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HomeMy WebLinkAbout0132 EMERSON WAY I,.— ,o... N, , ��;,- u.• -tr '�'_ �I:..� tE.� iF. ¢'� '� F�'4 le +,:G., cu. r• �' -._. r p3ry ::?.n. ,N x `'i :.._ . r.' s .ems ,; '" d',: �:�.�.r •''�- i' c Y' *•�, 'y ' v T: i a r tr i • F 1 c` ., 1, �, , •' .. .: - � d � a e Val Town of Barnstable *Permit# 10 �I& -3 q D Expires 6 months from issue date �T Regulatory Services Fee s t auuvaTasi.E. « - M"�'39 Richard V.Scali,Director i6 ♦0 a® prED MA't a j�o Building Division ®a Tom Perry,CBO,Building Commissioner , 200 Main Street,Hyannis,MA 02601 FE_b 17 L6 ire www.town.barnstable.ma.us Office: 508-862-4038 i 60b- 906ti0 M � OVO EXPRESS PERMIT APPLICATION - RESI F WL N�Y Not Valid without Red X-Press Imprint Map/parcel Number Jfq z/v Property Address 2. dr1 d ►.r IhC �?6 • f Residential Value of Work$ //o$a7 silo Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address (cf 4 foti. 4 Contractor's Name o y lz 1 dvy�{ C crr�S :e us .,ti � Telephone Number Home Improvement Contractor License#(if applicable) 'Email: c4dy Ler'4�omsecoro cas, .aE7 Construction Supervisor's License#(if applicable) i /3 orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner r o [-fhave Worker's Compensation Insurance FEB r D Insurance Company Name AfL." O Ur lirl,1 Workman's Comp.Policy# d01 �0 710/ N 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 roof) 0,Re side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows " #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doC Revised 040215 Ile Comrlronivealtih of-VassachIusetts , I epm-tllrent o,f I'rrdush ialAccidents f3,}°rce ofimlestigations 600 Washington Street y Boston;MA 021II ft�tVllillla.��Tf)f'1�f1lYi Workers' Comlpensatkn Insurance Affidavit BadersiCiantractorsiFIecfr,cians/Plumbers Applicant InfGnnatinn / L Please Print LeaibIy Name(9u wJ0rganizatiYmAndim&al}.s� Address: 4• 6CY- city/sta&zip- (OA .Phone : Are you an employer?Check the app opriate box: Type of project(required): 4. I am a general contractor and I I.LEI a�a employer with. ❑ employees(full and1brp�* Have hired.the sub-contractors 6 1°i construction 2.❑ I am a sole proprietor or partner listed on the attached sheet. 7. ©' dehng p These sub-contractors have slip and have no employees $_ ❑Demolition woding for me in any capacity_ employees and hav a workers' c insuraut5e# g- ❑Building addition. [NO Sli orb--M, cflmp.insurance �_ 9. F Electrical or required_] 5. ❑ We are a corporation and its repairs a,ddft ons 3.❑ I am a homeav«er doing all work ork officers have exercise d their I L❑Plumbing repairs or additions sel€ o workers' right of exemption per MGL �` � - 12.❑Roof repairs insurance required-]i c.152, §1(4h and we have no employees.[No workers' 13.❑'other comp.insurance required.] 'Any gTHcamt that chedEs box 91 amst also fill otthe section below shirring their workere compeasetianpoticy informsuaaL i Homeowners who submit this.d9dant indicating they are doing all wol aaii then hie outside contractors mast submit a new affidavit indicating mcb. fCanttactors that check ibis box must attached an additional sheet sho the name of the sub-can=ctm and state whether or not tbose entities ham employees.Ifthesub-caata Mishne employees,theymnsrpmrdde their workers'romp.palicy number. I a�n arm erspIo}�er tJertt is pro><zdirtg workers'coarpertsatiorm iusuratrce for pry enrpiny es Below is fate policy and job site irzfor-rnrrfian. � Insurance Company Nam:_ Policy 44,or Self--ins.Lic.# �a G✓�`�� V FoTiratio n Date: � 'd5_y J414 Job Site Address: /Z2 En f+BN W01-1 City/StaW2l p: r.. —►Ae tgd? Attach a copy of the corkers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required.under Seztion 25A of MGL c.1572 can lead to the imposition of criminal penalties of a fine up to$1,50D 00 andr'or one-year imprisonme as well as ci dI peualties.