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HomeMy WebLinkAbout0076 PINE AVENUE oFtME,� Town of Barnstable *Permit#:R-i tZ24V Tres 6 months from issue date Regulatory Services fee f y htnss. Richard V.Scali,Director �p 1639. rFD�,.ta r A;.0 C) Building Division a Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 PER • r www.town.barnstable.ma.us DC, Office: 508-862-4038 ,, /� TQ14LAI n 704 Z�1 Fax: 50'8-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTI9�L. ONLY Not Valid without Red X-Press Imprint V Number .'-d�..Zs�—s —.._ - q�� , ' C Property Address c, piVjt [Residential Value of Work$. f 5 oc> Minimum fee of$35.00 for work un $6000.00 a Owner's Name&Address lZ0 �` L L �. � J SZ— "'Z fZo,V—/�J z-, ,i-4A � �i �n, -�S� Contractor's Name 2 ,�tt� � Telephone Numbe5� �`6( 7Y! Home Improvement Contractor License#(if applicable) /98 16 Email: l c-/�� �t� jl�• Construction Supervisor's License#Cif applicable) ' _ Ellw�orkman's Compensation Insurance Fk one: am a sole proprietor ❑ I am the Homeowner 'r ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders.U-Value maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is requi W. SIGNATURE: ` 4 Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc 06/20/16 TTie Comynomvealth of-Massachusettr Deparame ct afrn lrsstrialAcciderds - - O}}frr-e of Inw—stigafio U. 600 Washington Street Boston,-41A 012111 wivii 7ilas*mgovIdia NltGrkers' Cmmpensat Gn Insurance Affidavit:Btilders/CuntractGrslElectricians(Phumbers AypHcant Infarmat Gn. Please Print Lem tIv Na=(BasmessPOrgan�ationlfnd�ival} // Address �� b Citgl tatel ig � Phone� 77� Are you an employer?Check the appropriate box: Type of project(required): I.❑ I am a employes with 4 Ejiam a general contractor and I 6- ❑New constuction employees(full andfor part-time).* lrave lliredfhe sub-contractors 2.El I am a sole proprietor orpartaner- Misted on the attached sheet. 7- El Remodeling sb p and have no employees . These sob-confrac#ors have g. ❑Demolition w g forme in an employees andhave workers' adon.� y capa�t3`- 9. .El Building addition sv arlcess' Comp-rTac�„re Comp-snsurant� required] 5. ❑ 3,We area corporation and its 10-,❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1L❑Plumbing repairs or additions myself-[No workers'ramp- right of exemption per MGL 1`2.❑Roofrgmirs c.152, §IM andwe have no employees.[No workers' 13-❑Other comp-insmmce required •Any Wffczmt&2t dmcks box€1—st also Maathe secdonb9owshi sins Their wmkee compeasatiaupORU iaformadmL #HameMnersvrlmsabm tdus.affidaeuingEut gtheyaiedGmgOwanksn4d=bireauuidecoatxnctorsnmstsubmitanewafdzeit:mdiestin rnrfi Z0antcaetm1hz2 chedr ily s bout must attached=sidditianal sheet shou-Ing tbenme of the sub-carat=tars and state whMher.arnotibase eafities have employees. wodEe&tamp.pdhcy nun bLr. I alit all ettipialwr treat ft:provfditrg workers compensidion irwirance for usey wipLyees $eloiv is flte panty andiah rite irtformrrtian - ` Insurance Company Name: Policy 4f,or Self-it,Lic.; ExpirationDate: Job Site Address: CitylStatelzip: Attach aropr of the workers'compensationpolicy decIararion page(showing the policy number and expiration date). Failure to secure covenga as require under Section 25A of MGI.c.152 can lead to the`imposition of criminal penalties of a fine up to$UOD.OG andfor atie yearimprisau :emt,as we`ll as-c` penahies.in the form of a STOP WORK ORDERand a f me of up-to$250-00 a day against the violator. Be adidsed that a copy of this statement maybe forwarded to the Office of Ittvestigatiofls of the DIA,for msurmw coverage verificatiam.. I d'a If ere-byc this prints antdpett ' s u,fper�r}'tfiatdie intforma#iortprmi&d abmne s&ue and/carrect Sitmature: •�ti �� Q� s Phone ik CJ P51- OfiTchal use only. Da nat avrrte in this area,to be cfrtripleted by taty artann afficiat City or Town: Fermitffikense 9 Issuing Authority(icirde one): L hoard of Realth 2.BuTting Department 3.iStylrown Clerk 4.Eeetrical Inspector S.Plumbing Inspector 6.Other Contact Person Phone#: -- --- -- - -- - 6 IMformation. and Instructions hfas a hsetts General Laws ffiVtes 152 requires all emplopess'fn provide wa3es'compensation for their employees. Pr,raM-Mt-tD this s-t�nte,an ernpinyee is defined as"_.every person in tie serPice of another under any couiract of hire, express or implied,oral or wr dtmf An euzpluyer is defined as"au izidivi±mL pmtamzhip,assodalioa;corporation or o"h=Iegal entity,or any two or more of the foregoing engaged is a joint enterprise,and including the legal+ffPresentaiiyes of a deceased employes,or the receiver or trustee of an individual,partnership,association or otherle:gal entity,employing es¢ployees. However the owner of a.dwelling