Loading...
HomeMy WebLinkAbout0090 BEARSE'S WAY r o S f �4 Town of Barnstable .*Permit# ' of T"E'biy� • p Expires 6 months from issue date Regulatory Services Fee RAIDWARM MAS&sea ��$' Richard V.Scali,Director - pa Building Division - Tom Perry,CBO,Building Commissioner -_-- 200 Main Street,Hyannis,MA 02601 —- - www:town_barnstable.ma..us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERNUT APPLICATION - RESIDENTIAL ONLY[, a Map/parcel Number Not Va�lid without Red X-Press Imprint "i�Sra1 �JjJ� c� ' " � Property Address JUN 1 4 2016 C 1 ! UVVN OF 8Al�Ill�liq�LF Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address .Q�-� Contractor's Name 9 C_ eQ_ (-I Telephone Number _�aR—,�D� aneJ11,6 Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: 9-1 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 Request(check box) J gRe-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 ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. ` SIGNATURE: QaWPFILES\FORMS\b'uilding permit forms\EXPRESS.doc Revised 040215 Elie Commomvealth of-Wassad�rftsetts Dept rafteut of lndm&ial Accidents Office 0fb"Vx69C7fiVns " ' 600 Was bigtou Street _ Boston,CIA 92111 svfmmam govIdia `-- _ '"rarlcers CU>Mvensatitm.Insiu-a ce Ada BufldeimlC ni cE rsJEl ebricians(P"Iumhers �T pplica�i#InfurmafrQn ---- -- - — Please hin -Lew'M�— -- Narne causine ganirafi n&&1yidaff r ,1 Address: / CitglSta& Ph ogle c� �1 c V Are you an employerl Cte&fhe appropriate box: Type of project(required): 1.❑ I am a employer with 4 ❑I am a general contractor and I 6. ❑New censtuctian: employees(full andforpart--timed* have hired thi sufr_ConaraCft= Z&I am a sale proprietor orpartuer- wed on the attached sheet. 7. ❑Remadelg sip and have no employees These sub-co ac#ors base 9 ❑Dembaon w for me in employees and hax a worirers' °fib �� INC Wodmrs'comp.invhrxnre comp_insurance-1 9. El B.uildmg addition required_] 5. ❑ We are a corporatim and its 10-❑IIectdcal repairs or additions 3.❑ I am homemmer doing all wcuk offers have e r-Ised their 1L❑Plumbingrepaits or additions myself[No worlaers'camp- rigU of a=np on per MGL IX EI Roof repaim insurance required_]i c.152,§1(4) andwe have no �� employees.[1Vowo&ers' ao afer 1 Y camp_insurance required.) •tiny sW icautffiat dheftbox E mast also fhM cut the swdambelawshmhdug ibeirivo&e&compehhsatiavpaIity infl=tWQon_ THnmeownerswhosubmitibisfdaclunuEczt,m,rtkyamdomgzUwadtsad.d=hixoutsidecontmctorsamstsubmitanewaf idav tmdicatir sadL ICan=ctucs lhzt cbecY ibis bay must attached an.sddiiiaaat shed`b&m!=g the name of fe sacl state whether or not fbnse entities bay aap3oyees.If the sub-caatactahshaveemployees,daeymustpmridetheir warken'gyp.policyhunnbeL I and an snipIoy r flsatis prer}zdir �i�orkers'cotirpertsatian iizsurarice f or lei*eQrpluJ�ee Below is i7tepolicy aizrl job sfte iazfoC riiafiors lusurance companyName: Policy;A,or ins:Iic_ Fxprration Date: Job Site Address_ cityfsta dzf p: Attach a copy of the work-ere compensationpolicy declaration page(showing the poFicy 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$1,50a 00 sailor one-year imprisanmenk as well as civil penalties in the farm of a STOP WORK ORDER and a fine of up to$250-00 a clay agar the-violator. Be adtased that a copy of this statememt may.be fxwarded to the Office Of Itwesk gatians ofthe DIA for insurance coverage verificatioa- I do he mby e pabis andpen afgerjury attfie irifonsmtiaiipt oW&rZ ab/mom is true acid correct itmature: Irate: Phone a Zdal use ord}. Da not write in diis area,to be compLetesd by City arfo n oficieL City or Town: P'ermitUcense# Issuing Authority(virile anel: 1.Board of Health 2.Building Deparhment 3.CitylTown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: laformation and lastruction s � hfassachusctts Ge=al Laws chapfier 152 regnaes all employeaa'to provide.work='coarpensation fDr ffieir employees. Pursuant-to this sfatutc,an.enploy=is defined as."_.every persanin$re service of another under any corrfract ofhire, express or iinplied,oral or wzitem" An mTFayEr is defined as"an indrvidual,partner,aMdaliim,corporafion or other IegaI entity,or any two or more Of the foregoing=gaged ni a joint Vie,and including the legal representativm of a deceased employer,ar the receiver or$ustee of an individmL pmtaership,association or otherlegal entity,employing employees- However the ownex of a dweIIing house having not more than tl=apartozeufs and who resides therein,or the occapant of the - dwelI house of anofer who eurploys persons to do mahitmmi e,contra on or repair wok on such dweIImg house or on the grounds or building appniteaaritthereto sbaRnotbecause of such employment be deemed to be m employer." MILL chapter I52,§25C(S)also states that"every state or local licensing agency sho wif hold the issuance or renewal of z licc=s e or permit toop erafe a business or to construct buildings in the commonwealth for any applirautwho h:as notproduced acceptable-evidence of cdmplrance with the insmznce.coverage regair� Additionally,MM chapter 152, §25C(7)states"Neither the c=m-mwmhh nor iay ofits political subdivisions shall e deuce of co Iiancewifh the inset-ance. enter into any contract for the perfonnaance ofpubho work u nE accepiable n mp rec u menfs of this chapter Dave been presented to the contracting auf mity_" - AgpHcasts Please fill Dirt the workers'compensation affidavit completely,by checking the boxes that apply to your situation anc,if nxessa3:L supply sob-contactor(s)n e(s). addresses)and Phone mxmbei(s)along with their certifica(s) of h=rance- Limited Liability Companies(ILC)or Limited Liability Partnerships(LLP)withno employees other than the members or partners,are not required to carry workers' compensation ins rand If an LLC or LLP does have employees, a policy is required. Be advised fiat this a.ffidayh may be sabmittnd to the Depa-tment of Industrial Accidents for conf=ation ofm�ce coverage Also he sure to sign and date-.he atlzdavit The affidavit should be retnmed to i`he city or town that the application for the permit or license is being request-tL not the Department of inc�nef,;al A ccidem� Should you have any questions regarding the law or ifyou are required to obtain a workers' compensationpolicy,please call theDepartmentat the numberIi_sbdbelow, Self-fimn-cdcampaniesshouldentertheir self-mince license nmnrbes on fhe appropriate Ime. City or Town Officials . Please be srae that the affidavit is compldd and priufed legR3 y_ Ihe Department has provided a space at the bottom of the affidavit for you to Ill out in the event the Of of Investi�o has to contact you regarding the applicant_ Pleas a be sure to fill in the pen�itIliceose member which wM be used as a reference immber. In addition,an applicant that must sabmt muYpIe peon /license applinatiom m any given year,need only submit one affidavit indicating current p olicy inlfbnuation(if necessary)and under`lob She Ad_�ese the applirmt should write"all locations in (cry or town}_"A copy of the affidavit fiat has best officially stamped or marked by Ae city or to maybe provided to the applicant as proof fiat a valid affidavit is on file for future penis or licenses A new affidavit must be filled out each year.Whet e a home owner or cifizrn is obtaining a license or petit not related fn any business or commercial v6Ire Cie,_ a dog license orpennit to burn leaves etc.)said person is NOT required to compkte fais affidavit The Office of Investigations would lake to thank you is a.d4-aucO for your cooperation and should you have any questions, please do not hesitate to give W a caIL The Depariineut's address,f$lephone and fax mmnber: -The C:G j-ft of Massachnsst s , Depai t mt L f did iiiaz Aocident� �Q�T�ash�tan� ` 614 617 7 -4900(-,xt 4-06 car 1-9 MA_SgAFF, Fax 9 617-727 7M Kevised 4-24-07 W .mass gcEgf�a J y��rgyti 9� i6SS. �` Town of Barnstable ArEo�. .19 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, �( V � ZI S , as Owner of the subject property hereby authorize (/ to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job f ) . 6 S*Mtnte of Owner Date _ f -571T VK R4z/s i . Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q:\WPFa ES\FORMS\building permit forms\0TRESS.doc Revised 040215 I Town of Barnstable d Regulatory Services �drIHE A Richard V.Scaly Director Building Division * BARNSUBLF°' Tom Perry,Building Commissioner MASS. � 1659. 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HO1%EOWNER7: name home phone# work phone# . CURRENT MAILING ADDRESS: - city/town state zip code The current exemption for"homeowners"was extended to include owner-occuied 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 Persons)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 building permit. (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 lackof 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:\WPFIL.ES\FORMS\building permit forms\MTRESS.doc Revised o40215 c. u � C�fie�pammw�ru�ieaLC� C%vGcreaac�cuael�s ,. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration tN 36003 Type: Explrati=� =18. Individual BRUCE P..MILLS T-) BRUCE MILLS 16 CROOKED POND'R ;y' • ,M ki HYANNIS,MA 02601 . Undersecretary Az J use group vuluch Unrestricted-Buildings of any 991m3)of . 35,��Q cubic feet contain less than enclosed space. possess a current edition of the Massachusetts Failure to p for revocation of this license. State Building Code is cause Mass.G0v/DPS For DPS Licensing information visit: www. Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-078687 BRUCE P M 11 S 16 CROOKED PQND3 e HYANNIS MA 02601 r Expiration Commissioner 05/29/2016 �l Dfs W� � � F P d / i i a © 11U � � Town of Barnstable *Permit# Expires 674thsfrom issue date Regulatory Services Fee BAPJWABM M+ss Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not valid without Red X-Press Imprint Map/parcel Number (.0 Property Address to , en-rne-. , C :1 danrta� gResidential Value of Work$1 y OU ,OO Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address [e 6r-C L's geci.-se'-�-- LA):Zy Ga&k^c5 Contractor's Name Sprinkle Home Improvement Telephone Number 508 775-1778 Home Improvement Contractor License#(if applicable) 103757 Construction Supervisor's License#(if applicable) C5 U6 -�— Df Workman's.Compensation Insurance Check one: J U L ? ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name Associated Industries of MA Workman's Comp. Policy#AWC 7004943012011 v Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to f ❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors -Replacement Windows/doors/sliders. U-Value - 3a (inaximum..35)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Hom Jpprovement Contractors License& Construction Supervisors License is e SIGNATURE: C:\Users\dccollik\AppData\Local\Microsoft\W'indo%N s\Temporary Internet I=ilcs\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 www.massgov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/Individual): Sprinkle Home Improvement Address: 199 Barnstable Road City/State/Zip:Hyannis, MA 02601 Phone#: 508 775-1778 Are you an employer?Check the appropriate box: Type of project(required): 1. OK I am an employer with 9 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part time).* have hired the sub-contractors 7. ❑ Remodeling 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance.$ required] 5.0 We are a corporation and its 10. ❑Electrical repairs or additions 3. 0 I am a homeowner doing all work officers have exercised their 11. ❑Plumbing repairs or additions myself [No workers'comp. right of exemption perm MGL insurance required]t c. 152,§ 1(4),and we have no 12. ❑Roof repairs employees.[no workers' 1 ether GOL'&A" RPM comp.insurance required] 'Any applicant that cheeks box 01 mast shio®1 out the section below showing their workers'compensation policy Information. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tcontacion that check this box must attach an additional sheet showing the name of the sub-contracton and state whether or not than entities have employees. If the mh-contractors have employees,they must provide their workers'comp.policy number. I ant an employer Neat is providing workers'compensation insurance for my employees Below is the policy and job site informadom Insurance Company Name:Associated Industries of MA Policy#or Self-ins.Lic.#: AWC 7004943012011 ((Expiration Date: 01-01-2012 Job Site Address: �� � S y City/State/Zip: &a ri rl is, MA 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 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 $250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coveraae verification. I do herby certify and penalties of pedury that the information provided above is true and correct Si re: Date. zk 1 PK&Name. Brad Sprinkle phone#. 508 775-1778 Ext.10 Official use only Do not write in this area to be completed by city or town of f trial City or Town: Permit/license#• Issuing Authority(circle one): 1.Board of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact person: Phone#• MkOL Town of Barnstable Regulatory Services Thomas F.Geller,Director Building Division Thomas Perry,C130 adidwg Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable w&= Office: 508-M24038 Fax: 508-79"230 Property Owner Must Complete and Sign This Section If Using A Builder LYE tJf�2i-� ,as Owner of the subject property hemby authorize Sprinkle Home Improvement to act on my behalf, in all matters relative to work authorized by this building permit application for. �0 Gar -sv,-S y Y (Address of job) -Suture of Owner - Date Print Name U Property owner b applying for permit,please Complete the Homeowners License Exempdon Form on the revere side. C: 1LocaNNicroso8lVYmdows\T�ouzy Inter"Fik��Comm�t.0utloo�DDV87AAZ�RBSS doc Revised 072110 Bu:ir�,I :�1 B??iltlin_ ftr_ul;?u: n� .Intl ?;tn?I;?r '•. Office`ofonsumer` f`ftairs �usmessegulahon N Construct?on Sucervtsor --icens HOME IMPROVEMENT CONTRACTOR ci ns. S 6643 r Registration: 103757 Type: Expiration: 7/9/2012 Private Corporatic 00 SP NKLE HOME IMPROVEMENT,INC. BRAD K SPRINKLE 190 LOTHROPS LANE Brad Sprinkle W BARNSTABLE, MA 02668 199 Barnstable Rd. _.. Hyannis, MA 02601 Undersecretary 5478 Restricted to: 00 License or registration valid for individul use only 00- Unrestricted before the expiration date. If found return to: IG=1 2 Family Homes Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 Failure to possess a current edition of the c�---� Massachusetts State Building Code is cause for revocation of this license. Refer to: WWW.Mass.Gov/DPS Not valid without sign tore CERTIFICATE OF LIABILITY INSURANCE DATE 1/24/2010Y) 7TIT 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(a). PRODUCER CONTACT Bryden & Sullivan Ins Agency rAy Inc IA/C. No. R.O: wC. No): E-HRIL 88 Falmouth Road ADDRESS: PRODCCIm Hyannis, MA 02601 CUSTOMER IDS• INSURED(S) ArYORDING COVERAGE NAIC a INSURED INSURER A: A.I.M. Mutual Insurance Cc Sprinkle Home Improvement Inc INSURER B: 199 Barnstable Road INSURER C: Hyannis, MA 02 601 INSURER D: INSURER E: INSURER r: 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. POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE POLICY NUMBER NRoURn/YrYYN ONN/fm/Ym> GENERAL LIABILITY EACHoccoRAN3 a ❑COMMERCIAL GENERAL LIABILITY DANIM TO RMITED1:10 a IIAEtQBEe(EA.oaonzronao) CLAIMS MADE ❑OCCUR M07 EEP (Ay o0o poY�onl 8 PERSONAL A ADV INJURY 6 GPdI'L AGGREGATE LIMIT APPLIES ER: GENERAL AGGREGATE 9 ❑POLICY ❑PROJECT ❑LOC PRODUCTS -COMP/OP AM 9 a AUTOMOBILE LIABILITY COMBINED SINGLE LI)¢T MANY AUTO (u A cid=0 a ALL OWNED AUTOS BODILY INJURY (p—P.= ) a ❑SCHEDULED AUTOS BODILY INJURYip�aaotd�t) a ❑HIRED AUTOS PROPERTY DAHAOE (P-a Ld-t) a ❑NON-OWNED AUTOS a ❑ a UMBRELLA LIAR ❑OCCUR EACH OCCURRENCE a []EXCESS LIAB ❑ CLAIMS MADE AGGREGATE a ❑DEDUCTIBLE - 9 ❑RETENTION a a WORKERS COMPENSATION rc RrsAru- _ AND EMPLOYEES LIABILITY ® roRY rJMtY� EOTXR THE PROPRIETOR/PARTNERS/ E.L. EACH ACCIDENT 9 500,000 A EXECUTIVE OFFICERS ARE ® incl ❑ excl 7004943012011 01/01/2011 01/01/2012 E.L. DISEASE-POLICY LIMIT a 500,000 Y.L. DISEASE-EA EMPLOYEE s 500,000 COMMENTS DESCRIPTION Or OPERATIONS OR LOCATIONS: WORKERS' COMPENSATION COVERAGE APPLIES TO MASSACHUSETTS EMPLOYEES CERTIFICATE HOLDER CANCELLATION PROOF OF INSURANCE 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 REPRESENTATIVE