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 maybe forwarded to the Office of Iuvest gations of the DFA for insurance coverage verification. I do hereby certify uatder thgPI isms petma&.es ofpeg'ui y that the in,fbrmadoir pm ided abmv is h a acid correct Sit�ahzre: JJ Dare: I /6 Phone# Official use only. Do not write in this area,to be completed by city artown official City or Town.: PermitUcense if Issuing authority(tilde one): 1.Board of Health 3.Budding Department 3.Cityl Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions M:tss�hmse Geaeaal Laws chapter 152 reqaires all employees to provide workers'compensation for their employees. Pmsuaatto this sty,an.cu plvyn�is defined as_"_.every person in the scrvice of another under any contract of hire, express or implied,oral or wr>ttezi" An CVTIvyEr is defined as"an individual,partnership.association,corporation or other legal entity,or any two or more of the foregoing engaged is a Joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the - dweIling house of another who employs persons to do ma;nfenan m,construction or repair work on such dwelling house or on the grounds or building appurtenanrtihcmb shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(t7 also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance.coverage regnir ed." Additionally,MGL chapter 152, §2SC(7)states"Neither the commaaweatth nor a'ay ofits political subdivisions shall enter into any contract for the performance ofpnblic wotic mii7 acceptable evidence of campIiancewith the insurance, . rcT=f,ments of this chapter have been presented to the contracting arzthozify." Applicants Please fill out the workers compensation affidavit completely,by cherk;,,oc the boxes that apply to your sitnatiou and,if necessary,supply sub-Contractor(s)name(s), address(m)and phone numbers)along with their cer[ificate(s) of hasm-ance. 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 insmance. If an LLC or LLP does have employees, apolicy is required. Be advised that this of idayitmaybe submitted to the Department of Industrial Accidents for con:E=ation of fiL =ce coverage. Also be sure to sign and date the afidavit. The affidavit should be retrnned to the city or town that the application for the permit or license is being requested,not the Department of n ,ct,;al A ccMents. Should YOU have any questions regarding the law or ifyou are reqaired to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insled companies should enter their self-m Tra ce license namber an the appropriate lime. City or Town Officials t Please be sine that the affidavit is complete and pried legibly. The Department has provided a space at the bottom of the affidavit for you to BE out in the event the Office of Investigation has to contact you regarding the applicant Please be sure to fill in the pen litllicrose number which will be used as a refcrence number. In addition,an applicant that must submit multiple penntUcensa applications i a any given year,need only submit one affidavit indicating can: policy mbrnation(rf necessary)and under"Job Site Address"the applicant should write"aII locations in (may or awn)_"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 futae 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 (Le, 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 call The.Dep_artmenfs address,telephone and fax number Tl�e C:G.mMMWeattt-of Massachusi-its ' Deparbnmt of IncImttzal AOCZents f f it�e Of TlmesEiotio= Soo,Wa sbivGI,Sint Boston,MA 011£ TeL 4 617 727-4900�4-06 or 1-97-MAMAFF, Fax 9 617-727-7M Revised 4-24-07 W =ass-gavIdia �1ie�porrvrrwouuec>�C�.a�Vvuraaao`ucae� ffice of Cousamer Affairs&Business Regulation License or registration valid for individul use only before the expiration date. If found return to: ME IMPROVEMENT CONTRACTOR Weigistration: 145954 Type: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 piration:'3(1_5120_17: Private Corporatio. Boston,MA 02116 = =' G, DOYLE+THOMAS CO`.N`ST INC: TROY THOMAS 499 NOTTINGHAM DR" -:-` CENTERVILLE,MA 02632 Undersecretary Not v id.wi Y out signature ' . -J_. - f Restricted To:CSSL CSSL-RF-Roofing Windows.and Siding Failure to possess a current ed' • State Building Cale is cause for on of oc the Mass achusetts For DPS Ucensin iqn of this license. n B information it: www:Mass,Gov1DPS v Massachusetts Department of Public Safety .Board of Building Regulations and Standards Construction Supervisor Specialty License: MSSL-099913 :Err.ti 0 TROY;A THOMA5F` %. 