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1301 BUMPS RIVER ROAD
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AW+ a:t .�. 4, ppLL�p}�..F" .tr .: o'!YI' ® II i,,. �a-FIL�ku71" :q>,,.,.,+,t,:. - .. : x. --:r _. ;> - ... v.➢s. _ .. :-. „_..,+,w.,.wt- i ,eu•L', 7 ,p. r SlY ',ktr ;i,{ , „+. -' _1,� -,� ...;_r;+� w,a:r k. -,r• is.R __ ,,,.�: &;,�#it. ��. l �,�.;'.a it"-'A1._ r i V. . i j1KE T-Ovn of Barnstable *Perm it# Expires 6 months from is ate Regulatory. Services Fee * BnaivsrnBM y�pTMass Thomas F. Geiler,Director fD MA A Building Division do 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 130 , 49 C "'VZ`U�. [Residential Value of Work J,g&0 o Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address o u 13 o let Contractor's Name ./goyly Telephone Number Home Improvement Contractor License#(if applicable) 3� Construction Supervisor's License#(if applicable) E orkman's Compensation Insurance ` -PRESS PERMIT Check one: ❑ I am a sole proprietor APR ® 9 2009 ❑ I am the Homeowner [] I have Worker's Compensation Insurance �. TOWN OF BARNSTABLE Insurance Company Name T36' e'LZc Workman's Comp.Policy# aJb Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) - ❑ 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 Window E!O r /sliders.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. A copy of the Home Improvement Contractors License is required. SIGNATURE: Q:\WPFILES\F0R1vMS\building permit forms\EXPRESS.doC Revised 100608 f i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _ 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly ��J a Name(Business/Organization/Individual): /�'lbb'JlI A5 07e_-/q Address: �/ facer 4 6; 6 0,0Zi.Ve_ City/State/Zip: I AJ) _5ocl`� AT 02-e9SPhone.#: Llo/ - 7/ ' 6 y� Are you an employer?Check the appropriate box: Type of project(required): 1.P9 I am a employer with d-t) 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. Demolition workingfor me in an capacity. employees and have workers' 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 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no 13. Other � � employees. [No workers' _ comp.insurance required.] *Any applicant that checks box#1 must,also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an.employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: V00.6&_/b tllva / S • (�O Policy#or Self-ins.Lic.#: a'$ J��,6 Expiration Date: Z 6 t v`t° �o city/state/zip: Job Site Address: 3 O l /j!/w s Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as.civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi nder the pains andpenalties ofperjury that the information provided above is truge and correct Signature: Date: ( - 0/ Phone#: Official use only. Do not write in this area,to be completed by city or town official ' City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r F=rvm, "t unr Robinson,I'EFirnter lma it ance At:Hunter Insurance,.Inc, Fay,103 T'Q:Denise Glude Oates gr2WU6 I I Iis�4,t ),aqw 4 01 a A t CERTIFICATE OF LIABILITY ICI'SU �Gl� ����sw��11/"Cl) I£t1-100d31-1 09 £d:iCE�F THIS CERTIFICATE IS ISSUED A A MATTER CF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Hunter Insurance, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 389 Old River Road, 1P,o, Box. 1 ALTER THE,COVERAGE AFFORDED BY THE POLICIES BELOW. Phon+a '401 -7E9 9500 E°ax 401-76 -9502 INSURERS AFFORDING co tERAGS NAICtt H75tJf�ECs �w� Moore AssociatesInc. hhh tireia�xt- ---- 3 axxx nee c a . DBA Gutter Helmet €Pi-,rbf%£R}i �8r#aian 3,sutcsK! ltwxa**ixs,r C. .. DBA tutu EIIznot Roofing d €a trt 1137 Park East Drives €wa €#URc Woonsocket RI 02095 COVERAGES INSukr=Fd E; ,,L IS-1E,714£101-Y s 43V€_CE`:#;N i .€i'C,TO ln,C.IN.-Ak .P Atf-'0 A.E5,.Wz'f't3R If l ICY MR€00 1F-41Ca TELI:W:A 111 ?,.arse->. z^<iY waE a.�d13eF;;wr"€dt,%€'PM a$p'F 0,',4 A 1;,3:'S OF NiY W4IRA,CT OR OT14-N C�k,".t r�.1C€�3C wi'Yd'i€'&{•`"„P€':CT TO LVHIN€TI*@ CFPT€!'f(,ATE^i.'w`Y U €,,;.t I€•:S"i 94 . N*AY PEcRIA€wi,T),C *sPtS:i AI E+#t€:SLC7€Y 9 i£d.6a 8 3 t .i:, T 1 C3 t§.r I,"Pd 1'y b i »4(€x.5 ALL t ftJ€d10J,W ,H f _,KAE`.i AOORE4,Wr OMITS S4Kt3`v4N MAf tub's:;txEEN RF TW(� C.A by PAO C€.AD4', - R fW. _„ _ _R ._. � , , _. _�. �. m 'fiCTL "�"laE'ix"Fd�tTalfit9T7 � �....._ .. LYr9 SEt TYPE OF€wiSURAUCC POLICY wl Es15R DATE IM rYy DATE{a�thtllrfsTfYl € - LWIT'S Fi t t smIAL b sff rf t t Al€+n trT:YiV a _. 1{10000 0dErrtt€AD€L€TY �a=rw > W,4—Wt o1 �CE C9fS6/CJ €a Essae 5)tCQ3t !a 1 c T 31f 1000000 GENERAL 000000 r,C.P1°L e�a$fTir', ,A-i`.€€P.r,A 444,I,.,, T 3 ,,,k.T ,cst d'faA AGG E�T'AE 4�"q � T 1€O € AUTGrt06ILEL.EANt_€€Y ,r... IOT#0000' F'A. ANY NW) Et1."a�*.`661..4. "� 09/16/ow 09/16/09 IE.A�t�€Et�tsS ALL 01w'447I A:.3TY,t.a Eli, L k I �(€•df a7a;rb§ate} wet Y t,3 L�"b Ey3S E€1 f?'€'?w'bud7jpw t.,ARAGE UAEI€L#tY. A#Y�tA%Y FAA AUTO tom.Y . r. _*e E l rT rw,t,s}<IA. tJ fsfil9. 139/15/(35 09/16/09 Ids"ttE � C a:C3+x"nLE ; v#z fsMEi2a CMPEr >.VONALI[I iIH Y €AhtP I €sr �. Ewd6'[.C€YEht+'CEAS3Ii.tYY - B a$ 10/01/+0E 10/01:/09 C€ E €€A f..... € a 00000 ANdY€�w weiE:r N Fi€..ibf 3L,.iaL€P LLt iY"As [fit€$xf;4LE; tS00000 s o0000 I t,k�»iC'f'tEwxYlCsPt taE"'Gyw"71rr AY'li"}ld t,bCraTTONS I VEIACtEi€b t EXCLRIME A;.DMI E#Y N0ORSENIKHr d SPECIAL PRt7YIEO€•iS - w...:....... CERTIFICATE HOLDER CANCELLATION BLI1 T.L11 t4 SHOULD ANY CIF THE AQOVE DESCRIBED POL IC€ES EE CANCELLEO OFFOIRS THE EXP RAT?car# DATE THEREOF,THE I SUTH44 INSURER YvILL.ENDEAVOR TC€MA€€n 10 DAYS WRItTEN Building Cont. Reg. Board NOTICE TO'THE CERTIFICATE HOLDER NAMED TYT THE LEFT,OUT FAILURE TO 00 SO SHALIL Dept. of Administration Orin Capitol Hill €w<+w�Ez 'Nrs rst�L„IOA"t€c�ra ORL.t: #a;airy OF auff€��azA UPON THE�aStER.ITS,;;E€r€;x OR Providence RI 02908 REPREWITATIVES, - AU tk ezEi'�*R SENTATIVE ACORN 25(200'I OR) 0ACORD CORPORATION 1908 . r License or registration valid.fur indivldul use only � noard of Building Regalationsr and Standards before the expiration dattr.b Tf found return W HOME IMPROVEMENT CONTRACTOR TOR Roard of Ruilding Regulatlows and Standards One k+titbttrton Place Rm 1301 Reglstratlon: i1t,)>3 a Boston,Ufa.02109 xplrrtlo": -12412009 Tr# 130185 Type* f'Clv<atr trps`,tttrtt MOON ASSOC INC JAMES MOON 1137 PARK EAST DR. Not vafl ithout signature WOONSOCKET.RI 97895 Artrr�irtlstrht:br flat . Itr: tt� « l+° +:�E.t€ravttC ego` 'c ltii ' �;tC:4 Restrietedto, RF,WS �Vw l;a,at3 al Sri itttii€i€ta`„; !��=,�trt.:ts§btt� �tfrti "�I:;ttt�i,��^i€� r . fr rtt r aar r. r s caA}'r tlgt r°ne 1A.- Nw%,onryrunty LICRoof Covering ' £, t t W «wfndows and siding; tr,e r= fe. RF,wS + M rrtCcl Gael Burning esftns Rini:-Demolition only JAMES MOO 48 PAINE ROAD Failure to Frxtsoss a current edition of the CUMSERLANO, PI 02,864 mas:submsetts State Building Code is cause for revocation of ttlis litenw, Refer to: NVWW,il4ass. (jv1.l)F RenewalCustomerNmie: /3_ cJ t/ dear Built ereii v rsen t 2d& sm Ali zsr _l ( ; f9�S !7 tr t R I b sde a Cope Goa � � SSales ggreC'I� en t B•CZ Guatomei.L3 11.37ParcEist�)-iym �YAt1C �i Sept, Cici State,ZiP { 7Fi y ti�� f 2 G:3 LO:dcr i�<Tur.fber: _ l�annso ket,R1 M95 WINDOW REPLACEMEHr un.4 ae csCary PhD I anz � _ 775' t S (� „ Phone-Work P iF Date ✓ l c `sc�Ri t?Zj9-:vfA 119535-CT ave 0562725 Etr)aii r j � mIT5 Technical Stec vre Dimensions GRILLES ... rr aE Room t r8age a. a .. -a _,z <.,z �� a c&. a oaai �•<t as " - cz Description - z EG' -L`^r`r rcsy aka . ;rer u;S:, _ �..`Y.- p '_ i$Iex 5.' a .N'" y"a� c �.I. �m ,ede vb ; m3 „ar." E — . .oE 7i- �a a' vs,� 'S PRIC?t8 ��. u..n' t'im: a G �- �� xn8 O� ! �•° ',S - T ACC N� F} � Rt� � 4 la Ns — O _....� W c7 � is e i -- �. 1 �I T f �I t -54 _�� _. ---- � — — ........_ r - S. 3 I 3 i � a P w u t s r fa c m awe n r 4isrcilaucom Credits Pr ri n es ScaTotal m a2 a ...Lt.c..-,Gt sand sxa�,....a arr�•an..z a.Hoer CexcuLncr a.d air 1Lrap<Ro Ste'adt;1'am.r�i,erc 1 -- Pdl+iSl@ht IEtE3©d -. :. .. - .7c c..x rioat!''totem - .. -$Price 5._.. L�aL< op•A C I s X p S 7' G.t�l1J�7 _ _ m - Csastarzx r hr..ep2a t.0 You zYc S tri - i, a. .r .d r n cc^.xp,ex ehz. .. --. s j, rrcecc-sLe Eo.,a.a; ace uhdesss vx.:.:a4n,r»r I z ...ei;car.-. z<c..nl.n�su r to^..a k:axt: s -tf-'(?.-.� J -7'� PvtiSe.Credits orE%pEnS --�'� leek Sec .CVCIse Side far T-rrn.s and Conditions of Sale.You.the buyers may cancel ' '7 J�!,��_. _ .� II _Tatar ndng -- _.... led this t[2n5actYpn ai nisi'tSlTle prior Ln midnight of the tbird business day after i —_.' — - � Fit p card the date of this trunsaednn.Please sec attached notice o£cancellation fnx a.n -- ekplanation of this ' • .. - --1` ?+r rlla a Cre3awv 1=x Gns c' -�.' : .: x 3 'r da '3 ary Saks T� -- o :,; (.-xenvcs r-ai o r3..tespcu c.t..n,:,.ip Work erfili Cost ^)�/ AA31 orEer Pon+uA:taeyed ,rrs_..0 5tynaa� ._...:._-_.. i ... '.� .. .. /' t d:i,xE Oirdeell the app;yii a Ordt,y'oxes Total Amours otAgreesnent r Wo a- sr.-D.. Dot" c2 y d . S y.. E yteLiw t'y Cox : Deposit liegvire zt7 va+r'e;5<s 9u FeGew lyyPm,e-sa Ra.aTata de sr<.a t5ees acuh,r 'r -�*. rsaoair^� :: 'W�C(I.j MTh a dJt50iq - .. na �-.^ar res,.an, vGi "` !sw amz, ..__ -- _ Balance Due on,Campte#?on a+,+:r Lens GCh a u<n,s nab eF sfoL lee aaa rs.:,ar;au a I f-kL...a t;srsa<t ,. x F.haw:oi:hz�h a:i„ores.rL�rm debrs ibe _ L i..laslcs Li.w e Is Lnsd.u..' ag¢ tlftiF S. K � I .;,' i� /j�� soli nose. deer.ymsnwr�is,n an.. .,rh.<- Ise-�az .- Leaim :andett_ J-.,t rvuustarc laced.Cus#corer ? CL.momtr,N (,�y Customer aY nee Yelcw-.nsta&a..^ Fink-tsLrmtoev^,er t; `P* ` P P Isitiais:. Initials: z. C. a w fi !�yw Moon Associates Ins93i)3Y Rya+ia a atxr`anAridersex,Gmzsy. °'Original Sp�'c sl,ee #: The undersigned agreo to amend the Home lmprovemenfi Contract dated {the"Original Cflnfract"} between Renewal/iy Andersen and DV: f v ' (the"Purchaser'') relating to Job# ;and hereby authorize the changes specified ecified:below. . CNANGES.TO SPECIFICATIONS $ Increase J ; Lisfi any additions,,revisions or deletions using descriptions,from the Prf ng Works hpot, and specify,details {Decrease) : , wS tz - 16 � " Do n. Netlncrease {Decrease) in Contract Amount: 4E .. The Contract Amount shall be amended as follows: SUSI ITTED 13Y: Original Contract Amount' 9 $ gales Consultant Date Increase (Decrease)' $ ,Amended Contract Amount ;,ACCEPTED SY: Less: Original Deposit. $ 2 ( ' S .. Homeowne ©ate r Balance Due on Completion $ _ i 1 lomeavvner: Dat e e Will the Installation be delayed?: E]Yes E]Na CHARGE BACK INFORMATION (if,applicable} CIiARGE:TO AM (JUNT REASON: DETAILS J COMMENTS- 'If the contract was previously amended, use the amended contract amount(not the original contract amount). " ContAmend-RBA-0808 oF1r Town of Bar stale *Permi �b (l 13� Expires,6 monthsfrom issue date Regulatory Services Fee MRNSTABLE Thomas F.•Geiler,Director 9 MASS! q, 1039.- Building Division ATFD NIAI h U Tom Perry, CBO, Building Commissioner OK /I1`3/, 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 ro ed Property Address 601 b UP't fps � 1 � �� li Residential Value of Work / Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address ' t d d) ' Contractor's Name a.d11 Pc M Db h / U�o l Iq S QC Telephone Number Home Improvement Contractor License#(if applicable) l :� �J C5PER _ i„ ❑Workman's Compensation Insurance ,-PRESS Check ne' OCT 3 ❑ I a sole proprietor ❑ am the Homeowner TOWN OF �� � ���� I have Worker's Compensation Insurance Insurance Company Name C. 0-a Workman's.Comp.Policy# (0 Copy of Insurance Compliance`Certificate must be on file. Permit Request(check box) ❑. Re-roof(stripping old shingles) All.construction debris will.be taken to ❑ Re-roof(not stripping.. Going over existing layers of roof) ❑ R -side Replacement Windows/doors/sliders. U-Value V 3 V (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. A copy of the Home Improvement Contractors License is required i o �� I�f�. , (� ss 1°W d. SIGNATURE: /—/ — 31 Ir ?) fry 1a :. 1 ( Q:\WPFILESTORMS\building permit forms\EXPRESS.doC Revise020108 �1a..,n�huatr. Delrartment of Puhlic Board nt Building Re-ulatiowu ;uid Stanriardk Construction Supervisorr-Specialt License N N . m m _ License: CS SL 99840 m..rn to a C) s - CL Restricted to: RF,WS �m th o 4A JAMES MOON am T ;j 48 PAINE ROAD L .R _ a CUMBERLAND, RI 02864 CD as - .' expiration: 3/23/2012 ' ( iiuiii..h n•r Tr--*: 99840 U ! ! ry h Restricted to: RF,WS - IA- Masonry only RF- Roof Covering WS-Windows and Siding SF- Solid Fuel Burning Devices DM-Demolition only Failure to possess'a current edition of the Massachµsetts State Building Code is cause t'or revocation of this license. Refer to: WWW'.11fass.Gov/DPS - - ,l�ze Vi ovirmwouve¢� o�✓Ii[�e�ac�uiasl�d License or registration valid for iadividul use only Board dfBuilding Rig"Iations and Standards before the expiration date..If found return to: HOME IMPROVEMENT CONTRACTOR Board of Building Regulations and Standards One Ashburton Place Rm 1301 Registration: 119535 Boston,Ma.02108 Expiration: 7/24/2009 Tr# M.185 Type: Private Corporation MOON ASSOC INC JAMES MOON . 1137 PARK EAST DR. Not valid ithout signature WOONSOCKET,RI 02895 Administrator 671 � Board of Building Regula ions and Standards One Ashburton Place - Room 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Registration: 119535 Type: Private Corporation Expiration: 7/24/2009 Tr-# 130185 MOON ASSOC INC JAMES MOON - 1137 PARK EAST DR. WOONSOCKET, RI 02895 Update Address and return card.Mark reason for change. DPS-CAI 0 50M-05/05-PC8490 Address Renewal Employment., Lost Carl From:Shaunga Robinson,Hunter Insurance At: Hunter Insurance,Inc.- FaxID: To:Denise Glode Date:929108 1 1:18 ANI Hage:Z Ot J acoW CERTIFICATE O LIABILITY INSURANCE DAT09/29/0Y' OP.ID . S MOONA-1 09/29/08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Hunter Insurance, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND;EXTEND OR 389 Old River Road, P.O. Box IALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Manville RI 02838-0001 Phone: 401-769-9500 Fax:401-769-9502 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: National Grange Insurance Co_ Moon Associates Inc. DBA Gutter Helmet INSURER B: Deacon Nut"ual Insurance Co- DBA-Renewal by Andersen of 'RI INSURERC: DBA Gutter Helmet Roofing 1137, Park East Drive INSURERD: Woonsocket RI 02895 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR - MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR - TYPE OF INSURANCE POLICY NUMBER - DATE(MM/DDIYY) DATE(MM/DDIYY) - lIM1T§ - EACH OCCURRENCE $'10 0 0 0 0 O. GENERAL LIABILITY A X COMMERCIAL GENERAL LIABILITY MPS26619 - 09/16/08 09/16/09 PREMISES(Ea occurence) $500000 CLAIMS MADEFk] OCCUR MEDEXP(Any_one person) $10000 PERSONAL&ADV INJURY - $ 1000000 GENERAL AGGREGATE - - $2000000 GEN'L AGGREGATE LIMIT APPLIES PER:. - PRODUCTS-COMP/OP AGG $2 O 0 0 O 0 0 O- LOC POLICY JEPRCT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1000000 A X ANY AUTO BIS26619 09/16/08 09/16/09 (Ea accident)' ALL OWNED AUTOS BODILY INJURY (Per person) SCHEDULED AUTOS -HIRED AUTOS _ BODILY INJURY' $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY - - - AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN- EA ACC $ - AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY - EACH OCCURRENCE $ 1000000 A X OCCUR ❑ CLAIMS MADE CUS26619 019/16/08 09/16/09 AGGREGATE $ DEDUCTIBLE X RETENTION $10 0 0 0 $ WORKERS COMPENSATION AND - ' TORY LIMITS ER B EMPLOYERS'LIABILITY 28586 10/01/08. 10/01/09 E.L EACH ACCIDENT $500000 Y AN PROPRIETOR/PARTNER/EXECUTIVE _ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-FA EMPLOYEE $5 0 0 0 0 0 If yes,describe under E.L.DISEASE-POLICY LIMIT $ 5 0 0 0 0 0 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION BUILDIN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Building cunt. Reg. Board NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL _Dept. of Administration - IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR One Capitol ,Hill REPRESENTATIVES. Providence RI 02908 q D REPRESENTATIVE ACORD 25(2001/08) ©ACORD CORPORATION 1988 p o Customer Name: �F l r y Y Year Built: Renewal by Andcc of RI&Cape Cod RPI�a Saies Agreement Address: 13 o r (l-t/111//3 i 1✓,9 if Q J�1 Customer ID#: 1137 park East DTive �P►r e �' City,Sutc,Zip:CbHMA Vic L;r L7,4 Q-6 3 2 Woonsodtec RI 02895 7 Other Number. �en� Phone-Home:.a�7 75- :L 2-/S WINDOW RE►LnCrntE1IT -And,mehC—,psdy - aJ ticense#RI 12259-MA 119535-Cr Phone-Work: Page: of Date: "3 0562725 Email: 7!ednlal Meagre } UNITS 1?imetxians GRILLES eRoom o d � ggt S s? k ! � F }+�a _ � � +�sa SE f Y = e` Lm N j h J $pRKES } E " x 1, fr �, I rl 1t rr t � � a/ o rr 41 A C m << y r fr 1r !r 1 r r 31 1 �1 v -3/ o 1D61 mull r>s Crodits or Er sub laid sewn Payment Method 'Proposal:Allof d,e a6ave rind .vd dam oa be provided Forfie rC amown dR.,in the rear,are'I4,e W Rae pxamoAon,etc - v p l b�11d r:ma x a or w yea m as mom c a a Der a,axa er,brenoae sa Ma sge as t tom g np 2e�y ) PaYrn rn f'p'vided��' � Dose ¢an I Notts' S a S Sub Total tbae.rscsw F�/ Check Pee Sdea Rcpecseonm2 Sgvmue C�L(_ p/S�✓C.i rY7'Yi9PPL/. ) -sub Total V.r.,w `'p `b o a `-" Credit.Card p--t er A« e:Yw sre leeshy s,.i,oriaed eo F,a,itn m rindoa,�ddo�.oq.,�..a c mplere sus - - .wise Credits a Expenses Q eke T7�:5'9t�t e A n r? �^ !0 7�' �mt Far,�i,;dz eager osr«t m paj ti,e ta,wor ram ut ri,�sgo®mt and a�as�°me r�,s t»r See Rsvet'se Side for TerrnB and Conditions of Sale.You,the buwr,tits cancel Q Financing this transaction at ury time pnor to midnight of the thud business day after Sao 1 L83b 7,S-Y2 rz,i P 1V)b Total 2 the date of this transactio Tease sce attached notice of rmcelladon for an S_-C rr �')L Salesiax oma d wn orgy e;planation Of cutsToralnli dlancous Credits orFxp— ndauob to Ys santoAttad ed 11}"}p�. rv►� .t t� ego r (mrry—r. 0 m m uedir,ap—miunn a riot) work permit Cost 1 17C Dace Appsord ivwas•urdt all ua.e+oWA. A—.,d Spe ial Order Nores Told Amount of Agreerrmn C!-'bl'L roso Door St—oocr er,Tso. rmy aver Dsrs Sfeeewee by ntaasgeer Signauin A t7l x3 f trw.L L - Deposit Rid 3 lC N N.i oa�.ti,rL rninlrp or Benra+,Iynndu,eo Wa,.ueal od re:mrdaeon n.aR Dort maretR inkw a .mil jl' {J t- �I 1z 17U rl pl } - v Impe.lrq wall,tsar does na gwren¢e ae d.mdo.,co..n rveen aa.,ge Ho..e�a,ift L�7G L✓�np C L�+A v Balance Due on Con etlon oo 6e reededkmtlnduded Br at?rkjtul wlrmw ne mwru�ari of Is�smYad aniy lmtielrmn wt wilapte Nicrinchrdaiabor,a taials,insallauoa, ln,�a]reenvtYnlers <aKnr�,am,aew� aea.smmr:u�le:s er,da�aryaeaao<mtnwisw�wr�� � ,6 spwrx+tli r�re�e6a,a as i,aa W. cR,erix rx,xd. pt tln tod of rl,e JoC xll ruecvrpon debts vAI be Ythioe-Reraewselky Andersen Yellmr-Insallation stink-Momto r emo L and disposal ofprodum nplaced. - Cerstorrser //�� ,D�� CUSIMer - Customer Ise lnswaeon am. - CD hiitlab: lbw t�i� Initials: WWI. ' 'Nv.e..16fAMen.'.dd.Ma...lh'nNm.n bF a,mdm..6d.�edoa Co.pora'a,.Oa,oL'..h..m GTn�.wll gyn,m.d rYE eDvh+aF-3apf.a' . Assessor's office (1st floor); umber map an n W¢ THE ( � ......... T°�♦ Bknee ,do of Health (3rd floor): D t/ f .� ,� n age Permit number ................................ Ten ep� 9 L ..ring Department (3rd floor): ` ,. -y s �o rasa abuse number• ...................... ..................I .. ...................... �. � YP�.6\0� 0 Definitive Plan Approved by Planning Board -------------------------------19`-------- , APPLICATIONS PROCESSED, 8:30-9:30 A.M. and 1:00-2:00. P.M. only TOWN OF BARNSTABLE BRUIN& INSPECTOR APPLICATION FOR, PERMIT TO 1- LQ.!1?.:.1.P....1 X.15.7:t. .J c( WC�IlP g........................ TYPE. OF CONSTRUCTION .....V.P..Q.q.47r.... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ........ ...... .... .....lz.C�...... 1 .�" .v� L.4--�.. ...... ............... Proposed` Use ............ ..t4 .�!.�.. '!v ...... Zoning District ......... /. `...�... ......... ................................Fire District .. /V :..Q.^�. ".!.(.L.. l�.. ......... Name of Owner ... .1..... V p...V ............:.....Address ..�301ICwQK1Gd R... ... ... .... Name of Builder .12 ....�` 1............................Address o�S ...Y7.M!-w.. �, ...... ......... 9.xws .I�uC/ �oX 7a� Name of Architect .��-OV.f./J..: ......... ... . ..............Address :................ .. .. ....... ..... ....IV.�./.'.�'�✓1... ... .. Number of Rooms ... .A-I4.A.t C�.. .. .:d.!!�../�W�.V4°.....Foundation ....�T�,....4 0!�/.4. A. P................ Exle for ...... ..4. .141r... S.kLlilVGr:,.LA.S............... ........Roofing ....,..�}�Z.. N.L4� .:..........,.... Floors ........4. � .Dw..!.................:...............................:..Interior ........ Heating .... ..4.J.4 ...1.�r:.�.�l�r��.6..........................Plumbing .........IV.D..M �.... ..................................: Fireplace ..:...........N....,N.. ....................................................Approximate Cost .. ...... d O O;f Area... ... .�....:.... .�... Diagram of Lot and Building with Dimensions., Fee ........................................ Epp - rwXd4) OCCUPANCY PERMITS REQUIRED FOR. NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnsta4le regarding the above construction. Name Construction Supervisor's License 3 DUPY, ROY- L. 3 ! a r• y n, ;. • No 32:062•..• Permit for ...ADDITION/•GARAGE/DEN ; Single. Family....Dwel•ling............ ,�.'--,•;, l ........ r - Location ..1301 Bum ....... 1 Centery , ..................... ..... .�11.. ....................... .. ...... Owner .......R4Y...L. P'PPY................... Type of-�Coristruction ....Fr,ame.......................... - r r__ ....................................... , _ - Plot ... ..:. . ... Lot~ ......... ... ........ ' Permit Granted Y r M r .� •._....•.. } / ......Jul......1:�...... .__:1,9 8 8 Date of Inspection ...... .. `` 19 t ; Date Completed ....:.. ..... .......:is If :f �� !k � of i� � -..• • ,;:; 1 ,�^ ._. ....._._ -•__.' t. - S ..P. - 7 r . a:_...e y,. .,:v:.,;w,: �.iy,._i..i�*..[7..4:w:b e 3{ :;�:; �::,i..i..�X;r l�ta�^'d +dip,�.:s f+'AR. ;rn1 y M.,.`ck r f '5;.+:iw; �n:ax+ .,�,.�.r;w•^.A`a.isti,.S:-dye+'i.,Z...�.wi�r$ .,:;!�"r�.ftr"% . . Assessor's office Ost floor): J . ..°T THE Assessor's map-and lot number ... ! .... .... TOE:. f-d of Health (3rd floor): -r- -� J r--�� fO�Q ♦� OK Sewage Permit number ................`.............................ar .. t BAan?A LE. e . —. cw.gineering Department (3rd floor): �� . 5 'oo i6}9 ♦� Housenumber ........................................................................ a YaT o'. Definitive Plan Approved by Planning Board _______________________________19________ . APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO l.4......... : ' + ... .............. A. TYPE OF CONSTRUCTION ..... ..� .... n TO THE INSPECTOR OF BUILDINGS: The undersigned hereby`applies for a permit according to the following information: �� MA'� J �z.... 2 Cz�"j �. �7 � � �' G.L�, Mrs Location ........I.. ...... .........................'................11r.......... .:.......................f..............,.................................... 'Proposed Use ............ .K�Q. !. ......�'�.!`�.`�. � � ° '. ........ ............. :. �............................. t. t�" Fire District .. .f� �'— r'1 Y)'11LI.... -Zoning District ......�.........:........................................................ ........................:.f`....�.j.....................(..... Name of Owner ...1.` .... ... .:}.. ..................Address t 6?. t Name of Builder �...u.../...............................Address .(tN......�C!r Q�44 Name of Architect c" U� d .. .c7....1�.J.. .n l!�i a ! ..................Address ............... Number of Rooms q..q 'l..:4:0.V.C'.....Foundation ..... . ...r"c..,C!C 2.. P Exle for .......... c.�`' fa. ......`a../.!..,:�: .!�..!..�..5........................Roofing ...... .ci.. . X1./. .!......................................................... Floors .......... .....?.....`v.... ......................Interior a 4./•.!?.a d /�-.- f Heating �'. 4�...: .L...:..:..V g .I D l� ! Fireplace .............. ....... ....................................................Approximate CostamO 4 Q ............................... Val �j/dI y Area .............................. Diagram of Lot and Building with Dimensions + , Fee i �w L= v� OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. r Named� r ............ ...................................... !/ Construction Supervisor's License ....:. !*�...... .. DULY , 1R'OY L. A=188-072 N 3".0 6.2 4 .... .... Permit for ..Addition./Garage/Den .......S 4.g 11P...E4.M.i.ly...Wg.lur g....... Location ....1.10.1...B.Ijmp..9...R iv e.r... .........................C.P—ntexVille........................... Owner ....RQ.Y...L,....D.IIAPY............................I...... Type of Construction ...........Yrame.................. ............................................................................... Plot ............................ Lot ................................ Permit Granted ........July 12.............19 88 .................... Date of Inspection ....................................19 Date Completed ......................................19 Assessor's map and lot 'number �.... � . � LMI STALL'" ��iN COMPLIANCE. •i ' ; VdtTH ARTI CLE u STATE Sewage Permit number ...... �y SCIMITAR +c4DE Aria TOM �Of7NETD�y RMU TOWN O Ft ' BA RNS TA i E88B9TAELE,;i 11DING INSPECTOR Op z639 `00 .l Q ypV APPLICATIONFOR PERMI T ............................. ..... ............................,................................. or TYPE OF .CONSTRUCTION .... ...............,...... !... ... !. 'c.E.... .............................................. 1t1.4...PS.........,9.2+1 ! ` The undersigned hereby applies for a.per�ir according to the following information: - Location .......�.3 .!.....� .s�.w� .s.... .f.ta�. ..Q .?.. 3` .n. ,1.��.t../.I.!. .......................... ... I Proposed Use .... . .hk l...l d IN. �..:$.. 4 k,4 .lr�......................................................................... a7 { .. Zoning District ....... ..N.......................!.. .....................Fire District ... $9. /IILt.�[.0....... s.4/ /x.. r ' Name of Owner ..!L...O.. .. 41.. .................Address Name of Builder /. N ......::...............Address �....................... / ................................. ............... ............. Name of Architect ..... A.M.. M&W.C.1:.....................Address .................................................................................... Number of Rooms ............... ........................................,.......Foundation .............. 1 r Exterior ........ .F: ..j/V.D..V... ............................................Roofing ...........,t4. ll � ......X.il./.��./4.0............. Floors ............ ..� (I!/.f�.i�.. ..........................................Interior ........V.*...". ...1,,,!(/.is .I&.. : a Heating ..........................................Plumbing .......... ..it ..................................................... bw Fireplace ....../.�/ N..�...............................................Approximate Cost ......... �if Or.. .A.......................:........... Definitive Plan,Approved by Planning Board ---------------____-----------19________. Area ........................................... , �+ 50.... Diagram of Lot and Building with Dimensions fFee �...................... ................ SUBJECT TO APPROVAL OFFS OARD OF HEALTH 00 6 •� 1,44E.N Sl ' cl, i Y � LL ,i f I I hereby agree to conform to all the Rules and Regulations of a To f Barns rega ng the above construction. < Name ...... .... Dupuy, Roy L. Date of Inspection 9 19 � `.^.--.^.—.—.--....^...^^^^................. ^ ' \ Assessor's map and lot number, ... , �4 ...... L /r � Sewage Permit number yoFTH11 ETo�♦' TOWN OF BARNSTABLE, • BA"STABLE, i 9� .. NABS. °yam Ar,� RU.1,01NG INSPECTOR APPLICATION FOR PERMIT. TO ........................... .................................... ...... .................. TYPE 'OF CONSTRUCTION .:. . .....