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Home My WebLink About0041 HALYARD WAY �I i III, p. e III TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION o Map Parcel l q 1-0 G Application # Health Division Date Issued 6 Conservation Division <J57Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address /4 !Vlf/"b Village C c ti7 cr V/ L G 1- Owner x �� '� Address Telephone - Permit Request N9 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation d Construction Type c_ 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: ❑ Full ❑ Crawl ❑Walkout ❑ Other UBasement Finished Area(sq.ft.) Basement Unfinished Area (sq fit) Number of Baths: Full: existing new Half: existing i6w Q Number of Bedrooms: existing news Total Room Count (not including baths): existing new First Floor Ro" m Coin' co Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other u, m / N 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 ❑ new size _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 (BUILDER OR HOMEOWNER) Name QG/L%N "V Telephone Number Address CL( M License # l Z 6 /hA. 7�.3 Home Improvement Contractor# /L<6 Worker's Compensation # EXL 1v?107 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO oflv C For-P �V 4ST- IA,--C. ivEL✓ orb A4 SIGNATURE DATE Gy��_ FOR OFFICIAL USE ONLY APPLICATION# t s DATE ISSUED ' MAP/PARCEL NO. ` ADDRESS r VILLAGE - OWNER DATE'OF INSPECTION: s'r FOUNDATION FRAME :h - =4 INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING '7 DII 4 h _ r DATE CLOSED OUT , r r ASSOCIATION PLAN NO. f" ,per The Commonwealth of Massachusetts 41 Department of Industrial Accidents Office of Investigations ' 600 Washington Street ` s -Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A. licant Information Please Print Le iE Name(Business/organization/Individual): Gwf N E/ Nr_ N/V wC IF A/ANC• Address - Zq AID1�.� ��l.�SI�NET /' �' ` • A 3D d G' City/StatcJZip:�CI(SE,/NLc�� !1• 02 7f��hone.#: 7 7 Are you an employer? Check the appropriate box: .'Type of project(required):. 1.❑ I am 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,❑ I am a sole proprietor or partner listed on the attached sheet 7. Remodeling ship andhave no employees These sub-contractors have g• ❑Demolition employe d have workers' working for me in any capacity. 9.' ❑Building addition [No workers' comp.insurance c insurance. 10.❑•Electrical repairs or additions required.] 5• e area corporation and its p 3.❑ I am a homeowner doing all work . officers have exercised their l l:❑Plumbing repairs or additions ' myself.[No workers' comp. right of exemption per MGL 12.❑ Roo airs insurance required.]t c152,§1(4), and we have no 13 ther ��1� employees. [No workers' comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy inforrna on. 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 nsy employees. Below is.the policy and jab site information. k Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page'(showing the policy number and.expiratiou 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 agauist the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1-do hereby certify under afe pain and penalties of perjury that the information provided above is true and correct. Si tore• /� Date; — Phone# 7 7` 0 d 18 7 OffIcial use only. Don write in this areal to be completed by.city or town official.. City or Town: Permit/Licease# Issuing Authority(circle one): ` ,Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5,Plumbing Inspector" 6. Other Contact Person: Phone#: 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 i52`,,§25.C(6)als6-states that"every state or local licensing agency shall withhold the issuance ors, {'a renewal of a'liceii`se b gerinit•to operate•a business-or to construct buildings in the commonwea.1th.for any �. applicant who has not pro.duced-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.compliarice wi#h 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-contractor(s)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 nurqber 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 ate b thottom 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 permitgicense applications in any given year,need only submit one affidavit indicating current policy information.(if necessary)and under"JSSite 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 maybe provided to the applicant as proof that a valid affidavit is on file for future peimits 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 bum 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 Departments address,tefephone•and fax number:: _; �; 4 �, �> r•, , The Cdb 'rya q nonwealth,of 1�assaGl7u`s�tts f Dqpartinentof dvistfiai A 61dents�; .. ..0` ;N, '.()��Zce�of kla�est�ga�oz�s„ a: _•.�,�. w , .. ...�• 6E14 VashingtQii Street . . . Boston,_MA 02111 TO. #61 7-72'-4900 ext 406 or 1-977-MASSAFE Fax# 617-727-770 Revised 11-22-06 www.mass.gov/dia �OtIHE rpk O Town of Barnstable.. Regulatory Services MUSS. Thomas F. Geiler,Director Building I?ivison Tom Ferry, Building Commissioner 200 Main Street, Hyannis,Kk 02601` www-town;b arnstabl e.ma.us Office; 508-862-4038 Fad: 50S-790-62.30 Property Owner Must. Complete and Sign This Section If Using A Builder ,.as Owner of the subject property hereby auth0rize1fC&*-T1-1WF7 /17 llm L-141✓C 4 to act on my behalf in all matters relative to`wo.rk authorized bytlii.s biulding permit application f or, ;w, (Address of Jo Signature of Owner Date Print Name 0:r0RMS:OWih=' RMISSI0N 9.4e Office of Consumer Affairs and usiness Regulation 10 Park Plaza - Suite 51.70 Boston, Massachusetts 02116 Home Improvement contractor Registration `Q D 00 Q - C m C Registration: 166946 _ z r- ; . t ? type: Corporation o.z .; !i _ Expiration: 7/26/2012 Tr# 201217 . ACUSHNET MAINTENANCE CORF�QRATIO t< '� E o QUENTIN TOMASIK �' = 829 MIDDLE RD 4 i� D ACUSHNET MA 02743 V CA ►� G rJ\R Update Address and return card.Mark reason for change. ` P OPS-CAI 0 SOM-04/04•G101216 ❑ Address Renewal Employment Lost Card fn 'O - .. � „F � °r=^"n"'0�";ma�h::;..,• � a!u€�sar ,z m^�r.m. mamT,�nr ..... .. ..... .. . . i ur xF = �e 'Foorir�neorunrci/l/ � �.; aar��c/uaeCt License or registration valid for individul use only p • k '' Ofticc ol'Cm►sumeo Afluirs&its.rmcss Regulation before the expiration date. If found return to: . *° "' HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation i -M �•: R - : Registration: .166948 TYPe 10 Park Plaza-Suite 5170 Expiration 7/26/2012 Corporation Boston,MA 02116 - -.� AC HNET MAINTItNANCE CORPORATION ". QUENTIN TOMAS,*\ ` 829 MIDDLE R6 r' •. C. ACUSHNET,MA 02743;.``! .'.;;. ' Undersecretary Not valid without signature :. �_. .. G/V OA17`.4 GQ�2B,4GE G,e%voE.e //D X,3 = 330 G. /,OoO 7107-44 s/OELr/.4LG .G.2EL! = /So 5..�: � � C��c �• I 7-O7-.44 AV Jb f {s N R ( . ' 4i J sk T y I , U SUILLPVAN 1 .' RICHARD P9,191,NO, 3 EAXTERik o.2 0M 0 4 r s y �C 6•�� es 101, 7-':VT' O FG• = /oZ. t� �FG. �` �, ate; /.v✓. -AZ •'� L��ct�P:r 'y Box � y�.�,� SEon'C �� '�•' Fi4�� SANE .• /yZ �� G'E,2T/F/EO PGOT .PLAN pL-C.V .ZEicE,2E.VC� / GE,er/�)-' 7;.'.4T T.yE f/E,�EaN Cpiy�GY.S w/�TiyE S/dEL,/NE BfIXT�,2��t/rE /NG. AiVO.SE'Ta/�G` ,2E4U/ZE�l�Nr.S o/= Th'� ,2EGisr�ecO,Gcrvo slieriEya,�S ��iv /,f iVoT r3.4fEp Gnr,a�V/iY.ST,e-. S�`7olt/it/f/E,e�4N•5.4�/�UG1J yaT!�� U.SE� S 1 D G IL- . 5 7 E P 12 v vw 1v From hoo r Pr C s . r C Try p as i + kAlt' N? 36" 7-AL PCB vac' $'GurClb 7-0 )o#Si w� 7`,5r ALr,u sr,e r5 "Ro fE if O, C — 2x8 Zo15r ��. .� SiMPsow H�Z 2 X8 P i• 1) Ck 7o1S7 16 " O. C 7ro :r cure �9.- 15 F _ p Z - 2x10 WC A Dar `�x6Pos7 cArr�gC f3oLr 7" -ro I-IC-A-V r N 1 P 51 5 C G E D 7-O TU o C LA/ J"hl - ,.,. _:.. ID„ L -(36GT t SIr�PSoN A4'�6 G L ,� % I N ro e li ( �'L,j i C5- — A r co0i- GrA D t N l 0 � _ i r 3 — 2' AUA16 u c i ow GrAD t 5Pgc c- b P 5 F CC-T- O. C. � t rr l r Dryw A/ l3 AG usfaNC /VIA1Afi'`e1Vj1VCC { k - t IT - . j I Town of Barnstable F *'Pe:rm it# �S EVires 6 nwnddis from issue date Regulatory Services Fee MstvffUWs,NAM t &63C Thomas F.Geilei Director Building Division Tom Perry,CBO, Building Commissioner. 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number � I . Property Address � ' `dGt CY 1..�0.� C�� q i`` Residential Value of Work Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address y� t�ya fcl • �y k � � �I�e� _. Contractor's Name Sprinkle Home. Improvement Telephone Number 508 775-1778 Ext. 10 Home Improvement Contractor License#(if applicable) 103757' R ES S PERMIT NMI Construction Supervisor's License#(if applicable) CS 6643 S XWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor El am the Homeowner TOWN.OF BAR NSTABLE ® I have Worker's Compensation Insurance Insurance company Name Associated Industries of.MA /.A.I.M Mutual Insurance Co. Workman's Comp.Policy# AWC 7004943012012 Copy of Insurance Compliance Certificate.must accompany each permit.` Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles);All construction debris will be taken to, ❑Re-roof(hurricane nailed)(not stripping. Going over ` existing layers of roof) ❑ Re-side _ #of doors . . . A Windows/doors/sliders.U-Value o f3� (maximum.35)#of windows VVV'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 co of t Improvement Contractors License&Construction Supervisors License is qui SIGNATURE: C:\Users\decoll"pDataU=W\Microsoft\Windows\Temporary temet Files\ContentOutlook\DDV87AAZ\EXPRESS.doc Revised 072110 f , The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations 1 Congress Stree4 Suite 100 . Boston,MA 02114-2017 www.mas&gov/d a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ApuUcant Information Please Print Leidbly Name (Business/Organization/Individual): Sprinkle Home Improvement Address: 199 Barnstable Road City/State/Zip: Hyannis, MA 02601 Phone #: 508 775-1778 Ext. 10 Are you an employer?Check the appropriate box: Type of project(required): 1. ✓❑ I am a employer with 10-12 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner_- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees.` These sub-contractors have g,,❑ Demolition working for me in any capacity. employees and have workers' . [No workers' comp.insurance comp. insurance. t 9. ❑ Building addition 5. We are a co ❑ pairs or additions required,] ❑ corporation and its 10. Electrical re 3.❑ I am a homeowner doing all work officers have exercised their I I-b 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' 13.00ther LA)"&kLA)C 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. Insurance Company Name: Associated Industries of MA./A.I.M Mutual Insurance Co. Policy#or Self-ins.Lic.#: 7004943012012 Expiration Date: 01/01/2013 Job Site Address: y Iv". yI Cl V City/State/Zip: 1n sex 1(i 1 e- . 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 instrart verage verification. I do here certi u d aloes o u that'the in ormation provided above is true and correct Si ature: I V 2L�2Date Phone#: 508 775-1778 Ext. 10 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#: Town of Barnstable Regulatory Services Thomas F.Geller,Director Building Division ; Thomas Perry,CBO Banding Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barmtable.ma.us Office: 508-862-4038 Fax: M8-790-6230 Property,Owner Must Complete and,Sign This Section If Using A.Builder `. osro^ ,as Owner of the subject property hereby authorize Sprinkle Home improvement to act on my behalf, in all matters relative to work authorized by this building permit application for. mil( ,cul L'L (Address o Job) S' tore of Owner Date Print Name If=Property Owner is applying for,permit,please complete the Homeowners License Exemption Form on the reverse side. V 7AAZ\EXPRESS.doc ' \ nteaAOutloo�\DD S C:\Users\decoltik\A Data\Lucal\t4iicrosoft\WindowslTemporary Internet Files Co PP - Revised 072'1'10 Unrestricted -Buildings of anv use roue which group contain less than 35.000 cubic feet (991m')of '� .Massachusetts - 'Department of Public Safety closed sace. pen Board of Building Regulations and Standards Construrtiom Super%kor is e n se,'CS-006643 'BRAD K SPRINKLE 190 LOTHROPS LANE Failure to possess a current edition of the Massachusetts W BARNSTABLE MA 02�66414 State Building Code is cause for revocation of this license. For DP5 Licensing information visit: ww,f.Mass.Gov/DPS `J,•G..- �i`.�• zxairazicr Commissioner 10/08/2013 tr Office of Consumer Affairs S Business Regulation License or registration valid for individul use only , k90ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 103757 Type: Office of Consumer Affairs and Business Regulation !" Expiration: 7/9/2014 "' Private Corporatior 10 Park Plaza--Suite 5170 Boston;MA 02116 SPRINKLE HOME IMPROVEMENT, INC. Brad Sprinkle ° - 199 Barnstable Rd. f} - Hyannis, MA 02601 Undersecretary Not valid witho :signature _ F 12/20/2011 9 : 35 : 33 AM 8740 ® 02/09 DATE(M"DNYY) CERTIFICATE OF LIABILITY INSURANCE 12/20/2011 TaY�9 CERTIFICATE IS I88U® A8 A iD►TTEn Of ItrORMATION ONLY AND CONFERS ■0 aiOaTs UPON THE CERTIFICATE BOLDEA. Tale CEPTIFZCATa DOES NOT ArrlammVELY 02 NEGATIVELY AMEND, EMBED OR ALTER Tab COVERAGE ArroRDED RY THE POLICIES BaLOW. TRIG CERTIFICATE Or RA INSUNCE DOES NOT CONSTITUTE A CONTRACT BBTWRAN THE 288UINB INSURER(8), AUTHORISED REPRESENTATIVE OR PRODUCER, AND TINE CERTIFICATE ROLDER. - - IMPORTANT: If the certificate holder 12 an ADDITIONAL INSURED, the policy(iss) must be endorsed. It SUBROGATION I8 WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsemnt. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemnt(s). PEmoQA cADTACT Brydea 6 Sullivan Ina Agency P V Inc (A/C. E.. an): ..MAXL 88 aalmouth Road Dole a nraUMS Hyannis, HK 02601 MTOQ'IDt. - DetDEs•(t) A!■tRDIIO COSAAOi OIG{ INEOpRO - DEwm A. A.I.M. Mutual Insurance Cc 33758 Sprinkle Home moprovemeat A. nIIIAu E: 199 Barnstable Road ,,.C. Hyannis, bA 02601 DTMO E: 113mm IN COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: Tale Is TO CNNTaf!4 TIN POLICIES or INSURANCE LINTRA SSAW RAVE afa IESURD To Tag an=n EsIEE)ABOVE PON TIN POLICY PERIOD INDZCMD. sOiWI7WSTaIDING ANY sapOINa1QF, Tsot RA CONDITION of ANY cOEnwr an onER DoeU1QP Wrm aESPRCT TO mmCa TEn CRRTItICaTE MY ME ISSUaD as may PRA'aa, TIER INSUSAECE awae RY Tan POLICZii oSERINRA UNIX= Is x9mms To ALL TIN• "no, sfaAsmas am OONDITLOas Or mcm POLICIES. Lzorm ssoss RAY RAos NINE SEDUCED BY PAIN LZAaa. s..r PoLzar NmssR NOO,ICY wr POLICY @ Lnem M• TYa or asOaAaw - � tRWn/rrTn ' oMronmr, GENERAL LIARII,ITV - sm occ mms [--IcC MRKIU GENERAL LEADILIn, DaeEE tD EOTNE - PAi1lIssslE•.•...re••o•) { 013CLAIM3 MADE OCCUR P9 m (Aq a P.—) t - y PYEOAo1.G ADD,MUST { - �EDL ROOAEOATE {. . GEE'L AGGREGATS LD)IT APPLIES ER: EIPOLICT CIPRMCT❑IOC ■AiUCTs- COW/O am { i AVID LL><II.1TY COODSD ZZWLE LIIIT _ (..•o.id st) t 0An AUTO EOIL!DAISY (Nr Mnol i ALL QOED AUTOS MILT IOIEQ(Nr•mid-o { �SCNEDW,NE AUTOS PAePRT!Duets t ❑OIRED AUT03 (P•r•..lY,t) . 0E0E-OIe6D AUTOS ,, - OMRELLA LIAR 0 OCCUR EaC,1{CC(O110aC[ t 119DCE53 LEAD El CLADO MADE DNEUCTIDLE - t aofines oa�aaATzaE ® °TM AND mLOI�i rsAsarLT '�L96Ti n` THE PROPRIE'OR/PARTNERS/ E.L. EACH AcemssT ..tit 500,000 A E%ECUTTIYE OFFICERS ARE t ® inc1 ❑ excl 7004943012012 01/01/2012 01/01/2013 E.L. DIEEM -POLICY LnaT { 500,000 E.L. 9I3EANE -EA EOLDYEs , 500,000 Comm", Kscamrso t■ NEEEanew OA LOCATLEEs: WORKERS COMPENSATION COVERAGE APPLIES TO MASSACHUSETTS EMPLOYEES CERTIFICATE HOLDER CANCELLATION PROOF OF INSURANCE aHofLD ANY or am ABOVE DRscRam soLxas ME cArcar.ISD svoas THE - RUINATION DMM WMEOl, NOTICE WILL RR DB,IVaM IN-ACOOUMM WITH TIER Paz=PROvlsloas. aurraNEsm NEPEsso■nriE . 5289