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0545 SCUDDER AVENUE (7)
6 Lf ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Z Parcel D I . � Application �© SIX)-7 40 i Health Division Date Issued?— Z`� Conservation Division Application Fee 5� �� Planning Dept. Permit Fee IV �[Z Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 5"'1'� g od o Ave Village b 0 Owner `/ Address e- VAI ✓� uN�r Telephone D F v" ®� Permit Requ st [ i�l e-I`i` gfa 4,q ' &M JM j N t'D A + 2o��I1 Square feet: 1 st floor: existing/proposed 2nd floor: existing proposed /OY Total new Zoning District & Flood Plain Groundwater Overlay Project Valuatio 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 200 Historic House: ❑Yes X No On Old King's Highway: ❑Yes ❑ No Basement Type: A Full ❑ Crawl 2❑ Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing_ new r Half: existing i, . new Number of Bedrooms: 02 existing 2 new Total Room Count (not including baths): existing new First Flook 'oom Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: )(Yes ❑ No Fireplaces: Existing New Existing wo'd/coal 9t-ove:Zl Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn. ❑ existing O%ew size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes O Noii If yes, site plan review# Current"Use r,PAri`GcY Proposed Use ' APPLICANT INFORMATION _- - (BUILDER OR HOMEOWNER) Name. A0 � b. aA Telephone Number So Address 71a u) License # iii ®9pU/d ! 0 Z Home Improvement Contractor# Email aPJ9 Worker's Compensation ALL C_ ONSTR C ION DEBRIS ESULTI FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE /� FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED a MAP/PARCEL NO. ADDRESS , VILLAGE i OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. The ComtonweaT#h ofMassachuretts Deparfinent oflndusfrial Accui'ents Office of Investigations ' 600 Washington Street Boston,MA 02111 www.mass govli a Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le "b ' Name(B`usiness/organizaflonmxuviffi i : op t�tJ Nk- o Ca - 2(� City/State/Zip:� q�d L hone#: 90 -�p— ,3- 11l. Are you an employer? eck the appropriate box: Type of project(required); 1.P I am a employer w&,3 4. ❑I am a general contractor and I employees(full and/or part-time).-* have hired the sub-contractors 6. ❑New consfmction 2.01 am a sole proprietor or partner- listed an the attached sheet 7. odeliag ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.msruance. 9. ❑Building addition r am] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ officers have exercised their I am a homeowner doing all work 11.❑Phunbing repairs or additions myself [No wormers'camp. right of exemption per MGL 12.[]Roof repairs mi ace rea�r;re�]f c. 152, §1(4),in�we have no employees. [No workers' 13.❑ Otter comp.insurance required-] *Any applicant that chocks box#!1 must also fill out the section below showing their workers'compensation policy information- Homeowners who submit this affidavit indicating they ate doing all wodc and then hue outside contractors must submit a new affidavit indicating such. :Coatraehrrs that check this box mast attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employers. If the sub-contractors have employees,they nn1st.pmvide then'workers'comp.policy cr. I am an employer that is providing workers'compensation insurance for my employees Below is the poU y and job site information. Insurance Company Name: Rim MAA LwLALy Policy#or Self-ins.Lic.# �it�(e, ' M v 46Z'1pSDS—Zo 4 A ExpizationDate: J Job Site Address: ~�h�� au&&a6 City/State/Zip: ,� (� Attach a copy of the workers' compensation policy declaration page(showing the policy nut er and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the impositi of cr mat penalties of a foe up to$1,50D.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 again� the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insmaace coverage verification_ I do hereby c fy under pains Penalties of perjury that the informer ion provided above' true and correct Si �f'L�G•� Date: �.� Phone#: official use only. Do not write in this area to be completed by city or town ooiciaL City or Town: : Pe'rm iMcense# Issuing Authority(circle one):_.. ..