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C',, �l­­p,, ,��!;t�,-j; �L �� to Q, I I ko,�I­.q,I j I"; , " I " � , 'I, ; ,g ME I I ,o I�L,� . `,,� L�j,,� "': �; �:',�""-,,'!��,,3 1"i".." �,,,­", �` ra.v` .i I",I ��',,� 111 '_��._,I :��.'�%,­L L,t��I 0,pi,�] ill,` � H M",�.�j V I sly j"Iyown ��',�� 1�­�-,��it,-� I I ��', , �� �,­ -i � i Wqs� - _ � ­q,; ,"" =A��;' �qr,k,�­ AM; ww,t . , 4; � I I , - I �P, ',��'­;­ , I'll - " 1'1111'��il­� _,��-'1'00`11 . W ij ; `,�:, , '�,.; kir�,. i�­� -� � s :;;�7777 1, - , 4", ­,­­-� " �Try� ;-� I 1., ,_l 1%)I��*I- , , 1". . . 11.- - �v .T vw�, . ,",.� �,i ga,% ,,,�/., "I , , , ,ii I'll N 1�� N � �_ ,., N � .in! I ­ ­ 7� 1 �"I ­11, , �,: , I' N � � �l.;� r,�, ", ,.,� �,­ I ,plk% - i � , V ."%"���,,�,,,,,���i,l��,��,",�,�.�, _� J 1, , I , , -, , , �, jx�' " �,�: 1 A I j '. ��, !�;� I � '.I - 1, ,�i,,',�,�,,�?,��, , ��.����1:"!" ;, , 1; "I'll ; .... ; �,�...... � is :,�, ,,,,�z��li�'i`���� ji� I,-;" ­1 � ;, 1'" �� � . "111, �� , , 11,11.1:Jit si�i��`..;11,11',,�,': .� : ; ,� - F,� on. �;; 5" , 1 Z, � s u24'.�', i�� ,;���' A 1� it� 101", " �� ,�",;ti��,'!L��'-.'�,,�i,�,)�,!", I x ...,;"I .­­ 05rD:1 hi), o nw, al h of Massachusetts. ' r Map Parcel -PRESS PERWap Date: Permit# Estimated Job.cost:. $ k ITS-W 'SEP, 10 2014 Pit Fee,.$ Plans Submitted: No .'. TOWN OF BARI ,}STV uis etnewed: 10 Business License# Applicant,License# C 5M _ Business Informatio Property Owner/Job Lacabnn Information: ern ��. �_. - .�: - Name: o` Name: Y`WI SWa 4&n Street: Street: . atm 'w \Qj Crty/Towzt; �� �� 0 Rc tyrTown: C-ea� U1Q .N(1_ 0 Telephone. � �qw-51m Telephone: Photo I.D. required t Copy of Photo M.'attached: S, V NO..- J-1./ -1-unrestricted license X2/M-2-restricted to dwellings 3lstories or less_and commercial up to 10;000 sq. #t./2-stories or less Residential: 1-2 famzly Multi-family Condo/Townhouses Other Commercial: Office ;Retail Industrial Educational Fire Dept. Approval listitutional Other, Square Footage: under•10,000 sq.:ft over to 000;sq:ft, Number`off Str oriesi • Sheet metal work to be completed: New Work: Renovation: HVA.0 Metal Watershed Roofing Kitchen Exhaust System . IVIeta1 Chimney,T Vents 1✓ "Air Balancing Provide detailed description of work to be done: 4 i 4 INSURANCE COVERAGE;. ; ],have a current liability insurance policy or its equivalent which meets the'requirecrtents of M.G.L.CK 112: Yes l 40 El i If ou•have checked indicate the of coyera e, checkiri the' . ro riate box.belotrr 'Y Y&;; type' by 9 pp p A liability insurance policy ( Other type of indemnity ❑ BOnd OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage:required'by Chapter 192 0#the Massachusetts General Laws,and that my slgnature on this permit:application.WajyA5 this,requirement: 4 Check>One Only i Owner ❑ Agent ❑ Signature of Owner.or Owner's Agen! , „ By checking this box11hereby certify that all of tits details artd`infom►ation 1 have submitted for entered}regarding this application are true:and accurate to the best of tray knowledge and that ail sheet metal work and-installations performed under the permit issded for this application will be in compliance with ail pertinent provision of the.Massachusetts Building Code and Chapter 112 of the General Laws.. Duct inspection:riquitred;prior to insulation installation:YES NO _ press. Date Carnmezits . t Date Comments; Type of License BY Master rile ❑Master-Restricted aitylTown ❑Jouneyperson. _ Signature of Licensee ' ❑Journeypersan-Restricted ° License Number. =ee$ 0. Check at .ntass.am0lal J .' nspector' ignature of Permit Approval n f The Commonwealtkof Massachusetts (�' `Pant Form Department of Industrial Accidents m Office of Investigations -� Congress Street,Suite 100 Boston,MA 02114-20.17 ~V.mass gov/dia Workers' Compensation_ Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl l Name(Business/Organi`zlation/Individual): l'�{ Tl C {'�1' A Address: RO City/State/Zip: \ �a��� Phone#: -fi I1y Are.yo n employer?Check the appropriate box:. - Type of project(required): 1. I am a employer with 4, ❑ T am a general contractor and I 6. []'New construction employees(full and/or part-time) have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed.on the attached sheet. 7. ❑Remodeling^ ship and have no employees These sub-contractors.have ❑Demolition workingfor me in an capacity. employees.and have workers' Y P ty• 9. ❑ Building addition [No workers'comp.insurance cQmP insurance required.] 5• ❑ We are a corporation and:its'' lb.❑,Elect rical repairs or additions.' 3.❑ I am a homeowner doing all,work officers.have exercised their l.l.❑Pluriibing repairs or additions myself. [No workers',comp. right of exemption.per:MGL- ,` 12.❑ of repairs insurance required' t a 152,§l(4);and we have no z employees.,[No workers'` 13. Other (1 comp.insurance required.] Ch1 L00% tOl Any applicant that checks box#I must also fill:out the section below showing their workers'compensation policy information. °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 ofthe 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 I am an employer thatis providing workers compensation insurance for my employees. Below is the policy and job site information. r Insurance Company Name: 1'1C�VQ �I:I UAe�'�Sf �1i� Policy#or Self-ins.Lic:'#: 1A `1 �(�(�� Expiration Date:_ Job Site Address: tJ City/State/Zip: Q! 1\e 'A .XQ3C Attach a copy,of the workers'compensa on,policvAeclaration page(showing the policy number and expiration date). Failure to secure coverage as required tinder 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-.yeauimvrisonn ent,as well as.civil penalties in the form.of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be:advised that a copy of this.statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebv cert u r t pains: enalties o er'u that the in ormadon provided above is true and correct Signature, Date. _ Y Phone Offcii4i use only. Do not write in this area,to be completed.by city or,to.wn.offciul . City or Town: Perinit/License# Issuing Authority,(circle one): w. - I.Board.of Health 2.Building Department 3.Cty/Town Clerk 4.Electrical Inspector 5..Plumbing Inspector, 6.Other ,. Contact Person; 1. - Phone#: t t r 9/5/2014 9:30 AM FROM: Hart Hart Insurance Agency, Inc. TO: 15084775733 PAGE:`002 OF 002 AC�® .• •: DAMYDDYYYYY) v CERTIFICATE LIABILITY INSURANCE' DATE(M09/05/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE"HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAM : Laura J Murphy HART INSURANCE AGENCY,INC. •' - 243 MAIN STREET arc N o Ex : (508)759-7326 No:(508)759-7366 PO BOX 700 E-MAILADD Imurphy@hartinsuranceagency.com BUZZARDS BAY,MA 025320700 � phY� INSURE S)AFFORDING COVERAGE NAIC A - INSURERA: MAX SPECIALTY INSURANCE'. 26079 INSURED Sandwich Chimney Sweep INSURERS: ATLANTIC CHARTER INSURANCE COMPANY 44326 ' PO Box 90 Sandwich,MA02563 INSURERC: INSURERD: INSURERE: INSURERF: COVERAGES CERTIFICATE NUMBER:. REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD. INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED.BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, LTR TYPE OF INSURANCE INSR POLICY NUMBER MM OD EFF MMIDCY on-Im LIMITS' A GENERAL LIABILITY SCO060025001396 10/09/2013 10/09/2014 EACH OCCURRENCE $ 11000,000 COMMERCIAL GENERAL UABILITY' - - DAMA E O RENTED - 100,000 PREMISES Ea occurrence $ CLAIMS-MADE O OCCUR ,, • Mm EXP(Any one person) $ ` -5,000 ; PERSONAL&ADV INJURY $ 1,000,000 s' GENERAL AGGREGATE, $ 2,000,000 i GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPROP AGG $ 1,000,000 POLICY PRO- LOC AUTOMOBILE LIABILITY Ea accident. $ ANY AUTO e BODILY INJURY(Per person) $ _' ALL OWNED SCHEDULED - BODILY INJURY(Par accident) $ AUTOS AUTOS ' HIRED AUTOS. NON-OWNED - PROPERTY DAMAGE - $ AUTOS Per acddont $ CLAIMS-MADE AGGR U ATE MBRELLA LIAB _ - - - - .. OCCUR� � � - EACH OCCURRENCE, $ EXCESS LlAB RETENTION$ EG _ $ DED B WORKERS COMPENSATION WCV01153100 05/132014 05l13l2015 WC STATI, orH- . AND EMPLOYERS'LIAB117Y YIN g - _ T I ANY PROPRIEiORIPARTNERIEXECUn VE OFFICERIMEMSER ECCLUCED? N 1 A - { �' E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ - 500,000 , If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-'POLICY LIMIT $ DESCRIPnON OF OPERATIONS 1 LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remark&Schedule,if more space Is required) Operations as performed by Terms&Conditions in the policy. r CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ' Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE•'WILL BE DELIVERED IN w 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. s Hyannis„Ma.02601. AUTHORIZED REPRESENTATIVE T 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD "Tbwn of&irlia e egu 'jtory Semites e BAWWABIX HAM Thomas F.Geiflcr, irecior Tom Perry,Building Commissioner 200 Main street,Hyannis,MA 0260 1 vim+wAdwn.bainstable:ii3a.ns Office: 508-862-4038 F'ax. 5,08-790-623. 0, Property ®der Must 4 ` C6rgpkte and SimTs Seioahi if Using A Builder i I, ,as Owner of the subject MA toperty hereb authorize ' Y to act can mp be alf,., in 2E Matters relative to-work.autliorized'_by this:building permit (A:ddres of job). . Pool fences and.alarnis are'the responsi.bdity.af the;agplic`ant P®ois . . are not to'be£11ed before fend is installed. and pools aye•not to be, utilized until ,u finals hspections are•performed and accepted: m Sigraa f Owner a f Applicant �AM Print N Ta � 1 unt Name Date R Q. osowrrEiu� sTONPocs . v d , il"!