HomeMy WebLinkAbout0099 CAMP OPECHEE ROAD 9
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel Application# 3
Health Division
Conservation Division - Permit#
Tax Collector Date Issued
Treasurer Application Fee LJ
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board 5/?310-
Historic-OKH Preservation/Hyannis V
Project Street Address 99 (�Ai'►')O o e-G h Gt
Village C..P41,
Owner Address
Telephone /
Permit Request S i R A,-\4 re-S�ge 0i Se, w j 4, w� ce-d v r Sh ��► �e c
Il1 r 00 �, over ex; s d ec-k ;n si�nLl
Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
lk-Project Valuation 00 d Construction Type
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family Uk`�_ Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No
Basement Type: 2ru'll ❑Crawl ❑Walkout Cl Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full:existing new Half:existing new
Number of Bedrooms: existing 3 new
Total Room Count(not including baths):existing new First Floor Room Count
Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other D
—t
Central Air: ❑Yes XNo Fireplaces: Existing New Existing wood/coal sto e: ❑Yes, Eft-o
Detached garage:Ba isting ❑new size Pool:❑existing ❑new size Barn:❑exis ❑new ize ;
Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes 1r o If yes, site plan review# CA
Current Use >Ke S, Proposed Use S24rn e--
// BUILDER INFORMATION
Name /1� c� L�9r��. k G� Telephone Number
Address quo Q Acro0 S License# 12�0,o
Home Improvement Contractor# ��4/9
Worker's Compensation#
ALL CONSTRUCTION D -RESULTING FROM THIS PROJECT WILL BETAKEN TO A1W fn G/.Vn �eC4G�
SIGNATURE DATE
FOR OFFICIAL USE ONLY
PERM117 NO.
DATE ISSUED ,-
MAP/PARCEL NO.
�a
ADDRESS VILLAGE
OWNER ?
F /
r
DATE OF INSPECTION:
FOUNDATION /Z4/6.7 i
o-
r FRAME a` ghb/0-2
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL r
PLUMBING: ROUGH FINAL' m
k
GAS: ROUGH FINAL
� _ I
FINAL BUILDING 0 5 1
DATE CLOSED OUT
ASSOCIATION PLAN NO.
t
4j
3
Town of Barnstable
ti
Regulatory Services
SAmsrAkr. Thomas F. Geiler,Director
.y MASS. g
163;.,a`e Building Division
Thomas Perry, CBO,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
PLAN REVIEW
Owner: a kt- Map/Parcel: '�2/0 0 0 Y
Project Address 96 CC4 cc c Builder: TMG 6'!5 ed
The following items were noted on reviewing:
ii
? MLt. a InnM (o q '( VX
3) ��t-Cd.n a 1►101 �"'���,.iv rC�ci AT F'0� `� W��` Cb u�+n eG�i p a.�,S
Pa1-
M16SX7 S ec-L'r-c
Reviewed by:
Date: shn/
Q:Forms:Plnrvw
The Commonwealth of-Massachusetts
Department of Industrial Accidents
02
4 Office.of Investigations.
600 Washington Street
Boston,MA 02111 _
www.mas&gov/din
Workers' Compensation.Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
pplicant Information Please Print Legibly
(ame (Businesscrpnizationan&vidual). --J �Y �. G
s
,ddress: `7 {o �� Lc) r.
lty/State/Zip: Al o-r'f�v% a 21 BOG ' Phone#: SIBP`2F. -.SO-ox-
re you an employer? Check.the•appropriate box:. Type of project(required): `
�J I am a employer with . I 4. ❑ I am a general contractor and I 6 ❑New constcnction
employees (fall and/or part time).* have hired the sub-contractors
] I 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 mein any capacity. workers' comp.insurance, g, ❑ Building addition
(No workers' comp. insurance 5. ❑ We are a corporation and its
regq �] officers have exercised their 10.[] Electrical repairs or.additions
] I am a homeowner doing all work right of exemption per MGL ME3 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no. 12.❑ Roof repairs
insurance required•] t employees. (No workers'-
comp.insurance required.] 13.❑ Other
y applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information:
=eowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
ntractors.that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.
n an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
�rmation.
arance.Company Name: u f An G
icy#or Sell`-ins.Lic.#: C: 3 '(ot7-S Expiration Pate: 112
Site Address: 7 421?w Ck(. 0,e.. Q Gt City/State/Zip: Geit /`vl/��.
.ach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
lure to.secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
up to$1,540,.00 and/or on nment9 as well as civil penalties in the form of a STOP WORK ORDER and a fine
ip to$250.00 a da%' bjr
the ator. Be advised that a copy of this statement maybe forwarded to the Office of
estigations of the ce ge verification.
hereby ceV, nder e p s pe aloes of perjury that the information provided above is true and correct:
nature: Date:': 3
)ne#:. rO 7- Z rr- S
Official use only. Do not write in this area,to be completed by city.or town offtciaL
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#:
Information and. Instructions
assachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. n
Lrsuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, s
;press or implied,oral or written." '
n employer is defined aS:':?n individual paTtu .ip, association, corporation or other legal entity,or any two or more .
[the foregoing-engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
Zeiver or trustee of an individual,partnership,association or other legal entity, employing employees. However-the
weer of a dwelling house having not more than three apartments and who resides therein; or the occupant of the
welling house of another who employs persons to do maintenance, construction or repair woik-on such dwelling house
r onthe grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.".
4GL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
enewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
pplicant 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
rater into any contract for the performance ofpublic work until acceptable.'evidence.of compliance with the insurance
equirements ofthis chapter have been presented to the contracting authority."
applicants
'lease fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
iecessary,supply sub-contractors)name(s), address(es)and phone nimiber(s)along with their certificate(s) of
asurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
nembers or partners; are not required to carry workers' compensation insurance. If an LLC or LLP does have
,mployees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Icidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
)e returned to the city or town that the application for the permit or license is being requested,not the Department of .
ndustrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
;ompensation policy,please call the Department at the number listed below, Self-insured companies should eater their.
;elf-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. ace at the bottom
Athe affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sme'to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"*the applicant should write"all locations in L(city or
town)."A copy.of theaffidavit 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•orli6enses..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
(ie. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. :
The Office'of Investigations would like to thank you in advance for your cooperation and should you.have any questions,
please do not hesitate to give us a caIl
['he Department's address,telephone and.fax number:
The Commonwealth of Massachusetts . .
: Department of Indnstdal.Accidents
..Office of Investigations
' - 600'Washingfon�Street `
: Boston,MA 02111..
"Tel. #617-727-4900 ext 406 or'1-877-MASSAFE
Fax#617-727-7749
05
wised 5-26-
. www.mass.gov/din •
r
°ftHE,°� Town of Barnstable
Regulatory Services
33AMSTAZM ' Thomas F.Geiler,Director
9 "ss. $
16 9. `0 Building Division
ArfD Mph a b
Tom.Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601 `
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
Permit no.
Date
AFFIDAVIT
HOME EVIPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the"reconstruction, alterations,renovation,repair,modernization, conversion,
improvement,removal, demolition,or construction of an addition to any pre-existing owner-occupied
building containing at least one but not more than four dwelling units.or to structures which are adjacent to
such residence or building be done by registered contractors,with certain exceptions,aloe€wdth aper
requirements. /
Type of Work: 1( r&e`'- � Estimated Cost Z0, vJJ
Address of Work: 4 I,(
Owner's Name: A,k k-
Date of Application: S 7 D
I hereby certify that:
Registration is not required for the following reason(s):
OWork excluded by law
❑Job Under$1,000
Building not owner-occupied
[]Owner pulling own permit
Notice is hereby given that: -
OV4 NERS PULLING THEIR OWN PERMIT OR DEALIN TH GISTERED
CONTRACTORS FOR APPLICABLE HOME IMPR MINT DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM FUND UNDER MGL c. 142A.
SIGNED ENAL P Y
I hereby apply for a permit as the age o the wn
s�7
Date �C-ontractoi Signature Registration No.
OR
Date Owner's Signature
Q:wpfiles.forms:homeaffi day
Rev: 060606
tu , nuy
Date.3I26/2007 04:50 PiV9 Page:2 of,
AC-ORD. CERTIFICATE OF LIABILITY, INSURANCE MM/
OP ID C DATE IDDNvYY)
:oLueER THGCA01 03/26/07 s
�- 3na'i0'cd ency Inc THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
860 Lanfty Ave ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P.O. Box 68 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
IMF. Attleboro YaA 02761- ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURED
INSURERS AFFORDING COVERAGE __ NAIL#
rasuREP,a: PX®vidence Mutual Ins.
