HomeMy WebLinkAbout1046 PHINNEY'S LANE o `NCO vi rt E �°
77
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1HE Application number....X.�. .....�...................
BUILDING DEPT. `
Fee ............�6 ...................................................
�JUL 3 0 2020
Building Inspectors Initials.......................................
TOWN OF BARNSTABLE
DateIssued.................................................................
Ma 2 6/0
SCANN D Map/Parcel..... ................
O TOWN OF BARNSTABLE
EXPEDITED PERMIT APPLICATION:
ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION.
PROPERTY INFORMATION
Address of Project: $'_ 6 1 1�1 l Ce [4f(L V 0 N-� ¢' I s
ER STREET VILLAGE
Owner's Name: M l NUMBER,
.el Va,Q U-9 7, Aone Number 21
Email Address: Cell Phone Number
Project costs f -kln.. Check one Residential Commercial
OWNER'S AUTHORIZATION
As owner ofthe above property I hereby authorize .
to make application for a building permit in accordance with 780 CMR
Owner Signature: Date:
TYPE OF WORK
Siding ❑ Windows(no header change)# ❑ Doors (no header change)#
DInsulation/Weatherization 0 Roof(not applying more than 1 layer of shingles)
❑ Commercial Doors require an inspector's review Q
Construction Debris will be going to 'r®W rN Win. I � Lk,C, - e&
❑ Certificate of occupancy with no construction(complete be w)
Occupant/family relationship or business name
or Existing amnesty apartment(attach a copy of recorded comprehensive permit)
CONTRACTOR'S INFORMATION
Contractor's name
Home Improvement Contractors Registration(if applicable)# (attach copy)
Construction Supervisor's License# (attach copy)
Email of Contractor Phone number
ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR/F THE SUBJECT PROPERTY IS IN
A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED.
�r
APPLICATION NUMBER ;
*For Tents Only,*
Date Tent(s)will be erected Removed.on number of tents total
Does the tent have sides?Yes No (If yes please attach floor plan with exits marked)
Dimensions of each Tent X X X
Additional tent dimensions can be attached on a separate piece of paper.
Purpose of Event --
Check one: this event is a: for profit non-profit event
Check one: Food served Yes No
Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent
Fuel source being used LP tank 20 lbs. or> Yes No , if yes, a gas permit is required.
Natural Gas Yzs � --Na �- , i -yes;•a�gas permit-is required
If food is being`served'at your event please obtain a Health Department approval between the hours
of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval.
*WOOD/COAL/PELLET STOVES *'
Manufacturer# Model/I.D. {
Fuel Type Testing Lab _.
Offsets from combustibles: front back left side right side `
HOMEOWNER'S LICENSE EXEMPTION
Homeowner's Name: � t C�(�-�. 1
VOL Ix�
Telephone Number �-�®� '��! / �'� t' Cell or Work number
I understand my responsibilities undei the rules and regulations for Licensed Construction
Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand
the construction inspection procedures, specific inspections and documentation required by 780
CMR and th ow of Bar tab e.
Signature Date 71-2112- 0
- APPLI ANT' IGNATURE
i -
Signature Date 7 2'Z 2-
All permit applications are subject to a b 'd g o cial's approval prior to issuance.
L a
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dta
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ' Please Print Legibly
Name (Business/Organization/Individual): t1 �4VA. e�
Address: 10h 6 PK1AAe&J
City/State/Zip: C&12 R Phone#: -50 S < ,l v7zJ
Are you an employer?theck the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2:❑ I am a sole proprietor or partner- "='listed on the attached sheet: 7. ❑ Remodeling -
ship and have no employees These sub-contractors have g, ❑Demolition
workingfor me in an capacity. employees and have workers'
Y P h'� 9. ❑Building addition
[No workers'comp.insurance comp.insurance.=
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
�. 3.4 I am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
i insurance required.]t c. 152, §1(4),and we have no
'r..,,,�+1 employees. [No workers' 13.❑Other
comp. insurance required.]
