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0025 PINE VALLEY ROAD
a5 �� v�y 2� , nas Town of Bar table- Buildn t . F, .. - . :, _ c:, = _F on.Job-and:ahis Card'rMust bgi� i��. eN:Ke t , K oved<:Rlans MusL.be, eta�ned. P , _ .. t., �s..Vs Fr the,St e A r .. t Th+s.Car. SotT b. om ....Pos #. AfA88. Fi ahlns ect�on Has:eeen,Made., Posted Until .¢ Permit ,: halLNot�be:Occu �edruntl a.<F�nal Ins ect�on-has.been..made ere a Certificate of . cu ancy;fs Rec#uired,sta l�48ualdang s, p p Applicant Name. CAPE COD INSULATION, INC Permit:No. 13-17-2872 Approvals Date Issued: 09/07/2017 Current Use. Structure Permit.Type.-. -Building_Insulation-Residential Expiration Date:,. 03/07/2018 Foundation: Location: 25 PINE VALLEY ROAD,HYANNIS Map/Lot 248-069 Zoning District: RB Sheathing: Owner on Record: GARVEY,RICHARD A&PATRICIA A Contractor Name: CAPE COD INSULATION, INC Framing: 1 Address: 47 PARK AVENUE , Contractor License .153567 2 WELLESLEY, MA 02481 Est Project Cost: $4,700.00 Chimney: Description: weatherization & Permit Fee: $85.00 Insulation: b # Y Project Review Req: weatherization Fee Pa $85.00 Final: Date 9/7/2017 Plumbing/Gas OT Rough Plumbing: - °Building Official Final Plumbing: R This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within sa months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved applicationzan pproved construction documen d the ats°for which this permit has been granted. All construction,alterations and changes of use of any building and structures'shall�be incompliance with the local zon g b`y laws an codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for pubhcymspecii.n for the entire duration of the work_ until the completion of the same. Electrical � � �� The Certificate of Occupancy will not be issued until all applicable signatures by the Bwldmg and Fire�Official�s are provided on thispermit. Service: Minimum of Five Call Inspections Required for All Construction Work ' 1.Foundation or Footings 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 shail not'proceed until the Inspector has approved the various stages of construction Final: .. ';Persons contractln Wtth upregistered-contractorshave access to the guaranty fund'(as setforthln 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 QQ Map a y Parcel d 6'1 Application # Health Division Date Issued 7 11-2 Conservation Division Application Fee Planning Dept. Permit Fee v Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address ,�.�"�yi�� aZII ,v gal Village Owner O a!�g /V Address Telephone/( ? 47,M ;F Permit Request - / s 2T,�K12 9/9 1��,��L�� J � 1AS.f Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type 1,e11G/igou� Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 0"' Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes U 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) 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: BUILDING DEPI Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# AUG 2 3 2017 Current Use Proposed Use TO WNW ram- QAC'MIQYAM, APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name a06AL ��/�/�a&I Telephone Number 4-7 Address ,/9f V e,,&l z/ i License# A Home Improvement Contractor# Email � �yG/�/6 /'��f,��r�1 i /� 4t Worker's Compensation # 3 /9® ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE / �I FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. J P�oF I NC r Town of Barnstable Regulatory Services anxtvsraxr , Richard V. Scali,Director 9�0 1839 � Building Division 0 oil Paul Roma Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section I, PING K GRAY , as Owner of the subject property hereby authorize Cape Cod Insulation to act on my behalf, in all matters relative to work authorized by this building permit application for: 25 Pine Valley Road Hyannis, MA 02601 (Address of Job) 6 -ZI - J 7 Signature of Owner Date r, d rJ-�rt �, 6�y k( Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form. C:\Users\decollik\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\L7U69LF2\EXPRESS(2).doc 01/25/17 w The Commonwealth of Massachusetts Department of Xndustrlal Accidents I Congress Street, Sulte 100 Boston, MA 02114-2017 www,mass,gov/dla Workers, Compensation Insurance Affidavit: Builders/Contractors/Electrlclans/Plumbers, TO BE FILED WITH THE PERMITTING AUTHORITY, Aoolicant Information Please Prinf Le ,bi Name (Buslness/Organization/Indlvidual); Cape Cod Insulation Address; 18 Reardon Circle City/State/Zip; South Yarmouth MA 02664 Phone #; 508-775-1214 Arc you an employer?Mack the appropriate box: I, I am a employer with 48 Type of project(required); © employees(full and/or part•tlma),d 2Q 1 am a sole proprietor or partnership and have no employees working for mo in 7' New construction any oapaclty,(No workers'comp,insurnnoe required,) S. ❑ Remodeling 3,[]1 am a homeowner doing all work myself•(No workers'comp,Insurance required,)t 9, ❑Demolition 4,[]1 am a homeowner and will be hiring oontractors to conduct all work on my property, I wiii 10 M Building addition ensure that all contractors either have workers'compensation lnsu=e or are sole proprietors with no employeas, 11,[] Electrical repairs or additions I am a general oontraotorand I have hired the subcontractors listed on the attached shoot, 12,❑plumbing repairs or additions These sub•contraotors have employees and have workers'comp,insurertcat 13,[]Roof repairs 6,C]We are a corporation and Its officers have exercised their right of exemption per MOL o, 14,21 Other W eatherization 152,11(4),and we have no employees,(No workers'oomp.Insurance required,) *Any applloant that cheeks bgx rFl must also fill out the section be showing their workers'compensation policy Information t Homeowners who submit this,Mdavit indicating they era doing all work and then hire outside contraotora mutt submit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheet showing the name of the sub-oontracton and state whether or not those endeol have employees, if the sub•eonuactors have employees,they must provide their workers'oomp,policy number, 1 am an employer1hat is providing workers'compensation Insurance for my employees, Below is the policy and fob site lrt ormation, Insurance Company Name; Atlantic Charter WCE00431902 Policy#or Self-Ins,Lto,#, Expiration Date, 06/30/2018 Job Site Address; — Ci /State/Zi ' h' p•w. ..ozG,g% Attach a copy of the workers' cotnpensatl n policy—deelafanon page(showing the policy number and expiration date), Failure to secure coverage as required under MOL 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, 1 do hereby certVy under the pains and penalties of perjury that the lrf'ormatlon provided above is true and correct �W KW MWMM WVYYY, S_i¢nature; Henry Cassidy �'y',,;t,,;",•�`� `r"~�"'�~�^M ate: 2 2�� Pone#; 508.7 7 5-1214 _..._ Offlcfal use only, Do not write In this area, to be completed by city or town ojylclaL City or Townt Permit/License# Issuing Authority(circle one): 1,Board of Health 2, Building Department 3, City/Town Clerk 4, Electrical Inspecton:5► Plumbing Inspector 6,Other Contact Person: Phone#: CAPECOD-27 KDOYLE '4��E)w CERTIFICATE OF LIABILITY INSURANCE FDATE 06/30/2017 06/3012017 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(les)must have ADDITIONAL INSURED provisions or 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 endorsements. PRODUCER C ACT Rogers&Gray Insurance Agency,Inc. PHONE N Ext: AIc,No: 877 816-2156 434 Rte 134 ( ) South Dennis,MA 02660 5-epAg'Lsso mail@rogersgray.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Peerless Insurance Company 24198 INSURED - INSURER B:Safety Insurance Company 39454 -. Cape Cod Insulation,Inc. INSURER C:Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURERD:Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E: 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 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 TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LTR POLICY NUMBER LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,0001000 CLAIMS-MADE r X]OCCUR CBP8263063 04/01/2017 04/01/2018 DAMAGE TO RENTED ES 100,000 MED EXP(Any oneperson) $ 6,000 PERSONAL B ADV INJURY 1 11000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000 X POLICY jreT Fl LOC PRODUCTS-COMP/OP AGG 2,000,000 OTHER: B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT(Ea accident) 1 11000,000 ANY AUTO 6232707 COM 02 04/01/2017 04/01/2018 BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY X AUTOS SSWNEp BODILY INJURY Per accident X AUTOS ONLY X AUTOS ONLY fi PPe�accRdent AMAGE $ C UMBRELLA LIAB X OCCUR EACH OCCURRENCE 1 2,000,000 X EXCESS LIAB CLAIMS-MADE EXCI0006635002 04/01/2017 04/01/2018 AGGREGATE $ 2,000,000 DED RETENTION$ D WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY R/0 WCE00431902 06/30/2017 06/30/2018 ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT 1,000,000 �vlanFFICER/MEMBER EXCLUDED? �N NIA 1,000,000 datory In NH) E.L.DISEASE-EA EMPLOYEE If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 11000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) Workers Compensation includes Officers or Proprietors. Additional Insured status is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thielsch Engineering Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 195 Frances Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Cranston,RI 02910 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD hoard OfhSvIldting Regulatlonsf nd standarTy rds Lloensel os•100988 ' Oonatruotlon supervllsor, �"i1'' Is 1" HENRY E 0A06IDY%N 0 SHED ROW WEST YARMOV H r' R � I� �I111U1 Expiration; ' Co�misaloner 11/1112017 Offloe of Consumer Affairs and Business Regulation, 10 Park Fla;a Suite 6170 Boston, Ma b. usetts 02116 Home Im roveme p rr�.��,©;,:raotor Reg Istratio n • r� •;.-�,.�, '�'�°I11+11 }• ) rype: "oor oration Cape Co•� Insulatlon Ino istratlon� p 18 Reard� ' rr1 ;.� I:.; ; 10$097 �1' Cirole ,�;;,+.x a',,! ';rc w xpiratlo ' 12/14/2018 So,.Yarmouth ;yy, I ,` MA ,02884 ',1 cal%�� ,•.:�.1�� u '��,�C�+',r ��, zoM'odn� `'••, Update Address a '-•••--'•--"—„......,,.,,,.,,,,.,,,, — nd return oard, Mark reason for ohange, w.. "'-'�}r,•.r..owwwr•,inn,ru.r.soon•.r r..uw....... ..uru, O�a�o,n�eo7eevorr�t/oyoO�G`�taorro/cwstto� �+��+r�,.,(,'l..tir'r•n�at;n!_r�l.Q,,.n;plo,�m�,nll:Cl.J..sa.,a#..^�r�f... OHIoe of COneumerAllairs &euelnees Requlatlon HOME IMPROVEMENT OONTRAOTOR TI.0.o.l Oorporatlon Rsgletrellon valld for Individual use only „ ,+ before the explratlon date, Jtl It ioun urn toi 1>�14� 4Mz AHalrs and al es Re ulallon I.,. •i,� r, f7 12/14/2018 16170 gHens Oaselul�l I Bry RcG80,Yarmouth,M Vndsrseoretary hoot sl a� r r Town of Barnstable 200 Main Street, Hyannis MA 02601 508-862-4038 Application for Building Permit =j1 E2 ZZE Application No: TB-17-2187 bate Recieved: 7/12/2017 Job Location: 25 PINE VALLEY ROAD,HYANNIS Permit For: Building-Insulation-Residential € Contractor's Name: Elwell H Perry,Jr. State Lic. No: CS-104088 �; w r Address: Acushnet, MA 02743 Applicant Phone: (508)992-5770 (Home)Owner's Name: Gray,Robert Phone: (617)947-5339 (Home)Owner's Address: 25 Pine Valley Rd., Hyannis„MA 02601 Work Description: 20 hrs.Air Sealing. Install 9" Cellulose to 320' open attic. Install 2" rigid ins.to 260' kneewall rafter. Install 6" Cellulose to 815' slope area. Install R-19 fiberglass and 2" rigid ins. to 40' kneewall slope. Install 2" rigid ins. to 175' kneewall area. Install 6" Cellulose to 185' open kneewall floor. Install 1 mushroom vent. Install insulated hose to bathroom fan. Total Value Of Work To Be Performed: $6,613.00 Structure Size: 0.00 0.00 0.00 Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. -I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: Elwell Perry 7/12/2017 (508)992-5770 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost: $6,613.00 Date Paid Amount Paid 1 Check#or CC# Pay Type Total Permit Fee: $85.00 7/12/2017 $85.00 X3 -X70 c-XXXX-J Credit Card ........................4419..._._. ............................. Total Permit Fee Paid: $85.00 ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Permit# Health Division-,` Date Issued ' o 3 Conservation Division �r Fee: ( 1 Tax Collector 1 � • - '"'ICn SYSTEM MUST BE Treasurer �e� �3�ZC��D _PF.STALLED IN COMPLIANT WITH TITLE 5 Planning Dept. Ie1 2O '4VsR!0haENTAL CODE ADD Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address Village Owner Address Telephone � � �a�� 2ge Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing 11L proposed Total new Valuation, 101 AD- Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family l Two Family Q. M ulti Family(#units) Age of Existing Structured:A Historic House: ❑Yes On Old King's Highway: ❑Yes ❑ No Basement Type: Ufull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) &J-6 Basement Unfinished Area(sq.ft) Number of Baths: Full: existing 9/ new Half: existing new Number of Bedrooms: existing 7 new Total Room Count(not including baths): existing '7 new First Floor Room Count Heat Type and Fuel: ❑Gas ail ❑ Electric ❑Other h- Central Air: ❑Yes Flo Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage:❑Zisting ting ❑new size ool: ❑existing ❑new size Barn: ❑existing ❑new size Attached garage: ❑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 BUILDER INFORMATION ~ (Name �.% Telephone Number ,tAddress License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO IGNATU DATE L[I i2lo- . FOR OFFICIAL USE ONLY - PERMIT NO. , DATE ISS1nD r MAP/PARCEL NO., + ADDRESS "° VILLAGE OWNER t DATE OF INSPECTION:4q FOUNDATION i FRAME INSULATION - FIREPLACE - T z 3 ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL 1 GAS: 'ROUGH ^► : FINAL' - FINAL BUILDING , DATE CLOSED OUT "= :. A4 ID 1 ASSOCIATION PLAN NO. • . ° k t ne c.ommonwealut of xassachusa= Depanment of Industrial Accidents -" = O�caall�nstl��s 600 Washington Street r Boston,Mass. 02111 .Workers' Cumnensation Insurance Affidmit asarst nm&ii /EM location- " ` LA ciri hone d I am zh=e==P _ all warn myself ❑ I am a sole aromiaor and have no ono wo�ae is aaP caaacitr ❑ I am as empiover providing wad' .. far mY egvees tin this 'ob. . ..........::Y;}:�...:. .'..:... .. ......:.v.:::;:•:�.i'.:'• :.••.:Jh..:.r .ai X::i.,M}v •.;:::.v. .M na,, ...:N.v;.. :••vv<{Mv:..:.V:}}fir}Y::i},;.,v1a;i:{.,}..:i:i.v...>:{:::�$::%!i•::;}y:'.:y�i:�:C':....... ...::: ......................�::;:....,...,. ...,... :..ti[7y,{{. .v{ti4:i.:v.;......::.WaXnn v.v::...:}....rv:::.::v:r}i-.....: - .......... x W..•.•:::.v:.v"ihh2w..... , .v:.... .. :.:.:..:. .....::':.i?:i:;Jn::v:..... .:?... :...v;nk.�.�\:.. ..... ....:. h .........v ... :�:tl.~�Lti.L•'�„}`.4::}:i�`.'::::.:::.::.::�.. 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" :Gi{n;.w:::n::v:r:x- v. .. ...........v::cow......»v..,Y??i:•i:•• n.kv.{»::::+»:: •nwrww:<Za3` .::::v::.:::.:i:�:T.�i:::::: ............. .... $.,.}..,n»i. ......... r}70CJJOiA'•±..:..,..�tAanvw,.„• ... M.::�:;«2: ..::.�.�.:�:.,;,..�...::.�?:•:.:::::.?.....w.,^»..:.:.ems. ... ii '�:b�c«,��x.<w<:;�:�n;;o*spa;�<�;s:;>::�.;w;��; Failsar to seeps cot erap as regmnd,todes Seedoa2SA of MQ.1S2 tamleed to t htftopa�taaotaimmd peadtlss of a�e aP to SL'�.� one!ean'imprnon= s"wed as dvfi penaittss is the form of a STOP NOBS GZ=mada fiM OMCOM a day apt=um. I=da m= Copt of this stassmaes=27 be forwarded to the Ocoee otIaresdpdoas of Oo DUfareovasp vafaodam. I do ncrbv cvtrrfy trrsdv,ht patr:s a pataltics fP07ury that dw=ferrntat=providtd about is tarp and=rtrt Dae 1=n -� r / Phone o tarinl use only do not write is this arm to be completed by a tt or town oIDdal dt►or town: pe�dt/lleeaselt (]ftadia=Depfr=d LJIltessm;Boasts J chc&if lmmediau response is required ❑Sdec= tt's Old _ (:317.uhDepssr=cnt comet person: phone ❑pihtr� 5 : e 1 IMM 1 • _ i _ \ 1 \ r \ 1 i . • • I • • � • \ j • 1 • • • • as Cut wMmmun j %' - Tablal.LZ2b(co�faaad) h=uiptive?=icag=fordas and Twe-Fsmi*Rmid='W Baildla $woad with FoscI Faro MAXIMUM 1 MINIMUM . M=vg QL>zag Ccin will Roar $Lb Arm'(K) U.vailwi R vsioe� 1G ghzl RrvaluJ wall Pc==C r P:use R.vaius� Rwzia =1 to d" Deate Dave Q 121.12 i M40 I 3E 13 19 10 I 6 1 NM=zi R 12% I am I 30 19 19 —(—to 1 6 I xarmai s 1r.% 1 asp I 3= t3 19 to I 6 I is ARM T 13%A I 035 n 13 ZS WA ( WA ( Nam U IP'A I U6 n 1 19 I 19 10 I 6 I Nmmsl v Isi. I aA4 I 31 13 25 WA I WA 1 tSARM w 30 19 19 10 I 6 1 IS ARM ' - x 13% 1 a3z I 31 13 2S 1 WA I WA 1 Nonaal Y IEV/. ( 0A2 n 19 2S WA I WA I Normal Z 18% 1 042 1 n 13 19 10 ) 6 1 90 AnM AA Ir/. 1 Q,Sp ( 30 19 19 10 I 6 1 90 AF M 1. ADDRESS OF PROPERTY: ,� 2. SQUARE FOOTAGE OF ALL E:CIE DR WALLS: 3. SQUARE F OOTAGE OF ALL GLAZING- 4. %GLAZING AREA(#3 DIVIDED BY#2): S. SELECT PACKAGE(Q—AA-see dram above): NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIRE:ti1ENTS ARE AVAILABLE. ASK US FOR THIS INFORMATION. BUILDING INSPEr-70R APPROVAL: YES: NO: i 780 CMR Appendix J Footnotes to Table JS 11b: ' Glazing area is the ratio of the area of the glazing assemblies (including sliding Blass doors, skylights. and basement windows if located in walls that enclose conditioned space, but excluding opaque doors) to the gross wall area, expressed as a percentage. Up to I%of the total glaring area may be excluded from the U-value requirement. For example,3 ftz of decorative glass may be excluded from a building design with 300 ft of glazing area. 2 After January 1, 1999, glazing U-values must be tested and documented by the manufacturer in accordance with the National Fenestration Rating Council (NFRC) test procedure, or taken from Table J1.5.3a. U-values are for whole units: center-of-glass U-values cannot be used ' The ceiling R-values do not assume a raised or oversized.truss construction. If the insulation achieves the full insulation thickness over the exterior walls without compression, R-30 insulation may be substituted for R-38 insulation and R-33 insulation may be substituted for R-49 insulation. Ceiling R-values represent the sum of cavity insulation plus insulating sheathing (if used). For ventilated ceilings, insulating sheathing must be placed between the conditioned space and the ventilated portion of the rco£ •Wall R-values represent the sum of the wall cavity insulation plus insulating sheathing (if used). Do not include exterior siding, structural sheathing,and interior drywall.For example,an R 19 requirement could be met EITHER by R 19 cavity insulation OR R 13 cavity insulation plus R-6 insulating sheathing. Wall requirements apply to wood-flame or mass(concrete,masonry,log)wall moons, but do not apply to metal-frame construction. R 'The floor requirements apply to floors over tmconditioned spaces (such as unconditioned crawlspaces, basements, or garages).floors over outside air must meet the cc tg requirements. The entire opaque portion of any individual basement wall with an average depth less than 50% below grade must mee: the same R-value requirement as above-grade walls. Windows and sliding glass doors of conditioned basements must be included with the other glazing. Basement doors must meet the door U-value requirement described in Note b. :,... 'The R-value requirements are for unheated slabs.Add an additional R 2 for heated slabs. ' If the building utilizes electric resistance heating use compliance approach 3, 4, or S. If you plan to install more than one piece of heating equipment or more than one piece of cooling equipment, the equipment with the lowest efficiency must meet or exceed the efficiency required by the selected package. 'For Heating Degree Day requirements of the closest city or town see Table J5.2-la NOTES: a) Glazing areas and U-values are maximum acceptable levels. Insulation R-values are minimum acceptable levels. R-value requirements are for insulation only and do not include structural components. b) Opaque doors in the building envelope must have a U-value no greater than 0.35. Door U-values must be tested and documented by the manufacturer in accordance with the NFRC test procedure or taken from the door U-value in Table JI.53b. If a door contains glass and an aggregate U-value rating for that door is not available, include the - glass area of the door with your windows and use the opaque door U-value to determine compliance of the door. One door may be excluded from this requirement 0-c,may have a U-value greater than 0.35). c) If a ceiling, wall, floor, basement wall,slab-edge, or Crawl space wall component includes two or more areas with difffemnt insulation levels, the component complies if the area-weighted average R-value is greater than or equal to the R-value requirement for that component. Glazing or door components comply if the area-weighted average U- value of all windows or doors is less than or equal to the U-value requirement(035 for doors). f EST/MA TEO PROJECT COST WORKSI-HEET Value SPACE t= LIVING s feet X SI 151sq. foo (high end construction) (above average construction) s feet X$961sq. foot= (average construction) quare feet X 5571sq. foot= GARAGE (UN FINISHED) square feet X'$251sq. foot= square feet X S201sq. foot= PORCH quare feet X S151sq. foot= DECK s , feet X S??/sq• foot= OTHER Total Estimated Project Value i The Town of Barnstable �. ""9 Regulatory Services O • E�a� Regulatory Thomas F. Geiler,Director Building Division Elbert Ulshoeffer, Building Commissioner 367 Main Street.Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6''0 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction.alterations.renovation.repair.modernization.conversion. improvement.removal,demolition.or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors.with certain exceptions.along with other requirements. o� XA�lr� tType of Work: Tel O Estimated Cost Address of Work: A v C Owner's Name: Date of AppIication:�Z/S I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law []Job Under$1.000 wilding not owner-occupied 1vowner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME 52ROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby app y for a permit as the agent of the owner. 6 Date Contractor Name Registration No. Date wner's Name q:fb=s:Affidav "Uaivsrnat The Town of Barnstable .>r Regulatory Services Thomas F. Geller, Director Building Division Elbert Ulshoeffer, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: . 508-790-6=:0 HOMEOWNER LICENSE EXENIPTION Please Print DATE: 10B LOCATION: tf number street village "HOMEOWNER": Z, :._/ �,11� — I • name home hone# P work phone# • CURRENT MAILING ADDRESS city/town state rip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said proc ures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35.000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S E710vMFnON The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors.Section 2.15) This 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 pan of the permit . application.that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:FORMS:EXEMM N t. �pFIHE rp Town of Barnstable Perms# p Expires 6 and s from issue date ♦ r Regulatory Services Fee 6 �< s " ;�': Thomas F. Geiler,Director �pTFD►iM't A Building Division 110�� C�411 1 °�`dz'�I�', Perry,CBO, Building Commissioner OP ��Q 200 Main Street,Hyannis,MA 02601 '9RjV www.town.bamstable.ma.us Office: 508-862-4038 `STq�I,� Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY l Q Not Valid without Red X-Press Imprint Map/parcel Number `t U Property Address Residential Value of Work �� Minimum fee of$25.00 for work under$6000.00 Owner's Name&Addres A. 1t.4, Contractor's Name' L Telephone Number Home Improvement Contractor License#(if applicable) 7S � Construction Supervisor's License#(if applicable) '.S" ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ lam the Homeowner I have Worker's Compensation Insurance Insurance Company Name X-L-' Workman's Comp.Policy G, 062 0 Z �3 t7 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to Re-roof(not stripping. Going over existing layers of roof) ❑-Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is re ired. SIGNATURE: Q:\WPFILES\FORMS\bui d' g permit forms\EXPRE doc Revised 090809 r �SHETpf, Town of Barnstable Regulatory Services 9 snxxnsi a MAS& g+ Thomas F. Geiler,Director en 39.E� Building Division Tom Perry,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 as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) -Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:O W N ERP E RM I S S I ON Town of Barnstable o Regulatory Services " Thomas F. Geiler,Director sARNST"LE. MASS. i639. a��� Building Division lfn Mai Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us . Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION rr Please Print / DATE: ,j ,.9 / r JOB LOCATION: vi number stre . ' lla e� s7,�}g "HOMEOWNER": name home phone#F work phone CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extende to include own -occupied dwellings of six units or less and to allow homeowners to engage an individual for hire wh does not ossess a license,provided that the owner acts as supervisor. DEFINITION OF OMEOWNER Person(s)who owns a parcel of land on which he/she resides intends to reside,on which there is,or is intended to be, a one or two-family dwelling,attached or detached structure accessory to such use and/or farm structures. A person who constructs more than one home in a two-year peridd s all not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a for accep ble to the Building Official,that he/she shall be responsible for all such work performed under the building permit. ( ection 109.1.1) The undersigned"homeowner"assumes responsibility or compliance th the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that'he/she nderstands the Town of •arnstable Building Department minimum inspection procedures and requirements and that he/she will comply ith said procedures and requirements. S' nature of Homeowner Approval of Building Official Note: Three-family dwellings ontaining 35,000 cubic feet or larger will be require o comply with the State Building Code Section 127.0 Co , truction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeownerr shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results.in serious problems,particularly when the homeowner hires unlicensed persons. 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/li�er responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\bomeexempLDOC The Commonwealth of Massachusetts Department of Industrial Accidents ' Office of Investigations f_ 600 Washington Street Boston, MA 02111 y www.niass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ib --�� Please Print Leal Name (Business/Organization/Individual):r CE6 yn 1,-, Address: `,fig. C/fC�t� / — - � ' A City/ tate/Zip: / ,let i Phone #: a' Are ou an employer? Check 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 ► workin for me in an capacity. employees and have workers' . g 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.❑ I am a homeowner doing all work officers have exercised their l l.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.�g Roof repairs insurance required.] t c. 152, §1(4),and we have no 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. tContractors 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 any employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Z4-/e, 6 db .� � Ul -��e jrExpiration Date: ��� A) . . Job Site Address: � �C \ City/State/dip: ` , Attach a copy of the workers' compensation policy declaration page(showing the policy num er and expiratie *ky 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 cert' u, der theaparand penalties of perjury that the information provided above is true and correct. Signature: Date: /"©.` Phone# Official use only. Do not write in this area, to be completed by city or town offieiaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone#: t 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 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 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, arked by the city or town maybe 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 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 V Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE - Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia 1lassachusetts- Department of Public Safet} - Board of Buildin!y Regulations anti Standards Construction Supervisor License R License: CS 52554 F Restricted to: 00 JOHN A WEGMAN 15 GREAT It RD r k E SANDWICH, MA 02537 Expiration: 7/15Q011 ("o nmivi one r Tr#: 17972 II — _— . .HOME IMPROVEMENT CONTRA License or registration valid for individul use only �r©R Registration: 144544 before the expiration date. If found return to: EViration Board of Buddin 10/13/2010 T One Ashburton Place Rm 1301 and Standards O 275104 TYPe lndiyidual Boston Ma.02108 49MA. GMA01' of valid without i ature--- -"- --- r of - • F. G. T_ I ` ip • F h l r e . _ u i DATE(MMIDDIYYYY) Aft - CERTIFICATE OF LIABILITY INSURANCE 7/8�2oo9 ISSUED AS A MATTER OF INFORMATION : -7 472-3000 x606, Fax(617)472-7248 THIS CERTIFICATE IS ONLY AND CONFERS 'NO RIGHTS UPON THE CERTIFICATE j•platner, Hurley Insurance Agency, LLC HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR `klin St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. MA 02169 `th Mendoza INSURERS AFFORDING COVERAGE NAIC# 11RED INSURER A:Em to er r s Fire Ins CO 7ohn A Wegman INSURER B:AIM Mutual Insurance .5 Great Island Road INsuRERC: INSURER D: 3andwich MA 02537 INSURERE: OVERAGES 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. POLICY EFFECTIVE POLICY EXPIRATION ,ISR ADUL LIMITS TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY DATE MMIDD/YY 06/01/2009 06/01/2010 EACH OCCURRENCE $ 1,000,000 GENERAL LIABILITY FBIU78201 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 300,000 MED EXP An one erson $ 5•,000 A CLAIMS MADE �OCCUR - - PERSONAL&ADV INJURY $ 1,000,0001 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,0001 PRO- POLICY MJECT FILOC AUTOMOBILE LIABILITY. COMBINED SINGLE LIMIT $ . (Ea accident) ANY-ALIT :._:... - - BODILY INJURY .ALL OWNED_AUTOS $ (Per person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ ,(Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EA H RR N E $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE Is r OMPENSATION AND VWC600738601200901/29/2009 01/29/2010 WRY LIIMIT OER'LIABILITY SOLE PROPRIETOR EXCLUDED E.L.EACH ACCIDENT $ 100,000 IETORIPARTNER/EXECUTIVE. 100 000 EMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE$be under E.L.DISEASE-POLICY LIMIT $ 500,000 OVISIONS below OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS JOB: 67,OAK STREET, COTUIT THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR JOHN WEGMAN CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE,DESCRIBED POLICIE&.BE CANCELLED BEFORE THE TOWN OF BARNSTABLE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 200 MAIN STREET 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT HYANNIS, MA 02 601 FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE �� Michael Prendergast/JM ©ACORD CORPORATION 1988 .ACORD 25(2001/08) Page 1 of 2 INS025(0108).08a