Co. - 15040
INSURER B: Hanover Insurance Co. 22292
TMG Carpentry Inc. INSUPER C: American xnteznatiml Group
46 Barrows S t. oa
Norton IAA 02766 IN_IJPER D:
1N_URER E
COVERAGES
TFkE F i T I E S OF tr.![a7GwdCE LISTCD BE QD N HA E BEEti ISSUED TO Ti IE INSURED i*4,11EC).EBpvE FOR THE POL,r_'r F
F PI ! tNCt ATFD h10F.'ITH7TnrdQlhh3
�rdS- t IIF ErdEftT T—�Ci1 -R L fdU�Tl J qAi r'C-pf7TF a!�T:R�Tf-IER COOL!M1ENT ITti RESFECT TV 4':HIhl THtj ERTIFI' '.TE t`t<ir'EtE I�Jt Ir[ _iY+ `
P;t4Y FFRT.,.!�l THE R:I R?tP r•F'?FCE('6 THE POLICIES DESCRIBED HEREIrI Ic_I!6JECTTO ALL THETFRhtS.E;•�LE!tihiplS fdD CnrdrJtTlrth�^.F SUCH
FOL{ {FJ. ATE LIMITS S �i'rra r•.w,r rw,VE BE
REGUcEC'6,,FAIR CLAIajIS
LTR IN TYPE OF INSURANCE POLICY NUMBERLIFECTIVE
DATE IMWDD/YYI DATE(9AMlDD/YY} LIMITS
GENERAL LIABILITY
EACH.OCCURPsi-icE _ p 1,000/000
X cmv.•IEPeI:L c;Eat=aFt.uslLnr CPP 0054571
—= /1 / $
i 03j17/07 I 03 7 0 4 "" ---
F Etvih>E:i-(Ea xa�ren,_ci '6 50 000
-� tEt E,x,,P(t•ny one person I$5,000
--- ..— -'. --- ----- — PERSONAL y,a,t,-:-iNJUN7 I F 1P Q4{?/0®®
s2,000,000
I �Eh1=Av�3REG?.TE Ub91T APPLIES PER: —
rPC U C LOC
•Pllr �--- T_- __�rdr`OF ,004D,000
_ JECI
UTOMOBILE LIABILITYart I i:, rn[.!iEC 1N LEJ-44 B 6103198 03/17j07 03/17/08 � eru5 �ILI IFl LPT IEtaatEG.,ITi'S �er�;.r„onl 100,000
HIRED AUTOS If ---
I B'.?DII. INJUF.:Y :5 300,000
r r»,;piEC?G,.:UT4S I{{ (Pee n:r:Id,;rll
I
FR PERT`+'D,^,1• ----
;P-r t �E g 100,000
GARAGE LIA87LITY ... _---.--
� ( �.UTii E.,rfdL'r-E.�.ACiStiErdT :5
�--
AUTO 0-I
v $
rEXCESSIUMBRELLA LIA8IUTY -REG4TE
r ECG!CT12LE �I a L _{
$ t
4
I _WORKERSC ..
COMPENSATION AND -
C EMPLOYERS'LIABILITY t Rr ll.l1T I �Fp'
.aN PP'?PPIEI 6PaR'I"taEFt-'.ECUTi`dE WC1760821 01/24/07 01/24/08 FL C,<HAf. .l"�CNT .1: 100,000
OFFIfR,I�1Er,1BFF F'�CLUPEC)
dctscnt,e under E L DISFP,SE-FA Fro1,F'I.O`vFE 500,000
sFEC CAL PRG'J ls!otis t,etaar
OTHER
E L o;_.F...,,SE-FE;L;C,LI:.rT ; 1100,000
I
DESCRIPTION OF OPERATIONS!LOCATIONS I b`EHICLLESI EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROS/1Si0NS
CERTIFICATE HOLDER CANCELLATION
STA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN
eyva of Barnstable NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO DO SO SHALL
200 Main Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
Hyannis MA 02601 REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
• mhnmse Ra%rc4enle6
BOARD OF BUILDING REGULATIONS
CONSTRUC
TION SUPERVISOR
License:
060351 ,
Number.CS s
�• 1 Birthdate 02119/1970
' 0211912008 Tr.no'- 15636
Expires
ctian CS.
;�stry. ReStriGted 00
THO MAS M GEORGE G- fJ
i ST`
ssioner
46 BARROWS ,
NORT N MA 02766 Com+ni '
op .
Board of Building Regulations and Stands License or registration valid for individul use only
HOME IMPROVEMENT CONTRALTO -, before the expiration date.::If found return to:
v� Board of Building Regulations and Standards
Registration.: 114958 r`
. One Ashburton Place
lug Expirahon 11L.15f2007 z Boston,Ma:0"
TYpe-Private Corporatron f
T.M.G.CARPENTRY
�.
THOMAS GEORGE
46 Barrows Street -
Norton,MA 02766 Administrator; Not valid without signature'
Apr-02-uf 11Sccm
.L Vl+frfs COIL kD7a ablk
Regulatory Services
' Thiim"F.GiUii,Diiiai)i
Building Division
Tom Terry', Building commissiouer
200 Maio Stmat, HyamIIs,MA 02601
e; 508-862-4039 Fax: 5R8-79"230
Property (Owner Must
Complete and Sign This Section
If U- sing A Bugdes
u l ro
as owner of the s b3ect P Pem
hezeby suthonze
_-- _ -- -- - .-to actors my behalf,
in all matters relative to wozk authorized by this building permit aPPlication for.
qq
(Address of job)
Sipature of Ownet 0ati .
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Town of Barnstable *Permit# C?064
Expires 6 months from issue date
I (y„"�✓ Regulatory Services Fee 1/Z eo
Thomas F.Geller,Director
Building Division
Tom Perry,CBO, Building Commissioner X-PRESS PERMIT
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us APR 13 2007
Office: 508-862-4038 Fax:®��ARI�S�A�LE
EXPRESS PERMIT APPLICATION - RESIDENTIAL J§RN
Not Valid without Red X Press Imprint
lap/parcel Number 2/0/ 00 y
roperty Address
Residential Value of Work_ /, Q0(' Minimum fee of$25.00 for work under$6000.00
owner's Name&Address
t G
.ontractor's Name ���i4 '�/�u --/i G. Telephone Number_
[ome Improvement Contractor License#(if applicable) 7 9
]Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
D—nave Worker's Compensation Insurance
asurance Company Name 4e—r ,n -LY-A
Vorkman's Comp.Policy# 1,,2 / l 2 02 2
:opy of Insurance Compliance Certificate must be on file.
'ermit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will betaken to
❑Re-roof(not stripping. Going aver existing
.layers of roof)
Re-side
❑ Replacement Wind o oors/sliders. U Val (maximum.44)
'Where required: is ante of this permit does not e t complian a with other town departmentrepktions,i.e,Historic,Conservation,etc.
***Note- Property O must ign Prop Owner Letter of Permission,
A of the Hom rov e ontractors License is required.
;IGNATURE:
j:For=:expmtrg
.evise061306
Regulatory -Services
i.?a—Z � �'iio s F.C,eiiei,Diiecioi
°� Building Division
Tom Perm, Building Commissioner
Z Maio stet. `Hyamus,MA ozoot
e: 508-862-4039 Pax: 560o6-623b
Property Owner Mast
Compleie and Sign ''his Section
If U7sg A BuUder
t ,
---- --- ;as Owner of the subject property
hereby authorize
�/ 6 � �'1.. _.__. _ __ .._ to act on m beha3f,
y
in all matters relative to work authorized by this building pmnit application for.
-qq 6fip Opedee
(Address of job)
0
Suture of Owner ae
Got
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BUILDING R�TIONS
BOARD OF BUILD RVISOR
I License: GONSTRUGTION SUPS
� 060351 . ,
Number CS F
0211911970
B�rthdate Tr.no: 15636 t
Expires 0211912008
,ons#rtgn :GS, 00
Restricted 1
THOMAS M GEORGE T
76
issioner
46BABROWSS G-
MA 02 Comm
NORTON,
�
lie �an�nreomruecr�,lJi o�.��
Board of Building Regulations and Stand License or registration valid for ittdividul use only
HOME IMPROVEMENT CONTRACTOR:
n befor date. If found return to:
e the expiration :
ti Board of Building Regulations and Standards
Registratwn 114958 r: One Ashburton Place
ExpJrahon'. 11/1.5/2007 � Boston,Ma:021
t - Type=- Private Corporation ��
T.M.G.CAR
PENT,RY t
THOMAS GEORGE j
46 Barrows Street
Norton,MA 02766 Administrator ' ' Not valid without signature
i
t-rom:Caron At:R.A.Rembold Insurance Agency,Inc FaxID: To,TMG Carpentry Date:3/26/2007 04:50 PM Page:2 of:
AGORD. CERTIFICATE OF LIABILITY INSURANCE OP ID C DATE(MM10OffM)
TMCCAO 1 03/26/07
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
R.A. Reinbold Ins. Agency Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
860 Landry Ave HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
P.O. Box 68 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
N. Attleboro MA 02761-
INSURERS AFFORDING COVERAGE NAIC#
TU-SURED INSURER A,
Providence Mutual Ins. Co. 15040
INSURER e: Hanover Insurance Co. 22292
TMG Carpentry Inc. INSURER C� American Xnternational Group
46 Barrows St. INSURER D:
Norton VIA 02766
INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR.THE POLIC'i PERIOD INDICATED.NOTtIVITHSTANDING
Arts'REQL[IREfvlEW,TCRt,IOR-OPJC-iTf,--,NOF.ANY,--,,Dl,.ITRACTOP,,OTHER C,OCUMEI,IT',qITH RESPECT TC,,d,i,l-iiC,11-nqi:,-CEPTiFiC,ATE Mi.k-.BE ISSUED OR
MAY PERTAIN.THE INSUP.At-ICE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERI&S,E)<CL Ij'IONS Pj,.ID CONDITf0t IS OF SUCH
POLICIES.AGGREGATE LIMITS SHCNVN MAV HAvE BEEII REDUCED BY PAID CLAIMS.
INZ>K AIJIJ L PQLICYEFFECTIVE POLICY EXPIRATION
LTR INSRE TYPE OF INSURANCE POLICY NUMBER DATE(MMJDD/YY) DATE(MM/DOJYY) LIMITS
GENERAL LIABILITY E.A.CH OCCURRENCE $ 1,000,000
f'
A X CPP 0054571 03/17/07 03/17/08 FREruSEs(F�occur Heel
50,000
CLAIMS 1,11,DE IAED F.XP(Ant one person? $5,000
PERSON41-8.ADV INJURY $ 1,000,000
s2,000,000
C-EN L.Aj3-REGHTE LIMIT APPLIES PEP. PRODU(J-2-C—OMP!or,P c- T 2 000,000
POUCYJECC LOC
AUTOMOBILE LIABILITY (-CGIBINED SINGLE LIMIT $
B AM 1 6103198 03/17/07 03/17/08 E.9accidcni)
............
ALL OvYNED AUTOS
BODILY INJURY
X SCHEDULED akITOS ;Per person)
HIREID.4UTOS B A 3JrUbF:
F 300 000
-04,TjS : -c iocide PROPERTY DAMAGE $ 100,000
iPer aC-'Adentl
GARAGE-LIABILITY ALP-0 ONI.Y-EA.ACC'J1.-)F;JT
CfHLR IH/-',N
AUTO ONLY $
EXCESSIUMBRELLA LIABILITY iOCCURPENCE
OCCUR CLAIIA-S MADE E g.
DEDUCTIBLE $
-1-1
WORKERS COMPENSATION AND TOF'iSTAILl- 7147 I
EMPLOYERS'LIABILITY
C ANY PROPPIETCPiPAFII4&--'ft:AEC UI N`E WC1160821 01/24/07 01/24/08 EL FACHACCIDIENT $ 100,000
QFFiC1-RjMEI`,1BEP.FXCLUPED' FI.. DI,,EASE $5OO,OOO
II yes,descfibe under
SPECIAL PROVISIONS belo,4 E L DISEASE-POLIC(UIMIT $ 100,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
BA msm SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL
Town of Barnstable
200 Main Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
Hyannis HA 02601 REPRESENTATIVES. --I
AUTHORIZED REPRESENTATIVE
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