__. .. I.Board of Health 2.Building Department 3.City/'Town Clerk 4.Electrical Inspector 5.Plumbing Inspector ` 6.Otlier PContact Person: Phone#: Information and Instructions ' Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. tantto this statute,as employee is deed as"_.every person in.the service of another under any contract of hire, express or implied,oral or writ tEm" An emplayer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged is 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 oa 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 applicantwho 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 ofpublic work until acceptable evidence of compliance with the ins�c0. requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checlziag 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 cerfificate(s)of insurance. Limited Liability Companies(LLC)or Limited LiabM 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 maybe 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 Depa tmeat at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials T - 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 applicafions in any given year,need only submit one affidavit indiraf g 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 (ir-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 than 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 Massachust%- Depaitment of ladnstlial Acczdents Office 4f f nvestigations GQQ washivon Sfrl-,et Boston,MA G1 I I I Tel,#617-'27-49QO cxt 406 or l-377-MASSAFE Fax 4 617-727-774-9 Revised 4-24-07 • w .mass_govf ilia 2/9/2015 2 : 36 : 07 PM 8790 ® 03/04 cc� a CERTIFICATE OF LIABILITY INSURANCE °A�`M °D"""' 0 210 912 01 5 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(les)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). CT PRODUCER 04485-001 W. Mark Sylvia Insurance Agency j Q%,Ext (508)957-2125 N (508)957-2781 404 Main Streets: Centerville,MA 02632 INS AFFORDING cOvERAGe NAIC# INSURERA: A.I.M.Mutual Insurance Company 33758 INSURED INSURER B Nordys Construction Inc INSURER C P 0 Box 660 INSURERD: South Yarmouth, MAL 02664 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. I TYPE OF INSURANCE l POLICY NUMBER � p LIMITS G EACH OCCURRENCE $ GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES Ea wwrence CLAIMS•MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADVINJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ OLICY OC COMBINED AUTOMOBILE LIABILITY alord)SINGLE LIMff $ ANY AUTO BODILY INJURY(Per person) $ ALL ONMED SCHEDULED BODILY INJURY(Per aocident) $ AUTOS NON-OA.UTOSWNEDPROPERTY DAMAGE $ HIREDAUTOS AUTOS (Per accident) UMBRELLA UAB OCCUR t EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE � AGGREGATE $ DEEDRg�pMpRRErEENNITIIONN$ Vy�S7p7t� $ XIRD EMPLOYERS'LIABILITY X TORY L kS OER !Wy R�PR��7R�pqR7NER�EXE YIN El.EACH ACCIDENT $ 1,000,000.00 A OFF IMIMEMBOEREXCLUDED7 C"'[N NIA AWC•400-7026505-2014A 5112014. 5M12015 El.DISEASE-EA EMPLOYEE $ 1,000,000.00 (Mandatory in NH) D�AGRIP tee4"PERATIONSbelow E.L.DISEASE-POLICY LIMIT $ 1,000,000.00 DESCRIPTION OF OPERATIONS ILOCATIONS IVEHICLES(ACaeh ACORD 101,Additional Remarks SehedWe,If more space Is required) ` x CERTIFICATE HOLDER CANCELLATION .Town of Barnstable 200 Main St. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Hyannis,MA 02601 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ®1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 7378 School House Pond Condominium 545 Scudder Avenue Hyannisport, Ma 02647 (508)775-9315 February 5, 2015 Holly Management and Supply, Inca 297 North Street Hyannis, Ma 02601 Re: Schooi House Pond Condominium Unit E, basement renovation To Whom It May Concern: Please be advised as the School House Pond Condominium managing agent I have reviewed and approved all plans and description of work prescribed by Nordy Construction, Inc. to finish condominium E's basement to a full bathroom, at 545 Scudder Avenue, Hyannisport. If you have any questions or concerns please feel to contact me. , Since ly, thryn Kolka Vice President of Operations ` CC: William Sargent, President of School House Pond Condominium Association 9 Massachusetts -Department of Public Safety; Board of Building Regulations and Standards Construction Supen isor License: CS-090682 DAVID O NORDBERG PO BOX 660 . SO YARMOUTH�ViAr02664 a J,2..-�d� . >��r��` Expiration Commissioner 04/23/2014 177 p , Ct6JfGC tltJ6LtJ', � y , �J/e��x�naouaect�l�a f'P/Gl office of Consumer Affairs&Business Regulation w �. y e ' ME IMPROVEMENT CONTRACTOR TYPe } $ egistration 144905 ,DBA piration 11/1812016 NORDY S :. P DAVID NORDBERG tt 1196 RT 134 {' E.DENNIS,MA 02641 . Undersecretary + WE T Town of Barnstable Regulatory Services ragas. Richard V.,Scab,Director 1639. �0. Building.Division Tom Perry,Building Commissioner ry ' 200 Main Street,Hyannis,MA 02602�. ` www..town:barnstable maxs Office: 508-862-4038 Y N'` Fax:r 508-790,-6230 Property Owner Must Complete and Sign This Section , ' If Using A Builder l; njOwner of the subject pxoperty herebyauthorize I d� ' acYon inybehalf, in all matters relative to work authorized'bythis.building permit-application for. (Address ofJob) --' 'Pool•fences and alarms are the responsibility of the applicant. Pools'- are t to be filled or utilized before fence is installed and all final r , W u#pe ns are performed and accepted. Signs c, f er-t- '� ignattiu Applicant z , Print-Name, Print Name I-Th r i r - Y m r V Date , Q:FORMS`OWNERPERMISSIOIeOOLS a n Z.4L* T ; - y -�,( , - ; • ell &t-Ae- i•-r t�ti�letr� d ' t UutuL LAXKQ lir .1 15 A .-I Ad* t • t Ell A n f Z�S�Z�i55'- � 1 1 Q r . 4 . . Golrt } . _, a M.� ...• � � � �r � } • 2-- [512- 15 51�5 . 4tL*' ----} ;� �atln . 4 ,toor �•� ice. 5t c� µ q 0 Ctto 4 r Proposed Bath = Detail TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel 1Z I—d—& Application # r)d/5 2�5I ?10 Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 5 Ll s ��u d r--<— A,,c—' Village �-f✓��.n P`� Owner :�L- (Jc.A,_-&o,r 4 Address S U � Telephonef Permit Request �he, rve e4 Co L&r Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 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 $-a Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ii:) I Number of Baths: Full: existing new Half: existing ;Z_ new'' 77.1 Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Roomrount �r 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 d Ica ` _ Telephone Number 771 Address b ,A_- c.� License # C 5 Cal/ �C> �l�`1'�►-cA,"-1— IUA O 6,g`'(e Home Improvement Contractor# -6_XX Email A,,. Az, &&Pt—t Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ern � 7/u�-r�-o�'�-• G�'cc���-r �'l—e-�-h it , SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. • Client#:43622 2MJNA ACORD,, CERTIFICATE °ATE`0/20Y5 OF LIABILITY INSURANCE 07/10/2015 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 5087781218 ^• - AIC No Ext: AIC No Insurance Agency E-MAIL ADDRESS: 973 lyannough Rd., PO Box 1990 INSURER(S)AFFORDING COVERAGE NAIC# Hyannis,MA 02601 INSURER A:National Grange Mutual Insuranc INSURED - INSURER B;Associated Employers Insurance M J Nardone Carpentry,LLC " 299 Whites Path INSURER C: INSURER D: I South Yarmouth,MA 02664-1214 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDD/YYYY MMIDDIYYYY LIMITS A GENERAL LIABILITY MPT1209E 3/26/2015 03/2612016 EACH OCCURRENCE $1 00O 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $500000 CLAIMS-MADE F_X_1 OCCUR _ MED EXP(Any one person) $1 O 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 JEQT 1-1 PRO- F-] LOC I f $ 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 $ i, AUTCS .. Per accident UMBRELLA LIAB HOCCUR - EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE - AGGREGATE $ DED RETENTION$ ti' $ B WORKERS COMPENSATION' WCC5005O119792015A 4/25/2015 04/25/201 X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N .. 4 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500 000 OFFICER/MEMBER EXCLUDED? a N I A (Mandatory in NH) r E.L.DISEASE-EA EMPLOYEE $500 000 If yes,describe under DESCRIPTION OF OPERATIONS below .. ° E.L.DISEASE-POLICY LIMIT $500 000 r DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION ` Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN fl 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE C. ©1988-2010 ACORD CORPORATION.All rights reserved.. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S154399/M154395 LS1 - r. The Commonwealth of Massachusetts Department of Industrid Accidents Offrce of Investigations 600 Washington Street ' Boston, MA 02111 www.mass govIi9a Workers' Compensation Insurance Affidavit: Builders!Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(Business/Organization/Individug): f(Qot'� C.arnM4ry '(- Lc Adress: a City/State/Zip: So..-Ak . �fr-o-A Wg.-i Phonet. 508. 971 • ;�9a 7 Are you an employer?Check the appropriate box: Type of project(require: I�1. i am a employer with 4• ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or part—time).* have hired the sub-contractors 2.❑ I am a'sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling s ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'con:p,insrn•ance comp. insurance,$ required_) 5. ❑ We area 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 o workers' co right of exemption per MGL Ys mP• 12.❑Roof airs insurance required.]t c. 152, §1(4),and we have no employees.[No workers' Other •�•� M lam. comp.insr rance required.] *Amy applicant that checks box#1 must also fill out the section below showing their wwi=s'compensation policy information. t Homeowners who'subrnit this affidavit indicating tbey are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that cbeck tins box must attached an additional sheet showing the name of the sub-contractors and state whether ar not 6rosc entities have employees. If the sub cDntrectar s have employ=,they must pravidt their worlaers'comp.policy number. I am an employer that is providing workers'cornpensatinn insurance for my employees Below is the poficy and job site information. T Insurance Company Name: Al i,� Policy#or Self-ins.Lic.#:- O b.1�0 rn 1,�t'l-1o1 Esxpiration Date: r i Job Site Address:_ ��,� Sc..�.0� �/,.L City/State/Zip: Mp�,I,Ppf ►•tA 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 a 152 can lead to the imposition of criminal penalties of a fine tip to S 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 5250.00 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. Ido hereby certify u epains-andpenalties ofperjwy that the informadonprovided above is true and correct S tore: Date: ' ;7_03c�"I Phone# ���•��•��� Official use only. Do not write in this area;tb he 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 Inspectot'5.Plumbing Inspector . 6.Other _ Contact Person: Phone#: i i massacnusetts-Uepartment or Punnc safety �! Board of Building Regulations and Standards Construction 4ti+ Supervisor ;? a P a ' _ f1J License: GS-081139 04, I MICIiALLJNARfiONE 299 WHITES PATT3 1 South Yarmouth WA a2{'6,4""' :;It." • y i ,�.�.. Expiration Commissioner 091161201! / u elm Office of Consumer Affairs and u's'13 mess Regulation 10 Park Plaza- Suite 5170 Boston,Massachusetts 02116 i I Home Improvement Contractor Registration. 1 Registration: 135887 f Type: Ltd Liability Corpor Expiration: 5116/2016 Tr# 250229 M J NARDONE CARPENTRY LLC. MICHAEL NARDONE 299 WHITES PATH SOUTH YARMOUTH, MA 02664 Update Address and return card.Mai-it reason for change, [] Address ❑ Renewal Employment Lost Card SGA 1 4/ 20M-05/11 &X(f I('n/N q[oJtlaRRl(�Of�r r��CIJJUC�fLJ(•/fl I�I License Office of Consumer Affairs&Business Regulation a registration valid for individu[use only i OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: 9 egistration: 135887 Type: Office of Consumer Affairs and Business Regulation xpiration: 5f16/2Q16 Ltd Liability Corpor 10 Park Plaza-Suite 5170 ' Boston,MA 02116 i M J NARDONE CARPENTRY LLC, MICHAEL NARDONE 299 WHITES PATH SOUTH YARMOUTH,MA 02664 Undersceretary W0tIIvithout signature s Y a ' fj SCHOOL HOUSE POND CONDO ASSOCIATION 297 NORTH STREET HYANNIS, MA 02601 Phone: 508-775-9316 Fax: 508-775-6526 July 24, 2015 To Whom It May Concern, This letter is to notify you that School House Pond Condo Association authorizes M J Nardorie Carpentry LLC to perform work at School House Pond Condominiums, Condo E, 545 Scudder Avenue,Hyannis MA. This company has been hired to put the unit back together after it was damaged by a broken sprinkler pipe., r They will provide the Association and the owner of Condo E with certificates of insurance. If you have any questions please contact me at the number listed above , Sin erely, ka Vice President of Operations pP1ME rop, Town of Barnstable ti Regulatory Services * * BA MASS. � Richard V. Scali Interim Director 9 MASS. $ �A i639. �0 rFo� .�A 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 NOTICE TO THE BUILDING DIVISION OF LICENSED CONSTRUCTION SUPERVISOR ASSUMPTION OF RESPONSIBILITY I, •C���e N G(U�o n� , Construction Supervisor License # �3 ��k� , hereby certify that I have assumed responsibility for the project under construction, as authorized by building permit#3 aD 1-03Q issued to (property address)-- S y.S� Sc,. « .n--� GI'i►• ��� -1 A-4 on , 201 . The following documents are attached: copy of my Massachusetts State Construction Supervisor's license or Homeowner's License Exemption form (if applicable) copy of my Home Improvement Contractor registration(if applicable) Commonwealth of Massachusetts Workers' Compensation Insurance Affidavit. Road Bond (if applicable) OLDER DATE q/forms/newconub rev:103113 _; 4 ! Ra FNCi•ARiC f Town of Barnstable Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www town.barnstable ma.us Office; 508-862-4038 Fm 508-790-6230 Property Owner Must Co. aplete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize QCAf nL to act au,my behal in all matters relative to work authorized by this building permit application for. sc.-Ur Ave .(Address of job) Signature of Owner „ Date Print Naive If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q-\WPF=\FORMS\bundmgpcanitf ms\]DTR84S.doc Revised 061313 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Q- Application tc / v Health Division Date Issued Conservation Division t-"7 Application Fee�y Planning Dept. Permit Fee .90 Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Pro'ect_Street Address S'yS 50-d lPr Ajcn..c 1 =VillageVann. S Owner.- J3o�) aJ L c,,.r• Address Telephone <dd 30 9 Permit Request. ��r JCArc)r C O n O - Dv-4- 6c c e o n S�16 one r'', or I.'. i t S k 4 n ® 646dLCWy10 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Pcroject�Valuation /® 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'!E Highway: ;0 Yeses❑ N # , Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq _ r _ Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new m Total Room Count (not including baths): existing new First Floor Rool Count-= - i 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: 1 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 4tY c�Y1� Telephoner Number Address. 1 b4A'JeS SoLk4h 0d96 4 Home Improvement Contractor# 2 Email Worker's Compensation # W C. C - 500 ` 561 I _ ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO /- SIGNATURE DATE �3 �/, FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. 4 y ADDRESS VILLAGE ` OWNER DATE OF INSPECTION: r FOUNDATION T ' FRAME r' INSULATION J FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL t GAS: ROUGH FINAL FINAL BUILDING r. DATE CLOSED OUT ASSOCIATION PLAN NO. el t ! Rl T7NCTART F. f. = g Town of Barnstable Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO 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 I r5O%0 cc+SOIL ,as Ownet'of the subject propertp hereby authorize M� tVu dor-c to act onmpbehalf, " in all matters relative to work authorized by this building permit application for: (Address of Job) r7-a 7-1.r Signature of Owner Date 13c7 Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. - Q:\WPFMES\FORIYM\buUdmgpamitfarm MTRFSS_doc Revised 061313 f SCHOOL HOUSE POND CONDO ASSOCIATION 297 NORTH STREET HYANNIS, MA 02601 Phone: 508-775-9316 Fax: 508-775-6526 July 24, 2015 To Whom It May Concern, This letter is to notify you that School House Pond Condo Association authorizes M J Nardone Carpentry LLC:to perform work at School House Pond Condominiums, Condo E, 545 Scudder Avenue,Hyannis MA. This company has been hired to put the unit back together after it was damaged by a broken sprinkler pipe. They will provide the Association and the owner of Condo E with certificates of insurance. If you have any questions please contact me at the number listed above. Sin erely, aatlka Vice President of Operations d_ itom{ Massacnuserts-uepartment or rudnc safety • J Board of Building Regulations and Standards Construction Supervisor i1 y'vy;lra,n License: CS-081139 `- MICHAELJ N O r, tz: :i �__ f 299 WHITiESPATH F i i South Yarmouth MA , I i Expiration Commissioner 09/16/20111 � �:/ J�G't% �.PQ/�9?r?'�ZQ�d2rGU�'�liG�l?� t'1�' ���G�;(iC(IJ�t'Z�'!2G(�.�Pi��• Office of Consumer Affairs and u's' B Iness Regulation 10 Park Plaza- Suite 5170 i Boston,Massachusetts 02116 Home Improvement Contractor Registration . Registration; 135887 ! Type; Ltd Liability Corpor Expiration: 5116/2016 . Tr# 250229 M J NARDONE CARPENTRY LLC. MICHAEL. NARDONE 299 WHITES PATH SOUTH YARMOUTH, MA 02664 Update Address and return card.Marlc reason for change. SCq 1 20M•05711 (] Address [� 12eneival [] Employment [] Lost Card 5 t} �a�nivrrrorrrueall�n�CC?rL�rruur/rrir/tt r� Office of Consumer Affairs&Business Reguta6on License or registt•ation valid for individut use only 1 _ OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: J� eglstration: 136887 Type: Office of Consumer Affairs and Business Regulation xpiration: 5116/2616 Ltd Liability Corpoe 10 Park Plaza-Suite 5170 � •- it M J NARDONE CARPENTRY LLC. Boston,MA 02116 MICHAEL NARDONE 299 WHITES PATH SOUTH YARMOUTH,MA 02664 Undersecretary ot� it vithout signature ' 3 a Client#:43622 2MJNA ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/Y 07110/2015 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 5087781218 A/C No Ext: AIC No Insurance Agency E-MAIL ' ADDRESS: 973 lyannough Rd., PO BOX 1990 INSURERS)AFFORDING COVERAGE NAIC# Hyannis,MA 02601 INSURER A:National Grange Mutual Insuranc INSURED INSURER B:Associated Employers Insurance M J Nardone Carpentry, LLC INSURER C 299 Whites Path South Yarmouth,MA 02664-1214 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. INSR ADDLSUBR - POLICYEFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDD/YYYY MMIDDIYYYY LIMITS A GENERAL LIABILITY _ MPT1209E D312612015 03/26/2016 EACH OCCURRENCE $1 000 000- X COMMERCIAL GENERAL LIABILITY - - - DAMAGE TO RENTED PREMISES Ea occurrence $500 000 CLAIMS-MADE Fx�OCCUR MED EXP(Any one person) i10,000 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- 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 H OCCUR - EACH OCCURRENCE $ - EXCESS LIAB CLAIMS-MADE - - - AGGREGATE $ DED RETENTION$ - - $ B WORKERS COMPENSATION WCC50050119792015A 4/25/2015 04/25/201 X WC STATU- OTH- AND EMPLOYERS'LIABILITYIOBY LIMITS ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $500 000 ] OFFICER/MEMBER EXCLUDED? N/A - (Mandatory in NH) _ - E.L.DISEASE-EA EMPLOYEE $5OO OOO If yes,describe under _ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I 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 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 #S154399/M154395 LS1 ry, TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map. Parcel Application # + .� 6 P&o Health Division Date Issued Conservation Division Application Fe / Planning Dept. Permit Fe" Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 45_�LS .5GG( J @A- Village Owner 90 6ew, WAOrs ad Address SAvn e-- Telephone 40 6' 4- 30 Permit Request Kenny_ Anil bn;Ase ®r 54e.! rn o�/� ��e/54L,a'nOra,, At J vn_5 O N / 9 r- AW d 84S-,AV'e,+ f7-&y^-5 2 45- 776 A. 44t*4T S'Foin../CLea, Ae f - IV a SToeeecr-ttge_ &/7 a v.4-4 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 3,5'&o - Construction Type Lot Size Grandfathered: ❑Yes 0 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 Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count 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 `I:l Existing 0 new size_ •mxA -y -_ Attached garage. ❑ existing ❑ new size _Shed. ❑ existing ❑ new size _ Others Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # � Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Nam&- C6-0�~- — - uR-1 �- "��� - Telephone Number s"4 7 7 -Address d L E�� ,err /�� �d J"1� • License# C,S r-A - OS 7 Home Improvement Contractor# Email 4-4 R i i4 ZI-7 (0 A) C4-»" Worker's Compensation # Z uuG' 6 ® liS 8. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO `�clt�ST�✓L p ,►c, 5 � r-e, SIGNATURE DATE f t FOR OFFICIAL USE ONLY j } APPLICATION# 5r DATE ISSUED MAP/PARCEL NO. t F ADDRESS VILLAGE } OWNER ` DATE OF INSPECTION: FOUNDATION • FRAME Y INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL , GAS: ROUGH FINAL FINAL BUILDING, Y DATE;;CLOSED QUT ' ASSOCIATION PLAN NO. r e + a MULTI-STATE RESTORATION, INC. FIRE* FLOOD*WIND* SMOKE*HURRICANE*VANDALISM Fed ID#050515889 CONTRACTORS REGISTRATION#140427 AUTHORIZATION TO PERFORM SERVICES AND r ' ' DIRECTION OF PAYMENT &h herein referred to as "Customer",authorizes MULTI-STATE RESTORATION,INC.,herein referred to as "MULTI-STATE",to perform any and all necessary cleaning and construction services on Customers'property at: f -q,5�'���- Telephone: 617 �'?ter �;Z�� and with res ect to items that need to be cleaned at a remote location,to remove and clean such items as necessary. Customer authorizes 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 pa Customers'deductible in the amount of$ that applies t thi laim. . r If the loss is not covered by insurance,Customer,agre s t a the total amount to MULTI-STATE upon receipt of the invoice. Signature o Ow It is*my understanding that the services to be performed ULTI-STATE will be limited to those,which are authorized by my Insurrcce`Company. U 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 rea th' t completely understand and agree to same. ' Signature Date Printed Name P.O. BOX 2210•MASHPEE, MA 02649.866-921-9111 •FAX 774-238-4422 YTAff CMn77rffAw=I&gfmcEssachm� �e�r �ref'�>�tti�cc€dei� 60 Wm*hVun See-t frgsfav�HA a2M wec w xn=go v1dia Workere CmmEg t Iss=-an A a } dersf t cfi rsl -ecfr�cia�slPlu�sl�ers I t�rnia t t Please Frhif LegzW Na= L-n SEd e.S%�(ZA`r/DJo.) r' res f4- - - (:ftgfSfEftf-Jap. ?`j0JS4i Pee A- Phan-, -SOS 4-7-7 3333 yan an employer?ChwkdEa 2ppmpriafr-btr . 1 V I am a employer with .'¢ ❑ I am a confiacEor and I _ ePl aye's(fall Mwopar�- -)* hn lj�-tbe ems ItTe s r c work ❑ I am a sole proprietor orparfner- listed an the attacked shwL' +- ❑R==odeEng ship and have no employees Tlev-,sab-aoatactoss have g- ❑Demalitina femme in an emplayeex 811d have workers= '�o�ng Y��!`- - $ 4_ ❑3uilrFmg addition • [tt WDrL-ffi'camp-ft mn-mre COIIkp_m-cnrarcrn- I 5_ ❑ We am a corporafianand ifs 10.0 lilect ical repaim c r additians I❑ I am a hnmeawner drying all work officers have C=- sed their 11-0 Plumbing repair C)r additions my-t[E [No worh='•c=-'p_ :d�.ofemutpiioa Per MGF- 12 .Roof 7 m c-1 1rr aadwe hose na crxanre�ed_IF �� l�= - °y �o 13--❑Ofiir mmp-in.—mance re ire3 *I�xy�xph�f that c5edisbos rl mnstalso fiIl onti'�s�na helot2ch�;�c iheawo�e=sT co�z�nrstiou poS�- tcautcum ff�wnes��i�t�this s�d�:u ig 3�ey e..2'eam�=II_={e�thy*h**e at��conlre[mrs Est sahaat a n�gmdscst*+��sorb. zrthstrhwl-ads box maststhduh dsa:8rT;tir,.,AIshe.ishnumgthenM31,-nf63EMV-COBksCb3--M ta3zuhet�erarnntfi�nse S etlnyses. if thesoTrcnad�usb ree�n3o [3te�z�st ;�Pth�u w�k� �ffmp.paIitym�h� .Irzrn rtrm7ap rkrisgrat�idiHg rraricers'corm izzrr�Frrrtca far rre��etrty�rs. Belaty is fftega&c}raid}ob sii� irt�at rrtQfiean �^ T�nc ,companymame: AM u/1'/LJ �/V J CO . Poficg ar S f iris Iz� a IN c�t o 01 g ErpiratianDate= —7 16 /S Job!sit� S SCu Jj"' '41 cite, zp_ S/.hVNiS Pow �6 Attach 2t copy of&h-WGrk�-ss`ct*mpeusati�n poIit�dec�sstion page(���the policy stnurber arsd¢pnatian�ste�: Fa$vie fo secare c�ti etage as rirednnder Secfio�z S ofCrL c I52 can Lead to fihE impasitum of criminal paffies of s fine np to L SOt}_f#fY andlor one yearimpusaa as well as m-it pew in rf e fg=of a STOP WOKK OR ER-and a Hns of up-to$250.00 a day agaiust the violafar_ Be advised tmt a cry of this stag maybe forwarded ttr fire Office of Invesfimtxnm of the DI_ik for rt,=-cam cov�ge vrc acdwt- I do,hereby cerf fp under tk cs uttrf psu�iss u� utF 1leatfh���'arrza�n pia car£abaxre is true cmd cap rsct 6 9' St-7 F 'ci'TL us-e au£y. Da not writer in fads mrea, bg campleted by ciiq or farm a,�tcznL CiiT or To-wm Par lib ;caase 9 Is!�Aufhori'tg(mcIe nney . L ward ef$eali 2. mng Iartmtt calxecor fi.Pabmg F� tor 6.Cfher c(Yat:tct I=naL PIar�n Massarliusetts General Laws chapter 152 requi=adl=uployers to provide workers'compensation for their employe:es_. FUrMIa f t D this sfatOb--,an enrp£apee is defined as" may person in the service of anof er under anY Contact ofhire, express or in�liecL oral or written.." . anPT1'ez is def red as`'aa iadmffii l,partnership,associafon,corporation or other legal entity,or any two or more of the foregoing engaged in a Joust enterprise,and ina udiDg the Legal representafives of a deceasedl employer,-or the receiver Car trustee of as individual,partnemhip,association or other legal entity, employing employee;. However the owner of a dwcjling house having not mare than three aparimmts 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 dweldmg house or bn the grounds or building appurtenant thereto shall not because of such employment be deemed to be as employer." -MGL chapter 152, §25C(t7 also sfahes thA`every state or local Ticamsing agency shall withhold the issuance or renewal of,a Hr"'e, or permitto operate abusiness or to construct buildings in the commonwealth for any applicant whto has not produced acceptable evidence of compliance with the insurance.coverage required.-' Additionally, MCTL chapter 152, §25C(7)slates"Neither the commonwealth nor any of its political subdivisions shall entr_r into ray contract for me perfibnnan.ce of public work until acceptable evidence of compliance vrith the i su:rance requirements of this chapter have been presented to the contracting anzhority.' Applicants Please El out the workers' compensation affidavit completely,by Checking the boxes that apply to your sitvztion and,if necessary, simply sub--contractor(s)nam.e{s), addresses)and phone n=ber(s)along with their cer Cate-(s) of msm-d ce. Limited Liability Companies(LLC)or LimstedLiability Parmers4s(LI.P)withno employees other than the members or partners,are not required to carry workers' compensation insurance_ If as LLC or LLP does have employees;a policy is required- Re advised that this affidavit may be submitted to the Department of Industial Accidents for confrmation ofinsance coverage. Also be sure to sign and date the affidavit The arindavit should be mtumed to the city or town that the application for the peomit or license is being requested,not the Deportment of Industrial"Accidents. Should you have any queStons regards f ,1_aw or if you are required to obtain a?rorkers' compensation policy,please call!he Deparim eat at the mmmber Listed below. Self-insured companies should enter their self-i =once license number on the appropriate line. City or Town Officials Please be sure that that-affidavit is complete and pr�legibbr, The Department has provided a space ai the bottom of the affidavit for you-to fll out in the event the Office o f lavestigaiions has to contact you regarding th e applicant Please be sure to fIl in the p= it/lieense number which will be used as a reference number. In addi on,an applicant that must submit multiple pf— it/limnse applications in any given year,need only submit one affidavit indicafng current policy infoznaiiou(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 fire city or town maybe provided to the applicant as proof that a valid affidavit is on flt for future permits or licenses A new affidavit must be filled DIAL each year.When,a home owner or citizen is obtaining a license or permit not related.to any business or commercial venture venture (i e, a dog license or perma to bum Ieaves etL_)said person is NOT required to complete this affidavZt 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_ ` a�C�omman a of Ma&3achu Drat twat of Inclustial A� e,:at ofvau TeL 617 749 (xt4 �� 1-977 i� F�� 1 -727-7745 Revised 4--24-07 Client#:34309 MULTISTA ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 05/12/2015 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 Maria Barnowski Starkweather&Shepley PHONE FAX A/C No Ext:401 435-3600 AIC.No):401 431-9326 PO Box 549 E-MAIL SS: mbarnowski@starshep.com Providence,RI 02901-0549 INSURER(S)AFFORDING COVERAGE NAIC# 401 435-3600 INSURER A:American Safety Insurance INSURED INSURER B:AmGUARD Insurance Company 42390 Multistate Restoration Cape Cod INSURERC:Hartford Ins Group 19682 Division,Inc. P.O.Box 2210 INSURER D: - Mashpee,MA 02649 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. INSR ADDL SUBR - POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DDIYYYY MMIDDIYYYY LIMITS A GENERAL LIABILITY EPKI06790 1/01/2015 01/01/2016 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $50,000 _ CLAIMS-MADE �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 X POLICY PRO- JECT LOC $ C AUTOMOBILE LIABILITY 02UENOT4762 1/01/2015 01/01/201 EaaccdeD SINGLE LIMIT $1,000,000 X ANY AUTO - BODILY INJURY(Per person) $ ALL OWNED 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 CLAIMS-MADE AGGREGATE $ DED RETENTION$ - $ B WORKERS COMPENSATION R2WC510288 7/16/2014 07/16/201 X WC STATU- O AND EMPLOYERS'LIABILITY TH- ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N OFFICER/MEMBER EXCLUDED? FNI N I A E.L.EACH ACCIDENT $500000 (Mandatory in NH) - E.C.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional.Remarks Schedule,if more space is required) - RE:545 Scudder Avenue Unit E 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 02602 AUTHORIZED REPRESENTATIVE CL- SA1ttAPL 4J24: ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S691739/M672348 MBB f ^ d7/1e�ponrnwruaeal ', �C taadaj, 6 ` fSce of Consumer Affairs&Business Regulaiton ' .f.icense or registration valid for individul use only. ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: o egistration.,140427.; Office of Consumer Affairs and Business Regulation Typ 10 Park Plaza-Suite 5170 Expiration `10/1572015 .:. Supplement Ord Boston,MA 02116' MULTI-STATE RESTORATION J:NC.CAPE COD ' RICHARD LAURIA - P: 0. Box 2210 MASPHEE,MA 02649 i Undersecretary i Not valid without signature Massachusetts = _ 3oarq of 3u-. . �ePartment of Ju n9 Keguia.. ahPubuc S Ionafety "4u LIC@Ilse: "Siiiiiv CSFq-0517 Mill �`�D j .1 t��ct rr.t 84. Rocidand� = TRY 02370Co irlissioner Expiration 0410112017 f 5�f Sc �c�2 4V S Look- �t ANC'iS PO ` 1-14 • g2�ta..ov r'1 ' tl �Sllx FK t&r '2;P C1eS�T � I v� L t v,N 9 2wi G 5�5 sGK��e� P'V ok FWA-c.« r A Closes �-rex-- l3e-j?.do-1, X l2'Z 'r t3" ALI . �{ s P s Pv nT Vh A F7 lay 03 b(U<,o u ?s5o