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0500 OCEAN STREET (10)
1 a 3�V--T uni-ILa}► 3z; o No �M f� I� �I �� Town of Barnstabli ing e v °�1 Buelde Post This Card So That it is Visible From the. Street-Approved Plans Must be Retained on lob and this Card Must be Kept t �,rsn�•�rn��.�,/,M vss 0��/- posted Until final Inspection Has Been Made. Permit � o Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has,been made. Permit NO. B-17-3820 Applicant Name: JOHN A MACKENZIE Approvals Date Issued: 11/28/2017 Current Use: Structure • Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 05/28/2018 Foundation: Commercial Map/Lot: 324-040-OBR Zoning District: RB Sheathing: Location: 500 UNIT 24 OCEAN STREET, HYANNIS Contractor Name: JOHN A MACKENZIE Framing: 1 Owner on Record: DONOHUE,WILLIAM J Contractor License: CS-085363 2 Address: 1699 DOWNING STREET,#405 Est. Project Cost: $5,000.00 Chimney: DENVER, CO 80218 Permit Fee: $ 160.00 Description: Remodel 5x8 bathroom Fee Paid: S 160.00 Insulation: Project Review Req: Date: 11/28/2017 Final: Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted.• Rough Gas:All construction,alterations and changes-of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work: Service: 1.Foundation or Footing Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed - Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5�-Prior to Covering Structural Members(Frame inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final:- "Persons contracting with unregistered contractors do not have access to the guaranty fund (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION � I Map > Parcel v l02' ?1 Application # �_ `S v Health Division , �� Date Issued 1 2X 1. Conservation Division -�� �,. � Application Fee Planning Dept. j Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address Village Owner 1 �/%. /�' ✓� IV Address �� �Pl / �P✓(i�� � Telephone '*r7"`"Z � l0 Permit Request fe�h G � jC J �Gr7��•�y/ ��,p��¢i� ,� ' Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District _ Flood Plain Groundwater Overlay Project Valuation �-� d � if . Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑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 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 �/'/' G (�✓�i�-� Telephone NumberSO'e- Address c � ��,,o -? License # ✓���?0 Home Improvement Contractor# ME 5� Email A P4✓ ��� Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING ROM THIS PROJECT WILL BE TAKEN TO DATE SIGNATUR �1��/ a FOR OFFICIAL USE ONLY -- APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME r INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. I 1 I ' The Commonweakh ofmawadrmeffs Off-we of h"-VMgGfi0 s _ ..... 60.0 WQShiIEeQFz 8�TSef _...... 1 L'FVEfLTtIasx90 plrE�itt Workers' CamVensagmIIIsmra3ice Afidayit:ltmlders/Contrmcfar5,1.IIwftkiaus(pluanbers AryHc"axd TMfMM ,f= P1e2Se Prhrt Name Axe you an cmplaye . Checkthe appropriate b� ' Type of project(re quireel}_ L l�cT i oaf a e aplayrr wf& O�'` 4 I am a general cc atmct=and I euxplaYees CfJ f RF dfflrpart-f=e * #avehin dthe sub-ca bMCt= 6. D Neff ciiag 2.0 I am a sale pmpaietor arpartaw- fisted on&e aftarhed sheet 7: adeling G!3�?and have no employees These=b-c=ftac=have g,Q DemalEffoDn 'Waring forme marry capacitg enTloyees and have WQAlfgrs' 9. �Barilc3"tag adu�iaa jldo UP&M s'camp-insurxaucei comp_n,smMiM. recfaifed-] 6- ❑ We axe a•cmpaiatiou and its 10 0 Ekcfdcal repaim-or a,Eioas 3-❑ I axa a h0MeoWM:er doing all work officers have¢Yewsed theEr 1L0 Plar abingrepairs or$dclttitazrs Myself[No waif='camp- tight of emmnpEm per MGL ❑ Roorrqxim MMMa=erequmed-j i a 152,§l(4k and we havens' exoployam[No worms' 13-0 omer COMP-insuuarrce regsired] 'Any M 6=tcberksb=',J Yr!= aura�a�the sec aandowsbaRiug e�e2ruor$es'mmp aL�F orl T uha snbn* g&1-72mdain.-SH—k zn&&M ke c�c�xs�st su5m�anemaSa t mdic a rnrTi Zi--U= t0-1 T=ch—Tr tbk b=m=sffidied mr addiei�sl suet shnomig tbeasm of�e camt<s[ smmd st�fe WLe7h��nnt mouse eatiteshs� empbrees.Tf the m&=tnamm empiv dL7 P=rsidetl&nr ssorkr�' �P•P�amnlreL I rztte att etrt.player SiatisgrMriutg uwrkes'campensa an ittstzraacg f br ffW errtgfvJTM $eFaw is flea paficy arm f ab rye €tc�arzrtQliots . 1 ceCompanyNa 'P liicy 4�,L or Self-iM Jir ��{G // �pixatioaI}afe_ l� Job Sife-Addregs; Attach acopy of the warkers'c0MpenSXd0 P0JicY•de4d2ratioaPage(showing the poFcp number and espirmdon date). Failure to secure coverage as required under SecEinrr 25A of MM CM lead to the imposidnn of c-Aminal pmakies of a fcne up is$15Q[k 40 azrdlar sae-gear impxisorsneut:as well as civil,peaal9 s m the fazra Gf a STOP WORK OMERand a Fm of usp to$25Q@kQ a dog aaai d the Astor- Be advised tuna a COPY of this sEatet maybe forwnded to the fiJffica of I4Lvesfrgations oflhe DJA€or iasmmce-coverage vedficaion- Ida herby c fire pains asdpsriafiies a„fFar*ry flratflea hire and carrrect Phone ik af'xci`aI zrss Do hurt�tvita tit fly areo�far be arrrrpfet bJt caip rzrta urn u 'ieruf EUy-or Toga: PermitUcease# Emus Authority(carte one): L BOard Of Elealffi -.IIuTrmg Department 3.CitylEown,Clerk 4 Electrical Faspe eWr S.Phunbing Imsgector Other Contact Person: Mom-#: 6 Mr..t l� >■all 1 i3■■n ••wis l■ •1 •• .' •••1■.1i!■• .Im■n.it .lt n■ i■f it l ifnn . �- Its guua .n ..II • •ant it a�.t i-a. • uu• �,. ur: a ••tlu:+a •. il■ut .l a.. ..• n n u- ' ■ Ji II I •% •- tlt�I .■. .■■. •nY. .Y_■ t■i3R■t.. 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Brian Florence,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 o—, r . as Owner of the subject property hereby authorize / P�� f�/ to act on my behalf in all matters relative to Work authorized by this building permit application for: (Address of Job) **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 Lecns are-performed and accepted.. - ignature of Owner S` ature of Applicant Print Name Print Name. Date Q:FORM&OWNERPERMISSIONPOOL4 Rev:0&/16(17 DATR Yaot to�bet padxmed as isiWinemd is lie rapaest wa �v the unfit as b.9 the unrt,, mLhe=work as defined im the osat c'mem=xtes:ufialsZ _. Sited Uad,��Paisxe�d•Pe�ls�af-Pe��g t�us, ;dag of -• 20�� . s ._ �- - . .... �`:._._: . ,, ,.'_ .. .__ ,.,.._ S'^.TesI��_ zi - •• - �. a_v .._a.� w� ..._._,.._... _.. ern<-�...- U M _..:. - _ K��•' __ .- ..._ ,_ ...... _ .. _ .. - _ J1D�fJ��+-� �o P�• :�.��`��i=• _- tt r� r �� r ,. .. r w _y } / - .. - � j. � . Ski t80, -_ .�, a .�,-•-- et r }' P. Offe'P i / �JiG/t7ddoc�il Ts;_ icee of Consumer Affairs&Business R ' , . k - HOME IMPROVEMENT- e9ulation ; CONTRACTOR s ` e TYPE�t ndNidual ' Reastrati _'-10/27/2019 Y JOHN MACKENZfE2 ' JOHNp,MACK i ENZIE 248 CAMP ST L.1 �`o �* �•�=�C f- W.YARMOUTH' MA 02f;7., q - Urid'ersecreta f "rYa ...� •, 4 I Massachusetts Department of Public Safety k Board of Building Regulations and•Standards . License: CS-085363 ` Construction Supervisor °a ; JOHN A MACKENZIE 248 CAMP ST.L-1 WEST YARMOUTH MA Wn 078 Expiration: Commissioner 01103/2019 ` •' - 7, The Commonwealth of Massachusetts = W Department.of Industrial Accidents a I Congress Street, Suite 100 Boston,MA 02114-2017 'w� SVey't www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: ,?dr 61ft/ City/State/Zip: /��"' ' O 'er Phone#: Are you employer?ChecU the appropriate box: Type of project(required): 1. I am a employer with employees(full and/or part-time).* 7, El New Construction 2.Q I am a sole proprietor or partnership and have no employees working for me in $. Remodelin any capacity.[No workers'comp.insurance required.) ❑ g 3.O I am a homeowner doing all work myself.'[No workers'comp.insurance required.]t 9. ❑Demolition 4.F1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole I I.Q Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.t 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: l Job Site Address: City/State/Zip: 4•Y '/j�a/'�S . Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do here b erti under the pains and penalties of perjury that the information provided above is true and correct. Sijznatu e: Date: / Ax X 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector `3f 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as can individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the who employs persons to do maintenance;construction or repair work on such dwelling house dwelling house of another t because of such employment be deemed to be an employer." or on the grounds or building appurtenant.thereto'shall no MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§2-5C(7).states"Neither the commonwealth nor any of its political subdivisions shall k until acceptable evidence of compliance with the insurance enter into any contract for the performance of public wor requirements of this chapter have been presented to the contracting authority. Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance 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 Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the.Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating care nt policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file.for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia ,�►co CERTIFICATE OF LIABILITY INSURANCE 7(MM/DD(YYYY9/11/17 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 CONTACT United Insurance Agency, Inc. NAME:PHONE FAX 199 Main Street E-MAIL 508 759-6595 / No: (508) 759-3822 ADDRESS: P.O. Box 1013 INSURE S AFFORDING COVERAGE NAIC# Buzzards Bay, MA 02532 INSURERA:Atlantic Casualty INSURED INSURER B:Travelers Indemnity John Mackenzie INSURERC: 248 Camp Street INSURERD: L 1 I NSU RER E West Yarmouth, MA 02673 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. INSR ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POUCYNUMBER MMIMN MM/DDIYYYY LIMITS A GENERAL LIABILITY L117002318 9/23/17 9/23/18 EACH OCCURRENCE $ 1,000,000 DAMAX 701M MERCIALGENERALLIABILITY PREMISE (Eaocc occurrence) PREMISES E Ea occun'e ce $ 100,000 CLAIMS-MADE �OCCUR ME EXP(Any one person) $ 5,000 - PERSONAL&ADVINJURY $ 1,000,000 GENERAL AGGREGATE $' 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-CO MP/OP AGG $ 2,000,000 POLICY PRO- LOC • $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Eaaccdent $ ANY AUTO - BODILY INJURY(Per person). $ ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ + HIRED AUTOS _AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MACE AGGREGATE $ DED RETENTION$ $ :B WORKERS COMPENSATION 6HUB0632289117 9/24/17 9/24/18 �( WCSTATU OTH-AND EMPLOYERS'LIABILITY Y I NLIM ANY PROPRIETORIPARTNER/EXECUMVE E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $' 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES,(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Carpentry Workers Compensation policy does not include coverage for John Mackenzie CERTIFICATE HOLDER CANCELLATION ' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN John Mackenzie ACCORDANCE WITH THE POLICY PROVISIONS. 248 Camp St Ll - AUTHORIZED REPRESENTATIVE West Yarmouth, MA 02673 Kris Dexter ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: dijon55@hotmail.com L No � ■��i � �� =ice =i ■�ii��i � ' � �so �_�� '�i iiiQ� � � � ME�� MISS ON �ii TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION �Map Parcel Application # V Health Division Date Issued — Conservation Division Application Fee Planning Dept, Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _Preservation / Hyannis Project Street Address s, (1 v 0612E-4i Village S Owner::k. ® &C-1 Address S—DO aeaei Telephone �� - /' 3 13 1 / Permit Requester .r-/V p 5 s Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation D DVO Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach s porting c§currr. tation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) ..w . Age of Existing Structure Historic House: ❑Yes ❑ No On Old Ki4islHighway:,,�Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other -a Basement`Finished Area(sq.ft.) Basement Unfinished Area (sq.ft(` Number of Baths: Full: existing new Half: existing nevF 