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HomeMy WebLinkAbout0019 SPRING STREET 1 VE Town of Barnstable *Permit# _ 1 �� jqj F�iT 6 months from' ue date ��. Regulatory Services Fee * ° � 0 Richard V.Scali,Director Building Divisionvk� Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address �,�/c e' e— Residential Value of Work$ S&V&V Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address N Q Contractor's Name o'" D (, Telephone Number Home Improvement Contractor License#(if applicable) Email: 6_nn o9� la fSU�h'Lr1�G-�� Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor. ® I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. , Permit Request(check box) ® Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to 1�It ❑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: ,j r A —+n ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red Sand inspections required. Pei tl-C--SfJel 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 required. Q A SIGNATURE: ®fib �. a iD 144CUA- Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc 06/20/16 4 AC® CERTIFICATE OF LIABILITY INSURANCE °ATE`MM/°°"Y,rY, 1 07/26/2016 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 have ADDITIONAL INSURED provisions or 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: Luisa Miranda TRU Insurance Agency,Inc. PHONE FAX 1626 Pond St. EMn,io E t (781)281-9688 AIC No,(781)394-8808 Ashland, MA 01721 ADDRESS: Imiranda@tru-inSUrance.COm License#: 1950671 0 _ INSURERS AFFORDING COVERAGE NAIC1f INSURER A: The Main Street America Group INSURED INSURER B: LM Insurance Corporation Carrijo Construction&Remodeling Inc INSURER C Deivid Carrijo INSURERD: 69 Howe St. INSURERS: Framingham, MA 01702 INSURER F COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 23 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 ADDLTYPE OF INSURANCE INSD WVDSUBRI -POLICY NUMBER MMIDDPOLICY EFF MM/DD1 POLICY EXP LTR LIMITS A X COMMERCIAL GENERAL LIABILITY MPT2557T 09/11/2015 09/11/2016 EACH OCCURRENCE $ 11000,000 CLAIMS-MADE FRI.00CUR PR M DAMASES Ea occu ante $ MED EXP(Anyone person) $. 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 I, PRO- ❑ POLICY a LOC PRODUCTS-COMP/OP AGG $ 2,000,000 PRO- OTHER: - $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ - OWNED SCHEDULED BODILY INJURY(Per accident) $ ' AUTOS ONLY AUTOS HIRED - NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $- EXCESS LIAB CLAIMS-MADE ? AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION TO BE ISSUED BY CO 09/17/2015 09/17/2016 X STATUTE EER R AND ANY PROPRIETOR/PARTNER/EXECUTIVE^Y/N - E.L.EACH ACCIDENT $ 1,000,000 � OFFICER/MEMBER EXCLUDED? N/A - (MandatoryinNH) ❑ E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The original workers compensation certificate of insurance wilf be issued by the carrier on a separate form: CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE' THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Joao Geraldo Araujo ACCORDANCE WITH THE POLICY PROVISIONS. 19 Spring St Hyannis, MA 02601 AUT-HGRtcE8. SENTATIVE LCM ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by LCM on July 26,2016 at 10:31AM ACo CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD,YYYY) 6_/ 1 07/26/2016 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 have ADDITIONAL INSURED provisions or 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 TRU Insurance Agency,Inc. PHONE Luisa Miranda FAX c No Ext: (781)281-9688 A/C No: (781)394-8808 162B Pond St. E-MAIL Ashland, MA 01721 ADDRESS Imiranda@tru-insurance.com License#: 1950671 INSURERS AFFORDING COVERAGE NAIC# INSURER A The Main Street America Group INSURED INSURERS: LM Insurance Corporation Carrijo Construction&Remodeling Inc INSURER C: Deivid Carrijo 69 Howe St. - INSURER D: . Framingham, MA 01702 . INSURERE: INSURER F COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 23. 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 TYPE OF INSURANCE ADDL SUBR- POLICY EFF POLICY EXP. LIMITS LTR -POLICY NUMBER MM/DD/YYYY MM/DD A X COMMERCIAL GENERAL LIABILITY ,MPT2557T - 09/11/2015 09/11/2016 EACH OCCURRENCE $ 11000,000 ®OCCUR DAMAGE TO RENTED CLAIMS-MADE . PREMISES Ea occurrence $ i MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JERa 0 LOC - PRODUCTS-COMP/OP AGG $ " 2,000,000 OTHER: $ AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ - AUTOS ONLY AUTOS ONLY , Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ •- $ B WORKERS COMPENSATION TO BE ISSUED BY CO 09/17/2015 09/17/2016 X STATUTE EER PEI H AND EMPLOYERS'LIABILITY _ YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 . OFFICER/MEMBER EXCLUDED? NIA - (Mandatory in NH) ❑' - E.L.DISEASE-EA EMPLOYEE $ _ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below t I I E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The original workers compensation certificate of insurance will be issued by the carrier on a separate form. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN .Joao Geraldo Araujo ACCORDANCE WITH THE POLICY PROVISIONS. 19 Spring,St Hyannis, MA 0260.1 AUTHeg+zfaREPRGSENTATIVE D. LCM ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Printed by LCM on July 26,2016 at 10:31AM Town. of Barnstable, Regulatory Services dE Richard V.Scali,Director Building Division t . ~ Paul Roma,Building Commissioner MAM 39. ��� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION W Please Print DATE: l JOB LOCATION: y t�i(Yu' S 1 N y��rn m OPI .Q number 4/ ��JJnn street village "HOIvtEowNER": 0 CP/lU-C Grb iC`�'�OQ.��o SO of `�� ' _ 7 3-a e fi�rr° D home p ne# work phone# CURRENT MAILING ADDRESS: 5 ryrN, m K) 0.2 city/town U state i� zip code The current exemption for"homeowner`s"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 p 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) r The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations: < ' The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requireme and tha he/she will comply with said procedures and requirements. _aj&ture of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. !.' HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire-to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&:Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is� ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities, many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page 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 Town of Barnstable Regulatory Services KAMRichard V. Scali,Director. ►�� 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 , I ,as Owner of th subject property hereby authorize to act on ray behA in all matters relative to work authoriz by this building permit pplication for. (Address of Job) **Pool fences and alarms are the responsibi " the applicant Pools 1 are not to be filled or utilized before fe a is ins ed and all final inspections are performed and accep Signature of Owner Signature of Applicant Print Name Print Name Date QYORMS:OWNERPERMISSIONPOOIS .77xe Commarrrpeakh gfM°assadi msettF Deparftffewt of ludustridlAt:ciderats _ fIj ce ofrMWE#gatiotts 600 Washi igton xS`Ireet _ Boston,HA 02111 iPnn tmass`gvv1dia Workers' Camrpem.afi an Iusurauce AffidavaL Bmilders/C.UndractursXle�tcians timbers APPUcant Infarmmatiaa Please Print Addre= / lewof rl --—c;tgfs — gvve-, � at1 -- �T- -- -, Are you an employer?Qreckthe appropriate boas: Type of project(required -- I.❑ I am a employer vdtith 4. I am a general conimctor and I employees(full andfor part-time}* have hired ffie sub�-canbactom 6- ❑New �.❑ I am a sale pzopdetar orgartuer- fisted cathe attached sheet. 7. ❑Remodeling ship and have no employees . These s b-camtrraactars have g_ ❑Demoliffou woffing for me in any sty employees mad have wa&ms- [No wok='camp.:xmurance comp.Rmaran-M 9. ❑Bu&dtag addition require&] 5. ❑ We are a corporatifln and its lo_❑Electiical repairs or aticrdions 3.❑ I ama homeowner doing all vo& officers have esercised their 11-0 Plumbsagrepaim or additions my-self o workem' - right of emempfon per MGL 12-❑Roofreaisicxane rPqtrpd-]t c.152 §I(4h andwe have na employee's.[NO workers' 13.❑other coap-inst mnce ] #Any a pgiicntabstebec1mbax#1masialsofMcuttheswdonbdm -&mvugdmkwoameccmpensatio-apoycyiafcrosrdmL �ameootaers who sabmit dais af5daeiE io g they axe dain�aIl;cadc aa� hiia outside coatrsctms�ct sflbmit a new afdav t maieatino sadL fCaUact=f=rhFw'1r s box mast X t f-h au additim ShEd shaming tbename of the sob-cars and state whtlhec or not Chase entities haw± empbyem IfthemA--=uzdaishnmmupicyw flLey=srpMv e&eit vadm s'tomp.imikyam fiber. . . I am all etsploysr Heat SaTo w is the paTicy and job site information. Insmmce Company Name: ' Policy or self-ins.. ic.;9 ExpiEz on Die: Job Site Arl m= �,�� Y ►(e 74 Citylstate!2sp Attach a copy of the workers'compensationpolicp declaration page(showing the policy number and:expiration date. Failure to secure coverage as raequim under Section 25A of MGL c-157—can lead to the imposition of criminal penalties of a fine up to SL50D OD andror otii;y ear imprison as well as cif peaa19t-s in the farm of a STOP WORK ORDERand a fine of up to$250.00 a day abgainst the violator. Be aidsdsed.ffid a copy of this statement may be fiuwafded to the Oface of Imvestegatiaas ofthe DIA for hzuraace coverage veafrmiam._ Ida hereby nuWfy mum er tits painr andpanabhu a gerjrUq thatthe inforumfi rt�provirled abmv fig hue and cvrred Sia�ature: A �lt. (3 Y Date Cv !o Phone ik �O? 9,S 3 Official use only. Do not wrRe in furs area,to be w npTeted by city artow a,,�'aL City or Town: Perro itUcense 9 lisming Aufbarity(drde one): L Board of Health 1 Bwffifing Degarbnmt 3.fji}YTown Clerk 4.Flechrical limpector S.Piumbi ag Emspecter d.t7ther . Contact Person: Phone#: laformation and 11astrac ons Massar oft General Laws avtur l52 regM=all employers to provide work='compensation for their employees. Pmsaanttu this stHt3iD,an CZT&gM!!is deed as".every person in tit a srrvice of another under uny contract ofhnr,, eXprC s Or i3:Ep]ied,oral Or =pbyer is dew as"an mdiivid ml,partnership,a-ssocialicm,caipor.dion or other legal Cie ,or any two or more of the foregvmg in a joint uprise,and inclndmg the legal repres�ves of a.deceased emplayer,or the rc=ver or trustee of an indvidnal,paxtaership,association or otheaIegal e atit9-, Ploy �P�y - However the over of a.dwelling house having not more than three apa¢tm=±,-.and who resides therein,or fh.e occupant of the - dwmMng house of mxfj2m who employs persons to do mamtenancc,consfracti on or repair woi on such dwelling]house or on.the grounds or bm7dmg appurtenaz¢themb shallnotbecamse of such employment be deemedto be an employer." MGL duptnr 152,§25C(6)also that"every state or local licensing agenicg shall wifihhold ffie issuance or ren:evgal of a Hcerse or permit to operate a business or to construct buildings in the commonvQealih for any applicant-who has not produced acceptable evidence of cumpThanmwith tha bnmxance coveXa.ge required." Additionally,MC EL chapter I52,§25C(7)siais�Teitherthe cormnMW althnor amy ofitspoIiiical subdivisions shall enter min any contract for the performunce ofpubIic work until acceptable evidence of{ampli�ce vriiiie msm'anr�. regret emeats of this chapter have been presented to the mntL�ardhoaty." Applicants Please fill ovt the workers'.compensation affidavit compidely,by chug the bores ffiat apply to your situation and,if necessary,supply sob-contractor(s)name(s), (es)andphona'-m— =(s) alongwtihtheir certificate(s)of insurance- L.imitrdLiability Companies(LLC)or Limited LiabilityPartnerslups(LLP)wffhno employees other than the members or pa tneas,am not regvaed to carry workers' compensation insurance. If an LLC or LLP does have employees,apolicy is required. Be advised that this a$day]tmaybe sabmifted to the Deparfinent of Indnstial Accidents for conffimation of msm—ce coverage Also be sure to sign and date the affidavit- The affidavit should be retvmed to ffie city or town that the application for the permit or license is being requeshA not the D eparbnemt of Itdustrial A_ccidenim Mhouldyou have any questions regarding the law or ifyou aie reqmffi�d in obtain a workers' compensation policy,please call the Department at the amber listed below. Se -msraed comp=es should enter$heir self-i suu-unce license number on the appropriate line. City or Town OfEldaTs Please be sore tip the aTidavit is complete and prirt clilegIly. The Departmenthas provided a space at the bottom of the affidavit for you fn fill out in the event the Office ofInve��hone has to comactyouregarding the applicant_ Please be sure to Ellin.the pen gWlicense=xmber which wM be used as a refere nce rm tuber Im addidon,an applicant that must submit multiple pem&Hcen sse apphtatioas in given year,need only submit one affidavit indicating cmzent polio,,information Cif necessary)and under`job She Address"the ipplic�t should write "all locations in ( 'or town)--A copy of the-affidavft that has been officaally stamped or marked by tie city or town may be provided to the applicant as proof that a valid affidavit is on fie for fnt ar perms or licenses A new affidavitmust be file d ovt eoaclh year.Where a home owner or citizen is obtaining a license or permit not im ated i D any business or commercial vfttnr, (i e- a dog license or peunit to burn leaves a _)said person is NOT regnizEd to camplete this affidavit wouldlTke-to-thank uiaadvanceforyourcoopea�ionandshouldyou.haveanygnestions, The:Office ofIn Yo vestlgaiions please do not hesitate to give Ms a call- The Department's address,telephame and fax rmmbm-- Delta dmmt cif hid i Accidents Office of In g ti=,% -Ted..:#6I7-' --900=t 406 ar I-M-WSSAFE Fax 617-727-7M Revised 4-24-07 gavidia Department of Ir s&ud Acddm3�6- ft},�ce a}'�atans. 600 Washu t meet Bvstonj,MA 02111 - witnw.mas&goP1dza Warleie Ca mpensafinn Insurmce Afadavit Buiders/ContractcirsJEI ian!s/PhEmbers App'bcant Tnfmmiatiqri Please Print Y NAB12 4/�%� /0' - COfStat-�- Phcno-,cf-- o�-goy- �zo Iq Are YOU an employer?Checkthe appropriate bar: Type of project(required): I.EK I am a employes with Z 4 ❑I am a general contractor and I 6-' ❑New eons on employees(fish audfor part-time).* have hired the sob-candraoE 2.❑ I am a sale propxietor:orgarfaer- listed on the attached sheet~ 7- ❑Remodeling shz p and have no employees Mere sub-contractars have 9. ❑Demolition working forme in any fy_ emFlorem and have wod ws' 9. .❑Build addition [NO Wodoers'Comp_finurance Comp-msuranml reclaired] 5. ❑ We are a�orporafioa and its 10-❑Electrical repairs cr a,d�ions 3.❑ I am a homeowner doing all work officers have exercised their 1L❑Plumbing regains or$dditiams €[No o workers' - rigbtof hot per MGL c § { dwe have noins ra=ereqqired] L_�Roafrepairs 1 _®{)alter Et/1��Cf/f employees_(No,workers' cam- requir ) #$nyz"5csat&*tdmdmbcz#1—stalsaMvwihesectioabeImvshaviagtheawmleW compeasariaapeycyinfoE =9ML t Homemnem who submit dm aifidarit in ag tlwy are doing alE wow sad then autsid�caa�cEorsnmst submit a nem affida>�t mdiEyting saclL ICaattactoatfiat cbe t'hIs box mast attarh additional street sbowingthenameof the sub-camtscm Smmd stMe whether ariwttwse emitiesbnm employees.7ftbe:sob-contra;ctaashmmemplayee%&eymustpmvIde&eir wadm&gyp•pGIL-5 er- I am an eeipr raise is pr�ruidireg�urrrkers'cornrperrsrrfian ursziratrcenr my empJnj�ees: $etory is flte prr�icy aruI job srte irr�ormatins. . lusuranmCompanyName:�(/ /!/ O E /fiG e Policy-4 or Self-im Lac_--.1k Job Site Addse;a: %���� 'S ��!',aV Cdy/StateW2.p Aft2ch a-mpy of the workers'catmpensationpolicf declaration page,(showing the policy*number and eaph-ation date). Faiinre to secure coverage as reguiredunder Section 25A of MM c�15-7 can lead to the imposition of criminal pettaYt%es of a fine up to$L,54aOD arrd for one-gear imprisoumed.as wag as civil penaltie is the form',of a STOP WORK ORDER and a foe ' of up-to$25&00 a day-ab-aiast the violator. Be advised did a copy of this statement maybe forwarded to the Office of InveuEgatians of the DIA for insmmace cavecage vac ali= Ida 14es-46Y ceri fp order to pains anrFpajralr s s, pet jrry at f7ra irrf arrtratrarspro�tdari abm�a" true d carrect oz o r Date- Phase a- SO A 9NO e-t ' 4S 2 O Ot 0jgIdd use aptly: Do just writs in This ama, be CVIAP<et0d b�Cify artstFn a;oaciat City or Turn: Plermiffkense;g Issaing Auflmrity(code one): L Board of HesIfh r.Bw mg Depaa-tmeat 3.CliptTown Clerk 4.Electrical hRwctor S.P1mbi ng InsltectDr 6.other Corr#ac person: Phone#: 6 lafprm' ation and In.strudions 1VFaceac:IIWeft�e3 Lam chapter 152 req==all employ= o provide WoMs''co�easafion forthezr empic7yees. Pursuant-to this sty,an=n kgo Wis&feed as.¢.evrrypersoninffie service of maunder nay=L-act ofhnr, express or M33PHec%oral orwriiiun." An.mV&y�is defined as"an fiva idnal,p=ftjmsb�,asmcisi%on,corpora m or other legal entity,or any two or more of the foregoing=apgCd is a joint eofeap6se,and inchzdmg the legal=p=enfatives of a deceased e3ployea,ar the receiver or trustee of an individual,partnership,assoeiaiion or other legal entity,employing=3p7oyees- However the owner of a.dwelling house having not more than three apartments and who resides ihmem,or the occapaat of the - dw Mrig house of an'offia who employs persons to do mair�ance,conefraot i on or'repair wow on such dwrDing house hereto shaI{nntbecanse of sack employment deemed to be an employed." or on.the grounds or budding app MIsI,chapter 152,§25C(e7 also sites that"every stafe or Iocal ficensbg agency shah withhold the issuance or renewal of a license or permit to operate a business or to mnstract bwldnxgs in the commonwealth for any applicantWho has notproduced acceptable evidence of cdmpranm with tee insurance mvera.ge required." 25 states�Ncitherthe nor gay of its poIifica1 subdivisions shall Add�.onaIIy,MCrL chapter ISZ,§ C(T} _ an into any contract for the pe than ce ofpnbho wart-until arxeptable evidence of compliance with fhe insarm requireazents:of this chapter have been presemtod to the contras drug aufhozzty." Applicants 4 Please f ill oin the wcd=' compensation affidavit completely,by g the boxes ffiat apply to your situation and,if necessary,supply sub r(s)name(s), addresses)and phonenimber(s) alongwiththr r certificates) of msnzunce. Limited LiabrZity Companies(LLC)or Limited LiabiIityParboeabrgs(LI P)wrfhno employes other than the members or partners,are not regaired to cry wozce&compmsaiion insTrza m If an LLC or LLP does have employees,a.policyisrequimi Be advised that this affidavkmaybecnbn+;tft-,dto the Depaitmentof Industrial Accidents for confa'maiion of msm-,ce coverage Also be sure to sign,and d:afm the affidavit The affidavit should be retxnneti to the city or town that the application for the pe=it or license is being requested,not the D epartne nt of Ldasbag Acciden tr, TxMld you have any gnestians regarding the law or if you air rimed to obtain a workers' compensation policy,please call the Department at the nnmbea listed below. Self-marred companies should f!n their self insurance Hcemse n=3bed an the approzisfa line City or Town OfFrcials Please be sure Biat the affidavit is complete and printed legibly. The Deparime nt has provided a space of the botf:oo of the affidavit for you to fill out in the event the Office ofInvestigations has to conULr.:E you:regarding the appy cant Please be stn a to fll in the pemzit/Iicm=number wbich will be used as a=Bf nmce number- In addition,an applicant that t submit mvltrple p�Iicense applitafions in any givear year,need only submit one affidavit indicating ensent must policy information.(if necessary)and under"lob She Addres "the applicant should write"aR 10miions i a- (may 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-proo-ft that a valid affidavit is on file for fufnre peanzts or frcenses- A new affidavit:mzTst be filled out ear-h year.Where a home owner or citi=is obtunmg a hoemm or permit nct.related to nay business or commercial.veatnr0 (ie.a dog license or pmmit to bum leaves etc.)said person.is NOT requaed to complete this affidavit The Office oflnyestiga*=wouldlrketio ihankyoum advance for your cooperation and sbovldyorm have any questions, please do not hesitate to grve us a call The Deparimefs address,telephone and fax rmmber. Depa�mt of 13i A=Zenta t�4 T�as�.gbau . Basto-n4 MA CdI11 Ta.4 617' -49'40*xt 4€6 or 1-9 MASS Fax 9 617 727 7749 Kevised4-24 07 , gam Ate® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) RA 1 07/26/2016 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: LUlsa Miranda TRU INSURANCE AGENCY INC. PARKC,N EXt: (781)281-9688 FAX No: ADDRESS: imlranda@tru-insurance.com 162B Pond St. INSURERS AFFORDING COVERAGE NAIC# Ashland MA 01721 INSURER A: LM INS CORP 33600 INSURED .INSURER B: - CARRIJO CONSTRUCTION & REMODELING INC wsURERC: INSURER D 69 HOWE ST INSURERE FRAMINGHAM MA 01702 INSURERF: COVERAGES CERTIFICATE NUMBER: 71774 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR D POLICY NUMBER MM/DD MM/DD/YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED 41PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑ PRO ❑ LOC PRODUCTS-COMP/OP AGG $ PRO- OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS - Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY _ ANYPROPRIETOR/PARTNER/EXECUTIVE YINF---i E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? I N/A N/A N/A WC531S390197025 09/17/2015 09/17/2016 — (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification . Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE :WILL BE DELIVERED IN Joao Geraid0 Ar aUJO ACCORDANCE WITH THE POLICY PROVISIONS. 19 Spring Street AUTHORIZED REPRESENTATIVE Hyannis MA 02601 Daniel M CroV�yey,CPCU,Vice.President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD