HomeMy WebLinkAbout800 BEARSE'S WAY (17) 4xW-
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map `i1� Parcel 64,10 i Application # aNcM 160
Health Division Date Issued ` I
Conservation Division Application Fee d
Planning Dept. Permit Fee L
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Street Address rJ f_-<,- li � - '
Village eJ e S
Owner Llo dl ,A Wu Address-* ��4� �'�60i2 4✓, 'Iff a a� t®i
Telephone
Permit Request 12AU14v-_ 1't o CAM a) XJA!9�_ 1 P
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation /5 0 0 Construction Type Lt
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) C �
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout Udther*.-/-A 6
Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)
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
(BUILDER OR HOMEOWNER)
Name �1)(:5/����f��5 / Telephone Number
Address -AAA) S R��9 h) L001 License# l2 S ®21
Home Improvement Contractor#
�J ask co�e Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE `(" 9--
FOR OFFICIAL USE ONLY
APPLICATION# 3
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
}
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL .
FINAL BUILDING
{
DATE CLOSED OUT
ASSOCIATION PLAN NO.
The Commonwealth of Massachusetts
Department of Industrial Accidents
' Office of Investigations
' 600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organizalioi>/Tndividual):.Ben -b � �/ �j�'���r"- �Lt�11�
Address: P 01 Boy 4�Zq j�.n `SGb�__Lal j ,l)T I Ue.) �7
City/State/Zip: Sandw ^ Phone
Are you an employer?Check the appropriate box: Type of project(required):
1.Z I am a employer with 10 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. modeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp, insurance comp. insurance. 9. Building addition
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp, right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152,§1(4),and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees, if the sub-contractors have employees,they must provide their workers'comp.policy number.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Z ,
Policy#or Self-ins.Lic.M 10 Expiration Date: /
Job Site Address: - 4461 ?V City/State/Zip: v
Attach a copy of the workers'compensat on policy eclaration page(showing the policy n ber and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500,00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the.DIA for insurance coverage verification.
I do hereby cer if rut a thepains andpenalties ofperjury that the information provided above is true and correct.
signature: Date:
Phone#:
Official use only.. Do not write in this area, to be completed by city or town:official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
RightFax N1-1 12/22/2011 7,19:42 AM PAGE 3/003 Fax Server
A '
ISSUE DATE
.:�.f 12/22/2011
,+THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO BIGHTS UPON THE CERTIF•ICA HOLDER THIS
CERTIFICATE DOES NOT ATFDUITATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BX THE POLICIES
nuow,THIS CERTDRCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN TIM ISSUING INSCREWS),�UTHORI?,1?,D
REPRESENTATIVE OR PRODUCER,A.NTD THE CERTIFICATE HOLDER.
IMPORTANT:N the certificate holder Is an ADDITIONAL INSURED,the policoss)must be endorsed.if SUBROG TION IS WANED,subject to the
terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate d as not confer rights to the
certificate holder In Hsu of such endorsements.
PRODUCER CONTACT
OCEANSIDE INS GROUP NAME:
52 WEST MAIN STREET A/C'o,Eat; FAX
No),
HYANNIS,MA 02601 64ML
ADORES$:
PRODUCER
CUSTOMER ID T.
INSURED INS S AFFORDING COVERAGE NAIC ft
BENABBY INC DBA INSURER A ZURICH
DISASTER SPECIALISTS INSURED B
P 0 BOX 480 INSURER C
SANDWICH,MA 02563
INSURER D -
INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT TO POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TTIE INSURED NAMED ABOVE F F.THE POLICY PERIOD INDICATED.
NO-TWITHSTANDRIO ANY REQUII1FhfL^7T,TERN OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TMS CERTIFICATE MAY BE
ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRMED JMREIN IS SUBJECT TO ALL THE TERMS,E XCLUSIONS AND CONDITIONS OF SUCH
POLICIES,LIMIT'S SHOWN MAY HAVE BIrV REDUCED BY PAID CI.A1M5.
INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY E LU1IITS
LTR INSR WVD i
GENERAL LIABILITY i EACROCCURRENCE S
DAMAGETO RENTED S
0 coia OENERALIIABr= PREMSES(ErJ1 LU. '
occurrmca 1
` MID.EXPENSE Wy mse S I
0 CLALUSMADE OCCUR persw
D PERSONAL&.ADV $
INJURY
D - ! 0ENERALAOOAE0A7E $ i
GEN'L AGGREGATE 1,114T APPLIES PER
PRODUCTS-CoteloP I j
D➢OLICY 0 PROJ CT D LOC AGO
AVTOMORII,ELIABILITY CONBR•IDSINGLE $
LDNT
. ch accident
D ANY AV7Ti i BODB,YINNRY S
M Pers
D ALL OWNED AVr08 J BODB,YINTURY S i
i (Per Aceidcd)
D SCHEDULED AUTOS PROPERTY DAMAGE S
<r acmdmt i
D RUM AUTOS S
D 1I0N•OWNFDAU70S
0
D U.NGRELLALIAa DOCCUR EACH OCCURRENCE S
D EXCEPBLW 0CLAUS-MADE AGGREGATE S
D DEDUCTIBLE S
D RElE1r1-.011 E S
Vol KERS'COMPENSATION we
A AND EMPLOYERS LIABILITY NIA STATUTORY
YIN LQ4IS
ANYPROPRIETOR/PARTNER/ I
EsCECUrMOFFICRAr1. ER N NIA 6ZZUB-4102P700 01101/12 01/01/13 LLDM�LjA=-
CctDENT s500,000
EXCLVDEDT —EACx(NLtNDA7oRYINNIi) $500,000
Ifyrs,describe mdciOEaCRIPRON OF -POLICY 5500,000
OPERATIONSbelow
DESC1i1PTIONOFOPERATIONa2oCAttONRMMCLES(ACach ACORD 101,Addikonel Remarks SchedWc,itmdre space¢requireA `
THFTHW ED'S MAWORYERS COMPENSA710N POLICY AND ITS UKED01TI3RETAM IN'5URANCEENDORGENIM AUTHORIZE37HEPAYMEFItFBENEIT,S FOR CLNM9MADE BY THEDISURED'
L\9LOMES IN STATES CYNF3t THAN MA NO AUTHORIZATION IS GIVEN TO PAT CLAMS FOR BENEFTFS IN ANY STATE OTetER THAN MA IF rM INnRFD HW=,OR HAS HIRED,EN(PLOYEES OUTSIDE i
MA MPOUCYDOrSNOTPROVMBCOVZMGBIIORAITYCTA7'EOTI-V,TR"LiA
THIS REPLACES ANY PRIOR CIIYRFICATeMSUT:DTOTnE CERTIFICATE HOLDERAFFECTINGWOR)MMC MP COVERAGE
ARE ;,.I�.,,t iySxT, .r, _,, ...:_.:x..... y a�ltlA4'xl�b NIt) ._ x.. e _ ..... 5,•
- - - I
SHOULD ANY OF THE ABOVE DEBC W POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,N TICE HALL BE DELIVERED IN
ACCORDANCE WITH TILE POLICY PR VISIONS.
+, ...... AUrtWXITt71D RtPRE MAME
„! BYCIxW MdtL6RW
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Super kor
License: CS-071402
JO 5lEIUA L CORN
1082 OLD STAG .
CRNTERVE LE
� 20
tom''` Expiration
commissioner I V3112013
—�\— MCC of Consumer Affairs&Business Regulation -
ME IMPROVEMENT CONT License or registration valid for individul use only
q RACTOR before the expiration date. If found return to:
egistration
® 108642 Office of Consumer Affairs and Business Regulation
Expiration 8/20/2014 Type' 10 Park Plaza-Suite 5170
BENABBY INC/DIS gSTER.SPECIALIST Supplement�.`:ard Boston,MA 02116
JOSHUA COHEN
Box 480
Sandwich, MA 02563
Undersecretary
Not valid without signature
ZME roy, Town of Barnstable
Regulatory Services
BMMSTABM
y Mass. Thomas F.Geiler,Director
�A 1639. ♦�
rEDMA�0. Building Division
Tom Perry,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, 4M,111'/L/4,V 141,d ee-L-t -7�/'/7^ , as Owner of the subject property
hereby authorize —e"I j, C- to act on my behalf,
in all matters relative to work authorized by this building permit.
L90 gCe-J-z
(Address of J b)
**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.
ad
S' ature o wrier ature of Applicant
�etin f
Print Name Print Name
Date
{
Q:FORM&OWNERPERNSSIONPOOLS 6/2012
5 , TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map `L9 y Parcel 061 -OAS Application
Health Division �� n'�i� Date Issued z ?_
Conservation Division Application Fee
Tax Collector Permit Fee
Treasurer
Planning Dept.
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis
Project Street Address 500 74-11LSIO- (,c✓14^, VA TT 2s R (-1'y#Vt-c S` {r
Village
Owner L6N4P4[ tN0 Address N
Telephone6goe) '1-7,S_ 14 a
Permit Request Zosv 4 E AwN� S W PF-cf K.VT y
AwW,TL asNTPom No o 6 fzc&s )
Square feet: 1 st floor:existing 120 proposed 174 2nd floor:existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuations S°® Construction Type 6dA#-V2CAL
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) CO�Da
Age of Existing Structure Historic House: ❑Yes d�o On Old King's Highway: ❑Yes ANo
Basement Type: &Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) �� Basement Unfinished Area(sq.ft)
Number of Baths: Full:existing new Z 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 216ectric ❑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 0 Yes ❑No If yes, site plan review# '
Current Use 5 ) Proposed Use
BUILDER INFORMATION
t
Name RAN I FWA304*0 CuYrom '90UAW-S Telephone Number &096 -4 M - 7 1 If-7
Address ybX S 1 b I License# GS - 0$S S g I'
somdWs MAu-S . Mk 01-4`t Home Improvement Contractor# 14 4 77s L
Worker's Compensation# 3 R 2 4 S 0
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �ua�RS�fz�
,R�x �-r�nr1VE
SIGNATURE DATE I /it 0'a
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
a; -
4. MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
i
} DATE OF INSPECTION:
{� FOUNDATION
FRAME -
INSULATION +
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
A
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111'
www.mass.gov/dia '
Workers}Compensation Insurance Affidavit: Builders/Contractors/Electridans/P Legibly
-
Applicant Information .Please PrintL v
Name(Business/Organization/Individual): .
Address: 130 K i(o
City/State/Zip: AAPIONE M21ti37 OU4Sphonet 1, y28 -7 j y7
A�.I
�am
employer?Check the appropriate bog: :Type of project(required):.
n 4. ❑ I am a general contractor and I
1. employer with 7 6. []New construction .
' employees(full and/or part-time).* • have hired the sub-
contractors
listed on the:attached sheet. 7. ❑Remodeling
2.❑ I am a'sole proprietor or partner-
ship and have no employees These sub-contractors have g, ❑Demolition
employee's and have workers'
'working for me in any capacity. 9, ❑Building addition
[No workers' comp,insurance comp. insurance.$
5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised their 11.❑Plumbing repairs or additions '
'3.❑ I am a homeowner doing all work .
myself,[No workers' comp. right bf exemption per MGL 12,❑Roof repairs
insurance.required.]t c. 152, §1(4),and we have no
to o workers' . 13.❑Other
employees. [N Y •
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information,
t Homeowoers.who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have ;
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am co
an employer that is providing workers' mpensation insurance for my employees. Below is.the policy and job site
information.
Insurance Company Name: &f*PW-f7
Policy#or Self-ins.Lic.#: 24 Expiration Date: 1l 0 $
Job Site Address: goo B09*u Wa'( t RYANh#-5 t MA 02-60( 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 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 maybe forwarded to the Office of
Investigations of the CIA for insurappe coverage verification.
I do hereby certify under the pains•andpenalties ofperjury that the information provided ab ve.is true and correct
Si afore: Date: t 1 6 f3 _
Phone##: 6 4-1" r 1 14 7
Official use only. Do not write in this area, tb be completed by,city or town off cial
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
Phone
Contact Person: #:
The Cape Cod Carpenters
Ranney& Rimington Custom Carpentry
QUOTE www.TheCapeCodCarpenters.com
December 5,2007
Site: 800 Bearse's Way, Unit 2SB,Hyannis j
Lorraine Wu (508)775-4491; (781) 935-1210
Bathroom Remodels
Rork to include: i
a Removal of toilets&sinks to be completed by customer supplied sub-contractor
a Remove vanities
a Remove-all non-water resistant gypsum wall board that has been exposed to water leaking
a Includes trash removal I
a Repair framing as necessary
a Install fire blocking to code where it does not currently conform to state code
a Strap ceiling for wall board installation,(not existing at this time) >,
a Install insulation to code in ceiling
a Install new water-resistant gypsum wall board
a Install in-tub `sleeve walls' on all 3 sides of both existing shower/tub walls; caulk until water tight
a Tape, corner bead,joint compound, and sand all newly installed wall board !
a Sand&joint compound additional coats as necessary
a Prepare ceiling to textured finish
4
a Install rile on floors including laundry closet floor (tile material allowance $2.00 per square foot)
a Reinstall customer supplied vanities
a Install baseboard trim 1
Paint bathrooms&trim to customer chosen colors
. I
rr
P.O.Box 8,16
Marstons Mills,MA 02648
License#CS-088595 ti Phone:508-428-7147
Home Improvement Registration# 144752 Fax:.508-428-7167
Liability Insurance#08SBMUM4864 E-mail:
\X/nrkman'c rmmnancatinn fE\X/rA'1974A0 infnt@thornnarnrlrnrnontorc rnm
• Please note: does not include the removal or reinstallation of washer&dryer to allow for wallboard or
tile installation; does not include any plumbing or electrical work;does not include any electrical or
plumbing fixture
TOTAL LABOR & MATERIALS $ 8425.00
Initial deposit requested to schedule work S4200.00
Balance due upon completion
Please note:
a) Contractor is not responsible for any damage to lawn or plantings around demolition area.
b) All work to be completed in a prafessional manner according to standard practices.
c) Any alteration or deviation from above specifications involving extra costs will become an extra charge over and above the estimate at M.00 per hour
plus materials. If cost of materials and labor changes,this quote may increase no more than 10%.
d) No verbal agreements will be considered valid.
e) All"demoed"and replaced items(including windows,doors&appliances)will be considered hash unless other indicated by homeowner.
f) Any repair,moving or installation of alarm system is the responsibility of the homeowner
g) If an allowance is included in contracted,it is based on the maximum amount allowed. No refunds will be given.
h) If painting is to be done by The Cape Cod Carpenters,paint or paint samples are to be supplied by homeowner and painting is included on new
construction only or to stopping point near new construction(unless otherwise specified). It is possible that a larger area may need to be painted to
match this area exactly,which would be at an additional cost
i) All painting quotes are based on white(unless otherwise specified),darker colors may incur additional costs due to additional coats of paint required
j) Property Owner's failure to make payments for work duly performed may result in a mechanic's lien against the homeowner's property.Owner is
responsible for any legal fees and court costs Ranney&Rimington may incur to collect the monies due on this contract.
k) Any and all necessary construction-related permits shall be obtained by the contractor,with the permission and authorization of the Property Owner,as
,---pwner's agent
co let' n. er f�th e Cape Cod Carpenters may display a small si a e property during the duration of the work and one month after
for The Cape Cod Carpenters
1P ate Property Owner Date
(dba Ranney&Riminglon Custom Carperttry)
Board Of Building Regulations and Standards
HOME IMPROV6 AEHT CpNTRACTOR
Re9istratlon 144752 T 124729
_.� •• 1=xAiratlon_1112f2008
;Type:
RANNEY&RIMINGTON GUSTOM'CARPEN v
ALEXANDER RANNEY
J.
267 MEIGGS BACKUS-.RO_. Administrator
SANDWICH.MA 02563'
BOARD OF BUIL:DIIvv REGULATIONS
License: CONSTRUCTION SUPERVISOR s
4 Number.CS 088595
Expires 041.6%2008 Tr.no: 88595
Restricted_oo
AL_EXANDER M RANNEY y
267 MEIGGS-BACKUS
SANDWICH. MA 02563 ' Comro�ssioner
NEWS nklm"111"'l-1:43
GRANITE STATE INSURANCE COMPANY 32166-0000 WC 438_i -00
13102 013-66-0807-00
PENNSYLVANIA
..- a
PATR I CK .R 1 M I NGTON K ALEX RANNEY Member Companies-of
PO BOX. 816 Oil" American Intemational Group
MARSTON MILLS, MA 02648-0000
EXECUTIVE OFFICES:
70 PINE STREET, NEW VORIC, N.Y. 10270,
SEE NAME AND ADDRESS SCHEDULE - WC990610
I.D# MA Ulf:
ROGERS GRAY
WORKERS COMPENSATION AND EMPLOYERS 640 1 YANNOUGH RD.
LIABILITY POLICY INFORMATION PAGE HYANN I S, MA 02601-0000
INSURED IIS PREVIOUS POLICY NUMBER -
PARTNERSHIP' RENEWAL 00439248o
OTHER WORKPLACES NOT SHOWN ABOVE:SEE NAME AND ADDRESS SCHEDULE WC9906lo -
ITEM 2 POLICY PERIOD 1201 A.M.standard time at the Insured's malting address FROM 08/06/07 To 08/06/08
WM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed
here:
MA
B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A.
The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
Bodily Injury bV Disease $ 500,000 policy limit ;
Bodily Injury by Disease $ 100.000 each employee
C. Other States insurance: Part Three of-the policy applies to the states, if any, listed here:
SEE ENDORSEMENT - WC200306A
ITEM The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and-Rating Plans.
All information required below is subject to verification and change by audit.
Estimated Total Rate Per Estimated
Coda Number Remuneration 3100 OF Re. Premium
Classifications muneratlon
Annual ❑3 Year �Annual 3 Year
SEE EXTENSION Of. INFORMATION PAGE - WC715h $478
TAXES/ASSESSMENTS/SURCHARGES
EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE 13Y STATE) $284 MA
MINIMUM PREMIUM OO MA TOTAL ESTIMATED PREMIUM 01
If Indicated below,interim adjustments 01 premium shall be made:
Semi-Annually 11 El
Quarterly Monthly DEPOSIT PREMIUM
ENDORSEMENTS jFORMNUMBER) SEE ATTACHED FORM SCHEDULE - WC990612
08/23/07 ASSIGNED RISK -66
Issue Date Issuing Office Authorized Repres I entam`ve we 00 00.01
39967
IiiNtSUp
Z•d d9Z:eo 80 S I, per
® 22 08 08:32a p.1
American Properties Team, Inc.
January 18, 2008
To Whom It May.Concern:
At their meeting on January 17, 2008, the Board of Trustees of the Cape
Crossroads Condominium reviewed the construction plan.presented by
Lorraine Wu for the bathrooms at 800 Bearses Way #2SB.
The Board hereby gives its approval for all nessessary requirements and
permits to be. granted to complete the work needed to restore her unit,
including any needed changes to conform with appropriate current
building codes.
If you have any questions or need further information, please-call-me at
781-932-9229 ext. 239.
Sincerely,
American Properties Team as agent for ,
Cape Crosroads Condominium
Deborah Jones
500 WEST CUMMINGS PARK • SUITE 6050 • WOBURN • MA • 01801 781-932-9229 • FAX 781-935-4289
2
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