�4 S sICI S Oi'iit,coi'Cojistjiiiei-Affairs&BusiiiessRegulation C)a r cl e 6__!,,-AOME IMPROVEMENT CONTRACTOR 4' egistration: 05 kor I 1289 Type. J� a­'.','Expi ration: 3/12/2016 Privat6 CorCorporate. CSFA-058557 SANDWICH CHIMNEY SWEEP, INC. KEITH[A CLIFF PO BOX 90= KEITH CLIFF SANDWICH MA-02563 28 EMERALD WAY FORESTDALE, MA 02644 Undersecretary 021/27/2015 COMA ONWEAL111 OF MASSACHUSETTS Um ..SHEET METAL WORKERS :,AS:A,MASTER-UNRESTRICTED L TED, ISSUES THE ABOVL LICENSE TO:. :CEWIFIED\#2722 I CHIMNEY TH; C L I F F p. c 2� Valid Tliru_ EMERALD WAY Julie FORESTFIALE- h1 A 02644— 1530 2015 1'l 088 02/28/15 330094 Saildwich C11111111ey 5m-"OP &--mdwii,li, MA' Restricted - 011e-'and kvo-Eam ly dweillitgS or W 641 .0g """-"ory building thereto,, irrespect vLc of sire. registratidli-vidid for in(jivi(jul use only before the expiration date:.1j,found return to: Office 01,C0111SLImer Affairs and Business lZegidIjItion 10 Park Plaza 7 Suite 51*70 A BOstoll,NIA 02116 Failure to Possess:a Current edition Of-theMassachusetts State B ui Id I nV Code Is cause for revocation of this license. for DNS Licensing ation visit: WwwMass.Gov/Di'S A inlorm d No 'all"ripout signature CSIA Code of Ethics I fwlyoe%noAedf,t mat ceniff-08n ny lot cnminzy 'rely Iiijittlite of Anledca tCSIA)Cal i its witil it ca,taro m 10S to a Inner stanumd of puilorniance and professional t Of, desticy;l�cj, 110tily yClur Boa a, (�-1 befia,io, an al)ldicaua aws.rules oi revuati6nj 111 Inis eitwd.I pledge: TL,icam and"liliza all enllnnay and V.11IM9 solay plaell-s and I"I'IlliqUES ii,11110ted by CSIA; to a 6'my S­IC.3 I'lLar 6"1.31 o'Id fall manna., 'o'll a"wouing lo-,,nlail ol a 111�:-, J, Lit- 11 0Sz:' ShOmi i,,� L�h&ngra.d, 110 iiY YGLII fju iftj­j lo,al,am 1, "Ein"a I I I . I pfac,kas­11aking any"rilli,ol-dec,epliva late-, of con j`),,,:',):& Jr --iddlass to III 1-ille PjoI >r indiling Of next. Items jimillfinolk.t'lollifflitta to%viLin(Ewald to Lila R --al of 1j)a CSIA logos. Licvi. Ajvvay�� .[0-YOUC 110WISe lit-IlItID&I 3 To C.11�11ly 11111).11 aPIA11111le bL11101-1W­Clel V,ille -This i'� ZUbjact to ti'le iJrovlt�iorls of the Ganal.�-,d e . ,. a,eas . me.."'Ith Ine'llanLiloCILIft 3 intimation Lis a,I) if to,III&j)1.411clii I m3taii,alto win Pai,scaial Pliviloi:e,and Must rlo�be "cogna'd cmilincy and veiling plactices Of-a ssigi i0c Ka a) ihiS IiC6!`S0 Ji i y 0 U f 4.To plwilllle alla aLlucate co,ls,lmali abO111 sal P 0 l,11jimley and—iling 13mell-s Pei sc-11()1 0,', b 'I 5 Z'. to stn,-et.comt,wally.update my mwwadwa,skills. olld 1601MLILIESI Will)leg4ld 10 c&lall uceplea 11dirney and velidoo safety i)factj,;e$. d To colOcill"Myself in a(lece'l(,'especit.'r-d"d pofeiijonai manner when serving in my caraciiy Is a ojniwey sweep,o,woe ati&njing a i,metion o'­eol of all o,gjaizatioo In fit cmilvicy.6i ncaarl 7 To comply ill It pope,usaoa of rile C51A Rcirislod I)aclermifl,as claimed in tric CSIA T,,jjvma-,,Use GLAtIC11116 doe,miam. Is' Revised 51;Li.;I I Assessor's Office(1st floor) Map Parcel 0// Permit# . *7 a8 O q Conservation Office(4th floor)(8:30- 9:30/ 1:00•=-2:00) Date Issued Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) Feea S, Engineering Dept. (3rd floor) House# •3 7 1� � �tME rq PlanIn floor/School Admin. Bldg.) ° BARNSTABLE. Defroved by Planning Board 19 *q,�e 9. TOWN OF BARNSTABLE . Building Permit Application Projss �J -�..