499 NOTTINGHAM C NTERVELLE�4IA �J,,�,,,. �` Expiration Commissioner 04/13/2016 r v f ACC CERTIFICATE OF LIABILITY INSURANCE °ATE`MWD°",rYY' 08/03/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE,A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Debbie Mark Sylvia Insurance Agency,LLC PHONE FAX 404 Main Street (,VC,No Ext: 508 957-2125 A/c No): 508 957-2781 E-MAIL Centerville,MA 02632 ADDRESS:mark marks iviainsurance.com INSURERS)AFFORDING COVERAGE NAIC# INSURER A:Farm Family Casualty Insurance INSURED INSURER B D&T Construction,Inc. I ' PO Box 168 INSURER C: Centerville,MA 02632-0168 INSURER D: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE D L UBR POLICY NUMBER MM/DDY EFF POLICY MM/DD EXP LIMITS LTR A X COMMERCIAL GENERAL LIABILITY 20OIX0485 7/21/2015 7/21/2016 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR DAMAGE TO PREMISESS Ea occurrence) $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECT PRO a LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS H AUTOS Per accident UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION 2001 W7501 7/25/2015 7/25/2016 PER OTH- AND EMPLOYERS'LIABILITY STATUTE OR ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A - (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below- E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived or extended the Coverage provided by the policy provisions. Carpentry The workers compensation does not provide coverage for Troy A Thomas and Shawn M Doyle. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE D&T Construction Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 168 ACCORDANCE WITH THE POLICY PROVISIONS. Centerville,MA 02632 AUTHORIZED REPRESENTATIVE f ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 508-328-1635 SPECIALIZING IN ALL FORMS OF ROOFING & SIDING doyleandthomasconstruction.com ACCREDITED P.O. BOX 168 BUSINESS CENTERVILLE, MA 02632 Fully Licensed & Insured Construction Supervisor Lic# 99913 Doyle and Thomas Inc. Proposes to perform the following work: Location of proposed work: Mr. Seth Taylor 132 Emerson Way . r Centerville, MA 02632 Date on which construction should begin: January 2016 The homeowner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that cannot be avoided by the contractor shall not be considered as a violation of this contract. The contractor agrees that when such delays become known to the contractor;the contractor will advise the homeowner,as soon as possible. The homeowner hereby acknowledges that in certain remodeling work,the demolition process may reveal defects in the existing structure which must be repaired, creating additional work which may need to be carried out in order to complete the work described in this contract. In such case the homeowner agrees that the duration of the work and the schedule date of completion may differ,and that such variation is not to be considered a violation of this contract. The total cost for labor and materials under this contract: $11,082.10 Above proposal to install Maibec A white cedar siding shingles on..both gables&back of the home&install Certainteed Cedar Impressions Vinyl siding on entire front of the home as'discussed Proposal to install a.Therma-Tru two light front door would be $1,125.00 Proposal to replace the rotted trim that was not finished around the home by the previous contractor would be $2,250.00 � 4 Thank You For Giving Us The Opportunity To Help You Improve Your Home In the event that while stripping the siding we find rot that needs to be replaced,the homeowner then has to agree and authorize any replacement or restoration. Then in addition to the above contract price,the homeowner agrees to compensate the contractor for any repairs or restoration at the hourly rate of$45.00 for a carpenter and$30.00 for a carpenter's laborer, plus the cost of materials. -Siding to be stripped and cleaned of all old siding&debris -Home to be papered with Typar house wrap Maibec Grade A white cedar shingles to be used in the installation -Certainteed Cedar Impressions vinyl siding to be used in the installation Thurma-Tru fiberglass front entry door to be installed with new hardware -5 Yard dump trailer will-be needed on site; and will be removed at completion of the job -Contractor will be responsible for all,building permits needed at the property NOTICE REQUIRED BY LAW With the agreement of the contract$500.00 of estimate is due. Further payments under this contract are as follows: 1/2 of the estimate due at the start; and remainder due at completion of the job. Balance of all materials and labor shall be payable in full upon completion of work described in this contract. Payment as agreed upon shall be made when due. Any payments which are delayed shall be subject to a finance charge of 1.5% per month. The contractor warranties the work completed under this contract for a period of one year from the date of completion. During the stated warranty period the contractor shall be responsible for the service of the repair or adjustment, but the contractor shall not be responsible for the normal maintenance, repair due to abuse, misuse, and or normal wear and tear,which shall be the responsibility of the homeowner. All warranties for the materials supplied by the contractor shall be passed directly to the homeowner. The homeowner may be required to register or mail in such warranty card or evidence of ownership in order to activate such warranties. Homeowner failure`shall not create any responsibility for the contractor under the warranty,provisions;the choice of repair of replacement shall be at the discretion of the contractor. The homeowner acknowledges that the form, content, and notices contained in this contract are intended to comply with the applicable portions of the Mass. General Law Chapter 142A, and regulations promulgated there under. In the event of any instance of non-compliance,only such portion shall be invalid and the remainder of this contract shall be in full force effect. In addition, any such portion not in compliance shall be read and interpreted so as to have its intended meaning to the maximum extent allowed under such law and regulation. Signed as a sealed instrument on this date: Date: Homeowner Contractor i ok /1hC?A3 Town of Barnstable �*©It# oFTME , Expires 6 m s m i ate d Regulatory Services Fee aeatvszeBM v M"9. Richard V.Scali,Interim Director Building Division 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 n Not Valid without Red X-Press Imprint Map/parcel Number U� Jr��,, Prozesidential Address E ✓ (/( O (_r `4 Value of Work$ d Q Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 1 cr 2US, 6 1/1 hX4 Contractor's Name Oe Telephone Number Home Improvement Contractor License#(if applicable) `J �� Email: 5P CI( P,((IZOt/1; wl Construction Supervisor's License#(if applicable) ( �� ' (� So ,-- ❑Workman's Compensation Insurance Check one: NOV 18 2013 ❑ I am sole proprietor ❑ I the Homeowner have Worker's Compensation Insurance TOWN OF BAIRNS7ABLE Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will betaken tor��� ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ e-side Replacement Windows/doors/sliders.U-Value ac} (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation;etc. ***Note: Property Owner must sign Property Owner Letter of Permission. opy of the Ho mprovement Contractors License&Construction Supervisors License is r uired. SIGNATURE: TAKEVIN MBuilding Cha RESS PERMITXP SS.doc Revised 061313 The Coinvionspealth o,f'Massachusetts Department of Industrial:4ccidents Offrre of Investigations 600 Washington Street Boston,MA 02111 win+ niass:gmAd a Workers' Compensation Insurance Affidavit:Builders/Contractors/ElectriciansiPlambers Applicant Information Please Print Legibly Name(Baaines ni fittait ,_ ��, IW I V wr Address: i l l� S �►t-�� City/State/Zip: ey I I I MALO&�'Phone s `4W_6iOgD Are ygwan employer?Check"propriate boss Type of project(required): 1.V,am a employer with l 4. ❑ I am a general contractor and I employees(full and/or pad4ime). s have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1. odelir►g These sub-contractors bm e ship and have no employees $. El Demolition working for sue in any capacity- employees and have workers' [No workers'comp.inturramce' camp.insurance I 9. El Building addition ed] 5. ❑ Zile are a corporation and its 101]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I Ln Plumbing repairs or additions myself:[No workers'comp- right of exemption per MGL l2.❑hoof t eparrs insurance required]I c.152,§1(4} and we haLv no employees.[No workers' 13.0 Other comp.insurance required.] - _ ;Any appficstst t checks hbs#1 tst a]sa fill aiu the secteca Wlyw shoteint than workaV compenEation policy infamistearL i Homeowws who submit this afiidatrk indicating they ere doii4 eU nrox and thin him outside contractors ma submit a new aff davit indicating such. tcoatr arms._that check this box must stt�ched an additional sheet showing the name of dre sub-cortmtors and state wheher or not those des hsee employees.If the sub-contractors bare-Ployee%"f angst pride:their a arkers'comp..policy number. I am are eanpla}vr that is providing ivorkers'conipensalfon insurance for lay enrpioyees. Belofp is the policy and job site information. Imurance Company-Name: Policy;9 or Self-ins.lie. 4-1-zl Pa.?—a �i Farpiration Date: � Job.Site Address City/state/Zip: 0_0,,-t�r U iG` ! A--oi�&3 ' Attach a copy of the workers'compensation policyWclaration 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 S1>SO6.60 and/or one-year imprisonment,as well as chzl penalties,in the form of a STOP WORK URDElt and a fine of up to S250.00 a day against the violator. Be advised that s copy of this statement may be forwarded to the Office of Investigati o e DIA fibs insurance coverage verification. I do Te by c �3`mauler the pm rJ f P. - , yid ald, e a drat the information rot�ded above is true and correct Si /..Date: �J Offlrial atss only: Do not write in this area,to be completed by city or t©mi of`i'e nil City or Tows.: Permitd kease if Issuing Authority(tdrde,one): 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector a.Plumbing Inspector 6.Other Contact Person: Phone#: ACC>REP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) �� 10/28/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Germani Insurance Agency PHONE FAX 908 Main Street AIC o E : 508 428-9194 A/C No:508 428-3068 E-MAIL ADDRESS: Osterville,MA 02655 INSURERS AFFORDING COVERAGE NAIC# INSURER A: Essex Ins.Co. INSURED INSURERB Scott E.Crosby Builder,Inc. 1112 Main St.Unit 7 INSURER C: Scottsdale Ins.Co. Ostervllle,MA 02655 INSURER D: Hartford INSURER E: ' INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE INSR WVDR POLICY NUMBER MM/DDPOLICY/YYYY1 (MMIDDNYYYI LIMITS A GENERAL LIABILITY 2CN6590 10/12/2013 10/12/2014 EACH OCCURRENCE $ 1,000,000 x COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ CLAIMS-MADE Fx_]OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT - Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR XBS0025685 10/12/2013 10/12/2014 EACH OCCURRENCE $ 2,000,000 x EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000 DED RETENTION$ $ D WORKERS COMPENSATION 4727P23-8-11 6/23!2013 6/23/2014 WC STATULIMIT- OTH- AND EMPLOYERS'LIABILITY Y/N -ER ANY PROPRIETOR/PARTNER/EXECUTIVE NIA A E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? �N (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) k CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE �I Scott E.Crosby Builder,Inc. THE EXPIRATION DATE' THEREOF,k•NOTICE WILL BE DELIVERED IN ' ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD • lAlN31'ABIE. MAM Town of Barnstable Regulatory Services Richard V.Scali,Interim 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 kj�� f I, UL I�� ,as Owner of the subject property hereby authorizer (i to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address 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. TAKEVIN_MBuilding Changes\EXPRESS PERMITAEXPRESS.doc Revised 061313 i I Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-043556. SC OTT E CROSB)" 62 CROSBY CIR: S OSTERVIILE 1VllA 02 1 V4 i )r w��. Expiration Commissioner 12/13/2014 i Vlze 1poa���aoazcaea���a�c�/!ir'cza�ac�uae� Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: T_e1gistration: 151882 Type: Office of Consumer Affairs and Business Regulation xpiration: 7/13/2014 Private Corporatic i lO Park Plaza-Suite 5170 Boston,MA 02116 SCOTT E CROSBY BUILDER INC. CROSBY 1112 M 112 MAIN ST UNIT#7 OSTERVILLE,MA 02655 Undersecretary Not valid without signature