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Home My WebLink About0008 PARK PLACE � �A� CHARGE: 630103 CASH: 00 100100 TREA REV: 016301 433150 12636682 2012 0 PERM 19705 06 0 2012 20120334 CHARGE: 630103 CASH: 00 100100 THE REV: 016301 433150 12636687 2012 0 PERM 19705 06 20 2012 201203390 CHARGE: 630103 CASH: 00 100100 THE REV: 016301 433150 12636690 2012 0 PERM 19705 06 20 2012 201ZO3459 ; CHARGE: 630103 CASH: 00 100100 THE REV: 016301 433150 12636692 2012 O, PERM 19705 06 20 2012 201203756 Report generated: 06/25/2012 12:10 user: barrowsd Program ID: arrctpst Town of Barnstable Building Post This"Card So That it?is Vis�ble;,From the Street, A. ,roved;Plans�Must bef2etamed on Job a�nd.,this Card Mustbe Kept U4RMMAelJe. M Posted Until`Final Inspection Has Been Made �� `' z � ��,�� - � � m 1 3 .. � •sa j � ,, r r ._ �' Permit ° . Where a Certificate of Occupancy is Requcred,such Bu�ldmg�shall Not;be OcCvpied�untd a Final Inspect�on�,has been made� b,. Permit No. - B-19-998 Applicant Name: SILVIA&SILVIA ASSOCIATES INC. Approvals Date Issued: 04/01/2019 Current Use: Structure Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 10/01/2019 Foundation: Residential Map/Lot: 286 017 Zoning District: RF-1 Sheathing: Location: 8 PARK PLACE,HYANNIS ct z r ' Contraor.Name A RONALD J SILVIA Framing: 1 ? eZ Owner on Record: DRUMCHAPEL HOLDINGS LLC x Contractor License':. CS-016932 2 ,: v " Address: �92 PRINCE STREET �> Est. Project Cost: $5,000.00 Chimney: WEST NEWTON, MA 02465 K �, Permit Fee: $85.00 WljvInsulation: Description: EXSTING WALL MAKE 8'OPENING, INSTALL HEADER�INTERIOR WALL Fee Pa�dc� $85.00 eA (1) PARALLAM.3 1/2"X9 1/2" Date 4/1/2019 Final: Project Review Req: ' f ' Plumbing/Gas fr Rough Plumbing: r� Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six rnonths 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: ture All construction,alterations and changes of use of any building and strucs shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access str :road and shall be maintained open for public inspection for the entire duration of the Final Gas: eet'or work until the completion of the same. Electrical The Certificate of occupancy will not be issued until all applicable signatures by the Budding and'Fire Officials are provided on this,permit. Service: Minimum of Five Call Inspections Required for All Construction Work: r 1.Foundation or Footing � g 2.Sheathing Inspection N„ F Rou h: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 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. "Persons ntrac )withunregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Fire Department Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT final: I O Application Number.... .'..1 ......... ... .............. *PIP MASS. f3U'LD/N _ Permit Fee.......................................Other Fee........................ p-r FO Mfg a 1'`Qtf 2 8 2019 Total Fee Paid............................................................... ...... TOWN OF BARNSTABI;E`Hg,E Permit Approval by...... ... . ... BUILDING PERMIT . r n map.......��.(.62............Parcel............................................. APPLICATION Section 1 — Owner's Information and Project Location Project Address �} �r I��(� Village Owners Name I G l� W, • 4 Owners Legal Address City4yaState UA Zip Owners Cell# G 1 rl' 81 r7- 81 G I E-mail ►�1 C KG CJl1) QLrCk. Cot—i Section 2 —Use of Structure f Use Group 1eF- ! ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet Single/Two Family Dwelling 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 FIb]1 Addition ❑ Retaining wall ❑ . Solar I�t Renovation ❑ Pool r ❑ Insulation Other—Specify 1& �OZ. M LC.. a . Section 4 - Work Description i NTMOF.- wQ LL (1 ) -PARALLAU 3YA"X ?%„ Last undated: 11/15/2018 Application Number..................................................... Section 5—Detail Cost of Proposed Construction 5 Square Footage of Project Age of Structure 56 y ears Dig Safe Number # Of Bedrooms Existing Total#Of Bedrooms (proposed) QS 110 MPH Wind Zone Compliance Method .❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics ❑ Wiring ❑ Oil Tank Storage ❑ Smoke Detectors ❑ Plumbing ❑ Gas ❑ Fire Suppression 0 1Vlsc rChimne ❑Add/relocate bedroom El Heating System - -- _a my y 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 D"'No Section 7—Flood Zone e Flood Zone Designation _ Within or adjacent to a wetland, coastal bank? Yes ❑ No Section 8—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 s Required Proposed- ' Side Yard `" . Required Proposed i Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No J Last updated. 11/15/2018 JILVIH & %.'>ILVI/H ASSOCS. 8 Park Place, H-Port, MA Wall presently open for witness. Current plans call for removal ____________________________________ and replacement w/ continuous PSL header. PSL header will Philbrook Engineering support intersecting kitchen/entryway beam. Final configuration - a j e dependent upon wall removal and connection details - TBD Project No: P19-07 ,F p _ I �- 3.5"x 9 5" 2.0E ParalLam PSL a i w. t 2/2"x 4" KID SPF r lank Sti irl Park R t t �r t t i r ' � Fad I -_ �.3.....¢`.+.".,'�•� f � ;�`~ � 1w,5y��st. +s,.. � ' k-; Max Span = 9'3" Clear � -- { ry I y i � M j we s s •x*^ S. r j! V � • '® � ° MEMBER REPORT Level. Wall:Header PASSED 1 piece(s)3 1/2"x 9 1/2" 2.0E Parallam® PSL SILVIA & SILVIA Assocs. Overall Length:9 9 0 8 Park Place, H-Port, MA - ----------------------------------- Philbrook Engineering Project No: P19-07 0 0 930 J 0 All locations are measured from the outside face of left support(or left cantilever end).AII dimensions are horizontal. Design Results Actual @ Location Allowed Result LOF Load:Combination(Pattern) System:Wall Member Reaction(Ibs) 4480 @ 0 18 4463(3.00") Passed(100%) — 1.0 D+1.0 L(All Spans) Member Type:Header Shear(Ibs) 3928 @ 10 8 6428 Passed(61%) 1.00 1.0 D+1.0 L(All Spans) Building Use:Residential Moment(Ft-Ibs) 13122 @ 4 0 0 13057 Passed(101%) 1.00 1.0 D+1.0 L(All Spans) Building Code:IBC 2015 Live Load Defl.(in) 0.240 @ 4 9 4 0.317 Passed(L/475) — 1.0 D+1.0 L(All Spans) Design Methodology:ASD Total Load Defl.(in) 0.425 @ 4 9 3 0.475 Passed(L/268) — 1.0 D+1.0 L(All Spans) Deflection criteria:LL(L/360)and TL(1./240). Top Edge Bracing(Lu):Top compression edge must be braced at 0 6 0 o/c unless detailed otherwise. Bottom Edge Bracing(Lu):Bottom compression edge must be braced at 9 9 0 o/c unless detailed otherwise. Bearing Length Loads to Supports(Ibs) !¢Upports Total Available Required Dead Floor Total Accessories 1.•Plate-SPF 3.00" 3.00" 3.01" 1926 255S 4481 None 2-Plate-SPF 3.00" 3.00" 2.62" 1646 2245 3891 None Tributary Dead Floor Live Li�7aa+ Location(side) Width (0.90) (1.00) Comments 0-Self Weight(PLF) 0 0 0 to 9 9 0 N/A 10.4 Residential-, i -Uniform(PSF) 0 0 0 to 9 9 0 800 25.0 40.0 Bedroom&Ceiling above Areas Point load from Intersecting 10tchen/Living LVL. 2-Point(lb) 400 N/A 1520 1680 16'ceiling on 14' beam-Bedroom goad+Partition above I Member Notes Member sized for Full Width of the Double Opening-See Pic Weyerhaeuser Notes 1 SUSTAINABLE FORESTRY INITIATIVE Weyerhaeuser warrants that Ule sizing of its products will be in accordance with Weyerhaeuser product design criteria and published design values. Weyerhaeuser expressly disclaims any other warranties related to the software.Use of this software is not intended to circumvent the need for a design professional as determined by the authority having jurisdiction.The designer of record,builder or framer is responsible to assure that this calculation is compatible with the overall project.Accessories(Rim Board,Blocking Panels and Squash Blocks)are not designed by this software.Products manufactured at Weyerhaeuser facilities are third-party certified to sustainable forestry standards.Weyerhaeuser Engineered Lumber Products nave been evaluated by ICC ES under technical reports ESR-1153 and ESR-1387 and/or tested in accordance with applicable ASTM standards.For current code evaluation reports,Weyerhaeuser product literature and installation details refer to www.weyerhaeuser.com/woodproducts/document-library. 4 = The product application,input design loads,dimensions and support information have been provided by Forte Software Operator Forte Software Operator ,lob Notes 3/26/2019 8:01 49 PM T Varnum Philbrook &Ivia/Siivia-8 Park Place Forte v5.4,Design Engine:`J7.1.1.3 PHILBROOK ENGINEERING Hyannis Port,MA P19-07;8 Park Place,4t:? (508)385-8682 Tvarnphjl,@VedZon.nei P19-07 Page 1 of 1 Commonwealth of Massachusetts ." (c 0"0 Division of Professional Licensure Board of Building Regulations and Standards i� :.. Constru'.0 on Supervisor CS-016932 Ekpires: 11/18/2019 RONALD J SIL-VIA 44 ICE VALLEY RD OSYERVILLE 6A�665i F =R Commissioner CIL M � I ?2�1�'li/�?i��iG(J��Cli�/G OI' �./��1 G �'�' � y • C" Office of Consumer Affairs and Business Regulation A<f 1000 Washington Street - Suite 710 Boston, assachusetts 02118 Home Improvet-Contractor Registration Type: Corporation Registration: 101627 SILVIA&SILVIA ASSOCIATES, INC. P.O.BOX 430 Expiration: 08/23/2020 OSTERVILLE, MA 02655 In T + ` 'r----7 SCA t is 20M-05/17 Update Address and Return Card. �Mv�z02uie¢��o�✓//19CG1JOC/t[GJB/l� r Office of Consumer Affairs&Business Regulation HOME IMPROX�EMENT CONTRACTOR Registration valid for individual use only TY�t;.Cornoration before the expiration date. If found return to: Regis'trafion_- Expiration Office of Consumer Affairs and Business Regulation D'01627 _ ; 08/23/2020 1000 Washington Street-Suite 710 SILVIA&SIL 'VA4ASS:OOIATES"INC. Boston,MA 02118 L.. RONALD J.SILVIA fj` 1284 A MAIN ST. OSTERVILLE,MA 02655 Undersecretary Not valid Without signature co , p , Ile- DATE(MM1DD/YYYY). A6�Z® CERTIFICATE OF, LIA- ILITY WRANCE ' 03l26/2019 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 1.POLICIES BELOW. THIS CERTIFtCATEOF INSURANCE DOES NOT`CONSTITUTE,A'CONTRACT BETWEEN THE:ISSUING:INSURER($),AUTHORIZED REPRESENTATIVE OR PRODUCER',AND THE:CERTIFICATE'HOLDER. IMPORTANT.of the:certificate holder is an ADDITIONAL INSURED,the policy(les)must have`ADDITIONAL INSURED provisions`or.be'-endorsed,' If SUBROGATION IS WAIVED,Subject to the terms and conditions of thepolicy,certain policies may require art,endo'rsement.,,A Statement on this certificate does not confer rights to the certificate'holder in lieu of such endorsomerit(6),; PRODUCER CONTACTNAME: . Kathy:Silvia The Fair Insurance Agency Inc. PHONE /C No Ext:. (508)775-3131 C (5t38)790-1677 618 Main Street 'ADDRESS: kathy@thefairagdncy.com, Suite 1: •1NSURER(S):AFFORDINOCOVERAGE' NAIC'# Centerville MA 02632;, I'NSURERA::' Berkley Assurance Cc INSURED INSURER :-Hartford Underwriters Ins.-AR 804:1;1 Silvia&Silvia CCC INSURERL P:O.Box 430 _ INSURER'D:. '1284 Maio-Street" '. INSURERE.:.. _ ...._ OSterville MA 02655': INSURERF: 18-19 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,TERWOR CONDITION OF ANY CONTRACT OR OTMER;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-ERNIS; EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAib.CLAIMS. EXP LTR - TYPE OF INSURANCE .. INSD 'WVb POUCYNUMBER- (MM/DO/Y FFY POUDDIYYYY LIN11T5 - _: OCCURRENCE, b COMMERCIAL LIABILITY 1,000,000 CLAIMS-MADE. DOCCUR : PREMISES Ea:ocairrence g 50;000, 'MEDEXP(Anyone persani $ .. 5;000 A VUMA0121721 08/0.1/2018 :;08/01/2019 PERSONAL&ADVINJURY y 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE g 2,000,006 x POLICY-❑JEa lOC PRODUCTS-COMP/OP AGG g 2;000,000 - ': OTHER: - .AUTOMOBILE LIABILITY - COMBINED SINGLE;LIMIT - Ea acradent ANY AUTO BODILY INJURY-(Pe11p1 ) $ OWNED. AUTO'S LED BODILY INJURY(Per accident 5 AUTOS ONLY AUTOS � ) ' - ,HIRED: r NON;OWNED PRPERTYDAMA E' AUTOS:ONLY AUTOS ONLY Per accident S UMBRELLALIAB OCCUR EACH OCCURRENCE. S. EXCESS-UAB; HCLAIMa_MADE. - AGGREGATE... .- E. - ..DED - RETENTION-5 .. WORKERSCOMPENSATION .OTH- AND:EMPLOYERS'.LIABILITY :STATUTE ER - Y.tN ANY PROPRIETOR/PARTNER/EXECUTIVE i. E.L.EACH ACCIDENTg 500000 B OFFlCER/MEMBEREXCLUDE02 NIA' 6S60UB5831076219 04/01/2019a .04101/2020 (Mandatory In NH) _ E:LDISEASE-.EAEMPLOYEE ,g 500000 if yes.describe under .-.. DESCRIPT(ON:OFOPERATIONSbelow' _; - E.L:.DISEASE:-POLICYLIMIT' g 500;000 . .. .. :. DESCRIPTION OF OPERAT10NS7lOCATIONS!VEHICl:ES(ACURD,101;Additional Rerredis,Sctiedute;may be attachod if more space to"tequlred). - 8 Park Place Hyannisport,MA - .CERTIFICATE HOLDER CANCELLATION` , ' - SHOULD ANY OF'THE ABOVE DE$CREBED POLICIES BE CANGELGED-BEFORE- THE EXPIRATION DATE`CHEREOF,NOTICE WILL BE;DELIVERED'IN To Wnof-Barnstable - ACCORDANCE-WITHTHE'POLICY-PROVISIONS; -AUTHORIZED REPRESENTATIVE Hyannis MA. y ` ©1088-2095 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) 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,AM 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name(Business/Organization/Individual): 11 V I A 1`�1G7 Ln Address: I �Aain a le-fL City/State/Zip: vl''� Phone#: Are you an employer?Check the appropriate box: 'Type of project(required): 1 X I am a employer with 6 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 ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.msurance. 9. ❑Building addition 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 I myself~[No workers' comp. right of exemption per MGL 12.❑Roof repairs fnc=r,e required.]t c. 152,§1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $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: 1 S r a 1 n G Policy#or Self-ins.Lic.#: (P S co Q Q ,J 58 31 a-'(D Z.i 9. Expiration Date: Job Site Address: �0� r K I Qom' City/State/Zip: M H 0 21(0 Attach a copy of the workers'compensation policy declaration page(showing the policy xi=4 and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of'a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi r ains and penalties of perjury that the information provided above is true and correct Si a e• -�- Date: c3 a7I IF Phone#: O B O G 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.EIectrical Inspector 5.Plumbing Inspector. 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pur ian to thisstatute,an employee is defined as"...every person inthe 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 dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appintenant 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 contract 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'lieen 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 or Limited Liability Partnerships(LLP)with no employees other than the insurance. Limited Liability Companies(LLC) �' 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 L�rdustria3 At C1dCY1`L5. 3'1'2vuiu Y VU h'aJe y;uesticm:S reo�.�g 1he la —if you are r�red 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 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 pennit/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 fa me 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 bum 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. w t z The Camm(mweaM of Massachusetts Derpmtment of Industdai Aoddents flee of Xnvestiptions 600 Washimgtan t Boston,MA 02111 Tel,A 617-727-4M ext 406 or 1-977-MASSAFE Fax##617-727-7749 Revised 4-24-07 WM= gav/d1a r Section 12—Department Sign-Offs Health Department ❑ Zoning Board(if required) ❑ Historic District ❑ Site Pian Review(if required).❑ Fire Department ❑ Conservation . ❑ For commercial work,please take your plans directly to the fire depgrtrnent jor approval '. Section 13-Owner's Authorization n as Owner of the subject property-hereby authorizeA- to act on my behalf, in all matters relative to work authorized by this building permit application for: Tz- r r e (Address of j b) 2 Q1 Ct Si afore of Owner date Print Name : Last updated l 1/15/2018 ,Y Section 12 —Department Sign-Offs Health Department ❑ Zoning Board(if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ Conservation ❑ ' For commercial work,please take your plans directly to the fire department for approval Section 13— Owner's Authorization I, 1C: 1 r) , 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 j b) Signature of Owner date TICK WY TON Print Name 1 i _ I 1 i I • I i s Last updated:11/15/2018 Application Number........................................... Section 9- Construction Supervisor Name 1'S0ndW ,S S,V41 a Telephone Number ®ZZ6 X\(D(,o Address`; 't4' Ce V rI ray PfZp_ City V I-1C- State Zip LorL TW(--Ran License Number C5-010 32. License Type sL4?ert Sc rExpiration Date ] g 2019 Contractors Email IRS i I Vk A(5 tVYt G ardSt�V kO,CodYl Cell # 5 oil--4W 2q lo3 I 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 required by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signs Date Section 10—Home Improvement Contractor Name o nal d Telephone Number O 420 OZZ6 x 4® Address 126yA M f4IN . City. State I Zip 0 2-&ab Registration Number l0 (oa q Expiration Date E31 Z3 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 Town of Barnstable.Attach a copy of your H.I.C... i . Signatur ��_/ - Dates/f Section 11 —Home Owners License Exemption Home Owners Name: Telephone Number Cell or Work Number I 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 required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT SIGNATURE Signature 'Date a7 / Print Name —&)U/S Ln Telephone Number 508 Im 0?96` E-mail permit to: Last updated: 11/15/2018 Page 1 of 1 it --q-On g , f has F y e P141,z I-t-I�}�E ( r IyAPJA3 http://it99.pohotobucket.co a ums n riw/nlriwl2/hy031013h zpsOe534c4e.jpg 3/10/2013 Page 1 of 1 VIA c. 4 h ://i99. ho o ucket a ums 291I /nlriw/nlriwl2/h 031013i z saea46c27 j /1 2 nP P y _ p Mpg 3 0/ 013 r Page 1 of 1 �.' ♦ .�.t '+fie �� .. d�' •- _. s� �rwd. +.4y � e..+A .y..,,... �� yyy .. a V Slowex W http://i99.photobucket.co tun //hy031013 z s7c49b2c4. I10'�2013 g_ p Jpg l , TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION p,Ma Parcel O A pp licatiori�� . Health Division Date Issued 7 /43 Conservation Division Application Fe Planning Dept. pp Permit Fee 'r Date Definitive Plan Approved by.Planning Board 9� 7--17��3 Historic - OKH — Preservation/ Hyannis Project Street Address Village NJ 6,L �i Owner �(1�4p ,I &w' Address T .Telephone Permit Request A&dre- �- IQA Square feet: 1 st floor: existing IsA proposed O 2nd floor: existing proposed Total new3)('z�s Zoning District Flood Plain ss a Groundwater Overlay e� Project Valuatio Construction Type Lot Size Grandfathered: ❑Yes &Klo If yes, attach supporting documentation. Dwelling Type: Single Family � Two Family ❑ Multi-Family (# units) 1 Age of Existing Structure Historic House: ❑Yes tom' 6 On Old King's Highway: ❑Yes �_No Basement Type: II ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) byo Number of Baths: Full: existing_ new Half: existing new Number of Bedrooms: G existing I new Total Room Count (not including baths): existing 0new First Floor Room Count J� Heat Type and Fuel: ❑ Gas J"Oil ❑ Electric ❑ Other Central Air: ❑Yes Flo Fireplaces: Existing New Existing wood/coal stove: ❑YeJd"N* o Detached garage: ❑ existing ❑ nbw size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ � ' o Attached garage: ❑ existing view size _Shed: ❑ existing ❑ new size _ Others r O Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ � � 1 Commercial ❑Yes Pilo If yes, site plan review # y r1n Current Use 1 - _-___ __:_.__Proposed=Use r— APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name c Telephone Number J �2-0 � Z Address 776, 1114 N? License# 71 CS7 b s[a,iv�ks , LAk. 62c� Home Improvement Contractor# Worker's Compensation # (4) c`SnL!� &OW vz— ALL CONSTRUCTI TMU LTINGG FROM THIS PROJECT WILL BE TAKEN TO �cs�.ul 8 SIGNATURE DATE `ZL7 13 �r I� FOR OFFICIAL USE ONLY ! . APPLICATION# DATE ISSUED ` MAP/PARCEL NO. • r ADDRESS VILLAGE OWNER DATE OF INSPECTION: r y 4FO-UNDATION � , ;:__ ,-•. :' i,tiks{, r� FRAME -,INSULATIONji.F 'x FIRE'PLACE ELECTRICAL: ROUGH FINAL 'Y PLUMBING: ROUGH FINAL ` GAS: ROUGH FINAL ` FINAL BUILDING ` DATE CLOSED OUT ASSOCIATION PLAN NO. r TME T Town of Barnstable Regulatory Services RIMSTM MASS. �, Thomas F.Geiler,Director 16.9. �6 'fin ' Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must _Complete and Sign This Section If Using A Builder I, iLs�A, o ��^� , as Owner of the subject property hereby authorize_ )- \I' to act on my behalf, Sin all matters relative to work authorized by this building permit PIke- "rJ.'J AA-1-7 (Address of ob) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. S e of Owner Signature of Applicant Print Wame Print Name 017-C 3 62 ate Q:FORM&OWNERPERMISSIONPOOLB 62012 Town of Barnstable Regulatory Services Thomas F.Geiler,Director 'UM g Buildin Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 - www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building Rermit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require;as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. C:\Users\decollik\AppDataVocal\Microsoft\Windows\Tempomry Internet Files\ContentOudook\QRE6ZUBN\EXPRESS.doc Revised 053012 � I f f :Massachusetts - Department of Pui)lic Safety,. Bo I'd of'Builtlin�� Re�ulZrtions iintl Standards' Construction Supervisor License One-and Two-Family Dwellings License: CS 71165 CHARLES R CROVO 45 HATHAWAY RD OSTERVILLE, MA 02655 a Expiration: 12/20/2013• (1 mmisi�r�icr Tr#: 5542 V/�e rpo�nunw�rzcuea`l�n�P/j�ecv�tcc�ccaeCG� aeq � Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR beforeth piration date. If found return to: gistration: r1`75638 Type: Office o Co Sumer Affairs and Business Regulation piration: 5%28%2Q15:. Corporation 10 ar PI -Suite 5170 s n, A 2116 DUNHILL COMPANIES LTD J CHARLES CRORO II r 45 HATHAWAY RD OSTERVILLE,MA 02655 - Undersecretary ova out signature The Commonwealth of Massachusetts Department of IndustrialAccidents 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): ,1 '11 (fSAAP Address: City/State/Zip: 6A",c, Phone#: Are you an employer?Che k the appropriate box: Type of project(required): 1.❑ I am a employer with 4. 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. emodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' insurance.: 9. ❑Building addition comp. [No workers' comp.insurance 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.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: J®C�loqrr /tS' sJ Policy#or Self-ins.Lic.#: b U 7— Expiration Date: Job Site Address: D v � City/State/Zip: J Attach a copy of the worked, compensation policy declaration page(showing the policy nunker and expiration date). Failure to secure covera. required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,50.0.0 d/or ne-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a aga' the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of e f r' ce coverage verification. I do hereby c d h pai a es of perjury that the information provided a rove is true and correct Si ature: � Date: Phone#: (� Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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 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 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 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-contractor(s)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 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 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 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia Client#: 15284 2DUNHILLCO ACORD,. CERTIFICATE OF LIABILITY INSURANCE =05/15/2013 YY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Dowling&O'Neil PHONE 508 775-1620 FAX Insurance Agency EMAIL'Ext• arc,No: 5087781218 9731yannough Rd., PO Box 1990 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Hyannis,MA 02601 -INSURER A:AmTrust E&S Insurance Service- INSURED INSURER B:Associated Employers Insurance Dunhill Companies LTD INSURER C: 776 Main Street r Osterville,MA 02655 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF.INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE, FOR THE POLICY PERIOD. INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSL7RR TYPE OF INSURANCE NSRL SWVD POLICY NUMBER MUBR OM�LDDY EFF MPDY EXP LIMITS A GENERAL LIABILITY NES100415800 D812112012 0812112013 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $50 000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $5 000 X 81/1RD Ded:1,000 PERSONAL&ADVIINJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $1,000,000 POLICY JET LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea a.dent ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED P BODILY INJURY(Per accident) $ AUTOS AUTOS ( ) HIRED AUTOS NON-OWNED PROPERTY DAMAGE. $ - AUTOS Per accident UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ B WORKERS COMPENSATION WCC501088012012 7/75/2012 07/15/201 X WC STATU- OTH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $500 000 OFFICER/MEMBEREXCLUDED? � NIA (Mandatory in NH) a. E.L.DISEASE-EA EMPLOYEE $500 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,-waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Greg Anderson SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2 Irving Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis Port,MA 02647 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S111278/M111277 LS1 Rightfax C:3-2 2/28/2013 :5:20:4.6 .AM PAGE. 2/002 Fax Serer CERTIFICATE OF LIABILITY INSUR;+ NCE DATE.fmmrDla/rilrYl IFICATE 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 ISSUINGINSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER AND THECERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED;the policy(ies)must be endorsed..If SUBROGATION IS UVAIVED,,subject;to; he terms and conditions of the.policy,certain policies:may require:and,endorsement:. AS' on.ihis certificatedoes not confer rights to he certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PAUL PETERS AGENCY INC PHONE FAX 680 FALMOUTH ROAD (AIC,No;Eict): ()VC No). MASHPEE,MA 02649 E-MAIL ADDRESSi. 28'LBR INSURER(S)AFFORDING COVERAGE NAIC M INSURED INSURER A: ACE:4MERICAN WISURANcE COMPANY TS REED INC D 3P.REED PL=JNlB?NG&;HEATWG INSURER.B:. INSURER C: INSURER:D; 1.29INDUSTRIAL DR�rIT l: INSURER.E: MASHPEE,NL4 02649 INSURER F: i COVERAGES CERTIFICATE NUMBER: REVISION NUMBER. THIS CERTI T THE POLICIESOF INSURANCE LISTED BELO t S 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 WHIE THIS CERTIFICATE MAY BE ISSUED-OR MAY PERTAIN:THE INSURANCE AFFORDED BY THE POLICIES DESCRBED-HEREIN IS SUBJE&TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMRS'SHOVdpI NAY- HAVE BEEN REOUCED.BY.PAID CLAI/AS. - - - - INSR ADD SUB POLICY'EFE;DATE POLICYEXPDATE LTR TYPE OFniSURANCB L R POLICY'NUMBER _(.MMDD%YYYY) (MA71DM.YYYY1 LINTS GENERAL LIABILITY ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY: .CLAIMS MADE OCCUR. AMAGETGRENTED EMISES:(Ea pccurrence) ED.EXP(Arty one person) S. GEN'L AGGREGATE LIMIT APPLIES PER: ERSONAL ADV INJURX $. POLICY PROJECT❑LOG ENERAL AGGREGATE. $ ODUCTS=COMPIOP AGG' $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE. $ LIMIT(Ea acm ert) ALL OWNED_AUTOS; BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS' (Per accident) PROPERTY.DAMAGE: $. (Per:acCident) UMBRELLA LIAR M OCCUR EACH OCCURRENCE. EXCESSLIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $. RETENTION A. WORKER'S COMPENSATION AND WCSTATUiORY OIriER EMPLOYER'S LIABILITY YIN:. UB-5B756587-12' 12/292012 12129.2013 LIMITS ANY PRGPERITORIPARTNERIEXECU[Nc N)A,_ - E L EACH ACCIDENT $ 0==10ERIMEMBEi2 EXCWDED? 5Ou,000 (MandatoryinNH) E.L.DISEASE-EA:EMPLOYEE:$ 500,000 - it yes.describe under - - DESCRIPTroN O=OPERATIONS beldW E.L DISEASE-POLICY-Lliwl7 .$ 500`,000 DESCRIPTION:OF OPERATIONSILOCATIONSNEHICLESif STRICTIONS;SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFTCATE 3S1 TED TO THE;^ERTIFICATE HOLDER AFFECTING w0RIC$RS CONP.COVE AdE: CERTIFICATE HOLDER; CANCELLATION DUNHILL.CO_'vMPANIES SHOULD'ANY OF THE:.ABOVE DESCRIBED POLICIES BE'CANCELLED 776 MAIN ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL B IN ACCORDANCE WITH THE.POLICY PRO AUTHORIZED REPRESENTATIVE O S TE R VIL L E,.NS?,.,:02 65 5 ACORD 25;(2010/05) the ACORD name and logo are.,registemO marks of ACORD 1988.2010 ACORD CORPO rights reserved. COLECOS-01 CLEDDUKE '`" 4:>R ZX CERTIFICATE OF LIABILITY INSURANCE DAT 2 J28/22812D/Y013 3 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME,cT Strategic Business Unit RogRte 134 ers 8 Gray Ins.-Dennis Branch A/C,N 434 Ext:(508)398-7980 ac,No):(877)816-2156 South Dennis,MA 02660 E-MAILADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Main Street America Assurance Co. INSURED INSURERB:NGM Insurance Company Coleman Costello INSURER C: 15 Bennett Ave. INSURER D: West Yarmouth,MA 02673 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTRR TYPE OF INSURANCE IN SR WVD POLICY NUMBER M ADDLISUBR P�p EFF MMfD Y EItP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY MPT2553D 1/19/2013 1/19/2014 PREMISES Ea occurrence $ 500,000 CLAIMS-MADE [XI OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADVdNJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE.LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS PER ACCIDENT $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LUIS CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X WC STATU OTH- AND EMPLOYERS'LIABILITY TRY LICIT ER B ANY PROPRIETOR/PARTNEPJ—ECUTIVE Y I N WCT2553D 9/17/2012 9/17/2013 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? y N 1 A - (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) The certificate holder is an additional insured under CGL,provided it is required in writing to name the certificate holder as an additional insured.Injuries to Coleman Costello are not covered under the workers'compensation policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Dunhill Construction THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 776 Main St Osterville,MA 02655 AUTHORIZED REPRESENTATNE "uA1e ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD I Cliarif#>44947 2ALLCA13 UA lE(M 001YYYY) - ACORD- CERTIFICATE OF LIABILITY INSURANCE 03/19/2013 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]SSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certifcata holder is an ADDITIONAL INSURED,the:policy(iac).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 doas not eonfet rights to the certificate holder in lieu of such endorsemant(s). PRODUCER NIA t - NAME Dowling&O'Neil PHONE -1620 `AX 5087781218 AIC No Fit,:508 775 AtC Nb: Insurance Agency EMAIL . - 973 lyannough Rd., PO Box 199Q aoDre�ss' UISURERj3)AFFORDPIC COVERAGE NAIL& Hyannis,MA 02609 INstilitR A.Acadia.InsuranC9 INsuRtD Richard SullivanINSURER;B,Associated Employers Insurance. ` &.Alision Quattromini iNsuRER a:;Commerce Insurance Company DBA All Cape 775 Pro INSURERD.i. P.O Sagamore;MA 02561 INSURER t .. - 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BEISSUED.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 REDUCIED BY PAID:CLAIMS. MSR ADD U POLICYEFF: POUCYEXP L.TR IY!'EOF.INSUWINCE INSR.wvD. POLICY NUMBER IMWDDtYYYVI IMP41DWYYMuMtIS A ceNEKALLIAMILILY BOA5077759.10 D110212013 011,0212014 EACH OCCURRENCE $1 000000 .A <'.OMPAF HC:IAI CiFN)-KA1 I IAHII11+f. DAMAC*-10 Ri-N 11-1) PREMISES Enbawnwlw $50000. CLAIM •m1 br: F—xl ottun MEDEXP(Ally VIiH.pmWn). $5 000 )`t,KSONAI It ADv IN:iurii'. $1;000;000 GENERAL AGGREGATE $2 000 000 fFMI.ACi(iHFCAfF'1IMI:IAPPItFSYFR. PH61it if'I ciG PvtpmkAtin, $2,000;000 POLICY :PHt7- LOC _$JECT . .. . C AUPOMOIIII+uABILIiY 13MMBBWC86 110512613.'011051261' (tea" Bdl)Sw("1h.I.Iml1 g1000,000 ANY.AUTO - BODILY INJunr(rbl vWisin), $: ALLOWNED SCHEDULEDAt I I OR PIODUYINJIIRY-Mrrarntlrnt -$ HIHFU AI)1 Dfi NON•OWNtU. iPRO=,1,)AMAGF" .$ AUTOS fti acudwd $ HCLAMS-MADE UMBRELLALUIB'. FACHTtt:Cukklhe* :$ EXCtSSUAB AGGREGATE 3 l)FII. HFI FN I ION WORKERS,COMPENSA LION'. ..... ..... VYC.:i l All). O:I'H- B' AND'EMPLGYERs,uABB.try W=666501.16252013A ,11021261.3 01/02/261 X ANY PROPRIEToRIPAnTNERIEXECUTNE Y1 IN F.I.FAC:H ArOW-NI $5011 000: 01-FIC:FRIMFMPiFK FXCI till - N 1A (Mandatory In NH) .. .. E.L.DISEASE S EA.EMPLOYEEI$500A00' If Y IPs,J anu tin,rl nhP I .. ❑Escmr ION.OF oCEnknNS-bWI ),j DI$FAll"t---FIN ICY IAMI I $500000 DESCNIP(IOM01-OPERA IONS 1 LOCAhONS)vfhKICLES(ASpchACORU 161,AddlUomi"Mar III;Schedule,:llmdre space Is rogWradl ; Insu gisl iedoherms,contons, x.cl.usions;;otNer,limitations and endorsements:.eim e Nothing contained.in the certificate of insurance shall be deemed o have altered,waived,or extended.the. coverage prov(dad by the policy provisions, CERTIFICATE HOLDER CANCELLATION DUnhiIl;Com an SHOULD ANY OF"THE ABOVE DESCRIBED POLICIES BE CANCELL.ED BEFORE P y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELVERED IN 776-Main street. ACCORDANCE IANTH, THE POLICY' PROVISIONS: Osterville MA t 02655 AUTH0R2ED REPRESENTATNE: >19884010 ACORD CORPORATION:All rights reserved. ACORD 2612010105). 1 of The ACORD name and logo are nagisterad marks of ACORD #S1089091M108908 L81 ACORI DATEIMMIDDIYYYY) CERTIFICATE CF LIABILITY INSURANCE 0?707-2013 THIS CERTIFicATEIS 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 CERTIFICATEOF 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 ADDITIONALINSURED,the policy(ies)must.be.endorsed. If SUBROGATIONIS WAIVED,subject to, the terms and conditions of the policy,certain policies may require an endorsement. A statement On this,certiffcate.does not confer rights to the certificate holder in lieu.of such endorsement(s). PRODUCER .. .- ... .. ..... Co -.... NAME, PAYCHEX INSURANCE .AGENCY INC PHONE FA X 210705 P O- F: (888)443.-6.112 A'C N°<Ext: (A/C;Nd): ($98)443-6112 PO BOX 3 3 01:5 ADDRESS: SAN ANTONIO TX 78265 INSURER(S)AFFORDING:CO.VERAGE NAIC;C INSURER.A: Twin 'City Fire Ins Co. INSURED. INSURER B . �: : INSURER C HULTEN INC 2 MAGNOLIA RD # :B INSURER D. YARMOUTH PORT MA 0.2635 INSURER INSURER-F.: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW:HAVE BEEN'ISSUED TO THE"INSURED`'NAMED ABOVE.FOR THE POLICY PERIOD. INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY`GONTRACT OR OTHER OOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO.ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF$UCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE-OF INSURANCE I LIMITS LTR .. 11NSR WVD POLICY NUMBER �fMMIDD1YYYY► (MMIDDNYYY) fiENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY UAMAutivritivitu PREMISES (Ea',omurrence) $ �I CLAIMS-MADE. OCCUR MED EXP IAnyvne person); $ U u [PERSONAL&AbV INJURY I S _ . GENERAL AGGREGATE.: $ GENT AGGREGATE LIMIT APPLIES:PER- PRODUCTS-COMPIOP:AGG $ POLICY �I PRO= I I LOC .... - 1.. S .AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S IEa accident) .ANY AUTO :BODILY,INJURY(Per person) :S ALL OWNED —SCHEDULED ' I BODILY INJURY(Pe accident) $ AUTOS u AUTOS.. PROPERTY DAMAGE HIRED AUTOS NON=OWNED (Pecaccident) H.AULOS S ., S UMBRELLA LIAR U OCCUR EACH OCCURRENCE S EXCESSLIAB CLAIMS-MADE._u : I.._. ,'AGGREGATE. :$ ._...._., DED!. I RETENTION $ -S WORKERS COMPENSATION WC STATU• OTH- AND EMPLOYERS'LIABILITY Xs'TO Y LIMITS PER _. AN - Y PROPRIETORIPARTNER/EXECUTIVEY N N,/A E.L.EACH ACCIDENT. . . 5. 100 000; A OFFICER/MEMBER EXCLUDED? I ' 76 WEG. TQ3295 02/21/2013 02/21/2014 :,. (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 100 000 If yes,describe under DESCRIPTION OE OPERATIONS below El.DISEASE.=:POLIC.Y'LIMIT '9 5 0 Q r Q DESCRIPTION.OF.OPERATIONS I LOCATIONS.PVEHICLES.(Attech ACORD 1Q1.Addtionel-:Remarks�,Schedule;_if'more space;is;required) - Those i1sual to the Insured;'s Operations.,, GERTIFICATE_HOLDER' _CANCELLATION SHOULD ANY:OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE .Dunhill Company DELIVERED IN.ACCORDANCE WTH THE POLICY PROVISIONS. AUTHORIZE PRESENTATIVE: 776 Main St. Osterville. , MA 02655 Cl 19Rg=261.0 ACORD CORPORATION. All.rights reserved;. ACORD-25 (2010/05► The ACORD-name and Iogo:;are.registered marks of ACORD' i '1Fik' 1-�-"r'CJl� .