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0516 SKUNKNET ROAD
n �. 0 4.. Town of°Barnstable *Permitowff, Expires 6m issue d Regulatory Services Fee o ansxsrwBr,E, = � 16 9. � Richard V.Scali,Director ® p ,y , Building Division Tom Perry,CBO,Building Commissioner 1 3`2015 200 Main Street,Hyannis,MA 026 1 www.town.barnstable.ma us "IAB L E' Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERAHT APPLICATION RESIDENTIAL ONLY Not Valid without Red X Press InWrint s Map/parcel Number I og D 1 Property Address �i I o pc [iesidential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address CJ �Q ()�UA 4 Contractor's Name Ct�()(�K l �I " ; Telephone Number �`� a Home Improvement Contractor License#(if applicable) Z Email: Construction Supervisor's License#,(if applicable) ❑Workick 's Compensation Insurance one: , I am a sole proprietor ❑ I am the Homeowner ' ❑ I have Worker's Compensation Insurance , Insurance Company Name *' Workman's Comp.Policy# { Copy of Insurance Compliance Certificate must accompany.each permit. ' Permit Requ t(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 b. wy a ❑.Replacement Windows/doors/slider.s:U-Value _' (maximum.32)#of windowsM #of doors: ,5 ❑'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. rx Ap ***Note: Property Owner must sign Property Owner Letter of Permission. s , A copy of the Home Improvement Contractors License&Construction Supervisors License is require SIGNATURE: QAWPFILESTORM building ermit forms RESS.doc Revised 040215 - _- 2ia aJ_i• :ail' - •�9iiTJ it a��Y:i �v ilk r r 1i ��r= �'R ■a lfia:-r•.'1t;i!] 7..it .tl'r' � )rI■� it i i7 1 i1�ir _.rtr7 Yt�/u.wl,.i t flr1.r'► c1�yF. 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It■� .• It" /•1.w•l ■t -t/• .:.■ /.■ • "•." � •tr%..). f. . ■I t • •I • i■ •■/ 1 ■■1: .. .��■ •■■M:I• 1:..{.�. •: .._f■��■ • tt / • at i.•'l w- • .I •• •�. • II i =/•I .+:■\ - . •• Ia_ . :It• • 1 •n 1' 1\ ■\I.•I - ..11w l u ►�. - t ■r l. tw. . �{i• • 1 l �[ i ■� - ■•.1- • ■r •! Mia•//• ••1:/..a/' .r3.t.� •1 .art.1 .• tea 1• _f1 •.A•aw i�i •I I\I•Ll.!A w •1•t.. " . •.' rwa • I�■..1 .. .t1/■ � 1 • .� "•t 4 � �./.. ►• 1• I.■w I t" ■. : It.. ■- �I■► • ■t•w•':■•. "•• ! I.�" [. It:w. •t ■[ :•t•:U r' .■t ..l ••..� _../t ..!• t.■ t a .: ■ r•a•■.■rat :•a �. I�.'.I of- a1. s: .nn. ■- •n:■■•er•'=�: n • .,�w I ram...■■, v in i 1 i n■•- 1111 ti■ �� 1 / �t * R , �,�� Town of Barnstable Regulatory Services Richard V.Scali,Director. Building Division Thomas Perry,CBO 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 as Owner'of the subject property hereby authorize to act on nay behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date Print Name i If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q:\WPHLESTORMS\building permit forms\EXPRESS.doc Revised 040215 Town of Barnstable Regulatory Services of Richard V.Scab,Director Building Division t Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Ep www.town.barnstable.ma.us Office: 508-862-403 8 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- 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 buildingpermit. (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:\WPFlLES\FORMS\building permit forms\E PRESS.doe Revised 040215 ' WN Q 4v $ 1 � � Sa��ili5@� ��rtrtf�,rE1 6f PiihltC �� $` 7 x3 itul Idlifl Uk�!iq#ss ats�Sta un '` ttftcr:n r`: ralf LtG�ASP C�L t4� z r, `' .GartttYA�Stb'A� � #resrt Office of t onsumrr Affairs&Business Regulation ,j' License or registration v alid for inditi idul use only before the expiration date. If round return to: � �OMEIMPROUEMENTGONTRAGTOR P . 3311kegistration: 173192 Type: Office of Consumer Affairs and Business Rehulation .;t:xpiration: 9/11/2016 DBA- 10 Bark Plaza Suite 5170 Boston,;`LA 02116 COREY AND.COREY CONSTRUCTION PATRICK CLIFFORD 12 BALDWIN RDaDENNIS.MA 02638 Ctodrrsecretary Not valid°without gnature C iY COREY Ut CONSTRUCTION 1672 FALMOUTH RD #117, CENTERVILLE, MA 02632 PHO;HE_-` ,'141 -77T5�.gZL4,p CE=RTAIRTEEDt L.AR0, KARK PRO: L:I: F'ETIME--ALGAE: RESI:START ARCHITECTURAL, STYLE RE- ROdOF'I; NG PR.O¢ POSA.L . February 3, 2015 BOB PACKARD 516 SKUNKNET RD EM: packardbb@aol.com CENTERVILLE,MA Tel: 508-364-3636 COREY & COREY hereby propose to perform the following services in a neat and professional manner and in accordance with the manufacturer's specifications and local building codes. Remove and Haul Away All of-the Old Asphalt Roofing Shingles. Remove and Haul Away All of the Old Sheathing from the Original Part of the House. Supply and Install 5/8" CDX EXTERIOR GLUE PLYWOOD SHEATHING on the Original House. Supply and Install CERTAINTEED LANDMARK PRO: LIFETIME WARRANTY, 10 YEAR a SURE START PROTECTION,CLASS A FIRE RATED, COPPER/CERAMIC STONES-for a FULL 15 YEAR WARRANTY AGAINST ALGAE i CONTAMINENT,250 POUND,EXTRA HEAVY WEIGHT, 130 MPH WIND WARRANTY,CATEGORY III HURRICANE, STORM/HURICANE NAILED (6 NAILS PER-Hi GLF.), MULTI-LAYERED, LAMINATED ARCHITECTURAL STYLE,FIBERGLASS BASED ASPHALT SHINGLES. COLOR..1l'L'rrllP Supply and Install HICK'S VENTED ALU 1lNUNM DRIP EDGE After Cutting an.Opening at the Top of the Fascia Boards. Supply and Install CERTAINTEED WINTER-GUARD (Ice& Water Shield) WATERPROOF UNDERLAYMENT SYSTEM on Roof Eaves& Under the Step Flashing on the Skylight and Gable Wall. Supply and Install #15 BLACK SATURATED,FELT ROOFING PAPER Supply and Install AIR VENT SHINGLE VENT H RIDGE VENT on the Both Main Ridges. Supply and Install ALUMINUM& NEOPRENE SOIL PIPE FLASHING Clean.and Remove Debris from work area after job is completed. TOTAL INVESTMENT ------------- $ 9350.00 L".' OREY & "COREY '0 CONSTRUCTION POSSIBLE EXTRA CARPENTRY: Any Rotted or Otherwise Deteriorated Trim Boards, Plywood Sheathing,Missing Metal Flashing, Side Walling or Any Other Carpentry Needing Replacement will be done and charged for as an Extra: Materials Plus Labor at the Rate of$ 80.00 per Hour. PAYMENT SCHEDULE: A Deposit of One Half is due at the Signing of this Roof Proposal and the Final Payment for the Balance is Due Immediately Upon Completion. WORK SCHEDULE: All Roof Work is Scheduled for Completion Within 60 Days of Acci&�,4ance and Receipt of Deposit providing the Materials are Available. Therefore Deposits Received are Non-Refundable After a Three Day Cooling Off Period from the Date of signing. This Proposal May Be Withdrawn By Us If Not Accepted &Deposited Received Within Thirty Days Or Before The Next Price Increase In Materials Please Make Checks Payable to: PATRICK CLIFFORD COREY & COREY Warranties the Shingles and Labor for 10 years. CERTAINTEED Warranties the shingles and labor 100% for the First 10 Years and the Shingles your LIFETIME if the shingles becomes defective. CERTAINTEED Warrants the Shingles up to a CATEGORY III HURRICANE-130 MPH WIND WARRANTY. CERTAINTEED Warrants the Shingles to be Algae Resistant for a Full 15 Years. COREY & COREY carries Workman's Compensation and Public Liability Insurance on the above work DATE OF ACCEPTANCE: ACCEPTED BY: SUBMITTED BY: . OB PACKARD AiIARLES COREY, CONSULTANT HOMEOWNER COREY & COREY CONSTRUCTION , ilill /12/2015 RON 13. 5 FAX 5089923538 southeastern IA ,�• corm r, CERTIFICATE OF LIABILITY INSURANCE DATE(MM1ODlYYYY) 1/12/2015 IS 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: Ifthe certtficate.hoider Is an ADdIT10 AL.INSURED;the>pollcy(fes)must be endorsed. If SUBROGATION IS WAIVED, subject to the certificate and conditions of the policy,certain poilnes may require an endorsement. A statement on this certificate does not confer rights to the certtQcatehofder in Ileu of such endors.ement(s). PRODUCER _ SoutheastFra Insurance NAME Joanne Bretton 439 State Rd. Agency, Inc. PHONE -- _-.__- Ar No ), (508)997-6061 FA A L - I AIC.No:(508)990-2 731 Ill Box 79398 - •jb=atton@southeasternins.com North Dartmouth NA D2747 INSURERIS)AFFORDING COVERAGE NAIL x INSURED - --------- —_ INSURERA�.rbella Protection Insurance 41360 All Cape Exterior Remodeling LLC INsuREReAEIC - 12 Baldwin Road INSURER c: --- . INSURERD: ------ - Denni s INSURER E MA 02638 _ - _ --.....__.._.._.. _ COVERAGES INSURER F: CERTIFICATE NtJM13ER;2.035. THIS IS TO CERTIFY THgT THE POLICIES OF INSURANCE LISTEREVD BELOW HAVE BEEN ISSUED TO THE INSURED hAISION MED ABOVE OR THE POS PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TOCH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE.AFFORDED BY THE IPOLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYftAVE BxEN REDUCED BY PAID CLAIMS. INSR LTR; TYPE OF INSURANCE - I. I - .. GENERAL LIABILITY POLICY Nldil9cR OLfOYEXP i -- POLIO. EFF �P I i MMiDD1Yyy fMMIDO 1 LIMITS - X 0314+=�cA _t I EAeH Dcc Er,CE I£ 1,000,000 rER:-�LiA91LITv r A E I I !unA,,c. :e:v:_L: r------- LAI!dc,.MA7E I.X OCCUR 500041 '1 100,000 I I 933 .. tl/14/2015 1/14/2016 ; --"-- I i 4' C<P A•,y c;e ca c�.- is 5,000 I PERSONAS d A'1 JU I, 1,000,000 EN'L AGGREGATE iAM-Ao IE3 p=R j I j G 1v_PAL AGE aA E £ 2,000,00o 2,000,000 PCD,--y!� FlAuromOSILE L r < 9ODIY;NdUPY( r ce•so r INJURY i'er:c:Jwit C. I A er --------- I I UMBRELLA LIAB I �--� Li OCCUR15 1 EXCESSLIAB 1 i!CLAIMS67Ar3E - i EACH _ } P� I P"•TENTiON: I _ I AGCRE.,, - £ $ WORKERS CO MPENSATION AND EMPLOYERSCLtAStLITY - I I - ANY PROPoic7 /p c c Y/.N I I £ - L A TT,ER,�K.CUTNVE D-FICERrr,+It,3EREXCLUDED. IN/AI s LL — I(Mandatory kC5 0 0 18 9 62 014A 1/9/2015 - EACrc A _ NT T '1 000 000 I If res,tle✓.yE br:d5r --_-�i I �/9/2016 -� t .._SCR T OM1 O_OP`RATIONS be!cw I I i' "'SEAS-=A E IP;CYEE!£ 1,000 000 j I I E=_ ,oucr 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORO 101,Additional Remarkr Schedule,If more space it required) - CERTIFICATE HOLDER r CANCELLATION SHOULD'ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DAT E THERE I EOF 'X1 H o OlIIe TICE WILL Advisor ACCORDANCE WITH THE POLICY PROVISIONS. LL BE OELIVEREO IN 14`0.23 Denver West parkway Golden, CO 80401 EIiREPREsENTAnvE Joanne Bretton/JB •�' ACORD 25(2010/05) INS025 t?elan;eI ©1988.2010 ACORD CORPORATION, All rights reserved. The ACORD name and logo are registered marks of ACORD TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma Parcel /00 �p�plicatbn #lP Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fees Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Street Address S1 0 Village A I �e (/ V,- c Owner ` P6L(k9,1A11-1Address �S y y T Telephone ��� 36 3 6 Permit Request 4r`✓ ete do clol ct 4 leLte�, i Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation �V^ Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach � porting Ocum%tation. Dwelling Type: Single Family L� Two Family ❑ Multi-Family(# units) o Age of Existing Structure Historic House: ❑Yes ❑ No On Old King'$ .ighway: Yes° ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Othercn Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) ' w .rn 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: ❑ 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 ❑ 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 r (BUILDER OR HOMEOWNER) Nance 'h M(d tieAxsvt. Telephone Number, Address I ��w License# �C C Al IK Home Improvement Contractor# / v Email Worker's Compensation #/�-V6 33"3 ro ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 7 /� k` FOR OFFICIAL USE ONLY APPLICATION# 5 DATEISSUED r _ MAP/PARCEL NO. 1 , y ADDRESS VILLAGE t OWNER i r DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL 4 GAS: ROUGH FINAL r' FINAL BUILDING d '- DATE CLOSED OUT ASSOCIATION PLAN NO. Building Permit Authorization . I, Bob/Theresa Packard as owner hereby give my permission to Cape Save, Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Office:508-398-0398 to take all necessary steps to obtain a building permit to perform work at my property located at 516 Skunknet Rd Centerville, MA 02632 Signed v Date i The:Commonwealth of Massachusetts _ Departn:ent of Industrial Accidents Office of Investigations ' k 1 Congress Street,Suite-100 .r " yY . _,. Boston,MA 02114-2017 www.mass.govVia`` r; t Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. : % Applicant Information " Please Print Ledbly ~ Name i o Business/Or anizatin/ndividual)• _ ( g . -. Cape Save Inc °• _ '- ;- Address: 7D Huntington Ave City/State/Zip: South Yarmouth: MA 02664` Phone#: 508-398-0398 " Are you an employer?Check the appropriate box: Type of project(required): 1.0 1 am a employer with 4: 0 I am a general contractor and I� 6.`0'New construction employees(full and/or part-time)'- _ have hired the sub-contractors ,.: 2.0 I am a sole proprietor or partner fisted on the attached sheet. Remodeling ship and have no employees These.sub-contractors have 8_T1 Demolition ; workingfor me in an 'c,a acit . employees and have workers' y ' P Y 9.'0 Building addition comp. insurance.- [No workers comp.insurance required.] 5. 0. We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work= •� ' �, officers have exercised their l LEI Plumbing repairs or additions myself. [No workers_' comp.. right of exemption per MGL 12 [] Roof repairs insurance.required.]t c. 1,52, §1(4),and we have no employees. [No workers' 13.0✓ Otheer lnsulation.,-. A comp. insurance required.] + 'Any applicant that checks box#1 must.also fill out the section:below showing their workers'compensation policy inforination. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit;anew 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. 1 -I ant an employer that is providing workers'compensation insurance for my employees..Below is the policy and job site . . . information. r Insurance Company Name: Tec in6logy Insurance Company Policy#or Self-ins.Lic.##: TWC3353968_ �. . _ Expiration,Date-' 04/09/2014 " Job Site Address; City/State/Zip; 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 welt as civil penalties in the form of a STOP WORK ORDER and wfine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DlA for insurance coverage-veriftcation.- 1 do hereby certify under the pains and enalties o er' that the information provided abov is try,a and correct T , ' Siamature: Date =/ VZZ2 4 Phone#: 508-398-0398 .~ + Official use only.'Do not write in this area;to be completed by city or town official City or Town: - - - Permit/License# Issuing.Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other. Contact Person: r Phone#2 ACCOR" CERTIFICATE OF LIABILITY INSURANCE 10/22/20 3' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE-HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on.this certificate does not confer rights to the certificate holder In•lieu of such endorsement s CONTACT PRODUCER NAME: Colleen Crowley Risk Strategies Company IN&N . (781)986-4400 AC No):(701)963-4420'- 1S Pacella Park DriveE-MAIL Suite 240 INSURER($)AFFORDING COVERAGE NAIC>R Randolph MA 02368 INSURERA:Selective Ins. OF America INSURED wsuitEits:safety, Insurance Ccmpany 33618 Cape Save, Inc INSURERC:Technol Insurance 7 D Huntington Ave INSURER INSURER E South Yartoouth MA 02664 INSURER COVERAGES CERTIFICATE NUMBER:CL13102268490 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. NO1WrIrHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 1NrrH RESPECT TO VMICH 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. LTRR TYPE OF INSURANCE POLICY NUMBER 'POLICY EFF MIDD EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISESoccurrence) $ 100,000 A CLAIMS-MADE a.00CUR 91994480 O/16/2013 0/16/2014 -MED EXP(Any one parson) $ 10,000 r PERSONAL&ADV INJJRY $ 1,000,000 GENERAL AGGREGATE $ 2.,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO X LOC $ AUTOMOBILE UABILtTY COMEs. 'dent NED SINGLE L tC _ 1 000 000 ANY AUTO BODILY INJURY(Per person) $ B ALLOV%NED SCHEDULED 6208200 1/6/2013 1/6/2014 BODILY INJURY(Per accident) $ AUTOS X AUTOS X HIRED AUTOS X AUTOS PROPERTY DAM E. $ Per accident) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000: A EXCESS LIAO CLAIMS4ADE AGGREGATE $ 1,DOD,000 DED RETENTION S1994480 0/26/2013 0/26/2014 $ Q WORKERS COMPENSATION Officers .Included for X I O STAT IU- OTH AND EMPLOYERS'LIABILITY ANY PROPRIEfORIPARTNERIEXEGUTIVE YIN rage E.L.EACH ACCIDENT $ 500,000 OFF] CERIMEMBER EXCLUDED? I NIA /9/2013 /9/2014(Mandatory ih NH) jrr-3353968E-L.DISEASE-EA EMPLOYM$ 500,000 Ilyes,describe under, 7 r ' D SCRPTtON OF.OPERATIONS below 9 E.L.DISEASE-POLICY LNAIT $ 500,000 _. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD101,Addlional.Remarks Schedulo,If more space is required) Weatherization Specialists GL: Blnkt AI, Blnkt PNC, Blnkt WOS, Per Proj Agg, Per Loc Agg / GL Exclusions: Snow & Ice Removal/OCIP/Wrap Ups X ; CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE.'EXPIRATION DATE THEREOF, NOTICE WILL .BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENrATME . chael. Christian%CLC ACORD 25(20101001 ®1888-2010 ACORD CORPORATION. All rights reserved. INS025 polowpi The ACORD name and.logo are registered marks of ACORD R Office of Consumer Affairs and Business Regulation f 10 Park Plaza:- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 171380 Type:. Corporation Expiration: 3/14/2016; Tr# 249649 CAPE SAVE INC. WILLIAM MCCLUSKEY 7-D HUNTINGTON AVENUE SOUTH YARMOUTH, MA 02664 Update Address and return card:Mark reason for change. scAi zorwsii, Address [I Renewal f,Employment Fj Lost Card. �Xrr...r.nr-iucri�/t�r� llrrsiic/t<reli, . Office of Consumer_Affairs&-Business Etegulatl0n License,or registration valid for`individu f use only fiOME,IMPROVEMENT CONTRACTOR' before the expiration date. If found retain W. U. ;I2egis2raUon 171350 Type: Office of Consumer Affairs and.Business$egulation. Is ve , Expiration 3/14/2016 Corporation. 10 Park Plaza Suite 517.0 ' Boston,MA.02116 CAPE SAVE INC. WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE SOUTH YARMOUTH;MA 02664 a Undersecretary Not vali �thotitsignature 'I� ��aSSc"TCili�5��s5 '�F�3�.'"'f•'2ft"J "�,.di1.s -•�;T it `✓ $oartl`.o lild'rg Reaulaifions.an.. s4a. ri2fCiS Cunscruc€icsn-:Suitcriis Speciiilry Lf erase::CSSL-102776 WLL4,M r MC CLUSEEx 37 N`kUSETR AIS West Yarmouth MA 02673 O6/28/2015 -y e`7. Cape Save Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 508-398-0399 DATE Il�ll�l4 r i t , Thomas Perry CBO " r .e Town of Barnstable Building Division 200 Main St. Hyannis,MA 02601 t RE: Insulation Permits Dear Mr. Perry This affidavit is to certify that all work completed for 516 Skunket Road(#201402227) has been inspected by a third party Certified Building Performance Institute(BPI)Inspector. All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey 319viSHIN 30 0101 Assessor's offioe (1st floor): M - uF v Assessors map and lot number � SEPTIC SYSTEM k�1�415� ��`� THE t INSTALLED IN COMPLIANCCt Board of Health (3rd floor): WITH TITLE 5Sewage Permit number ...... ...... EAH Z d9TADLE. S Enginepring• Department (3rd floor): ENVIRONMENTAL CODE AKN ,o rasa House number ........................................................................ TOWN REGal11. A79--CVS 039.A? o Apr APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. 'only f TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ......(iC. �c�! RY..L..' ...... ......1�.................. ........................................ Q TYPE OF CONSTRUCTION ..................t/ .d C1T1�..... .h�.Rrr tit.P......................:................................................ (. ............. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location � ... ............ ........Rd........... .... ...... ..... .. . Ba ProposedUse ...Rw-4- ,l..... R-44...................................... .................I............................................ Zoning District ..............................p......................................Fire District ......C. .. 0 ti. ............r.. ....1..!.�1....... ................ Name of Owner ...��Cp ..... ...............Address ............... Name of Builder .. .... ..... .....Address Q. �k . . .,..i�� ... .&W—Cil Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ..........Z- ........................................................Foundation PCX4"1.j- Exlerior .........17 67J...........................................................Roofing .......... ... . . . ................................................. Floors .... ....... ....................................................Interior ......... ...��.........��.�?R�h.�t}. . . .............................. Heating . . . ....................................................Plumbing ........................ .. . ..... -- Fireplace ..................................................................................Approximate Cost .........1� ....................... Definitive Plan Approved by Planning Board ________________________________19________ . Area ......� .................. 1� Diagram of Lot and Building with Dimensions Fee � SUBJECT TO APPROVAL OF BOARD OF HEALTH 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 ... ....................... Construction Supervisor's License ..�..�..Q..!N 70 Location ...�j&Mnknet Road Owner ......J��6���' ----.----- ` Type ofConstruction .........TzAT9...................... .. ~ --------------------------. . � Plot —.-------- �t ----------' ' ^ ' . Pa,nit'G,on+»6 Jooe 27 86 - -------��----.—]9 ` r~ Date.of, Inspection ------------lq Date 'Completed ......................................lg 1.7 - . . ' �0ww ~ 0W . . . ` - ' - ` � . � ` ~ . - - . . r vctSl�twat AW Qt f" i ����►'�.�( '�_ _per �� jov- �1 � 1 rq I q s v V Kee �ocv::i Assessor's offioe (1st floor): /3 Assessor's map and lot number ...........Q............ ...............�.... °*TWET°�` Board of Health (3rd floor): v iJ Sewage Permit number S.........�.... Z BAUSTODLE, Engineering'Department (3rd floor): '�o MAB \sofa Housenumber ........................................................................ o�AY a. APPLICATIONS PROCESSED 8:30-9:30 A.M. and! 1:00-2:00'P.M. only TOWN OF BARNSTABLE BUI"LDIHG INSPECTOR APPLICATION FOR PERMIT TO �-' ) /K 1,....../.................. TYPE OF CONSTRUCTION ..................00 ..... - �................. ..-----....19 ..... ; TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ����... ............... .......... ........... ............ ........ ..g.................................................... ................ RProposed Use ......,._4.......... .uVl..�.......�..4 ...................................... .................'............................................ Zoning District .. ........... ............Fire District ...... ..� r.............................................. �I.... ' Name of Owner ...���d .....PrQNL,�Xj............Address ............ .� ? w _.. ... ......................... ........................... ....... Name of Builder ..76A-r�'rt� 1. ..... ......1 -/.1......Address Nameof Architect ...............................................................r..Address .r.................................................................................. Number of Rooms ..........z........................................................Foundation ...c....................� ............................ Exterior �) ..............................Roofing Gttl .........Z.V.. ............................ .............. ....... , ................................................ Floors ............!`.. ............:........................................................Interior ..........1... ........................... Heating ^........................................Plumbing ............... Fireplace ........................................Approximate Cost /��W ................................ ...J.................,........�................. Definitive Plan Approved by Planning Board ________________________________19________ , Area ...... � ........................ -Diagram of Lot and Building with Dimensions Fee .......7!��/.7 ................... SUBJECT TO APPROVAL OF BOARD OF HEALTH 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 ...................... Construction Supervisor's License ...�� .gy �0 .................. J ' PACHARD, ROBERT A=169-15-1 No ...29578... Permit foi .... uild..Addition. Single..Family„Dwe lling................... Location ...516. Skunknet,.,Road....................... ...........................Centerville............................ Owner .....Robert.....Pachard. . ......................... f Type of Construction FXaMP...................... ................................: L........ .. ................................. ' Plot ......................... .. ot ................................ Permit Granted June 27, 19 86 Date of Inspection ....................................19 Date Completed ......................................19 Assessor's map and lot number ...................... I E TOE Sewage Permit number g ....;................................................ !' 1 f Z BAUSTADLE, i House number .......................Y.:...............................:.............. 9 SAM 000,i639 i ''FO MPY{I,� c TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ........ 0r.9tr1 .t....�at�.tE?11,1Y7.1':..................................................................... ....... .. ............ TYPE OF CONSTRUCTION OCtC1 .�'X'�I11 ..................................................................................................................................... D Ger_ib�'•x.......................19..8Tj ................ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ...........�,q�...:�...S1 :knet...Road ...Gen.derv.il�z....................................:........:... Proposed Use ....9.! gle I''a.m. l.v �74Y�?�..�. TL ................................................................................................... ........... ...................................................... Zoning District ...........�� . ..E�...=........�..:...............................Fire District .................l y?I1��.,�� 3;�P.�V11 :�................ Name of Owner fA<�1P.S K. Smith ................. X�..f;c1b... ................................................ .............................:............. h ................. Name of Builder .......Jam "...r.R...STi.th.......................Address ..........���ast.�bl ................................................ Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ........A.......................................................Foundation ....PO1?.red Qn-nCt etp—_ ............................................................... r�,r )C1= 'cox `f? .l l �. �)21.� i Exterior ...................................................Roofing :.:. in, l e, Floors T'7 n . fir) ........7. .................Interior ;,`...y ..1......................................................... ................. .............................................. ..........:.1,r. ......... HeatingP I; y1 r' . '..........................................................Plumbing ........ ?'....? 11..................................................... �Fireplace Q t r t?n �` ...............................Approximate Cost :aft Definitive Plan Approved by Planning Board _______________________________19________. Area 916 Diagram of Lot and Building with Dimensions Fee _ SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name GvY'f•LJL...' . .. .......... ............ ......................... SMITH, DAMES K. A=169-15-1 No ..z. �'.��.. Permit for ..One Stork ........Sinq.le...Fami1y..Dwelli.nc s Location .Lot #1 516 Skunknet Road ........................ Centerville ........................................... ............. Owner .....James„K. Smith Type of Construction ... .VMe.......................... ................................................................................ i Plot ............................ Lot .:.........:.................... t ` Permit Granted ....Ja.nuAry,,,.- 2........19 81 I Date of Inspection .........� .........................19 Date Completed .........f............................19 PERMIT REFUSED ............................. EIS............................... 19 ' ........................... /................................................. :................................................... i .... !. ".f ? ......................... Approved ................................................ 19 ............................................................................... Assessor's map and lot number 9 -' - �FTNEr� oellSewage Permit number .................. .f........ ....`...... B8BB9TADLE, House number, ............ 1. .......::........:............. raes. ,.. SEPTIC SYSTEM MU °" •�� TOWN` .OF BARNS�� TFTLE6 E ROMMENTAL CODE AND, BUILDING I.HSPE T ��a:�� REGULATIONS C OR � Jf APPLICATION FOR PERMIT TO ........ ons UruC,t,°'i f cell ng..........................................:...........................�. TYPE OF CONSTRUCTION .....................Wood...frame................... ............................... ...:.......................... ...December.......................19..8V TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ..........Zot..1...Skunknet...Roada...Cent.erville... Proposed Use ..............Single...Family..;"w iU............................................................................:......................: Zoning District ...........Residential Fire District Centerville-Osterville Name of Owner ..........James...K.... Smith .....Address Barnstable ................... .................................................................................... Name of Builder .. ;TaT11eS.........Smith.......................Address. .:........Barnstable................................................ Nameof Architect ..................................................................Address ......................................:............................................. Number of Rooms ........4.......................................................Foundation Poured Concrete Exterior Clapboard..&...T111..................................::.Roofing ..........Asphalt...Shin.ales................................ Floors Wall....a.o...wall.............. ...Interior ..........Dryw..4lj . Heating .0........................................................ Plumbing ........Ona...bs tx1......... ........................................... Fireplace ..Done A Cost:...........:........::..................................................... Approximate .......&3-0.,.0.QQ.......................................... Definitive Plan Approved by Planning Board __________________________:_____19________. Area .....816.... ............ Diagram of Lot and Building with Dimensions Fee `` .................................... SUBJECT TO APPROVAL OF BOARD OF HEALTHd I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name{.{ � .: ....\1....... .................................... V� S7'.1ITH, JJAXIES K. 2 2 8'0 One Story No . ............ Permit for .................................... -single Family Dwelling .................................................................... ........... Location .....Lot #1 516 Skunknet Road , ........................................................... Centerville ................................................................................ Owner ....James...K......Smith ........................... ....... .. .. . ....... .. .. Type of Construction ......F.r....a.m...e...........................:................................. ......................I........... Plot ............................ Lot .......... ..................... Permit Granted ...January...12, 19 81 .. .. .... .. ..... Date of Inspection ..........................'. ........19 mple ed ............ Date CC 19 L PERMIT REFUSED ..................... ... ......................... 19 ... .. . .....................t .. ........................................ ..................... .....................),v.s................................................... ..CA........ ........................................ Approved ..... 19 ........... .................................................................... ................ ........................................ T• o .Z�41I8s•�. ,E�." b � �� l O L gs 07 134> 6A25A6E 69-1 NMF-2-._. E2_'T- 1 F" i tom` PL.-GAT PI....p iA ,, (-1vG.AA►L..�f Fl�c�v�l=,3�C�liQ=3�OGPD. _ �csc� 5 >rt G "f'ANt::�z: 33e--.s>l l3t>/o=495 G PD q ` 1v!' 5 K. SM iT4-� u�,✓ i000 At.... 4-- �-r i`� t �9 W�,�� Atz A = 8 5.F �EN-rt le --t_..G A.2N--,-rAat_e) MASS. ��4•r•469�1•a$)�x.5) 194-1,-,Pa ( - 13�rrQ M A z E A Z a8 S 5A�t-r-E rz ,. N�l . DET,��i_ 0 D15+�'o5L1� j p S GtT1F� -t �1-�'T1-1t= FQuN�A-r1Q ( c,�'t"4-�. TQV�IIt( d F 3A�t s� -"��..,--• dct, — ' A. BAXTER 1o�zU�ao may: (op.p ,ti yam, to 61i _ QL.q• '1�1 rt,� �}�4��''/c�j�."1.+81�y.�` fi -•• ` i'L-w%•♦r Y,T1.7`6•'`ty�2P3 rwf %k.� f3.o `` ,Z o r utAs►id t +t ECM-Tbp -:��-4/w pp— �TOWN OF BARNSTABLE - Permit No. - --------------- -------------- Building Inspector »nA Cash a WIN�\ OCCUPANCY PERMIT --------- _ � Bond "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date 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. ...................................................... 19.._ __ .............................................« .......... . . . Building Inspector Town of Barnstable *Permit# `f Vila o tpjy Fxpires 6 months from issue date P Regulatory Services Fee Thomas F. Geiler,Director prEo � Budding DIVIS10n Tom Perry, Building Commissioner A P�< 200 Main Street,-Hyannis,MA 02601 Office; 508-862-4038 r 44 4 Fax: 508 79o-6230 A-IAON - RESIAENTIAL ONLY EXPRESS PERMIT Not Valid without Red X Press Imprint Nlap/parcel Number Property Address J U�. Value of Work pYmer�deutial s Name&Address c `/ �l �Cvv 1 L elephone Number Contractor's Name Contractor License#(if applicable) Home Improvement _ Construction Supervisor's License#(if applicable) orkman's Compensation Insurance Check one' [] I am a sole proprietor I am the Homeowner I ave Worker's Compensation Insurance Insurance Company Name J 4—0 Woria a&S Comp•Policy# Permit Request(check box) Re-roof(stripping old shingles) All constriction debris will be taken to []Re-roof(not stripping. Going over existing layers of roof) (� Re-side' [] Replacementwindows. U-Value (maximum.44) not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. *Where regwse� fssuaace of permit does ***Note; Property Owner must signProperty Owner Letter of Permission. Home Im rov ent Contractors License is required. v Signature David Sawyer Construction 318 Meiggs Backus Road Sandwich, MA 02563 (508)-539-1992 �� Pro osal Submitted To: Work Place: Date_ -`1 ��- 1�C 7 r Strip, Remove, and Haul Away all old roof shingles. SUPPLY&INSTALL: 1 ? ? Re, a w N 3a Qx h s 11Wce, X w aj, A 6a p-je.I-e if uy? att ( cLcL v0 O o'er f:&- a-�d -1vb-a- Uj/ Alwai CLEAN&REMOVE ALL DEBRIS FROM WORK PLACE AFTER JOB IS COMPLETED. ALL DEBRIS TO LANDFILL. �� TOTAL INVESTMENT FOR MATERIAL&LABOR$ `�`i All material is guaranteed to be as specified, and the above work to be performed in accordance with the specifications submitted for the above work completed in a �" /" substantial workmanlike manner. Payments to be made as follows , ri, l( �7riiQ C� Any alteration or deviation from the work specifications involving extra costs will be executed only upon UU written order,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control. 10YEAR LABOR WARRANTY/PLUS MANUFACTURES SHINGLE WARRANTY. NOTE-This proposal may be withdrawn by us if not accepted with 301days. "�00 Respectfully submitted � ��hCy4 I t ACCEPTANCE OF PROPOSAL The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified.Payments will be,made as outlined above. VDatkA �Signatu 3-31 Oat c in 2 weed ��� 34��4 - 3�5;�3V 9.4-e -ea " Board of Building Regula ions and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 134313 Type: DBA Expiration: 10/24/2005 DAVID SAWYER CONSTRUCTION DAVID SAWYER 318 MEIGGS BACKUS RD. SANDWICH, MA 02563 Update Address and return card.Mark reason for change. Address ❑ Renewal Employment nLostCard o. ✓fie Vanvnzan.�u� a��//�Gaaaacstuaet�6 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 Board of Building Regulations and Standards cpiration: 10124/2005 One Ashburton Place Rut 1301 Boston,Ma.02108 Type: DBA DAVID SAWYE ONSTRUCTION DAVID SAWYER 318 MEIGGS BACKUS RD. � SANDWICH,MA 02563 Administrator Not 41ifi wi out signature Travelers WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6KUB-801 4A88-A-03) RENEWAL OF (6KUB-92GX406-A-02) INSURER: THE TRAVELERS INDEMNITY COMPANY 1 NCCI CO CODE: 11347 INSURED: PRODUCER: SAWYER, DAVID R KERRY INS AGCY INC 318 MEIGGS BACKUS ROAD PO BOX 1945. SANDWICH MA 02563 NORTH EASTHAM MA 02651 Insured is AN INDIVIDUAL Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 09-01 -03 to 08-28-04 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSEMENT WC 20 03 06 0 D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 09-11-03 ML ST ASSIGN: MA OFFICE: ORLANDO INDUS AFF 161 PRODUCER: KERRY INS AGCY INC 28SHB f 005134 /