp advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation o£insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the app4cation for the pemut.or license is being requested,not the D apartment of Industrial Accidents, Should you have any questions regarding the law-or if you are requirecl to obtain a workers' comp ensationpolicy,please call the Department at the number listed.below. Self-insured companies should enter their . self-insurance license number on the appropriate'kine. City or Tow;i Officials Please be sure that the affidavit is*completa'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 fain the permit/license number which will be used as a reference number: In addition,an applicant that must submit multiple permit/licensa applicatious in any given year,need only submit ono affidavit indicating current policy information(ifnecessaty)and under"Sob Site Address"the applicant should write 11a11•loc4ons in or town)."A copy of the affidavit t4t.has been officially stamped or marlcedby the city or town maybe provided to the applicant as proof-that a valid affidavit is on file for future permits or licenses. A new aff davit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related fo any business or commercial venture (i.e. a dog license or permit to bum leaves•eto,)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-anti questions, please do not hesitate to givens a call The Depaximent's address,telephone-and fax number:. T,o Commoaw-Wth of Mwadl=ds 600 Washing Spa t=MA 02111 TO.0 617-727-4 ext 406 Or. 1-M-MASSAFB Ftc#617.727- 749 Revised 11-22.06. WwWMA� g6vfdia ; RightFax Norcross 2/2/2007 11 :44 PAGE 004/004 Fax Server flA r e�L/1ltilm r' 7I"Qi I .... DATE( \ODIYYj - - PRO.... IS C IFIC T ISSUED I AS TTER OF IN OR ATIO ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE EDWARD A GRAZU-J INS AGCY HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR Fo Box 337 ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. MARSTONS MIL-J S 2+uA 02648 COMPANIES AFFORDING COVERAGE COMPANY A HzgTiORD UNDERWRTTEIRSURA14CE C - INSURED COMPANY R L T CCNSTRUCTION INC B _ 31 MANNI CIRCLE COMPANY CENTERVILLE NLR 02632 C f 30MPANY D COVEA/AGES 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. LT TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LT DATE(MM,DDYY) DATE(MM\DO\YY) GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERALLA31_tTY FRODUC-S•COMP/CPAGG. $ C-AIM S MADE F7 OCCU 3. PERSONAL&ADV NJURY $ OWNERS&CCN-RACTOR'S P307 EACH OCCURRENCE $ RRE DAMAGE(Any one ts) $ MED.EXPENSE(Any one perscr) $ AUTOMOBILE LIABILITY COMBINED S!N L E $ ANY ALTO LIMI- ALL OWNED AUTOS BODILY IN,iURY SCHEDULED ALTOS (Per Persil $ HIRECAJTOS �. < BODILY!NJL13Y NON-OWNED AUTOS (Per Ascident'; PROPERTY U a AM GARAGE LIABILITY AUTO ONLY• a !DENT ANv AUTO 0-HE3 THAN AI` NLY: ' 'i. =ACkftIDENwffT $ AG= GATE $� EXCESS LIABILITY EACH OCCURRENCE $•• En UM3RELLA FORM AGGPEGATE )-HER-HAN UMERELLA FORM WORKER'S COMPENSATION AND EMPLOYERS LIABILITY (UB-1051C04-3-06) 12-24-C6 12-24-07 STATJTOR LIM-S T EACIACCID=NT inn orin ARPRO cKl 'L DISEASE-PO ICY LN1 PTVEPCW INC, OF=CERSS ARE EXCL DISEASE-EACH EMPLOYEE Is 1 rl 0 ; OTHER DESCRIPTION OF 0 PERATIONS!LOGATI ON SrV EHIEL S!RESTRICTIONSJSPECIAL ITEMS TFE POLICY CES: NAMED ABOVE =S CANCELED EFFECTIVE 02/14/07 THIS REPLACES ANY.PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER. AFFECTING WORKERS COYP COVERAGE. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL TOWN OF BARNSTABLE 10 DAYS WRITTEN NOTICE70 THECERTIFICATE HOLDERNAMED TO THE ATTN: BUILDING DEPT LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR 2C O MAIN STRES T LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTSOR REPRESENTATIVES HYANNIS MA 02601 AUTHORIZED REPRESENTATIVE fit!