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HomeMy WebLinkAbout5026 FALMOUTH ROAD/RTE 28 S6 2l� -a► �nnoviln �-na� - � _ —� I I f Subject: From: sobrien8@babson.edu To: shawnobrien411@yahoo.com Date: Thursday, September 27, 2018 12:06:39 PM EDT y, u kE W1,401 � k� �p T �` y W L �y g ,.. Shawna 3 O'Brien Babson College I Class of 2019 Campus Box `1473 (508) 269-0305 I sobrien8Cclbabson.edu Act CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDOIYYYY) 01/10/2018 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: Erica Morin SULLIVAN GARRITY& DONNELLY INSURANCE AGENCY INC a"co No EXt: (508)453-2514 FAX No: E-MAIL erica.morin s dins.com ADDRESS: C 9 10 INSTITUTE RD INSURERS AFFORDING COVERAGE NAIC# WORCESTER MA 01609 _ INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER B: BOYSON STEPHEN INSURERC: INSURER D: 15 WINDMILL WAY INSURER E: SOUTH DENNIS MA 02660 INSURERF: COVERAGES CERTIFICATE NUMBER: 228643 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR TYPE OF INSURANCE ADDLISUBR POLICY EFF POLICY EXP LIMITS LTR I POLICY NUMBER MMIDDIYYYY MM/DDIYYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS-MADE J OCCUR DAMAGE TO RENTED I PREMISES Ea occurrence S ( MED EXP(Any one person) S i N/A - PERSONAL&ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: i - GENERAL AGGREGATE S POLICY u PRO- I LOC I PRODUCTS-COMP/OP AGG S JECT OTHER: $ AUTOMOBILE LIABILITY - 1 COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) S NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTIONS �/ S WORKERS COMPENSATION X I STATUTE ORH AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE YIN - E.L.EACH ACCIDENT S 500,000 A OFFICE WMEMBEREXCLUDED? N/A NIA N/A 6HUB2E92415117 10/29/2017 10/29/2018 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I S 500,000 N/A 7 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe 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/lwd/workers-compensation/investigations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Dennis ACCORDANCE WITH THE POLICY PROVISIONS. Po Box 2060 AUTHORIZED REPRESENTATIVE South Dennis MA 02660 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserves. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD XAgg. Permit Fee.......................................Other Fee ...................... ��►LDING DEPt 1 S 9' ToW Fee Paid................ . .................................... O(,0 }' TOWN OF B ermrt by ��A�L g.. .... ........... ..:on.::.018 ... P .......... ......... BUILDING PERMIT �.--..... .6as.......................-- ............ ....Parcel..... APPLICATION Section I- Owner's Information and Project Location Project Address �- e /�� Village �ini7 Owners Name L.04.2 Qd f-U,1✓ Owners Legal Address /Z V Cm, State _ P 0/—G Owners Cell E-mail /Section 2—.Use of Structure Use Group ❑ Commercial Structure over 35,000 cubic feet { • ;` ; ❑ Commercial`S=cd=under 35,000 cubic feet Single/Two Family Dwelling Section 3—Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory s ructure'� ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement. ❑ Family/Amnesty ElFire Alarm Rebuild ❑ Deck Apartment ❑ Sprinkler System ❑ Addition ❑ Relaining'wall ❑' Solar ❑ Renovation ❑ Pool ` `❑ Insulation Other—Specify Section 4 -Work Description FU T R.qt nndate&219/2019 Application Number.................................................... Section 5-Detail Cost of Proposed Construction f`Z, n o Square Footage of Project Age of Structure 4.k(A I Dig Safe Number #Of Bedrooms Existing Total#Of Bedrooms(proposed) . 3 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklistt Design Section 6—Project Specifics ❑ Wince ❑ Oil Tank Storage . ❑ Smoke Detectors ❑ Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System I ❑ .Masonry Chimney ❑Add/relocate bedroom Water Supply, f ❑ Public Private Sewage Disposal ❑ Municipal Jrsk On Site Historic District " ❑ . Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility:t �w{� c �a�A- I am using a crane ❑ Yes No Section 7-Flood Zone Flood Zone Designation Within or adjacent to a wetland,coastal bank? Yes ❑ No Section 8—Zoning Information Zoning District Proposed Use 2 Lot Area Sq.Ft. f Total Frontage Xaa Percentage of Lot Coverage #of Dwelling Units (on site), Setbacks Front Yard Required. UG Proposed Rear Yard Required C Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No Last uDdated:n/2018 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations IF 600 Washington Street Boston,MA 02111 , www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information yam° Please Print Legibly Name(Business/Organization/Individual): �� J A/ O cy ,f c-ju Address: !.t/k014II City/State/Zip: A.Piw it S Phone# 7 Y if36 - 615- Are you an employer?Check the appropriate box: Type of project(required): 1.0 lam a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.Xship I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling and have no employees These sub-contractors have' g, '❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance 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 d h z 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 and job site information. '++Insurance Company Name: dc-e�4 rr7 &//1 Policy#or Self-ins.Lie.#: U z, Expiration Date:lb Job Site Address: 6­6 2-G City/State/Zip: yf 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 c fy un he p ' and penalties of perjury that the information provided above is true and correct Signafore: Date: Z L Phone#: P00` 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.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." 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 446 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 www.mam.gov/dia Application Number............................................ Section 9—:Construction Supervisor Telephone Number Address t'S GtJl1014 t C L UAICity 's State zip U to D License Number C-5 Q5 i'(f License Type 5iocA sir Expiration Date l`( 1 Z 2 01 Q Contractors Email Cell# 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 by 780 CUR and own of Barnstable.Attach a copy of your license. Signature A Date Section-10—Home Improvement Contractor N I/ I� C� ! U�' Telephone Number Address �s wr , il � Cit3' ;�ci%S State Tip �� G(00 Registration Number Expiration Date Z 2' I understand my responsibilities under the rules and re ' ns for Home Improvement Contractors in accordance with 780 CUR the Massachusetts State Building Code. I fire construction inspection procedures,specific inspections and documentation required by 780 CUR and the T of Barnstable.Attach a copy of your HZC... Signature Date L4,A� Section 11—Home Owners License Exemption Hom ,Owners Name: Telep one Numb Cello ork Number ' I undm d my re ib ' es under the s and re Licensed Co 'on ervisor in accordance with 780 '\ CMR Mass ach State uilding . I the onstruction' ection pro dines,specific inspections and do on by 78 CMR Town Bamstab . Si Date APPLICANT SIGNATURE Signature Datej 2 G Print Name_STk y1f_- i�o VS ahi Telephone Number 7?V e3,� - 4" E-mail permit to:�­7dvkJOi T Itmnmo r Section 12 —Department Sign-Offs Health Department ® Zoning Board(if required) El Historic District ❑ Site Plan Review(if required) ❑ Fire Department Conservation ` ❑ For commercial work please take your plans directly to the fire deparonent for approval Section 13—Owner's Authorization L as Owner of the-subject property hereby authorize ( �Scr to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of job) Signature of Owner. ` date 5W)ky J Print Name t Last wdetc&192018