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HomeMy WebLinkAbout0016 COTTONWOOD LANE IN JIM im no, 4-9 T,.!' .4,t CUfi'bi, v t Alin 1=107 v gun; 4 k;71 43 jr do! G VM* ;v*�'Y' e 4,41, 9 R, il� 'w Mil"A"N SNIP py I 11 MR x Opq AIR J'j­( 11 4 4ft r "'If?"t 41, Rx 71 111 f I, ;XS .4 14­414, fill m!7 Vw-,1, ul �101 111"�, 7 P4 II 40"It M: 15 �M Mill, "wl. be, omq 4' .A - ? I l ' ',4 121 C woe, AaA, PI, V I Is AN is' 'A'A 114" li"'T "lit, AM pyj JK -A-1 � Ir 004 AV 1,15 ji�b�;A W�j f, p A cc 'V�,4qt �1 RAK 1A A- 14f(MA k g OJT, ff'7- y4q#7 � I, " 1wt"My "41 J lytx 4 4 T?. 't ` V3 WIT f It le4 -q(t i,�'lm I q -MR4 :lj ptor, Y",& i� 11 ff lilt MA I pp qgy, M_ A-1ripty"'11 q­; IX ii 0, A 't W'Ni fk, X I 11v YAV Zoll A I d , g I I 14 "M I "I mik. i pmm vo "1,19;� ­11KI,�2j,, Y .�R %"Ap tilt 1" Aq REA Nf, A4 9�I., wA 0A .4, *14 'k� , A4 1, ", 11 vizi 4M 4 fl I,41A 7", w" I NY"! Y! 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Energy, I-� Insulation Affidavit HomeWorks Energy has installed insulation at the following address that meets or exceeds Massachusetts building code and IIC requirements. Project Address: Permit Number:TB-19-2401 Lynn Sunden 16 Cottonwood Lane Bamta'ble Massachusetts 02632 Location Material Addt'I Thickness Final Assembly R-value Knee Wall Dow Polyi socya nu rate(R-14) 2" 7 Attic Floor Green Fiber,Cellulose 8" 49 Sincerely, Scott Veggeberg HomeWorks Energy Inc. CSL#103832 HERS Certification#3081658 HomeWorks Energy 107 Station Landing,Suite 110 Medford,MA 02155 wxpermitting@homeworksenergy.com 781-205-4516 Town of Barnstable Building vSTnmit Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept SA MASK. Posted Until Final Inspection Has Been,-Made. .`. �� Raa'° Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. Permit No. B-19-2401 Applicant Name: Elvis Verdezoto Approvals Date Issued: 08/02/2019 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 02/02/2020 Foundation: Location: 16 COTTONWOOD LANE,CENTERVILLE Map/Lot 252-163 _ _ _ Zoning District: RD-1 Sheathing: Owner on Record: SUNDEN, LEIF M& LYNN M ... Contractor Nme,"`..SCOTT VEGGEBERG, Framing: 1 _ L Address: 16 COTTONWOOD LANE Contractor License: CSSL-103832 2 - CENTERVILLE, MA 02632 _ Est. Project Cost: $ 2,294.00 Chimney: Description: Air sealing and weatherization inside the home., Permit Fee: $85.00 I Insulation: Project Review Req: Fee Paid:` $85.00 Final: Date _ 8/2/2019 ` c Plumbing/Gas Rough Plumbing: � Building Official ` . Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within'six months after issuance. All work authorized by this permit shall conform to the approved application and the'approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. " Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this;permit. Minimum of Five Call Inspections Required for All Construction Work: Service: 1.Foundation or Footing Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT >✓�- D A=A- s Ear �I • *✓ Assessor's map! and lot number ....�.J .-�.: �+ 4 F TH E tO x Sewage Permit number r y ,?C �Baea LE. • `� INSTALLEDp ye „� House number: ... �. ...'"CQ"" i ... j 41.e tl '00 M639 .;.. .... QL 6'ITH `TITLE 5_ I •,tea F �.. CODE f TORN OF BAR'N` ' 1rilo s ;. •�. F BUILDING y INSPECTOR . APPLICATION FOR PERMIT TO o�,�r �� c r- yew �u�c viw� TYPE OF CONSTRUCTION ....:..sS�//Z' L L= / f+1 r................... ...................................................................... ................ , /......................19,,,,.,`;K TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location4.a:T.,......l ........ TG w....... .............................................................� �^ ............................... ProposedUse .c: .t.,� n.r `................... ......... .... - ...............................................................I......................... Zoning District .�1.................... . . :.:Fire District .................................................................... Name of Owner .. t..d ..��L .�.? �. ..TiPe�rT ,Address he L L 1 S �..... 5,.nr .....c�......�.�J'J...... ': Nameof Builder u:!........ .. .f.. .... ........Address .................................................. .............................. . 'Name of Architect .,....... .................................... .. ..............Address .........:`...............................°::..............: Number of Rooms ......... �'v.........:.. ........ // Foundation .L. .......c leer ' „ .J�� � ta...... ........... + ... .. Exterior ....... ..................... ..... .,Roofing .. J /-!l � CLUJ Floors .�.. /r. c..��......................... ... . ..W..i3.A.e....T..`:.............................................cv i� . .................Interior .....:5........ ..,. .... • Heating _ '` ................................ ........... /� Gri Plumbing .... :...!a. Tr s y -1 Fireplace .... �. r.........(zJ...._............ Approximate CostJr�....a.�..�.......:............... Definitive Plan Approved by Planning Board '_------------------_-----------19________. Area ......1,•. 0 .................... Diagram of Lot and .Building with Dimension`s Fee . �, " " ° SUBJECT TO APPROVAL OF BOARD OF HEALTH ' - - OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS d ` I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name °..� ................. j • .Construction Supervisor's License ;�7 1;6 • L r '. : J D REALTY TRUST No, Permit for ... .-z..St.Q:y............ t ............ ;+ Location .Z,fQt...182 f......l.Fi...C.ottornw.0 d.. Drive .......... ...Gentexvi.11e...........:...................... ',� Y �,. f i • . , Owner'. ......... ': Type of Construction ......Frajlp............. `m Plot ..: Lot .................. Permit Granted ... 85 _ " - Y .. :19 .. I Date of Inspectio jt�bZ 19 Date Completed ..... ......:19 ,. � ..I f' � y r ) - i\• 1� �7i`L_ IL C1,'. 1 Z �`'^Grf� � .,../ / f.. Assessor's map and lot number ........ .b......�:...:'-............... Sewage Permit number � G e�P Rye r / a =0B4OA,WSTO DLE, House number ........................ ..... . . ..................... N a 39• i y TOWN OF BARNSTABLE BUILDING INSPECTOR G-�•vf r?a c P /l/�w �ulc ��/sv� APPLICATIONFOR PERMIT TO ............................................................................................................................. TYPE OF CONSTRUCTION S'/iv ` L- ................... .... ...............19..y. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: L ..� T /¢ 2 .Gp,TT��v Ct/a (�/�/v L L rvrI ... Location I....... ........................ ...... ProposedUs . rs..t:.. .' ' !'.. .. : ........e . . ..: . ?.. .. . . ......................................................... ..................................................................... Zoning District ��:�:z..............................................................I Fire District ...................... ' ,O- U Y'i L G7 /....7T�'dJ.r..... .Addres �oCL J ns r )r/�vTv�✓ Gy`f...... Name of*Owner ........ .. .... ..r.. s 1... . ............ .. ..... ................. .................... Name of Builder li''c .. 2 J .....Address ..........................................:........................ ..................................................................................... Nameof Architect ..................................................................Address ....................................................................................I Numberof Rooms ........(.. ................................................. Foundation G-.T.�..�............ .. ./...�.,...l.r.....c.......................... i Exterior ...(-� 0!...».....: Roofing ... 1a r krr l- G 4 J ..................................................,. .................................................................................... Floors .4..1.L............................................I Interior ,5e'C r I,.e c 4 Heating '.C.'................y................... W.......... ....................Plumbing .... ....13.�tT . r...................... .... ....................... Fireplace E-r / .......................Approximate. Cosh G ..�. ....................�............................ .......... Definitive Plan Approved by Planning Board -----------_______-----------19________. !.Area .............. ..................... Diagram of Lot and Building with Dimensions FeeO'............ SUBJECT TO APPROVAL OF BOARD OF HEALTH; C I r � J OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .. -�� i. ., :.�� .................. Construction Supervisor's License O 7/r G ` l J. D. -REALTY TRUST A=252-163 No ...2Z9.2.7.. Permit for ...1 Story.,........,, Single„Famly...Dwellinq............ Location ....L.Qt...7,8. .�......� ....................Geater ille.............................. Owner .... ..TzLls ............... Type of Construction ....FraMe......................... .................... ................................................ Plot ............................ Lot ................................ Permit Granted ........May...2.8................19 85 Date of Inspection ....................................19 Date Completed ......................................19 r � _ t= •n+ ,fir TOWN OF BARNSTABLE Permit No. z7927" , Building Inspector Cash -_ -- i +wa °'°� OCCUPANCY PERMIT Bond _-----�_-_----__ Issued to J. D. Realty Trust Address Lot 182, 16 Cottonwood Drive, Centerville ; Wiring Inspectory� Inspection date ` Plumbing InspectorAA ��c� r= Inspection date .FI,Z Gas Inspector raLZ C .. a.✓i~,r� Inspection date X Engineering Department Inspection date Board of Health j �` Inspection date r7 - THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. 23 �/ Building Inspector t .'O� yK _ Y ;-�.,.;f .Mt u y - ; ;i�,^•-p i i3 ?r- .�y A .•.s S NR�: 4�dx ..x„ �t . +• K. -«.. ,'q "+*ir`' -7' h- POF °•� TOWN OF BARNSTABLE BUILDING DEPARTMENT _ »�T TOWN OFFICE BUILDING ti rua HYANNIS, MASS. 02601 �o rrr►^ f MEMO TO: Town Clerk FROM: Building Department DATE: ,23 /��►� ,�� An Occupancy"Permit hasq been issued for the building authorized by � Building Permit #.............2�.».».».Z 7 »»..».». issued .to ..... ...� .».». » 1`-.»:.e*4r�J.»l S � » � C o .riIrvvr� G'�O l— Please release the performance bond. i m Lo-- . Igatj N N 10 - L[�T i - J I Z? I LOTrn l91 x 9 +' �'- �� J o • LC>T Ill � ELLIS No. 29874 Li.�Gv Ct=�Ti�IED ALIT ALAS-1 (_oT 182 - Cai-roLlwc�D Li . Mc,Tp—; LOT 182 Liss IU '�7L�oo Zov.sa 13ALSTA 6E r> JILLa -MA -n4 AT 741= GLI r=J-►T: WALAk lilS L L 15 >� TN CJ L rrJ I!-I G. CIS' Ot m FE:-,j jDA-n or_1 o ft m-!r�..� 81n14�- I55 Ltd IS L,=)cA-Te:a iw P-t1-PCflO�-1 T� 4-7 Q T4E7 8jC =*bwl l aAS7 SArJO�/r�, MA s•21�e5 Xn� Town of Barnstable *Permit# d( MITExpires 6 monthsfrom issue dap T Regulatory Services F4, A Thomas F. Geiler, Director 6 .$� Building Division TOWN ABLE , 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 tt)ithout Red X-Press Imprint Map/parcel Number 7- 67 21 Property Address _1(.O_ (_0+070W DOd 4 a—VI_e C64A14_eV1U 1 C EQ-- [�o Residential Value of Work'5 8 q . Minimum fee of$25.00 for work under $6000.00 Owner's Name&.Address_�_ 5V--1p k4-A Contractor'.s Name K&#_ s �n ��1 MlQ�2i feS LLC_.. _Telephone Numbe 3 Home Improvement Contractor License# (ifapplicable) [WWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner �] I have Worker's Compensation Insurance Insurance Company Name t 'l � 00� Workman's Comp. Policy#�/ Copy of Insurance Compliance Certificate Hurst be on file. Permit Request(check box) FV_] Re-roof(stripping old shingles) All construction debris will be taken to P,•Jl- s/15'u, ❑ Re-roof(not stripping. Going over existing Layers of roof) ❑ Replacement Windows/doors/sliders. U-Value (maximum..44) *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 Home Improvement Contractors License is required. SIGNATURE: ' 2 --- \ Keith C. Gilmore Enterprises, LLC / — — P.O. Box 17 )"0 Osw Centerville, MA 02632 O Date Estimate# 7/24/2008 SUT05 Name/Address Work Address Jeffrey Sutphen Jeffrey Sutphen 16 Cottonwood Lane 16 Cottonwood Lane Centerville,MA 02632 Centerville,MA 02632 Project #5 Roof Description *Permit to remove and replace the entire roof system on the home using Certainteed Landmark 50AR premium asphalt roof shingles with 110 mph wind warrantee in your choice of color. *Install Air Vent Inc.Shingle 11 solid vinyl ridge exhaust vent system and white aluminum strip soffit intake ventilation system with Azek PVC soffit trim coverage. *Remove and replace the siding and flashing along the front right section of the roof line using Certainteed Winterguard ice and water barrier, copper step flashings and extra clear white cedar shingles.. *Remove and frame in two gable louver vents to prevent negative airflow interference'with the new vetilation system. *Prepare and paint the new Azek PVC soffit trims to match the existing finish. *Please specify your choice of roof shingle color: Total Labor&Materials: $8,588.95 Smieg•Vem A me 9mpwaana l✓Veedv Since 1959! HIC#134443 MA CSL#98047 'Customer Approval Phone# Web Site (508)420-9934 www.gilmoreenterprises.net Town of Barnstable. Regulatory Services BnxNsrn$LE, 9 sass. $ Thomas F.Geiler,Director 16 9. AIfD �A Building DivislOII Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 "'W-town.barnstable.ma.us Office: 508-862-4038 Fax: 50$-790-6230 Property Owner Must Complete and Sign This Section If Using ABuilder it `'�� ��� C Sy I +-1 H'-1/0 , as Owner of the subject property c hereby authorize dG , � to act on my behalf,' in all matters relative to.work authorized by this building permit application for: .' . (,(_)A0L4 )a(l 04-7 (Address of Job) , / / S' na of Owner Date Print Name L Q:FORN S:OWNERFERMISSION Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR, before the expiration date. If found return to: Registration: 134443 Board of Building Regulations and Standards Expiration: 10/29/2009 Tr# 260307 One Ashburton Place Rm 1301 Type: Ltd Liability Corpor Boston,Ma.02108 ENTERPRISES,LLC. KEITH GILMORE 28 HIDDEN VALLEY RD. 2 - MARSTONS MILLS,MA 02648 Administrator Not valid without signature CEO p . . Op J 0 Board of Building Regulations/ Standards ' Construction Supervisor License " License: CS 98047 Expiration 7/1;5/2011 Tr# 98047 f 4Qtncti6n 00'3 ` 33 KEITH GILMORE ' ! y, PO BOX 17 CENTERVILLE,MA 02632 Commissioner 00-35,000 cf enclosed space IA-.Masonry only 1G._t 2 Family Homes Failure to possess,a current edition of the Massachusetts State Building Code is cause for revocation of this license. Nil 1� CORD '1 -1) TRW&DDIYY> PRODUCER THIS CERTIRCATE IS ISSUED AS A MATTER OF INFORMA N PAYCMEX AGENCY W. ONLY AND CODERS NO RIGHTS UPON THE CERTIRCATE 117$JCMN STREEY HOLDER. THIS CERMRCATE DOES NOT AMEND,EXTEND OR HE COVERAGE ammgn By THE Pol K=or-Low. WEST HENRIETTA,NY 14M ! ALTER COMPANES AFFORDING COVERAGE COMPANY A GUARDINSURANCE KEITH C GILMORE ENTERPRISES LLC COUP my PO BOX 17 CENTERVILLE,MA 02632• COMPANY C 1 " COMPANY - - D 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 REOUIREMENT,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 POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Lei TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION j I DATE(MWOO+YY) DATE(MM+DD+YY) UA@TS GENERAL LIABILftY i j GENERAL AGGREGATE > COMMERCIAL GENERAL LABILITY =�UUMS MADE (',OUR! I: PRODUCTS COMP/OP AGG 5 OWNER'S b CONTRAC TOR'S PROT I - PERSONAL b ADV INJURY S O j EACH OCCURRENCE 5 . - FIRE DAMAGE(Any One hre) :S !MED E XP(Anyone person) i S AUTOMOBILE UABILRY ANY AUTO 1 COMBINED SINGLE LIMIT i S ALL OWNED AUTOS SCHEDULED AUTOS ! j BODILY INJURY O HIRED AUTOS (Per person)j NON-OWNED AUTOS ;a0olly IwuRv . $ (Per aocidem) . ' PROPERTY DAMAGE !E OARAOEUABR.ITY AUTOONLY EAACCID£NT �5 ANY AUTO — O I OTHER THAN AUTO ONLY EACH ACCIDENT S AGGREGATE $ EXCESS LIABILITY UMBRELLA FORM i I EACH OCCURRENCE i S ! !AGGREGATE ;S O OTHER THAN UMBRELLA FORM WORKER'S COMPENSATION AND 1 $ A I EMPLOYERS'UABBJTY X OSXATuIS ) THE PROPRIETCNU - - EL EACH ACCIDENT '-S 500,000.00 PAp/11EpS+EKECU7nF ®'Na KEWC903816 02/04/08. i 02/04/Q9 EL DISEASE POLICY UM17 S 500,000.00 acRtERsaaE O EXCL! EL DISEASE EA EMPLOYEE j$ - 500;000.00 OTHER CESCNPTaIOFOPERATONSILOCATIONSMENICIESISPECHALITEMS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSRMNO COMPANY WILL ENDEAVOR TG AWL 30 DE DAYS WRITTEN NOTICE TO THE CL97VICATE MOLDER NAMED TO THE LEFT, BUT FAR.URE TO MAR SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTUMED REFIRE SEIffA�V�E Ify � . ...... ......... ......... ,.... .:.::::.:•:. :::..::::•: ::::®A�3RRF>rORP013fiTtfiK�9�>':'� lov, 20. 2007-10: 34AM--=Loveiette iresurance Agency No. 9781 °' i/2 ACDBA CERTIFICATE OF LIABILITY INSURANCE DATE(MbUDDlVY1 Y, �DO�� (508}775-4559 FAX 508 775-4577 _- 111 20/2007 i ( } THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Marshal I K Lovel et t e I ns. Agcy. ; I nc. I ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 396 Main Street j HOLDER THIS CERTIFICATE DOES NOT AMEND,EXTEND OR t ! P.O, Box 836 SALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Vlest Yar nlDut h, PA02673 (INSURERS AFFORDING COVERAGE INSURED Kei t h C. Gi I nor a Ent er pr i ses LLC j NAIL# INSURER A The Provi-deuce. Mut ual Ins. Co. i 000004 ! PO Box 17 INSURER 8 Center vi I I e, MA 02632 - INSURER C Y j I ! 'INSURER D --.._----' =---�— I I rISUPER E 1 f COVERAGES 1 THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING I 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 BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH I POLICIES:AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR NSRINSR TYPE OF INSURANCE POLICV EFFECTI VE POLICY E%PIRATIDN I POLICY NUMBER j pA ti�m��' —�E � LIMITS GENERAL LIasa'Tv CPP0053353051 11 l 0612007 11I D612008 1 EACH OCCURRENCE 1-GE r 1 i X f'`OMMEROAL GENERAL UA81LiT'f j - I ' I� I$ 1, 000.00Q ! --t— I DAMAGE TO RENTED i I CL AIMS MADE 1$X OCCUR I I i 50.00 A j ;i , -�.MED EXP(Any one person) $ 5 OOOI l ! I 1 PERSONAL 8 ADV INJURY j$ 1, 000.0 Oa 1 I I I GEERAL AGGRGATEGEN,AGGREGATE tiMTAP—LI 2 OOO OO POLICY PRG' I I PRODUCTS CO.PIOP AGG }$ UJECT I LOC j 2, 000.00 AUT01WO84LE LIABILITY t ANY AUTO t COMBINED SINGLE L!MiT 1 I I I I(Ea amoent) I$ J �I ALL OWNEC AUTOS ( I i I i SCHEOULEDAuTOS I j 180011_Y INJURY I$ i(Per person) HIRED AUTOS r -1 I ' i J NGNONPlEO A;;TOS i BOOILY INJUR'r ' I 1 iPer accl&nt, PROPERTY DAMAGE (Per arownt) GARAGE LIABILITY —� AUTO ONLY-EA ACCI 1 I I ANY AUTO 1 - DENTi$ ! OTHER ONHAN - EA ACC!�js i !EXCESSJUMBRELLALIABILRY - OCCUR rLAIMSMACE i 1 I - (EACH OC:URRENCE I$ l ! - I - AGGREGATE I$ . i I DEDUCTIBLE I i .. RETENTION $ I j I C$ 'WORKERS COMPENSATION AND I I 1 >,YC STATU O7H.I$ j EMPLOYERS'LIABILITY I j TORY LIMITS I ER , ANY PROPRIETOR/PARINER/EXECUTIVE ' I I I i OFFICER/MEMBER EXCLUDED I i I E L EACH ACCIDENT I$ I II Yes,eescrrbe under EL DISEASE-EA EtVIP L0`r­E$ SPECIAL PROVISIONS beiow OTFER - I EL DISEASE POLICE UMII 1$ i I I I 1 I I I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS AWED BY ENDORSEMENT I SPECIAL PROVISIONS —'- --�— „ILi berty Mitual Mbrkers Clonpensati on cert has been requested and Wi I I be faxed receipt i upon 1 I . I j HOLDER 0 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER HALL ENDEAVOR TO MAIL i O _DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY I OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ��� J M6Shera/JCHN -- ACORD 25(2001108) ohn - ----- ©ACORD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): V&M-( C 0�t 6119, eifUr::�1 Address ,o 639pr, l { a b Phone#: `l 314 City/State/Zip: 1Lf: f1✓`'� ��c Arq,you an employer?Check the appropriate box: Type of project(required): 1 I am a employer with O—3 4. I am a general contractor and I 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7.,qRemodeling ship and have no employees These sub-contractors have a/ 0� Demolition workingfor me in an capacity. employees and have workers' Y P tY• t 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 12.0 Roof repairs insurance required.]t C. 152,§1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#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. (Contractors 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. �� A Insurance Company Name: UW 0 �1�Pok, �'I/il 6G Policy#or Self-ins.Lic.#: &GJc `7 ()c311q, _ Expiration Date: 0?—0 4' — Job Site Address: City/State/Zip: C4(4 l v,W e— 040L- o Z�3 - 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 S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a.copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,u r the pains a penalties of perjury that the information provided above is true and correct Si ature: Date: �g d Phone'L Z0 -",3 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#: