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(EKD 10W
Town.of Barnstable *Permit#
i Expires 6 months rom' ue
Regulatory Services Fee
• snxxsrABM
brass. $i639• Richard V.Scali,Director
��
AjEp�.iO
Building Division .
Tom Perry,CBO,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address 767
❑Residential Value_of Work \Minimum fee of$�35.00 for work under$6000.00
Owner-'s-NNan1e&A�ddress'"7�-_ J5, '��i^J✓lJ
CF
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable) Email: �p
Construction Supervisor's License#(if applicable) PRMS� PENORS MET-
]workman's Compensation Insurance
Check one: J U N -.4 2014
❑ I am a sole proprietor
(K)l am the Homeowner
❑ I have Worker's Compensation Insurance TOWN OF BARN3TARLE
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 to
VC
e-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
e-side
eplacement Windows/doors/sliders.U-V / S aximum.35)#of windows
a #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 Ho a Improvem nt Contractors License&Construction Supervisors License is
required. ,
'kSIGNATURE:_
Q:\WPFILES\FORMS\bu' ing permit forms\EXPRESS.doc
Revised 061313
The Commorrwealth of-Vassachuseft
D:leparwwnt of lirriustrial Accidents
- 0,Twe o•f Imertigaiiens
600 Waa-,irington.meet
Boston,MA 0211
wnw.mass:govldia
Workers' CctmpensationInsurance Lffidavit:BuildersfContractorsMec-triciansTlumbers
Applicant Information Please Print Legibly
1`Y,7I8 3]�`(�r��inY-- nip 'on/Ia]diyldpaj7: ✓���� �/V �J�`�/�/
�CitylStat�e zz— (�1�L � Phonie s 5 "
Are you an employer?Check the appropriate bGx: Type of project(required):
�4. I smi s contractor and I 3'Pe pT' 9
I.❑ I am a employer with ❑ i 6- ❑New construchoa
have) the sub-contractois.
employees{hill andlosgarttime *.
r
2._❑ I am a sore proprietor or partner-
listed on the attached sheet 7- ❑Remodeling
ship and have no employees These sub-contractors have8. ❑Demolition
^mac for me in an capacity- employees and have wodcers'
offing y insurance, 4_ El Building addition
[No workers'comp.insurance comp.
X3r
inired_]
5. ❑ We are a corporation and its 10..❑Electrical repairs or additions
m a homeowner doing all work officers have exercised their 11_❑Plumbing repairs or additions
€[No wcrlrets'gyp- rat.of exemption per MCL 12..❑Roof repairs
insurance required_]1 c_1.52,§1(4),and webmeno,
employees_[No workers' 1�_.❑Other .
Comp_insurance,re1uir�`J
*Airy anpEcaut that checks boa;rl musk also fM out the section below shooing their woden'compemsadiou policy iuRxn tio¢
T Homeowners who submit this aftidsvit im&catnxg they are doing sII rroac and then hhi-outside contractors mast sm mtit a mwr afdsvit ind rgtin such-
tGoutractors that check this box must attached an additions)sheet showing the name of the suit-wit and state whether or not those efities have
employees. if the sub-contractors have employees,the}tmrst prmade their workers'comp.policy number.
I am an employer Mat is prm ieing workers conzimnmuion imsu rancefor my eng9ayeea Below is fate paHi7 and job S&O
informatiart.
Insurance Company Name: '
Policy 4 or Self-ins-Uc- L: Expiration Date:
Job Site Address: TM CitylStatelzip: '
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 ofrrin inal penalties of a
fine up to S 1,500.00 andlor one yearimpris t,as well as civil penalties in the form of a STOP WORK ORDER.and a fine-
of up.to$2510-00 a_day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations,o€die DIA 5or invtrsrnce,coverage verification-
Ida here ra ttisp79=WCf1fPeqUrY thd�tthe ire,jbrmation prini&d abinr is and correct
Sit acute . r-D`iU;,— � / l
Off Ecial use only. Do not ifrite in this area:,to be completed by citrty or town oficiaL
City or Town: PermitUcense#
issuing Authority(drde one):
1.Board of Health 2.Building Department I Cityfown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone!#_
6
Information and. Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. I
Pursuantto this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or vzitten."
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 Iocal licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct bnildings in*the.comrnon;y'ealth xor any
applicant who has not produced acceptable evidence of conipliauce with the insurance.coverage required."
Additionally,MGL chapter 152 25C 7 states"Neither the commonwealth nor i i -
> anyof is o 'ti r d�P § h cal s b rvrsions shall
Y P
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-contrac`or(s)name(s), address(es)and phone number(s)along with their ceruifcate(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 1I
employees, a policy is required- Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance Coverage. AIso 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/licease number which will be used as a reference number, Ju 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 ilz (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:
v a
The Commonwealth of Massachu mitts
Depa-dme.at of Tndustdal,Accid(�n .
office of11we'stigatloxts
600 Washington Strut
Boston,IA 02111
Tel.A 617-727-49-00 W 406 or 1-4 MASWE
Fax 9 617-`27-7 749
Revised 4-24-07 -
www.mass-gnvfdia
Town of Barnstable
Regulatory Services
1HE tgcyti Richard V.Scali,Director F
Building Division
r +�
BARNSTA13M Tom Perry,Building Commissioner
MAsa
9Q� �639. 200 Main Street, Hyannis,MA 02601
ArEDI a www.town.barnstable.ma.us
Office: 568-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
1 -
JOB LOCATION:" 126 l5�� ), 1_4A r y. all-
number,^ street p village
"HOMEOWNER �J /r'�/ �G owlq-7/-o(�15 -
- name home phone# work phone#
�-ADDRrs 74/ �2.
CUR-R:ENT,�NIAILING'ADDRESS: _ ``�A, �+ ?
r yl /r' d 2—
�t
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides.or intends to reside,on which there is,or is intended to be,a one or two-
family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form
acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section
109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws,rules and regulations. _
e under 'gned"homeo er"certi that he/she understands the Town of Barnstable Building Department minimum inspection
procedures and re qu' s a the/she will comply with said procedures and requirements.
Srgna re f Homeowner'
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required'to comply with the State Building Code
Section 127.0 Construction Control. '
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt
from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner
engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor
(see Appendix Q,Rules &Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often
results in serious problems, particularly when the homeowner hires unlicensed persons. In this case,our Board cannot
proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is
ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the
permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page
of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in
your community.
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 061313
BARNSTABLK «
' ,� Town of Barnstable
pTFD MP'�a
Regulatory Services
Richard V.Scali,Director
Building Division
Thomas Perry,CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601
• , r • '� www.town.barnstable.ma:us•
F
Office: 508-862-4038 =�� �;` j '..' ` t,.:' Fax: 508-790-6230
Property Owner Must,a t 3 +
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for: r
y
(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.
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 061313
�� aK g f z3�13
Town of Barnstable *Permit it Q ��
Regulatory Services EVE 6mo h i'ss
g rY
MIT Thomas F.Geiler,Director
1� Building Division
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
TQWWSP:F-5 -AkI- 038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number, ` V /'V,�'
Property Address �.� s - 15)/ 4 AP, - (.1'�/C� �"1 C �/�
❑Residential Value of Work T 8ig d Mi jnim�fee of$35.00 for work under$6000 00
Owner's Name&Address 1' �2
Contractor's Name Telephone Numb r_ ` ` (0
Home Improvement Contractor License#(if applicable) Email:
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
,�-❑ am a sole proprietor
am the Homeowner _
❑ Lhave Worker's Compensation Insurance --
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Re ueft_(check box)
�t Re-roof(hurricane nailed)'(stripping old-shingles) All construction debris will be taken to lti lJ $'R
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red Sand 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 ign Property Owner Letter of Permission.
A copy of a Hom prove ent Contractors License&Construction Supervisors License is
�—...
require
SIGNA °
Q:IWPFILESTORMS\b lding permit forms\FJPRESS.doc
Revised 060513
Emait.
Rw
' 1
Town of Barnstable
Regulatory Services
ABS.�R ' Thomas F.Geiler,Director
ta,+as ..�. - .
Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.b arnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
1,71Z,---
Please Print
DATE: 4kl
JOBWCATION:
`number street village
"HOMEOWNER": �OL (hA)
�� r
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-
family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form
acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section
109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws,rules and regulations.
Th undersigned"ho owner" ifies that he/she understands the Town of Barnstable Building Department minimum inspection
pro edures and m d that he/she will comply with said procedures and requirements.
Si atumofHomeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code
Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt
from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner
engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor
(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often
results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot
proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is
ultimately responsible..
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the
permit*application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page
of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in.
your community.
C:\Users\dwoll&\AppData\LocallMierosoft\windows\Temporuy Internet Files\ContentOudook\QRE6ZUBNIE2RFSS.doc
Revised 053012
Town of Barnstable
°* Regulatory Services
s Thomas F.Geiler,Director
1659. Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must ` °z
,y.
- - Complete and Sign This Section
�� i w
If Using A Builder47
J r
Z
as Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit
(Address of Job)
**Pool-fences and alarms are the responsibility of the4applicant. 'Pools-
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
Signature of Owner ' Signature of Applicant
Print Name Print Name
Date
Q:FORMS:OWNERPERMISSIONPOOL•S 6/2012
4
ne Com)no9f wd&Uf aSStic&us&f
.DDepartnrnt of 1'ti&utrit Accidents
ofImvestigations
' 690 Washington Street
Boston,MA 0211
wn*r anaamgoVdia
Workers'Compensation IummanceAffidavit:B1ilderslContractors/FAectricianMumbers
Applicant Information 4 Please Print . 'b
Name(BusmeaslOrgsnizatiamfIrc�vidnal): JF_-5 -AQ �` �'LJ
-City/Statef - l94:2G3 a. Phone i�-
Are :i7N
employer?Check the appropriate box: Type of project(requimd):
I= I employer with ,,,,��,,.� --qq 4. ❑I am a general contractor and 1 6. ❑New constaxtion
employees(fin andlb(� havehired.the
2-El am a sole proprietor or partner- listed on the attached sheet ?- El Remodeling
ship and bate no employees These sub-contractors have 8: ❑Demolition
to and have workers'
. �ivodzag forme in any capacity_ employees 9_ ❑Building addition'
[No work , Camp_hLgIU re Comp-insuranml
mod] 5. ❑ We are a corporatic nand its 10-0 Electrical repairs or additions
3`�I am a homeowner doing all wofk officers have exercised their 11-0 Plumbing repairs or additions
`myself[No worloers'camp- right.of exTmption per MGL MO Roof
istsurazlc repairs
e r=goired]T c.152.kl(4} andvehaveno-
13_❑Other
employees-[No workers'
comp msorance required-]
;prayapp}i ntthatchedcsboz91tmstalsoMc=tf�esectionbelowsLowingtteavrade:Waompeasafionpoliyinfa
Snmeoaners vrho subnut this affodnd mfficstkg they are doing al uuk sad&ea hue outside conuuctnn— submit a w,;off davit md'usting=IL
cmrs ibm check this boot mast soothed au additional sheet shuRiag the name of&c satr-emiftsmocs and Stda whether ornat these Mfitks have
anployen Ifthe sab•rnatcactats base employees,&ey must provide their warkes'Comp.pOHCy`maaber-
I am an employer thatisprafh&g"wrkem'cont,{m?mu'ion insurance for irzy etrgrlayees Bekw is fllepauq and job site
informatiart.
Insurance CompwyName:
Policy#or self-ins Lic.#: Expiration Date:
Job Site Address: . City/StaterMp-
A#ach a copy of the workers'compeasatfim policy dedaratiou page(showing the policy number and expfration date).
Failure to secure coycrage as required under Section 25A o€MGL c. 152 can lead to the imposition of criminal pr=ualties of a
fine up to S1,500.Oa and/or one-yearimprisonment as well as civil penalties i n the form of a STOP tORS ORDER and a fine .
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to,the Office of
Investigations of fhe DIA for insurance coverage veri$cation.
I do here c jyreirder th inj iPdjZT!qffafpedm7 that the informdian proszded ab is and rrec
SiEnalure. - - _Date:
Phone#:
Q;f�Rid are only: Do not write in this area,to be completed by city or town O ciaL
City or Town: PerrmtlLicense#
Issuing Authority(circle one):
1.Board of Health 3.Building Department 3.Ciiylrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
6
A
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 budding 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 in min ce
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 numbers)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 ins -mce. 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 pennit,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 pennitllicense 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 Comm vmgth of Massachusetts•
Dega-rimmt of Industrial Accidents
• Office of lmvestipfiGns
600 Wash V91L Street
BQAGn,MA 02111
Ta 617-727-4900 W 406 or 1477 MASSAFE
Fax#617-727-7749
Revised 4-24-07 www-mass.gov/dia
.� =0881210)120i
YYY)
CERTIFICATE OF LIABILITY INSURANCE
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
CERTIFICATE DOESNO HOLDER.
A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
IMPORTANT: ff the Cottificate holder is an ADDITIONAL. INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED:subject to
the terms and conditions of the policy,certaln policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder In lieu of such endoraement(s).
PRODUCER 04740-001 CONT/1CT -
(60B)775-1620 I�c.Nv.:
Miller McCartln
973 lyannough Road �"6ss
Hyannis,MA 02601
A.I.M.Mutual Insurance Compan 33758
INSURED
Jesse Van Fosaen
75 Thistle Dr
Centerville,MA 02632
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS is TO CNOTWITHSHTAANDING ANY REQUIREMENT,INSURANCE
TERM OR CONDITION OF ANY COBEEN ED BELOW HAVENTRACT OED TO R OTHER DOCUMENT WITFIINSURED NAMED ER RESPECT TO POLICY FOR THE PERIOD
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.
POLICY NUMBER M(�71D0 LIMITS
IITR TYPE OF INSURANCE
EACH OCCURRENCE S
GENERAL LIABILITY DAMAGE TO RENTEO
COMMERCIAL GENERAL LIABILITY S/Fe o e porn S
CLAIMS-MADE ❑OCCUR _PERSONAL oneperson)L4ADVINJURY S
GENERALAGGREGATE
PRODUCTS-COMP/OP AGG t
EN'L AGGREGATE LIMIT APPLIES PER:
OLICY RO OC
ECT C NED BINGL I IT S
AUTOMOBILE LIABILITY
BODILY INJURY(Per peravn) i
ANY AUTO
ALL WNED SCHEDULED BODILY INJURY(per ecclaent) S
OAUTOS
NON OWNED PR ERTY OA $
VIREO AUTOS (Per acdderM
AUTOS
S
EACH OCCURRENCE $
UMBRELLA LIAR OCCUR
ExCESS LIAB CLAIMS MADE AGGREGATE $
S
DED RETENTION 8 y�gT
n�� 1���, 1s ITl4�r X 7pply l ll� °�T'
p NN ECUTIVE E.L.EACH ACCIDENT 8 100,000.00
A °d' IC PM` F��� u6�` i` NE NIA AWC-400-7025726-2013A 4/1/2013 4/112014 E L DISEASE-EA EMPLOYEE s 100,000.00
(Mandatory In NH)691�9IPTRA of 5PERATIONS below E.L.DISEASE-POLICY LIMIT E 500,000.00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,AEAIIIonal Remarks Schvdvle,If more tipaGO Is requlrad),
Van Fossen Jesse Is covered by the workers compensation policy.
CERTIFICATE HOLDER CANCELLATION
Town Of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
200 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Hyannis,MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED RlPR69ENTATIVE
(P198 -2010 ACORD COR ORATIO It rights reserved.
ACORD 2512010/06) The ACORD name and logo are registered marks of ACORD
l/l 'd 0610 'ON 30NVUSNI fliVIDOM Wd1E :01 E[06 ,06 'DNd