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HomeMy WebLinkAbout0078 FERNWOOD AVENUE TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Zog Parcel Application # Z 01•� o �U 1 Health Division Date Issued `2 Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address r Village 17 Owner lya 17 C U Address io C ��/I�Ie�2U�e � • a Telephone Permit Request ICJ L Square feet: 1 st floor: existti/ing/proposed 2nd floor: existing proposed Total new Zoning District /�PSi 4 l Flood Plain Groundwater Overlay Project Valuat0 Construction Type Lot Size T�� Grandfathered: ❑Yes ElNo If yes, attach ss:upporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) 4i i Age of Existing Structure Historic House: ❑Yes C(No On Old King's�Highway.,❑Ye No Basement Type: Full ❑ Crawl ❑Walkout ❑ Other 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: �X 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 Telephone Number Address Z zz .0 -i License # Home Improvement Contractor# Email 17,do&i6eL� Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNAT DATE (D FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED ti MAP/PARCEL NO. ADDRESS VILLAGE OWNER s DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. i Isar P��Fri�� - Name - - AC3r J/0-���-5^' • �a ag e�In�er? th��priaf�bcr� r�af p��� �• •- L I a�a❑ I am a e.�plog�r� ❑ ca�act�sr�I � El e�xplopees{frill andlflrpa #m �* � e ❑ I am a soIV p=a r orparEnrr- lisfe-d on 1he wed shy 7- ❑egg shipmNd have nr,employ=s Them ors have 8- ❑ �-Enr m my�y e, ees anahzve ems' 4- ❑ - $dd�iau ias� C=3p 5. ❑ Wtama caTora iamaadifs I4 D Ieclzicalsepsnsorad� sans J. I am a homvo•unr&inb aZ WOA.- ` '•';��fh r 1I❑Phmling=pairs m add Ec.& off LNo V7cli='comp- z cffc=mptirimperMGL 120$nof=epaas xz7srrrs�n rg �.[ c-15Z�1(4„andwe Ira-a nv .[yawadme 4tber comp-mrnrmm requam-d-I . -�sf��t�i 6cxm•�Y s�sed m�,�.r:�,,,gt�QeY t�en�of� m3�iP.•w�etiz�t�at•�sa�t�esfv—ee mmrflz yam_rfrne=Ta-c�lLm�,me��r2aet� t o ar Itry��rk�is prat arkers'rot n tt WMMU=fOr My 8XTfDy= BeintF is the pa;LY aril jab sits 1'0FZLT;g Cr se f-inr,uc-f- i}aI}at lob Ma Ad6=sS - Ai ac'h 2t cOPY nf'tT33 wG lere c*mpcus ti'm paULT decla (--IOWb3g th�POBEY n er anE on ilate); Fas-nie to set�c cc��tage as vender Sec50n<.25A 0fhiM r- 152 can lead to tine i mpos i=D-'�A geaaffies of a f%ae EP fo�LS00:0a andl0r o�-yearim ss�1 a;�rI genalEi�m ffie f�of 8 S`�'CtP A�(bR�LI��$.and a� ofupta$250-00 a dsyafzaxstthevioWmL Be advisedtzf acaggofffris mapbeceded tvibe OfFina of Invi=-gxfiom of ibe DIA fhr imura=conga I cfu.hLtFt�=tfy ttrgpaia s lwd psmzhT s afp8dury ffFatffigLiz u prxzrdrua prauirlc�ub/ays is rend sct , �- �FnsaauF Dc trnt terihs Lu ffus area,fa hir crrR*t5i by cdy ar An=u-�c&l City orTaT4uifff;r L Board ff€H—Ith I ngDafzi�I CitFffawv—a=k 4-EItcEcicalEmpDctDr �.P €vr �.cKher . ���ccsr �aI Laws chaptr�I52 regnn�s all��to p2avrde warknrs'r�ensabon fnr�emplopc� . Pm= -tn this s an ploy=is deuned as=—every prasaa in ffie, vice of mother under a¢y co o fhae, � ib `TEEM Ur its Ted,anal orwtif " : An�,�y�-is defnzed as`pan par hm,P cialia a,caopaation or other legal e y,or�p tvro or more ofthe fmrgnmg=gaged m a3�Mai and legal v of a deceased emplHOW -7 the receiv ea atr tro3�e of an mayirT�aT p�•Tg,assoaiafian or other legal e�-y,employing CM:rPloyees. 133oweves the o Yn= of-EL dweIFmghouse havingnotmore than three apadm�s and who resides therein,cff the occ�ant of the dwelling hortse of another Who e3plo7s persons to do maiat e,contraction,or repair work on such dwefiing house or on fhe grafunds or bin7dmg, ant thereto s han nest because o-mc:h employment be d=med to be•an mapIoy cr." MCzL chapter I52, §25C(6)also stains that¢every state or local licensing agency shall withhold Elie issuance or renewal of a license or permit to operate a bus mess or to constrracf btradi ga in the commonwealth for any - agplirant vTl:ro has not prcidgced acceptable evideaCt of compliance with.fire ias�ane:�coverage required.' . Ar3ditiona.Ilp,MCL chapter 152,§25C(7)states'Neither$e commonwealth nor tay of io p .tn ce with the in al subdivisions shall enter in D any coEt- r t for the perfozmance of public work until acceptable evidence of compljan ice requn�ents of this chaptrihavebee=prescandto fbe co tares aT-fhollty- Applicants Please till out the workers'eomp=-s ion affidavit completely,by the king ,boxes that apply to yo-Lrr situation and,if necessary, supply sub--contractnr(s)name(s), addresses)mdph=m—ber(s)along with then cerancate(s) of 1 m.cirranCe T'.r _ mitEd Liability Companies(LI.C)or T.;m;t� (L Liability Partnerships I P)wth n o ern F �gees other than the, members or pzft=s,are notrequired to catty wMi='compensation m�T�ce- If an LLC or LLP does have employees;a policy is requited_ Be advised that this affi.davhmaybe submitted tD the Deplavit. of Industrial Accidents for confQmation ofm�nce Coverage Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested,'not the Departeieat of Industrial'Accidents. Should you have any mi moons rep rd= tT)e I.aw or if you are required to obtain a workers' compensation policy,please call the Department at the number Iisind below. Self ins�ed companies should enter their self-iosora ce license number on the appropriate line. _ City or Town Officials Please be sun:f�the affrdavit.is complete*and.gzir Ieg�1y TheDepartmeuthss provided a space at the boi a of ine affidavit for youth fin outmthe eventthe Office oflnycsfig�tins has to aonfatt.yonregaFding the applicant Please be ym:;C to fill in the pemzitllieense number which be used as a-mfemnce number. In add'-r ion,an applicant that must submit multiple pcmo itllimwr,applizations in any given year,need only submif One affidsvit indicating current = policy info i`on(if necessary)and under-Job Site Address"the applict should write roll locations m (city or ' town).-A copy of the affidavit that has been officially stamped or marked by the city or tovm may be provided to the applicant as proof that a valid affidavit is cyn fat for future permits or licenses A-new affidavit must be filed o ttt e ach year_Where a home owner or citizen is obtaining a license ar permit notrelated iD'any business or commercial ve aWm (Le,.a dog license or permit to b=leaves etc.)staid person is NOT req� to complete this affidaY.t The Office of Ihvest gations would hIm to thank You k advance for your cooperation and should you have any.quhstions, please do not hesitate tp give us a call_ The Departmen's address,telephone and 5xnm:ol s. _ ai:�CommDaw(-,attb-of MassaGhU Dtpail=Kitcfludj�±dalA tst _ �agtm,I C12II1 Ta.9 617-727-4 w±4-66 car I--V WZ�. . : Rwx 617-727' 49� h.r,vised 4-24-0 TOWU 01-Barnstable Regulatory Services `ox Richard V.Sca%Director 20 Building Division r t a� Tom Perry,Build mg Commissioner . lk 200 Main Stieck Hyannis,MA 02601 - wwvw town_barnstablema.ns Office: 508-862-4038 Fax 508-790-6230 HOMEOWNER LICEME EXEMTION DATE: �1'Ir�sePtint JOB LOCAT M.Z- -2Atexct IQ 'Cr TMRP �oMEowriEx: e �G 3�' name c� hompe phh0=# wok phone# CJRRENQT MAII M ADDRESS:- L!��� `-�c--1 "✓ i1 44 �� s� rip The current exemption for"homeowners"was extended to include owner-occupied dwelling 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 sumervisor- DEFl MON OF HOMEOWNER Parson(s)who owns a parcel of land on which he/she resides or mends to reside,on which thews is,or is intended to be,a one or two- family dwelling,afteched or detached strmetu res 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 bmUbj tierrok (Section 109.1.1) The rmdersigned"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 MrImsha ds the Town ofBarnstable Building Department minimrma inspection pro and requirements and that she will comply with said procedures and requirements. Si Romeo Appmval dBtu7ding 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 Comst action Control HOMEOWNER'S EXs1 MION The Code states that: "Any homeowner performing work for which a build permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of contraction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that sack 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. rn 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 My aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she anderstands 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/certifimtion for use in Your community. Q:IWPFaMMRMMWldmgpermithcm MaRMdoa Revised 061313 Town of Barnstable '4 Regulatory Services Richard V.ScA Director Building Division Tom Perry,Bmlding Commissioner 200 Main Stems Hyannis,MA 02601 www.town.barnstablema.ns Office:' 508-862-4038 Fax: 508-790-6230 Prope'I:ty Owner Must = Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my,behalf; in all matters relative to work authorized bythis building permit application for. (Address of job) **Pool fences and alarms are the responsibR7 of the applicant. Pools are not to be Med or utilized before fence is installed and all final inspections are performed and accepted Signature of Owner Signature of Applicant Print Name Print Name Date Q:F0xMs:0VnQ PEUMSMI 00M el-O;o7 GG . G 0 to� G G f W .,- y � 1. INU jo V I Ap O a ali;I"A v Sao �Tl� 0 GG re a 0 i� G f eta v . J V y' Ap I G O n i I G �� . �µv � .� � � � .� as � �, � � � ��i� � � �� �� � ~GCi ``7 �� �y �---� .e ., c► o _, !S/ - 1 l �� D' /� . fi� G 4 �_ f 0 `� V 1 \ T7 p O y ,R L� I 5 r. Town of Barnstable THE Regulatory Services snxivsras�. Thomas F.Geiler,Director �.i639 Building Division y� 1e� ATfD�^p�a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 PERMIT# 1 I FEE: $ 0 6KI SHED REGISTRATION 120 square feet or less Location of shed(address) Village C 65CIA� 5 06 2,�y 7,;7� 7 Property owner's name Telephone number Size of Shed Map/Parcel# ` N '! cn o r zM o N ao rry Signature Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? Conservation Commission(signature required) 2 � / PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THEY ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:121901 CA ® IQ 0 00 00 e� c� � 93 OFTME tp� Town of Barnstable *Permit# 7 3 P� ~O Expires 6 months from issue date ,� UE, = Regulatory Services FeeSTAB !1� v M"M Thomas F.Geiler,Director Building Division Tom Perry, Building Commissioner ® . 200 Main Street, Hyannis,MA 02601 XPRETS Office: 508-862-4038 L ? ZQ03 Fax: 508 790-6230 EXPRESS PERMIT APPLICATION - RESIDE _ Not Valid without Red%Press Imprint ��� � a Map/parcel Number Property Address 78% residential • Value of Work �� . � �. Owner's Name&Address � �}1 � � Contractor's Nameti'��. Telephone Number �J } Home Improvement Contractor License#(if applicable) r Construction Supervisor's License#(if applicable) r 4aWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name r Workman's Comp.Policy# Permit Request(check box) e-roof(stripping old shingles) All construction debris will be taken to / / A / �✓ ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side' ❑ Replacement Windows. U-Value (maximum.44) *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. provement Co to License is required. Signature Q:Forms:eapmtrg R a.,; onaanD� TO -n Z m u Q::G 0 > G)N Z Z tTI rn '� - M = e W n 'w' \I cn � � k m 3 a m p �a z j 3 by © I� Wa I " Off` CJ w m 3.m e. N W Z 0 a N R3 B ? o 'ba. a 4-4 M 00 a CCl O O II r`n tdow � r ` Cs O. ern a Fraser Construction Roofing & Siding Specialists Possible Extra-Any rotted or otherwise deteriorated trim boards, plywood sheathing, lead flashing, or other carpentry needing replacement will ri done / and charged for as an extra at the rate of$40.00 per hour, plus materials, plus 20% overhead mark-up on total extras. FRASER CONSTRUCTION Warranties the shingles and labor for 10 years. FRASER CONSTRUCTION Warranties the shingles against Blow-Offs for 10 years. CERTAINTEED Warranties the shingles and labor100%or the f es become defective. and then on a pro rated basis for 30 years total f the CERTAINTEED Warranties the shingles to be ALGAE resistant for a full 10 years. Any deviation or alteration from above specification will be executed upon written orders and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents necessary control. Owner should carry fire, tornado and other insurance upon the above work. We, if not accepted within thirty days may withdraw this proposal. FRASER CONSTRUCTION: Carries Workman's Compensation and Public Liability Insurance on the above work. DATE OF ACCEPTANCE: I SUBMITTED BY: Homeowner er onstruction 05/14/2011 15:46 5087785010 TUPPERCO PAGE 01/01 TUPPERTO.WN OF BARl►c-:TA, ,E CONSTRUCTION CO-L-Lc 79B MID-TECH DRIVE,WEST YARMOUTH,MA 026n 20'I3 M A Y '39 ; 9� PHONE: 508-778-0111 FAX: 508-778-5010 yyVAT_U._P_P E"RCO.COM Date: 'Loo f - Town of Bamstable Thomas Perry CBO 200 Main Street Hyannis, Ma 02601 (508) 790-6230 fax Re, Insulation Permits Dear Mr. Perry This affidavit is to certify that all work completed for permit application # C7/ �® 0 Issued on ��Z/�lj has been inspected by a certified Building Performance Institute (BPI) inspector. All work performed meets or exceeds Federal and State requirements. nner License # CS-69058 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map' lc_ _ Parcc lJ /�tion # Health Division Date Issued Conservation Division Application Fee ll Planning Dept. Permit Fee 7 Date Definitive Plan Approved by Planning Board °�C 6-ZI -/3 PF Historic - OKH _ Preservation/Hyannis Project Street Address A)000( Village Owner Address Telephone 50 d - /07,70 4 Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new ..Zoning District Flood Plain Groundwater Overlay Project Valuation 200. Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. r� ci Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old Kings High\Nl ❑ Yes ❑.No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq ft) Number of Baths: Full: existing new Half: existing Mew c+ Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: h(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 Telephone Number 502 - -7-7 Old Address Mew �eA - License # (�5 — ©&g059 02�7_3 Home Improvement Contractor# /aa 7__�5 Worker's Compensation # WL 50055gS0/Zol; ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WIL TAKEN TO SIGNATURE DATE 6" 't r `j FOR OFFICIAL USE ONLY r APPLICATION# DATE ISSUED ' MAP PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: --,FOUNDATION. r FRAME INSULATION i ,p FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL r GAS: ROUGH FINAL FINAL BUILDING ' } 't DATE CLOSED OUT ASSOCIATION PLAN NO. I I ,4 OWNER AUTHORIZATION FORM (Owner's Name) owner of the property located at 7 ,0 (Property Address) GNU (Property Address) Hereby authorize (Subcontracto an-authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. Owner's Signature Date ti3Ut#t7iNi Wlr i3H L ims t tJ f e, 1NC ,, ? Massachusetts-Department of Public SateYy 107 He $mod,Suits 11p ..,.Board of Building Regulations and Standards Mwta,NY 12020 Constructmn Superviso (877)274A274 It` License: CS-069056 wwwbpi.rxurp jg RICHARD S TUPPtR 79 B MID-TECH DR WEST VAWN16i CIi Widiafd.,U M, apt t ' ER I $ �4 , 61t.: -U, Expiration 1sEkpEv£M SIDE FOR DEs bsY EXPOTM UATE Commissioner 12/31nou r , 4 Office of consumer"ACF>ilra Br 11r[stt�ts�i Reg�t�tlan NOMIw IMP CiV6tt ENT CONTRACTOR f t , R69is 21845 Tik d `6xp ti 614 14 i�dNidual. RICHARC?'T � aka �➢%�� � �. � � - . 1stRtC � t RIGiiAR[} UP R 3 ry � s L, fppsi a W.YARMOU t5nderseerctary: y aec. ?G. 2012 4:37PM No, 8524 P, /2 A CERTIFICATE OF LIABILITY INSURANCE FDATE(MM ONYYY} 12/19/2012 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 SY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. R 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 ilau of such endorsement(s). PRODUCER NAME:CONTACT Lora Lowe Southeastern Insurance Agency, Inc. �"�No.E ; (508)997-6061 FAxc No; (508)990-2731 439 State Rd. EMAIL ADDRESS; P.O. Box 79398 PRODUCER CUSTOMS IDS:.. N. Dartmouth, MA 02747 _ W - GE INSURERIS}AFFORDING COVERAGE NAIL 0 INSURED INSURER A: Arbella Protection Insurance _ Tupper Construction Co LLC INSURERS: AEIC INSURER CNA Surety -- ----__._. ........................--...__...............:_..._....____-._..__....__:._....._..__..__..._................ 27 Roberta Drive INSURtRD: _ West Yarmouth, NA '02673 INSURERS. INSURER F COVERAGES CERTIFICATE NUMBER: 12/13--2 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 AUULINSR WVD POLICY NUMBER MWDO J MMID LIMITS GENERAL LIABILITY I 95000087411110112012 1110112013 Any RsEN.E a 1,000,000 IWA E T: 5t X COMMERCIAL GENERAL L IAB7U I( { RE"A S Ea a were: a 1QQ QQ ._......... i t.._. ...... ..�CLAiMs wbE IX OCCUR i { :MEC EXP(Any one Fam n) $. _ 5,000 i A _ PERSOWU a nry INJURY $ 1,000,000 --.._W_.._..........._.._...__- I GENERAL.AGGREGATE— $ 2,000,000 GEN L kGGREGA c LIM'TAPPLIES PER: I ?I20UI;CTS-COWRIOP AGG $ 2,000,00 PGLICY J�E T _ LOC $ i AUTOMOBILE LIABILITY .. 5666240000 1210112012 12f0112013 COMEINED.SINGLELVIT Y I 1,000,000 i ANY AUTO I i 8OD Lid h Ii'RY{Fer person! f$ Ali.OVMED AU•OS I .— �_. ,80UiL'i?NJUR`f{Psr actldenY I$ A X S 4EDULED AU-n$ j PROPERTY DAMAGE X ;HiRED:AUTOS (per o c de�tY �$ INC X NON OWNED AL 0S I i$' UMBRELLA LIAR Enc- DEDUCTiELEH OCCURRENCE .i$ EXCESS LIAR CLAIMS MAOr I: RETENTION WORKERS COMPENSATION WCCSQQSS93O12OQ 10/D3f20i2 IOIOS12013 X i ToMY"I MTs .X N A k AND EMPLOYERS LIABILITY ER B ANY EICERME SOR1PApTvE dEC TIDE YIN N!A' RICHARD TUPPER I FI EACHACt IrA $ 500,00 E] I LUDED FOR WC COVERAGEE SEASE•EAEMPLGvE,$ 500,00 (Mandatory In NH) D` II yy95 dsecrlcs iYK'ie'- i E.... ._..._. : . DEC.R PTI^N OF OPERATIONS-Gel6�r : D,SEASE Pv.ICY UR11 $ 500,000 Bond or theft of money & Or I 710688130212812012 02128/2013 Limit of $10,000 C property. DE RIPTIO OF OPERATIONS I LOCATIONS I VEHICLES(A(tech ACORD 101,AddItIonal Remarks Schedule,If more space Is requti 4 i ).ju�io0csgrp.com 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. Conservation Services Group. Attn: Bill )ul i o AUTHORIZED REPRESENTATIVE 50 Washington Street Westborough, MA 01581 Lora Lowe Q 1988-2009:ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD The:Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA.02111 Ulf www.mass.gvv/dia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians(Plumbers Applicant Information 'Please Print Legibly Name.(BusinessOrganizationtl.trdividitaO: Tupper Constr'ucti n Co: , LLG Address: 79B Mid Tech Drive City/State/Zip: West Yarmouth, MA 02673 Phone# 508-778-0111 Are you an employer?Check the appropriate box: 'Type of project(required): 1.El 1 am a employer with 4. ❑ I am a general contractor and 1 6. 0 New construction employees(full and/or part-time).* have hired the sub-contractors. 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.# 1. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp, insurance. q, R Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its officers have exercised their ME]Electrical repairs or additions required:] 3.❑ i am a homeowner doing all work right of exemption per MGL 1.1.❑Plumbing repairs or additions myself.[No workers' camp. c. .152,§1(4),and we have no 12.Q Roof repairs insurance required.]t employees.[No workers' t I.[]Other comp. insurance required.] 'Any applicant that checks boa#I must also fill out the section below showing their workers'compensation.policy in 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 their workcers'comp:poi icy itifortnation. .lam an employer that'isproviding worl4ers'compensation insurance for my employees. Below is the policy and job site e information. Insurance Company Name: AEI C Policy#or Self--ins. LicG#: WCC 5005593012012 Expiration Date: 10;/0 3J 2 01.3 Job Site Address: 0 �DG�CX l�la P Cit�iState?Zip 02601 Attach a copy of the workers compensation policy declaration page(showing the policy num_er and expiration date). Failure tdsecure coverage as required.under Section:25A of MGL a. 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$250.0.0 a day against the violator. Be advised that a copy ofthis:statement may,be forwarded to the Office of investigations of the DIA for insurance coverage verification. I do.hereby certify u r1 a gins rrnrt penalties of perjury that the nformath n provid d abtiVe is true and correct. Si nature: mate: J Phone#:._ _ 5 0 8 7 7.8,.0111 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#: