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HomeMy WebLinkAbout0460 SEA STREET Z-/(Oo 3.4 4 i2q()...................... Ap °cation num er Fe ......... .SY... ................................... � �o puss, F ��/(a O Building Inspectors Initials. **""....°."*'* *"*', T FB 2 FpT Date Issued........... ' Bq,Q Map/Parcel...: .... �. TOWN BARNSTABLE "y' EXPEDITED PERMIT APPLICATION: O'%AJNED ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION FEB 16 2020 PROPERTY INFORMATION Address of Project: Cf60 J - .5le-'UJ ' f. NUMBER STREET VILLAGE Owner's Name:/ 1 c C Phone Number Email Address: Cell Phone Number Project cost $ Check one Cesid7ential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for aob *,Iding p rmit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK n Siding U Windows (no ader change)# Ed Doors (no header change)# 2- DInsulation/Weatherization ED Roof(not applying more than I layer of shingles) Commercial Doors require an inspector's review Construction Debris will be going to hl-K l/y1.cO�t.c� 0 Certificate of occupancy with no construction(complete below) Occupant/family relationship or business name or Existing amnesty apartment(attach a copy of recorded comprehensive permit) CONTRACTOR'S INFORMATION Contractor's name f y�Ptt"t L 0 C/) Home Improvement Contractors Registration(if applicable)# l�Z (attach copy) Construction Supervisor's License# �J (attach copy) Email of Contractor Phone number. ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR/F THE SUBJECT PROPERTY 1S IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. 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 t,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 Yes No , if 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: Telephone Number Cell or Work number s I understand my responsibilities under 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 the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance. 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): Address: �u- Il �/ / hone#: F� 4 City/State/Zip L ARiam on an employer?Check the appropriate box: Type of project(required): 1. a employer with 4. ❑ I am a general contractor and I 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 g, []Demolition working for me in any capacity. employees and have workers 9. ❑Building addition [No workers' comp.insurance comp..insurance.t required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'-comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers'- 13.[1 Other comp. insurance required.] *Any applicant that checks box#I 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: 6S�X&tlaL4^ Policy#or Self-ins.Lic.#: QA/�` .S� E66 01 D Expiration Date: /State/Zi Job Site Address: t1k �9,7 Ci tY P: 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 ins ance coverage verification. I do hereby certify u r the ins and penalties of perjury that the information provided above is true and correct. Signature: - Date: Z 2 Phone#: Ll'-�6Lt- 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#: J Y 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 legibl .'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.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 , Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia AC R® CERTIFICATE OF LIABILITY DATE(MM/DD/YYYY) r,,,,� INSURANCE 02/21/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Joanne Ainswoth BRYDEN &SULLIVAN INSURANCE AGENCY INC PHONE o xt: (508)775 6060 ac No: ADDRESS: jainsworth@brydenandsullivan.com 88 FALMOUTH RD INSURERS AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INSURER A: LM INS CORP 33600 INSURED INSURER B: BEL ISLANDS HOME IMPROVEMENT LLC INSURERC: INSURER D: 204 CINDERELLA TERRACE INSURER E MARSTONS MILLS MA 02648 INSURERF: COVERAGES CERTIFICATE NUMBER: 507911 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY) IMMIDD/YYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE $ CLAIMS-MADE1-1 OCCUR DAMAGE 0 RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ MICITHER: L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ POLICY PR ❑JECT LOC PRODUCTS-COMP/OPAGG $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT . $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIREDAUTOS AUTO.OS NED PROPERTYDAMAGE $ Per accident UMBRELLA LIAR OR EACH OCCURRENCE $ EXCESS LIAR HCcLAc,.uS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION _ AND EMPLOYERS'LIABILITY Y/N X STATUTE OTH- ER A OFFICER/MEMBERANYPRO EXCLUDED?ECUTIVE WA WA WA WC531 S61566701 0 02/11/2020 02/11/2021 ( E.L.DISEASE EACH ACCIDENT $ 500,000 Mandatory in NH) EASE-EA EMPLOYEE $ 500,000 If yes,describe under i DESCRIPTION OF OPERATIONS below I I E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govAwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Andre;YarmcZlQvich ACCORDANCE WITH THE POLICY PROVISIONS. 204 Cinderella Terrace AUTHORIZED REPRESENTATIVE Marstons Mills MA 02648 Daniel C�,v y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. �`� �0�+�nirreo�izuse�c�o�C�acfivap� - 'Office of Consumer Affans&Buamess Regulation ' HOME=IMPROVEMENTCONTRACTOR TY Indi�ntival _ AND,REI Y.,A DB/A BEL ISLA, I��OVEMENT I ANDREI`YARMA t 204CINDERELLA�`` MARSTONS MILLS,MA 02648 Undersecretary eco k: ' mmonwealth of Massachusetts Division of Professional Iaicensure �,.. Board of Building.Regulations and Standards ,. Cons so CS-11.1305 if 'pires: 06/0V2021 4%NDRE YARAgALOV(CH r r 204 CINDER O TER ' MARSTONS MI S MA s 1�{,Il Commissioner i Estiniate DEL ISLANDS Al Home improvement 12/9/2019 1108 Bel Islands Home Improvement 204 Cinderella Terracee ;; g„ , Marstons Ma 02648 Mills, > Michael Loux Belislandsrooiingandsiding.eom Unit Aamaeet y`�o 508-280-1794 508-364-6909 Terms Project x r Dq!crtptloll �.}j�Tl s ` x R818 1 �0181 ' «. `s "a ,<',r, �. ...« r x . �. Bel Islands Home Improvement-ROOFING PROPOSAL- 6,400.00 6,406.00 F ,labor/materials( architect shingles)right lower section only front and back) BEL Islands Home Improvement hereby propose to perform the following services in a neat professional manner in accordance with manufacturers specifications and local building code Strip existing roof shingles(1 layer of shingles) and remove all debris.Any more layers of roofing needed to be stripped-it will be additional charge. and install: New Shingles:Certainteed Architectural Landmark shingles with lifetime warranty, 10 years Algae Resistant, 110 MPH Wind Warranty,240 Lbs weight/square-(Every shingle will be nailed by the code with 6 nails-storm nailing system) install: 8"Aluminum.Drip Edge install: Certainteed ice and water shield to eves,valleys,rakes,and skylights and low pitch areas ( 18"on rakes and skylights and 3 ft on eves and valleys to prevent ice dams) install Certainteed Swift Start-with self-adhering asphalt starter course on all eves and rake edges install Aluminum&Neoprene Soil Pipe Flashing Install : Synthetic underlayment paper(Rhino) install Pre-cut Certainteed Hip&Ridge shingles and new ridge vent Total i Pagel } - 5$1ma1' BELISLANDS Cate , � Esttti�ate# � ! Home Il�r�l p rove l~e n t 1�Sri©l y 1108 Bel Islands Home Improvement. 204 Cinderella Terrace ierne lddress y, : .: Marstons Mills, Ma ,02648 M chael;Loux 460 Sea street Belisland'sroori"ngands ding.com Unit A;ma 508-280-17.94 508-364-6909 t '4 r'v i.. ?s;,1: Terms Proleet 17escripttot� City Rate Total Bel Islands Irnpxovetnent-ROOFING PROPOSAL,- 6,400.00 6,400.00 . ,labor/materials( architect shingles)right lower seetion only:( front and back:) BEL Islands Home Improvement propose.to " perform the l'ollowingservices in a neat professional manner.in accordance with manufacturers specifications and local building aide t Strip existing roof shingles 0 layer of`shin,les) and remove all debris.Any more layers of roofing needed to be stripped-it will be additional charge: and install. New:Shingles:Certainteed!lrcbitectural Landmark" shingles ,J with lifetime warranty, 10 years Algae.Resistant,1,10 MPH Wind Warranty,240 Lbs wei.ghUsquare-(Every shingle will be. nailed by the code with b nails-storm nailing system} install; - $"Aluminum Drip Edge.: install Certainteed ice and water shield'to Eves;valleys,rakes,and skylights and low patch areas ( 18 onrakes and skylights and 3 fi on eves and valleys to prevent ice dams} install Certa nteed Swift.Start with self-adhering asphalt starter course; OD all eves and rake edges install Alumimirn&Neoprene Soil Pike.Flashing Install:: - Synthetic underlayrnent.paper(Rhino) install Pre-cut C:ei-tainteed Hip&Ridge shingles and new ridge vent Total Page 1 r sfimate BELISLANDS 12/9,2019 1108 Home improvement Bel Islands Rome Improvement 204 Cinderella Terrace Nama't�taarass gal r t Marstons Mills, Ma ,02648 Michael Loux. 460 Sea street Beii.standsroofiiigAndsidin.g.com Unit A,ma 508-280-1794 508-364-6909 " - Terms Project _ iDeSCrll?tlpll #o ! z }a#at tr .Extra charge to upgrade shinglek to Landrurk Pro is S 950 POSSIBLE EXTRA: Any rotted plynvood,trim boards,lead flashing of other carpentry needing replacement will be done and charged for as an extra;at rate of$b0.00 per hour,plus.15%mark up materials Bel.Islands Home Improvement Guarantees the labor rot-Lifetime of roof and against Blow=offs for 15 Years. Bel"Islands Home Improvement:Carries Worksman's Compensation and:Public Liability.Insurance on the above work, , certificate available upon request New.Azek trine installation(:Labor!materials)-roof linetrim and 4,800.00 4,800..00 front comerboards 1.Replace old rakeboards(2 members)with Azek trim 2.Replace old fascia boards,soffits and freezeboards,bed molding with New Azek trim .3,Replace front cornerboards with Azek.trim New vinel Siding installation(Lahorlmatcrials) Cedar. K,500.0t1 8,500.00 impression. 1.Strip old sidewall shingles 2.Supply and install proper utiderlayment. ; 3.Supply and install new vine)siding(Shakes look) Total Page 2 EsUmate BEL ISLANDS Home Improvement 12/9t2ot9 t10� Bel Islands .Horne Improvement 204 Cinderella Terrace barn > ddress � Marstons WIN,, Ma ,026.48 MichaeFLoux 460'Sea.street Be.lislandsrooftjrgandsiding.com t niiA,ma. .508-280-1794 t. 508-364-6909 Terms. Project a `7 New windows installation i labor/materials) 9 900m 9.900.90 1.Remove old exterior,interior trim and otd window-, 2 Supply and install new construction. Harvey windows-double bung(Classic DFl) 3.Supply and install new interior and exterior(Azek)trim Extra charge to upgrade shingles to Anderson 400 Series will be $3900 New front exterior doors installation(laborhriaterials)-2 units 2 900.00 I,S00.Q0 1.Remove old door' 2.Supply and install new exterior doors-same style 3.Supply and install new exxterior(azck.)trim and new interior trim Gutters installation 700M ?00.00 dumpster 100.00 700,0 permit 500:00'' 500.00. Total SD, 00.00 Page 3 t ` TOWN OF BARNSTABLE BUILDINGPERMIT APPLICATION p Ilk Ma 3 r-Parcel oA® ,,�.r;Tr�T;��FT��, q�FmR Permit# - Health Division , EN r i�1�=i. rf�i�.� ro Date-Issued • � Conservation Division a 60 : Fee �6 Q (96 Tax Collector Treasurer b= Planning Dept. Pi Date Definitive Plan Approved by Planning Board d Historic OKH Preservation/Hyannis 0 Project Street Address Village 1�7�1/i9il�iiY//P 464,� �� • d Owner = a Cow Address ' Telephone ' -4 Permit Request Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new Estimated Project Cost �Da �'''Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size' Grandfathered: ❑:Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family O 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 O Other ' t 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 0 Oil . ❑ Electric ❑Other Central Air: ❑Yes ❑No` Fireplaces: Existing a New,' Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:0 existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing U new size Shed:❑existing O new .size Other. ' Zoning Board of AA peals Authorization U Appeal# Recorded❑ Commercial .•�Yes ❑No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name �/VQ2 /_= lJ/�/�'L- Telephone Number ?6/,2 2 le 2 Address 3 9 3, License# (f 6 2(�-3 �l ? /VMS 11�4 G,L AM• a 2 6"'36 Home Improvement Contractor# %4�S✓2 Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM"THIS PROJECT WILL BE TAKEN TO 11 RglvnT/f 4?� SIGNATURE DATE ����/ Zdv d FOR OFFICIAL USE ONLY - PERMIT NO. DATE ISSUED . - 1 MAP/+PARCEL NO. ADDRESS X VILLAGE OWNER j • if , 1 i ~. Z ••' ` ' '. . •. t t « _ 1 r y, .. « ,.; � DATE OF INSPECTION: ,* # S ; •' } FOUNDATION - S. y FRAME. INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: 'ROUGH `FINAL 43 FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. os on, ass. Ozm Workers' Com ensation Insurance davit name: ` r location: city hone# ❑ I am a homeowner performing all work myscl£ e ❑ I am a sole Pluprictoz and have no one wo in any P.�Pam.. ..5...•••• ' com�easation for my employees worldag on this job. I am an employer den workers �...:.. cam anv name.. ;•,.:.:,.:?.:.}:<.:<.;:;.;:.;:.::::. .::.:::::::..::::::;.:...:;:.:?.:-:;::::.::. :::.;:.;;'..::.:.::.:.::::::.::::::.:.: .{.: :.:::.:;>}::......... :.,. .. .. ................. .. . .::.: .: . addss • ' .-:.;::::::.:�. 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I understand that a copy of this statement may be forwarded to the Omce of Invesstigations of the DIA for coverage vaiOCation. 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DUPREY 24 Fraser Ct/PO Box 373 7!� stable MA 02630 ADMINISTRATOR I ' POLICY NO. ISSUE DATE FILE DATE - POLICY FORM NO. QuUJJ� INSURED NAME.. ti)i, �_ n ;!._ :. r_( �T �' `� COVERAGE BASIC - '. ,. ADDRESS .J{. MTN LT.INC.f ANNUAL ELIM.DAYS C ' �K' PREMIUM s I DASIC MTHLY.IND.PERIOD j CLASSIFICAT IONt, BIRTHDATE SICK T CODE N0.ACCID GENERAL AGENT EXTENDED SICK. IND. INCL. PARTIAL ACC.ONLY $ WRITING AGENT(S) _ PARTIAL ACC.9 SICKNESS $ HOSP./NURSE/SAN. PER M0. $ IST DAY HOSP. IND. $ $ MOD PREMIUMt— TOTAL ANNUAL I$ 1:i iiiiL I Y L 4SiJ (!ihCt t:I(�� PREMIUM MAP 306 306 — , MAP 306 244 \ 17 #0 5 #28 X 5 -�- - - - MAP 306 , +� 245 #24 306 X 91 - _ _ _ - - - - MAP306 ' - 206 x MAP 306 " r _ MAP 306 # 14 190 ' - - - - #470MA ' P 90 1 ��e -, r, - � #22 e ., MAPMAP 3068 MAP 306 k 2 1 207 N 88 F C3 Fp #4 B k X. k 6 1:ldgnlconsenration.dgn Apr.21,2000 15:29:01 i } ,, :� �_ ,, #.. � f T, •,���q.,, _ --•_.___ tI` -ice_ , � _ .� _ { �j - � .�; ��"."_ j--• ,., f _ _'�.�� .� fit; •,r.,J,±C- t ! r ` t 1 1. R.r• � 3} \�,,[ i ��.3 3 s t