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0363 OLD CRAIGVILLE ROAD
i^. c i > ..,rt a �*'.•�.� �:• d � ,.ace � �t: M ,�.�,. � � `'.!] s n U' t h s k+ , e rr' . /- l7 -1�? Town .of Barnstable 200 Main Street, Hyannis,MA 02601 508-862-4038 - ' ` Application for Building Permit Application No: TB-17-99 Date Recieved: 1/17/2017 Job Location: 363 OLD CRAIGVILLE ROAD,CENTERVILLE Permit For: Building-Insulation-Residential t . :- Contractor's Name: Elwell H Perry State Lic. No: CS-104088 Address: Acushnet, MA 02743 Applicant Phone: (508) 992-5770 (Home)Owner's Name: BRENNAN,FRANK& BARBARA Phone: (508)771-0435 (Home)Owner's Address: 344 WEST 12TH STREET APT 211, NEW YORK,NY 10014 k ..� Work Description: SEE ATTACHED CONTRACT '" ~"= Co . tav Total Value Of Work To Be Performed: - $79352.00 Structure Size: 0.00 0.00 0.00 Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with"the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this'application or the authorized agent of the property owner and have' been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: Elwell Perry. 1/17/2017 (508)992-5770 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost: $7,352.00 Date Paid Amount Paid ? Check#or CCN Pay Type Total Permit Fee:. ' $87.50 1/17/2017 $87.50 XXXX-XXXX-XXXX- ` Credit Card 4419 a ... . ........... Total Permit Fee Paid: $87.50 J44— Sheet Metal Permit Parcel ��S ®{a+[�Jp!■]p/a��.�/(.[j/�].��i ; Date: .... JUN 0. 8 20a Permit:# /!o 6 Estimated Job Cost:S 5 oo 0 o ._I FBA ' Permit:Fee:3 STAB.L Plans Submitted.: YES NO" Plans Reviewed: YES NO Business License# Ak2lt Applicant License# 7` 51 Business Information Property Owner j6J ,Location.Inforination Name: firh o.t V 12Ali�� Name: I7 _ p rt^fcul Street /5 oeek ALI )j Street: laid: Git own: fJ Gr yl✓US City/Town Ce-v1 Vice Telephone 9�D k" yZ //7ta Telephone: 7 71 57�6 Photo LD.required/Copy of Photo.LD. attached: . YES -✓ NO, J 1/M-l-unrestricted-license. .J-2/M-2 restricted.to dwellings 3-stories or less and commercial up to 10;000 sq.-ft /.2-stories or less Residential: 1 2 family X Multi-family . Condo/Townhouses. Othei Commercial: Office Retail Industrial Educational . Fire Dept.Approval lnstitu#ional_ Other Square Footage:'under 10,OOO.-s4. ft over 1-0,000 sq.ft. Number of Stories: i Sheet metal Workto be completed: New Work: Renovation: HVAC Metal watershed Roofing. Kitchen Exhaust gystem ' Metal-Chimney/Vents .Air'Balancing I Provide detailed description of work to be done: .1 ns 'Al 34" 'A AAC A)'111 md& Air�ec L1dX�6' 'Ceu CU�c 14 14e - c i INSURANCE COVERAGE: 1 have a current Habilitv.Insuranoe poBcy or its_equivalent which meets-the requirements of M.G:L Ch.112 Yes❑,No' ' If you have checked ygg Indicate the type-of c6verage.by checking the appropriate box.below: 1 A iiabifty Insurance pol cy ❑ Other type of Indemnity ❑ Bond ❑ OWNEWS INSUR¢NGE WAn{El2:l am aware;that the licensee cioes.-nof have the insurance coverage required by Chapter 11�of the Massachusetts General Laws,and that my.-signature on'this-pennit applicaation*.wgives-ifiis requirement Check One Only Owne Agent ❑ - Signatum of Owner or-Owne -s Agent I By checking thls,box(],I hereby certify that all of the details and Information-I have submitted(or entsrec't)regarding this application are true,and ` accurate to the best of.-my knowledge and.'.thaf all sheet metal work and instdilations,performed under the permit issued forthis,appricatidn will be In compliance with all pertinent provision of the Massachusetts'Building Code and Chapter 112 of the General Laws. Duct Inspection required priorto-insulatiori installation:YES NO Progress.Inspections : : ,- - Date Co=eIIfis ----------------- Final Inspection Data Comments Type of,Ucense: 3Y ]K Master rfie ❑Master-Restricted '1ty/Town , ❑Joumeypeson Sign re of Licensee �eun t.# .❑Journeyperson-Restricted Ucense.Nurfibor. �W5 =ee r � Check at www.mass.grrKJc#bI - .. inspector Signature of Permlt ApprovaC a ( OMWE�►LTH MON OFM���A :�iUSESz S4ttpET�' ETNAL W0: KRS �74 - " Ia=SSFU EIS TH EiFO LOWIG aL f CAE NHS Eat ,RS Al�hl�lSuTER�UNRESrTRI� HYOw04�SR,I"EN S } y 3 6 N�E,CtC{�Ro����� � 5 y, c � ll I LICENS , _1-4 —'9d,NU NONE.. r3 r" j a 15 OAK NECK RRDsJ, ,` ' ° TeT77 N% � ��HYANNIS MA 02601.4584� '� — . ,. _� J I � DD:a2,ja 7D13 Rev W 152009t'it'`s� Fes 1• - T OINIIlAON111/EALH .. . Of M'1 A H,I S.E' .; SIDEE {kL WORN, f ISSl1ETHE FOLLOWING I_f•CENSE t+ �� ' ��� 4 -A ,AASTEUKRETRI� cc mm 1��OAKRFE1;K RDA �yt;v wa Z. c i - ` DRIDER' HONM2558 rtL. UNICT r :7 rY HXANNISiMAr026014584r ( - 3 >" �t�r�rorcte��f.�'�rrtr� 66:0 WmhiWan %'�-ee# ,. $mar,,MA 02 Winrkersa Campensati€=Lisw-ance dam Buff rs/Cnnt r+JE[echiciaus/Ph6abers ,r�7 tIafarmai t n Please PrintLeeibly Name C Q.rn - - - Addre—ss7 I ocep Meck APt 32- Ci€y/stattg4: "I fus (64 N-6 01 Phase 9-- So 9 Are you mu empkyer? mk the appcupriate btr:= Type of px rj tt(rogai=d�- ;_❑ I am a employer via 4. ❑I ama gCOMMI ctmfiactor and I 6_ ❑Ides c=xEr�oa employees{fall andforga t-f=e5* havehire&the gab-00ntE&dofs I'X I am a sole proprietor m partner- listed on the ached sheet 7- ❑Retmde4ig ship and hate no employees These sub-contractors have, g- ElDeanlifiba. wod ing forme in any capacity employees and have worms' 9_ F]Builrng addifion INa workers'comp:fimuance Eomp-,nsma e I - mir I 'S:❑ We are a cotporafianand ifs 10-I 3+'ieCEd a1 repairs or additions 3_❑ I am a bomeawner doing aII woik of rxrs have e=rcised thew II-E1 Fkmbirlg=sus or additionsfW . f[NoworSM'� of es anger)SrfQ. I� $nafrepahs, axt rrn+�reXeTaimdj T r-157,§I(4 and we have no =FAayees-INCr wodm& cam-n,s=aw.roluire&I `farmgr tad ehe fiv— osasn out t sectianbdaws'h�ffies T �Hameawn�as uba sffbalrttbis�d�afftn�g tizeya��g sIIzroric aesitbeabae o-�eco�etois�stsn�a�es s�d�t su['� �aatractncstbsFrS+orYthisbaxm>Fststlache�saa�dirioaYlsheetsbtrwdag the nameofthe scansfusE tiPsrye employees Ift1e soIr corf,,•�h3re r�pIayees,ffiegmvst pxuvi3e ter `tamp.palicS amuhez lam an gRrp7�yeF#hatispr�r► t�br�ers'cor�ansQhdt:€zurtFauce far rri}�eMp£oyczsa �elat�is fls���c}'rur3 jnb trtfbtYrtatirx�tt. - ' Insurance CompauyNarne: PoSL-j:g or Self-iceIi� - FxpifafsonDate_ Job Site dress i Cify/StatdZip: A-Rach a:cap'y'of the workers'compenI=tion pa&cf detTxrstion page(vhowing thep aRcy r€umher x)td exp�rztto L date). Failure fo secure-average as regffamd.nuder Sectmn 25A of MGL r- 152 can Imd to tie imposition of criminal pcmdties of a f e np to$I-5MOD andlor ow-yearin3p:Esanmient m wen as civil gem is the fours of a STOP WORD ORDER-and a fine ofttp to$250-00 a day against f .e violator_ Be advised that-a cog of ibis maybe fizwmiclod to the Office of Intesfigations of the DTA€or msarance coverage ran- I dd hgre-by certify under&zpains Andprnah9aqfperjW7 fh¢k$ia nxrrta`#iaa prrrtTidgd above ii truss and correct 1� r � Dam IWECLa£Use urtF}: E10 trat Write in tF S area,to bit camp&toff by ch�p arr tafm ojftc-&L Cif or Town- Pe3�itllicense Fss�c'l_tithority{drele ones L Board of$e.1th 2.Big-ding I3egartraeut I CiVr,awa Qerk 4-Eleaftical 1 nspmtor S.Plumhmg r .6.Clthfz- CeEfact germtut.: Phone 9z F ]Information an.d 1hastructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Piasnantto this s'FatotE, an employee is defined as"---every person in the service of¢pother under any contract of hire, express or implied oral or written-" An mFroyer 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,pmt=:s14,association or other legal entity,employing employees- However the owner of a dweIli:ng 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,wnstruction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to bean employer." MGL chapter 152, §25C(6)also states th2t¢every state or Iocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for arty applicant who has not produced acceptable evidence of compliance with the insurance:coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting anthority-" Applicants e Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone numbers)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or United Liability Partnerships CLEF)with no employees omen 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 Deportment 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 numbers listed below. Self-insin ed companies should enter their self-in irrance license number on the appropriate ae. City or Town Offfcials . • Please be sure that the;affidavit is complete and pzizrted legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be.sure to fill in the pezaah/license number which will be used as a reference number. In addition an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address-the applicant should writ$"all locations in (city or town)."A copy of the affidavit that has been officially stamped or m ±t-,d by the city or town may be provided to the applicant as proof.that.a valid affidavit is on file for firfinepermits 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 rewired to complete this affidavit The Office of Investigations would lice to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call- The Department's address,telephone and fax number: act CoM=rzt W1h of Massachustits Depaztmeint Qf Ind a1 Aocjde �s 600 Washmgtou $ zz�Ili G2111 764 A 617 727-4 M t.-xt 4-06 or 1477-MA.E�S� Fax 0 617-`27-�49 Revised 4-24--07. - Yww-mas5�.gavIdia Town .of Barnstable ' .� Regulatory Services MAM Thomas F.Geffer,Director BuRding Division Tom Perry,Bufid4:CommMoner 200. Stredt Hyannis,Mk 02601. www:towiLbamstable=a.us ` Office: 508-8624038 Fag; 5.08-790-6230 Property Owner Must Complete"and.Sign This Section If Using A-BrdIder as Owner of the mb'ect to . .l P -Pert9 hereby authorize )R o fL © to act.an mp behafif, in .to work.authorized by ihiS.building:Pemlit 3(.3 6)d CMnV(1)r Cehkyr f Ce .(Address of Jab) *Pool fences and alarms are tl 'e responsibility of the applicant. Pools are not to be filled before fence is installed and pools are not to be utilized until all fmal inspections are performed and accepted. Signature of Owner d. S.ignature of A cant Print Name Print Name Z 1'6 Date Q:FORMS:O W NERPERM3M.ONP00t.S C �1►�iy ,F_ g6 a r Town of Barnstable *Permit# Expires 6 months from issue date �7 Regulatory Services Fee IARNSTABLE f Q ❑ '{1} rtAss.039. $ Richard V.Scali,Director — Buil — Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 _ - www.town.barnstable.ma.us V�EIA Office: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY yD Not Valid without Red X-Press Imprint Map/parcel Number - _- Property Address ���.� /_IPrz� 4'� fig zlll " fo Residential Value of Work$ - Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name �,� �� Telephone Number l7G'✓�' � - Z Home Improvement Contractor License#(if applicable) Email`. Construction Supervisor's License#(if applicable)—� ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner 0/1 have Worker's Compensation Insurance Insurance Company Name ��I�c�[�Cf Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit R st(check box) ,�J UquRe-roof(hurricane nailed)(stripping-:old shingles) All construction debris will be taken to }jit� t���/�' ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked-with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. 'Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is wired. ` SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313 � E Town of Barnstable Regulatory Services * anxxsresr,E, . Mass. Richard V.Scali,Director i639 �� 'DrEo " Building Division mom-P-err-y,-Building-Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 ``-Tax: 508-790-6230 -.rt Property Owner Must Complete and Sign This Section - If Using A Builder ,as Owner of the subject property hereby authorize � �1 � to act on my behalf,- in all matters relative to work authorized by this building permit application for. (Ad(Iress of Job) Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature er Signature of Applicant Print Name Print Name • ate Q:FORMS:OWNERPERMISSIONPOOIS Town of Barnstable Regulatory Services �oF TOiyy Richard V.Scali,Director ' Building Division t Tom Perry,Building Com" issioner Mass. 1639- ��� 200 Main Street, Hyannis, 02601 ATEO �s www.town.barnsta e.ma.us Off-ice: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION �n- - Please Print DATE: - -. - JOB LOCATION: number',,.. street f village "HOMEOWNER": f name \, home phone# work phone CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"wads extended to inclpde owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not po sess a license,provided that the owner acts as supervisor. `\ DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/shejesides�or intends to reside,on which there is,or is intended to be,a one or two- family dwelling, attached or detached structures acces`s'ory 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 res onsible for all such work performed under the building permit. (Section 109.1.1) \X The undersigned"homeowner"assumes responsibility f�`r 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 d requirements. Signature of Homeowner i R i Approval of Building Official t Note: Three-family dwellings containing 35,000 cubic feet or larger will be required t comply with the State Building Code Section 127.0 Construction Control. i i HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provi ed 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,RuIes &ReguIations for Licensing Construction Supervisors,Section 2.1S) This lack of<4wareness often results in serious problems, particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor_ The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS,doc Revised 061313 o The Carnmc nypeal i of Mm-achusela Deprtment afbuhv3&d Accaderrt -- — - .- - Boston,MA lJ2MI . N�F4'17�rrius goWdia Workec-s' Compensatiuxil sm-anc davit:Buildersf,Cogtra_ctorslE:ectricians/Kumbers pEcant Infarmation. Please Print Leeibfy Name �oypnizafionaividual7_ —T-7� City/StatL-JZip= _ Phone _Are you an employer? Check the appropriate boT.: T of. o sect r fi-_ I atrf a eueral confractor and'I �' � ����- 1_gI a_m a employer with g 6- ❑New costitxtoat employees(fait andlo�* have hired the surd-contractors. 2_El I^,Tn a sole p opr etor or partner listed on the s ached stet 7- ❑llemodeling sbm and bzve no employees Thee VA-coatracfors have g- ❑T3emoliiion suozl£iag forme many c cr �_ emaplxa��and have woikers' Y � t1 9_ ❑Euildiag addition oworkers' C:6IIlp_STiCnSTAnr'e camp_InS11raIICe_ 5-❑ 'biz are a corporation and its 10_❑Ebecfiical repairs additions x�gntreti� 3.❑ I a hom rnet rifling all wort officers bwtim exercised their 11-0 Plumbing rep .arrs or additions. rrr-yself [No workErs'ccaaT_ right of e2mmption per MGL 12�i�of�s iasurance required_]I c- 152,§1(4} and we have no - ernploy-ees_[No worm' 13_1-1€)firer comp-insurance requriresl_jI rry pborat that rhacks box fl mast slso fal out the section-below shny ing inea woa3cers�cos�ertss�io�Pow i r�rdio� ,ro szDma his afdxv f inffirstatg tuey sre 6rmg g11 xf� and Bien bire outside:cootrsams sue&_ fi tr-tmctrnrs fa-,rt check this box matt attached an sddifionsI Meet shvumg 1L nxme of s ors�md stslg vrhetlec dcna those ufies 5 Ernlffyers_ IytTh--s-a-coat�--ctum 1zce mpIoyees,the}u-Si pm,—e th-._r cvor3esss'comp_policy memberZIA- �m an t:rtg?oy�'7`r3rrttisgrat�i�g tvor�ers'c� turfivtt arisrtrartce f`at-rrt��emzgi�ye�. f�aIatF is tFt�gaFic,}arcd job ifs u�_fctma�ost< Itce Gornpari?�Name: � ZlZ�t'�; '� � - 1 Fo3icy S�1f ice_Lim Expiratiort Date:_ Job Site A-d&ess �Ly � i/ ,�9' ) 1 i, Citw''StatdZip: �I AMaclz a copy of then'workers'compensation polio-declaration page(showing the policy-number and expiration date). Failure to secure coverage as required ender Section.25-k of MGL cc 152 can lead to the imposition ofcximinal.pezaalfics of a fine up to S 1,500_DD and/or one-yearimpri50=ncat,as well as civil penalfies in the foam of a STOP WORK ORDER-and a fine of up.to$250-00 a.day against the violator_ Be advised that a cbpy of this statement may be forwarded ta-the Office-of Im egtigado3s of the DIA far ama—nic-e.coverage verification_ I do harebyI rti}y Ib tksgrans and-PenauTes o�`g dal,y fftatfTre iruformatcr2n prm2dsiiabenre is tnxa and correct Signature: Bate_ Phone :y L ©Uncial use only, la not wr&in this area,to bs comp eted by cif}:at town oficiaL City-or Town: PwoiitUcense# issuing Authority(circle one): 1.Board of llealtlr BuUdiog Department I Gityfrown(Jerk d.Electrical inspector 5.Plumbing Iuspeeor .6.Qther Cost-tct Perron: Phone 9: 6 Information and Instructions . . Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees• Pursuantto this statute, an employee is defined as"_..every person in fire service of another under any contract of hire, express or implied, oral or written_" An employer is defined as"an individual,partnership,associati corporation or other legal entity,or any two or more of the fore ing engaged in 2-joint enterprise,and including legal representatives of a deceased employer;or the receiver or ee of an individual,partnership,association o other legal entity,employing employees_ Flowever the owner of a d ell3ng house having not more than three ap ents and who resides therein,or the occupant of the dwelling house of another who employs persons to do m ' enance,construction or repair work on such dwelling house or on the groan or building appurtenant hereto shaIl.no because of such employment be deemed to be an employer." MGL chapter 152, §25C(t7 also si2�s that"every state or local licensing agency shall withhold the issuance or renewal of a licen or permit to operate a business r to construct buildings in the commonwealth for alay applicant who has of produced acceptable eviden e of compliance whiz the insurance.coverage required." Additionally, MGL ch pter 152, §25C(7)states"Ne- er the commonwealth nor any of its political subdivisions shall enter into any contract Or the peiio_rmance of publi work until acceptable evidence of comph.o_nce-will-i the insurance requirements of this chat r have been presented t the contracting authority" Applicants Please fill out the workers' c�mpe sation a�1i vit completely,by checkir..g the boxes that apply to your situation aid,if necessary,supply sub-contractors)naine(s), dress(es) and phone m rber(s) along with then cei-ificaut(s) of insurance. Limited Liability Co?Tipa35 CLL )or Limited Liability Pas�ie��lps(i_LP)vrrhno err�play��s other than i1e members or partners, are not<eed to workers' compensation i 3siL once_ If an LLC or LLl'Foes have employees, a policy is req il red- fie advise Ihat this affidavit may be snbmiited to the Depart rent of Indus-trial Accidents for confirmation of insur ance co-el C. Also be sure to sign and date the affda•c t "11re a;Edavit should be returned to he city or town that the app cati �for the permit or license is being requested,not the Depar anent of Industrial Accidents. Should you.have any questiDs regarding the law or if you are required to obt a -i a workers' compensation policy,please call'he Dep eat at e number listed below. Self-insured companies saoild enter. their self-incilrance license number on&je anpr prime line. City or Town Ofl-acials Please be sure that the affidavit is cempl,te and printed legibl The Departrient has provided a space at the bottom of the affidavit for you to fill out�the q'�ent the Office of Inv ations has to contact you reg�:rding he applicant Please be sure to fill in the permit icens° number which-,,U be us as a reference number. In addition an applicant that must submit multiple penit/h=lapplitations in any given ye need only submit one ar�davit indicating current policy information (if necessary)and q�, der"Job Site Address"the app cant should write"all locations in __(city or town)."Acopyof the affidavittllaihadeen officially stamped or marke'by file city or town may be provided to the applicant as proof that a valid afrida�iz`is on file for future pessi or lncens . Anew affidavit met be filled out each year_Where a home owner or citizen 6 obtaining a license or permit not relat to any business or commercial venture (i_e,a dog license or permit to burn leaves etc.)said person is NOT required to mplete this affi davit_ The Office of lnvestig Lions would lit e to thank you in advance for your cooperatr a and should you have any questions, please do not hesitate to give us a tali. The Department's address,telephoned fax number: 'b�Commnnwt-,aTttt of hfassach sets De- aztment of Iiidusbial Ac-r-ide-nts Office of uyesfigatian! 600 Washes oa Boston,MA 02111 Ttl,T 6I 7;727-49-Qo w 406 or 1-97 1\LkSSAYE Revised 4-24'-07 Fax r 6 f 7-727- `t 91 W WW Ba_aS.S_gnvF C. -- ork�no,n�.ae�.11/'gt'G ivua�/r�a 11� Liana or rctittratlop valid for individul wo only. Oftice of c5o wsrer AfWro&Bwlaess aegvisflos hdore the uptratiop date. 1f foved return to: ImpiNNFmENT CONTRACTOR oRlee of Conover Af[airs and Basluss Repistion 100497 10 Park Pim-Suite 5170 mom; 3 g . Private Corporador Boom MA 02116 OAVIa OOX INC. David vox 19 LAVENDER LN W,YARMOU TH,AAA 02673 Undenwretery Not valid v►ititout signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards Caastructinn Supem-Sor Licenae' CB-0d363yJ�,' po BOAC 401 r - South Yarmouth FAA. Om lei J,�•••�� „ �,� � =xoiraSlCn '1a15WIS Commissioner I INI..I'.Yvlr vu.lwv ,Wd. •. ^....., DAVIO-2 OP ID:KG CERTIFICATE OF LIABILITY INSURANCE 0 wNYyr��1 „ ' THIS CERTIFICATE 13 138UED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE GOES NOT AFFIRMATIVELY OR NEGAMVELY AMEND; EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER14 AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE.HOLDER, IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)trust be endorsed. If SUBROGATION IS WAIVED,SL"e-t to the terms and condttlons of the Policy,certain policies may require an endorsemenL A statement on this eertllleats does not confer rights to the oatl8oste holder In lieu of such endorsements. COWACT M60-- It Northwood0 Main t eK 8'uiti 'Inc. ,308.771.1632 L tAJc.N. 508.393.2958 Hyanrds,MA 02601 WWRKOI AFFOPUNO CawstA3e NAIC t _ INSURER A:TraV610M InsuranCe Company Nam David Cox. Inc. INSURERS: P.O.Box401 $Ya rm o uth,MA 02664 INeURER 6: INSURER F: r _ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS iS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOVV HAVE BEEN ISSUED TO THE INSURED NAMED A50VE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR.CCADRION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICt' THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBEC HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITiGNS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. AUMT►PE OF 1NANCG PQ_ICY NUMBER...... LIMR4 —� A i GOMMIlft OVARAL LIApWTY EACH T CLAIW.SM.40E UCCUR j 0a1481M7 03i14/2014 03114/2015 I i I; ,«;rra 300,00 X usineee C11 nsm �. MEDeKP{Anv one pwzonl S 5,00 ilI QE�ML AGGRE:a w E_iN1`APPLIES PETi' I i 4 I `� f• GENERAL AGGREGATE S •2.000, PQU,:° PR l I w PrP.O—QVCTS• MziOP Avv S yOOOe i JEr:T LOG I OTHER. I �T i (E5 t;adenC ANY AU-') 1 F Oi_i 1 ft.t.URY;Par person} S ALL`WNEU r" 9CHLDU�EC I AU'TGS AUTOS I I BOLO-Y?+'dYURY(Pnr a=dantl I HIRED AL'TOH NON 4VJNEi.r i AUTO. Par asiaenn I S UNSRULA UAI 0,_:LIR I EACH 0::JP4E1q.? I s y 4riCffaiLiAti C1.ACrl5-MAD. I i � `AGGREriA7E __TS DEDi 7=T iJ S W0 R{C YI STATUT: j R _ _ AND EYIF:OYlRB'LIAEIJTY A W1 PROPRI£TORIPARTt1£R,£ieCLM 1 YIN jf ORRTWILr.FOLLOW PROM 00 Oti18/2014 0711612015 E L.EA.Cr ACgOENT 5 100, Imar tit EX�.ut7ECr I NIA! I [WITHIN 3 DAYS _ _ _ _ Q E� GISEASE•EAE�FLUrf 5 1DD, U�Y6:.d9e MIW tWar y E t.DISEASE.POLI_Y LIMIT ._._80 DfZ6CR ri 1. FOPEQA'IONS.QiCW I ..,�_ i pEeCR�)tCN OF OP`cRATIOHe f LOf ATtONe 1 YEMCI ae (ACORD 101,AddIU®nal Remarks Sehad,Aa,maybe atted ad P mere apace la required) CERTIEGaTg HOLDER CANCELLATION TOWNBAR SHOULD ANY OF THE ABOVE DEBCR SSO POLICIES BE CANCELLED BEFORE THE EXPIRAMN DATE THSREOF, NOTICE WILL U DELIVERED IN Town of EElrnstable ACCORDANCE WIRN THE POLICY PROVIEIONY• 230 Main SOW Myantlls,MA 02601 AUTHORIMpt6P%t58E IAl" ioe (D1988.2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD