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0170 HORSESHOE LANE
. n � _ w��.� _ . .1 u �, " J ) F '1(J 1 fi nf= N t =, J�'�= _ - t F tr I +. ,.. a , f a Application number...z......... ..........7. f '®q EYE i i N Fee ....................................:......................................... KAMA ` s (r ^ Building Inspectors Initials.............�,� .......... �, �.. Date Issued.............. i �.-................................ TOWN I ft bNKIVb Map/Parcel.............:................................................... TOWN OF BARNS-TABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WIND O W S/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: NUMBER STREET VILLAGE Owner's Name: ��' � t.. 5� �;a Phone Number Email Address: Cell Phone Number Project cost$ Check one Residential �- Commercial -OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK ❑ Siding ❑ Windows (no header change)# ❑ Insulation/Weatherization 0 Doors (no header change)# Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name LLCM Home Improvement Contractors Registration(if applicable)# C -9 y (attach copy) Construction Supervisor's License# CS (attach copy) Email of Contractor S A`11 QSf_0 (.@- Wtikod _c. Phone number K6k-�4 Z-Z101�4 2 Z101 ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. i i 1 APPLICATION NUMBER............................................................ `` W *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No " (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one:.this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent Fuel source being used LP tank 20 lbs. or> Yes No , if yes, a gas permit is required. Natural Gas Yes No , if yes,a gas permit is required. If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4.30pm. Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature Date� Mal— 1 All permit�aications are subject to a building official's approval prior to issuance. The Commonwealth of Massachusetts Department of Industrial Accidents i Office of Investigations 600 Washington Street Y Boston,MA 02111 www.mass.gov/dia i Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name(Business/Organizationllndividual): Address:_ City/State/Zip: aZrr 3c Phone#: Are you an employer?Check the appropriate bojcl'_ Type of project(required): 1.❑ I am a employer with 4. [Ti 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 working for me in any capacity. employees and have workers' insurance.$ 9. ❑Building addition comp.[No workers' comp.insurance p• 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 re❑ - pairs . insurance required.]t c. 152,§1(4),and we have no 13.LQ Other: Cj� 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. tContractors 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 the policy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: -,ter— -��,�- . T Expiration Date: 2- 20 ucc SGD �'0697 5 2-06 -A- Job Site Address: �,� p, t� p, City/State/Zip:. 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 certify under hens and penalties of perjury that the information provided above is true and correct. Signature: /� aCn Date: � 1 Phone#: 7 (J b A -;26 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#: h J Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written.." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or 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 required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit(license number which will be used as a reference number. In addition,an applicant that must submit multiple 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 (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts, Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 u.mass.gov/dza 6� 15�36 HYA!`J N BAF-NSTAE3L.E EX?. Telephone:. Date: A1 .- I c�-p r�ui=FC-O@YAH M For The Amount Of. i k)0 r u,e-� J !O�CLI —0 Lc..A�°� I L vim " 2- w1i1 �1 G " Payment Schedule: / r Customer Date Stephen Duff Date Toe, Folnz' dew Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvem6IContractor Registration Type: Corporation Registration: 188860 STEPHEN DUFF CONSTRUCTION,LLC a `" t Expiration: 09/11/201.9 1586 HYANNIS RD M _ BARNSTABLE,MA 02630 �r Update Address and Return Card. SCA 1 0 20M-05/17 .... ..- ,/� !>///2/724/lll1eQ�✓L 4�✓//17�1/'CLG'/LLG1E�� Office of consumer Affairs&Business Regulation Registration valid for individual use only HOME IMPROVEMENT CONTRACTOR g TYPE:Corporation before the expiration date. found return e . Office of Consumer Affairs and Business Regulation Registrcatio6 n Expiration __ _60 09/11/2019 1000 Washington Street-Suite 710 WR_fflBoston,MA..02118 STEPHEN DUFFSTRUTION,LLC STEPHEN DUFF J2_6,-� 1586 HYANNIS RD{ Not valid without signature BARNSTABLE,MA tl'23'0�' Undersecretary i (9/e�poo�ur�aarzcuealC� �/'jacXuje4'4 Office of Consumer Affai s&Business Regulation Registration valid for individual use only HOME IMPROVEMENT CONTRACTOR 9 TYPE:Individual before the expiration date. If found return'to: Registration Expiration Office of Consumer Affairs and Business Regulation 159-942_'_, 06/10/2020 One Ashburton Place-Suite 1301 Boston,MA 02108 JOSEPH i JOSEPH RENNIE 4 WAYSIDE LN �NOt valid without signature SANDWICH,MA 02563_` Undersecretary Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Con strq<;tib4t�IS`f5., rvisor ^f CS-086728 > r 1 4�ires: 12/1612019 JOSEPH A RENNIE � i 4 WAYSIDE LANE ; p � SANDWICHMA:02563� Commissioner a Town of Barnstable Ulldin- "�9�� .,,.�, x"ai"✓" � «,. `1 '� aw:. .r✓' r ,. '� �x .. ��. �::' PostaThis Card So That it;isVisibl'e!From he Street "Approved Plans;Must be Retamedson Job and thissCard Must be Kept a : a�nietsewsLe *s, , 6« Posted Until`Final insp39 ection Has vBeen Made p rPermit Where,a Certifiea`te.of Occur anc`'i`is"Re aired such Buldm shall=Not?,be Occu iedluntila Final Ins ection has:been'made g.: a ..a ��,...p,fw..�...4 ,. .. Permit No. B-18-2205 Applicant Name: CAPE COD.REMODELING,• 1-C. Approvals - Date Issued: 10/01/2018 Current Use:.,.: Structure Permit Type: Building-Addition/Alteration-Residential Expiration Date: 04/01/2019 Foundation: Location: 170 HORSESHOE LANE,CENTERVILLE Map/Lot 207-130 Zoning District: RC Sheathing: Owner on Record: SUKHIA,SAROSH P& NANCY J TRS Contractor Name' ,-CAPE COD REMODELING'LLC. Framing: 1 CO D o Address: 1213 MARL BANK DRIVE e Contractor License 178816 - 2 HOPEWELL,VA 23860 _` HEst Project Cost: $58,000.00 Chimney: Description: Re4novate the sunroom to a 4 season kitchen expansion currently Permit Fee: $345.80 Insulation: under roof. Renovate :kitchen, bath,add 1/2 bath and add laundry Fee Paid:; $345.80 closet.Add 3.5 wide x6 platform to exit raised space`Witl;.steps to Final O Z L ground on each side(3-4 steps). Replacemenf"windows;front,and" Date 10/1/2018 sides. New Windows, kitchen and kitchen extenstion:. Plumbing/Gas Project Review Req: iV Rough Plumbing: z... Building Official Final Plumbing: Rough Gas: Final Gas: This permit shall be deemed abandoned and invalid unless the work authorzed by.tHis,permit is commenced.withm six months after issuance. Electrical All work authorized by this permit shall conform to the approved application and the approved consteuctI n documents forwhich:this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoningFby laws and codes. Service: This permit shall be displayed in a location clearly visible from access street orroad and shall:be maintained open for public inspection for the entire duration of the Rough: work until the completion of the same. The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Final: Minimum of Five Call Inspections Required for All Construction Work: Low Voltage Rough: 1.Foundation or Footing 2.Sheathing Inspection low Voltage'Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Health 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Final: 7.Final Inspection before Occupancy Fire Department Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final: Work shall not proceed until the Inspector has approved the various stages of construction. "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). 05 applicationrTU3nb . ........................................... ... TOWN OF BARNSTABLE. � ; * MASIL ii cm F=.......................................Other Fee........................ 1696 ,� 1 19 "CR I 1,r°3 10: E e Total Fee Paid................... TOWN OF BARNSTfABLE` m. Pew oval by.. ........................ o�....�bll�� :........ . s.x.. t1 x3+ BUILDING PERMIT o�D �� MV....»...»............................Psrcxl. .........»: .......................... APPLICATION ,n,aa-c. s Section I— Owner's Information and Project.Location l. CcR-�3 :Project Address � +© S S � e . Owners Name L:5_N Vzp S L/� S J Ir5� 9 r A- Reg. r Owners Legal Address C�tyy l i ►�J - State zip Owners Cell# eO E-mail<J Section 2—Use of Structure Use Group ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under35,000 cubic feet Single/Two Family Dwelling Section 3—Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) ElFinish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment ❑ Sprinkler System ❑ Addition ❑ ReWning wall ❑ Solar Renovation ❑ Pool ❑ Insulation Other—Specify Section 4 -Work Description o S�so� �c�I"c.b�a✓" SI C� ( o Q_t�o V -Q-!- C, LJ M1 Application Number.................................................... Section 5—Detail Cost of Proposed Construction ��y Square Footage of Project7�0 Age of Structure Dig Safe Number. i'-T' # Of Bedrooms Existing Total# Of Bedrooms(proposed) Alo cJ -� 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics a u�, [TWin'ng ❑ Oi1 Tank Storage moke D rs t Plumbing ❑ ,Gas - ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑Add/relocate bedroom Water Supply El Private uPP Y Sewage Disposal ❑ Municipal "QOn Site 'c D' H Historic District Old I-E wa Huston District ❑ yannis ❑ Kings gh y Debris Disposal ili . &n—Hot2W— I am using a crane ElYes�No �P Fac tY' Section 7—Flood Zone Flood Zone Designation 3 Within or adjacent to a wetland, coastal bank? Yes ❑ No El Section 8—Zoning Information I Zoning District Proposed Use Ci Lot Area Sq.Ft. 3 Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard R ' ed Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No `-«` Last undated:2J9201 S Application Number................ Section 9—:Construction Supervisor Name Telephone NumberS05 L,�_g 7 3 77 Address;?7,y)4-nV a_� S I City M 4S W'C State M r Tip w 0,�� ' License Number C5 I License Type Expiration Date 1 l's5-. e Contractors Email RLAV&' � d&)l�o�,C�v Cell# S � I understand my responsibilities under the rates and regulations for Licensed Constrbction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the contraction inspection procedures,specific inspections and documentation r 80 CMR the Town of Barnstable.Attach a copy of your license. Signature Date . 27l Section-10—Home Improvement Contractor Name ki. ' �°L !'�'''' Telephone Number • � �/�� �� 7� AddressZ7/fj/*P�Si City Registration Numb Expiration Date S �� I understand my responsibilities under the rules and regulation for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and doc=entation required by 780 and 76f;Ba;msta7blei Attach a copy of your H.LC... qq Signature Date Section 11—Home Owners License Exemption Home Owners Name: Telephone Number Cell or Work Number I understand my responsibilities under the roles and regulations for Licensed Contraction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Bamstable. Signature Date APPLICANT SIGNATURE Signature Date 7 /8 AgPrint Name 6(J Telephone Number SOJ'5 ( `j E-mail permit to: (V() %ZO e2 T f..r.....i..aa.n einni.0, Section 12—Department Sign-Offs I ealth Department Zoning Board Cif required) ❑ Historic District ❑ Site Plan Review{if required) ❑ Fire Department ❑ �onservationAW, 3 For commercial work,please take your plans directly to the f re department for approva.L Section 13—Owner's Authorization ry as Owner of the-subject property hereby authorize to act on my behalf, in all j matters relative to work authorized by this building permit application for: (Address of j ob) i Signature of Owner date Print Name i Last=dated:Z92018 101, 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 LeLyib � -Name(Business/Organization/Individual): / Ay Address: �a City/State/Zip: MA5HT30& Phone#: S 8 ?S-6 79 7-S Are you an employer?Check the appropria a bog: Type of project(required): 1.❑ I am a employer with 4.9,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' Y P tY• 9. ❑Building addition [No workers'comp.insurance comp.insurance.t 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 employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#I 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 anew affidavit indicating such. �Contraotors 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 the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 certify under he pains d penalties a fperjury that the information provided ove trueand correct S -71 i afore: Date: s 45 Phone#: �C�/ � 7573 Of 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." artnershi association,corporation or other legal entity,or any two.or more An employer is defined as"an individual,P P� of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or 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 required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." eq� ha P Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone numbers)along with their certificate(s)of insurance. Limited Liability Companies(L LQ or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple 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 (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn 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 Department's address,telephone and fax number: The Commonwealth of Massadhusetts Department of Industrial Accidents Office of Investigations 60-0 Wasbinton Street Boston,MA 02111 Tel,4 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 www.m=,gov/dia L— �. Town of Barnstable Building Department Services IL NAM ' Brian Florence,CBO 1"9. Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.maxs Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using'A Builder property as Owner of the subject l hereby authorize Jto act on my behalf, in all matters relative to work authorized by this building permit application for: ( -70 k-6v-c-e-Av- (Address of Job) **Pool fences and alarms are the responsibility f o the applicant. Pools are not to be filled or UkV,ked before fence is installed and all final inspections are performed and accepted. at 1 '4 i-'Illt' ,Signature of Owner Signature of, Lpph A- Print Name Print Name Da Q:FORMS:OWNERPERMISSIONPOOLS Rev:08/16/17 tigwomapun 649Z0 VW`33dHSSVW u6es}notw.m p11eA ION -- '�� LOZ#*IS 13)Wn LZ ku3AV OUVHOIu 011,'JNIl300W3u.000 3dV3 Botzo VW uwtso9 9488L1 LOST apnS-soeld uojjnggsw au0 uogeln69u ssoulsng pug snegV jawnswo 10 GDWO uo_ :o1 wrgai punol g •alep uogejldxs OLD ago}aq Ol 1 3dAl *o asn Ienpinlpui Jo;plleA u04eJIsi69u UOj3Vli1N001N3W3AOudWI MOH uo.Mn5&H sseuisne-g wiw jewnsu0010 GOWO r Jyr.)77fJDfl7)�)j0�0�J�UaantoP6 wwA 00000 �n r Massachs:setts Department of Public Safety Bos,rd of Building Regulations and Standards ' -License: CS-084771 Construction Supervisor RICHARD T AVERY PO BOX 2416 MASHPEE MA 02649 / �� � �� Expiration: j,; Commissioner 0111512019 ACO® DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 04/02/2018 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: Linda Sullivan DOWLING&O'NEIL,INSURANCE AGENCY a/c°NN , (508)775-1620 a No: ADDDDRESS: Iullivan@doins.com 9731YANN000H RD INSURER(S)AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INSURERA: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B LOCKS HOME IMPROVEMENT INC INSURERC: INSURER D: 116 COMPASS CIRCLE INSURERE: HYANNIS MA 02601 INSURER F: COVERAGES CERTIFICATE NUMBER: 252866 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I�TR TYPE OF INSURANCE ADDD SUB POLICY NUMBER MMMIDPOLI�EFF MPOLICYWDDI EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑JET LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED tid N/A - BODILY INJURY Per accident)AUTOS AUTOS ( ) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per a.dent $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X STATUTE EOTH R AND EMPLOYERS'LIABILITY Y l N ANYPROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? WA WA WA 6S60UBOK97178417 10/06/2017 10/06/2018 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEd$ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E-L-DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/twd/workers-compensationtinvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Cape Cod Remodeling LLC ACCORDANCE WITH THE POLICY PROVISIONS. 'PO Box 2416 AUTHORIZED REPRESENTATIVE Mashpee MA 02649 � L Daniel M.C�y,CPCU,Vice President—Residual Market—WCRIBMA @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD A CAPE COD REMODELING, LL.C. CAPE COD Ig€ray MUIBA11;�MI RE ( A4J RICHARWAVERY IC D — AVERY V 0.0. P.O.71 7c�; 4 ,ASHPEE, MA 02649 MASHP€EjMAO49' CELL: (506) 956-7 73 CELL: (506) 956-73'73 NEW DORM ".r TRIM BOM09 OEIOEB NOTE" AND Q 2"ISTOORAL HEADERS AND NEW SORAL TRIM • TO FOLLOW SPECIFICATIONS NS FOR L 18 80RAL S ITY ICAL)$]USAND NEW INI EA) WwOOwOITYPICAtI AND rJGw NAMDows. BOAR DS TOFOLLOWND STORAGE. TO AGE. SFOR t BURROUB O A D CORNER • NANDLIE F AND TOE, BOARDS. 18OAOEFASTENERSTO BE STAINLESS STEEL WITH ADEQUATE I� PENETRATION TORS MA I UM2UBSTRATE. 