home bavingnot more than tbree apartmejts and who resides therein,or the occnpam of the - dweM g bouse of another who employs persons to do maintenance,consfruction or repair work.on such dwellinge house, or on the groimds or building appurtenaatthereto shallnotbecause ofsach employment be deemDdto be an employees." MOL chapter 152,§25C(6)also slates that"every Sfat m 4r local ficensmg ageiicy shall withhold the issuance or renewal of a license or permit to operate a busing or to construct bufldings in the commonwealth for any aPpTicantwho has-not produced acceptable evidence of compliance with tm-e i„sm-ance.coverage requirecL" Additionally,MCrL chapter 152,§25C(7)states-N6itber the commonwealth nor any ofits political subdivisions shall enter mw any con-fra et for the performance of pubhc wcuk u±a acceptable evidence of compliance with the;,,suza ce._ requirements of 1h:is chapter have been presented.-n time c nta r_ti ag ardholAy.", Applicants Please fEI obt the wormers'compensation affidavit completely,by c hecloag the boxes that apply to your situation and,if necessary,s PP Ty sub-coniractor(s)na in, (s), addresses)and phone number(s) aIong with.their certfficat]--Cs) of a entrance. Limitsd Liability Companies(LLC)or LimitEd Liabflity-Parbmeasbips(LIP)withno employees other than tho members or partners,are not required to catty workers'compensation insurance- If as LLC or LLP does have employees,apolicyisregII.ired. BeadvisedtbattHsaffidayitmaybeS❑_bmttr-dto the Depal-trnentofIndustrial Accidents for confainaiion of ins ancd coverages. Also be sere to sight and date-the affidavit---The affidavit should be retrained to the city or town that tine application for the permit or license is being requested,not the D eparbneat of Lo-d s ial Accidemis. Should you have any questions regamdmg the law or if you are rmloi-ed ties obtain a workers' compensation policy,please call tine Department at the,nninbea listed below. Self-kozrd companies should enter their s eIfLi sn co Reese number on the appropriate line. City or Town ofalcials Please be sure that the affidavit is complete and priidedlegibly. The Departnenthas provided a space at the bottom of tie affidavit for you to fM out in the event the,Office ofInvestigations has to contact you regarding the applicant Please be sure to f171 in the penn>tlliccme,number which will be used as a reference mmnber. In-addition,an applicant that must submit muYT15 pemziVhcrose applications in any given year,need only submit one affidavit mdica± mg=rcat p olicy info�a tihn[if ney)and under"lob Sire Qess"the applicant should write"aII locatives in (may or town)_"A copy of the-affidavit that has been officially stumped or marked by the city or town may be provided to the applicant as Of that a valid affidavit is on file for futare,pemli�s- licenses or li A new affidavit must be filled out each year.Whew a home owner or citizen is obtaining a license or.permit not related. any business or commmcW vcntiare a dog license or peunit to bum leaves etc.)said person is N0T regoaed to complete this affidavit The Office of Investig ons would Izke to t�Ic you in advance for your coopeesatian and should you have any questions, please do not hesif to to give us a call The Department's address,telephone and faxnumberr C_amn3�aaWmj bE of Mamachh ` - ` �cif I�d�iat Ac�icl�nts . Bo MA E 111 T(�-L 4 617' -49W cxt406 car I-a' ILkSSAFF Fax 9 617 727 7M Revised4-24-07 - �� Town of Barnstable Regulatory Services `S. Richard V.Scali,Director. �sb3q. �� Building Division � Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.maus —Office 508-862-4038--- --------__.. __ ..._______-_ Fax: 508-790-6230 ---- Property Owner Must Complete and Sign This Section If Using A Builder I d ;as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: -76 (Address of Job) **Pool fences and alarms are the respbnsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. J1L—LZ,4�L Signature-of Owner ! Signature of Applicant Print Name U Print Name Date QYORMS:OWNERPERMISSIONPOOLS Town of Barnstable Regulatory Services ' oFtr �ryp Richard V.Scali,Director Building Division Paul Roma,Building Commissioner � i639. $ 200 Main Street, Hyannis,MA 02601 AIEo A www.town.barnstable.ma.us Office: 508-862-403 Ly Fax: 508-790-6230 HOMEOWNER LICENSE EXE TION Please Print DATE: JOB LOCATION: number street illage "HOMEOWNER":-- name home phone#„y _ work phone#. CURRENT MAILING ADDRESS: 9 - city/town state zip code The current exemption for"homeowners"was exte ded to include owner-o ti ied dwellin s of six units or less and to allow homeowners to engage an individual for hire who do s not possess a licen ,provided that the owner acts as supervisor. D FINTTION OF HO OWNER Person(s)who owns a parcel of land on which he/she r ides or intends reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accesso to such use d/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a home wner. Su "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be res risible'or all such work performed under the building ermit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for co m iance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she unders ds th Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply ith said rocedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings conta' g 35,000 cubic feet or lar r will be required to comply with the State Building Code Section 127.0 Construction Control. ' -HOMEOWNER'S,EXEMP ON The Code states that: "Any ho eowner performing work for whi a building permit is required shall be exempt from the provisions of this section(Se ion 109.1.1-Licensing of constructio Supervisors); provided that if the homeowner engages a person(s)for hire to do su work,that such Homeowner shall-act a supervisor." Many homeowners who u e this exemption are unaware that they are ass ming 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. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities, many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit formS\EXPRESS.doc 06/20/16 Cape Cod Remodeling, LLC. Contract ARTICLE 7 Approvals Si ature Date d 0' CMSIX Properties LLC Executor: Signature/ Date r� j CMSIX Properties LLC Project Manager: Beth F ng Siggature Date Richard Avery, Cape Cod Remodeling, C 4 License or registration valid for individual use only \_ Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: -HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registration:, 178816 Type: 10 Park Plaza-Suite 5170 ' Expiration: 5t22/2018 LLC r Boston,MA 02116 CAPE COD REMODELING LLC RICHARD AVERY FOUNTAIN ST 39 MASSHPEE,MA 02649 - Undersecretary of valid without gnatu � Massachusetts-Department of Public Safety _ Board of;$uiid':n0Qqul0 1 s and Standar.''.s • - �ai"iSii iiCinli�au7ri�iiii �.. License. Cs4T71[�� RICHARD T AVFJty ram; p0 BOX 2416 03 Mashpee MA 02(19 V Expiration �,,�,,,.�• 01/15120W Commissioner C6errt0:763570 2H MHCp ACORIL ' CERTIFICATE OF LIABILITY INSURANCE 6WIM6 TIM CERTMATE IS tSSUFD AS A MAATiEROF UMORMATION ONLY AND CONFERS NO RMft UPON THE CERnRCATE HOLm3L TH M CERitFlCATE DOES NOT A RMMATIVELY OR NEGATIVELY AMEW MITCND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THUS CwTCATE OF INSURANCE DOES NOT CONSTI m A CONTRACT BETWEEN THE ISSUING ROURER(S),AUiHORom REPRESENTATIVE OR PRODUCER,AND THE CERTIRCATE HOLDER MPORTANT:If the certificate holdw is an ADDITIONAL INSURED,the poficy(es)mast be endorsed H SUBROGATiON B WAIVED steed tip tie terms and conditions of the policy,certain policies may requilre an endorsement A statement on Hds ed rfBcate does not confer rights to the certificate holder in Neu of such endorsemeld(s). PIWOUCIER Dowling&a Nell Insurance Ag yy F 9731yannough Rd,PO Box 1990 Egan. 508 775'16� 5087781218 HyannL%MA 02601 ADDRRSS: 508 775-1620 a aFFORnINccov talcs mStHKRA:Commerce Insurance Company High Color Painting inc paswaR B-Guard hsurance Group 184 Compass Circle olsuPERC- Hyannis,MA 02601 INSURERD j INS E: IIF• 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. LTRR TYPEOFRISURANCE TOM im— � POLINUNRIERCY[ F i POLiCiE� LlrUls A 03181ALLlaeurlr BGXCRT D6=2016 0000201 EACHoccuRREticE $1 000000 XFXPD COU L cE+e�aL`AUUJW Ell m ce E100 000 �° °AOE ®° MED EW(Arty mie per) $ 000 Ded:500 PERSONAL aADVKOM $1,000,000 GENERAL AGGREGATE s2,000,000 GEM AGGREGATE LRruraPPLIESPer I PRODUCTS-COMPIOPAGG $Z000,000 POLICY JECTT LOC a AMMOBILE LIABRA Y coeimee�swE�a LfAIIT - I _ $ ANY AUTO BODILYKWRY(Perpwsm) s ALL O SCIii�Ul[M AUTOS AUTOS BODILY INJURY(Perms $ HIRED70S q�-0�ED PROPB(TY[)AMAGE $ I S UMBRELLA LOB OCCUR EACH OCCUR[UNCE S E7(CESS LJAB CLAICds4MF AGGREGATE y DED BETE mnoN s $ B VLWOR103McoMPENUTM EMPLOVERW LIABILITY HMC745836 Dsmi2owr06l01Y1YIN01 X vucsTATu- Onl TORYLIMITS OFFEC ANY D(�n NIA EL EACHACCDE NT Wm 000 (MmdatoryByes,desrnbe�Niger EL.DISEASE-EA EMPLOYEEs5M000 DESCRIPTION OFOPE3tAT10NSbelor F1DiS -POLICYLINTr $W%000 DEse TEONOFOPsu►TIONSILOCATIIDNS/vaap.MPUlachACOW'10%AskViond Reams N spmEs FeqtftQ Insurance coverage is limited to the term,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall he deemed to heave attered� rQ� coverage provided b!r the l CERTIFICATE fKXVER CANCELLATION r SHOULD ANY OF THE ABOVE DESCRIBM POU GEE BE CANCELLED BEFORE f THE EXPIRATION DATE THEREOF, NOTICE tMEul BE DELIVERED IN ACCORDANCE WITH THE POLICY ptOV1SONS iTATIVE ®1988-2010 ACORD CORPORATION.AUjeft reserved. ACORD 25(2010I8S) 1 Of 1 The ACORD ratite and logo are registered narks of ACORD dS172643JM172642 CBD i Mass. Corporations, external master page Page 1 of 2 a� r MR i Corporations Division Business Entity Summary ID Number: 000969281 Request certificate I New search Summary for: CMSIX PROPERTIES, LLC The exact name of the Domestic Limited Liability Company (LLC): CMSIX PROPERTIES, LLC Entity type: Domestic Limited Liability Company (LLC) Identification Number: 000969281 Old ID Number: Date of Organization in Massachusetts: 01-18-2008 Last date certain: The location or address where the records are maintained (A PO box is not a valid location or address): Address: 63 LAWTON ST. City or town, State, Zip code, BROOKLINE, MA 02446 USA Country: The name and address of the Resident Agent: Name: MOY FONG Address: 63 LAWTON ST City or town, State, Zip code, BROOKLINE, MA 02446 USA Country: The name and business address of each Manager: Title Individual name Address MANAGER RAYMOND`FONG _ 63 LAWTON ST. BROOKLINE, MA 02446 USA MANAGER ANDY FONG 63 LAWTON ST. BROOKLINE, MA 02446 USA MANAGER I MOY FONG 63 LAWTON ST. BROOKLINE, MA 02446 USA In addition to the manager(s), the name and business address of the person(s) authorized to execute documents to be filed with the Corporations Division: Title Individual name Address SOC SIGNATORY RAYMOND FONG 63 LAWTON ST. BROOKLINE, MA 02446 USA The name and business address of the person(s) authorized to execute, acknowledge, deliver, and record any recordable instrument purporting to affect an interest in real property: http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN=000969281&... 10/4/2016 Mass. Corporations, external master page Page 2 of 2 Title Individual name Address REAL PROPERTY MOY FONG 63 LAWTON ST. BROOKLINE, MA 02446 USA REAL PROPERTY RAYMOND FONG 63 LAWTON ST. BROOKLINE, MA 02446 USA REAL PROPERTY ANDY FONG 63 LAWTON ST. BROOKLINE, MA 02446 USA ❑ ❑Confidential ❑Merger ❑ Consent Data Allowed Manufacturing View filings for this business entity: ALL FILINGS ` Annual Report Annual Report - Professional Articles of Entity Conversion �> Certificate of Amendment ui View filings Comments or notes associated with this business entity: New search http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN=000969281&... 10/4/2016 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION r Ma © Parcel Z. p ,.� �( Applicatio ZHealth Division Date Issued ��` ./Conservation Division ' WILDING DEIST Application e Planning Dept. Permit Fee ��. Date Definitive Plan Approved by Planning Board 0 9 2016 I OWN OF BARNSTABLE .%Historic - OKH _ Preservation/ Hyannis Project Street Address 74> F I NI E A VG-I Q Village OwnerCM,S f X � �PC l2- �qE Address L �1�0^� St` a 9_0,� nlR- Telephone (? 7 1 �'� F— "�O Permit Request kCf?6A 1 R__ IF::'t 2 C— b/gym A el. .1 GCS ro1E i-IadCE Square feet: 1 st floor: xis g proposed 2nd floor: existing proposed Total new O Zoning District Flood Plain Groundwater Overlay Project Valuation Aonton Construction Type (:boo 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 O.No Basement Type: Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) e600 Number of Baths: Full: existing new N Half: existing ® new I-� f�- Number of Bedrooms: existingf new Total Room Count (not including baths): existing new First Floor Room Count 4: Heat Type and Fuel: Gas ❑Oil ❑ Electric ❑ Other Central Air: ❑Yes 0 Fireplaces: Existing New Existing wood/coal stove: ❑Yes WNo Detached garage: �J axisting ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed:lcisting ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes *o If yes, site plan review# Current Use i s- M Proposed Use tit APPLICANT INFORMATION (BUILDER OR HOMEOWNER) - - - � T ,�^ L Name _ � ��1 �� `� Telephone Number �O p �3 7 Address © , &0 OAT _ License# CS d 0 71 (0.. Home Improvement Contractor# `� 1 Email 'I� !k\1 Ell ®UTLO 014 . C o Worker's Compensation # N �t ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Z6 SIGNATURE DATE i1 ry i 3 r FOR OFFICIAL USE ONLY APPLICATION # E z DATE ISSUED MAP/PARCEL NO. r ADDRESS VILLAGE OWNER DATE OF INSPECTION: -� FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING 2� t DATE CLOSED OUT ASSOCIATION PLAN NO. 't' 17ie Comrlronrvea.Itili of-Massadrusetts Department ofrndus-trial Acciderrtr Office of 1mvstigatiom 600 Waskington,,street _ Boston,CIA#211I wivinmasmgovIdia WnrIcers' Cainpensaf an InsuranceAffidavit:Bnildei-JContr-acinrsXlecchicians/Plumbers Applicant Informatian Please Print LeRii Na=(Busing l tgan�ahonlInd�*��ual lC t �'n�� Address: . C) `( Y Cityfsta�2* t�s'14P�C A � az ,6 ' Ph n _ �a 7377 Are you an employer?Check the appropriate bow Type of project(required).:I.❑ I am a employer with 4 f��a'genet contractor and I employees(full ar1rlJ`or part-time).* have lvredtFre sub-contractors 6- 0 New construction 2.❑ I am a sole proprietor orpartuer- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-comtractors have g- ❑Demolition -Wadring for mein any capacity_ employees and have rockers' [No W06Mrs'comp.instance comp.insuranmi - 9. ❑Building addition required-] 5- ❑ We are a corpomfion and its 10.❑Electrical repairs or additions 3.❑ I am,a homeoumer doing all;work officers have exercised their 1L❑Plumbing repairs or additions my [No workers'comp- right of exemption per MGL 12.❑Roof repairs. insuranceregnired]Y c.152,§1(4k and we have no employees.[No workers' 13.0 Other comp-insurance required.] *Army appfic=dsatchecUbos gl—st alsa fMcathe secdo¢bgawshouiag theaaru&exe com3pmufi,,policyiafo madcaL l l ameDwneu who submit dais ai#idn,g imCxatiug they ale daing all wa&and then]tire outside contmcmn mast sabmit a new aMdavk indicating sndi fCantisctots Ike f-bedr this bax must atmched as additional sheet sho hig the name of the sub-cantwAm s sad state whether or not those eatitks:hzM employees.Tftheavbtamfitactnisbaveemployees,theymustpmuidetheir workers'-camp.polky number. lam an ersp �er that is prfttztiirrg ivrrrkers'catrrlrerrsahirft irrsriratrce for ary'eazp£oy�ees, $e£aav is thepa£icy aftd jab site information. Imsuraace Company Name: Policy,At or Self--ins.Uc.;: Expiration Date: Job Site Address: City/StaW27p: Attach a copy of the workers'compensationpolicy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c.1527 can lead to the imposition of criminal penalties of a f ae up to$1,500:00 andfar one-year imprismmenty as well as civil penalties.in the form of a STOP WORK ORDEKand a fine or up to$250-00 a day against the violator. Be adi ised that a copy of this statement may be forwarded to the Office of 1mvestigations of the DIAL for insurance coverage i,rufrratism. I fro heneby csrhj3t cruder the pains and pen a)ffes o f erjury thatf7re information prmided ahmv fs tare and carrect SiE©atrne: c I)at, Phone 1 � I Official use only. Do not write in this area,to be cotmp£eted by city artomn official City or Town: Perw&ff icense 4 Issuing Anflhority(ca cIe one): L Board of Health 2.Building Department 3.C�lrown Clerk 4.Electrical Inspector S.Plumbing Inspector ntact Person• Phone 9: lbaformation and Instructions Massachusetts rt setts General Laws chapter 152 regr res all employers to provide warkers'compensation for their employees. Prirstrantto this fie,aa.mployee is defined as-'-.every person m the service of another under any contract of hfre, express or frrplied,oral or waftEa" An mTfoyer is defined as"an individual,partnership,associatioA corporation or other legal entity,or any two or more of the foregoing engaged in a Joint Vie,and including the legal represwt atives of a deceased employer,or the r=eivrr or trustee of an individual,partamsbip,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apad mems and who resides therein,or the occapant of the - dwelling house of another who employs persons to do mairtmmm,rrnstructi on or repair work on such dwelling house or on the grounds orbuilding appuntenarrtthereto shallnotbecanse of such employmmtbe deemed to be an employer." MGL chapter 152,§25C(6)also states that"every star or local licensing agency shall withhold$ze issuance or renewal of a license or permit to operate a business or to construct burldings in the commonwealth for any applicant who has not produced acceptable evidence of cdmmpfiance with the insaran ca.coverage required." Additionally,MCzEL chapter 152,§25C(7)states Neither the commonwealth.nor any ofits political subdivisions shall enter mho any contract for the performance 0fpublic work miff acceptable evidence of compliance with tine fnsurance. requfreniemts of this chaptPahavebeenprese�tedto the cmr--r ao'hol*" Applicants Please JUI o-ot the worms'compensation affidavit completely,by checking me boxes ilk apply to your situation and,if necessary,supply sub-coatractor(s)names), address(es)and phone number(s) along with their certificates)of itstuance. Limited Liab114 Companies(LLC)or Limited Liability Partnerships(LU)with no maployee-s other than the members or partners,are not rcquard to carry workers' compensation insurance. If an LLC or LLP does have employ(-,es,a policy is regn.:aed. Be advised thatthis affidavitmaybe submitted to the Department of Indu_sftiA Accidents for confirmation of msnrance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town flat the application for the permit or license is being requested,not the DePar ramt of h2dnstjzl,A Should you have arty questions regarding the law or ifyou are rego>red obtain a workers' compensation policy,please call tine Department at the number listed below. Self-insured companies should enter their self-msorance 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 fry out m the event the Office of Investigations has to contest you regarding the applicant Please be sure to fill in the peunit/license number which will be used as a reference number. In addition,an applicant that must sabnrt multiple pmmitlli ceuse applications in any given year,need only submit one affidavit indicating current policy mfo=oation Cif necessary)and under"Job Site Ad-ress"the applicant sho77Id write"all locations is LY or town)_"A copy ofthe-affidavitt3rathas ben officially stamped or marked bythe city or town maybe provided to the ' applicant as proof that a valid affidavit is on file for form a permits or licenses. A new affidavitmust be,filled out each year."Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venue (Le. a dog license or permit to burin leaves etc.)said person is NOT rimed to complete this affidavit The Office of Invesiiga d=would at to thank you m advzmce for your cooperation and should Yon have any questions, please do not hesitate to give us a call The Deparfn enfs address,telephone and fax n mmber: e *of MasmChmttts DEeparbnenfi cif h iciustzal Accidents ==of lavegtkatio= GW-Washhwou t - 'Tf,-L 4 617 727-4 e,-xt 4-06 or 1477-MA-SgAFF, Fax 617 727 7749 Revised 4-24-07 -PV/dia- Town of Barnstable Regulatory Services a � s muss. Richard V.Scali,Director �3� 1 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstablema.us Office: 508-862-4038 Pax: 508•-790-6230 Property Owner Must Complete and Sign This Section. If Using A Ruilder as Owner of the subject property hereby authorize C C K to act on my behalf, in all matters relative to work authorized by this.building permit application for. (Address of'ob) �/ .�,I"-�Jl s **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature o€ er Signature o Applicant AN b Print Name (y Print Name Date Cfientrlti 46422 2LOCKSBA ACORD. CERTIFICATE OF LIABILITY INSURANCE 11M8@015 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 BEiWEEN THE ISSUING DWRER(S),AUTHOR® REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER_ IMPORTANT:9 the Certificate holder Is an ADDITIONAL INSURED.the pormy(ies)must be endorsed,N SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain poliaies may require an endorsement A statement on this certificate does not confer rights to the cerd holder in fieu of such endorsement(s)- PRODUCER CONTACT Dowling&O'Neil Insurance Ag PHONE 508 775-1620 9MalL�`E_ tac,Nor 5087781218 9731yannough Rd,PO Box 1990 E Hyannis,MA 02601 ADDPES&- 508 775-1620 1RNM1RER(S)AFPOP DING COVERAGE NA1C! INSURED INSURER A:National Grange Mutual Insuranc Locks Home improvements,Inc Ir wRm a:Associated Employers Insurance 116 Compass Circle INsuRERc' Hyannis,MA =01 INSUREtD_ INSURER E INSURSt 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 I 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. FN— LTR TYPE OF INSURANCE ADD SUER POLICY NUMBER POLICY EFF POLICY OtF AKMAM LIMITS -- A SAL LIABILITY MPT5335L 1010412015 1010412011 EAcH oc cuRRENcE $1,000,000 X COMMERCIAL GENERAL LIABILTTY - OAMAGE TO RENTED - PREMLSES Eaoogorerrce $500 000 CLAIMS MADE OCCUR MED EXP(My one person) $10 000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GENL AGGREGATE LIMIT APPLIES PER PRODU -COMPIOPAG6 S2,000,000 POLICY PRO_JECTLOC CTS $ AUTOMOBILE LUM39MY COMBINED SINGLE LNNIT accident ANY AUTO (EA ALL OWNED SCHEDULED BODILY INJURY(Per person) $ . AUTOS AUTOS NON-OWNED BODILY INJURY(Per accident) $ HIRED AUTOS AUTOS PROPERTY DAMAGE $ Per accideno UMBREI r e LaBJ4_ _ S OCCUR EACH OCCURRENCE $ EXCESS LUIB CLAIMS MADE AGGREGATE $ DED RETENTIONS B INFOAND IMRSEMPLOYERS' O�nONOYERS'LUIBRITY $ AND WCMOW125302015A 0/04/2015 10/MOI X WC sTATU OTH- I�LY PROPREETOR/PART►��aMVE Y/N OFRCEAN LMEMBER EXCLUDED? a N f A EL EACH ACCIDENT $500 000 ff yes,describe under EL DISEASE-EA EMPLOYEE $500 000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S500,000 DESCRIPTION OF OPERATIONS I LOCATIONS f V6ICLES(AUach ACORD IN,Additional Romabs Sdredrde,H more spaee as nxpmuM Insurance coverage is limited to theterms,conditions,exclusions,other limitations and endorsements. Nothing Contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Cape Cod Remodeling LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PO BOX 2416 G I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WiTH THE POLICY PROVISIONS_ Mashpee,MA 02649 ;s # AUTHOR®REPRESENTATIVE 01988-2010 ACORD CORPORATION_All rights reserved_ ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S161089/M161088 CBD I ACC>v® CERTIFICAT DATE,MMA,,,YYYY) E OF LIABILITY INSURANCE f 12/21/15 THIS CERTIFICATE IS ISSUED AS A MATTER OF WORMATION 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 if BELOW. THIS CERTIFICATE,OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INURER(S), AUTHORIZED i REPRESENTATIVE OR PRODUCER,AND THE CERTIFCATE HOLDER- IMPORTANT- If the certificate holder is an ADDITIONAL INURED,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 j certificate holder in lieu of such endorsenent(s). f PRODUCER cN°AME T JIM HINDMAN Schlegel & Schlegel Ins Broker PNONE ---- --- 34 Main Street (508) 771-8381 �X N : (508) 771-0663 West Yarmouth, MA 02673 ADDRESS: SCHLEGELINSURANCE@GMAIL.COM INSURE )AFFORDING COVERAGE INSURERA:NGM INSURANCE COMPANY —_ __ ;14788 INSURED INSURER B:TRAVELERS CAPE COD SPRAY FOAM LLC INSURER c:PROGRESSIVE - 49 SI SSON ROAD ---— ----- ...----- -- --------- INSURER D_- HARWICHPORT, MA 02646 INSURER E. 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 AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I INSR ADDL'SUBRj POLICY EFF OUCY E XP ., .LTR: TYPE OF INSURANCE I } POLICY NUMBER M(DD/Y AMIDWYYYY II LIMITS A p-GENERAL LIABILm j MPK9358X 11/16/151 11/16/16' EACH OCCURRENCE is 1,000,000 I X_^COMMERCIAL GENERALLIABWTY I i ' f NTffo— PISES(EaEouurrensel S _5.00,.000 CLAW-MADE r I 1- E �:OCCUR D EXP(Any one person) PERSONAL BADVINJURY1.,,000.,OQO GENERAL AGGREGATE S 2 000.000 GEN'L AGGREGATE LIMIT APPLIES PER j ( PRODUCTS-COMPIOPAGG S 2,000,000 I --- POLICY I PRO- i l LOC i €S C ,AUTOMOBILE LIABILITY 107881343-4 5/8/15" 5/B/16 COMBINED SINGLE LIMIT 0 I _ __S 1,_0 0,OOO l a accden¢)-- _ ANYAUTO j ! ! BODILY INJURY(Per person) $T- — ALLOWNED SCHEDULED - AUTOS X AUTOS I ? (BODILY INJURY(Per accident):$ i 1 ? HIREDAUTOS' _.AUTOSED I E PROPERTY DAMA $ -"- 1 I E.S... . 1 UMBRELLA LJAB OCCUR EACH OCCURRENCE t EXCESS LIAR CLAIMS MAC! 1 i AGGREGATE $ DEO RETENTION$B f S , WORKERS COMPENSATION '6HUB6B13035513 AND EMPLOYERS!LIABILITY 7/17/15 7/17/16f , ORYL U- i tOR Y/N I { =IDRYlIM1IS i ER'--------:--.. ` ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? N:l f N/AI I ! p E L_EACH ACGDENf__--..-._,;-,S_.. .- 5OO,000 (Mandatory in NH) ! E.L.DISEASE-EA EMPLOYEEi'S___-..._50_0,000 If yp�describe under ! ! r 1-- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT i$ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101.Additional Rerwft Schedule,if more space is required) ::ORPORATE OFFICERS HAVE ELECTED TO BE COVERED UNDER THEIR CURRENT WORKERS COMP POLICY ( I ? CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CAPE COD REMODELING LLC ACCORDANCE WITH THE POLICY PROVISIONS. j PO BOX 2416 MASHPEE MA 02649 AUTrIORtZEDREPRESENTArIVE I 01988.2010 C RD CORPORATION. All rights reserved. WORD 28 J2010108) The/CORD name and logo are registered marks of AC 'how Fax: E-Mail: RTAVERY@OUTLOOK.COM Massachusetts -Department of Public Safety Board of Building Regulations and Standards License: CS 0847T7 RICHARD T AVEO PO BOX 2416 % oo s Mashpee MA Mg Expiration Commissioner 01115=17 ,�` �e�mnznra�uue�r�l a����ui3nc%seLlt \ Office of Consumer Affairs&Business Regulation License or registration valid for individual use only — HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: d Registration:,::. 178816 Type,: Office of Consumer Affairs and Business Regulation Expiration 5122/2O18 LLC 10 Park Plaza-Suite 5170 CAPE COD REMODELING,.LLC.:_. .-` Boston,MA 02116 RICHARD AVERy ' 39 FOUNTAIN ST 4ot MASSHPEE.MA 02649Undersecretaryalid without gnatur r �oo� r r Cc fe F f cfi AKE DET TORS REVIEWED BARNSTABLE BUILDING DEPT. DATE DEPARTMENT DATE LTH::I::URESARE REOU/RED FOR PERMIT) j -7 ' ��rjoc, y 1 P P. i �, ;; �- -. �-� / , ( � �, �; f� . � � , ,:,� .. r a FRIEDLINE&CARTER ADJUSTMENT, INC. 436 Main Street, P. O. Box 338 Hyannis, Massachusetts 02.601 Tel. (508) 771-3232 FAX (508) 790-2344 TO: (/Building Commissioner or Inspector of Buildings ( ) Board of Health or Board of Selectmen O Fire Department TOWN OF BARNSTABLE TOWN HALL HYANNIS, MA RE: Insured: C AND M REALTY TRUST Property Addr ssj6 Pine Ave. Hyannis, MA 02601 Policy Number: DWP00097006 Type of Loss: FireZE Date of Loss: 2/27/2016 ZZ File#: 124818 , za a UJ Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. General Laws, Chapter 143, Section 6 to be applicable. If any notice under MGL, Ch. 139, Sec. 313 is appropriate, E. please direct it to the attention of this writer and include a reference to the captioned a insured, location, policy number, date of loss and file number. On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by First Class Mail. N. DOWNING Adjuster 2/29/2016 4 1- . E lay Town of Barnstable *Permit# �10 G 3 r7 �.•� Expires 6 months from issue date BMMABIA Regulatory Services Fee ,3'? f� i639. `0� Thomas F.Geiler,Director Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax. 508-790-6230 `; EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press imprint r„= r p/parcel Number ,perty Address l Cc a residential Value of Work ! ` ©� 'Minimum fee of•$25.00 for work under$6000.00 mer's Name&Address 0, J a2 ntractor's Name Telephone Number o� )1 -7 7 11ne Improvement Contractor License#(if applicable) _0 3 1 J. y instruction Supervisor's License#(if applicable) © 2(p 33 a 5 �7orkman's Compensation Insurance 1161 Check one: m PRESS PERMIT 0 I am a sole proprietor ❑ I am the Homeowner NOV 0 9 2004 '[ I have Worker's Compensation Insurance surance Company Name �r^�✓��,-r���,l-A)� . TOWN OF BARNSTABLE -ori man's Comp.Policy# opy of Insurance Compliance.Certificate must be on file. mnit Request(check box) %IRe-roof(stripping old shingles) All construction debris will betaken to r&A p OTA L ©Re-roof(not stripping. Going over existing layers of roof) 0 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. Home 7royam=t Contractors License is required. ignature "A.4 Toams:expmtrg - evise063004 f HiE Town of Barnstable Regulatory Services ? 8ARN8T^BLE, ' Thomas F.Geiler,Director NAM Fn.39;.ta`0� Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.nia.us Office: 508-862-4038: Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property 4 hereby authoriz ,A to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Jo Ignature of er Date Mo� -Print Name Q:FORMS:OWNERPERMISSION ACORD- CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION McShea Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 749 Main Street, Suite#H ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Osterville, Ma. 02655 —508-420-9011 INSURERS AFFORDING COVERAGE INSURED Paul J Cazeault & Sons INSURER A: Lloyd's Roofing Inc. INSURER& v S-Insurance 1031 Main Street INSURERC: Osterville, Ma 02655 INSURERD: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE MM/DD/YY DATE(MMIDDIYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1 ,000 ,000 COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one fire) $ CLAIMS MADE ®OCCUR MED EXP(Any one person) $ H LGLO34776 04/30/04 04/30/05 PERSONAL&.ADVINJURY $ GENERAL AGGREGATE $ GE AGGREGATE LIMIT APPLIES PER: POLICY PRO- PRODUCTS-COMP/OP AGG $1 ,000 ,000 JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per person) HIRED AUTOS NON-OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ HANY AUTO EA ACC $ OTHER THAN AUTO ONLY: qGG $ EXCESS LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND TAT - H- EMPLOYERS'LIABILITY TOW RY LIMITS ER 7PJUB-0095864A04 08/13/04 08/10/05 E.L.EACH ACCIDENT $ 100,000 B E.L.DISEASE-EA EMPLOYEE $ OTHER E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER ADDITIONAL INSURED;INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10— DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. - AUTHORIZED RET A I ACORD 25-S(7/97) 0 ACORD CORPORATION 1988 rG,e Board of Building Regulat'ons an =an �ars One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement`.Contractor Registration Registration: 103714 Type: Private Corporation Expiration: 7/9/2006 PAUL J. CAZEAULT & SONS, INC ! ' ' Paul Cazeault 1031 MAIN ST ' OSTERVILLE, MA 02658 Update Address and return card.Mark reason for Chang Address Renewal Employment Lost Card DPS-CAI 0 SOM-04104-GIO1216 /cc 6�o�lr�lr�uueaQ/ O�✓�aooac%uo�lla Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR License or registration valid for individill Ilse ouh Rogisiratlort:. 103714 before the expiration dale. If found rclul to: Board of Building Regill.t0ous alld SL•uidards Expiration::7/9/2006 Unc,\s111rur(on Place Itrn 1301 ;Type Private Corporation lloston, Nla.02108 PAUL J.CAZEAULT;&.SONS,INC Paul Cazeault !-? 1331 MAIN ST CSTERVILLE,MA 02658 ✓�+a ' o,,,iieoiaoeu // Administrator Rio BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 026325 Birthdate: 10/20/1959 Expires: 10/20/2005 Tr,no: 8603.0 Restricted: 00 PAUL J CAZEAULT 1031 MAIN ST Z�— I,__ OSTERVILLE, MA 02655 Administrator 677-1 Board of Buildingg egulations One Ashburton Place, Rm 1301 Boston, Ma 02108-1618 License: CONSTRUCTION SUPERVISOR LIPENSE Birthdate: 10/20/1959 Number: CS 026325 Expires:10/20/2005 Restricted To: 00 PAUL J CAZEAULT 1031 MAIN ST OSTERVILLE, MA 02655 . i ' Tr,no: 8603.0 Keep top for receipt and change of address notification. j �a� c o� o � 0 t :t' °'0 V.�:p-e KE DET ORS REVIEWED BA IL DIEPT. dA, DAT F E D PART ENT, DATel BOTH SIGNATURES ARE REQUIRED FOR PERMITING -74 P A I I i I I i i 1 3/3 Otrai r Stvu av,d -�-;rc �