�"!. ... tt�'1! �,/�tl �i+ff.....°. (.'a! d fd r .................................... ...................... ...............19... TO THE INSPECTOR OF BUILDINGS: w _ The undersigned hereby applies .for a permit.according to the following information:` Location ...................................................................................................................................:................................................... ProposedUse .................................................................:.........:................................................................................................. ZoningDistrict. .................'.......?.................:...................... Fire District ..................... ............................................ Name of Owner ......................... .......Address F - Name of Builder. ....................................................................Address .........:.................. Name of Architect ....... Address .................................... Number of Rooms ..................................................................Foundation Exterior . ............Roofing `.................. .......................... Floors .......Interior ................................................... ............................... Heating .........................................................:........................Plumbing .............................................................................'..... Fireplace Approximate Cost .........................................................: ........ Definitive Plan Approved by Planning Board ________________________________19--------. Area 1 '............... .................... Diagram of Lot and Building with Dimensions Fee � SUBJECT TO APPROVAL OF BOARD OF HEALTH f "ti I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .................................................................................. 0opuy» Roy L. ' No -]L7l7�— Permit for —.. .ahmd...... � = ----'---------'---------^^--' Location ....... ..]�LY.gir.ftRAd.......... � - -------.�XAt;.q.T.Va.1.Pr----------.. Owner .........B0.)K.X,'A4PVY................. ........ .. Type of Construction --.�.rAP.0....................... � . ................^...........................'.................................. � Plot ............................ Lot ................................ Permit Granted ---.~Iamue''25.----'lp 74 Date ofInopechon ------------lg � Date gomo|e,e6 ------------'lV ' PERMIT REFUSED ----.,---.------------.. 19 '------'—^'----'--'—^---------' ` � '--'--''--''------------------'' ...................... ----^--'-----'---'—'----'----- Approve6 ................................................ YA ' —''`-----'------------------- -------------------....~—...... . | ` ) | . � FEE a S TOWN' OF BARNSTABL9, MASS. d c dye 19 O ato > °-q THIS IS TO CERTIFY THAT A PERMIT IS HEREBY GRANTED TO 0. ° IL- = > ° ...........................................................»..................................... _ (PROPERTY OWNER) - (ADDRESS) � I)1)b ti a To ............................................................._................_.........._........._ » / [y (BUILD) - (ALTER) (REPAIR) d 4) Ci to ...................................................................................................................._..».»...... _.._...._»_.............................. .................................................................................._...._....._._ I O O 11.O (TYPE OF BUILDING) (APPROXIMATE SIZE) ` M ,g o be a) LOCATION .............._._......._..............._.» __...................................._.._ ................................................................................................................_.__..__..._.___..� (� V It) (STRMET AN NUMBER) (VILLAGE) v �ao� NAME OF BUILDER OR NTRACTOR __.___ ...._.._..._......»........................._.».............................................................................._....................... _._ 4 APPROXIMATE COST .. ...._.._......». ...._....................__» y w boas 1 HEREBY AGREE TO CONFORM TO ALL THE RULES AND REGULATIONS OF THE TOWN '.J OF BARNSTABLE, REGARDING THE ABOVE CONSTRUCTION. d °McA p.. a _.....__._.........._.._».......»..._..._.............................................................. »....._._...........»............................................................................................................................ h 0 Ce CO (OWNER) (CONTRACTOR) � C ao uov y ..... _...._.._....... C BUILDING INSPECTOR Subject to Approval of Board of Health. .. c,� .��G'� ALL'.? �s #Y1:1S r �"•� '�-.,t f>'Y`s`f� .� •�}ts'`;a.Sa1' '�' �",1a',7s;,w3 'C ,* d�'-.3 E��..'{-� "" :d,i x '��' '."�713."°i a� 4`•!.�°l'•'ti1� i i$A }� uz F. I f F�, r P oFr r Town of Barnstable �y y *Permit# 0 Regulatory Services- E eC�s6„� a sl rrnsue rr �. 6 A�m�Q Thomas F. GOler, Director (�Z/23/11 Buildi'ng'Division Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma:us Office: 508-862-403 8 Fax: 508-790=6230 EXPRESS PERMIT APPLICATION - RE,SIDEIS'TIAL ONL Y Nol Valid)vllhoaf RedX-Press Intprin/ Map/parcel Number tesidential Address / I& S 11/e}' C �r U6 IIeelzs Value of Work Minimum fee of$35.00 for work<underS6000.00 Owner's Nam e & Address. &A, �. 6 Contractor's Narne A00N Telephone Number r� C� - c�� d Home Improvement Contractor License#(if applicable) 1f9 j 3 Con ruction Supervisor's License#1(if applicable). Workman's Compensation'Insurance Check ❑ I ?,a sole proprietor k r 4 am the.Homeowner _(4 s? I have Worker's Compensation''Insurance pany Name Insurance Com �. Workman's Comp, Policy# 6 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request (check box) ❑ Re-roof(hurricane nailed) (stripping old shingles) All construction debris will be±taken to ❑:Re-roof(hurricane nailed)(not stripping. Going over existing layers of rood ❑ Re- ide #of doors ' Replacement Windows/doors/sliders: U-Value D. 3s (maximum .35)#of windows *Where.required: Issuance of this permit does not exempt compliance with other town department regulations,i.e. Historic,Conservation,etc. **,`Note:. Property Owner must sign.Property Owner Letter of Permission, A copy of the Home Improvement Contractors License & Construction Supervisors License is required. ;INATUIZE: 'PrILESIFORMSIbuilding pcnnii formslEXPRESS.doC The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street' Boston,AM 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers- Applicant Information Please Print Legibly Name (Business/Organizatio ividual): r ,SsOC /1/G Address: /$ City/5 to/Zip: U-2 Phone #: 40 ^ C?/— 140a Are on an employer?Check the appropriate box: Type of pr 'ect(required): , 1. I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ w construction 2:El am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling 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' 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 11.0 Plumbing repairs'or additions myself. [No.workers' comp.- right of exemption per MGL 12.❑Roo€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 bok must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees;they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: MC /1/ Policy#or Self-ins.Lic.#: 0 s cRi Expiration Date: Jl Job Site Address: .)(/ lj City/State/Zip: ey Vi^,! a 6 3 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a.STOP WORK ORDER and'a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office.of Investigations of the DIA for insurance coveral6 verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. } r Signature,- ''��v`.-....�... . . 'Date: Phone#: -` Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: t-rom:5naunna KODInSDn,riumer Insurdm;u ^t.nui aei a iaui a-v,it- 1 nnw. MOONA 10/05/10 OR CERTIFICATE OF LIABILITY INSURANCE OP ID SR DATE PROD'CER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Hunter Insurance, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 389 old River Road, P.O. Box 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Manville RI 02838-0001 Phone: 401-769-9500 Fax:401-769-9502 INSURERS AFFORDING COVERAGE NAIC# INSURED Moon Associates Inc. _ INSURER A: National Grange Insurance Co 14788 DBA Gutter Helmet DBA Renewal by Andersen of RI INSURER B: Beacon Mutual DBA Gutter Helmet Roofing DBA Moon Works INSURER C: 1137 Park East Drive INSURERD: Woonsocket RI 02895 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE.INSURED NAMED ABOVE FORTHE 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR INSRE TYPE OF INSURANCE POLICY NUMBER - DATE(MMIDDIYYYY) DATE(MM/DDIVYYY) - LIMITS - GENERAL LIABILITY EACH OCCURRENCE $ 1000000 .A n COMMERCIAL GENERAL LIABILITY MPS26619 09/16/10 09/16/11 PREMISES(Ea occurence) S 500000 CLAIMS MADE X❑ OCCUR - MED EXP(Any one person) $ 10000 PERSONAL&ADV INJURY $ 1000000 GENERAL AGGREGATE $2000000 GEN'L AGGREGATE LIMIT APPLIES PER: - - - PRODUCTS-COMP/OP AGG $ 2000000 POLICY JPE0. LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT A X ANY AUTO BIS26619 09/16/10 09/16/11 (Ea accident) $ 1000000 ALL OWNED AUTOS - BODILY INJURY. $ SCHEDULED AUTOS (Per person) HIRED AUTOS . BODILY INJURY $ NON-OWNED AUTOS - - - - - (Per accident) PROPERTY DAMAGE $ (Per accident) .. GARAGE LIABILITY AUTO ONLY.-EA ACCIDENT $ RANY AUTO - - OTHER THAN EA ACC $ . AUTO ONLY: AGG $. EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 1000000 A X OCCUR ❑CLAIMS MADE CUS26619. 09/16/10 09/16/11 AGGREGATE $ kDEDUCTIBLE $ .. X RETENTION $10 0 0 0 $ WORKERS COMPENSATION - X TORYWC LIMITSAIU- ER AND EMPLOYERS'LIABILITY YIN B ANY PROPRIETOR/PARTNER/EXECUTIVE 28586 10/01/10 10/01/11 E.L.EACH ACCIDENT $ S00000 OFFICERIMEMBER EXCLUDED? FJ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500000 It yes,describe under SPECIAL PROVISIONS below - - - E.L.DISEASE-POLICY LIMIT $500000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED.BY ENDORSEMENT I SPECIAL PROVISIONS - - - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION, MOONASS DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL .10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Moon Associates, Inc REPRESENTATIVES. 1137 Park East Drive AUTHORIZED REPRESENTATIVE Woonsocket RI 02895 ACORD 25(2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD � d �- V > � n_.�cy,-�y��n��i ywi- We MOON • �^ _ i-AM @� y�"p] _ c/�[(�d�t �F 1 tF ���Win• •`"� �; • . Fj t ,,�:�Public,.•�+.s�-~mas^":� _, �xa d 4 Build - 4 Ree. lations afw math" -ace, License RrMM jAW17-S MOM . 4-1 PAHME � r. Jan 0611 12:26P Jim 508 699 3938. P-5 1_37 Park East Mire VI sass sihfi3Ps3rilAeca,scysai ct wbatsociet 3+tacit Island I= �i� cam rtc MUM pawn aaro WIS I c.) (BOC11975�bo6 erase.•ral.isislhrociras.•+kaa:nJ purdoser(s)manta: (2 Li InstallationAd*m:1301 13�J9j �`l✓Jc�l JL1Z• C"ZIj n' 1g 1,4 7 Qj< 2 — — mailing Address: - r7- Morne Phone;,CCde 2 71Z ZJ/SeenPhona: E-thrall. year wenetlalh••_-Ly`si-CustoroerWXQI-- IE t TaYesWidinTowmof: Ifvle,the above a.rchaser(st(Rurchaserts)'l and the cvrrerfsl cdthe prooerty(ccate9 at the zoom h-callaSan adcress,f•erebV0`rIh'8nd5everaWaf:•ee to contract ait•t Noon Associates,Inc-l'M3Orw4.Wj to tarn sir.:el ver,and install of at ratt;Ylats as described to th6 Agreement(Agree-sent",,Me at:Kned Spec St-eexs)anc alagram(s)%allow we incorporated here r by•eterellca and made apart ureaf.A Ccr(letior Ce-t bmte w I be executed for ad ions at 7ha a-ld of tie Install;60n. •der N•.smber: '�OM Number• �(rderNuntbu aroiect Type- P a'L) i roaect Type:r P stee Type: ,�grCefllentAlnOJnt A$reemertA.wuM S Ag^eementAmorht $._ ._.. Less Deans tt S as Uepositt 4 Less Oesas tE seance We OnCXnpleton S JV r� aa'anxD�e7rComple�ica $,�„ Balance Due Or Completion $ i SV+mT 33Vd t;MMM sxvwt raea m. SKS%'fam?y!o'ft'ee tY -61JMo'+trrertm:Mevntdo urona'.aeuM't ' j vdlgte pay ran aM1eNrod for Blanca xW%Wea pap,Ave maeod For Roar= tdeooe Paowas ansahod FW Bahama Due at Time of Instagation: Due at Time of tmtallation: Du a at Time of Installation. Est.Sort Cate E;t.Cwapl2tior Dith3' Est.Start Da•e: Est Como etlan Da ES.Stars Date: Est.Comaletion date: - DEPOW/PAYMENT OPTIONS t5Aimloh-4 aenlleation antler u=ui'PPtmQ C O 1,Check,Cashier's Check or Money Order Ck a 3.PA"Cing iMado.mace to Moorrvrorks) Jka a Appravei Code 7-Credit Card'(c•'rck; Visa taste Car Dlscr er Aect a Approva'Code •Vera itrrl'o+a�r Mbonwaete:�1Yraa•f!reb r�rad urA cardrxtaa txxasa o'na.lr. Actta;401 Lfh7rt.49Pfr fn0Datelr r SecurtrCode JIL hetahaiahrmxerr:ya2anmaedZr+nupasaaeoarana mmarde.l eaaeaes:_ it is geed by and between the parties that this Agreement cornifrot at the entae umdersWW%V betwaft Chit PIN end aware arc no w&W understandings clmhaing or moci ybtg amy of the teems of this Agreement.Purchasers}hereby atkhcowlelgas that Pureiaaer(s)1)fm raid the trout and reverse of this Agreement and has received a completed,signed,and dated copy of this Agreement,Including the two MWINF>uWing Natice of Con<ei4ation jam,on the date first wrldem above and 2}was orally Worried M hls/herright to cancel twistranswBon.Do NUT SIGN THIS CONTRACT IF THEIR ARE ANY BLANK SPAM. purchaser Purdtaser ra 5gnatu-e gna u e 7A., as S. ,i_a(• Drb1l.tame, Print ham otint Wne YOU,THE BLIVER(Skr MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF Tiff THIRD BUSINESS DAY A"M TNT: DAIL Or?HIS TRANSACTON.SEE THE NOTICE OFCANCEWITION FORM BELOW FOR AN UPLANASWNdF71HIS RIGHT. NME OF aC `OCEWITIOhi NOTICE OF_ WLTIM1 Date of Transaction af' S`1/ Oahe of Tmnsadtion_L you may cancel thb translaetfok without tarry penaky Of 0 You a" coned ihf; iO� without anv p—hy or abligatlon, within these business days from the above date.If you ranoai,ahtY vAthbh three busumss days firm the above date. It You cwwel, amy property traded in,arty payments made by You under the Contractor proper"traded in,any payments node try you under the Corttraa or Sale,and tarry regotlable irn&wment ewKuted bV you will be returned sale,and any negotiable Instrument ercecuteed by you will he returned within 10 days following reaetpt bV due Seller of ywr canceVWJDn within 10 days fogirt ow receipt by the Seder of Yaw cancellation notice,and any smrffV htterest arising out of the transaction war be nntics,and arty steno tV interest arfsihtg out Of the traruaclson uAit be ceteeeled.if you Cancel,You must make avaiHMe to the seller at Vow canoe"If you cancel,you mast make available to the Seller at Your residence,to substantially as good condition as what recehm&any residence, in substantially as good cond0don as wean rece7Yed any goods delivered to you under this Contract Or Sale:Or You may,if you I goods defivereed to Vou under thls Contract or Sale;of VW may,if you wisk eaffy ly with the inswuctlams of the Seiler regarding the return ttwh,comply with the instructions of the Seger regaedkm8 The return shipmead o1 the Booth at:he Sellers expense and rink.If you do make shtpmerrt of the goods at the Sellers eWmse and risk if you do make the good&avattable to tha seller and the Seller does not pick them up the pods avallabie to the Seger and the seller does not pick them UP wkMn 20 days of that date of your Ndfce of Catweiledon,you 90V within 20 days of the date of war Notice of CanoehatiON Von MY retain or dispose of the goads wkhout any furtfher obli6aMon.If Vou retaim tar dispose of the goods without any frtthm Obaga don.If you fag to make the goods dvaliable to the Seger,or it Vou agree to return fail to mains the Bonds available to the Seger.ar if You agree to return the goods to the War and fail to do so,them you rea m n liable for Stun goods to the SERK and fait to do so,ton you mmain gable for performsWce of no tab iger aals under the Contract.To cancel*18 pedarmarme of ad nbf Oms under the Contract. To cancel this transaction, mail or deliver a signet and doted copy of this Iraasomion, mail or dellar a signed and dated copy of this cancellation a WC0 or any other written naCce,or send a telegrahnto cancellation nodce or any other wasters noti e.or SOM a telegram to MNWoan 1137 park East Rive, WOottsadeet, Rhode island Wcanworfm, 1137 f'astt fist Drive, WoOns"*ct, Bit island OO 02VA,NOT LATERTHAN MIDNIGHT OF �`S'•'J/ toateL longs.MylAlotTmANtAIDNIGHTOFLI—r—/—' Mote- 1 HEFfEBY CANCELTMs TRANSACTION. 1 HEREBY CANCEL THIS TRANSACTION. Date Coesumeessignature Dole / Conclarhet's Signature ,•y N O Y 6 , t.l.'• _,.. .. _..:SX:t l,t:'- t.Y'1:,?T ;*1 tt l�.;..Na::.1 tip..':1.4ci