11 LEA FI'' 'I� • INSTALLDWITHABTENE M UM2NDCF4S. O OE I��/JBI • FILLNAILANO CREWHOLE6wA TO BODY FILLER. A MUST IO PANTED ONE PAINT O EXTERIOR OF INSTALLATION. PAINT WITHIN ISO DAYS OF IN6TALUTION. SH NO EHINOLEOTONGONNATO STOBI MIMED DO MoNTOR AND dHINOLEB TORE FSTALLON FRONTATCH EM TIPA1NT0C.ATO 0'.0"FINISHED OL OFPAI.LATi01 ER 6HIN Lr18 ARE IN AC COAT CF'PAINT AFTER 6HItJOIEO ARE IN RACE(TYPI FLOOR Barnstable Bld .Dept. Approved by: Permit [�^ O PANEL�gy Iy�Q INTET WLL110RN LA�TPANGL AO•I71�+OIIM1'PGO.CMNNNNNS' . IBALU8TR SQ w O.0 HORIZONTAL. ORONTR OOVMO r XAI N9RI(FLArPANEl aO'NT4 A.2. 1 O SEIINPOIO.CA 9WAA DAWS ER QA1 0L 4YOIZGNT IA"sOUARE MweTERa®a°oe NO., REVISION DATE MORtLONTAL. AAZEKVfGA 'rER ACOLLECrION'A NDiNGTOSE OORAL TRUEXMR)R FOR STAIR RISERS AND C E TRIM BOARD. t 5AMIA Residence 1TB CDrdeMI1. A taro MllY M MA 02853 0'.0"FINISHED L : 114"=1'. ' FLOOR TITLE:REAR EXTERIOR ELEVATIONS DATG FEBRUARY 24,2018 MiCHAELA.JIMERSON A.I.A. ARCHITECTURE A INTERIORS 193 Hm.*.Lwm CYntmvlila MA.02032 $09 7154264 ' mAlAmh�camewl.net CA PirE COD REMODELING, LL`C. RICHARD AVERY TOWN OF BARNSTABLE MA,SHPEE, MA'G$649 �v ' ld: 10 CELL: (50.6) 959-73'73 ? L 1 •T`. 7 S� � 'Yn } 1 D F BEDROOM#1 5 5 E R tl \/ D O C De v20 \ 7E ISLAND 3 BEDROOM#2 BEDROOM#3 LIVING ROOM A.3. 1 NO REVISION DATE CLIENT: SUKHIA Residence 170 Nor,mhoe lam t' ELECTRICAL LEGEND Cewrvnl.MA 02032 O DUPLEX OUTLET (".¢.HALO L 403WBS TRIM I REFLECTED CEILING PLAN 'U-°-� wl 4"TL 403WS5 TRIM KIT. GROUND FAULT LE:REFLECTED CEILING UONTINO DUPLEX OUTLET �DEFIANT LED#DFI.5862-WH AN D BV#TCKINO PLAN SINGLE POLE SWITCH TWIN LED FLOOD LIGHTS. DA.i PCBRUARY 24,2018 3 WAY SWITCH GE'ENSRIOHTEN'17'LED ®HARD WIRE SMOKE -DIRECT WIRE UNDER CABINET MICIIAELA JIMERRON ALA ARCHITECTURE 6 INTERIORS DETECTOR LIGHT. 193lf.—h.Lam .S PROVIDE 530.00 FOR F PANASONIC'LNHISPER GREEN Co*rvIII"MA.D2632 —WALL MOUNTED FAmJGHr#FV-05.11VKL. $087754731 SCONCE OVER SINK. mglmoheaamcon.nc, RICHARD AVER IP'"0. BOX 241 MASHPEE, MA 02E 49 ADD FRAMING®EACH SIDE OF CORNER CELL: '(508) 958-7 73 IN ORDER TO HAVE(4)HOLD DOWN ANCHORS. SET ANCHOR BOLTS INTO EXISTING FOUNDATION AND SET WITH NON-SHRINKING EPDXY FOR A CONTINOUS LOAD PATH. 314"T.BG.PLYWOOD GLUED AND NAILED YPICAL ISE EXISTING 2"x 4"WALL ABOVE t----, EXISTING P.T.PLATE.w1 P.T.FRAMING AND NEW P.T.BILL PLATE SO AS TO ALIGN w/ \EXISTING. d► s i i i i i TOP OF / i 1 i i i FOUNDATION GAS LINE. P-TRAP SEWER. / i i i i i i I i i I i i i i i 2"N 12"P.T.LEDGER BOARD AND HANGERS ADD 21'RIGIS INSULATION BY i i wl 3W DIA.x 5"GALV.ANCHOR BOLTS Q 16" DUPONT C0IRNING�ON TOP OF I O.C.STAGGERED TO EXISTING WALL. 71-0° EXISTING CONCRETE SLAB ! �RIO♦�TO NPW FLIbOR! ! ! V-10.7/8"BOTTOM OF FLOOR FRAMING. REt'4SACE TEMP.LALLY - RAM G, i 1 COLUMNS w/(5)CONCRETE i i i i i i EXTEND HEAT DUCTS THROUGH FOUNDATION WALL FILLED LALLY COLUMN w/ i i i i i i TO PERIMETER WALL OF KITCHEN EXTENSION SIMPSON STRONG TIE POST 2"jt 10"R.T.0)a"0•Cy. I UNDER FLOOR FRAMING UNDER NEW WINDOWS. TO BEAM CONNECTOR. i FLOOR JOISTS wt i i i O (2)iROWB OF BLOCKING ! ! 2"z 12"P.T.LEDGER BOARD AND HANGERS 1 ! ! ! ! ! w/3/4"DIA.x 5"GALV.ANCHOR BOLTS®IW , I 1 ! ! ! I O.C.STAGGERED TO EXISTING WALL. ADD LLON RY LL __ CON CT COO POUTS. REPLACE AN GRADE EXISTING ELECT L PANEL Q BOX.ADD TO DEDIC D CIRCUIT FOR WASHER/ DRYER,WALL OVENS,AND W H]FURNACE REPLAGF FJ(ISTINti HOT WATER HEATER FUTURE CENTRAL AC. W/RINNJAlf X751N 7.5 GPM INDOOR LOW NOx TO BE CODE TANKLESS NATURAL GAS HOT WATER t*,47ER. COMPLIANT WITH CURRENT CODES. - A.0 NOTE: - SPRAY CLOSED CELL FOAM INSULATION FROM THE EXTERIOR RM BOARD AND NO, RMSION DATE SILL PLATE UP TO THE SUB-FLOOR TO THE FACE OF THE FOUNDATION AROUND 1' ,• ;O THE ENTIRE PERIMETER OF THE BASEMENT AND PERIMETER OF NEW WENT: H2O S.O. ENCLOSURE. 5: 5UKt11A Residence t ro Nan.m..l.m cenl«vum NA nel7 5CALE: 1/4"=I'-(7' '•3 0'-10 UATE:rEbRUAeY24.2017 MICHAEL A.MAMMON hLA ARCHITECTURE 6 INTEHIOM 193 H_.h.lam C.RI.rvHb,MA,M637 508 77l-0764 mWmv6*omes not l w : . o NOISIAIG 09 :01 �1 : Ii c3�':iBIQ .: 319VISUVO JO Nyi0i 1 1 77 : p<i - m'ov1slum -0 Wk of Application numbe .� ^.aa`�...... AUG212018 Date Issued............$ Zl .!..s............................... +' WNSTJtBL MAM Building Inspectors Initials....... ................. Map/Parcel..... .... .......�..................... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDO WS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 7 C 2 t o - T r NUMBER STREET VILLAGE Owner's Name: S V__0 S S J V 44 o A— Phone Number�� � 7Z-1 3 7 Email Address: 'r A d34 Leel�hone Number 57ob 8 7?73 Project cost $ Check one Residential Commercial OWNERS AUTHORIZATION As owner of the above property I hereby authorize to make application`for a building permit in acc/ordan�with 780 CMR Owner Si ature: J� T���% .. Date: �n I S TYPE OF WORK ❑ ❑ Siding Windows (no header change)# Insulation/Weathenzation ❑ Doors (no header change) # Commercial Doors require an inspector's review Roof(not applying more than l ,layer of shingles) / f Construction Debris will be going to �— / C� I J9 1 CONTRACTOR'S INFORMATION Contractor's name "� � r s - Home Improvement Contractors Registration(if applicable)# 176 3 (attach copy) Construction Supervisor's License# node l (attach copy) Email of ContractorYE���' Phone number ALL PROPERTIES THAT HAVE STRUCTU ES OVER 75 YEARS OLD OR 1F THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s) will be erected Removed on number of tents total Does the,tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X .f _L , Additional tent dimensions can be attached on a separate piece of paper. Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES* Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number. Cell or Work number I.understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature Date All permit applications are subject to a building o�IciaVs approval prior to issuance. � > Town of Barnstable Building Department Services rasa. Brian Florence,CBO 63;9. 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 N If Using A Builder. as Owner of the subject l property hereby authorize c to act on my behalf, in all matters relative to work authorized by this building permit application for: • (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are perfortned and accepted. �G �J4 Signature of Owner Signature of Applica .- • A- Print Name Print Name Dat UORMS:O WNERPERMSS10NPOOLS Rev:08/16/17 , Massachusetts Department of Public Safety ' Board of Building Regulations.and Standards- License:CS4Q84771 Construction Supervisor RICHARD T AVERY PO BOX 2416 MASHME MA 0260 ti Expiration: Commissioher. 01M6f2019 �/Fe TOn�xixauu�G�a��2r�aaia�l�� . Office of Consumer Affairs&BushOw ReguMm R �W forirrfiividt�use Only TYPE HONE fiMt IO NT CONTRACTOR before the wWwation date. If found velum 1w M LLG office of Consener Affair's and Business Regulation One Ashburton Place-Suite 1301 1788t&' - 2t Bost^MA 02108 CAPE COD REMODBJNG,LLC.. RICHARD AVERY 27 MARKET ST. oT' - Not wild without Sig MASSHPEE.MA 02549 UnderSecreWy r f - The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www hums gov/dia Workers?Compensation Insurance Affidavit:Builders/Contractors/Electricians✓Plumbers. TO BE FILED WITH THE PERM-MG AUTHORITY. Apiplicant Information Please Print 'b Name(Business/Otganization/Individuan: 7 T� Address: � ciY1� City/State/Zip: Phone#: Are you an employer9 Cheek the approp to box: Type of project(required): LE)I am a employer with employees(hill and/or part time)-s 7. New construction 2.[]l am a sole proprietor or partnership and have no employees working forme in $• Remodeling any capacity.[No workers'camp.i641r8nCe required.] 3.0I am a homeowner doing ell work myself:[No workers'comp.insurance required.]t 1 ❑Demolition 0 Q Building addition 4.E]I am ahomeowcer and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions proprietors with no employees 12.Q PI bmg repairs or additions 5�a general contractor and I have hired the sub-cont actors listed on the attached sheet 13. . Roof repairs These subcontractors have employees and have workers'comp.fimm ice: 6.Q We are a corporation and its officers have exercised their tight of exemption per MGL c. 14. Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy iirformation. t Homeowners who submit this affidavit Wicating 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 shed showing the name of the sub-contractors and state whether or not those entities have employees. If the subcontractors 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 are policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: _ Expiration Date: - Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby the pams andp^akies ofperjury that the information provided q a fte and coned Si Date: L 0 Phone eV!!S93 OfiSddl use only. Do not wrke in this area,to be conr&ed 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#: ' 2d� � vRd CERTtFwATE OF L1mmy 1N.SURANCE 018 o�rl0ms TM CETTi IME IS BSIED AS A URTUR OF OWOTl KUM W&Y MID©DWERS NO RfC, M UPON IME CEffnFWA-M lKUM3L IM CBl7ri I D0 AFM MU 6I NOT IUMMY OR WM-IRE-Y MElIO.EXIM OR ALM TM 4XNER1/1R,1E MOUND Btt'M PODS anow Tm CERInumi OF lISINN11 m OOES NOT CONSI UTE A CONTRACT TIETHIfim im mil,AllflfORsmD rm Fm=3im7moRpRaoucERmaimcERnwAirEummm MNVWANr: N to m 1, t oNw is m AoomOidlL 0118WtM the poicgpts)mast be N SI ERWAIM TS WANED.sdtjeet to tlta terms 8M eoaAli of tht f m-'j t I I I poFN*S Sy s endorsees A Ott on ifiis S doe.oat oade+r �tt�s oer68wie holder H1r 6eN of sndl ems} wi0ouc�t tsuL Lida SUM= D0WJNG&OMM INSURANCE AGENCYoffighJaak t ( 77s 1620 I malt 9T3 TYANNCtX*f A1*011=6aoN NAtt:8 HYANNS MA n im n- A- HAR :KM U vds CO 30104 sssuns) ' mswms: LOCKS HOME offRovEpmwr WC rt aec- D- 116 CLASS CIRCLE stsutartE- HYANNIS NIA 026M srsssarF- COVEPJkGES CERTR:KA7E NuNMt 252m REVISION MUMBEft IM IS TO CERTWY THAT Its=POLICIES OF BMIURAICE LISTED BELOW HAVE BEEN ISSUED TO THE 6 WA MD ABOVE FOR TM POLICY PMW R*N(ATTal ANY REQUIRElINBIT.Tt3a/OR Como mom OF ANY cONTRAIT OR ORt63t DocumEw iArTH REspEcr TO vaum im CEKW(ATE WRY HE 09 OR WAY PERT K THE MOMMCE AFFORDED BY 7W POLKM HiMM 13 SM=T TO ALL THE 7E FOK SANDCOl®lr MOFSUCNPOUCIErLLYTIISStt011ldrHYAYHAVEBt$0REDUCED BY PAN CLAN& OR 7YPEeFa1S1ltAtrC� t+egCYN®t POgc1tEFF tB LatS ommunnym EA1ilOCClrBtHICE i CIJ1�6aIA0E Q OOdR i t1EDEXP ant i WA PERWWkLdAOVR M7 i GltLAtg1EtAltiTAiPLtEiP6t i npm=EIJPWRDF' ❑LOC PROaUM-CORIPMAM i OTHER i AU101110WELMRM I sL i aai AWAUiD gamyKnR1fwpm" i H SCHEMIED AU M AUM WA �Y p?traarmq i HMMAM S Pam_MANUMEAUM i 1�iMtLtBHCZA=.... 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