Ct(
Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit,indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
mployees. f.the sub-contractors have-employees,they must provide their workers'comp.policy number.
1
lam 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:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby r ' unde 'the pains penal ' of perjury that the information provided above is true and correct
Si atur ` Date: Z
Phone#: AhLbJ
Official use only. Do not write in this area,to be completed by city or town ofciaL
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#:
-a
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"an 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
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
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,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall_".
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
'requu-emcnts 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-contractors)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 %k
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 tohobtain 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 current
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.here a Dome owner or citizen is ob'iaining a hcerise-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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
office of Investigations
600 Washington,Street
Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax#617-727-7749
www.mass.gov/dia
�t++E Town of Barnstable`
Building Department Services
,A �, Brian Florence,CBO 41
200 Main sit,Hyannis,ILIA 02601 3 20,j
www.town.barnstable.mausA �/�
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section If Using A Builder
I I
Owner of the subject property
hereby authorize A. 1�2-K� t�1r1�1�� to act on my behalf,
in all matters relative to work authorized by this building permit application for.
14 a (4 03 &A e
(Address o ob)
**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
inspectio are pe ormed and accepted.
UYA
Signature of Ow er V o Applicant
a
Print Name Print Name
a l
Q:FORWOWNE UMMOSTONPOOLS
Rev:0911CW17
f
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-'`--
` �_
�®�
Town of Barnstable Building
Tfi�s - rd� That � Visible From the tneet' A ,'coved�Plans Must;be Retame on io"",band this CardxMust be Kept ,_ -
i:a�Rx$'[xBi.t. •. 6 `�i ... ,,
pP
�` „ wired~such Build�n shall of b Occu ied until-Final lrtis` ect�oriuhas..been-made „ �1 mit
,. ,ems-• , ° Where. ert�ficate of Occupancy�s Rey ...: g e p p, .y,
Permit No. B-17-2948 Applicant Name: DM STORRS CHIMNEY LLC. Approvals
Date issued: 09/20/2017 Current Use: Structure
Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 03/20/2018 Foundation:
Residential Map/Lot: 273-010 Zoning District: RC-1 Sheathing:
Location: 1046 PHINNEY'S LANE,HYANNIS
Contractor Name DM STORRS CHIMNEY LLC. Framing: 1
Owner on Record: VAZQUEZ,MICHAEL G x' y �
Contractor License 179200 2
Address: 1046 PHINNEY'S LANE - ,
„y Est Project Cost: $0.00 Chimney:
CENTERVILLE, MA 02632
40
Perm1""Fee: $85.00
Description: Line Masonry ChimneyW/ss liner including components o vents Insulation:
gee Paid: $85.00
heating appliance ..> Final:
ate 9/20/2017
D
Project Review Req: Line Masonry ChimneyW/ss liner includmgacomponentsto uen# - -
heating appliance 4 — ;� - Plumbing/Ga's
r
Rough Plumbing:
Building Official
Final Plumbing:
This permit shall be deemed abandoned and invalid unless the work au homed by this permit is commenced within six�monWtthsafter issuance.
All work authorized by this permit shall conform to the approved appi6Uon andathe approved construction documents forwhich this permit has been granted. Rough Gas:
"
All construction,alterations and changes of use of any building and structuresshil be in compliance with the local Zoning by lawsand codes. Final Gas:
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
work until the completion of the same. a Electrical
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Service:
Minimum of Five Call Inspections Required for All Construction Work: z
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 MGLc.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
f � 7
y
'I Map Parcel F Application # I
Health Division z �,I Date Issued q 2 7
i t
Conservation Division Application Fee
Planning Dept. _, Permit Fee CO
Date Definitive Plan Approved by Planning Board V
/
Historic - OKH _ Preservation/ Hyannis !