�V 440,d ems / Village _Owner 3, " WtV Address Telephone S V Permit Request First Floor square feet Second Floor square feet Estimated Project Cost $ -S ®Q cc Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Commercial Residential Dwelling Type: Single Family I Two Family Multi-Family Age of Existing Structure Basement Type: Finished Historic House Unfinished Old King's Highway Number of Baths No.of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other Builder Information Name /40/ e -���t,) '�`"�8� Telephone Number �� 7' =5 Y'i� 9 Address 2 Z. (5iaoi,�P/ License# Home Improvement Contractor# Worker's Compensation#_770"�e�!lJo• —.SSG NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE / i cxz�f DATE 0//z BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY K PERMIT NO. ' l DATE ISSUED F ; MAP/PARCEL NO. ADDRESS - `. { /., J'# VILLAGE OWNER DATE OF INSPECTION: + a FOUNDATION FRAME INSULATION - FIREPLACE Y ELECTRICAL: ROUGH r FINAL PLUMBING: ROUGH FINAL GAS: ROUGH r FINAL FINAL BUILDING r DATE CLOSED OUT ASSOCIATION PLAN NO. , t a C9 11 Ir7h w �oFrru row Town of Barnstable `7oi6o(� ol 2 Permit# o Regulatory Services >�eCes6mol rsjrarris•,wr-Aare Y aASS. 619- ,1b or Thomas F. Geiler, Direct - ` Building Division Tom Perry,.CBO, Building Commissioner 200 Plain Street, Hyannis, MA 02601 www.town,barnstab le,ma:us Office.- 508-862-4038 EXPRESS PER Fax: 508-790-6230 MIT APPLICATION - RESIDENTIAL-ONLY y No!valid 1pilhott!Red X-Press Imprint Map/parce I Number —1 r ll L/ Prop rry A d _� dress �.� ✓�`r.� �r ,.�,. wj I) Residential Value of Work j 100 Minimum fee of$35.00 for work under$6000.00 Owner's Name 1: Address f / Contractor's Name � � `-- � �' ?'�� Telephone Number -77 Home Improvement Contractor License #(if applicable) f -S' !�rz, Cons uction Supervisor's License#(if applicable)- Workman's Compensation Insurance "Y R I I Check one: ❑ 7 am a sole proprietor nV 5 ' 20 0 ❑ m the Homeowner �"�WN OF BA�NS�'A�L I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy#_ Z,/t'_-7 3/S- 3 /7 Z / J Copy of Insurance Compliance Certificate rnustaccornpnny each permit, Permit Requ=urricanc box) nailed) (stripping old shingles) All construction debris will be taken to i,�„. ❑Re-roof(hurricane nailed)(not.stripping. Going over existing layers ofroo0 Ej Re-side ❑ .Replacement Windows/doors/sliders. U-Value #of doors r (maximum .35)#ofwindows *Where required: Issuance ofthis permit does norexempt 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 require ,'IGNATURR; •1WPCn C0%r:0Pk4.Qlhni1dino A_ _ - X.. I' 1 The CQmmomverrllh ofAfassadiuselis t :-- - - Dep- artmerr.l oflnditstrialAccidents (' Office ofIlan, stigalions �" .. r 600 Washint lost Sire.. �� Boston; r'�l� OZIII �y 11-10 t.rliass.gon�dia 'Workers' Campelrsat on Iusuxance ff1.da-6t: B till ders/Contr.actoi-s/E ec-oiClalls/Phu bei-s Applicant Information Please Print Legibly Name. (BusinesvlOrganizabonlIndividtial): A-ddDBs's: Z- T � NC�3 , ICity/State/Zip: �4 1 - 0 � F17 Are y u an employer? Check the appropriate boa:: T,)?e of project(.required): 1.. I am a eanplo}rea uith Z $, ❑ I am a general contractor and I ���jj etuployees(full and/or part=tiiue). , .have hai-e:d the sub-contrucior3 6- t—1.Ne'Wc'On'St1lJCt10�n I❑ I am a sole proprietor orp8rtue57 listed on.the attached sheet- 7. ❑.Rernodeling ship.and have no employees These sab-contractors have. 8 �.Demolition working :for me in any capacity. employees and have workers' [No workers' comp-insurance comp insurance. x 9. ❑Building addition 5. We are.a co_ oration.andits 10.❑Electric:alrepairs ora.dditions required.] ❑ 3.❑ :I am a.homeo- ner doing all work. afficexs have exercised their 11.❑-Plumbing repairs or additions myself. [No workers'camp. right of exemption per iWGI, 12.0 Roof repairs insurance required,]T c_ 152, §1(4)„and.use have no employees. [No wort-ens' 13..❑ Other carvp.:insurance required.] 'Any applicant that checks box#1.mist also h1low the section below'sbomng theirworken'compensation policy infonwtian- t Homeowners who submit this.tffidavit indicating they are'doing all'wwk and then hire outside:contraclors must submit.a uew affidavit indicating such- 1Contraclnrs thsl check this box mirst attached as sdditional sheet showing the:nsme ofihe snb-coutrscmas and stale rrhether or not those entities have enigp7oyees. Tithe mb-contractorsbsve employees,they.univ provide their workers'comp.polioy number. I am an miplo:yer•that is provid rig iwykers':contpe'Nsah°on ittsrx raw.ce for rrty ettrploy6vs. Motr is the policy and job site igformatio& / r Insurance Cornpany Naive Policy#or Self-ins-Lic.. C Z —3 7/S 3 /j7/� 1l— C� 3 Q ExpirntronDate` f Job Site Address:: 3 7 S�� r"'Z42"Y � Y , Jl Cit)'/Sf'ate/Zip: CC h- ,r✓r /�� 1 Attach a copy of.the wol-kers'cotnpeusation policy declaration page(s:ltoiiing the policy number and espu•.ation date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penal#ies of a fine up to 31,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP 1VORK 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 Invt?stiga;tions of the D.IA for insurance coverage verification. I do ltr byy certify rxrr k paws.andpenalties of p,Prjerry that fife'izrforrrtatiort prmdd8d abotYe is trrca.arrd correct. Si nture.: Di fe: ! )f Phone#: SU 77 Z.ti 5-1 et `7 l FBz,(grd e only. Do not write iat this area,Yo be corrtpltrted by citt.'or town ofcial Town: Permit/License# thwity(circle one): Health 2 Building Department 3. Cityffown Clerk 4,Electrical Inspector 5.71impector son: Phone R: Aco 11 CERTIFICATE OF LIABILITY INSURANCE °ATE'MMI°°"""' `� 10 19 2010 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT'CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER BRYDEN & SULLIVAN INS - CONTACT NAME: 88 FALMOUTH RD PHONe 508 775-606 FAX(AIc No): HYANNIS, MA 02601 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER-A: Liberty Mutual Group INSURED CAROLYN BOBOLA& STEVE BOBOLA INSURER8: - DBA MASS BUILDING SYSTEMS INSURERC: 24 SAINT FRANCIS CIRCLE HYANNIS MA 02601 INSURERD: INSURER E: ` INSURER F COVERAGES CERTIFICATE NUMBER: 8569507 RE:RSION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR . - - POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MMIDDIYYYY GENERAL LIABILITY EACH OCCURRENCE - $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY - PREMISES Ea occurrence $ CLAIMS-MADE F—IOCCUR - - , MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC - $ AUTOMOBILE LIABILITY - - - COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY.INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) AUTOS AUTOS - $ NON-OWNED PRO DAMAGE PER D HIRED AUTOS 8 AUTOS Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ _ DIED RETENTION$ $ A WORKERS COMPENSATION WC2-31 S 317211-030 10/3/2010 10/3/2011 WC STATU- AND EMPLOYERS'LIABILITY YIN TRY LIMITS ANY PROPRIETORIPARTNER/EXECUTIVE - E.L.EACH ACCIDENT $ SOOOOO OFFICER/MEMBER EXCLUDED? 7 NIA. - - (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 00000 If yes,describe under DESCRIPTION OF OPERATIONS below - - E.L.DISEASE-POLICY LIMIT $ - SOOOOO r DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) NO PARTNERS ARE COVERED BY THE WORKERS COMPENSATION POLICY Workers Compensation Insurance:Part One of the policy applies only to the Workers'Compensation Laws of the State of MA. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED.POLICIES BE CANCELLED BEFORE TOWN OF YARMOUTH THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATTN: BUILDING INSPECTOR ACCORDANCE WITH THE POLICY PROVISIONS. 1146 RTE 28 SOUTH YARMOUTH MA 02664. ,. AUTHORIZED REPRESENTATIVE • �� Cot - Jeff Eldridge ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD CERT NO.: 8569507 CLIENT CODE: 1306875 Deb DerochemonL- 10/19/2010 7:37:40 AM Page 1 of 1 PROPOSAL FROM: Mass Building Systems 24 Saint Francis Circle "PAGE NO. I OF I PAGES Hyannis,MA.02601 DATE 10/30/10 508-771-8979 PROPOSAL SUBMITTED TO: Mary Sullivan 112 Elm St. JOB NAME:Same Charlestown, Ma. 02129 ADDRESS:537 Strawberry Hill Rd. PHONE:617-242-4953 CITY/STATE/ZIP:Centerville,Ma.02632 We hereby submit specifications and estimate for: 1)Remove all roofing and dispose of debris,price based on one layer of removal. 2)Apply new dripedge,install ice and water shield to baseline valleys and protrusions. 3)-Install new pipe boot flashings,cover rest of roof with felt paper. 4)Install 30 year architectural roof shingles in owners choice of color. * Contractor to obtain permit and remove debris We hereby propose to furnish labor and materials—complete in accordance with the above specifications, for the slim of Three Thousand Nine Hundred Dollars($3,900.00)with payments to be made as follows: 2,000 at start, 1,900 upon completion All material is guaranteed to be as specified.All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and a he esti ate.All agreements contingent upon strikes,accident or delays beyond our control.This proposal subject to acceptance within 1.5 days and it is void therea a opti e it dersigned. Authorized Signature ACCEPTANCE OF PROPOSAL The above prices,specifications and conditions are hereby accepted.You are authorized to do the work as specified..Payment will be made as outlined above. ACCEPTED: Signature DATE�� 7 (� Signature ©E-Z CONTRACTORS FORMS FORM NO,PROP 31 r. ✓fie �o na��zoncueczllfi o� aaaacfivaeCta Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: A Registration`a,,'158588 Office of Consumer Affairs and Business Regulation Expiration`-=�2f4_9L2012 Tr# 291750 10 Park Plaza-Suite 5170 5 Boston MA 02116 r Type + Partnership' MASS BUILDINGISYSTEMS=_t STEPHEN BOBOIA _ / 24 ST.FARNCIS CIRCLE <� HYANNIS, MA 02661 Undersecretary Not valid without signature ►ti4athutitttk'- Dcli�ii tmcnt.►►t I'ul�ttc S tt t A. Board �►f Sutld 6 I2e;tilatu2ri� and-:Stantl� i cry' % ' - �orisructon Supervisor. License 4 License 'CS 58987fi P . R�, �ted to 00 ', � ,� ', •'" � F , ram- - `STEPHITN E°BOBOLA 24 ST`FRANCIS HYANNlS MA 0260fi �� •` {AMllin slop °H' ° t i Tr# 5882 .q- i ..`v... .-hwYHd"�4a'n.lr,..,a.Yirw.-t .G..✓w r ..n,n.;-Ai• ..rr,...L:s w.. :. tr:.::" n EITI' PUBLIC' PTACE,' -�01­f I I-' E ASHBURTON 1995 BOSTON ? 'H!,, 0 2 1 6)1 OCT I S-C)R L iv) i r e B t 1-1 d a te 997 10V2011959­- j Z/T---,A U; -,I, -fold .1d ',aniinate license ca'-di. .0 v-i-1: e Keep top for receipt and chn ac­ ' o f a d d r es,s n J_f -in '2_ 3 4 0 7 i;�L 7 S C,2 f r, v c r j, 0'_Ite �� 2a HOME IMPROVEMENT CONTRACTORS REGISTRATION I Board of Building Regulatfons and Standards One Ashburton Place— Room 1301 Boston , Massachusetts 02108 HOME IMPROVEMENT CONTRACTOR ----------------------------- ------ Registration 103714 Expiration. .0.7/09/98 -071. Type - PARTNERSHIP HOME IMPROVEMENT CONTRACTOR Registration 103714 FIAUL. J . CAZEAULT & Type - PARTNERSHIP 5ONS,,_,.R,O.OFI.N_G J . Cazeault 22 'Giddialt Rd . P .O . Box 2781-­_ Expiration 07/09/98 Orleans MA 02653 I PAUL J. CAZEAULT & SONS ROOFT Paul J. Cazeault Giddialt Rd. P.O. Box 278 ADMINISTRATOR Orleans MA 02653 �+ '. DATE(MM/DDIYY) A�ORD,. CERTIFICATE OF LLA�ILITY INSURANC ID DR kAULJ 2:; 07/31/96 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION y ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Drake, Swan & Crocker HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 14 Lot's Hollow Rd. ,PO Box 429 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Orleans MA 02653-0429 COMPANIES AFFORDING COVERAGE Peter G Walther COMPANY Phone No. 508-255-3212 Fax No. A Assurance Co. of America INSURED COMPANY B Credit General Insurance Co. Paul J. Cazeault etal DBA Paul COMPANY J. Cazeault & Sons Roofing C P 0 Box 2781 COMPANY Orleans MA 02653 D COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MM/DD/YY) DATE(MM/DD/YY) GENERAL LIABILITY - _ GENERAL AGGREGATE $ 1,000,000. A I X COMMERCIAL GENERAL LIABILITY CFP25552812 05/01/96 05/01/97 PRODUCTS-COMP/OPAGG $ 1,000,000. CLAIMS MADE FX]OCCUR PERSONAL&ADV INJURY $ 500,000. OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 500,000. FIRE DAMAGE(Any one fire) $ 50,000. H MED EXP(Any one person) $ 10,000. AUTOMOBILE LIABILITY i ANY AUTO COMBINED SINGLE LIMIT $ rALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) i HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ ' PROPERTY DAMAGE $' GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ I ANY AUTO OTHER THAN AUTO ONLY EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ WORKERS COMPENSATION AND WCTOR STATU- OTH Y LIMITSI ER - EMPLOYERS'LIABILITY EL EACH ACCIDENT $ 100,000. B j THE PROPRIETOR/ INCL TO BE ISSUED 08/09/96 08/09/97 EL DISEASE-POLICY LIMIT s500,000, PARTNERS/EXECUTIVE OFFICERS ARE. EXCL EL DISEASE-EA EMPLOYEE $ 100,000, OTHER I DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS Roofing CERTIFICATE HOLDER ;CANCELLATION! BRUCEHI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND ON TIE COMPANY,ITS AGENTS OR DEPRESENTATIVES. AUTHORIZE EP ATIVE ACC ©ACORD CORPORATION 1988 a ' �WE The Town of Barnstable ZM SIAM epartment of Health Safety and Environmental Services �9. Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. o Type of Work: Est.Cost Z Address of Work: 7 T (—,,eA, &4 Ile, Owner's Name �fi 1-'ie Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under SI,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the gent o the owner. -----__� Da a Contractor Name Registration No. OR. Date, Owner's Name