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HomeMy WebLinkAbout0675 MAIN STREET (COTUIT) (8) �v'7 f� ma-In S'�, Gen �7L �9- Town of Barnstable BUlldlil 'z .�,wd', • �� . r - PosLwThis Card So That rtis Usable Fromhe"Street A roved"PlansRMust be.;Retamedon;Job=and this CartlM s beKe t .",' • DAhNB'CABLB ' .'� �"�a" y::""ram ,, � 3,:', �,�a rr� ✓ ��,_., �2�: �`r _'.'sue s" • 6" Po`stedUnt�l Finallnspection Has Been Made �� "` _ . ^ Where a Certificate of Occu anc ">Is Re u�red such°Buldm sMall`Not be Occu ied�unt�l a�F nalIns ection has been made Permit gip_ . Y . .�4�„�.�' „g P p ��� - Permit NO. B-16-2045 Applicant Name: DANIEL MCGRATH Map/Lot: 036-015 Date Issued: 08/25/2016 Current Use: Zoning District: Permit Type: Building-Addition/Alteration-Residential ' Expiration Date: 02/25/2017 Contractor Name: DANIEL MCGRATH Location: 675 A2MAIN STREET(COTUIT),COTUIT -, Est. Project Cost: $50,000.00 Contractor License: CS-107897 Owner on Record: PLM BUZZY LLC v Permit Fee ,4. $255.00 Address: 120 EAST AVENUE,3RD FLOOR € Fee Paid $255.00 ROCHESTER, NY 14610 Date: 8/25/2016 Description: . FIT OUT OF UNIT A-2 BUILDING#1 TWO BEDROOMS 2 1/2 BATHS Project Review Req : FIT OUT OF UNIT A-2 BUILDING#1 TWO BEDROOMS,2 1/2 BATHS S � T Building Official This permit shall be deemed abandoned and invalid unless the work authorized by this permit's commenced within six months after issuance. All work authorized by this permit shall conform to the approved application andtheappro�edconstr"action documentsfor which this permit has been granted. ;, �f All construction,alterations and changes of use of any building and structures.shall be"in compliance With theslocal zoning b"taws,and codes. 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 work until the completion of the same. 3 The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided onthis permit. ' Minimum of Five Call Inspections Required for All Construction Work: ', 1.Foundation or Footing61 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before fir est flue limngais installed �a�` 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation 7.final Inspection before Occupancy Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. 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). Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel O 15 Application Health Division � � Date Issued r r Conservation Division a ��� oro Application F/ J Planning Dept. � �" Permit Fee Date Definitive Plan Approved by Planning Board U Historic - OKH _ Preservation/ Hyannjoollo Project Street Address i� 75- A - ,aiYA Village l.b+() Owner !P L, M Bu-7, L,t--�i Addres,°604 e/Mu Jig LA4,�� Telephone $- 776 Permit Request �i�- 000 rJ- (A )a ... ( -20 Beef rar)Mn c �Z �iL� ►'f Square feet: 1 st floor: existing proposed 11,20 2nd floor: existing proposed 02 Total new Zoning District Flood Plain Groundwater Overlay . Project Valuation Construction Type �r�n.i� Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: XFull ❑ Crawl ❑�W^aallkout ❑ Other Basement Finished Area (sq.ft.) -- Basement Unfinished Area (sq.ft) /12n) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existinglilnew Total Room Count (not including baths): existing new First Floor Room Count Z Heat Type and Fuel: Gas ❑ Oil ❑ Electric ❑ Other Central Air: )(Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing Xnew si74 Shed: ❑ existing ❑ new size — Other: 3 Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name D b -R) Telephone Number 70 776 - 7-S- ?7 Address 31,2 CQrnQ �5+ License # CS ' / o 7 ,9 97 tA)• \IQ 12 0016,TS Home Improvement Contractor# 1_ 1 Email C �� �t&A Ut/�orker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO c SIGNATURE DATE -7 15rl 1 ; ' FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER f + f , DATE OF INSPECTION: FOUNDATION r FRAME ,, INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL G9S: ROUGH FINAL X �j II P\ FINAL BUILDING IG�i � � � V DATE CLOSED OUT ASSOCIATION PLAN NO. 1� • TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel (��� Application # Health Division_ Date Issued _ Conservation Division Application Fee 03 Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address 1. - m a l e') Village_ eafu,+ Owner P L M Bu`LZ�.N ��,..[�, Address 0 Telephone .�Off' 7 7 6 `/1�3 610 Permit Request 4 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed "" Total new I ill Zoning District Flood Plain Groundwater Overlay Project Valuation DOW Construction Type 4,,IC Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting'docu- entation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) x Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: �Q Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) /12C1 Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: V Gas ❑ Oil ❑ Electric ❑ Other Central Air: �d Yes ❑ No Fireplaces: Existing New Gas Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ c(xlq Attached garage: ❑ existing 29 new s1ze _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION -_ (BUILDER­OR HOMEOWNER) Name Ni l (6f4- Telephone Number (��� 77�0_ �s 7 7 Address 30 C iv)® 6-1 License # QS - rig 7 WPSi- 1 Q T it � � Home Improvement Contractor# Email ' 6 M 6A- n t/,O(,70Q , kJt4— Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE r FOR OFFICIAL USE ONLY APPLICATION# r .DATE ISSUED MAP/PARCELNO. 1 • E ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL ' r FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 27te Commomveakh gfMaysadtrtsetts Department&f1ndus&ia1Accide7dg BUILDING 1 r-^7- lifOff we of Fir s4afiom s©o Washington Street AUG 0 4 2015 Boston,CIA 02M . iPnnv.mas�gvv1dia TOWN OF BAhi ,,�JBLE Workers' ConupensaffimIusuranceAffidavit:B:ud ders/CaniractarsXlecfaicians/Plumbers Applicant Information Please Print LeerlTv Are you an employer?Check a appropriate bom Type of project(required): I.❑ I am a employer with 4 I am a general coufmctar and I employees(full ar�dfor part-ime). * havehiredthe sub-co�actm 6. New 2.❑ I am a so•Ie prapdetm orpartner- listed auntie attached sheet. 7. ❑Remodeling ship and have no emplzyees These sib-contrac#oss have g- ❑Demolition. waddng forme in any capacity. employees and lm�e warms' JNo ,comp.;i,s�,ce camp.n,sura,m l 9. El Building addition required-] 5. ❑ We are a corporafim and its 16- Electrical repairs or additions 3.ElI am.a bameov«et doing all work officers have e=dsed their 1L0 Plumbiagrepairs or additions myself[No waif' - right of ememgfion per MGL -- c 1 andwehaveno ❑Roofrepairs employees.[No woAoe& 13.❑Other comp-k=an m tee&] 'Any gy5cs�Hsat checJmbos R mast also Moaf the secfianbeIawshofii their wor3cere cmnpensaliaapo&Lg it ffiaMz iaa #Sameawnera who sab=dt Ails dEd2v i g they sin doing ag wa k Mma then ham ou caatmc * amst suhmk a new 2Mdzvi iadietino such- fCautcaLsnrsIEW theirthis boa nmst sasdditimal sheet showing theneeof the sub cao�c�rss ffid stare tvhe2hec ornotthose entitiesbme emplayems.Tftbemilb-c taadocshase emgla s,d2eyxnusrgms�de tiueir ems°romp•palicg aumiser_ .Tam ara e1rcPar Heat isprenzdirrg ic�orkeis'canrrsativrt utsrirace jar act earplvy�ee� Betviv is tJtspatic}�artd joh sits inforrRa om Insurance Company Name: 'Policy 41.or Self -ias.I.ic.;g.`_ 1xpiudonDate- Job Site tlddress= Csty/Stafamp: Attach a copy of the workers'compensationpolicy declaration page(showing the poRcy,number and expiration date). Failure to secure coverage as required under Section 25A of M(M c�152 can lead to the imposition of criminal penalties of a fine up to$L,50U OD andfor one-yearimpprison==#,as weal as ciud penalties in the fora of a STQP WORK ORDERand a fine of up to$250-DO a dap against the violator. Be adsised tint a copy of this statement=ay be fx vnded to the office of IQvestrgations offiie DIA far insurance coverapp vedficati I•arro h csrtai under ttt� d n Q atAa informa6mpra i&dabmv is true and correct iosa�frcrp- Date: 2 Phone ik 0,,07ciid use wr£J. Do rust write in fds area,tic be coutpTeted by city artaen a,,�al City or'Pasta: Permiffiicense;ff Lwxing Asflmrity(drde one): L Board of Health r.Buffiling Dqm meat 3.Chyfrown Clerk d.Electrical inspector 5.Plumbiaa Inspector 6.Other Coact Person: Phow t: -- 6 �1 ® ; ^�o CERTIFICATE OF LIABILITY INSURANCE ��( �6/9/)15 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: Donald J. Medeiros Insurance A 508 678-1271 No): (774) 365-6552 154 Rhode Island Ave PHONEADDRESS: don@donmedeirosinsurance.com Fall River, MA 02724 INSURE S AFFORDING COVERAGE NAIC# INSURER A:American European Insurance INSURED INSURERB:Safety Indemnit Edgar Mauricio Agudo Ortiz INSURER c:Liberty Mutual dba Ecuamerica Construction II INSURER0: 39 Seymour Street INSURER E: Berkley, MA 02779 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MIDDIY M I/DD/YYYY LIMITS A GENERAL LIABILITY SKP2000957 10 4/23/15 4/23/16 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENE RAL LIAB ILITY DAMAGE occED P (Fa oca MUSES(Ea imence)_ $ lOO OOO CLAIMS-MADE F_x1 OCCUR MED EXP(Arryone person) $ 5,000 PERSONAL&ADVINJURY I$ 1,000,000 GENERAL AGGREGATE I $ 2,000,000 GENTAGGREGATE LIMITAPPLIES PER PRODUCTS-CO MP/OP AGG $ 2,000,006 7}[ POLICY PRCT LOC $ AUTOMOBILE dDSINGLELIM B 6223581 COTiH $ 1,0001000 ANYAUTO BODILY INJURY(Per person) $ ALL O WNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIREDAUTOS X AUTOS eraccident I $ UMBRELLA LIAB OCCUR I EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MAD AGGREGATE I$ DED RETENTION$ $ C WORKERS COMPENSATION WC231S372831 5/5/15 5/5/16 X WCSTAI'MTU- OTH- AND EMPLOYERS'LIABILITY IR ANY PROPRIETOR/PARTNER/EXECUTNE Y/N E.L.EACH ACODENT ! $ 500,000 OFFICER/MEMBER EXCLUDED? NJ A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE!$ 500,000 If yyes,describe under DESCRIPTIONOFOPERATIONSbelow E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Sdredule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Residential Management INC ACCORDANCE WITH THE POLICY PROVISIONS. PLM Buzzy LLC 2604 Elmwood Ave Suite 352 AUTHORED RE PRESENTATIVE Rochester, NY 14618 Heather Williamson ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: ACO® DATE(MMIDDIYYYY) `� CERTIFICATE OF LIABILITY INSURANCE F10/16/2015 E(MWD 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 endorsements. PRODUCER NAMEACT Kelly Sel The Driscoll Agency, Inc. PHONE 781 421 2490 FAQ N :781 421 2491 93 Longwater Circle EAI ,- Norwell MA 02061 AD%Rfiss,kseip@ddscollagency.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:HDI-Gerling America Ins Co 41343 INSURED 218590 INSURER B:Navigators Insurance Company _ KOBO Utility Construction Corp_ INSURERc:The Charter Oak Fire Ins Co 25615 4 Victory Drive P.O.Box 578 INSURER D Sandwich MA 02563 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1697556991 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�TRR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF MM/DDY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EGGCC000107815 10/1/2015 10/1/2016 EACH OCCURRENCE $2,000,000 CLAIMS-MADE �X PREMIOCCUR DAMAGE (RENTED PREMISESS Eaoxurrence $100,000 MED EXP(Any one person) $excluded PERSONAL&ADV INJURY $2,600,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2,000,000 POLICY�PRO- CT 17 LOC PRODUCTS-COMP/OPAGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY EAGCC000107815 10/1l2015 10/1/2016 COMBINED SINGLE LIMIT $ Ea accident 1,000,000 X ANY ALTO BODILY INJURY(Per person) $ ALL OSV�MIEO SCHEDULED AUTOS A BODILY INJURY(Per accident) $ X HIRED AUTOS Ix NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident A UMBRELLA LIAB X OCCUR EXAGCOOD107815 10/1/2015 10/l/2016 EACH OCCURRENCE $10,000,000 B X EXCESS LIAB NY15EXC7901951V 10/1/2015 10/1/2016 CLAIMS-MADE AGGREGATE $10,000,000 DED X RETENTION$0 $ A WORKERS COMPENSATION EWGCC000107815 10/1/2015 10/1/2016 PER (OTH- AND EMPLOYERS'LIABILITY Y/N XSTATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEd$1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$1,000,000 =onlractors Equipmment QT6606B268829COF15 10/1/2015 10/1/2016 Special Formw/Theft 2,160,412 Floater Install Ea jobsite 450,000 ted equip Leased/rented 250,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE:671 Cotuit Road Residential Management Inc &PLM Buzzy Inc.Are included as Additional Insured for Automobile Liability on a Primary Basis for the conduct of the(Named)Insured, but only to the extent of that liability. See Attached... CERTIFICATE HOLDER CANCELLATION 30 Days except 10 days for nonpaymen SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Residential Management Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 120 East Ave Rochester NY 14604 AUTHORIZED REPRESENTATIVE f ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD THIS CERTIFICATE SUPERSEDES PREVIOUSLY ISSUED CERTIFICATE AGENCY CUSTOMER ID: 218590 LOC#: A�o ADDITIONAL REMARKS SCHEDULE Page, of 1 AGENCY NAMEDINSURED The Driscoll Agency, Inc. KOBO Utility Construction Corp. POLICY NUMBER 4 Victory Drive - P.O.Box 578 Sandwich MA 02563 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Residential Management Inc &PLM Buzzy Inc.are included as Additional Insured for General Liability and Excess(Umbrella)Liability,for ongoing and completed operations,as required by a signed written contract or agreement with the Named Insured. The Additional Insured coverage for General Liability&Excess(Umbrella)Liability detailed above applies on a primary,non-contributory basis where required by a signed written contract or agreement with the Named Insured. The General Liability,Excess(Umbrella)Liability,Automobile Liability,and Workers Compensation/Employers Liability Policies include a Waiver of Subrogation in favor of Residential Management Inc &PLM Buzzy Inc.on whose behalf the Insured is required to obtain this Waiver under a written contract or agreement executed prior to a loss. Notice of Cancellation provision is 30 days except 10 days applies for non-payment of premium. ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD A CERTIFICATE OF LIABILITY INSURANCE 6/3i2015 YY) 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 terns 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 Karen Bernier NAME: Southeastern Insurance Agency, Inc. PHONE (508)997-6061 F (508)990-2731 439 State Rd. EAI -ML .kbernier@>southeasternins.com P.O. BOX 79398 INSURERS AFFORDING COVERAGE NAIC w North Dartmouth MA 02747 INSURERA:Arbella Protection Insurance 41360 INSURED INSURER 8 R J Bevilacqua Construction Corp. INSURERC: P. O. BOX 628 INSURERD: INSURER E: Forestdale MA 02644 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1542700879 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. ILTR TYPE OF INSURANCE A L U POLICY NUMBER MMK)DY MM/oOrcEri LIMITS GENERAL LIABILITY EACH OCCURRENCE _$ 1,000,000 ACE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMIS occurrence) $ 300,000 A CLAIMS-MADE 7XOCCUR 8500018147 /15/2014 /15/2015 MED EXP(Any one person) $ 5,000 X XCU Included PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 X POLICY X PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 11000,000 ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED 020014548 /21/2015 /21/2016 AUTOS N AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOSNON-OWNED PROPERTY DAMAGE P $ AUTOS Uninsured motorist8l spUtlimll $ 250,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 14DED I X I RETENTIONS 10,OOC 4600062061 /15/2014 /15/2015 $ A WORKERS COMPENSATION X WC STATU- I X OTH- AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETORIPARTNER/EXECUTIVE E L_EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? NIA (Mandatory in NH) 088680414 /27/2015 /27/2016 ElDISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Project: 671 Main St, Cotuit, MA Email to: Danno.McGrath@verizon.net and MLuttrell@dhdventures.com CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN DfID Ventures ACCORDANCE WITH THE POLICY PROVISIONS. 2604 Elmwood Avenue Roches ter, NY AUTHORIZED REPRESENTATIVE Karen Bernier/KM fj J/v ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005)01 The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE . DATE(MMIDDNYYY) 104/29/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PAUL SCHLEGEL SCHLEGEL INSURANCE BROKERS INC PHONE 508-771-8381 FAX 508-771-0663 (AIC,No,Eat): (A/C,No). 34 MAIN STREET E-MAIL --�-- ADDRESS: SCHLEGELINSURANCE@GMAIL.COM _ WEST YARMOUTH MA 02673 INSURER(S)AFFORDING COVERAGE NAIC0 INSURERA:NGM INSURANCE COMPANY 14788 INSURED INSURERB:NGM INSURANCE COMPANY 14788 Gary Matsik Dba Matsik Concrete INsuRERc:NGM INSURANCE COMPANY 14788 185 Barcliff Road INSURERD:NGM INSURANCE COMPANY 14788 INSURER E: Chatham, MA 02633 INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDPOLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (Move- 'Y) (MM/D0lYYYY) LIMITS A GENERAL LIABILITY I MPT0076H 01/22/2015i01/22/20161 EACH OCCURRENCE S 1,000,000 AM�GETiRENTED— X COMMERCIAL GENERAL�LIABILITY PREMISE S(Ea occurrence) S 500,000 CLAIMS-MADE x OCCUR I MED EXP(Any one person) —}$ 10,000 I _ I PERSONAL 8 ADV INJURY S 1,000,000 (IL--- GENERAL AGGREGATE 5 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG 5 2,000,000 POLICY JEC n LOC I $ BINFO SINGLE LIMIT B AUTOMOBILE LIABILITY �M1T2489L 09/05/2014109/05/2015 aaccidenq 5 1,000,000 X (E ANY.4UTO BODILY INJURY(Per person) S ALL OWNED f SCHEDULED BODILY INJURY(Per accident) 5 AUTOS LX I AUTOS f 'NON-OWNED DAM%+G S $ HIRED AUTOS • X I AUTOS I(Per accident) I 5 C If X. UMBRELLA LIAB X OCCUR CUT0078H 12/17/201412/17/20151 EACH OCCURRENCE 5 1,000,000 iEXCESS LIAB (CLAIMS-MADE AGGREGATE �)S rDED RETENTION S S D WORKERS COMPENSATION WCT0078H 01/21/201501/21/2016 ]{ TORYLMTS1 ER AND EMPLOYERS'LIABILITY — ANY PROPRIETORI•PARTNER/EXECUTIVE YIN E.L.EACH rCCIDENT S 500,000 OFFICER/MEMBER EXCLUDED? FN NIA (Mandatory in NH) I I i I E L.DISEASE-EA EMPLOYEE $ 500,000 ribe If yes,desc under I DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,.if more space is required) GARY MATSIK HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSASION POLICY CERTIFICATE HOLDER CANCELLATION DANIEL MCGRATH CONSTRUCTION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 312 CAMP STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN WEST YARMOUTH MA 02673 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ' DANNOMCGRATH@VERIZON.NET C 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/06) The ACORD name and logo are registered Uarksf ACORD 1 Massachusetts -Dhaartment.`of Public Safety Board of Building•Regulations and Standards C'un,tructi;n:Supenic�,r Lice nse='C5107897 a . DANIEL MCGRATH 312 CAMP STREET 1( West Yarmouth MA 02673�# . : : J,�,. �11/Sf' ► ;E `. E::xpiratior, 06113/20% _.. Ct}mmissioher ......- (49 Office of Consumer Affairs-and Business Regulation 10 Park Plaza.- Suite:5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Registration: 179293 Type: Individual Expiration: 7/15/2018 Tr# 419291 - DANIEL J. MCGRATH DANIEL MCGRATH 312 CAMP STREET 'ag N ' - "i -WEST YARMOUTH, MA 02673 A Update Address and:return card.Mark reason for change. SCA 1 s, zone-os/» Employment:F1 Lost Card .. Address .[]iRenewal C��e ay�ecxnircc eall�u` lcc jc,c erc.e!!1 Office of Consumer Affairs&Business Regulation:' License or:registration valid for individual use only @HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: • - Registration 179293 Type Office of Consumer ABairs and Business Regulation Expiration 7/1512018 Individual 10 Park Plaza-Suite 5170 Boston,MA:02116 DANIEL J.MCGRATH f - DANIEL MCGRATH �c 312 CAMP STREET r WEST YARMOUTH,MA 02673 — Undersecretary Not valid wt qut ignature Massachusetts Department of Pu.blic:5afety 1 Board of.Bu€idlri� Regulations acid Standards .... .Clow i_ructiiall Supe l.kar ":..:' ... ,License: CS-107897 DANIEL MCGRATH: r 312.CAMP STREET West Yarmouth MA 02673 enyr3assdore� 06/13/2018 , /JJn1j{{{ VY/VJ16 Office:of Consumer Affairs and Business Regulation `10:Park Plaza-:Suite 5170 ti . Boston'Massachusetts.02116 Home Improvement Contractor Registration Registration: 179293 Type: Individual Expiration: 7/15/2016 Tr# 25487T: .. DANIEL J. MCGRATH DANIEL .MCGRATH 312:CAMP STREET , ..: :. WEST YARMOUTH MA 02673' :. ' - Update Address and:return card.Mark reason for change. Address Renewal. 0 Employment Lost Card sca I 0 20M-W1Y:: 0�/re t7i-1 7lCGJfC[tflllNa �,rrc/rr%,e(t Office of Consumer Affairs&Basidess Regulation :. License or registration valid for individul use only, — before the expiration date. If found return to: =- _OME IMPROVEMENT CONTRACTOR P egistration:. 179293 _ Type -Office of Consumer.Affairs and Business Regulation 'ration: 7/15/2016 Individual 10 Park Plaza-Suite 5170 -f , Boston MA 02116 DANI J.MCGRATH _. DANIEL:MCGRATH 1 312 CAMP STREET l: WEST YARMOUTH,MA 02673 Uiderseereffiry . .. Not valid witho s' ' cff ask v,.HA f2 •r,,Kw 7N g&Rfd i '€��-�xs��mp�a�T�-a��� �aeit B�dersf�rr-��___E•sl�e-cirFcian_.�u��er� Infurm2dim Pipe�'Srig ib c f N�f - - ��/�-awe��� _ � � a. - s 12 C M S� atyfstat = cam- R rm �` ® - 77 6 - '/T7 :. . Are}era ag�iOy�•F t�reckt�� b� -". T�af pFo�e��'•���= • I_❑ I asn a employer Its ctaciur a L IETeuc =Ployees(fall.MWOrpnt-� e)-* hav�l fiie�s -_ '❑ I am a soIe.prapdr orparfncr- fisted on t�l dbl iel-sh" 7- ❑R==ZcEng ship zzuf have no employees Tlx�v3b-mntm:t fs ha-ve g- ❑ fion- Ong forme m any capaciLy- �I andba*�re wogs' a `=nlp_figtrame mcnr , Q- El Bnr�ngadd�on COffiP- ' I 5. We area ccrpw dicnaQd ifs I0-0 Eleriutai sepaQs or a'Mi inn a J_❑ I am a homaa weer&r: alI v ofiuxrs have em,�T sed Their I ]ginmbmg n�sii�ar ad�tfons rrys5 [NQ'wnd='MMP- art ofcmmpfujn per KM I2-0 LZnofrepaim oY LNffwo s` U'-El Qthes comP-m3M-Me j fir} ffig� thNd ri3gdc ar0l bmctR150�aft s finabgow,-d�R f}& vDikae mmn fi ,spot #M-Y nc=s urtr,sub=&&rLL r. 6p-!y:-e dmg IIr. •4 tem k++-e amtid=cont:Aa=mnst svbsm2 sa�cr z dzczt m^' srsls_ ZC-WM,-M=t8Lstch,-k&iF6ac=caststtrhedsa:rlrf;r;,, A d, thenmmx of�esuesmdst�uhem�ecnut�msae��esh-� Mgduyees- Iftbe sabta=kMts 12M®roe-BE s,die mast gmvide tl� w��s'camp.p met i it grz s Ipper isgrfrcw ,�mar&crs'ca�an tnsur ar fir t¢y en less He�arF is na paUcp artd job siia Tuc xmnc e GompaayN me- arofiLT:ff or-Se-HI-ins-Iic- £ fiiaaI}ate- IDT}Sires Addir . Cdy}Stat�. - ATtac7i 2t copy ut the wDrkere cuinpensafian pvliLT deriz=tion page-(showhtg th-C P0UCY nUD3ber Msd ration ilxte): Failn�t n sere c tage as to re3undPs Secfion_SA of BlM r- I52 cm Lead to tfie imgosilina ofaimmaf penal s of a fin,Bp to- UM OD an V r-o=-Y—r;mP6mnmcnt M wen a;c irZ per-allies in$ie form of a SAP WORK ORDER.and a fine cf-cp-to S250-QO a day against ffle violater- Be wised that a copy offer stdemeot maybe fmtwarded to the ofFce of IaresEiga ims of iie DTA far iusura=commge vac di=-. I cta her, rcardrr-&cpq'ns andpsnahT4 atffig ux�prnza#rgn pratu�tT aFxrr*e is true rmd rmrrect Pliarm 4 0 - i Erse anF� 1Q-net wriir La€ &arecr,la&T cq* Mplew by cffy or farann offid l City or Town -9 LBo rdofHw 3.$mlUngIle t atpTaviTnO=k &$fet� calpaspwtur S.PhMhfilghLT=tor CKher C� ctTt tson; Thonef-- i ux mom.uuu auu .Pi a tlu ifs��G=:ral Laws chBptmr 152=I=es all engloyers to Provide Workas'compemEfficrn for their employees Pnrsnm:±-b€bis ,an enrp£opeg is dcaed as_evmy person is the service of aaod=under any contract of tire, express Or implied, oral or An mp&yer-is deed as`pan individnal,partaeasbip,association,corporation or o'dier.legal enfify,or any two or morn offfie foregoing=,gaged in a joint Mtt:rpzise,and inctading tiie legal rcp==b&es of a deceased employe•r,-or the receives or tr�of an indiviffinl,partaembip,association or other legal entity,employing employee;. However the ovtneaC of a dvreIIiirg house having not more than agartmeufr and who resides thezem,or the occupant of the dwelling house of another who empIoys persons to do mafijt ice,construction,or repair work on such dwelli g house or on the gia`unds or b-nldiag kppmten'ar±thereto shaII not becanse of such employment be deemed to be-an employer." MGL chapter 152, §25C(6)also sW=that¢every S'tBtE or local Iktn.ins agency shall withhold f le issuance or -renewal�f a Frceuse,or Permitto 6geTafie :bess or in coustrutl bBildings,tilt the cQmmonwcaIth for a�xy applicant whb has not'prnd-aced acceptable evidence of coiapftaace with the 4nc c:e-.coverage required' Additionally,MGM chapter 152,§25C(7 states Neither the commonwealth nor any of itspolitical subdivisions shall enter into any comet act for the perfnrmanee of public worl-until acceptable evidence o f compliance v�ith the;n gran ce r-Prz�ents of this chapter have been presented to the contracting ar hority." Applicants Please fill or± the wormers'compensafion affidavit completely,by rdieclm�gthe boxes that apply to your situziion and,if necessary, supply sub-contractor(s)name-(s), address(es)audph aa t numbm S. along with their cerouc e(s) of n,.crrrance. Limited Liability Companies(LLC)or L>mitcdLi:abilhy Pm- eiships(LI.P)withno employees o$ierffian the members or partners,are not required to cagy workers' compensation m ura ce_ If an LLC or LLP does have employees;a policy is requueci Be advised that this affidavitmay be submitted to'the Departmeat of Industzial Accidents for confrmation ofmnce Coverage. Also be sure to sign and date the affidavit. The affidavit should be retrmmed to the city or town that the application fur the permit or license is being requested,not the Departneut of Indus'zial Accidents. Should you have any questions regarding tie 1 or you are regLired to obtain a workers' compensation policy,please call the Department at the number listed below..Self-insured.companies should enter their self-in�ce Iicense numbez on the appropriate Hine. = City or Town Officials ... . � :.... - : `- ' Please be sure fhat'tlie affidavit is complete and prated legibly_ The:Department has provided a space at the bit you i�fill out in the event the Office oflnvzstigations has to contact you regarding ire applieght of'the affidavit for ' Please b e s m e:to m the p®itllieense ntmmber which w�be v red as a reference number. In addition,an applicant that must submit multiple peniiit/Iicense applications m any given year,need only submit one affidavit indicating cum eat policy inknn-- ton(ifnff-= ry)and under:Job Sits Address"the applicant should writE'all locations in it or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be prop-ided to the applicant as proof that a valid affidavit is on file fur fahze permits or limnse.& Anew affidavit must be,�Ii led out each year.Where a home owner or citizen is obtaining a license or permit noItrelated to'any business or commercial Yeatm-e (Le.a dog license or permit to bmn leaves etc.)said person is NOT rued to complete this affidaiZt The Office of Investigations would at to thank you in advance for your cooperation and should you have any Blest ions, please dD nothesitate to give ns a call_ The Departmcnfs address,telephone and faxnumber_„ . Thy CoMmn a of Ma-ssachvset� , M D of C.f ELlistrlal A�Qcid�ts I�Lcr i�MA(12111 Te•L.��I'�'�`�-4-�E��4-46 4r I-�'���A��,4F�. . - • • F=4 6I7-727- 4-4 Revised 4-24--07 ��a �vsrwsu, : 03MAS Town of Barnstable Regulatory Services Richard V.Scali,Director , Building Division Thomas Perry,CBO t Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, kov" 0 5 mn5ACe(�►►�_ ,as Owner of the subject property ` hereby authorize �)atJ i L'( `to act on my behalf, in all matters relative to work authorized by this building permit application for: &75 - A-a Mtoo 6�, craws�- (Address of Job) 7h16 S' a of Owner a l EOM A S PS R5CLt Print Name r If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. QAWPFILESTORWbuilding permit fonns\EXPRESS.doc Revised 061313 Regulatory Services oxt"E Richard V.Scali,Director Building Division MAIDWABXX ` Tom Perry,Building Commissioner 16yg. �� 200 Main Street, Hyannis,MA 02601 A www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": 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- F 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. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of 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 06,1313 ITze Comma nveeakh of Manach-myets Deparbwent of rnduslrid Accidents 4vw, . Office-o�'Firt?�figaticrns ��B�.D B�Ca D E PT. 600 WashiyWtom meet Boston,MA 02.HI AUG o 4 2016 Wcwkers' CalmptnsaffanIns�ce Affidavit: TG�n��v �nilde��rnfr�cfnrsJEIe�rlt�ians,�F�h ers mlicant Infarmatian Please Px int F,e�'bIy Dame ft3neinR- �, ,� .0 6)N t Q, Add�e� ��� r�i C�/►')D ��o Are you an employer?Check a appropriate bom Type of project(reguireq: I.❑ I ant a employervwith. 4 %I am a general couftactar and I 6- 0 New Corr employees CfW1 and/or parwime * have hiredthe sgr-cocoas 2.❑ I am a sole proprietor orpsrtuer- listed on the attached sheet. 7. ❑Remodeling slip and have no employees These sab-coa'hactars have ❑Demolition wod-ng for me in any capacity_ employees and have workers' [No workers'comp.fimAM e: comp- ,� nrce 1 9. El B.nildmg adzlitioa r -] 5. ❑ We are a corporatioa and its to-❑Electrical repairs or additions 3.❑ I am.a homeorw=doing all Mork offiem have exercised their 11-❑Phrmbsagrepaim or additions myself[No worlaets'comp- riot of eswV6on per MGI. L_❑Roof repairs im=a cerequi.regY c.M §lM andwehavemo employees,(NO wcr$ers' 13_❑Otlte[ cow_insurance required.] Any apphuntfut chadaboz gl mast also fffioatthe sectioaheIomshofiiag t6eo wadseaT cvmpeasatiaapaTicgi�aamaYion �nmeoames who snba�t riris aft u is caTiag 8iey are doing ag waoi[agd oils auis;de contmc�arsmnst submit a nem xMdwdt indi,,tk sucT tCd=RCt=Iffutshedthis box mastattachedasadditirmal shad shommgthea—of the sub-cautzcto-mand state whe&etarnotf6nseemitieshn-e employees.Tfthesnh-castadaeshwe empleyea%dLeYnmsrpmside dw*warkers'tamp•ladicg=nber. I am are employer that is prataduzg imrkers'songs-rzsafian fimlianca for Nzy wzpFnyem $eEow is fJte po cy acid job site informafram Insurance Company hrame: P ficy 41orSelf--ins.Zia Expiration Date: Job Site address: City/stdar4p: Attach a copy of the workers'compensationpolicf declaration page(shewing the policy,number and expiration date). Fadmm to semwe coverage as requiredudder Section 25A of MGL c.M can lead to the imposition of criminal penalties of a fine-up to$1,Saa 00 and/or ane-yeimimpaisonmeuk as will as civil penalties a the fora of a STOP WORK ORDER and a fine of up to W100 a dap abgaicst the violator. Be whised that a copy ofthis statementsway,be fxwarded to tine Office of iav s gations efthe DIA for iusuraace caverapp yerifrca4i Irfa her, cerfi srardRr Vaud r: a attire infor+rratimt protirfed abates is true and tarred �V ^�LafnrR Date Z ///0 Phone t)joYcial ass wily. ,Do net avrrte in tins area,to be cmrnpfeted by city srtiown afjrciat r My or Town: Per, 'F 91; ense;9 Issuing Authority(d rle true): L Board of MmIth 1 Bwlffing I gm1ment 3.C tyf Town Clerk 4.Electrical hmpectur..5.Pmmbiag Inspector 6.Mer C'oRt2ct Person: PlaanE#- �1 ® oATE(MMIDo/YYYY) A� CERTIFICATE OF LIABILITY INSURANCE 6i9i15 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CER71FICATE 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(es) 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: Donald J. Medeiros Insurance A PHONE 508 678-1271 1 FAX No): (774) 365-6552 154 Rhode Island Ave EAoDRESS: don@ donmedeirosinsurance.com Fall River, MA 02724 INSURERS)AFFORDING COVERAGE NAIC# INSURER A:American European Insurance INSURED -INWRERB:SafetV Indemnit Edgar Mauricio Agudo Ortiz INSURER c:Liberty Mutual dba Ecuamerica Construction II INSURERD: 39 Seymour Street INSURERE: Berkley, MA 02779 1NSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POU CY NUMBER MIDDIY MMIDD/YYYY LIMITS A GENERAL LIABILITY SKP2000957 10 4/23/15 4/23/16 EACH OCCURRENCE $ 1,000,000 }[ COWOdERCIALGENERALLV161LITY DAMAGETORENTED PREMISES(Ea occurrence $ 100,000 CLAIMS-MADE �OCCUR MED EXP(Ary one person) $ 5,000 PERSONAL&ADVINJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER PRODUCTS-CO MP/OP AGG $ 2,000,06b X POLICY I Z?T LOC $ ,} B AUTOMOBILE LIABILITY 6223581 5/17/15 5/17/16 COMB INEDM SINGLE LI(EaacciMfT $ 1 000 000 ANY AUTO BODILY INJURY(Per person) $ ALLOWNED X SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS eracddent I $ URBRELLALIAB OCCUR I EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION WC231S372831 5/5/15 5/5/16 X WC I IMIT OTH- AND EMPLOYERS'LIABILITY -- MYPROPRIETORIPARTNERIEXECUTNE YIN E.L.EACH ACODENT $ 5001000 OFFICERMIEMBENHR EXCLUDED? N I A (Mandatory in ) E.L.DISEASE-EA EMPLOYEE $ 500,000 If Yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY Lug- $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is regui red) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Residential Management INC ACCORDANCE WITH THE POLICY PROVISIONS. PLM Buzzy LLC 2604 Elmwood Ave Suite 352 AUTHORED REPRESENTATIVE Rochester, NY 14618 Heather Williamson ©1988 2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: AcoRL> CERTIFICATE OF LIABILITY INSURANCE DATE(MM,DD/YY" 1 10/16/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. CON PRODUCER NAME: Kelly Sel The Driscoll Agency, Inc. PHONE 781 421 2490 FAX N :781 421 2491 93 Longwater Circle E-MAIL Norwell MA 02061 .kseip@driscollagency.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:HDI-Gerling America Ins Co 41343 INSURED 218590 INSURER B:Navigators Insurance Company KOBO Utility Construction Corp. INSURER C:The Charter Oak Fire Ins Co 25615 4 Victory Drive P.O.Box 578 INSURER D Sandwich MA 02563 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1697556991 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 POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MMIDD MM/DD A X COMMERCIAL GENERAL LIABILITY EGGCC000107815 10/1/2015 10/1/2016 EACH OCCURRENCE $2,000,000 CLAIMS-MADE �X OCCUR DAMAGE (RENTED PREMISESS Ea occurrence) $100,000 MED EXP(Any one person) $excluded PERSONAL&ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2,000,000 POLICY�JEQ LOC PRODUCTS-COMPIOP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY EAGCC000107815 10/1/2015 10/1/2016 (Ea accident) LIMITOMBINED SINGLE $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS IX NON-OWNED PROPERTY DAMAGE $ AUTOS Per a.dent A UMBRELLA LIAB X OCCUR EXAGC000107815 10/1/2015 10/1/2016 EACH OCCURRENCE $10,000,000 B X EXCESS LIAB NY15EXC7901951V 10/1/2015 10/1/2016 CLAIMS-MADE AGGREGATE $10,000,000 DED x RETENTION$O $ A WORKERS COMPENSATION EWGCC000107815 10/1/2015 10/1/2016 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (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 C Contractors Equipmment QT6606B268829COF15 10/1/2015 10/1/2016 Special Form w/Theft 2,160,412 Installation Floater Install Ea jobsite 450,000 Leased/rented equip Leased/rented 250,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE:671 Cotuit Road Residential Management Inc &PLM Buzzy Inc.Are included as Additional Insured for Automobile Liability on a Primary Basis for the conduct of the(Named)Insured, but only to the extent of that liability. See Attached... CERTIFICATE HOLDER CANCELLATION 30 Days except 10 days for nonpaymen SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Residential Management Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 120 East Ave Rochester NY 14604 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD THIS CERTIFICATE SUPERSEDES PREVIOUSLY ISSUED CERTIFICATE AGENCY CUSTOMER ID: 218590 LOC#: ACOREP ADDITIONAL REMARKS SCHEDULE Page, of 1 AGENCY NAMED INSURED The Driscoll Agency, Inc. KOBO Utility Construction Corp. 4 Victory Drive POLICY NUMBER P.O.Box 578 Sandwich MA 02563 CARRIER NAIC CODE EFFEC nVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Residential Management Inc &PLM Buzzy Inc.are included as Additional Insured for General Liability and Excess(Umbrella)Liability,for ongoing and completed operations,as required by a signed written contract or agreement with the Named Insured. The Additional Insured coverage for General Liability&Excess(Umbrella)Liability detailed above applies on a primary, non-contributory basis where required by a signed written contract or agreement with the Named Insured. The General Liability,Excess(Umbrella)Liability,Automobile Liability,and Workers Compensation/Employers Liability Policies include a. Waiver of Subrogation in favor of Residential Management Inc &PLM Buzzy Inc.on whose behalf the Insured is required to obtain this Waiver under a written contract or agreement executed prior to a loss. Notice of Cancellation provision is 30 days except 10 days applies for non-payment of premium. ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACC® DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE L� F6/3/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsemengs). PRODUCER - CONAMENTACT Karen Bernier Southeastern Insurance Agency, Inc. PHONE (SOB)997-6061 FAX Nol.(508)990-2'131 439 State Rd. E-MAILAOORESS,kbernier@southeasternins.com P.O. BOX 79398 INSURERS AFFORDING COVERAGE NAK:0 North Dartmouth MA 02747 INSURER A:Arbella Protection Insurance 41360 INSURED INSURER B: ' R J Bevilacqua Construction Corp. INSURERC: P. 0. BOX 628 INSURER D: INSURER E: Forestdale MA 02644 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1542700879 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. ILTR TYPE OF INSURANCE A L UB POLICY NUMBER MMIDD�Y DDIYYYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTEU- X COMMERCIAL GENERAL LIABILITY PREMISE $ 300,000 A CLAIMS-MADE FXIOCCUR 8500018147 /15/2014 /15/2015 MED EXP(Any one person) $ 5,000 X XCU Included PERSONAL 8ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 X POLICY 1X1 PRO M LOC - $ AUTOMOBILE LIABILITY COE.MBINED acci6arrilSINGLE LIMIT 11000,000 ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED 1020014548 /21/2015 /21/2016 AUTOS X AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS P Uninsured motorist8l splitlimil $ 250,000 X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,000,000 4DED I X RETENTION$ 10,OOC 4600062061 /15/2014 /15/2015 $ A WORKERS COMPENSATION X WC STATU- X OTH- AND EMPLOYERS'LIABILITY Y I N TORANY PROPRIETORIPARTNERIEXECUTIVE E L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? FN N I A (Mandatory in NH) 088680414 /27/2015 /27/2016 E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ 1 000 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Project: 671 Main St, Cotuit, MA Email to: Danno.McGrat:h@verizon.net and MLuttrell@dhdventures.com CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN DHD Ventures ACCORDANCE WITH THE POLICY PROVISIONS. 2604 Elmwood Avenue Roches ter, NY AUTHORIZED REPRESENTATIVE Karen Bernier/KAB rJ/v ACORD 25(2010105) ©1988-2010 ACORD CORPORATION- All rights reserved. INS025(201005)01 The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 04/29/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PAUL SCHLEGEL SCHLEGEL INSURANCE BROKERS INC PHONE FAx (AIC,No,Ext): 508-771-8361 ((A/C,No1508-771-0663 34 MAIN STREET E-MAIL ADOREss: SCHLEGELINSURANCE@GMAIL.COM _ WEST YARMOUTH MA 02673 INSURER(S)AFFORDING COVERAGE NAICa INSURERA:NGM INSURANCE COMPANY ( 14788 INSURED INSURERB:NGM INSURANCE COMPANY 14788 Gary Matsik Dba Matsik Concrete INSURERC:NGM INSURANCE COMPANY 14788 185 Barcliff Road INSURERD:NGM INSURANCE COMPANY 4 14788 INSURER E: Chatham, MA 02633 1 INSURER F: -� COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR YV1/D POLICY NUMBER I (MM/DOIYYYYI (MMIDDIYYYY) LIMITS A I(GENERAL LIABILITY MPT0078H I01/22/2015101/22/20161 EACH OCCURRENCE � S 1,000,000 IX COMMERCIAL GENERAL LIABILITY I PME 8ESEaEoccccuurrerence) $ 500,000 ((��II CLAIMS-MADE I n r OCCUR MED EXP(Any one person) S 10,000 PERSONAL&ADV INJURY S 1,000,000 I GENERAL AGGREGATE S 2,000,000 GGEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPiOP AGG S 2,000,000 FI POLICY PRO- I I LOC ( S X JECT I LE LIMIT $ AUTOMOBILE LIABILITY M1T2489L 09/05/2014109/05/2015� I 1,000,000 (Ea accidenp � S X ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS IT AUTOS NOIJ-OWNED P TY AMAGE �S X HIRED AUTOS 1 R AUTOS ( I tPeraccitlem) C X UMBRELLA LIAR X (OCCUR CUT0078H 12/17/201412/17/2015;EACH OCCURRENCE _ S 1,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE S ( DED i RETENTION S I I S OTH D WORKERS COMPENSATION i WCT0078H 01/21/2015 01/21/20161' X ORY L M TS I ER AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECLMVE Y/N E.L EACH ACCIDENT S 500,000 OFFICEWMEMBER EXCLUDED? N❑ NIA i I `- (Mandatory in NH) f E L DISEASE-EA EMPLOYEE $ 500,000 If yes.describe under DESCRIPTION OF OPERATIONS below, ( i E.L.DISEASE-POLICY LIMIT s 500,000 _ / I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) ' GARY MATSIK HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSASION POLICY i CERTIFICATE HOLDER CANCELLATION DANIEL MCGRATH CONSTRUCTION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 312 CAMP STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN WEST YARMOUTH MA 02673 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE DANNOMCGRATH@VERIZON.NET ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered oarksf ACORD $ Massachusetts -Dypartrnent of Public Safety Board of Building Regulations and Standards Comtruetijin Super-isor License: CSA07897 DANIEL MCGRATH 312 CAMP STREET t.77(_� West Yarmouth MA 02 Expiration Conxmiss+orxer .06/131201#3 V kQ��1� Office of Consumer Affairs and Business Regulation - 10 Park Plaza - Suite:5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration 179293 's /, . Expiration: 7//512018 Tr# 419291 DANIEL J. MCGRATH.: DANIEL MCGRATH. .. _� 312 CAMP STREET WEST YARMOUTH, MA'02673 Update Address and return prd'Mark reason for change.:. reason SCA 1 i� 20M-OSM1 a~ Address .E] Renewal Employment Lost Card . `�- Office of Consumer Affairs&Business Regulation: : License or.registration valid for individual use only } =: HOME IMPROVEMENT CONTRACTOR' before the expiration date. If found:return to: 1 Registration: 179Z93 Type; Office of Consumer Affairs and Business Regulation Y w Expiration 7./1512018 Individual 10 Park Plaza-Suite 5170. _. f. z Boston,MA 02116 DANIEL J.MCGRATH DANIEL MCGRATH: - 4vand 312 CAMP STREETfv(c �. .__ WESTYARMOl1TH,MA 02673 Undersecretary t ignature r .. ✓r A J � i o ._ #675 IlD C 675 9B-2iBLDG :' 63 DNu DIlfIEX: ®i FEE QARAGE ux 61� S DA9 i . } 67 IlB-Y , /`' C��` 1 ��' '•.) J _.� n try -". 1. I e" FHL O5,0 PAl'FD PARWN � \. � 1._ �I ��. ..i LE.. Lot Area: CONSERVATION:: �a °-tl.�l ,.� 1,' kl u,. n. t EASEMENY .. ,., `t.t 2 r r - t °l l L �. .. rn ACRr ;racte- A L;rr � � !� � '� .. t u c,. F'l IDIUIi'r.ii i S1H:r,/aAhR 6 it - mRR lnr [0' �7� t llr .J f I � I -40 eu "�EE� � 0 675 -2 "`k675 1- I Sol:. �� i-0� rll A`u n aPousuiN v �rJre J - #675 C-1 675 @ r. ROUT ac FknCF 41,.E (" rvA�ilD M SIP IW^RPy11+r JRMS W • - InA �� ...., — I„'IRS .X „ ( j ~�--_J^ 5 MIPW .ZONING SU�AAARY. .. ' Ni M NDM wv rr I Ens,e D _,:_Pqa c'ao RAIN GARDEN PLANTS .. CUSE NUNDEH OF Dar IlINY`D iS •. ... ( IPI 4T NA4 - '1 / ®1't'l�J T I'�L+EN lAl1.)S MB1:M1�NA ES LLN. D R fl7:'05,1 (X.P 9 Mil CI ETIIrZA alN FfilA - I6 ZL IOJ.9 1 F- OJ,91J 4' - 1 1A'R} - ��� - � �.� pp,,,�r TTrr pJ ,(gyp) r,fF�� p��r1 �r�'p1{y��,�T r(yT 1t�T OT DN-GE vSD' ( -CGn L4 L(H,TI D 5011 /2 �i it �➢�1V11.r1U LL A➢BALL ➢BV.tr➢ H 11 VL'V V 1 V Q 11�llUSESD.. u.N or r-.FTe cE eels u 591s .. REFERENCES ... ,J1 . _ _ U H Scl(VA[I( 15•I.EL UL11iANLLY —` ASSESSIMS NAP D 6 PM 15 B I E 6R:fa ArA az d A\lYOU &➢.N[`�I➢DS(CA➢E S OL TLD Pt11NN HLSWxtt RarE d!DtFFI Av DEEO S.^AK 195111 AGE 510 I�R DOS R H 0 T1,G DDGtV0o0102 11_) 1 5i Ci -PLAN BOOK 101 PAGE'S5 sere s Lf1C rtn n:N n¢nP o.LrY as �er SB➢ PR AN .� or i.uda iN .1)fAIED NTX.N FENA 20.E C 9 S.p I _F,NVA19En zxwb ou w.,LvsEn aav : WNER I .O RECORD Iaa2 a�Nr u D>xAl STREET {jfzA1 1D rloHf 11 - .. .. •. XYANW'S NA 02SCI r u C C)1 l.Il L A PARKING CALCULATIONS: A NulIY I I h, 4�1 cx:uy — 7 J �OlE6dl X ArraclrEn DueLu o 1+Frs 0 SAINn;-1z o SPALEs - 604' 8 L A114)011 AV} lJl1 P ,3:1 p� +VIS!rORS Ar(12 k tom ,12 sp Ac s. �.ROc to ILR_NY 1401-_I4 IJ 2 SPACES HE()Il FFO J I aevrntvvstetrrr.corurt',Atn r.._ Y ( � �/J J 16 SPACES PRONUED - .. SCAIE: I D WE: .I-27-Oa SITE COVERAGE: '. REvlsiIt, 1-19-De RevsED„5-M-o7 r- ------- AoW17 capo OfighMenng,ift. REVISED. <-6-06 REIASL'D N-Is-o9 L LOGUS MAP I IDU-6Ulur6o FuorAiNc u.ai•9 6F SF-1,1.0a L Ci Vil L'npinEC,:y RiNISED.,2-i]-07 RtVISEO.:A-�10-09 _CAId:! 20_._ TUTAI.IENF, o"S q PA7109 t I'll i'•• 1a 7j,-- — /U/,t"i SufVdy lf.Y REViSF.D.:n-5-D7 RF.VISEU.:S-Li-09 TOTai,IN.ERN.fAIS CO\F.Rl"S � t93 A<so%O,K. MISFD, 4-5-D-.14 F.MSE CDMEIF,r,TS) DATE OA•:r^^,A W to Pl,.PL.ti '� /r:.• S of(Nr� G 1 5 ,'.2n ASSES60It5 MAI pJ0 MI.15 , NAl'JXAI.';TAIL'.AS,Crili Si 44,13 PRpNDEO. GAv,) " .. : .::' : ... _",• � III ty" a-a ...... -- ............... 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