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HomeMy WebLinkAbout0067 LONG POND CIRCLE ,y r. r i , 4 � Ir • 61 14 ,rt , _ 1 ., � �• -`{ ... � ._ - I �. r-. `.,, t' a, a .• , • a ti .. y r , „ , y v s �. i f , i � r. ..; n. .. _11P , %' .r a si h f , r { a y ., . +t �'. �' •,. .-.. 1. c - i 5 , w' i e^ ' , , m. ' u• : ., a q.. '..,< ..< � law .. - G, 5�`, - , - • ii ,. ' , , `4 �)i. - Yf. :n. F .. C I 11•.. d...., 11 .• ` rY, .., � ,. .0 ' ._ , , _ /, - r . . Y t •. ,. it -.. ' b • : , L a.a ^ , A .. fir. -. 4,• • i u Town of Barnstable imnaing Post:ThisCard So rtThat,rt i"Visib4e rom the Street Approved Plans Must be;Retamed on J,ob a'ndAhis Carrd Must be;Ke t * snit wec z p 5 rerm0 Posted Until'Final Inspection Has Been Made x h �n Where a Cert� cats of Oc cup is Required,such Build ng shall Not be Qccup�ed�untll a-,Final inspection has been made , Permit No. B-18-3575 Applicant Name: Carl Rebello Approvals Date Issued: 10/31/2018 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 04/30/2019 Foundation: Location: 67 LONG POND CIRCLE,CENTERVILLE Map/Lot: 209-032 Zoning District: RD-1 Sheathing: Owner on Record: GAROUFES, KALLIOPE G TR Contractor.Name: Carl J Rebello Framing: 1 Address: 67 LONG POND CIRCLE Contractor License. .CS=084358 2 CENTERVILLE, MA 02632 Est. Project Cost: $6,223.00 Chimney: Description: Insulation,Air Sealing& Door Weatherstrips. Permit Fee: $85.00 Insulation: Project Review Req: Fee.Paid: $85.00 Date.. 10/31/2018 Final: f r fray�- Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and the:approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall;be in compliance with the local zoriing by-laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. , z Electrical The Certificate of Occupancy will not be issued until all applicable signatures by�,the Building and Fire Officials ere:provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work:: 1.Foundation or Footing r Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final' Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final' "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT em.}TL SE.�T • a Town of Barnstable *Permit# LWkw 6nwnW �s d - 2014 Regulatory Services Fee ,s� �� SAPMABy i • } MAW Richard V.Scali,Interim Director Q5�/U)1 y I RNSTABLE Building Division �^J Tom Perry,CBO,Building Commissioner /► �� r; 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS�PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Z D� D 3 Z _ . Property Address A,)G ?C)N Q AResidential Value of Work$ � .s Minimum fee of$35.00 for work upder$6000.00 Owner's Name&Address f\ Ate/OD s 6 L t �, Cam,,,' ,f 'o A o 3� eriv Nov,f,�-6 Contractor's Nam / Gt) elephone Number'�0 - Home improvement Contractor License#(if pplicable) /7,3ZyK Email: Construction Supervisor's License#(if applicable) 01s7 70 / �Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ' ❑ I am the Homeowner J4 I have Worker's Compensation Insurance Insurance Company Name dw&w- MU— Workman's Comp.Policy# !4jC/ /Z 7 y 6 D 3,.23( Al W x Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Res-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) ❑ Re-side Replacement Windows/doors/sliders.U-Value —3 0 (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. A cop f the Home Improvement Contractors License&Construction Supervisors License is equi T SIGNATURE: TAKEVIN Muilding ChangeslEXPRESS PERMDEXPRESS.doc _ Revised 061313 11''. r, � - R �p-y�.pp�`pP,�r� u fir_ ��.,,T - E.N kL A 4F�nJ NPei'Jei {�. 1�f�.C:ii:'1 Yi tlYL'ia.a &7 d d��4��1�� �eb�1 "� RN A' 2+0 AgWair.ktmdi - Unte;M,1U )200 � +�vrmLu+0; wwwsars aas�3�e+ssie► se±4��+r�+�e+�%r - P.hann 066,591.1233,-tin 4Cl'1.AU166it yr far,!er li+s rrtr lf:�welcwirn,lgww R oommid W hadoup p B. 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Fin!Awes i - - now M_h.A C@po Whitit, paper Cam:Y, +, f+yer C4W MAk ' Southern New England Windows d.b.a Renewal by Andersen of SNE 'Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Super%kor License: CS-095707 , 11♦ BRUN D DENMS_dN 7 LAMBS POND CIRCLE .Charlton MA 01507 t� Expiration Commissioner 09/08/2014 Office of Consumer A alrs n Asinessly'(1=01.non 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Registration: 173245 Type: Supplement Card SOUTHERN NEW ENGLAND WINDOWS LL Expiration: 9f19f2014 DENNISON BRIAN 1137 PARK EAST DRIVE WOONSOCKET,RI 02895 Update Address and return card Mark reason for change. i11 a za+a.+n 0 Address [j-Renmal i]Employment Lost Card mce ofConsamer Al43n B:.Budom Regatatioo I.Ieense or registration valid for indlvidul use only OME 11aPROYEr CONTRACTOR before the expiration date.If found return to: Office of Consumer Affairs and Business Regulation 6'0915 atlon: IM45 Typa: 10 Park Playa-Sulte 5170 Eaplratlon:1V19f20/4 Supptement Uard Boston,MA 02116 SOUTHERN NEW ENGLAND WINDOWS I.I.C. RENEWAL BY ANDERSON ER1AN 1137 PARK `\ _ 1 Ui PARK EAST DRIVE WOONSOCKET•RI 02895 Uodr—wry _ Not valid witho t signature - Client#:30124 SOUTNEW DATE(MM/DD/YYYY) ACORD. CERTIFICATE OF LIABILITY INSURANCE TE(MMDDN 8/06/2013 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 Anita Little NAME: Willis of New Jersey,Inc. PHONE g56 914-4660 FAX 856-914-1881 A/C No ut: A/C No 1015 Briggs Road,PO Box 5005 Ao AIL anita.little@willis.com PO Box 5005 Mount Laurel,NJ 08054 INSURER(S)AFFORDING COVERAGE NAIL# INSURER A:Selective Insurance Co of the S 39926 INSURED INSURER B:Argonaut Insurance Co. 19801 Southern New England Windows LLC INSURER C:Beacon Mutual Ins.Co. 24017 D/B/A Renewal by Andersen INSURER D 26 Albion Road INSURERS: Lincoln,RI 02865 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 CONTRACTOR 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. EXP LTR TYPE OF INSURANCE NSR WVD POLICY NUMBER ADDLSUBR MM/DDY/YYYY MM/DD YYY LIMITS A GENERAL LIABILITY S202945900 8/10/2013 08/10/2014 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea oceurrence $100 000 CLAIMS-MADE �OCCUR MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $3,000,000 GEN'LAGGREG ATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $3,000,000 POLICY ECOT LOC $ A AUTOMOBILE LIABILITY S202945900 8/10/2013 08/10/201 (CEO eBcINd..,)SINGLE LIMIT 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS - X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ . AUTOS Per accident A X UMBRELLA LIAB OCCUR S202945900 8/10/2013 08/10/2014 EACH OCCURRENCE $5 000 000 EXCESS LIAR HCLAIMS-MADE AGGREGATE s5,000,000 DED RETENTION$ $ C WORKERS COMPENSATION 0000068028-RI 8/21/2013 08/21/2014 X 1TWCRSyTLATUj, orH- AND EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNER/EXECUTIVE AIC927818352394 8/21/2013 08/21/2014 E.L.EACH ACCIDENT $1 000000 OFFICER/MEMBER EXCLUDED? N 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(Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION Southern NE LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 26 Albion Road ACCORDANCE WITH THE POLICY PROVISIONS. Lincoln,RI 02865 AUTHORIZED REPRESENTATIVE -------------------- e ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S215109/M215088, AXL -K The Commonwealth of 11lassachusetis Department of Ihd&u al Accidents Office of Invesagadons . c 600 Washington Street Boston,ILIA 02111 www massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Aliplicant Information Please Print LeQibl Name(Business/organization4ndividual): —V k42 LLL' Address: a bl Al 1O d City/State/Zip: I'A/CDIM Mgb5' Phone#: !/D/ ?yt)O Are you an employer?Check the appropriate box: Type of project(required): 1.1 I am a employer with A V 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- Iisted on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers'comp.insurance comp.insutartce.t g required.] S. F1 We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.Q 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 8 Z W/sidolp comp.insurance required.] 4,60 .'Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information t Homeowners who submit this affidavit indicating they arc doing all work and.then hire outside contractors must submit a new affidavit indicating su& 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 and job site information. /1 Insurance Company Name: SUrQittl 4 Policy#or Self-ins.Lie.#: I[ri ��7d ��3 Expiration Date: 9�44 / Job Site Address: 67 top& -Air � City/State/Zip: ao� �(P IPA-, 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby certi under the pains and penalties of perjury that tl:e information provided above ' iru and correct c LL Signature: Date: 2 9 /� Phone#: L-1b a-� � — 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.'Plum bing Inspector 6.Other, i Contact Person: Phone#: oFTHE Own of Barnstable *Permit# I :t Services Expires6m 'roiu issue date IARNSTA PERMIT Regulatory Fee SLE 9� ,6 9. 2 6 2010 Thomas F.Geiler,Director OF ,gS Building ]Division r SARfVST ��Tom Perry, CBO, Building Commissioner ' 200 Main Street,Hyannis,MA 02601 www.town.barnstab le.ma.us Office: 508-862-4038 Fax: 508-790-6230. EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number6;0' � Property Address .44 �'.4 esidential Value of Work Zle er Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address A Contractor's Name � � - _��g�G.�� �� Telephone Number Home Improvement Contractor License#(if applicable)/ Construction Supervisor's License#(if applicable) _511"- ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I prthe Homeowner have Worker's Compensation Insurance Insurance Company Name j,i /�.�// H Workman's Comp.Policy#_� Copy of Insurance.Compliance Certificate must accompany each permit. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping.'Going over existing layers of roof) ❑ Re-side ; #of doors ❑ Replacement Windows/doors/sliders..U-Value (maximum.44)#of windows *Where required: Issuance of.this pernrit 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: A✓�� Q:\WPFILES\FORMS\building pennit forms\EXPRESS.doc Revised 090809 Page 10 of 10 The Commonwealth of Massachusetts Department of Industrial Accidents j u Office of investigations 600 Washington Street Boston,MA 021I f r z� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Elecctricibers Pleas Print m Legibly Applicant Information 1 E S O n s i�oo-1-t N G-Tiv L Name(Business/OrganizationAndividual): P I— �2 2 e o`U 1 Address: a s City/State/Zip:Q S e (-V 1 Phone#: So& y 2g l 1 -1-7 F2. you an employer?Check the appropriate box: r6. ;;E] f project(required): I am a employer with ��— 4. ❑ I am a general contractor and 1 New construction employees(full and/or part-time).* have hired the sub-contractors Remodeling listed on the attached sheet x I am a sole proprietor or partner- These sub-contractors have 8_ []Demolition ship and have no employees workers' comp.insurance. working for me in any capacity. P 9. ❑Building addition [No workers' comp.insurance 5• ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their required.] i ht of exemption per MGL 1 I.[]I.[]Plumbing repairs or additions r 3.❑ I am a homeowner doing all work g , § 12.0 Roof repairs c. 152 1(4),and,we have no myself.[No workers comp. employees. o workers' insurance required.]t 13.❑Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. AContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policyinformation. 1 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.#: G�J� 419 �!?�76 { Expiration Date: �1D Job Site Address: City/State/Zip: ��A, ��'�!'�l' ,-•:a1 Attach a copy of the workers' comp sation policy declaration page(showing the policy number and expiration date) f% � Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a e form of a STOP WORK ORDER and a fine fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in th of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury. that the information provided above is true and correct. Date: Signature. Phone#: �(B ` 2 , rFoffichadl use only. Do not write in this area,to be completed by city or town official y or Town PermitlLicense# Is-suing Authority(circle one): ns 5.Plumbin inspector 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector ector g 6.Other Phone#: Contact Person- l Boao mg �egul ao s an a n ar s = One Ashburton Place = Room 13 01 Boston_ Massachusetts 02108 Dome Improvement&Co:ntractor Registration Registration: 103714 Type. Private Corporation Expiration: 7/9/2010 Tr# 269847 PAUL J. CAZEAULT & SONS, INC Paul Cazeault 1031 MAIN ST OSTERVILL-E, MA 02658 Update Address and return card.Mark reason for change. :-CAI a soon-07/07-PC8490 � Address. Renewal � Employment Lost Card .�/ p ze l�om�nw�uae¢LC/ a�✓�aa�.�zc�weeCl Board or Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date- If found return to: Registration- 103714 Board of Building Regulations and Standards Expiration:_-T/g/2010 Tr# 269847 One Ashburton Place Rm 1301 Ppvale Corpora don Boston, Ma. 02108 'AUL J.CAZEAULT&;SOWN& 'aul Cazeault • Massachusetts - Department of'Public Sat•etN UVBoard of Building Regulations and Standards Construction Supervisor License License: CS 26325 Restricted to: 00 PAULJ CAZEAULT 1031 MAIN ST OSTERVILLE, MA 02655 i i Expiration: 10/20/2011 ( unmiissi mrr Tr,,: 7088 tLiU rax server b/ 11/20U�3 12 : 59 : 08 PM PAGE 2/003 Fax Server ACORDM CERTIFICATE OF LIABILITY INSURANCE ���DATE/1MIDDIY08/11/2009 PRODUCER-(800)666-0200 FAX (781)261-1111 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eastern Insurance Group LLC - Commercial ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 77 Accord Park Drive HOLDER.THIS CERTIFICATE DOES,NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Unit 61 Norwell , MA, 02061 INSURERS AFFORDING COVERAGE NAIC# INSURED Paul 3 Cazeaul t & Sons Inc. - INSURER Al National Union Fire Ins Co PA 1031 Main Street INSURER S: Qsterville, MA 02655 INSURER C: INSURER,0: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES.DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DO' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSR DATE MMIDD/YY DATE MMIDDIYY GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED ES 1E CLAIMSMADE ❑OCCUR MED EXP(Any one person) $ PERSONAL 3ADV INJURY $ GENERAL AGGREGATE $ GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO . JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLELIMIT ANY AUTO - (Ea accident) $ ALL OWNED AUTOS - BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS $ NON-OWNED AUTOS BODILY INJURY- (Per.accident) . PROPERTY.DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR D CLAIMSMADE AGGREGATE - $ .DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC009757764 08/10/2009. 08/10/Zolo X TORY TAMTU- OTR EMPLOYERS'LIABILITY - JE A ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 10000 OFFICER/MEMBER EXCLUDED? 11 yes,describe under E.L.DISEASE-EA EMPLOYEE $ 10000 SPECIAL PROVISIONS below - E.L.DISEASE-POLICY LIMIT $ 50000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL O3O_DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. For Your Information - LRRo!n�ad ZED REPRESENTATIVE ��,,�� � Cleaves/REF1 L- "� ACORD 25(2001108) ©ACORD CORPORATION 1988 Property Owner Must Complete & Sign This Form If lasing a .Roofer ! Builder. 1 (print) tv _ q,-�u a Own r / Agent of the subject property hereby authorizes Paul J. Oazeault & Sons Roofing Inc. to act on my behalf, in all matters relative to work authorized by this building t permit application for: Address of Job 7 �0f 30'arcC� f�� ��-�z Signature of Owner �t Mailing Address of Owner O-e .'1. I;-e r v Telephone# .tea P r t7 0 + a )S� ®ate (Please return this form to Cazeault roofing along with your signed contract;.It is needed for us to obtain the building permit required by your town, to complete your roofing project, thank you) fax#508-420-4555