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HomeMy WebLinkAbout0021 REGATTA DRIVE _ lJ e �� � � ��- - _- - ----_ R f �P I D-ld ;,, i{f - L� - _ OA Sf/OWN E.2E0.C/CO/�'!OL YS /Tfi�- 5'CA . '7 _ r'' �N� /OE.0/.C/� ANC SETB•Q C�- -� _ ,_ .�. M �`.C�E'Qf/�E�1E•vYs u.oF T.y�' :7-oiri,VaF - - .. . _ _ , � -57 I��►rt-yy.5�1-SLR `A/t/O'/.,S •��O T' F.LoGta�1 41 I��. � �g, WV 43,4 _�xTE,e6:VyE i vc. '7/"//S P.L4i!//S it/�T BASSO d .4�(/ i2EG/sTE.2EI> L.�L�V sue!/6Ya.c i, ?.�. .�/VST.2U�1�it/T S!/.e1/EY• €: TyE � . :G1STF�.�1//.CL�a �.4SS. Dom.vr'ETS Sya1,�/.j/Sh(DUL� 'VoT ` TOWN OF BARNSTABLE CERTIFICATE OF OCCUPANCY �w PARCEL ID 252 051 004 GEOBASE ID 43460' ADDRESS 21 REGATTA DRIVE PHONE ZIP LOT 59 BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT HY PERMIT 30257 DESCRIPTION SINGLE FAMILY DWELLING (PMT.027851) l PERMIT TYPE BC00 TITLE ci�.RTIFICATE OF OCCUPANCY j f CONTRACTORS: Department of Health, Safety ARCHITECTS: and Environmental Services TOTAL FEES: BOND $.00 OxINE , CONSTRUCTION COSTS $.00 756 a CERTIFICATE OF OCCUPANCY + * I * BARMABLE. • MASS. 039. BUILDING,DIV,1SLON i BY DATE ISSUED 04/21/1998 EXPIRATION DATE 6 _ f TOWN.-OF--"BARNSTAKE, ADDRESS REGATTA DRIVE E PHONE 7.1 p LOT 59 noc_k LOT SIZE DAA DEVELOPMENT DISTRICT HY PERMIT 27851 DESCRIPTION SINGLE .1.'AM.DWRLL. (SEWP4'.r 495-'6 30) PERMIT TYPE BUILD TITLE NEW RESIDENTIAL BLDG PM`I.' CONTRACTORS:CTORS: BAYSIDE BUILDING; INC . Department of Health, Safety ARCHITECTS: ry and Environmental Services FEES. BOND ti T $.00 V'IME 101. SINGLE FAN HOME DETACHED, I: PR,:CVATL E P ti fi -.,r, MA83. BUILD&G_ D V `5ION D.CEE ISSUED I.2/17/1.997 F ?IkATION DiO-'F THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY. EN- CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND WHERE APPLICABLE, SEPARATE 1.FOUNDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION PERMITS ARE REQUIRED FOR ELECTRICAL,PLUMBING AND ME CH- ANICAL 2. PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU- (READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ELINSTALLATIONS. 3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE._ 4.FINAL INSPECTION BEFORE OCCUPANCY. r POST - D SO IT IS VISIBLEFROM - BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS t 2, � 3 J 1 HEATING INSPECTIO ,PPROVALS ENGINEERING DEPARTMENT ' 2��y� rI�C ci �6 BOARD LTH OTHER: , SITE PLAN'REVIEW APPROVAL -AND VOW IF-` 'F^TIONS INDICATED ON,THIS--' ^N.BE ARRANGED_FOR BY BUILDING PERMIT I, � �I Cfi 77=)q t CF 1FIE Tq�,_ Town of Barnstable *Permit©/�u— Expires 6 nt s from issu ate y3' Regulatory Services FeeA. • BARNSTABLE, v� 1 MASS.. �' Richard V.Scali,Director A Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 . 1 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint - Map/parcel Number— olS a Y tOO LI Property Address o2 i J&qa f A 1�/ �,e Residential Value of Work$ f Zt 000 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address /4141f M Ci✓1 k1+rY Contractor's Name 'j C 0 �-� ��l/}-�I Telephone Number -71 `l-d 3 d--,7 U Home Improvement Contractor License#(if applicable) 1 4s—`'l5 Email: ✓cl;� LL a yAketU.Co►-✓1 Construction Supervisor's License#(if applicable) L ❑Workman's Compensation Insurance, Check one: M ,4� ❑ I am a sole proprietor 19 2015 TO AI V ❑ I am the Homeowner WAI �F p I have Worker's Compensation Insurance . RII t - A STgg�E Insurance Company Name .41,V0 i AALJ� UA Workman's Comp.Policy# GQCC ®%70 Q 9-0 V1"7 3 L -4.01 `'i �4 Copy of Insurance Compliance Certificate must accompany each permit. Permit Re uest(check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to 5AyUw A s(✓eV beJ y1,J LA41t•$4-0 ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ; ❑ 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. A copy of the Home Improvement Contractors License&Construction Supervisors License is requir _ - SIGNATURE: Q WNFILESTORMS\building permit forms\EXPRESS.doc' Revised 040215 I x III , Full Building Service All types of Siding Asphalt and Rubber Roofs � � Trim Replacement Cedar Roofs Window Replacement Customer Phone 5-oy—-7 (� a��4 s`e,�l�r Address 7.q,4 City/Town ��� �P✓(/t � � .�n � ®" Tarp off building and take precautions to protect landscaping. , 0- Strip entire roof and examine deck for rotted sheathing. Plywood replacement cost& s" sheet. Lineal decking replacement cost — foot. ®. Install CERTAINTEED WINTERGUARD ice and water shield on eaves, valleys, penetrations, and chimney. a- Install aluminum drip edge. Color: L,/1.,,, ®, Cover remainder of roof with CERTAINTEED ROOFER'S SELECT 151b. asphalt felt paper -0, Professionally.install shingles according to manufacturer's instructions. Shingle type: <o,/ ,,%Lze.cA Color: GWO(v -)Own (Ste W,, Ventilation: Install exhaust. Type: (t?.J r-,/-cvv Install intake. Type: ry 3 k d s S o r-• f C Install vent pipe flashing R, Chimney - Lift up existing lead flashing, wrap chimney with ice and water shield, insert step flashing Ll Skylights-wrap skylight with CERTAINTEED WINTERGUARD ice and water shield, and reuse existing flashing. Clean out gutters. 0 Magnetically sweep job site of nails U Clean and remove all job related debris from work area daily. Dispose of debris. 0 Provide CertainTeed SureStart Plus extended warranty. 4 10 year labor warranty on workmanship a Additional work beyond this scope is assessed at (, 'i! Per hour, +materials, + 10% Special Instructions t Cost. Good -4,4.JMAillc T DO V k I - Better 1Aet-)I'm"/i ?J/y 4t ry J�- Best Please select shingle choice Amount Down payment $ Payments are as follows:No money is requested until the project is completed. Special order shingles from our supplier require a 1/3 deposit down with the balance payable upon completion.Please-make checks-payable to: Scott Ryan Acceptance of proposal Customer signature Date of acceptance 10 DALE TERRACE • SANDWICH, MA. 02563 • TEL/FAx 508-888-8300 FULLY INSURED • MA. BUILDER'S LICENSE #81294 it q The Corramoinaealtii 4f assackusetft Deparrtrnent of Indrrsaial Accidents _ Office of Investigations — 600 Washingtora Street Boston,41A 02111 ' wmv naaamgvv/dira Workers' Compensaf on Insurance Affidavit: Btilders/Conti-acturdEled6cians/Plumbers Apiplicant Infennaflon // Phase Print LegibTy Name(Br� nnah Andavidual): I (vets�SV Gh 0✓1 L( C Address: (O -,o,+(-e -R✓✓Acle . i +City/Sta& : SA+,tJ_, O Zv Phme# "7r7 4-A 3 Y-d r 3 Q Are you an employer?Check the appropriate boa: Type of.project(required): 1. lama emp to .er v tkh 4. ❑I am a general contractor and'I 6. ❑New constriction employees(full and/or part-time)* have hired the sub-corthwtors 2.❑ I am a sole proprietor ar partner listed on.the attached sheet. 7. ❑Remodeling and have no 1 These sub-contractors have g Demolition ship employees, ❑ working for me in an c employees and have workers' �' " 9. ❑Building addition. [No worlmrs'camp.insurance comp.insurance. l required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homwwner doing all work officers leave emercised their 11.❑Plumbing repairs or additions inyself [No workers'comp. right of exemption per MGL 12..KrRoofrepairs insurance mod.]I c..152, §1(4X andwe have:rno eimployees-[No workers' 13. N Other kttJ Vw e camp.insurance required.] ;Any Aplicc=flat Checks bog#1not also fillcart the section befiow showing. workers'compensation policy information. Homeowners who submit this affidavdr mating they are de mg all]wow and&fin]sire a utol'e coot actors.rrrmsst sabmit a new affidavit indlCatlrrg such I ontractars that check this bw mast atached an additiawl sheet show wag the acme of the sub-contractors sad.=W whether or not Chase entities have emptayees. If the sub-wmamtars have emglayees,they mast provide their Arorkers'romp.policy number. ` lam an empka w that isprovidWg workers'conrpatmasadan fnmrance for Crag enrlv&iyrees. Below is dja polIq and job site in orRmarci on. Insurance=Company Name: Policy A or Self-ins-Lie.4- Expiration Date: Job Site Address: city/State/Zip: Attach a ropy of-the workers'compensation policy dec,Iaratio n page(showing the policy number and expiration elate). Failure to secure coverage as required under Section 25A of 1v GL c_ 152 can lead to the imposition of criminal penalties of a fide up to$1,50G.00 and/or one-hear imprisonment,as well as civil penalties is the form,of a STOP WORK ORDEM 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 Investigatimms of the DIA for insurance coverage verifi on- I do hereby ce difjP der thepMns andpenaifies gfpedur3'tlradlite in orma&npraauided'above is bw and correct i Cure: Date: Phone#: OfficW use only. Do not write an this area,tb be completed ky cfty ar town official i City or Towu: Permit/License tf Issuing Authority(circle one): 1.Board of Health 2.I3Ru ding Department 3.Cityf rown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDD/YYYY) Fo5/18/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY JOR 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 pollcy(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: JAMES R HINDMAN SCHLEGEL INSURANCE BROKERS INC PHONE 508-771-8381 FAX 508-771-0663 AM IL (AfC,No). 34 MAIN STREET ADDRESS: SCHLEGELINSURANCE@GMAIL.COM WEST YARMOUTH MA 02673 INSURER'S)AFFORDING COVERAGE NAIC0 INSURERA:NGM INSURANCE COMPANY 14788 INSURED INSURERB:NGM INSURANCE COMPANY 14788 Scott Ryan Construction Inc INSURERC:AIM MUTUAL 10 Dale Terrace INsuRERo: INSURER E: Sandwich, MA 02563 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. INSR LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY EFF POLICY E P (MM/DDIYYYY) (MMIDD/YYYY) LIMITS A GENERAL LIABILITY MPT5528P 08/07/201408/07/2015 EACHOCCURRENCE $ 1,000,000 R COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) S 500,000 CLAIMS-MADE ®OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY PE0. LOC S B AUTOMOBILE LIABILITY 08/07/201 08/07/2015 (Ea accident) $ 100,000 Ix ANY AUTO BODILYINJURY(Perperson) S 300,000 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ 100,000 HIRED AUTOS X NON-OWNEDPROPERTY DAMAGE AUTOS (Per accident) S $ UMBRELLA LIAR ROCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIM_MA.E AGGREGATE $ DED RETENTION E S C WORKERS COMPENSATION WCC-500-5013731-2014A 08/07/201408/07/2015 "IC STATU, I JOT AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANYPROPRIETORJPARTNER/EXECUTIVE E.L.EACH ACCIDENT 100,000 OFFI $CERJMEMBER EXCLUDED? ❑ NfA _ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE.POUCY LIMIT S 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES 1AKoch ACORD 1e1,Additional Remarks Schedule,if more apace is required) MEMBERS HAVE ELECTED TO BE COVERED UNDER THEIR CURRENT WORKERS COMPENSATION POLICY CERTIFICATE HOLDER CANCELLATION AL MCINTYRE 21 REGATTA DRIVE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CENTERVILLE MA 02632 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE EMAILED © 8 2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACO tj —_� C.gxec�u�iaaarrve�rl/�a�Cll�rirur�rrteGC� Office of Consumer Affairs&Business Regul r�a �Q ROME IMPROVEMENT CONTRACTOR rtegistration ;179545 TSB:. ` ,Expiration 8/12/2016 LLC MP RYAN CONSTRUCTION LLC -SCOTT RYAN " 10 DALE TERR � SANDWICH,MA 02563 # ` Vndersecretir .:. _J 8 Massachusetts -Department of Public Safety Board of Building Regulations and Standards I3o 9 Cunsfructiori Supervisor v License: C&O81294 SCOTT RYAN rr. 10 DALE TER SANDWICH MA';0256 L^ Expiration 07/03/2015 Commissioner Assessor's Office 1st floor Ma d�J Lot -�� Permit# ZE 57 Conservation Office 4th floor —��- --nn—� �� �R�r Date Issued 1.2 / Board of Health Ord floor Engineering Dept. lard floor) House# � 0 Planning Dept. (1st floor/School Admin.Bldg.): SE MUST BE Definitive Plan Approved by Planning Board 0 19 i' IN$TA MPLlANCE (ADUUeOlions Drocdssed 8:30-9:30 a.m.& 1:00-2:00 .m. �A f5 W-e to,,Car S d _ NVIRONMENTAL CODE AND S TOWN REGULATIONS TOWN O BARNSTA Building Permit App 'cation Project Street Address L-o r Village Fire District Owner Address Telephone (- /64z� Permit Request: C:exe � G ./1- �1.� e=��G G't[tyi�e G: Z 7,? 7L& J� Zoning District �`�s Flood Plain C- Water Protection `� Lot Size �7 �/ Grandfathered Zoning Board of Appeals Authorization Recorded Current Use J_,/ Proposed Use la e(Construction Type 6 4 c 4 Eaistine Information Dwelling T e: Single Fan-dlv Two family Multi-family Age of structure /V Basement type atkctel Historic House Finished / Old Kin 's Highway Unfinished 1/ Number of Baths No. of Bedrooms 3 Total Room Count(not including the -� First Floor S^ Heat T e and Fuel I Central Air �� Fireplaces Garage: Detached /� Other Detached Structures: Pool Attached CaA a <013 Barn None Sheds �- Other Builder Information Name Telephone number 771 ^LQ eGu Address 9 License# 0 Q 3--6 `(5- Home Improvement Contractor# `_"-- Worker's Compensation # toct 31z ZZIJ-1770 f3 NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN (AS BUILT) SHOWING EXISTING, AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Project Cost Ida V�U �- Fee ti 373 ` Q SIGNATURE DATE /2, -7 BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) • 9�� �` _ BPERM T FOR OFFICE USE ONLY ADDRESS VILLAGE , OWNER } r DATE OF INSPECTION: FOUNDATION v- FRAME j a INSULATION `S� L�:•• + i FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL . GAS: ROUGH FINAL , FINAL BUILDING- VL. DATE CLOSED OUT av ASSOCIATE PLAN N.O. a �" r r E fi s�.G�. . vAT'A t Flo G,��3Ac�E G!?I�J�E� P—�46,47774- PRe✓ ...'PAIL-( FLOW 3 x 110 — SE�1 Mo.Gl l Vv q , IOop GAI N \� � I 1 DI SPo�A� l- lavo ""A . /S STD jj�- I c� 51DEWdL, AP,'-=A! = 106), Sr BOTTOM AREA :_ '7 6 SF 4c;r ^7 OGJELL vC- j TOT-AL 'Der,16N - 54-F, `Toi'AL DA►tr F"L-0N/ = 3�0 6F'D 1, a� � N� o Peon 8 '�'Go(rATI6W'DAILY �! ' f✓ico� t7�Nu a TE I u 2.trtt��L�ss RT- F OF t� a rev y° PET FR k L i1 f,, <P "'q•`-"w'sty M.le P t i Tt6 r l�otrt:- 77,0 "r�_ TF G -A.Al G � 15? DUST 6,4L 77.3 77. !t I no° 76,5 7 goc 7�.� �7 i sCpr!c��o• GAL 7A N e- c Gf�, G. 11 EL WI d{ -TONE MM5 TAAhl A-' v P - St-(Ac.(. '8E N-Zo ' 2 �' 2 70•5 ope-W -pAe_e- S�a�+vlSroN MAP 2S2/51 253 A9 �I�I ED 'PIZUF I Lam-- N ' La��loN ':.. ___;, �a7,o o S�b!_�. . -• CEJ,ITERVIU.F /uyAW015 1b Cvfi ;� "8 ...(crr�/Z IYo W4rgK A.-z _yy e4 L E--% De,T�_ MA2, CE�ZT1T=F-r I�o ,�v PLAN 5F{C�<J►.! NE'ZEo N Co 7+1 kr T�{E vu> � .. :, '�'1'f'r-- �i ',vlTµ 'Tll� �jl•DE(.1flE jr=- TOWN or �Ar�NSrtia p� �� Soy PU. WI,11 111aQ�V El SOD �LAIU ,y LAND 4:ovzT .ti>uIJ 1 7F115 =i�� (� f�CT- rjA, p `rSfoEJ�ll_ .Ld!J� SueVE/oz;r� oN I,N IuSTL'v�,4EU1- �Surz�;c'� AiJD rN� oF�S�i"S ��vuL,� u T'p P r u �3E EEZ5 a c r L E�JG I r! ESTA aLI �n Fw- eL--T y APPLICANT; I�AySILt 'BUI%,b)NG Gn . ING. I a f N LT: � CYN 043 ,...a \ pp tnq a �. Pei V�7 •• ,C f {i-� 1 Pq v� O 1-1 P-1 1 an U A o�G 1-+ •.�-� cn .� •a-1 C� o cn a� I� c> Pq 13 QG l c � COMMONWEALTH OF MASSACHUSETTS le,.—_=P DErAI TNIT-NT OF INDUSTRIALACCID�N'IS 600 WASHINGTON STREET BOSTON, MASSACHUSEM 02111 James.: 'arlpDe1: �:or-ncss,one WORKERS' COMPENSATION INSURANCE AFFIDAVIT (licensee/permute) with z principal place of business/residence ac y22 6 3 a- (CscylSrzrcmp) do hereby certify, under the pains and penalties of perjury, than. [) 1 am an employer providing the following workers' compensation coverage for my employees working on this jobs. )4W 7 Insurance Company Policy Number ( ) 1 am a sole proprietor and have no one working for me. ( ) 1 am a sole proprietor, ncral conrmaor r homeowner (circle one) and have hired the contractors listed below who have the following wor ens compensation insurance policies: ��d; e J- Namc of Contracror Insurance Company/Policy Number Name of Concnc:or Insurance Companv/Policy Number Dame of Contracror Instuancc Companv/Policy Number 0 1 am a homeowner performing all the work myself. NOTE Plcasc 6c :wuc tt:t wbilc bomco»mcn woo crnpiov persons to do muntcnanct, construction or trpair..vrit on dWciiinc of not more tn>_n Mrce untu in %WW6 toe oorjmo oer aiw ►esioci or on the F►ouncut appurtcnaot thereto arc ant eeoenilt eonstaered to be croiovers under the Woriccn' Corovensauon Act (CL C 152. se. 1(5)), appil-tion by i boroeowoer for a license or permit msv MGCOcc the 1cFaJ sutut of in empioar under the Workers' Ceropensation Act 1 undc-stand :not a coon•OF thJS rtitC.:crit wtp be forwuCc0 to the Menu--tent oFIndusuiaJ ACAocnu' Olncc of Insurantx nor mkt CS vc- :t ::ton inc ;i m u w �; :aiiurc to secure vLrarc rrcrec unoc: Scenon 25A of V1GL 15: tin Iced to the irnDavrion or cri .Ice DCn2Jd ecnntone of : fine of ue to S1 500.Ov indior impmon=.c:.t of up to one trs ant aw u penairi in the form of s Stop L�io x Oros' u'c a fine of SI00.N a dw a€a:ns: mc. s r v SUBCONTRACTOR'S INSURANCE ENGINEEER: BAXTER & NYE ENG: (L) FIREMENS FUND - S30MXX80564866 (W) LIBERTY MUTUAL - WC1312595563023 WELLER & ASSOC: (L) NAT'L GRANGE MUT.- MSP45246 EXCAVATION & SEPTIC: ROBERT J. OUR (L) U S F & G - 1MP30109550901 (W) U S F & G - 771521695 DECO CONSTRUCTION (L) TRAVELERS - 660364K8342 (W) LIBERTY MUTUAL - 312446298044 FOUNDATION: BAYSIDE FOUNDATIONS: (L) COMMERCIAL UNION - ABR406267 (W) LIBERTY MUTUAL - WC1312201785044 WELLS: DENNIS SCANNELL (L) TRAVELERS - 660873E5627COF92 (W) WAUSAU - 151300062926 CELLAR/GARAGE FLOORS: MICHAEL BROWN: (L) AETNA - MP0023672849 FRAMERS: ROBERT DORRER: (L) TRAVELERS - W680526K991TIA9 (W) AETNA - 006CO023972416C MICHAEL DUFFLEY: (L) COMMERCIAL UNION - NBF821356 (W) LIBERTY MUTUAL - WC1312492127024 MASON: SHERMAN, WAYNE: (L) COMMERCE INS CO - N60689 (W) WAUSAU INS - TO BE ASSIGNED ELECTRICIAN: CHAVES ELECTRIC•: (L) HANOVER INS. - LHN2964649 (W) MISCELLANEOUS INS CO. - 0708878 91 1 PLUMB & HEAT: WHITELY PLUMBING: (L) TRAVELERS - 660365K1782COF9 (W) EASTERN CASUALTY - POLICY IN MAIL ALARM SYSTEM: BALTIC SECURITY: (L) FIRST FINANCIAL - FF0131 G400831 (W) COMMERCIAL UNION - CB0743379 CENTRAL VAC: VACUUM HOUSE: MERRIMACK MUTUAL - SBP1608045 i i INSULATION: MAP INSULATION: (L) AMERICAN STATES - 02CC326435-3 (W) U S F & G - 7711099932 SHEETROCK: MEL REED: (L) WORCESTER INS - CB817530 (W) COMMERCIAL UNION - CBH557387 INTERIOR TRIM: DAVID'S REMODELING: (L) COMMERCIAL UNION - NB F821442 M & R CARPENTRY (L) MARYLAND INS. GRP- SCP30235965 (W) CIGNA PROP & CAS.- C80049997 OAK INSTALLER: ROBERT BUDDEN: (L) NORTHERN ASSUR. - NBF528652 PAINTING: CAMPBELL PAINTING: (L) TRAVELERS - 1680251K4083COF (W) AMERICAN POLICY - WCC 186604 GARAGE DOORS: ALL CAPE GARAGE DOOR: (L) U S F & G - BSC14667590301 (W) COMMERCIAL UNION - CBH573757 STORMS & GUTTERS: ALUMINUM PRODUCTS: (L) AETNA - MPOO21014146 (W) AETNA - JC89258880 OAK FINISHER: AMERICAN FLOORS: (L) TRAVELERS - 680 342W754-0 CARPET, VINYL & TILE: CARPET BARN: (L) VERMONT MUTUAL - SBP6507393 (W) PHOENIX INS. - 6NUB476J652794 TILE INSTALLER: TONY AVERINOS: (L) ASSURRANCE CO. - CFP26528977 (W) HARTFORD FIRE - 77WZCY2409 WIRE SHELVING: CAPE COD CLOSETS: (L) U S F & G - BSC146983441 APPLIANCES: KITCHEN APPL MART: (L) FIREMENS FUND - AZC80453098 (W) HARTFORD INS CO 77WZNB1603 MIRRORS & SHOWER DOORS: L & M GLASS: (L) COMMERCIAL UNION - CBR409003 (W) U S F .& G - 0071439933 LANDSCAPE & SPRINKLER: COY'S BROOK: (L) COMMERCIAL UNION - ABR345850 (W) CIGNA COMPANIES - C41138178 DRIVEWAYS: NORTHERN SEALCOAT: (L) MARYLAND CASUALTY- EPA18716945 (W) THE PHOENIX - UB387K530 A � Z 9m i - 72 ED I OQ I :I �J I 0 I.I I� lil ���•� l� LL HIE EEJ - - - --�- __.-__ it l 11 ill � ' I , 00 I . --- - - - - - - -Tl i i I � i , w � ! � � � i � Q II li � � ! �' ® � � � � � � i �I � � _� � , _ _ � � � - � �--- _ � � �� - - _� �� i � ► � ` F� f r-I � I I II � I II , I i ^ 6 t 1 /ram bS4 in�454E j � `a 06 —a - N Wv , mi v ,Fr � '• j uA�ro:e- d I rrrnoa M7�6/do d� } N Oi N W� P �0 Z I O I •�•.t � . dE ( OD 1 O r _ ' U 'WI >0 JS f d r ��11 d NO --- W z � I a r hi �s a i j a� ..4��6+51 21 oLt Q yr • .2}6 .A.L d OI I N I -U40G'N'O L ,elf -lrovdv �nno� i —j—i— a. 11 nli i i m 4 7 y I -X - ? a nu �- - - -� N' J N Z 0 tp a 9 _ dON j j 0. 0 r 2 J � O V u CD-,% ia i I Z Li d L 4 t �t 01 Y I -0 — I � I) I i, I "CNI//\NEY F-OOTIIJ Ga I s i 1 I - L _ J I I I — — I ILI) CAN G 2 I I I. iI I I i r-1q, PLEA",.PC--W-F-T EISGFJ I I B••Y G'-W., G` rilo - OO TIN Cn S' !' 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