�: FA:t Fr•nt;t:h=1'r? Ii•i�+ULF.Iid>; t o ��'+t�1 a1=�-15� ='.�3ri: �'i; .��•4�'A�S.��. r aaTe It�frAvarcYrvi CERTIFICATE OF LIIA9ILITY INSURANCE P3je ` 00 1 03 f 1zJ2013 _ TIOS CERTIFICATE IS ISSUEDAS A►�IATTER(O FIN FIORMATION'ONLY AND CONE.-14S NU RIGHTS UPON TH-::(:ERTlFICR E H0.LD!ER.THIS CERTIFICATE DOES NOT AFFIRMATIVEI Ir 0.K 1dEGATIVELY.l1wwD,EXTEND OR ALTER.T.HE COVERAGE.AFFORUEDZY THE POLICIES BELOW. TH!.S GERTIFICAITE 01`:Ii'I31j,RANOE DOES NOT CONSTITU-tE'A dONTf3ltCT BETWEEN THE iS$jJll.- IN5URE6{{S};AUTiIORiZEu RLP RE$ENTA'1'IVH OR PROIDUCEFt,A.N.O.t E CERTIFfCATE tiOLUER: wKsATANT: N'the 00"ifitate hold.er iS an ADOITI©NAL INSURED,the 1S WAIVED,5-Alec(Ev he:terms and coW;llonSoftho00ley,toratnpoljciesmayregdirwanenclorsement:-Asatementurn,thE:certi iedwesnoS4crriEeerightsto4tre certificate holder i10 ilep of S:Ich:�ndor�em�nt(s).: W4IA"e cf Ta_paeas--e, '>DC. 26 Ccytury.UYvd: - - t,;.�,L7a•_ 871 �45 T37t3 P.O. sum 084"31 IF!'LaF Eft'SI L1Fr�fiO3MG C"sEtW_'F :_ ..._:_�_N.hC4 .. ftJSURER n:.n Uri th Am�sta3r %nautzose Cuwpzay a6535=CE5. " Cauzan%. $aeui:a>~ce 4 F}a,� J4t77-aCl NSP.1ra..tSlle;{ Pulldi:�ig YCOdUCtB: 1"- - — J.65' Gate Md.. I IN .lnER Amax ivan.-t3>,-d s�toe 6 Lxak tity 2a wrgn�e 26297-004 r r., snx 13A 'tom-- D: a�gaia��e ?eaata.. 39A: +12902-'3t1a: e4VERAGES sERTiFiCttTF Nt!?aI9ER.ia5?1ei. REV1Sf6�N N19�11�iEti:. _ T� N{S I )1 6 ?IFV T!'f:T 7Nr?CItCIES t�F IN uRIPICE i5TEE1 BLOW ttWE 6E5r1 iSSt1E(T^O TriE Ir.S r io 11RN4Eti AS'1T Pr'R.1rNE POL1- GE41C'D i ih {C:'ED.NOT'NITH�I�N71nr,a Y: RSOUTAEMENT,TEF4,4 O?CCNDIT oi-i OF;A.Y CONITF.A T DR D'THEft DOCLt1:fEWT.Yit!H f,ESPECT TO"WICH THi. Gr41IpICATE F.N:Y RF 15:WED OP."YY r-EPTAIN rHE ittl G. NCE PRFORbEb:$Y THE-P,U ,OE3,7ESCRIRED HEREIN is SUBJECT TO PLL THE TF_R.S° tXCLI�SiCt.'dS!+i!!Or PILIT:c�h'�P�F�SUhr'J�3C!E5 a_,tAIT S1-h1VJi�.IA3A'YH.AVrSEENR_EOFICED6'YPA'CIGLAINIS. :L�,.- ___ ___.� .--- ADD L-St!IT- C POLICY EFF _PULI Y£xP, I IU. TYPE`OPIN9tfixRNCE, 1 Pi)f�CY N_UNBER,. ,�rsxar�cxm�� EkM+SfSie�r Y'. A EI ERA LABILIT/ {{ n .d913s sz7 D6 IlUl l:/2OL2/1/2033 -•� U.LtIRREn E t �". i ? �DA�GE';iU RENTED ��- IL _ l ff 1 f Ee-t� err. 1 OL�O�C00 .Ccn:ui;; IRLN.,nt x ` - j _4. ZO __CQ_t I �. :, � �vF RAi:A GGiEL•0.Tc' 9 ...,4 tj_�6'..a a.... cM Rrr�A:rE L1AflT a'F3_i�', c'Z I ! �7R+'L`Jt T3 •..Op7R/4�_�Ft� �...4 IyGO'":a0a:.:. I i P 1 Rl X., C nSaGY-c'laa l'S.EUS T R E g WTOMWILELIAMIL � — Ic�Aa87eIti1(NYl IYDl1/gala k4:?T/203s tc auca �t 1rOt0 :000 �Las:aisas tc /asa/�+a1, { ai,;a:t 12 1^:�1(2913 C�rLY'NJ11aa(P ryaim z __ B tLrwvic i`I rr�bu ci. 2112E4i.NF` 1'OJ1i301a LG:/1,'2013:ta^ rtRa» tP3•�cctlsl, r� � —� A �4 ! e ._ niE'�a:lTUa X. ,AIT wtiE_ ICl�A5FTS127.(A"JSl; °. t,GJ1,2a11 �20/i/�Tl'? rPcrmtlen ��? I�•cy , ! �C14A52231Sb 13 11011/20'3; 5 _ - ,C IY.. !"IJYIIiPEtAtl.l�T]G- (,t,'.:':'h'... . (. I IbU(. 31�2D6Q�1`-- 110/Y/ 8 2x0:yix;t�3}.,EacMorc+_IRREncE �,,_1�,oGat30a . ' kxcus.uae a c4E�aTc IS 2 wrrzrERacasceNSAroN WC413952506 t�eG�j " 0'1/�OY2 iQyi(^oi�' X ,�Ytaln�_ F ANO EMPLOYERS ,ABt RY YIN; n CraY�l2n etlE'r+'ie9%kaluf,ExECJ.tVEi-h H/P,' ��`-Q13752806;(ilil 110(1;:Z412 (.OJ1(Z!?13 L ALHPCCC.liT �_."1 40R-J00 " OFFc wrnEntseR,rc uu:m �BG£E En�m�.aY } 11(100 094 l�iuli,trory nNHI I 04 r ns �nir —+ l Dix• E ^i]tk.'fLiJllT is: I OITD,'004 -- P. Ea�pse F.aemroL.3Rj (XS11S4$5?' JIG"1'2012 10�`r2^0;i'1 P4 OAO'080. Eq �aa — ' aS 33,000 OCU j: ; is �uz..iF.Ylyzng:aut"ez+oei.l g. DEbC,ilPTTON pFOPE4aTIONStcOGaTtONS`VT:'hICI.EsJ�"Ui:RdaRvn>U.%�s sacs xr... .., P CEkI r`:CArTEHOLOFrR CANCELLAI ION.. _.. SHOULDAla(OFTH.AW-3W DESUMBt)POLICi5z Be:CANCELLED5EFORE Ti-E EXPIRP'1'It7M :DA,E 'CHtRZ6r, n?QTIt;t WLt. BE 6L,L SROD IIJ. iCGOR AN •E 1AIT H THE ROLI(.'PM IS OtdS _ ter. �;.._`...::. ... �: ....�.... -fJ.'TMURGEDREPRESEtRaTNE : btRJfiS'LL CONSTRUC LON 7 @:waah'ST. 04Tc^N!f:l48 L A b2P355: CuYl 9034'.6b 1g1: 1595` 49 Ce*Ce195 "A1w )1988-aQ1'� t)iZDC(Jt+k�rSRATiDk,J4lirightsresPrvtiii.. ;ACORD 251201of(). TheACORo narne,and-lmge;arr registered marks of ACORD DATE(MMtDD/YYYY) A oRU CERTIFICATE OF LIABILITY INSURANCE 2/28/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND:CONFERS NO RIGHT..S 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 sWtement;on this certificate does not confer rights to the certificate holder in lieu of such endorsernent(s). -CONTACT - PRODUCER NAME: Leonard Insurance Agency, Inc PHOME „ (508)428-6921 Fes` (508)620-5405 A!C-No 6B3 Main Street EMaIL ..tina@leonardagency:com. Suite B INSURERS'AFFORDING COVERAGE NAIL# Osterville `MA 02655 INSURERA:Travelers Ind. Co of IL-ARWC. 13579 INSURED .INSURER.B:: Timothy Brennan INSURERC: Blueboard Specialists Plastering Co INSURERD: 117 South Main St. INSURERE Centerville MA. 02632 1 INSURER F COVERAGES CERTIFICATE NUMBER.WC'Master 2013 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 CONTRACTOR 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 SHO WN MAY HAVE:BEEN REDUCED BY PAID"CLAIMS.• INSR - ADDLSUBR .., ... .POLICY EFF POLICY EXP - LIMITS " LTR TYPE OF INSURANCE .POLICY NUMBER" MMIDDIYYYY M ! DIYYY - GENERAL LIABILITY EACH OCCURRENCE $ DAIWAGE TO RENTED. COMMERCIAL GENERAL':LIABILITY' PREMISES Ea occurrence` S CLAIMS-MADE DOCCUR MED EXP(Any one person)` $ PERSONAL B'ADV'INJURY $ GENERALAGGREGATE' $ GEN'L.AGGREGATE LIMIT APPLIES PO,ERb PRODUCTS-.COMPlQP Add POCKY PRO- t' $ " AUTOMOBILE LIABILITY 'Ea accident -COMBINED SINGLE,LIMIT "" `ANY AUTO BODILY INJURY(Per,person)' $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED. PROPERTY DAMAGE' $, HIRED AUTOS AUTOS Per accident UMBRELLA:LIAB OCCUR - 'EACH:OCCURRENCE $ RiCESS LIAR CLAUVIS-MADE AGGREGATE $ t DED RETENTION$ TH- A WORKERS COMPENSATION WCSLI 0ER AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER)EXECU_TIVEY/N E.L EACH ACCIDENT $.: 100, 000 OFFICERIMEMBER EXCLUDED? N❑ 'NI:A PJUB-0194N841B /.3X2013:" /3%2014 (MandatorginNH) E:L.DISEASE'--EA EMPLOYEE S 100,000 If yes;describe under - DESCRIPTION OF OPERATIONS%below E.L.DISEASE.-POLICY.LIMIT $'- 50.0 0.00 DESCRIPTION.OF OPERATIONS I LOCATIONS I VEHICLES(AttachACORD 101,Additional`Remarks Schedule if a ore space is required) CERTIFICATE HOLDER CANCELLATION (506)420-2791 'SHOULD ANY'OFrTHE;ABOVE DE$CRiBEDPOLICIES<BE CANCELLED BEFORE THE: EXPIRATION DATE` THEREOF, NOTICE WILL. BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Dunhill 'Group 776: Main St. Osterville, MA 02.655 AUTHORIZED REPRESENTATIVE Tina Boul9s/LEOTE11 !� ACORD;25(2010J05) ©1.986-20.16 ACORD CORPORATION. All rights reserved. INS025'(2o�oos)ot The:ACORD name and logoe d marks of ACORD 02L27I2613 10:30 19785214669 COWAN INSURANCE PAGE 01%01 ONYYY ACDRD CERTIFICATE OF LIABILITY LNSURANCE °��' '"'° ' 111�ft3 . PRODUCER ZA IFICATE IS ISSUED A$ A MATTER OF INFORMATIUrJ D .CONFERS NO RIGHTS UPON THE. CERTIFICATE Cowan Insurance Aging,lnc: THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 359 Main:Street RED.I3Y.THEPOLICiESBELHavtl►ill MA 01630 FFORDINGCOVERAGENAIC#IN3URED Gus Palntlng,Inc. n to rs Mutual Casual Com n 8 Woodbury Lane INSURER D: Associated Em to InsuranceCom a INSURER.0 .. ... Dartmoutb MA 02747 �J:N!URER RER Oi. E7. COVERAGES THE POLICIES OF INSURANCE LIVED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED MOVE FOR THE:.POLICY PERIOp INDICATED.MOYWITHSTANDBVG ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TEAS CERTIFICATE MAY BE ISSUED OR' MAY PERTAIN, THE INSURANCEAFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO:{1LL TH€TERMS E�iCLU510NSANO CONDITIONS=pF SUCH POLICIES.AGGREGATE LIMITS SHOWN.MAY HAVE BEEN REDUCED BY PN..D;GtAIMS.. POLICY NUMBER POIJCY.E CFIVE POI:ICY.EXPIRATKIN LQAIT3 - .. .... GENERAL LIABILITY EACH OCCURRENCE DAMRGE 0 RENTED - A x COMMERCIAL oENERAL LwealTv 2D48865 0410612012. O4Ip81x013: ES.�e cn a U 009 CLAIMS MADE �OCCUR mE6 EXP(AnyPe t S 000 z Slanket add8lonAl insured PERSONAL AADV:INJttRY a 100 000 GENERIH AGGREGATE` Z,000.000 _ GERL,AGGREGATE LIMIT APPuss PEA, PRODUCTS CONPJOP'AGG $2,000 000 X POLICY' PAc' 7.Loc. AUTOMOBILE UABIUIY COMB SIN :g ANYAUTO (EDm0dent) . ALL OWNEDAUTOS BODILY INJURY S (Par paw}) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ {pa:ecctdent}. NOW-OWNED AUTOS PROPERTY DAMAGE:. (Per ec"rR) GARAGFUABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHERHAN EAACC S' AUTO.ONLr ACC, s EXCESSNMBRELLA L ABILITY EACH OCCURFENGE' 8 OCCUR ❑CLAIMS MADE AGGREGATE: 8 7 DEDUCTIBLE $ RETENTION....: WORKERS COMPENSATION AND X.. EMPLOYERS'LIABILITY 8 WCC5004060012072 01122113 0014 -E.L EACH AccioeNT a 500000 ANY PROPRIETOMPARTNERIEXECUTNE OFFICERIMEMBEREXCLUDED?: EI:DISEASE-PAEMPLOYEE $500000 u y �iieatdts+un {�0 F E.L.oiase-poucY:;�rArr s:500 000. OTHER OE6CAIPT(ON Of OPERATIONO I LOCATIOND I VEHtGLFB/EXCLUStONB AD=OY ENDORSEMENT I SPECIAL PROVISIONS 509 420 2791 ti P41n6n contractor. All parties as reqtfired b ;contract are listed sn`add&natinsureds on the general liability Insurance policy, CERTIFICATE HOLDER CANCELLATION 9HOUl0ANY0fTHEABOVEoegcm9t�6P0Ugrogre NcrLL=BuonTKBEMRATM. Dun hiltGDmpanies. DATE TNEREOf,THE IBSUINQ'lN9URER NULL ENDEAVOR TO MAiI 10 DRYS YJR N 776 Main,St: Nomcc to Tim CERTIF TEHO RNAMEDTO THE LEFT,BUTFAILUREToD080smi. (m000n NO oumT OR1Jmu `OF;ANY.XtND UPON THE INSUREK rt9 AG> M.OR: Ostervflte,MA 02655 amaEs�ITATTUE AVTHoitRJDREP ENTAnVE. ACt?RD 25(2001109) 0ACORD CtORPORATION.10.. Parcel Lookup Page 1 of 1 I � Logged In As: Pa rCe( Lookup Wednesday,October 25 2017 Road Lookup Condo Lookup Multiple Address Lookup Reports Search options Search By Street, Street# # Street Name park place Village `Hyannis v Search <Prev Next> Page 1 of 1 Rows/Page: oo Parcel Location Owner Village Index Map 286-017 8 PARK PLACE DRUMCHAPEL HOLDINGS LLC HYAN 1207 286017 286-010 23 PARK PLACE LLOYD, TANGLEY CAMPBELL HYAN 1207 286010 286-018 26 PARK PLACE CONNOLLY, PAULINA Q HYAN 1207 286018 ` http://issgl2/intranet/propdata/lookup.aspx 10/25/2017 i 1 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel `application # Health Division .. Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Stree Address Village Owner - Address( �"fQ \ PUF N Telephone Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing .proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuatio X,C5Bkz� 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 Kingq Highway,,❑Ye. ❑ No ZZ Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other �<I 1_u T Basement Finished Area (sq.ft.) Basement Unfinished Area (sq>.ft) "` -n Number of Baths: Full: existing new Half: existing new 4 � � a Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Court Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing .New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current_Use Proposed Use APPLICANT INFORMATION _ (BUILDER OR HOMEOWNER) Name Telephone Number Address License # 12-- A b) Home Improvement Contractor# Worker's Compensation # (5�cc �O 16 nm)Z�IZ ALL CONSTRUCTI EBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �� .►� I - SIGNATURE DATE 5 2/ I • I d FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ' i ADDRESS VILLAGE !` OWNER y DATE OF INSPECTION: wF:O,UNDATIO.No,g( �, U DA i a FRAME - - - - - - - 1 . ;.k}INSULATION r FIREPLACE ELECTRICAL: ROUGH FINAL - `. PLUMBING: ROUGH FINAL GAS: -ROUGH FINAL FINAL BUILDING DATE CLOSED.OUT '• ASSOCIATION PLAN NO. I, - I = The Commonwealth of Massachusetts Department of Industrial Accidents - Office of Investigations 600 Washington Street Boston,M4 02711 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Businessiorganization/Individual): Address: ,% l�fn� City/State/Zip: .&,c& `Phone#: � �Z- Are you an employer? Check the appropriate bog: Type of project(required): 1.[] I am a employer with 4�am a general contractor.and I employees (fun and/or part-time). * 4 have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have gemolition working for me in any capacity. employees and have workers' comp.insurance.: 9.. 0 Building addition [No workers -comp. insurance P• required.] 5. 7 we are a corporation and its .10.❑Electrical repairs or additions 3.❑ I am a homeowner doing aIl work officers have exercised their I LE]Plumbing repairs or additions myself [No workers' comp, right of exemption per MGL 12.❑ Roof repairs instn-ance required.]t C. 152, §1(4),and we have no : . employees. [No workers' 13.7 Other . comp.insurance required.] *Any applicant that checks box#I..must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this effidavh indicating they are doing all wort: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 isproviding workers'compensation insurance for my employees. Below is the policy andjob site information. _ � l$ � ell Insurance Company Name: I` Poficy#or Self t� ins.Lie.#:_t_>�V N 2®�Z Expiration Date: 24 Sob Site Address: City/State/Zip: (A 1;K "/ Attach a copy of the workers' compensation olicy declaration page(showing the policy numb 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$1,50.0.00 and/or one-year imprisonment,-as weIl as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day the �•o t. B advised that a copy of this statement may be forwarded to the Office of Investigations of the D f c c erage verification. I do hereby-certify u the id er !ties of. a that the information provided abo a is true and coned Si afore: Date: r/0>4) Phone Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit(License# IsSu ng Authority(circle one): 1.Board of Health 2.Snilding Department 3. City/Town Clerk 4.Electrical Inspector 5.-Plumbing Inspector. 6..Other Contact Person: w. 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 emplayer 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 e house of another who employs ersons to do maintenance,construction or repair work on.such dwelling house` dwellingP �-- or on the grounds or building appurtenant thereto shall not because of such employment be�deemed to be.an employer. 1 MGL chapter.152, §25C(6)'also states that"every state'o local licensing agency shall Fithhold 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( )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 s : Please fill out the workers' compensation affidavit completely,by checkmg-the boxes that apply to your situation and, if. necessary,supply sub-contractor(s)name(s), address(es)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' 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 ins=ce 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 enterthair 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 yousegarding the applicant Please be sure to fill in the perzpitliicense number which will be used as a reference number. In addition,an applicant that must submit mtiltiple permit/license applications in any given year need only svbzuit.dne affidavitiiadicsting current. policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in city.or town)."A copy of the.affidavrt 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 relaxed to any business or commercial venture . . (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.l The Office of Investigations would Ile to thank you in advance for your cooperation and should you haveany questions; please do not hesitate to give us a call. ti .��' l' s: The Department's address,telephone and'fax number: " The Commonwealth of Massachusetts Department of Industrial Aaddents Office of Investigations 600 Washington Streit Boston, MA Q21I I Tel,#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 .evised 4-24-07 www.mass.gov/dia Client#: 15284 2DUNHILLCO ACORDr.. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/OD/YYYY) 05/15/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Dowling&O'Neil PHONE 508 775-1620 FAX Insurance Agency E-MAIL arc,No: 5087781218 973 lyannough Rd., PO Box 1990 ADDRESS: Hyannis,MA 02601 INSURER(S)AFFORDING COVERAGE NAIC A INSURER A:AmTrust E&S Insurance Service INSURED Dunhill Companies LTD INSURER B:Associated Employers Insurance 776 Main Street INSURER C: INSURER D: Osterville,MA 02655 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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. �TRR TYPE OF INSURANCE IANDSRL sWUVO POLICY NUMBER MMIDDY YY MM/DDY E'tP LIMITS A GENERAL LIABILITY NES100415800 D812112012 0812112013 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $5O 000 CLAIMS MADE I OCCUR MED EXP(Any one person) s5,000 X BI/PD Ded:1,000 PERSONAL&ADV iINJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $1,000,000 POLICY ECO- 0 LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ RED I I RETENTION$ $ B WORKERS COMPENSATION WCC501088012012 7/15/2012 07/15/201 X wC STATU- OTH- AND EMPLOYERS'LIABILITYYIN TO 1 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500 000 OFFICERIMEMBER EXCLUDED? F_Y� N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500 000 If yes,describe under - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Greg Anderson SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED.IN 2 Irving Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis Port,MA 02647 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S111278/M111277 LS1 COLECOS-01 CLEDDUKE CERTIFICATE OF LIABILITY INSURANCE DAT 2128/22812DIY013 3 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ' IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Strategic Business Unit Rogers&Gray Ins.-Dennis Branch PHONE 508 398-7980 FAX 434 Rte 134 ac No Ext:( ) A/c No):(877)816-2156 South Dennis,MA 02660 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Main Street America Assurance Co. INSURED INSURER B:NGM Insurance Company Coleman Costello INSURERC: 15 Bennett Ave. INSURER D: West Yarmouth,MA 02673 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE IN WVD POLICY NUMBER POLICY EFF POLICY M/D Y EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY MPT2553D 1/19/2013 1/1912014 DAMAGE RENTED PREMISES L occurrence $ 500,000 CLAIMS-MADE 1XI OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO JECT LOC $ AUTOMOBILE LIABILITY Ea BIKEDociden SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED P BODILY INJURY(Per accident AUTOS AUTOS ( ) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS PER ACCIDENT $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WCT2553D 9/17/2012 9117/2013 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) The certificate holder is an additional insured under CGL,provided it is required in writing to name the certificate holder as an additional insured.Injuries to Coleman Costello are not covered under the workers'compensation policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Dunhill Construction THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 776 Main St Osterville,MA 02655 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD r - �./ 12 ? 1 AM. 8 9 :5 Arc CERTIFICATE OF LIABILITY INSURANCE �TFrH„ti�;rY`✓YJ 02J1412013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORmArON ONLY AND CONFEi'S N RiC-HTS J"POaF 7ttE Ca-RTIFICATE HOLDER. THIS THIS [SCEs NOT AFFIKEAATIUELY OR NEGATIVELY:AMEND,-EXTEND,:OR ALTER THE COVERAGE AFFORDED BY.THE pouciES BELOW. THIS.CERTIFICATE OF INSURANCE- DOES NOT CONSTITUTE A.Ct3NTRACT BE?UVEEN THE.IMING:INSURENS),AUTHORIZED rth.v EPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.. PORTANT:if the cehificate holder is an AODMONAL INSURED,the policy{lest crust bp._endorsed i!SUIBROGAT1tdN IS WAIbE.^ s�liJscr to tarrns and conditiahs ofthepolicy,certain pnlici®s r Jay.requtro an b do' e 'it. A s:afamant�J�rtificate holder in Iieu of such en sorseJnesi6( }; 'PR:rDUCER 02317-JDi ..._ .. . _ 4 W ERCT .... _.. Lawrence-Catlin Ins Agency Incgzi_s5Q8r�4041 60 Fes.No. 230 Jones Road Falmouth,MA 02510 ` ass_ R1 r1iJWai nsJ3r�nLe CgrTpanq i 33758 Adam Pefty - A P Atlas Landscaping rra u4 R i 11 Pitch Pine Lane LinlsuLrE�o-^ �— East Falmouth,RIA 02536 f—. RSSURERF:. € - COVERAGES CERTIFICATE NtlhiirER _ RElfiE(OH NUM BER:. THIS IS,TO CERTIFY TAT THE POLICIES JF'INSURANCE IS TM BELOW HAVE S 5HE aSJRFD 4A1ED ABOVE E FOR THE.PuLt \ P_RIOC.NDIGA-EU N'CTP7 hSTANC!NG ANY REO J10.'VENI TERM •OR CON DITION:OF .ANY CONTRArT:Ox O1HZF l)aICUnr_t'i F4l H, R PELT,TO WFIGH:TFI.S CERTIFICATE MAY BE ISSUED OR prr:Y PE RT4rJJ He RvSURANC.E,&FFOR2ED BV TIE POLICIr .UF;�.r:;ibEu -100J 1S SUB.?E_:T TQ`ALL HF."ERMS,- cYCLJSION1 pi ,aN.!T;ONa07 S_-JCH P_.0 IFS.LIP*rS SHOd1FPj M9Y'H E-.PEEN RFD<JG U 2X.PF:!D:LAIrtS.. �� TrE_Of iNcttRA1JG` wok.WYQR POLIV UP4 3i. POLL v FF pp, iCry xy —�- -� I.'atdlC�/1'�YYIy iAl 1�Jtf 'W UVITS [GE, NEfW�LI461LI`t1 _ f arFJFi r r J ME -- ( i-- "N_ Sr .s. .;✓f - II.s c ` ra- 'li _._ 7 RSS CryPJ�PLY"S,gTI NN - .'_ - i AVD EMPLG�Eri.i 7AIL7'TY � � !P -._m is — L 4 C.:.Y,•A. I N wjA 90.-601333}-2.010"A I tr2$l2t t3: .f 2&`2U1w i J c E J s 100,00Q {JNxntlefory h Nl, r i , r -"'OEa�F PT,ON Orf?eRRTIDti2 c4` :4TiOPJSIVE»NCLES;4xa�h ACuRp:9'JJ A7aio 3na Ronan,i.:Scna e.Gmwespacais-r3gtlw,df - `- -" GERTIFiL'4Tt HOLDER CANCELLATION �Charies Do hill Deveiopmeiifi MaIr.Olt r41 Street SH0kJLt AIJY OF ThE A'0 DESK P!BEE POLICIES,SE CAtICELLED BE CRE CJster Ellie;ftRA 02555 'THE E>•PIRATICtf CAtt3 .7tIERE F. h6:JTIC@ Tfd[LL BE DcLItiEREtT. IF.. ACCORDANict wrrii'THE P.D[:JCf PROAsiolis pUT1?ORITEG:RFPRESEJJTAJDlt � ...��• .... ... 19�8""01C.4, : FFORATION.All isghIs mservad, ACORfJ 25(.201.0105) The:ACORD.ni jrne and logo are regtsterei mar4 e,,?f:AC�?d� , THE COMMONWEALTH OF MASSACHUSETTS For OCABR Use Only. OFFICE OF CONSUMER AFFAIRS A Re str o E I V E D BUSINESS REGULATION 10 Park Plaza, Suite 5170 d Boston , MA 0 2 1 1 6 Ef'ective Date MAY 2 3 2013 Application for Registration as a Home Improvement Contractor or Sub-Contractor E>piration Date: aw ,•"� (MGL c.142A;201 CMR 18.00) ) G 6013 1. NAME OF APPLICANT: (MUST BE EITHER AN INDIVIDUAL,CORPORATION,LLC,LLP,TRUST,OR OTHER LEGAL ENTITY) 2. NUMBER OF EMPLOYEES: 3. APPLICANT TYPE: _INDMDUAL CORPORATION _PARTNERSHIP TRUST (CHECK ONE—MUST BE SAME LEGAL ENTITY AS THE ENTITY IDENTIFIED IN#1) 4. FEDERAL TAX ID#: 0-/�1/ 77 ZZ S. APPLICANT PHONE#: �/7� 27 y Uf APPLICANT EMAIL ADDRESS: CC/7Y21_/0,odoy' 6, MAILING ADDRESS � }�1/y �/ STREET CITY STATE ZIP 7. PERMANENT ADDRESS �� E l 0 � �� STATE ��Lp STRE PLEASE NOTE THAT A P.O.BOX IS NOT ACCEPTABLE FOR'PERMANENT ADDRESS. YOU MUST LIST A STREET ADDRESS. $, IF THE APPPLICANT IS A CORPORATION OR A PARTNERSHIP,ES RESPONSIBLE O THE CORPORATION'S THE LEASE PROVIDE THE NAME,ADDRESS,SOCIAL SECURITY#AND TITLE OF THE INDIVIDUAL WHO WILL TRUST'S OR THE PARTNERSHIP'S WORK(Please review the Instructions before answering this question): LAST FIRST TITLE 9. IF APPLICANT IS DOING BUSINESS UNDER A DB/A,PLEASE STATE THAT DB/A,AND ATTACH A COPY OF THE FICTICIOUS NAME CERTIFICATE FILED WITH THE CITY OR TOWN CLERK: DBA NAME: 10. (a)DOES THE APPLICANT OR RESPONSIBLE INDIVIDUAL ®LD ANN MOTHER CONSTRUCTION-RELATED STATE, CITY OR TOWN LICENSES OR REGISTRATIONS. VYES— (b)IF YES,PLEASE FILL IN INFORMATION BELOW.ATTACH ADDITIONAL SHEETS IF NECESSARY. LICENSE TYPE ISSUED BY LICENSE/REG.# EXP.DATE LICENSEE NAME 7 � � /V A9,5S 9D��rPB M 1' 1 3 S 11.LIST ALL PARTNERS,TRUSTEES;OFFICERS,DIRECTORS,AND MAJOR OWNERS(10% OR GREATER OF OWNERSHIP)OF AN APPLICANT PARTNERSHIP OR CORPORATION,BELOW.USE ADDITIONAL PAPER IF NECESSARY AND INCLUDE NEEDED PAPERWORK(SEE INSTRUCTIONS).PLEASE INDICATE BY AN"X" IN THE LAST COLUMN THOSE INDIVIDUALS WHO REQUIRE AN APPLICATION FOR ADDITIONAL REGISTRATION I.D. CARDS.USE ADDITIONAL SHEETS IF NECESSARY. FULL NAME TITLE % OWNER ADDRESS P.CARD 12. (a)HAVE YOU BEEN REGISTERED PREVIOUSLY AS A HOME IMPROVEMENT CONTRACTOR? .V YES _NO (b) IF YES,PLEASE PROVIDE THE NAME AND REGISTRATION NUMBER UNDER WHICH YOU WERE PREVIOUSLY REGISTERED: NAME: HIC REGISTRATION#: 13.(a) ARE YOU CURRENTLY OR HAVE YOU EVER BEEN AN OFFICER,PARTNER,OR CO-VENTURER OF AN APPLICANT WHO PREVIOUSLYXPLIED FOR OR HELD A HOME IMPROVEMENT CONTRACTOR REGISTRATION? —YES 1/ 1`!O (b) IF YES,PLEASE PROVIDE THE NAME OF THE APPLICANT/REGISTRANT AND THE REGISTRATION NUMBER: NAME: HIC REGISTRATION#: 14. (a). ARE YOU CURRENTLY OR HAVE YOU PREVIOUSLY BEEN EMPLOYED BY A REGISTRANT OR APPLICANT FOR REGISTRATION AGAINST WHICH DISCIPLINARY ACTION WAS TAKEN? YES_/NO (b) IF YES,PLEASE PROVIDE THE NAME OF THE APPLICANT/REGISTRANT AND THE REGISTRATION NUMBER: NAME: HIC REGISTRATION#: 15. (a)HAVE THERE EVER BEEN ANY FORMAL COMPLAINTS AGAINST YOU WHERE DISCIPLINARY ACTION WAS TAKEN BY THE DEPT.OF PUBLIC SAFETY OR CONSUMER AFFAIRS,OR ANY COURT JUDGMENTS OR ARBITRATIO AWARDS ISSUED AGAINST YOU? YES V 1V o (b)DO YOU OWYMONEY TO THE GUARANTY FUND? YES YNO IF YES TO EITHER,PLEASE IDENTIFY BY DATE,CASE NUMBER,OR:DOCKET NUMBER f IMPORTANT FEE NOTICE: CHANGE IN LAW ABOLISHES CSL's HIC REGISTRATION FEE EXEMPTION. As a result of a recent change in the law (Section 80 of Chapter 27 of the Acts of 2009), the holders of Construction Supervisors Licenses are no longer exempt from the HIC Registration fee. CONSEQUENTLY,ALL CONTRACTORS,INCLUDING CSL's WHO ARE APPLYING FOR A_ HIC REGISTRATION MUST PAY A REGISTRATION FEE OF$150.00,AND A GUARANTY FUND FEE. (See instructions for Guaranty Fund fee schedule.) 16. REGISTRATION FEE ENCLOSED:$ GUARANTY FUND FEE ENCLOSED: PLEASE INCLUDE TWO(2)SEPARATE CERTIFIED CHECKS OR MONEY ORDERS,ONE MARKED "REGISTRATION FEE"AND ONE MARKED"GUARANTY FUND."ONLY CERTIFIED CHECKS OR MONEY ORDERS CAN BE ACCEPTED.ANY OTHER FORM OF PAYMENT,INCLUDING BUT NOT LIMITED TO PERSONAL OR BUSINESS CHECKS,WILL BE RETURNED AS INELIGIBLE.MAKE BOTH CHECKS PAYABLE TO"COMMONWEALTH OF MASSACHUSETTS." I ereby swear, under the pains and penalties of perjury, that all information set forth on this lication.and submitted in support hereof is true and accurate to the best of my knowledge. riher,I ce fy under G.L. c. 62C, §49A, that I am in compliance with all laws of the mmo a Ith relating to taxes, reporting of employees and contractors, and withholding ng of child support 5h Si re ot�Applicant If corporation or partnership, position held. ffate 4 1 1 1 becretary or the Commonwealth:Acknowledgment Page 1 of 1 The Commonwealth of Massachusetts William Francis Galvin Date: Monday, March 25,2013 PAYMENT CONFIRMATION Confirmation DateTime: 3/25/201312:03:34 PM Confirmation Number: 176272 Invoice Number: 02000040082272182113927 Payment Id: 3512627 Transaction Id 8227218 Entity Name: DUNHILL COMPANIES, LTD. Transaction Category: Domestic Profit Corporation Description: Annual Report Filing Fee: $125.00 Expedited Service Fee: $10.00 Total Fee: $135.00 Your payment has been successfully processed and your application has been forwarded to our office for approval by the Secretary of the Commonwealth. If your application is rejected for any reason we will contact you immediately. Please note that for security reasons your payment credit card and/or bank information is processed at a secure website. The Secretary of the Commonwealth does not retain any payment information. E-check Transactions require final approval from your bank. Such approval may take 7 to 10.business days.If the payment is returned you will be billed for the transaction at that time. If you have any questions or concerns you may contact our office at(617) 727-9640 or e- mail our support desk at corpinfogsec.state.ma.us Thank You for using our online service. Click HERE to print this page Click HERE to return to the home page https://corp.sec.state.ma.us/corp/payment/acknowledgement.asp 3/25/2013 �.•._ 'Ni tssachusctts- Department of Public Sufch ✓ eomv�no�zure�� Board of Buildinl- Relulations and Standards 'Office of Consumer Affairs&Business Regulation Construction Supervisor License HOME'IMPROVEMENTCONTRACTOR One-and Two-Family Dwellings Registration: 140459 Type: License: CS 71165 ` Expiration 10/2072013 Individual CHARLES R.CROVO ;' f CHARLES R CROVO P�J atf 45 HATHAWAY RDA CHARLES CROVE j OSTERVILLE, MA 02655 776 MAIN STREET _: OSTERVILLE,`MA 02655 , 1 Underse ry creta Expiration: 12/20/20.13. ' Tr#: 5542 f - License or registration valid for individul use only Failure to possess a current edition of the before the expiration date, If found return to: Massachusetts State Building Code Office of Consumer Affairs and Business Regulation is cause for revocation of this license. 10 Park Plaza-'Suite 5110 Boston.ly 2116 Refer to: WWW.Mass.Gov/DPS j a } - —^valid wi�hou.#signature 1 Bayside Electrical Contractors, Inc. 508-771-7270 "So-vinag all your electriced needs" 1-1av 20. 2013 Town of I3anstable Buik in-Department 200 Main Street Hyannis MA 02601 `v'JA FAX: .508-420-0453 RE: 2 Itvirg Lane Hvainiis-cull 5 Park Place I-iyannispm-t We liavo disumoected the peimanont power to the garage at 2 Irving Lmie. in Ilyarmisport, MA. Ploase feel frec: to contact, nie with air✓ducsti.ons, Co1.cy'C0401110 5 jS- 7-76-0009.. Sincerely. Z. f Arthur P. Dehcrty, Jr. B-_tyside Electrical Corntrac Ors, I11G. 372 Yarmouth Road•Hyannis,MA 02601-2G43 Te,1: 303.-771-7270• Fax:508-771-0617 wwruhaysideelec.com L'd ai.11cel3 OP!s(eg ez;�,:L 6 £ VeV4 05/19/2013 08:57 5084280453 PAGE 01 May 20,2013 Town of Barnstable Building Department 200 Main St Hyannis, MA 02601 To Whom It May concern: This Letter is for the`town of Barnstable Building Department regarding the property at 2 Irving Avenue/ 8 Park Place,Hyannis Port, MA. Dunhill Companies has been contracted to demolish existing sections of the home and the complete garage that were destroyed by fire, There is no Natural Gas running to the section of the home and garage that is to be demolished. Please contact me if you have any questions. Thank y May 20,2013 Town of Barnstable Building Department 200 Main St Hyannis, MA 02601 To Whom It May Concern: This letter is for the Town of Barnstable Building Department regarding the property at 2 Irving Ave/8 Park Place, Hyannis Port, MA 02647. Dunhill Companies has been contacted to demolish existing sections of the home and the complete garage that were destroyed by fire. The water has been turned off to the home and garage. Please contact me if you have any questions. Thank you, Charles DelVecchio Cape Plumbing and Heating, INC 3 69 �TMETOwti Town of Barnstable Regulatory Services sn MMn�.&t s Thomas F.Geiler,Director 16.19• � TFo r„o�" Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, �- , as Owner of the subject property ereby authorize � Y �. to act on my behalf, in all matters relative to work authorized by this building permit (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final . inspections are performed and accepted. T e of Owner Signature of Applicant Print e Print Name Q Dat Q:FORM&OWNERPERMISSIONPOOLS 6/2012 Town of Barnstable Regulatory Services BARDW'S E Thomas F.Geiler,Director �F •``� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. 'You may care t amend and adopt such a form/certification for use in your community. C:\Users\decollikWppData\Loca1\Microsoft\Windows\Temporary Internet Files\Content.Outlook\QRE6ZUBN\EXPRESS.doc Revised 053012 - THE ANDERSON FAMILY REAL ESTATE NOMINEE TRUST SCHEDULE OF BENEFICIAL INTEIRESTS The undersigned Beneficiaries and Trustees of the Declaration of Trust establishing The Anderson Family:.Real Estate Nominee Trust dated October 23, 2002, (hereinafter referred to as the "Trust") do hereby certify that the following are the holders of the entire Beneficial Interests in the Trust as of the date of this instrument and in the proportions indicated: BENEFICIARY PERCENTAGE INTEREST Dorothy M.Anderson. Revocable Trust Agreement 14.1% G&G Anderson LLC 85.9% This Schedule of Beneficial Interests replaces in its entirety the Schedule of Beneficial Interests dated December i!:L 2010. 2011. IN WITNESS WHEREOF,. we have hereunto set our hands and seals January s- TRUSTEES: BENEFICIARIES: -' Dorothy M.Anderson Revocable Trust / Agreement reg. Anderson Trust Company of Connecticut,Trustee By: Print name: _ s2 ��x Title: . Glenn .Anderson G&G Anderson LLC tG] t ember By derson, em er 01361000/528830.1 ' CIE ANDERSON FAMILY REAL ESTATE NOMINEE TRUST A•CCEPTAN�E OF SUCCESSOR IRLLSTEE Pursuant to Paragraph 9B of The Anderson Family Real Estate Nominee Trust established pursuant to written Declaration of Trust dated October 23, 2002, and recorded at the Barnstable County Registry of Deeds at Book 15796, Page 74, 1 Gregg A. Anderson, hereby certify that: 1• Pursuant to Paragraph 9B of said Trust, a vacancy has occurred in the office,of Trustee by reason of the resignation of Dorothy M. Anderson; 2. Pursuant to the terms of said section, I am the next named Successor Trustee; 3. I hereby accept such appointment. E3CF-CUTED as a sealed instrument this-th day of A 2 . 004. 4e - Anderson, Successor Trustee STATE OF NEW YORK SS. lt�X2 2004 Then personally appeared the above-named Gregg A. Anderso , Successor Trustee as aforesaid, and acknowledged the foregoing instrument to be his free act and deed, before me, EILEEN M. McINERNY NOTARY PUBLIC STATE OF NEW YORK NO, $0-4744841 QUALIFIED IN NASSAU COUNTY COMMISSION EXPIRES*WA9;4j--W Otary Public 674a� My commission expires: L:U iOMEu,I o1L.4RRY1AMERSOrnA,ccEPI.TRS i RARNSTABLE REGISTRY OF DEEDS f COMMONWEALTH OF MASSACHUSETTS Barnstable, ss. Z ,Th 2011 en personally appeared the above-named Gregg A. Anderson, Trustee as aforesaid and :,--member of G&G Anderson, LLC, Beneficiary instrument to be his free act and deed, in both pacitiess beforme,aforesaid.and acknowledged the foregoing ERICA C.KENNEY No Public TY� My Commission Expires: IV CA. f y STATE OF TEXAS SS. 1 2011 Then personally appeared the above-named Glenn W. member of G&G Anderson LLC, Benefici Anders°n, Trustee as aforesaid and instrument to be his free act and deed, in both capacities, before me,ac�owledged the foregoing �Y gr'. , Paula Jean Tarwn `i y MY commission Expires otary Publi 06/23/2012 of Y Commission Expires: (p 1occ7�p�( STATE OF CONNECTICUT Hartford, ss. January S 2011 Then personally appeared the above-named his capacity as _�. . .� of T t Com pan of C �K� �� in The Dorothy M. Anderson Revocable Trust Agreement, Beneficiaryonnec cut, Trustee of acknowledged the foregoing instrument to be his free act and deed, before me, aforesaid and Notary Public My Commission Expires: 7 - 3 1 - d ol_? 01363.0001528830.1 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 411 Map Parcel Application # Health Division Date Issued a � Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board otc q Z Z-r 3 P� Historic - OKH _ Preservation/ Hyannis Project Street Address Village �f y 100 Owner C rLeq q /mod e 2-S o W Address Telephone 570 3 8 Z- S a(9 5' ;Permit Request kph oVe_ j A ee TLvc k C c,,C l uC" f /q-t--,;D 1A15L L,#v 6A) O A) Le er r-D i i y 1?-re t, 4 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation ' �{ OJj ca 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 t7 Basement Finished Area(sq.ft.) Basement Unfinished Area x{ft) o Number cf. Baths: Full: existing new Half: existing :` w Number of.Bedrooms: existing _new ao A Total Room Count (not including bath3): existing new - First Floor 'oom Coat = Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal shove: Yes .❑ No Detached garage: ❑ existing. ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review#` Current Use Proposed Use ' APPLICANT INFORMATION -�-- -- - - (BUILDER OR HOMEOWNER) Name F--(cW✓ -go L f1r u a-i I Telephone Number 761 Address 1 Lt= fk W 1)R- License # C S S 2 '7 Rq R--oGkG.4� 0 2 3.70- Home Improvement Contractor# `j a -7 Worker's Compensation # CC 0 n 3 0 -3 1 7 0-0 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO S•T-pk C r/ota .'L-�K/'S'T r,/- c1 ly S l r-e- SIGNATURE /�L� !�--""- ��`' DATE Y g FOR OFFICIAL USE ONLY ' APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE i' OWNER DATE OF INSPECTION: ::•FOUNDATION - 4 FRAME INSULATION FIREPLACE ;r ELECTRICAL: ROUGH FINAL f, PLUMBING: ROUGH FINAL GAS: ROUGH FINAL 4 FINAL BUILDING �µ V' DATE CLOSED OUT ASSOCIATION PLAN NO. L 6 Y t l The Commonwealth of Massachusetts Department of IndustrialAccidents 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/orgwd.zation/Individual): 'lad LT1 Si-P"- - 2 e �/�0/ &r7 0A/ Address: P e. Q-C1,0 i (Z City/State/Zip:.. h 2;,e e AJ A - Phone #: ,5 a Are you an employer?Check the appropriate box: Type of project(required): 1.9 I am a employer.with 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 ship and have no employees These sub-contractors have g. RDemolition. workingfor me in an capacity. employees and have workers' Y P tY• � 9. ❑Building addition .. [No workers'comp.insurance comp.insurance. 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 I I.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insturance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other—.- comp.insurance required.] *Any applicant that checks box#1 must also fill oat the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating such. ! kContiactors 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-contractor;have employees,they must provide their workers'comp.policy number.. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. -�-- Insurance Company Name: 1 0 U;-P_a- 1 [2-out P — .Policy#or Self-ins.Lic.#: W C C- 06) 3 6 _3/ -7 O 0 ' Expiration Date: 7`�� /3 Job Site Address: 2r eL'4cL' City/State/Zip: {�l�7Viu7S' U 2i -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 violatot. 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,.certifyunn r the airs and penalties of perjury that the information provided above is true and correct Bi afore: --Z - Date: 'S' Phone# i -7 7 Off cial use only. Do not write in this area,to be completed by city or town official I 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: w Phone#: Information and .Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuantto 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 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 deemed to be an employer." MGL chapter.152, §25C(6)also states that"every state or local Iicensing agency shall withhold the issuance or renewal of a Iicense 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 hue. 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 per ait/licease 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 Lice to thank you in advance for your cooperation and sliould 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 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel,`#617-727-4900 ext 406 or 1-977-MASSAFE Fax# 617-727-7749 Zevised.4-24-07 www.mass.gov/dia Client#:34309 MULTISTA ACORDT. CERTIFICATE OF LIABILITY INSURANCE DATE CERTIFICATE 4/041204/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Dewn M.Pare . Starkweather&Shepley PHONE 401 435-3600 FAX 401 431-9397 AIC,No Ext: AIC,No PO Box 549 E-MAIL ADDRESS: dpare@starshep.com Providence,RI 02901-0549 INSURER(S)AFFORDING COVERAGE NAIC# 401 435-3600 INSURER A:American Safety Insurance INSURED INSURER B:Tower Group Multi-State Restoration Cape Cod INSURERC:Hartford Ins Group 19682 Division,Inc. 1135 Charles Street INSURER D: North Providence,RI 02904 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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. IN SR ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DDIYYYY MMIDD/YYYY LIMITS A GENERAL LIABILITY ENV0307221302 1/01/2013 01/0112014 EACHOCCURRENCE $1 000000 X COMMERCIAL GENERAL LIABILITY - PREMISES(Ea occurrence) $50,000 CLAIMS-MADE [--Xl OCCUR MED EXP(Any one person) $5,000 X BI/PD Ded:5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO- JECT LOC $ C AUTOMOBILE LIABILITY 02MCPHX6227 1/01/2013 01/01/201 COMBINED SINGLE LIMIT Ea accident $1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ OED I I RETENTION$ $ B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/" WCC003031700 7/16/2012 07/16/201 X WC STATU- OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $5OO OOO OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500 OOO If yes,describe under _ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $SOO,000 i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE:8 Park Place Hyannisport,MA CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S453522/M438672 DMP ,a r 8 MULTI-STATE RESTORATION, INC. FIRE* FLOOD*WIND* SMOKE*HURRICANE*VANDALISM Fed ID#050515889 CONTRACTORS REGISTRATION#140427 AUTHORIZATION TO PERFORM SERVICES AND D.�-I�Rt�IECTION OF�PAYMENT �� //•�QY/.Q�h �Qstil� 1�� 3Tr.M- �r~i nC�t.. V ;J 1 e4tia---AM3 A&,6tr -�� e.f ,herein referred to as "Customer",authorizes MULTI-SATE RESTORATION,INC.,herein referred to as "MULTI-STATE",to perform any aq all necessary cleaning and construction services on Customers'property at: �' � /J t . Ey+r�ltls a�'o✓`;/t v Telephone: and with respect to items that need to be cleaned at a remote location,to remove and clean such items as necessary. Customer authorizes / - �"G�Z /" �40V Insurance Company,herein referred to as "Insurance Company",to directly and solely pay MULTI-STATE. If for any reason the check should come to be or be made payable to the Customer, Customer then agrees to pay MULTI-STATE immediately upon receipt of the check from the insurance company. In order to expedite payment to MULTI-STATE, Customer hereby appoints MULTI-STATE as.attorney-in-fact,authorizing MULTI- STATE,to endorse Customers'name,and to deposit Insurance Company checks or drafts for MULTI-STATE services. Customer agrees to pay Customers'deductible in the amount of$ that applies to this claim. If the loss is not covered by insurance,Custome rees to a th total amount to MULTI-STATE upon receipt of the invoice gnatu Owner It is my understanding that the services to e performed by MULTI-STATE will be limited to those, which are authorized by my Insurance Company. Insurance Company Name Policy Number Customer agrees that MULTI-STATE is working for the Customer and not the Insurance Company or agent/adjuster. Additional remarks: I have d this document and completely understand and agree to same. S' tur Date �^ Printed Name P.O. BOX 2210•MASHPEE, MA 02649.866-921-9111 •FAX 774-238-4422 MULTI-STATE RESTORATION, INC. FIRE* FLOOD*WIND* SMOKE*HURRICANE*VANDALISM Fed ID#050515889 CONTRACTORS REGISTRATION#140427 AUTHORIZATION TO PERFORM SERVICES AND DIRECTION OF PAYENT . �eft,, ckec s)e- j 3 a,Q 1,2. �l✓� ,herein referred to as "Cus omer",authorizes MULTI-STATE RESTORATION,INC.,herein referred to as "MULTI-STATE",to perform an and all necessary cleaning end construction services on Customers'property at: �P i� Ai. �(+/�,vl S P u4, , +. Telephone: and with respect to items that need to be cleaned at a remote location,to remove and clean such items as necessary. Customer authorizes/� s � - �l� Insurance Company,herein referred to as "Insurance Company",to directly and solely pay MULTI-STATE. If for any reason the check should come to be or be made payable to the Customer, Customer then agrees to pay MULTI-STATE immediately upon receipt of the check from the insurance company. In order to expedite payment to MULTI-STATE, Customer hereby appoints MULTI-STATE as attorney-in-fact,authorizing MULTI- a = STATE,to endorse Customers'name,and to deposit Insurance Company checks or drafts for MULTI-STATE services. Customer agrees to pay Customers'deductible in the amount of$ that applies to this claim. If the loss is not covered by insurance,Customgagrees to pay tha total amount to MULTI-STATE upon receipt of the invoice? 1 igna e f Owner It is my understanding that the services to be performed by MULTI-STATE will be limited to those,which are authorized by my Insurance Com any. /f55 F41(? - P�H�1 Insurance Company Name Policy Number Customer agrees that MULTI-STATE is working for the Customer and not the Insurance Company or agent/adjuster. e ,e_Additional remarks: Dq,4:pe__ +hhavadd document and completely understand and agree to same. �C13 Date Printed Name P.O. BOX 2210•MASHPEE, MA 02649.866-921-9111 •FAX 774-238-4422 f J. MULTI-STATE RESTORATION, INC. FIRE* FLOOD *WIND* SMOKE*HURRICANE*VANDALISM x Fed ID#050515889 CONTRACTORS REGISTRATION#140427 AUTHORIZATION TO PERFORM SERVICES AND DIRECTION OF PAYMENT w ,herein referred to as "Customer",authorizes MUL -STATE RESTORATION,INC.,herein referred to as "MULTI-STATE",to perform any and all necessary cleaning and construction services on Customers'property at: d�Qt-1 - 1aC4- 14 VGAn"I �e - Telephone: .ti"/Z —3 c a-`S�Qo and with respect to items that need to be cleaned at a remote location,to remove and clean such items as necessary. Customer authorizes k Insurance Company,herein referred to as "Insurance Company",to directly and solely pay MULTI-STATE. If for any reason the check should come to be or be made payable to the Customer, Customer then agrees to pay MULTI-STATE immediately upon receipt of the check from the insurance company. In order to expedite payment to MULTI-STATE, Customer hereby appoints MULTI-STATE as attorney-in-fact,authorizing MULTI- STATE,to endorse Customers'name,and to deposit Insurance Company checks or drafts for MULTI-STATE services. Customer agrees to pay Customers'deductible in the amount of$ that applies to this claim. If the loss is not covered by insurance,Customer ees to ay e otal amount to MULTI-STATE upon receipt of the invoice. J Si afore caner It is my understanding that the services to be performed by MULTI-STATE will be limited to those,which are authorized by my Insure Compan InsuAnce Company Name Policy Number Customer agrees that MULTI-STATE is working for the Customer and not the Insurance Company or agent/adjuster. Additional remarks: 6 I have lead this docuiL7=_ e to same. p �larcl I-2U si at Date 1 Printed Nam P.O. BOX 2210 MASHPEE, MA 02649 .866-921-9111 •FAX 774-238-4422 _ Massachusetts - Department o1'Public Safety Board of Building Regulations and Standards Construction Supervisor License One-and Two-Family Dwellings License: CS 51784 RICHARD D LAURIA. 1 LEAH DR, ROCKLAND; MA 02370 Expiration: .4/1/2013` Commissioner Tr#: 12672 / — — I Office of Consumer Affairs&Bu mess Regulatton r .. L►cense or registration valid for individuI use.only OME IMPROVEMENT CONTRACTOR before the expiration.date. If found return to: Registration 140427 Office of Consumer Affairs and Business Regiilahon Expiratian T ' '10 Park Plaza-Suite 5170 �10lr5%__j Supplerro Boston,Mai 02116 MULTI STATE f�ES-10, ON IN:C.CAPE COD j 115 RICHARD: LAURVA. P. O. Box 2210 -jr MASPFIEE, MA 02649 unersecretary. Not v lid withou signature'. y Details Page 1 of 1 Licensee Details Demographic Information Full Name: RICHARD D LAURIA Gender: Owner Name: License Address Information Address: Address 2: City: Rockland State: MA ipcode: 02370 Country: United States License Information License No: CSFA-051784 License Type: Construction Supervisor 1 &2 Family Profession: Building Licenses Date of Last Renewal: 3/7/2013 Issue Date: 4/1/2011 Expiration Date: 4/1/2015 License Status: Active Today's Date: 4/5/2013 Secondary License: Doing Business As: Status Change: Prerequisite Information No Prerequisite Information Discipline No Discipline Information Documentum http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=1&license_id=240745& 4/5/2013 "I Z25 �✓V .,�R� \Y:jam, ym' S `j r THE ANDERSON FAMILY REAL ESTATE NOMINEE TRUST SCHEDULE OF BENEFICIAL INTERESTS The undersigned Beneficiaries and Trustees of the Declaration of Trust establishing The Anderson Family Real Estate Nominee Trust dated October 23, 2002, (hereinafter referred to as the "Trust") do hereby certify that the following are the holders of the entire Beneficial Interests in the Trust as of the date of this instrument and in the proportions indicated: BENEFICIARY PERCENTAGE INTEREST Dorothy M. Anderson Revocable Trust Agreement 14.1% G&G Anderson LLC 85.9% This Schedule of Beneficial Interests replaces in its entirety the Schedule of Beneficial Interests dated December 2010. , 2011. IN WITNESS WHEREOF, we have hereunto set our hands and seals January .S- TRUSTEES: BENEFICIARIES: Dorothy M.Anderson Revocable Trust / Agreement re An Trust Company of Connecticut,Trustee By: Print name: _ 6f,,,( Title: n Glenn . Anderson G&G Anderson LLC By: s r de on, Member By Gle . Anderson, ern er 01363-000/528830.1 14t _ THE ANDERSON FAMIL Y R EAL ESTATE NOMINEE TRUST �CCEPTAN�E OF SUCCESSOR T TEE �_ I Pursuant to Paragraph 913 of The Anderson Family Real Estate Nominee Trust established pursuant to written Declaration of Trust dated October 23, 2002, and recorded at the Barnstable County Registry of Deeds at Book 15796, Page 74, 1 Gregg A.Anderson, hereby certify that: 1. Pursuant to Paragraph 913 of said Trust, a vacancy has occurred in the office of Trustee by reason of the resignation of Dorothy M. Anderson; 2. Pursuant to the terms of said section, I am the next named Successor Trustee; 3. I hereby accept such appointment. EXECUTED as a sealed instrument this -�h day of 2004 4re - Anderson, Successor Trustee STATE OF NEW YORK ss. lvX� 2004 Then personally appeared the above-named Gregg A. Anderso , Successor Trustee as aforesaid, and acknowledged the foregoing instrument to be his free act and deed, before me, EILEEN M. WINERNY NOTARY PUBLIC STATE OF NEW YORK NO, 30-4744841 QUALIFIED IN NASSAU COUNTY COMMISSION EXPIRES AttGtd6;34f3 otary Public My commission expires: I j L:1HOiv1M I0ILARRYIANDERSONIACCEPT.TRS i RARNSTABCE REGISTRY OF DEEDS u wJ� COMMONWEALTH OF MASSACHUSETTS Barnstable, ss. vii?= 2011 __ , Then personally appeared the above-named Gregg A. Anderson, Trustee as aforesaid and member of G&G Anderson, LLC, Beneficiary as aforesaid and acknowledged instrument to be his free act and deed, in both capacities, before me, the foregoing ERICA C.KENNEY NOXrPAko .,MdMm=e Notary Public MYC*WhdWE*mApi429.got7 My Commission Expires: App1.cA f �/ r ! T STATE OF TEXAS ss. 1 �� 2011 Then personally appeared the above-named Glenn W. member of G&G Anderson LLC, Benefici Anderson, Trustee as,aforesaid and instrument to be his free act and deed, in both capacities, beforme,acknowledged the foregoing ?' Paul a Jean Tarvin • My Commission Expires �tar3'Pub_li 'Q 06123/2012 M OF y Commission Expires: STATE OF CONNECTICUT Hartford, ss. January r 2011 Then personally appeared the above-named $f ,(�,,� �„ his capacity as �,�y . .� of Trust Company of Connec!Cut, >n The Dorothy M. Anderson Revocable Trust Agreement, Benefici as ' rnstee of acknowledged the foregoing instrument to be his free act and deed, before ry aforesaid and , Notary Public My Commission Expires: ' - 3 1- 0)01-? 01363.000/528830.1 MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108-1904 1 (617)723-3800 Ma Only(800)392.6108, FAX(800).851-8424 3/12/2013 Form of Notice of Casualty Loss to Building Under Mass.Gen.Laws,Ch.139,Sec.36 BARNSTABLE BUILDING COMMISSIONER 367 MAIN STREET 367 MAIN STREET HYANNIS MA 02601 Re: Insured: DOROTHY ANDERSON,TRUSTEE OF THE Property Address: 8 PARK PLACE,HYANNISPORT,MA 02647 Policy Number: 1111185 . Type Loss: Fire(including Fire caused by Lightning Date of Loss: 03/10/2013 Claim Number: 312425 Claim has been made involving loss,damage or destruction of the above captioned propert,which may either exceed$1000.00 or cause-Massachusetts General Laws,Chapter 143,section 6 to be applicable. If any . notice:under Massachusetts General Laws,Chapter 139,Section 3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured,location,policy.number,date of loss and claim or file number. MPIUA Claims Division - . Ln CMA00021 � ..q SILVIA & SILVIA Assocs. 8 Park Place, H-Port, MA Wall presently open for witness. Current plans call for removal ____________ and replacement w/continuous PSL header. PSL header will Philbrook Engineering support intersecting kitchen/entryway beam. Final configuration ° Project No: P19-07 dependent upon wall removal and connection details - TBD 3.5"x 9.5" 2.0E ParalLam PSL " JJJ t ram. m • 2/2 x 4 KID SPF , o ° f f ^� .lar.kStiirlPark 1] ° 0 Iy' ° °'. q IX °, of' ❑ 08 J Ob ° cp Max Span �9'3" Clearfl. Q o g ° n ° � . B D^" d m, °p ,Qv r � S� �� ° cr °� °c' o° ev j A ° ° OD8 NI AQ m tl n ° i e e ° n ° u ° X .� 0 ® � ® MEMBER REPORT Level. Wa'- PASSED _ •` 1 piece(s) 3 1/2",x 9 1/2" 2.0E Parallam@ PSL SILVIA & SILVIA Assocs. Overall Length:9 9 0 8 Park Place, H-Port, MA ------------------------------------ Philbrook Engineering Project No: P19-07 930 0 All locations are measured from the outside face of left support(or left cantilever end).AII dimensions are horizontal. Design Results Actual 0 Location Allowed Result LDF Load:combination(Pattern) System:Wall Member Reaction(Ibs) 4480 @ 0 18 4463(3.00') Passed(100%) — 1.0 D+1.0 L(All Spans) Member Type:Header Shear(Ibs) 3928 @ 10 8 6428 Passed(61%) 1.00 1.0 D+1.0 L(All Spans) Building Use:Residential Mc :u�t(Ft-Ibs) 13122 @ 4 0 0 13057 Passed(101%) 1.00 1.0 D+1.0 L(All Spans) Building Code:IBC 2015 0.240 @ 4 9 4 0.317 Passed(L/475) — 1.0 D+1.0 L(All Spans) Design Methodology:ASD TC*cl i r:zc�' (in) 0.425 @ 4 9 3 1 0.475 Passed(L/268) — 1.0 D+1.0 L(All Spans) 7efleee.,ai,ran:;,:LL(1./360)and TL(L/240). Tar.1-oge Bracing(Lu):Top compression edge must be braced at 0 6 0 o/c unless detailed otherwise. �:(%Edne Bracing(Lu):Bottom compression edge must be braced at 9 9 0 oic unless detailed otherwise. Bearing Length Loads to supports(Ibs) SstppOrtS Total Available Required Dead Uve Total Accessories P61t -SPF 3.00" 3.00" 3.01" 1926 2555 4481 None '' Plate-SPF 3.00" 3.00" 2.62" 1646 2245 1 3891 None Tributary Dead Floor Live !Loads V Location(side) Wi m o (0.90) (1.00) Comments 0-Self Weight(PLF) 0 0 0 to 9 9 0 N/A 10.4 Residential- 1-Uniform(PSF) 0 0 0 to 9 9 0 800 25.0 40.0 Bedroom&Ceiling above Areas Point load from Intersecting Kitchen/Living LVL. 2-Point(lb) 400 N/A 1520 1680 16 ceiling on 14' beam-Bedroom Load I-Partition above Member Notes I Member sized for Full Width of the Double Opening-See Pic Weyerhaeuser Notes 5115TAINABLE FORESTRY INITIATIVE 'Weyeihaeuser warrants that the sizing of its products will be in accordance with Weyerhaeuser product design criteria and published design valutrs. l Weyerhaeuser eiresshj disclaim any other warranties related to the software.Use of this software is not intended to circumvent the need for e.design professional as determined by the authority ha%ing jurisdiction.The designer of record,builder or framer is responsible to assure that this caWc.c.ion is l compatible with the overall project Accessories(Rim Board,Blocking Panels and Squash Blocks)are not dessigned t "rare Products'manufactured at. :I Weyerhaeuser facilities are third-party certified to sustainable forestry standards.Weyerhaeuser.Engineered Lur •..�,"�.rr -+`;:e peen evaluated by ICE w5 I under technical reports FSR-1153 and ESR-1387 and/or tested in accordance with applicable ASTM standards For code evaluation reports,Weyerhaeuser product literature and installation details refer to www.weyerhaeuser.com/woodprpduM/ The product application,input design loads,dimensions and support information have been provided by Forte Software Operator Forte Software Opctrator Jab Notes i 3/76/201 3:01:49 PlU! T.Varnun. Ph brook Silt+ia7S'iivia-8 Paa<Race i Forte v5.4,Design Engine:V7.1.1.3 PHILBROOK ENGINEERING Hyannis Port,MA P19-0�'8 Park Piace.4'F I ('503)385-8632 Tvarnphil@Varizon.net PI9_07 I L -- ---------1`.------- ------ -, Page.l-of1 .. r F TOMIN OF q?It') ETAS- � 20i3 v -9 t, ' 9= S4 OTVT.:TC'<< AND- RSO.: N R SID NC HYAN N I S PORT, MA N4 . KE DE TORS. REVIEWED "AM BARNSTABLE BUIL NG DEPT. DATE NOTE: THE DRAWING SET CONTAINED HEREIN SHOULD BE FULLY REVIEWED BY THE GENERAL 'L-3- CONTRACTOR PRIOR TO THE START OF WORK. RE EPARTMENT DATE ANY DESCREPANGES, OMMISIONS, OR ERRORS BOTH SIGNATURES ARE REQUIRED FOR PERMITIIVG R SHOULD BE IMMEDIATELY BROUGHT THE . 1 ^ ATTENTION OF THE.ARCHITECT FOR REVIEW. _ �, _C��✓ NOTE: ALL EXISTING CONDITIONS TO BE FIELD ��`�� VERIFIED BY THE GENERAL CONTRACTOR PRIOR -zK�ul g�� 1 TO ANY WORK. ANY DESCREPANCIES, OMMISIONS, \ �AAA OR ERRORS TO THE DOCUMENTATION HEREIN ®H Z�✓ SHOULD BE IMMEDIATELY BROUGHT THE ATTINTION OF THE ARCHITECT FOR REVIEW. Y DATE: 1 J U LY 2013 DRAWING LIST A-0 Titlesheet A-1 EXISITNG FIRST f SECOND FLR PLANS A-2 PROPOSED FIRST FLLOR PLAN_ A-3 PROPOSED SECOND FLOOR PLAN A-4 BUILDING ELEVATIONS A-5 BUILDING SECTION AA A-6 BUILDING SECTIUON BB Project: ANDERSON Residence HYANNIS PORT, MA `r STEVEN BACZEK A = OI ' ARCHITECT `�_ w amn encrw ni=awaa`n J C`I ----------- ATTENTION: (f)MASSACHUSETTS LAW REQUIRES CARBON MONOXIDE DETECTORS IN wp ALL RESIDENTIAL DWELLINGS. Nw QF3 RETREAT BED RM 2 IN ADDITION TO THE FIRE ALARM mI SMOKE- DETECTORS REVIEWEL INSPECTION, THE INSTALLATION OF A CO DETECTORS, IN ACCORDANCE WE I WITH 527 CMR 31.00 WILL BE w VERIFIED PRIOR TO SIGNING THE N Z�•L�b'l :j " BUILDING PERMIT r DEPT.(VEN.#) DATE I sfise Ld _. �i BATH 1 m AREA OF SCOPE OF WORK6068 ---- -J � / __-_-____- 6WO�— ATH 2 ------------ -----------` RETREAT I ; BED RM 3 OF "WICK ! 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II 1I N1 II II PORCH Na �„ I I ;J pEA0C1t• 2868 7 " ACCESS OF ' 2668 , mac!+. _ - _ -,,_ _ - rE 11 II �' 11 j y •P -� GARAGE c�H CONCRETE SLAB e e e e ye CO BASEMENT 1�._�_;�--- -- -->'�� _�. 1 7 CONCRETE SLAB •f ] } . BED RM 1 U� PANEL � LLJ »� Z `„I ... O [.!-FLOOR PLAN (EXISTING) LIVING. RM SCALE 1/4•=1'-0• W Lod �. 21' - 1'-0' 4!-r 1-7I I 1 / E= ® OR I 0 �S••- ENTRY • i ; T i U68 A21 -TiNPERED PORCH (2)M432 h oo c 0 o i o i RO 2'-0 5/822-0 5/8' RO 2'6 I/6.2.T-4 7/8'FA 3060 m � � .�V�,I{ ` �• O & L_ � l9' 2668 '-3• I I`. i I L ___ _____________�_ ,I EVATION C -' _ aLE s/e•=i'-o- 1 (KITCHEN ELEVATION B e SCALE 3/8"=,'-0• - 2668 DP .KITCHEN I I ON II za DINING RM so ® ® y`n e ZWl— � b '� � ` '`.MUD � � N� ,� ` } 2 CAR GARAGE ; i ` ----- (2)rx2432 -- 31� 11m2'61 47eFw mW CD In ' sx o / n- 0 0 0 o J 1W2642 >c ckz ` RO Y 6 I/8':4 4 7/8 a 1 (KITCHEN ELEVATION A SCALE 3/8•=1•-0• 1 (FIRST FLOOR PLAN (PROPOSED) - SCALE 1/4•=I'-0- -- _.�rF - ,-. -_'.'''��I 9i�>n�<ly.-�"J'',H��Y..y�-.'?/y'r�,•-�:.•-f-.�5_>WFh.Ei'i99 J"�Fi8�F{;.t',:��£V��$fi��..r. 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T CAI----J r�I W2042 TEMPm a RD T-81/8'i441/8 � � Ir � n r ' F t f - y TOWN OF BARNSTABLE {` 7013 JUL -9 f,M 9: 54 DIVI IOAND RSON JR SID NC ,e° ; I ,I HYANNIS PORT, MA t No. 0211. KE DE TORS'REVIEWEDOF,,; -��.-13j BARNSTABLE BUIL MG DEPT: DATE NOTE: THE DRAWING SET CONTAINED HEREIN SHOULD BE FULLY REVIEWED BY THE GENERAL CONTRACTOR PRIOR TO THE START OF WORK. FIRE DEPARTMENT DATE ANY DESCREPANCIES, OMMISIONS, OR ERRORS BOTH SIGNATURES ARE REQUIRED FOR PERMITING SHOULD BE IMMEDIATELY BROUGHT R THE t ATTENTION OF THE ARCHITECT FOR REVIEW. NOTE: ALL EXISTING CONDITIONS TO BE FIELD VERIFIED BY THE GENERAL CONTRACTOR PRIOR TO ANY WORK. ANY DESCREPANCIES, OMMISIONS, OR:ERRORS TO THE DOCUMENTATION HEREIN SHOULD BE IMMEDIATELY BROUGHT TO THE t ATTENTION OF THE ARCHITECT FOR REVIEW. 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I666 I ------- m ----- /e '1668 1 I — 2666` 2666 I � I I IL__ I ' t L ___ 3666 L A_� FIRST and SECOND FLOOR PLANS ANDERSON RESIDENCE fiA� 6EMARNs. DUNHILL BUILDERS STEVEN BACZEK �� EXISTING ns Yuw�� ARCHITECT Q HYANNIS PORT, MA osrtmluc un o:sss �^acx�aL�xuwxo� ui _ --.--.__ —_--- _ — ---- ____ __._._-_._-. _._--.—_ -----.—_._ _._......_ .............. ........... ..... . ................... _....... __.......... ... .................. .._.........__..__ 3f-17 cn LSO yy NW�m U m O E 'L - WLL/ W j N ., - CRAWLSPACE N W L i i POLETWL NE GROUND COVER ' WITH STONE BALLAST ..I m O S _____________------------------- _ '.' t�'�Cy♦. II M6 II No. 021, PORCH ""� OF ACCESS - III -`.-r ---- ---- -- -c 2668 � ., .1 II I 1 /\ � GARAGE 2668 0 •o II•II II , / � ;; � < � CONCRETE SLAB u II II u n v II IILJL�II II . 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