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HomeMy WebLinkAbout0151 PITCHER'S WAY 151 ?i rc qc-R s tjo y o� Application number......... ..................4.(.. Fee ..........................4:�. ................... Building Inspectors Initials... ..8................. KAM Ak Date Issued.:...` q.......................... OCT 3 0 2019 ,- Map/Parcel.............:.. ... .. ® U................ LE TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION (--Addre`ss of Project:- JE 4Ck(?,rS WQ& n NLW ER STREET VIL GE `Owner's Name: I O I A _Phone Number_� -Email Address: Phi)1bTy ri I °-cai ehone Number- Project cost$ 1 , yU 0 Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK ' 4 0 Siding + ❑ Windows (no header change)# ❑ Insulation/Weatherization ❑ Doors(no header change)# Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)# (attach copy) Construction Supervisor's License# ,(attach copy) Email of Contractor Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT. YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER....................................`' ........ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X ,' X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent Fuel source being used LP tank 20 lbs. or>Yes No , if yes, a gas permit is required. Natural Gas Yes No ,if yes, a gas permit is required. If food is being served at.your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side t HOMEOWNER'S LICENSE EXEMPTION Homeowner's Named Ph f/ T I yl ) Kla Telephone Number-=" Xe11=or Work number=-'7y— ��ja3 'e o� Q 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 ow of Barnstable. Signature C s Date l U '3 U 02-0/ 9 , PI;ICANT'S SIGNATURE Signature--' _ Date All permit applications ale sub'ect to a building official's approval prior to issuance. Town of Barnstable Building Post,This=Card SoFThat it-is Uisible';From the Street,=Approved;Plans;Must be=Retained on Job and th�sgCar„d Musbe Kept eA"Srwea y x r 6 Posted Until Fmel Inspect�an Has Been Ma e '' z 3� Q `' � " '"`iic""is Re""aired suchfBuldiri"shall Not be,®c u ied,unt�ia Final Ins ectionhas Peen made.. Permit Where.a Certificate`ofDupa y a<,-q.: �. ' .. , g :, .A, p • ;; n p. . . .n ;.� Permit No. B-19-3664 Applicant Name: HOMEOWNER IS APPLICANT Approvals Date Issued: 10/30/2019 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 04/30/2020 Foundation: Location: 151 PITCHER'S WAY,HYANNIS Map/Lot: 289-016 Zoning District: RB Sheathing: Owner on Record: TYNING,PHILIP A ContractorzName' HOMEOWNER IS APPLICANT Framing: 1 Address: 151 PITCHER'S WAY Contractor-Lacense; EXEMPT 2 � - HYANNIS, MA 02601 Est Project Cost: $1,000.00 Chimney: Description: Siding ; Permi F.:eb: $35.00 Insulation: Project Review Req: Fee Paid $35.00 Date 10/30/2019 Final: Plumbing/Gas Rough Plumbing: Building Official " Final Plumbing: W MR11, This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced withinm six- onths-after issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents or whkh this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and str,,uctu res,shall be in compliance with the local zoning by la"ws amend codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. ow Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and'Fire Officials are provided on th s permit. Minimum of five Call Inspections Required for All Construction Work , ;: Service: �. 1.Foundation or Footing }. Rough: 2.Sheathing Inspection ..` 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). � Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): phl // l f Address: /5� �/ ��Ylr✓ City/State/Zip: CZ"IrJ . PX C?' Q a.(04hone#: Are you an employer. Check the appropriate box: Type of project(required): 1.❑ 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, ❑Demolition workingfor me in an capacity. employees and have workers' Y P h'• 9. ❑Building addition [No wo rs' comp. insurance comp. insurance.t reimired.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3. 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.[3 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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify c nder the 'ns andpenalties ofperjury that the information provided above is true and correct. Signature: -Date: " Phone#: �I 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-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 cant'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 4 Town of Barnstable m Building.z � � - � '� � * "�' °. �,'.'..z yE?V� ,•,,, "` .;:''"�' �' ..,;':.� `mob-'�.`, � .� x. '. Post Thrs`CardSo That rt s'°;Uisible''From'the Street A'; `rpved Plans Mu t be RetamedaonJob;and th'isFCardMust"be.Ke 't ' * sAPNfTPAtS.F.. M"S& Posted UntilFinal Inspection HasABeen � � • 1634 Permit m >, ", z.' ,� ti '= .tea Where a,CertificatexofaOccupancyas Required;such Build�ng�shall,Not be Occup�ed;until a Fna!lnspect�on�has:been made ��.� 1 ei 11j1t Permit NO. B-18-2125 Applicant Name: TYNING, PHILIP A Approvals Date issued: 07/05/2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 01/05/2019 Foundation: Location: 151 PITCHER'S WAY,HYANNIS Map/Lot 289-016 Zoning District: RB Sheathing: Owner on Record: TYNING,PHILIP A ct 5 Contraor Name. Framing: 1 Address: 151 PITCHER'S WAY Contractor License: 2 HYANNIS, MA 02601 3 Est Project Cost: $ 1,100.00 Chimney: Description: re-side Permit Fee: $35.00 Insulation: Fee Paid $35.00 Project Review Req: Date.- 7/5/2018 Final: 3 � Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after,issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and,the approved construction documents for which,Ahis permit has been granted. All construction,alterations and changes of use of any building and structuresshalI be in compliance with the local zoning by laws and codes. Final Gas:- This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for.public inspection for the entire duration of the work until the completion of the same. v. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and`"FiWOfficials are.provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work:`" 4` 1.Foundation or Footing Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons racting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT lr _ Application numbe G.?^ !. . ® � U1dN t Date Issued.......... 0�......... ...... '• sa�r�sr�at�. � � JUL 0 2 2018 Building Inspectors Initials. ............................. � OWN O� bAHNS I-ABL� Map/Parcel... ........ .............�.......... TOWN OF BARNST"LE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: ER STREET V I-AGE N Owner's Name: UMB P one Number Email Address: c(� �� a� -��`''. Cell Phone.Numbel � � Project cost $ 1 00, Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a b ' ding e t in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK 3 Siding ❑ Windows (no header change) # ❑ Insulation/Weatherization ❑ Doors (no header change)# Commercial Doors require an inspector's review El Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name n 4q- Home Improvement Contractors Registration(if applicable)# (attach copy) Construction Supervisor's License# (attach copy) Email of Contractor - Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. I APPLICATION NUMBER............................................................ L.. , Ai - *For Tents Only* Date Tent'(s)will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent - X X X AAditional tent dimensions can be attached on a separate piece of paper. '- Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION r�a a � Homeowner's Name: `y ��y Y'% .pys Telephone Number sag �� 7�� 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 •nstable. `-� Signature Date G �. APPLICANT'S SIGNATURE Signature Date o� All permit applications are subject to a building official's approval prior to issuance. A y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly N B siness/Organization/Individual): ��\� "T`J►'1 I. V-­ City/S e%Zip: c,rilt. Phone#: W i0o Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 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• ❑Demolition workingfor me in an capacity. employees and have workers' Y P tY• # 9. ❑Building addition Wam orkers'comp.insurance comp.insurance. ed.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions �3; I 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. $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: Policy#or Self-ins.Lic.#: " Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 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 der a ins and penalties of perjury that the information provided above is true and c rrect. Signature: �-Date:--- 8P 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#: r1' 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 g gJ rP � g g P 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of , insurance. Limited Liability Companies(LLQ 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 446 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass,gov/dia t� 1 '` IVME Town of Barnstable *Permit'# —1(0—ZU1(o ' Regulatory Services fee ►� n:hsfronissae e i6 1f ,N ichard V.Scali,Director JUL 1 8 2016 Building Division Paul Roma,Building Commissioner f �2` 0 _ am Street,Hyannis,MA 02601 TOWN O� BAHNSTA6`�Vwww.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Ma /parcel ber " Property Address sidential Value of Work$ r 0'0 Minimum fee of$35.00 for work under$6000.00 (Owner's Name&Address 1 Y%C,rA.,C_ V_-e— KLartIN Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑�am a sole proprietor 11CJ 1 am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name ` lam. Workman's Comp.Policy# .n Copy of Insurance Compliance Certificate must accompany each permit. n pAk Permit Req t(check box) \ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) A ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows ` #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. copy of the Home Improvement Contractors License&Construction Supervisors License is re q SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXP S.doc 06/16/16 f 17ze Camroynreakh of Marsadi=et& Deer 4nent afl"adustriatAcciden Q Of brPedkadem 600 Was7zazgtmt Street Gaston,MA 02111 - witn masmgovfdia Waorlm s' Cmnpensafimt Insurance davit StdIders]C mtracWrs)Uec dcam&Tbmibers Applicant Tmfkm=Ton. Please Prim Name�l1CRIP �P171IEfl��� 9&,rdu Ad& 3_blaG Avg Cityls PhMeAre you an employer?Check the appropriate barn T of project r I am a general c.8afrsctar and I Type )�°] (required): L❑ I am a employes with ❑ 6_ ❑New conStaction employees(Ed andfor part time)* have hared the subr-coUIMCtors 2.❑ I am a sale proprietor orpastner- Tisfed on the attached sheet 7. ❑modeling. shp and have no employees Mese sub-contractors have 9- ❑Demolifion wod-ng forme-many 7adly. employees and have wo&ars' 9. .❑B•uildmg sdditica [No wod: rs,Mmp-ins& a COIDp_insurance equire-C-I 5:❑ W_e are a-corpa:atian and its 10L❑Electrical repairs or a,ci&tious officers have exescised their 11- P r airs or additions 3. am.a homeoR�r doing all�orlc ❑ lz�biag eF [N°worms' - right of esemp6m per MGL L.❑P.oaf c.152, I and We have no reyfirs »acre required-]Y e t 13-❑Other n . employees.(bTo Wasters' Comp-;msarance regdre&] 'Any aW5=tdmt cbec3xbas#1 test also fliouEthe sectioaheiaa sag the¢wodces'rnmpeasatia�pefi�gi�n�2ir� fi�a�evamSst¢lw Salt ihi5 tLvy sie rlm�8lF WC�sad�eIl hia!aubide CdStCi�nI3Smist s aamit anew affidavR"mdiwk such FCantiaciacsSuR checYthis bax mast rmr% sn addiff-21 sheet d uwl=g thensxaeof the sub-cam2cscmo-a•red stye whether arnmfhase a dtieshaee employees:Ifthesnb•carbadumhaveemglayee,tiieymustpmvide&ekwodmw mp•parkyw aL lam an $etoty is the prTicy and jab site informaliars Insurance Company Dame: . oficy 4w'or Self-ice Lic-t Expiration Date: Job Mte Address: citylStawzE p: Attach a spy of the workers'comapensationpoiicy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of M--GL m 1572 can lead to the imposition of criminal penalises of a five up to$1,S4a 00 anitor orie-yea-r imprisonmerd,ns wiR as rivil penalties xi$re form of a STOP WORK€RDERand a fne of up to$250-00 a dap ab-ainst the violator- Be adtnsed ihat a copy of this tgement=ay be forwarded fig the Of of Iavestagadons of .for insurppe coverage verificati"om f ZTO fter�y s dpenabiss ofFerlr4q thatthe irafarmatimj-prmi&f abm a is trace and cffrect Siffiatu<e= Date 7' Pbnme k: 027cial use aWy, Do start write in this area,to be evinpleted by city ortop m offidQL City ar Town: PSTicense;9 LingAuthnr4(cirrIe tine): L Board o#$ealtii I.I3uWing Department 3.CRyfrown,Clerk 4.Electrical Fnspectoe 5.Phmdiing inspector b.other Conbct Person: Phone 9: haformation. and Instructions IV�A Cearl-mc 5 L&-w5 chapT M req=w aH employers In prMde WCM1=&Co�peIIsa�[ffII f�'�1eIr e[IIployeeS- 1 pms=Dtta this sue,an m pkyw is defroed as"_evezppersonin ffie sedvice of soother under auy contract ofhfim, or implied,oral or " ,. n mmpkyer is den med as"an m ' nal paziaersbi�,asm on;carPM or oiler legal en-c r a T twoor more �afives of a deceased layer,or ffic of the fi3regonag engaged�a Joint ,and mcbndmg the legal rep¢ss emP receivr r or t mstee of an individrzal,pmtacrship,association or of mlegal eniitY,CMploYiUg employees- HoVeves the owner of a.dwelling house having not more than twee apartments and who resides ffierein,or fie o=4mnt of the - dwelling house of anoffim who employs persons to do ma�cx,cams action or repair work on such dwelling boase or on the grounds or budding appmtenaatthereto shaHnotbecause of sash employmeartbe deemedto be an employer." MQ,chapter ISZ,§25C(6)also stems that¢every sfiatn or localJg agency shall wiihlnoId$e issaance or renewal of a ficense or permit to operate a bness or to construct bdiags in the coEumon�ealth for arty, applicantwho has notproduced acceptable evidence of compIran.ce with the incnranCE roveJc'age requ 17 Additionally,MGL chapter 152,§25C(7)stafes¢Nieiffi=file commaawralthnor MY ofifspoItical subdivisions shall enter into any contract fur ffie perfonance ofpabiic work uab1 acceptable evidence of compliance vviffi f mfim urs„cp.. re�ents of dais chapter have been presented in the conxacti g aufhouty"-' App4cants Please fall o:ct the w013ceas, compeosation affidavit compldcly,by chug f-e boxes That apply to your titer, and,if necessary,surpply sub-confr'actor(s)name(s), addresses)andphanemsmber(s) alongwiththc r certiacafe(s) of i lTmance. Limited LiabuR4 Companies(LLC)or LimftedLiabffity Pmtnedbips(LT P)wiano employees other flian.tiae members or pant am-s,are not requmrd to carry wmicers' compensation i„m:an ce- If an LLC or LLP does have employees,a.pohay isregaktZ Be advised that this afI$davitmaybe snbmiti:edto the Department of Industrial Accidents for confsrmation Dfmisaranze coverage Also besure to sign and datethe af—da-Qit. The affidavit should be retumed to ffie city or town that the application for the pennit or license is being requested,not the Department of Indrsihial.A_ccidm-ts. Should you have any questions*egaaFmg the law or ifyou are requm-ed to obfsm a wow' comen psation policy,please call the Deparmem±at the amber listed below. Self-imn-ed companies should en'utr their self;*,�r,nn,ce Iiccnse mm�ber an the�prolmiafe line City or Town Of Fidals t Please be sure ffiat the aftirlavif is complete and pre ded.Iegibly. The Department has provided a space at the botf= of the-affidavit for you to f M out in the event the Of of Iuvcsdgaiions has to c onac't you regarding the applicant_ Please be store tD fr71 m the pe�it/Iicevse member which will be used as a mfbrcace nmmber In addition,sn applicant That must snbmut m.Uhiple pc:matQ C ee applitaticm in any given Year,need=IY submrt one affidavit indicating cnn-emt p olicy infomration.[rf necessary)and rmr3 r"lob Site Address"fie applicant should write"all Iocafions in -(, or town):'A copy of the affidavit That has been officially stamped or marll::d by the city or town may be provided.to the applicant as-prooft3zat a valid affidavit is on fate for fo fm a peonies or licenses A new affidavits nst be-filled Olt each year.Where a home owner or citizen is obfai sing a license or permit not related;fn any bn sue=or commend veantre (i-e_a dog license or pmmit to burn leaves ram_)said person is NOT wed to complete this affidavit The Office of Investigations world h--to thank you m advance for your cooperation and should.you have any qn ors, lease do not hesibate to M a call. P � The Departmenfs address,telephone and fax number. . , f e�r�fludr�ialAcx.�d�nts Of ace of javt� tio= - ' Ta 4 617' -49-GO eft 4-06 or i-V-Mi M Fax 9 617 727'74 Revised 4-24-07 W -�+ c� Town of Barnstable Regulatory Services ` Richard V.Scab,Director i639 Building Division. Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable,ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This,Section If Using A Builder` t. as Owner of the subject property hereby authorize to act on my behA in all matters relative to work authorized by this building permit application for. (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. Signature-of Owner Signature of Applicant PrintName Print Name Date r QYORMS-OWNERPERMISSIONPOOLS Town of Barnstable c Regulatory Services p1Ft "yY Richard V.Scali,Director Building Division t > Paul Roma,Building Commissioner MAM i639. �� 200 Main Street, Hyannis,MA 02601 p � www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION 1 Please Print DATE: J JOB LOCATION: Ld:k4'� nu street p� vill e numb "HOMEOWNER": l D -3`/3-3 name I Aome phone# work phone# CURRENT MAILING ADDRESS: © O '" a t 7 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 d rsi e e wner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection pro a uire is and that he/she will comply with said procedures and requirements. r Sidfiat&e of Ho eowner Approval of Building Official Note: Three-family dwellings containing35,000 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 this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc 06/20/16 i ""t' �ry �\ l" /� c i REGISTRATION AND CERTIFICATION FORM =m' ? FOR FORECLOSING/FORECLOSED PROPERTY .< L r CD Thank you for registering in accordance with Town of Barnstable Code chapter`=224 NO 10 sections 224-3 and 224-4. Please complete one form for each property in foreclosure (section 224-3) or already foreclosed for which possession has been taken(sectioli 224- 4). Please file the original with the Building Commissioner and a copy with the Chief of 5 the Fire District in which the property is located. ' M If you claim you are exempt from registering under Massachusetts law,please state the reason(s) and complete section I (property information) and the first paragraph of section 2 (foreclosing party, court,etc. and foreclosing party representative, but not other representatives and attorney) so that the Town can review the exemption and update its records: Section 1 —Property Information Property Address: 151 PITCHERS WAY , HYANNIS , MA 2601 Assessors Map#: M_299578_822377 Parcel #: 289_016 Land area and description Residential Area: 1,086 sq ft Building(s)description and contents Building Style: Ranch Number of Units:0 Number of Rooms: 5 Occupied: No Occupant(s)(if borrowers so state and include name(s)) Phone.. N/A email: N/A other: N/A Vacant: yes Date: 12/14/2015. Anticipated Length of Vacancy: UNKNOWN Last occupant(s) )(if borrowers so state and include name(s)) ELIZABETH HARLOW Phone: N/A email: N/A other: N/A Has possession been taken YES If so, please explain and complete and file the maintenance and security plan form(unless exempt as stated above)see vacant Building Plan Section 2—Foreclosing Party Information Foreclosing Party(full name/title) Federal National Mortgage Association Foreclosure Case Court: N/A Docket# N/A Date filed: N/A Current Status: FORECLOSED Foreclosing Party's representative(s) for property(entry, management, repair, etc.)(name,title,): Alecia Passley Company (if different from foreclosing party): National Field Network Address: 4581 Route 9 North, Suite 100, Howell, NJ, 07731 Phone: 732-276-5563 email: violations@nationalfieldnetwork.com other: If an exemption is claimed, please do not complete the remainder. Other representative(s)(if foregoing representative is primarily responsible for property and/or foreclosure and is most likely to be able to address town matters concerning the property and/or foreclosure, please so state and do not complete contact information (i. e. "none"or"see above")). Name,title,other: Cindy Russell Company (if different from foreclosing party): Federal National Mortgage Association Address: 14221 Dallas Parkway, Suite 1000, Dallas, TX, 75201 Phone(s): 972-656-7224 email(s): Cindy_Russell@FannieMae.com other: Name,title, other: NA Company (if different from foreclosing party): NA Address: NA Phone: NA email: NA other: NA Attorney representing foreclosing party N/A Firm name(if different from attorney's name): N/A Address: N/A Phone(s): N/A email(s): N/A other: I acknowledge that the information provided is accurate and correct. I also understand that any inaccurate information will result in non-compliance with section 224-3 of chapter 224 of the Code of the Town of Barnstable. &C Aa&,4j ,FU 10 W Date: Name: Title: I hereby certify that the above-named foreclosing party is in compliance with the provisions of section 224-3 of chapter 224 of the Code of the Town of Barnstable. Date: Building Commissioner,Town of Barnstable MAINTENANCE AND SECURITY PLAN FORM FOR FORECLOSING/FORECLOSED PROPERTY Town of Barnstable General Ordinances, Code section 224-4, requires a mortgagee taking possession of a property before or during foreclosure, or after foreclosure if the mortgagee becomes the owner,to bring the property into compliance with the maintenance and security standards contained in Code subsection 224-4(B)within thirty (30)days of a notice from the Building Commissioner. Please either complete and file this form or another containing the same information with the Building Commissioner within thirty (30)days of the notice. If a mortgagee claims an exemption from the provisions of Code sections 224-3 and 224- 4, please explain, leave the remainder blank, sign at the end and file this form or letter of explanation and also complete and file the applicable sections of the registration form for foreclosing/foreclosed property 151 PITCHERS WAY,HYANNIS,MA 2601 ( ) Registration istration date: 3/8/2016 . If not registered, please complete the registration form and state date of filing or anticipated filing (2) If commercial property,describe space utilization floor plans required by the Fire Chief and filing date(actual or anticipated)NIA (if in possession or ownership must be certified as accurate twice annually in January and July). (3) Describe any hazardous materials on the property as that term is defined in MGL c.2 1 K and the date(s)and method(s)for removal as approved by the Fire Chief unknown (4) Method(s) and date(s)all windows and door openings secured (or will be secured) See Vacant Building Plan If left secured, name, address, and contact information of security personnel providing twenty-four-hour on-site security personnel on the property See Vacant Building Plan (5)Location(s) and date(s) "No Trespassing" signs posted or to be posted on the property See Vacant Building Plan (6)Name(s), address(es)and contact information of person(s)responsible for maintaining: structures, lawns and shrubs in sound condition free from excessive growth and the property generally in accordance with the Barnstable Zoning Ordinances the definition of"maintenance"in this Ordinance; any other provision of this Ordinance; and for disposing of trash, debris and pools of stagnant water as provided in Chapter 54 of the Town of Barnstable General Ordinances See vacant Building Plan (7) If the Fire Chief of the Fire District in which the property is located has approved turning off the water or electricity,please state: Date of approval ; Date(s) electricity turned off NIA on if applicable ; Date(s)water turned off NIA on if applicable (8)Name(s), address(es)and contact information pf person(s) responsible for maintaining all existing fences around swimming pools and spas or installing fences as required by Chapter 210 of the Town of Barnstable General Ordinances National Field Network-Alecia Passley Route 9 North,Suite 100,Howell,NJ,07731 732-276-5563 violations@nationalfeldnetwork.com (9)Name, address,telephone number and email address of person who can be contacted in case of emergency if different from the person named above or in the registration under section 224 3(A) ( name.and contact number to be posted on the front of the property if required by the Fire Chief or Building Commissioner National Field Network-Alecia Passley Route 9 North,Suite 100,Howell,NJ,07731 732-276-5563 violatiors@nationalfieldnetwork.com (10) Date(s)certificate of liability insurance on the property filed with the Building Commissioner Attached (11)Date(s)cash or surety bond of at least$10,000.00 filed with Building Commissioner to remunerate the Town for any expenses incurred in inspecting, securing and making the premises comply and continue to comply, a portion of which shall be retained by the Town as an administrative fee NIA (12) Date(s)scheduled for inspections with the Building Commissioner and Health Director, who may at his or her discretion include the Fire Chief, in order to confirm that the land and structures comply with the provisions of this Ordinance or to identify the provisions with which the property does not comply and establish a program to bring the property into full compliance (13) Date(s) when the property was sold, or is anticipated to be sold,to the foreclosing party. If neither,please explain See vacant Building Plan I acknowledge that the information provided is accurate and Correct. I also understand that any inaccurate information will result in non-compliance with section 224-3 of chapter 224 of tthhhe Code of the Town of Barnstable. ee4 CL, l - &l, 2 VM Date: Or l --r— Name: Title: I hereby certify that the above-named foreclosing party is in compliance with the provisions of section 224-4 of chapter 224 of the Code of the Town of Barnstable. Date: Building Commissioner,Town of Barnstable NATIONAL FIELD NETWORK ASSET GUARDIANS Vacant Building Plan National Field Network will continue to maintain the property (securing, grass cuts, inspections, etc.) until the property is sold by the owner. Should you have any issues with this property, please contact National Field Network using the below contact information: Property Maintenance National Field Network-Alecia Passley Company 4581 Route 9, North,#100 Howell,NJ 07731 732-276-5563 x 481 OP ID: SW ACo120 INSURANCE BINDER DATE(MMIDDIYYYY) 511212015 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM. AGENCY COMPANY BINDER® 28157 York-Jersey Underwriters, Inc. Underwriters at Lloyd's,London 185 Newman Springs Road EFFECTIVE EXPIRATION PO Box 810 DATE TIME DATE TIME Red Bank, NJ 07701 X AM X 12:01 AM Johnnie Rum bau h 05/08/15 12:01 PM 05/08/16 NOON PHNE FAX C,No,Ext:732-842-2012 (AIC,No):732-530-7080 THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY CODE: SUB CODE: PER EXPIRING POLICY#: AGENCY CUSTOMER ID:NATIONI DESCRIPTION OF OPERATIONSIVEHICLESIPROPERTY(Including Location) INSURED National Mgmt&Pres.Svcs LLC Mortgage Field Services dba Natn'I Field Network 4581 US Highway 9 Ste 100 Howell NJ 07731 COVERAGES LIMITS TYPE OF INSURANCE COVERAGEIFORMS DEDUCTIBLE COINS% AMOUNT PROPERTY CAUSES OF LOSS BASIC BROAD1-1 SPEC GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 L)AMAUL IQ X COMMERCIAL GENERAL LIABILITY RENTED PREMISES $ 50,00 X CLAIMS MADE OCCUR MED EXP(Anyone person) $ X $10000 Deductible PERSONAL&ADV INJURY $ 2,000,00 GENERAL AGGREGATE $ 2,000,000 RETRO DATE FOR CLAIMS MADE: 05/25/10 PRODUCTS-COMPIOP AG $ 2,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ $1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS MEDICAL PAYMENTS $ X NON-OWNEDAUTOS PERSONAL INJURY PROT $ UNINSURED MOTORIST $ $ AUTO PHYSICAL DAMAGE DEDUCTIBLE ALL VEHICLES _771—SCHEDULED VEHICLES ACTUAL CASH VALUE COLLISION: STATED AMOUNT $ OTHER THAN COL: OTHER GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO - OTHER THAN AUTO ONLY. EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: SELF-INSURED RETENTION $ WC STATUTORY LIMITS WORKER'S COMPENSATION E.L.EACH ACCIDENT $ AND EMPLOYER'S LIABILITY E.L.DISEASE-EA EMPLOYEE $ E.L.DISEASE-POLICY LIMIT $ SPECIAL Errors&Omissions 2,000,000(claims made)$10000 Ded.Retro Date 5-25-10 FEES $ CONDIT1ONsI Extended Personal Property$50,000 occ./$100,000 agg. OTHER TAXES $ COVERAGES ESTIMATED TOTAL PREMIUM $ NAME&ADDRESS MORTGAGEE ADDITIONAL INSURED LOSS PAYEE V LOAN# f AUTHORIZED REPRESENTATIVE ........... ....._.. ACORD 75(2004109) NOTE:IMPORTANT STATE INFORMATION ON REVERSE SIDE ©ACORD CORPORATION 1993-2004 OP ID:SW INSURANCE BINDER DATE(MMIDDIYYYY) 511212015 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT,SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM. AGENCY COMPANY DER®28158 York-Jersey Underwriters, Inc. Underwriters at Lloyd's,London 185 Newman Springs Road EFFECTIVE EXPIRATION PO Box 810 DATE TIME DATE TIME Red Bank,NJ 07701 X AM X 1201 AM Johnnie Rumbaucih 05108115 12:01 PM 05/08116 NOON PHNE IC,No,EI)I:732-842-2012 �c No 732-530-7080 THIS BINDER IS ISSUEDTO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY CODE: SUB CODE: PER EXPIRING POLICY#: AGENCY CUSTOMER ID: NATIONI DESCRIPTION OF OPERATIONStVEHICLESIPROPERTY(Including Location) i INSURED National Mgmt&Pres.Svcs LLC Mortgage Field Services For Fannie Mae dba Natn'I Field Network Only. 4581 US Highway 9 Ste 100 Howell NJ 07731 COVERAGES LIMITS TYPE OF INSURANCE COVERAGEIFORMS DEDUCTIBLE COINS% AMOUNT PROPERTY CAUSES OF LOSS BASIC1-1 BROAD SPEC GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE 10 COMMERCIAL GENERAL LIABILITY RENTED PREMISES $ CLAIMS MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ RETRO DATE FOR CLAIMS MADE: PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident. $ SCHEDULEDAUTOS PROPERTY DAMAGE $ HIRED AUTOS MEDICAL PAYMENTS $ NON-OWNEDAUTOS PERSONAL INJURY PROT $ UNINSURED MOTORIST $ $ AUTO PHYSICAL DAMAGE DEDUCTIBLE ALL VEHICLES Ll SCHEDULED VEHICLES ACTUAL CASH VALUE COLLISION: STATED AMOUNT $ OTHER THAN COL: OTHER GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ 21000,000 X UMBRELLA FORM AGGREGATE $ 21000,000 OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: 05/08/14 SELF-INSURED RETENTION $ $10,00 WC STATUTORY LIMITS WORKER'S COMPENSATION E.L.EACH ACCIDENT $ AND EMPLOYER'S LIABILITY E.L.DISEASE-EA EMPLOYEE $ E.L.DISEASE-POLICY LIMIT $ SPECIAL Errors&Omissions 2,000,000/$2,000,000(claims made)$10,000 Ded. FEES $ CONDITIONSI OTHER TAXES $ COVERAGES ESTIMATED TOTAL PREMIUM $ NAME&ADDRESS MORTGAGEE ADDITIONAL INSURED LOSS PAYEE LOAN# AUTHORIZED REPRESENTATIVE ACORD 75(2004/09) NOTE:IMPORTANT STATE INFORMATION ON REVERSE SIDE ©ACORD CORPORATION 1993-2004 OP ID:SW INSURANCEBINDER DATE(MMIDDIYYYY) 511212015 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM. AGENCY COMPANY BINDER# 28159 York-Jersey Underwriters, Inc. Underwriters at Lloyd's,London 185 Newman Springs Road EFFECTIVE EXPIRATION PO BOX 810 DATE TIME DATE TIME Red Bank,NJ 07701 AM 12:01 AM Johnnie Rumbau h 05108/15 PM 05108116H NOON PHONE IC No,Ext:732-842-2012 %xc,No:732-530-7080 THIS BINDER IS ISSUEDTO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY CODE: SUB CODE: PER EXPIRING POLICY#: CGENCY USTOMER ID:NATIONI DESCRIPTION OF OPERA71ONSNEHICLESIPROPERTY(Including Locatlon) INSURED National Mgmt&Pres.Svcs LLC dba Natn'I Field Network 4581 US Highway 9 Ste 100 Howell NJ 07731 COVERAGES LIMITS TYPE OF INSURANCE COVERAGEIFORMS DEDUCTIBLE COINS% AMOUNT PROPERTY CAUSES OF LOSS BASIC BROAD1-1 SPEC GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE I() X COMMERCIAL GENERAL LIABILITY X RENTED PREMISES $ � CLAIMS MADE OCCUR MED EXP(Any one person) $ X Errors&Omissions PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ $3 000 000 PETRO DATE FOR CLAIMS MADE: 05/08/14 PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS MEDICAL PAYMENTS $ NON-OWNEDAUTOS PERSONAL INJURY PROT $ UNINSURED MOTORIST $ $ AUTO PHYSICAL DAMAGE DEDUCTIBLE ALL VEHICLES SCHEDULED VEHICLES ACTUAL CASH VALUE COLLISION: STATED AMOUNT $ OTHER THAN COL: OTHER GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: SELF-INSURED RETENTION $ WC STATUTORY LIMITS WORKER'S COMPENSATION E.L.EACH ACCIDENT $ AND EMPLOYER'S LIABILITY E.L.DISEASE-EA EMPLOYEE $ E.L.DISEASE-POLICY LIMIT $ A.Information Security and Privacy Liability B.Privacy Notifications SPECIAL Costs$50K Dad C.Re ulator Defence and Penalties$50K Dad D.Website FEES $ CONDITIONS/ 9 y OTHER Media Content Liability$50K Dad E.Cyber Extortion$50K Dad TAXES $ COVERAGES ESTIMATED TOTAL PREMIUM $ NAME&ADDRESS MORTGAGEE ADDITIONAL INSURED LOSS PAYEE LOAN# AUTHORIZED REPRESENTATIVE ACORD 75(2004/09) NOTE:IMPORTANT STATE INFORMATION ON REVERSE SIDE ©ACORD CORPORATION 1993-2004