Project Street Address y1W\y_N� ►S Lyf
Village c-eVYMiV �Luc 0
Owner)OL,\. El-- V)A:�()LkGl- Address 104(o
Telephone :5cl` 1 . kq l A
Permit Request Li h L `A,%)M" C,1U)N n-( W1 71)•-'s. ( lln�.Q ,P2 tW,Lw01
C ,fVv�1Pi�� T ogL. y.`klVl� �-11
Square feet: 1 st floor: existing - proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation 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
-Y--� (BUILDER OR HOMEOWNER)
Name C)Y-Y\ Telephone Number
Address License#--
' Home Improvement Contractor# I�}q Lob
Email Ont, y2' Q (S Y-n0al ti—Worker's Compensation # U_f,W 0)03 'Iq 0q
I
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATUR DATE VIAhl
• FOR OFFICIAL USE ONLY
APPLICATION # j
DATE ISSUED ;
MAP/ PARCEL NO.
ADDRESS VILLAGE
OWNER_
DATE OF INSPECTION:
i
FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT.
ASSOCIATION PLAN NO.
263 Central Street
Foxboro, MA 02035 ® emu
®m ®® ®mom
l508) 698-1670 Tel ®® ®® ®®
emumm ■®e .®■
(774) 215-5669 Fax ®® ®® ®®
www.dmstonschimneycorn D M S T O R R S ACCEPTANCE
t11C#179200
Fully Insured—References Available C H I M N E Y
PROPOSAL SUBMITTED TO _ PHONE D TE
tC
STqECT 16 _q Vh(0 /)'j r JOB NAME
CftY�ATEDZIFFr JOB LOCATION •,�
WE HEREBY SUBMIT SPECIFICATIONS FOR:
le el
�.
C Gt 7� Q
el t�Q,-7_0t�/ ,I r
a117 4 `Z'Ga ile-
WePrOPOSe hereby to furnish material and labor-complete in accordance with above specifications,for the sum of:
dollars (S >.
Payment to be made as fellows: i
All material is guaranteed to be as specified.All work is to be completed in a workman- Authorized `
like manner according to standard practices.Any alteration or deviation from above Signature
specifications involving extra costs will be executed on written orders,and will become
an extra charge over and above the estimate.All agreements contingent upon strikes,
accidents or delays beyond our control.Owner to carry fire,tomado and other neces- Note:This proposal may be wi drawn by us
sary insurance.Our workers are fully covered by Workmen's Compensation Insurance. d not accepted within days.
Does not include electrical,plumbing,carpentry or painting.
Acceptance of Proposal The above prices,specifications and conditions are Signature
satisfactory and are hereby accepted.You are authorized to do the work as specified.Payment
Will be made as outlined above.
If paid by credit card,an additional 3.25%will be added to the balance.
Date of Acceptance Signature
i . r
a
ng
ousin
Assistance
Corporation
on Cape Cod
August 11,2017
DM Storrs Chimney LLC
263 Central Street,Suite 1
Foxborough,MA 02035
Dear Contractor:
This is your authorization to install and complete the job of installing a
stainless-steel chimney liner at the home of Michael Vazquez, 1046 Phinneys
Lane, Centerville,Massachusetts.
Housing Assistance Corporation(HAC)will pay$2,000 for the complete
installation of stainless steel chimney liner when all current state codes
regulations are met.
Customer is to pay the remaining balance of$92.00 due payable to chimney
contractor at time of installation,unless customer and chimney contractor
agree upon a different payment arrangement for this balance due.
Also,you have to provide and submit a SIGNED COPY of the
Installadon/Completion appropriate permit from the fire or building
department,prior to any payment being made from this agency for this
oil tank.
If you have any questions please call.
Sincerely,
V
Jo Ann Cournoyer
Program Coordinator
Energy&Repair Department
cc: Michael Vazquez
live learn work grow
460 West Main St. Hyannis, MA 02601 hac@haconcapecod.org 508-771-5400 fax: 508-775-7434
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08/11/2017 10:37 AM PDT T0:15085430798 FROM:6174886501 Page: 3
ACb& CERTIFICATE OF LIABILITY INSURANCE 08„20117 Y'
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
RDED BY THE POLICIES
BELOW.cTHIS CERTIFICATE OF(INSURANCE 0 SRTIFIATE DOES NOT AFFIRMATIVELY OR NEGATIVELY NOT CONSRDTUTEAM ,E XTEND A CONTRACT BETWEEN, OR ALTER THEOVERAGE THE ISSUING AFFINSURERS)AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions.of the policy,certain policies may require an andorsemenL es A statement on this certificate do not confer rights to the
certificate holder In fieeu of such endorsemengs).
NsMUCIA 01033-001 i
The Love Insurance Agency,LTG O Erg
PO Box 3 4
Foxboro,MA02035
i ffiERMAF VIU)ING.GOVERAGE HNCR
Atlandc starter Insurance Companv VDW- 44328
INsuam
DM Storrs Chhmy,LLC
:.ttSltRBi.0
263 Central Street,Suite 1 #H9NlREA.D - mm~�
Foxbmugh,MA 02036
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COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICES 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.
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DESCRIPTION OF ODERATIONS I UICATIONg I VEHICLE4 fA*+ ACORD r01,AMtbnd Renwks Sdwdub;R mac b nq-mw)
CERTIFICATE HOLDER CANCELLATION
ousing Assistance Corp,Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
West Main Street BEFORE THE EXPIRATION DATE THEREOF THE ISSUING COMPANY
Hyannis,MA 02601 WILL ENDEAVOR TO MAIL NOTICE IMLL BE DELIVERED It
ACCORDANCE WM THE POLICY PROVISIONS.
a AtrTHORtIfiDREPRESENTATIYE �4--
1968-2014 ACOIiD CORPORATION.AI rights reserved '
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
CERTIFICATE HOLDER COPY
�►����® CERTIFICATE OF LIABILITY INSURANCE � ?°14/27
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS.NO RIGHTS UPON THE CERTIFICATE HOLDER TMS
CERTIFICATE DOES NOT AFFIRMATIVELY OR.NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. TKS CER11RCATE OF:INSURANCE DOES NOT CONSTITUTE A,CONTRACT BETWEEN THE ISSUING ENSURER(S)r AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE.CUKI IRCATE HOLDER...
IMPORTANT: If the-Ce►lficats holder Is an ADDITIONAL INSURED-.the poiicy(tes)must be endorsed. N SUBROGATION IS WAIV®,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 endorsemen .
PRODUCER NAME .
The Lovely Insurance Agency IAtG N.PHONE . 50 54 — 131 FAX N • (508) S43-0798
6 Railroad Ave nra4ss: info@LovelyInsuraned.com
PO Box 374 INSURE S AFFORDM COVERAGE NAIL 0
Foxborough, MA 02035 INsuRERA:Nautilus
INSURE INSURERB-Plymcuth Rock Assurance Corp
D .X Storrs Chimney LLC INSURER0:
263 Central Street, Suite. l
nauRl:n D _
Foxborough, MA 02035 IRWRERE
INSURER F:
COVERAGES CERTIFICATE NUMBER:. REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE USTED 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 ANDCONDITIONS OFSUCH POLICIES_.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLANS.
R AWON a0%Ici+EFF POdVYEYP
LT TYPEOFINSURANCE POLICY MaMMDY,
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A GENEML1ABIUIY NN831111 7/1/17 7/1/18 EACH OCCURRENCE s 2 000 000
X CONMERCIALGENERALLPZUrY DPRERNSES(Fa
AMAGE TO RENTED S 100 OOO
CLAWIS-MADE ❑X ODOUR
MEDEW(AtVOM ersat) S 5 000
PERsONAL&ADVINNRY $ 2,000,000
GEN(ERALAGGREGATE' S 5,000,000
GEN'LAGGREGATELAAITAPPLIESRER PRODUCTS=ODb1P10PAGG S 2.000.000
17 POLICY PRO- LDC ¢
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ANYAUTO. eDOILYINJURY(P8tPsmon) 11 500,000
ALLOWNED SCHEDULED BODI.YINJURY(P.r CWenu $ 500 000
AUTOS AUTOS PROPERIYOAMAGE
HIREDaurOs --AUTOS.
, $ 250 000
- i
UMBRELIALUIS OCCUR EACH OCCURRENCE S
EXCESS LU113 CLAtALS-MADE AGGREGATE S
DIED RETENTION E S'
OTNa
WORKERS COMPENSATION WC STATU•.
AND O PLOYERS'LIABILITY
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ANY PROPRIEIDRIPAMNMeXECUTNE � NIA E.L. ACHACgDEMT
OFFICERMfEMSER E GLIDED?
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I E1.018PAE`-POLICY LMrT S
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DRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATLONS/lOCAMONS/VEHICLES(Artadr ACORD 101.'AdSdc dt Rertarks sdtsfte,11 mara spwa la quired}
ON ALL OPERATIONS USUAL .TO THE .BUSINESS OF THE INSURED
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 13E'CANCELLED BEFORE
:THE EXPIRATION DATE THEREOF, NOTICE WILL '.BE DEUVERED IN
ACCORDANCE WITH TLLE POLICY PROVISIONS.
AUTHORIZED. SEN TA
*�/ c
1114 IC GLN
019811 2010 ACORD CORPORATION. All rights reserved:.
ACORD 25 1201 W06)` The ACORD name and logo are registered marks of ACORD
Faz E-Mail:
,Phone: - - i
4
Massachusetts -Department of Public Safety _
Board of Building Regulations and Standards
Construction Sulmnvior
License: CS-107981
BRADLEY WHIT$`
30 PLAIN STREET y
.Stoughton MA 0202 2
Expiration
}
Commissioner 11129/2017' '
{
1 .
Office of Consumer Affairs.and Business Regulation
_ — 10 Park Plaza- Suite 5170
Boston, Massachusetts.02116
Home Improvement doba
ctor Registration
Registration: 179200
Type LLC
Expiration: 7/1/2018 Tr# 419291
DM STORRS CHIMNEY LLC.
DANA STORRS II;
263 CENTRAL STREET SUITE 1
FOXBORO, MA 02035
�tP Vie; 'Update Address and return card.Mark,reason for change.
.. Address [] Renewal Employment Lost Card
SCA 1 0: 2OM-05/11
rJea�nm<=nr«call/ny�r �assa�lucs�lts License or registration valid for individual use only
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to`s
Office of Consumer Affairs and Business Regulation
RegistrahortY 179200 Tye' 10 Park Plaza-Suite 5170
Expiration 7f112412 LLC
9 — Boston,MA 02116
DM STORRS CHIMNEY LLC , sip
T°'_ _
44 yy r
1 i.f F
DANA STORRS ' L
263 CENTRAL STREET s U 1 `� -N,. ,o-._L .... 77
—
FOXBORO,MA 02035 Undersecretary ot;valid,Without signature
i F
f
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information. . . Please Print Legibly
Name(Business/Organization/Individual): DM Storrs Chimney LLC
Address: 263.Central St., Suite 1
City/State/Zip: Foxboro, MA 02035 Phone#: 508-698-1670
Are you an employer?Check the appropriate box: Type of project(required):
1. ✓ I am a employer with 7 4. I am a general contractor and 1 6. New construction
employees(full and/or part-time).* have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have 8. Demolition
workingfor me in an capacity. employees and have workers'
Y P h'• $ 9. Building addition
[No workers' comp.insurance comp.insurance.
required.] 5. We are a corporation and its 10. Electrical repairs or additions
3. 1 am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12. Roof repairs
insurance required.]t c. 152,§1(4),and we have no ✓ Chimney Line
employees. [No workers' 13. Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Atlantic Charter
Policy#or Self-ins.Lic.#: WCV01031404 Expiration Date: 08/18/18
1046 Phinne 's Lane Hyannis 02632
Job Site Address: y y City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby c t nder the pains and penalties of perjury that the information provided above is true and correct
Sic Date: 8/24/17
Phone#: 508-698-1670
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#: