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Home My WebLink About0059 ANGUS WAY .� ... �- ; r ... .. � } � 4 �. tll `i J � rY .. .. .. - .. ,- y _ �.. � .a . .. �.. �� ,. � .. .. y r ' a .. .. �. .. i ,� ,. ( � .. o. � . :_,.ii .. - ,...a ..-. Y �^i `, o ,. ,. a .. ,,. � i �. , .. .� .. „ ;. - :�:� _ RBI �i? .- ,_ �.. .. � - a __ . . 1 Commonwealth 4 Massachusetts SheetMetal Permit Map as f Parcel (S-f X-PRESSPERMIT.' Date: APR -4 2013 Permit Estimated Job Cost: $ rOO O Permit Fee: $ TOWN.OF,BARNSTABLE Plans Submitted: YES NO Plans Reviewed: YES NO Business License 4 - _Applic4nt License Business Information: 'Property Owner./Job Location Information: Name: [I it F l zip t,) p[3 k MY(R eLJ,� -9►eName f5 kn C 6,e n Street: 7� (1oTI`�n�lnpn� �l r ,:Strtreet: A n�ju S City/Town: City/Town: Ce n e-r-v \l e Telephone: Telephone:. Photo I.D. required/Copy of Photo I.D. attached: YES NO (13 4. Staff Initial J-1/M-1-unrestricted license J-2/M-2-restricted to dwellings 3-Stories or less and commercial up to 10,000 sq. ft./2-stories or less Residential: 1-2 family Multi family Condo I Townhouses Other. Commercial: Office Retail Industrial Educational, Fire Dept. Approval -Institutional_ Other Square Footage: under 10,000 sq. ft. %' over 10,000 sq. ft. Number of Stories: Sheet metal work to be,completed: New Work: Renovation: HVAC V Metal Watershed.Roofing Kitchen Exhaust System Y Metal Chimney/Vents Air Balancing Provide detailed description of work to be done T17si, 11 aF hor�`Ai M in 47'11C- =FoR Pl.rsI r(cio(7 NSURANCE COVERAGE: have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes dNo ❑ f you have checked Yes" indicate the type of coverage by checking the appropriate box below: k liability insurance policy Other type of indemnity ❑ Bond ❑ )NJNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Aassachusetts General Laws,and that my signature on this permit application waives this requirement. ` Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent 3y checking this box❑,I hereby certify that all of the details and information 1 have submitted(or entered)regarding this application are true and iccurate to the best of my knowledge and that all sheet metal work and installations performed under the pbrmit issued for this application will be n compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Progress Inspections Date Comments Final Inspection Date Comments Type of License: y ❑ Master itle ` ❑ Master-Restricted . ity/Town ❑Journeyperson, Signature of Licensee ermit# ❑Joumeyperson-Restricted License Number. (P`t 7 �e$ ❑ , Check at www.mass,gov/dpl Spector Signature of Permit Approval The Commonwealth of Massachusetts l ,Department?flndustrial Accidents Office of Investigations 600 Washington Street' _ Boston,M4 02111 www.mass.gov/dia ' Workers' Compensation TncnrAnce AfddaWt:Builders/Contractors/Electdcians/Plurnbers Applicant Inforffiation Please Print Leejbix Name(Buahmsdorganization/S�: ,11 F t 12 wrh.t c� 0'g A .M[t e r City/Sta&zip: C.en i r�r� \��- Phone:#: 0$ 4 g 8 14 14.-7 Are you an emplayer?Check the appropriate box: e o a' �Typ f pr Ject(required):: -4. a I am general contractor and I 1. am a employer with ❑ 6. ❑New construction . employees(fall and/or pit tmme). * have hied fm sub=co„f actrsES listed on the-attached sheet 7. Remode 2.❑ I am a'sole gropzietnr or partner- , ❑ a$ and.have no to 'es These sub-ca�actois have 8. Demo � � Ye lition working for mein any capacity, employees and have workers 9. ❑ addhion [No workers' camp,insurance comp ;T,en, ,re.$' required.] 5. []"We area corporation and is . 10:❑-Electrical repairs or additions officers have exercised their. ep 3.❑ I am a homeowner doing aIl work 11.❑Plumbing r Vans ar additions myself: [No workers' camp. right 6f exemption per MGL 12.0 Roof repairs c. 15 1(4), and we have no ,-,,/m�QranSe req�ed.]t 2' § • 13.LVl ether employees. [N6 workers' N - comp.insurance reqidrrcL] °Any applicant duat checks box#1 must also fill out flee section below showing ihcia vad ts'compmsatim policy mfonaaiiurL t Homeowners who subnitthn affidavit inricafing$icy art damg all work and meen hoe outafde contractors Est submit anew afndavitmdicaiing such. #C=tractors that cheek this box moat affad, d sa addififfial sheet showing the narno of fe sub-�s and state whew•ornot those eafrtim have employees. If the mil—tm1a have employees,mey n-t7-vide their wmi rs'conp.poficynmmber: I am an Pmployer that is providing workers'compensation insurance for my employee,-Below is the policy and job site information. _ TncnraneP��Name: �2er'PSS '_ ; Policy#or Self-ins:Lie.A C 70 6(16 8 Exp ra Date: q1V113 Job Site Address: S9 A A W S i C e n ie�'i�``\�C chy/S tatdZip: C et i e r V,tl e Attach a copy of the workers' compensation policyd.eciara$an page'(showing the policy munber and expiration date). Faihxre;to.secm-e coverage as regained under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a f m.6 up to$1,500.00 and/or one-year impmomm t,as weIl as'civf1 penalties in the fort of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator: Be advised that a copy of this sbdzmciit may be forwarded to the Office of Investigations of the DIA for fimmme coverage yei flcabon I do hereby certify under the pains-andpenaldes ofperjwy that the information provided above is free and correct: Si�aiiue: Data. <f o�A7 Phone# $ Ya 8 - W Y3 Official use only. Do not write in this area,tb be completed by city or-town offzaiaL City or Town: Permit/hicense ff Issuing Anthority(circle one): .'1.Board of Health 2.Bmldiiig Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6. Other Contact Person: -• •Phone#: �IKETown of Barnstable Regulatory Services f t Al RT1cr'AAi�Y s - _ - Mnss g Thomas F.Geiler,Director 1659 1� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.maxs Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A-Builder �ir,Sc k CQ as Owner of the subject propertY hereby authorize (AJ', I i (� . to act on my.behalf, in aIl matters relat ve to work authorized by this building permit S-S A n f q� SI a (_-P�11 c-r Mti (Address of Job) *Pool fences and alarms are the responsibility of the applicant. .Pools. are not to be filled-before,fence is installed and pools are not to.be utilized until all final inspections are performed and accepted. Signature of Owner Signature APPlicant.. V1. -F Print Name Print Name Date QF0RhE.-0wrrERPERMISSr0r?00Ls T> Town of Barnstable o� Regulatory Services XAMr;MU Thomas F.Geiler,Director XAss. s639. �`,,,, ♦ R B�W.11 g Division �D MA't Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 509-790-6230 HOM EOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwelling 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. DEFIlliMON OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be res onsible for all such work Performed under the building ermit p rna p (Section log.1.1) , The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that "Any homeowner performing work for which a building pen-nit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,'that such Homeowner shall act as supervisor." . Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a forrn/cerdfication for use in your community. Q:forms:homeexerript WILL114 OP ID: TP Ace CERTIFICATE F LIABILITY INSURANCE rE DATDNYYY) `--'� � "�� 04126 04126112 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 781-914-1000 NAME: TGA Cross Insurance,Inc. PHONE FAX 401 Edgewater Place,Suite 220 WC,No Ext: Arc No): Wakefield,MA 01880 EMAIL Chris Hawthorne ADDRESS: INSURERS)AFFORDING COVERAGE NAIC 0 INSURER A:Peerless Insurance Co INSURED William Fitzgerald dba INSURER B:Peerless Indemnity Ins.Co. 18333 Mr.Plumb-Rite 376 Nottingham Drive - INSURERC: Centerville, MA 02632 INSURERD: INSURER E INSURER F t 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�TR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMlDD/YYYY MMlDDlYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CBP2240275 10/16/11 1OM 6112 PREMISES Ea occurrence $ + 100,00 CLAIMS-MADE OCCUR MED EXP(.Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,00 X NOAH-$1,000,000 GENERALAGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AG $ 2,ODO,OOO POLICY P=o FILOC - _ _ � � Emp Ben. - $ � NON AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS AUT WNEDO PROPERTY DAMAGE $ Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,00 A EXCESS LIAB CLAIMS-MADE CU8733556 10116N1 10/16/12 AGGREGATE $, ' 1,000,00 DED X RETENTION$ 10000 $ WORKERS COMPENSATION X WCSTATU- OTH- AND EMPLOYERS'LIABILITY YIN T Y LI111 ER B ANY PROPRIETORJPARTNERrEXECUTIVE WC8766668. 04/08/12 R04108/13 E.L.EACH ACCIDENT OFFICERMEMBEREXCLUDED? NIA $ SOO,OO (Mandatory In NH) E z. E.L.DISEASE-EA EMPLOYEE $ 500,00 If ye„describe under DESCRIPTION OF OPERATIONS below r E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS t LOCATIONS!VEHICLES (Attach ACORD 101',Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION BARNS-1 r , ' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL;BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. FAX: 508-862.4717 230 South Street AUTHORIZED REPRESENTATIVE Hyannis, MA 02601 Chris Hawthorne " T O 1988-2010 ACORD CORPORATION: All rights reserved, ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD • —� J /r 1:U1',dV1UNVVtAL I H OF NIA55AGHU5t 1 15 wr� r ETTS �DRI � ',�'> > �" -L Oar SHEET METAL WORKERS ' -I,,` ' ' AS,:A.,MASTER-UNRESTRICTED. ISSUES THE ABOVE LICENSE TO tr. ,a�' 2014r1�0E1'1F962 y rry �� 1 I wILLTAM G FITZGERALD jtl a b 6•01 M / �p^i �`�F� I 3 /6 HOT.TINGHAM, DR WILL'IAM G ;!;! I r lrI LASSACHUSET i5 yEa I 3�sNorrlNGHdj� CENTERV,ILLE MA 02632-,2136 CENTERVILLEMA t J ` 02632-2136 !' ' 0-1.1 1861 1j .:� x 1 J_ ..Ls /(; y OF TFtE Tp�, Town ®f Barnstable *.Permit p�o��C2 - tr 'TCh Expires 6 months from Lssrre dale istrsrABLE Regulatory ServicesFee tLAID M.9- Thomas F. Ge'iler, Director 09 TOWN Building Division 0 �`7�3a1o9 ARNsTABLE Tom Perry, CBO, 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 tvi6L &&fv r � Residential Value of Work_ 07C5 0- Minimum fee of S25.00 fot•work under$6000.00 Owner's Name&Address f SG� �D/Ir✓h t. ? Contractor's Name i r gArShe*4'1�9,, Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ��j orkman's Compensation Insurance[XW Check one: ❑ I am a sole proprietor I am the Homeowner I have Worker's Compe�satior} nsur Insurance Company Name (,t r'kNCB' r Workman's Comp. Policy# W'C -1 Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) o Re-roof(stripping old-shingles).All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum .44) *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. HG,me mp vement Contractors License & Construct Supervisors License is required, SIGNATURE: t Q:\W PF ILES\FORMS\Express\EXPRESSPE RM IT.DOC Revise060409 I BAMSTMM MAM ,. Town of Barnstable i°rsn nw+" - Regulatory Services Thomas F.Geiler,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 CW�8A as Owner of the erro subject l P p ry hereby authorize �1 L � to act on my behalf, i in all matters relative to work authorized by this building permit application for: ,�7 [joy (Ad ess of Job) Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\MY7NB41LTXPRESS.doc Revised 100608 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations + d 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual)): rS Address:- eri`q U.5 1,[�J�•/ City/State/Zip:C �r1 rVrtl te,. �f�d v Phone.#: Are you an employer? Check the appropriate box: Type of project(required): l.kI, a emP Y to er with I 4. 1 ant a general contractor and I 6: ❑New construction employees(full and/or part-time).* have hired the sub-contractors ' listed on the attached sheet. T. 0 Remodeling 2.[] I am a sole proprietor or parttler- ship and have no employees These sub-contractors have g. 'Q Demolition working for me in any capacity. employees and Have workers' 9 Building addition [No workers' comp, insurance comp. insurance.$ required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their ME]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant.that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is pravidin wo S .r4ompensation insurance for my employees. Below is the policy and job site information. ,1� (�-- Insurance Company Name`. / ) /��'Gt rCt t^C-e &JP Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: (JU City/State/Zip• Attach a copy of the workers' compens tion policy declaration page(showing the policy number and expiration date). Failure fo secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby certify under the ains and penalties ofperjury that the information provided a ove is true and correct Si ature: Date: 7AM0 Phone#: O !7 Official use only. Do not write in this area,to be completed by city or town officlal .City or Town: Permit/License # Issuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector. S. Plumbing Inspector 6. Other I Information and Insttucti®l's Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in.the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or Iocal licensing agency shall withhold the issuance or renewal of a license or permit to'operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall . enter into any contract for,the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)narne(s),-address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact.you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address' Lhe applicant should write"all locations in__(city or town),".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. .The Office of Investigations wound 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: U The Commonwealth of Massachusetts Department of Industrial Accidents Office of Yuvestigatians- 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-72777749 Revised 11-22-06 www.rnass.gov/dia 6 Boar o Building Regulat ons an Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 141078 Type: Private Corporation Expiration: 1/6/2010 Tr# 261850 E.A. BARSNESS & CO., INC. - ERIC BARSNESS 54 ANGUS WAY CENTERVILLE, MA 02632 Update Address and return card.Mark reason for change — Address — Renewal _ Emplovment _ Lost Card DPS-CA1 0 50M-07/07-PC8490 .. .__.._ .--- �� %p7If7)LfiOKl1CRl.C/Z O�✓!/GaddClC/Kld�4 � Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registration. 141078 One Ashburton Place Rm 1301 ExpkaWn: 11&2010 Tr# 261850 Boston,Ma.02108 Type: Private Corporation E.A. BARSNESS&CO.,INC. ERIC BARSNESS 54 ANGUS WAY Not valid without signature CENTERVILLE,MA 02632 Administrator I massachusetts - Department of Public Safeth Restricted to: 00 Board of Building Rrwlutions and Standards 00- Unrestricted Construction Supervisor License 1G-1 2 Family Homes License: CS 79883 Restricted to: ooF ERIC A BARSNESS Failure to possess a current edition of the Massachusetts State Building Code 54 ANGUS WAY is cause fir revocation of this license CENTERVILLE, MA 02632 -L Refer to: WWW.Mass.Gov/DPS �— J�- ' Expiration: 827Q011 (ommisirner Tr#: 20501 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) iM DATA CERTIFICATE OF LIABILITY INSURANCE Do3io2�2 9) (8,00)333-7234 FAX THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ,� Insurance Group LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE f HOLDER.THIS CERTIFICATE DOES NOT AMEND EXTEND OR West Central Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. ,atick, MA 01760 Regina Ferna7d INSURERS AFFORDING COVERAGE NAIC# INSURED Ea Barsness & Co Inc INSURER A: Berk7ey Excess 54 Angus Way INSURERS: American International Group '02 Centervi 11 e, MA 02632 INSURER C: INSURER D: INSURER E: COVERAGES 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 18 MA`(PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUB.lECT TO ALL THE TERMS,EXCLUSIONS F.ND CONDIT!ONS OF SUCH 1 POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Se( INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LIMITS NSRE TYPE OF INSURANCE POLICY NUMBER a GENERAL LIABILITY NC861738 0210712009 0210712010 EACH OCCURRENCE $ 100000Q �( X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100000, CLAIMS MADE IFTTI OCCUR - MED EXP(Any one person) $ 5000 n A PERSONAL&ADV INJURY $ 1000000 f t GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2000000 C POLICY PRO- JECT LOC' AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ t ALL OWNED AUTOS )IZI y BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS ' BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) ,el GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ SB OTHER THAN AUTO ONLY: - AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ arr OCCUR D CLAIMS MADE - AGGREGATE $ Ur $ DEDUCTIBLE $ Ot RETENTION $I R - $ WORKERS COMPENSATION AND k WC2251982 0810212008 0810212009 X WC S'IATU- oTH- AE EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNER)EXECUTIVE E.L.EACH ACCIDENT $ 100006 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ 100006 Cf if yes.describe under SPECIAL PROVISIONS below. E.L.DISEASE-POLICY LIMIT $ 50000C D OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS 08-487-0032 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL TOWN OF PROVINCETOWN O3O .DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDERNAMED TO THE LEFT, ATT; DARLENE BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY TOWN HALL OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. PROVINCETOWN, MA AUTHORIZED REPRESENTATIVE ACORD 25(2001108) FAX: (508)487-0032 ©ACORD CORPORATION 1981