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) c Name 1"( � Nt S0?i Telephone Number _t V/ Address � Law wt�S Pik r�& License # QT 5-7 D l ���41J f 0107 Home Improvement Contractor# lf� �5 ITT� � Worker's Compensation p' -L ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL B TAKEN TO SIGNATURE DATE 6 _ � /3 a FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED } MAP/PARCEL NO. t 4 ADDRESS VILLAGE ' 4, OWNER F DATE OF INSPECTION: FOUNDATION FRAME r INSULATION FIREPLACE 4 ELECTRICAL: ROUGH FINAL—, PLUMBING: ROUGH FINAL a t GAS: ROUGH FINAL FINAL BUILDING S DATE CLOSED OUT r� ' ` ASSOCIATION PLAN NO. Southern New England Windows d.b.a Renewal by Andersen of SNE Massachusetts -Department of Public Safety Board of BuildingRegulations 9 and Standards Construction Supen kor License: CS-095707 BRIAN D DENNISON s 7 LAMBS POND EIRCI:E Charlton MA 01907 .,tJir . Expiration Commissioner 09/08/2014 %yoll-c WeguIaiolug oonsumer A airs nd Business egulaUorr 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Registration: 173245 Type: Supplement Card SOUTHERN NEW ENGLAND WINDOWS LL Expiration: 9/1942014 DENNISON BRIAN 1137 PARK EAST DRIVE WOONSOCKET,RI 02895 Update Address and return card Mark reason for change, su t 0 zm Sn' (,]Address ❑Renewal i)Employment Lost Card rake ar0o umer AlTsin&eosioess Regalattoa License or registration valid for IndIvidul use only OME IMPROVEMENT CONTRACTOR before Iha explralloo date.If found return m: - - ^ _ '_ Office of Consumer Affairs and Swims Regulation Ro9latea0on: 173245 Type: 10 Park Plana-Sui1e 5170 Expiration: 911912014 Supplement:lard Boston,MA 02116 - SOUTHERN NEW ENGLAND WINDOWS U.C. RENEWAL BY ANDERSON - DENNISON BRIAN - 1137 PARK EAST DRIVE WOONSOCKET.R102895 Uaders ary Not valid without signature � � sir L1cen5e ti56o78 .. Renewal R> rEWAL BY ArmERSEN r4Atixnaesll7sZas by A nd�e� eT License#0634555 WINDOW REPLACEMENT n 26 Albion Road • Lincoln,RI 02865 - Iced Firm#1237 Phone 866.563.2235 a Fax 401.633.6602 tedeial TEa Ica#4"566630 Southern Now England Windows,LLC d/b/a Renewal by Andersen of Southern New Englund. CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyer(s)Name DaROF ne . t 42 Buyer(s)sweet Address,Ciq.Sag.and Tip M&!P.O.80 E-fWlAdMum - eTeleplahheNumber WATelephwe Number et Buyai(s)hereby jointly and severally agrees to purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal by Andersen of Southern New England("Contractor"),In accordance with the terms and conditions described on the front and the reverse of this agreement and on the attached specification sheets)(collectively,this"Agreement"). ❑Historic ❑ Cando d HOA? T a lJa :,a rntn ! 7 _ Rtin=d 5raNnr Ciao Method of Payment: O Check 13 Cash need Deposit Received(33%): Credit Cards are accepted for deposit only—maxlmum 1/3 of the Balance at Start of cab 3396: project cost(Please see Credit Cad Payment form.)By srgrting this ( ) •Estimated Completion Dare: Agreement you acknowledge that the Balance at Start ofjob and the Balance on Substantial t yy y _ 7 Balance on Substantial Completion of job cannot be made by credit Completion of Job(33%): card and must be made by personal check bank check or cash. Buyer(s)agrees and understands that this Agreement coustitates the entire understanding between the parties,and that these are no verbal understandings changing any of the terms of this Agreement.Buyer(s)acknowledges that Buyer(s) (1)has read this Agreement,understands the teams of this Agreement,and bus received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and(2)was orally informed of BuyerAs right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BIANK SPACES. (Rhode Csland Sales Only)Notice to Buyers(1)Do not sign this Agreement if any of the spaces intended for the agreed terms to the extent of then available infornoo4oio are left blank.(2)You are entitled to a copy of this Agreement at the time you sign it.(8)You may at any tam@ pay off the£nil unpaid balance due under this Agreement,and in so doing you,may be entitled to receive a partial rebate of the finance and ins rance.charges.(4)The seller has no right to unlawfully enter your premises or commit any breach of the peace to repossess goods purchased under this Agreement.(5)You may cancel this Agreement if it has not been signed at the main office or,a branch office of the seller,provided you notify the seller at his or her man office or branch office shown in the Agreement by registered or certified mail,which shall be posted not later than midnight of the third calendar day after the day on which the buyer signs the Agreement,excluding Sunday and may holiday on which regular mail deliveries are not made.See the accompanying notice of cancellation form for an explanation of buyer's rights. Buyer(s)received the?suimrkere caon materials provided by the Rhode Island ContractorRegistration Board. ($uyRenewal by tethern New England Buyers) _ fhtyrr(R) By: Si of P uct r re A Signature J' CIA L1(0'o �t-fir Print Name of Product Manager Print Name Print Name YOU, THE BUYER(S), MAY CANCEL. THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE TILE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. l-C— — — — — — — - - - - - - mac.--.- - - - - - - - - - - - - -2t NOTICE A NQTIGj;®F CANCELLATION Date of Tranaaotion ) .You may cancel Data of Transaction You may caned this transaction,without scary p r obligation,within this transacdon,'wkhout any penalty or obligation,within three business days from the above date.If you cancel,any I three business days from the above date.N you cancel,any property traded in,any poymeatas made by you under the l property traded in,any payments made by you under the Contract or Sal%and any negotiable instrument executed I Contract or Sale,and any negotiable instrument amuted by you will be returned within tan business days hollowing I by you will be returned within ten business days following reoelpt by the Seller of your cancellation node%and any l receipt by the Seller of your eanedbtloo notice,and any security Interest arising out of the transaction will be security interest arising out of the transaction will be canelled.Ifyoucancel.you must make ovailsWeto the Seller l caneled.lfyoucancel,yyoou must mASwaibibioto the Seller at your rasidence,in subota litially as good condition as when I at your reddenc%in suibsmntially as good condition as when received,any goods delivered to you under this Conllra4t or I received,any goods delivered to you under this Contract or Sale;or you may,if you wish,comply with the Insdwc"ns of I Salmi or you mm/,if you wish,comply wkh the instructions o1 the Seller regardleg.the return shipment of the goods at the the Sener regarding the return shipment of Die goods at the Seiere expanse and riek.lf you do make the goods available , Soli is expense and risk.lf you do make the goods avaiilalrle to the Solver and the Seller doeo not pick them 4 within to the Seder and.ths Seller does met pick them rm witldn twenty days of the date of cancellation,you may retain or twenty days of the date of cancellation,you may retain or dispose of the goods without arty further obligation.If you I dispose of the goods without,any f n Cher obligation.if you fail to make the goods mailable to the Sdkr,or if you agree 1 fail to make the goods'Fwailable to the Seller,or K you agree to return the goods to the Seger and fail to do s%then l to return,the goods to the Suer and fail to do s%then you remain Gable for performwice of all obligations under you remain liable for performs of all obligations under the Contract.Tb cancel this transacdo% mail or deliver I the Cortratrt.to cancel this transaction, mall or delver a signed and dated copy of this tanceIndon notice or any l a signed and dated copy of this cancellation noltee or any other writhlanr notice,or send a telegram to Renewal by I other written notice,or.send a telegram to Renewal by Andersen of Southern New England at 1137 Park fast Dr., I Andersen of Southern New England at 1137 Park East Dr. Wo n cachet;RI 02895,NOT LATERTHAN MONIGHT OF I Woonsocket,RI 02895,NOT LATERTHAN NPHIGHT OF Date I C 1 ELTHDISTRANSACTION. 11 HEREBY CANCELTHISTRANSACT10N. gbh gl6q,ptLer ruin tune oaae 6ay�s SlgwhLra Pert rlaa,w maw RbA Copy:White Buyer Copy:Yellow Buyer Copy:Pink 4 Renewal RENEWAL BY ANDERSEN Cenr- #56G,5 �^�^ Hu license#i732a5 by Andersen ersen - CT License#0634535 +rINNov REPLACEMENT mAn7mmCamomr 26 Albion Road-Lincoln,RI 02865 - . Et"Firm#1237 Phone 866.563.2235•Fax 401.633.0602 taderai Tax ro"6-0966630 SPECIFICATION SWEET Buyer(s)Name Date of Agreement The Buyer(s)fisfed above hereby jointly and severally agree to purchase the goods and/or services listed below,in akordaric -h the prices and terms described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING AGR£);MEM,of which this Specification.Sheet is a part. WINDOW DETAILS 1. Contractor will Install a total of---�_windows in.Owner's home,using the following individual quantities: Double HiaiS ME) ❑ Equal sash ❑ Cottage sash(1/3 top,2/3 boftotn) ❑ Orlel sash(2/3 top.1/3 bottom) Casement(CYe9 0-Hinge right D Hinge left(as viewed fiaam exterior) Double Casement(CAW) Casement/Picture/Casement(CPW) ❑ 1:1:1 or❑ 1.2:1 r 2 late Glidi's Window(GW) Glider/Picture/Glider(GPW) ❑ 1:1:1 or W1:2:1 Awithig Window(AW) Picture window(M -^Bay or Bow Window Patio Doors(sec separate Door Specification Sheet) Z. ❑Yes ❑ No Qty of Windows to be Custom Fit Replacement: 3. ❑ Yes ❑ No Qty of 0s to be replaced by Contractor: 4. es ❑ No Qty of Windows to be New Construction Pull frame(includes new interior&exterior casings): to Exterlor casln3x ❑I#ne ❑Maintrnatice-$gee tnateaiai❑iaui4rry tstrlrlitxl"afro iitnr:cbri��xn4k1 -- 6. dazing to be. ❑i^IiP law-E-4,M ❑ Other if:other,please specify: etrf�a.�n (�tt s OF 71 ja�A_ 6. Exterior color to be: ❑ White ❑Sand❑Canvas [Sr1'erratone Exterior On1gt[]Cocoa Beast Q Dark Bronze❑Forest Green El Red rock ❑Bloch 7. lmerior color to be: ❑White Q Sand❑Canvas 5�Aftratone❑Pine ❑Maple❑ Oak 8. Hardware: ❑ White [j.9cone[] Canvas [] Estate 9. Irulall Lily,will,DuuW Hung Windows ❑Yes❑_N6 10. Screens: windows to have: Q Half or Cj�-Full screens Screens to be.0?TTarglaw []Aluminum,,❑Truscene Check Mail Option Traditional(square) ❑ Contemporw7(cw ved) ❑ 11.Grilles ❑Yes tNX5_If yes:p Griue Between class ccec>❑removable interior wood om❑ ND Divided light aw Qty! (2tr. (2ty: Qly� (2h Qty Qty-. DN OH DM DH CwIRCWre Gfider CPW ar G Draw Grill Patterns Above *Use additional sheet if needed Owner apptmved Gnitials):( t ADDITIONAL WORK DETAILS 12. ONO Contractor will remove metal frames of windows. Qty of Units: is es ❑No Contractor will install new paint—read or stain-ready casing& or casing qty of openings: Exterior casings qty of openings: ❑Pine❑Maintenance-free material 14. ❑Yes []No Contractor will install new paint-ready or stain-ready inside or outside stops qty of open' Interior stops qty of openings: Exterior stops qty of openings: ❑Fine❑Maintenance-free material 15. ❑Yes ONo Contractor will wrap a�x,or casings with aluminum-coil sLack of =10r. NNre:Wrapping may be required with storm window removal;removal of storm windows will,leave screw holes in casing. 16- C�7Yes ❑No Contractor will insulate,caullcand seal windows with 3-point system to prevent water and air infiltration. 17.��r ❑No Clean up all job related debris including old windows will be removed.Vacuum nightly. 18 . l7Y ❑No A limited warranty shall be issued to Owner upon completion of the job and payment in full. 19. LJYes []No Building Permit—Contrwtor_will secure any and all necessary permits. The fee for the permit(s)is 300 included in the Contract Price 20. Lkes�❑No All current promotions and discounts have been applied to the above agreement amount-any future discounts or sales are not applicable to this agreement. 21. Owner is aware that Contractor does'not do aty painting. ( )Owner Initials ; 22. Owner is responsible for the removal and reinstallation of any existing alarm systems. Owner to call alarm co. 23- Owner is responsible for the removal and reinstallatlon of any window AC units 24. Owner is responsible for the remZ and re installation of window treatments&braclre . 25. Additional job details: 26. Efe3 ❑No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment. No/final paymmt shall be demanded tvrffl the contract is completed to the satisfaction of all parties It is agreed and understood by and between the parties that this Specification Sheetalong with the CUSTOM WINDOW AND DOOR IXIV1.ODELING AGREEMENT,constitutes the entire understanding between the parties,and there are no verbal understandings changing or modi(ving any of the terms.This Specification Sheet may not be changed or its terms modified or varied in aa�e:zKmo-utherja ch changes are in writing and signed by both the Buyer(s)and'Contractor,Buyer(s)hereby acknowledge t read this 5pwifiication Sheet. Renewal by A New England Btjyer(a) Buyer(s) By: y ✓ Sy, of t sign Signatare Gw / o� Print garne of Product Manager Print Name Print Name White Copy RDA Yellow Copy Customer RAM + 1 L - � MIM MW ME MIN rt DWI MW M NO E ME ME ME EME SIM � i Yachtsman Condominium Trust Acceptance of Trust Approval The undersigned Owner[s] of Unit#i24 of the Yachtsman Condominium Trust, 500 Ocean Street,Hyannis, Massachusetts, acknowledge[s] that the Trustees of the Yachtsman Condominium Trust Have approved the following proposal: ® Installation of a 5 Andersen; (Teretone) brand sliding glass doors to replace.existing sliders and one Andersen brand sliding picture window to replace existing window. All outside materials shall matching existing conditions. By acknowledging the Trustees' vote approving the proposal for Unit#43,the undersigned Owner[s] agree that: 1. The specifications provided to the Trustees for approval (copies of which are- attached and incorporated hereto) are the final drawings and specifications of the, improvements. There shall be no additions or variations to the said drawings and/or specifications without the Trustees' prior written.consent. 2. Approval by the Board in no way constitutes a waiver by the Board of the Trust's rights. Moreover, approval by the Board does not indicate that the Board accepts_ liability or responsibility for the actions of the owners. 3. Contractor Renewal By Andersen and sub-contractors)who is hired to work on the proposal shall obtain the necessary approval and permits from the appropriate local authority or statutory body required under any law(including any statute, ordinance, by-law and/or regulation). Any and all Contractors and/or sub contractors shall not commence;continue or complete any work without kiaving the appropriate permits and approvals;secured. Contractors and/or sub-contractors shall provide the Manager of the Yachtsman with copies of all approvals and permits,.contact information, including emergency contact numbers. 4. Any work undertaken shall complylwith all relevant local; county and state codes; by-laws, regulations and statutes. S Any contractors (and sub-contractors) hired to work on the proposal shall maintain the appropriate liability insurance. Contractors and/or sub-contractors shall provide the Manager of the Yachtsman with copies of the relevant insurance binders. ; b. Any;work undertaken shall be completed by Memorial Day and no work shall be undertaken again until Labor Day, unless approval is sought from and received from the Trustees. 7. 1/We assume(s) responsibility for any future costs associated with loss or damage related to the work.. , 8. Other: All work that cannot be done by thel Memorial Day weekend is limited.to work hours from Monday:to Thursday: As stated above, the materials must match existing y exterior materials. q 1+ Acceptance of Trust Approval Page 2of2 The undersigned Owner[s] of Unit.#24 tiherefore accept the approval of the Trustees of the Yachtsman Condominium Trust subject to the above-noted,conditions. ; ' Signed this ..' O-4, day of "�i` }� , 2013 Signature- U ' Owned ,t Print Name Unit Owner f Signature- Unit Owner Print Name Unit Owner' Wit ess / Manager Yachtsrna ondominium Trust t - _ Documents Attached: r t , ........... _......... _...._........----- ........_._......._. _ _...... .. t Permits Received (Title and.Date Received):: ...r....„».,. ....r. »._... • - ,: s 1 4 Client#:30124 SOUTNEW ACORM CERTIFICATE OF LIABILITY INSURANCE °ATE`MM/°DIYYYY) 5/08/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATNELY 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 endorsemerlt(s). PRODUCER CCNTTACT Anita Little Willis of New Jersey,Inc. PHCONE 856 914-4660 FAX 856 914-1881 AI No Ent: A/C No 1015 Briggs Road E-MAIL ss: Anita.Little@willis.com Mount BOX Laurel, INSURER(S)AFFORDING COVERAGE NAILY Mount Laurel,NJ 08054 INSURER A:Selective Insurance Co of the S 39926 INSURED INSURER B:Argonaut Insurance Co. 198-1 Southern New England Windows LLC D/B/A Renewal by Andersen iesuRERc:Beacon Mutual Ins.Co. 24017 INSURER D: 26 Albion Road INSURER E Lincoln,RI 02865 INSURER F 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 CONTRACTOR 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDD MMIDD/YYYY LIMITS A GENERAL LIABILITY S202945900 8/10/2012 08/10/2013 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILI'Y DqM M SES RENTED PRE I 3 Ea occurrence $50 000 CLAIMS-MADE F OCCUR MED EXP(Any one person) $5 000 PERSONAL&ADV INJURY $1 000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG. $2,000,000 PRO- LOC $ POLICY JECT A AUTOMOBILE LIABILITY S202945900 8/10/2012 08/10/201 E.a a.n SINGLE LIMIT 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per $ AUTOS AUTOS ( ) NON OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per acddent $ $ A X UMBRELLA LIAR OCCUR S202945900 8/10/2012 08/10/2013 EACH OCCURRENCE $5 000 000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5 000 000 DED RETENTION$ $ B WORKERS COMPENSATION AIC927698352394 8/21/2012 OS/21/201 wesTATu- OTH. AND EMPLOYERS'LIABILITY C ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 68028 8/21/2012 08/2112013 E.L.EACH ACCIDENT $1 OOO 000 OFFICER/MEMBER EXCLUDED? ® N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1 000 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,B more space Is required) CERTIFICATE.HOLDER CANCELLATION Southern NE LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 26 Albion Road ACCORDANCE WITH THE POLICY PROVISIONS. Lincoln,RI 02865 AUTHORIZED REPRESENTATIVE 01988-2010 ACORD CORPORATION.All rights reserved. ACORO 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORp #5214638/M214631 AXL The Commonwealth of Massachusetts Print Form Department'of Industrial Accidents r7 Office of Investigations 1 Congress Stree4 Suite 100 Boston,MA 02114-2017 www mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Api licant Information Please Print Legibly Name (Business/OrganizatiomTndividual): Soggy E./�i �J ,1 q��f� 1���0 j el Address: , (o 1'f 41 Al k0kb City/State/Zip: L./NGoIN Az �' ®1865 Phone#: �-lD� �� Are you an employer?Check the appropriate box: Type of project(required): 1.dI am a employer with O 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached'sheet. 7. ❑.Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers'comp. insurance comp.insurance. 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. ' right of exemption per MGL Y �o workers comp. 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no 15 employees. [No workers' 13.2 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. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Yqrl 0 4 60M Policy#or Self-ins.Lic.#: 4�� l 76 gg �oZ 3 Expiration Date:, o�� 13 Job Site Address: �G�t J r - aV T 9-y City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy num rand 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 certify under the pains and enaldes gCLer&Q that the in ormation provided above is true and correct Si ature: Phone#: -1 ,l c;L gg < �� 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#-