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Home My WebLink About121 Camp St #126 Building PermitsOF rq APPLICATION FOR PERMIT TO DO PLUMBING TOWN OF YARMOUTH (OFFICE USE ONLY) YATTACNEESSE By qb.9 0 Fee: $ ! J PERMIT NO. —D6— OJT Date 20�� /�1j� BuildingOwner's u :Location _ Name L 1 $ n05 Type of Occupancy New Renovation ❑ Replacement ❑ BUILDING DEP . ubmitted Yes ❑ No ❑ AP � 1�s Z Zf �/ co N M OY Z F Z >L; W W W Y J fA Q U Z 45 y Cr cc O Cl) F' W f/f FX U¢ IQ- y a cn Z Z Z \ a cc °C a w? a cn Z¢ a 2 - LL \` ` w O M w cWn ft) CC J C ' LL CC Q F a Q = N fl�l Q Q D Q OJ OJ Q FE CC ¢ Q O Q F Y m in 0 C] J = F- Cn lL a 7 0 Q ¢ m 0 J SUB-BSMT. BASEMENT 1ST FLOORilzL 2ND FLOOR 3RD FLOOR (PRINT OR TYPE) Installing Coml Check One: ❑ Corp. Address / ❑ Part ip it /Company Business Telephone ,� me of Licensed Plumbe S INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yes d No ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Onl�nly�� // Permit No. E-69 — d (6s Occupancy and Fee Checked [Rev.11/99] eaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 PRINTININKOR TYPEALL INFORMATION) Date: 07/18/2005 City or Town of: YARMOUTH, MA To the Inspector of Wires: this application the undersigned gives notice of his or her intention to perform the electrical work described below. (Street & Number) 121 CAMP ST., UNIT 126 Qwner or Tenant GATEWOOD HOMES, INC. Telephone No. 508 778 9669 Owner's Address 1600 Falmouth Road #25, Centerville, MA 02632 Is this permit in conjunction with a building permit? Yes X No ❑ (Check Appropriate Boa) Purpose of Building RESIDENTIAL Utility Authorization No. 1462032 Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service 100 Amps 120/240 Volts Overhead ❑ Undgrd X No. of Meters 1 Number of Feeders and Ampacity 2/100 Location and Nature of Proposed Electrical Work: WIRE HOUSE f'mmnl¢tlnn nfthe Allnwino mh1¢ mm hn wnivad by tho lncnartnn of Mroc - No. of Recessed Fixtures No. of Ceil: Susp. (Paddle) Fans No. o Total Transformers KVA No. of Lighting Outlets 8 No. of Hot Tubs Generators �rA No. of Lighting Fixtures 8 Swimming Pool Above ❑ In- ❑ md. rnd. o. o mergency Lighting BatteryUnits No. of Receptacle Outlets 30 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches 10 No. of Gas Burners No. o Detection and Initiating Devices No. of Ranges 1 No. of Air Cond. Tota Tons No. of Alerting Devices g No. of Waste Disposers Heat ump Totals: _umber.. Tons__. _.. _ _ No. o •Self -Contained 6 Detection/Alerting Devices No. of Dishwashers 1 Space/Area Heating KW Local ❑ n=t El Other Connection No. of Dryers 1 Heating Appliances KW Security Systems: No. of Devices or Equivalent o. a Water Heaters 1 KW 4.5 No. o o. o Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail ifdesired, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE X BOND ❑ OTHER ❑ (Specify:) 10/31/2005 (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the information on this application is true and complete FIRM NAME: PATTON ELECTRIC. INC. LIC. NO.: A 15542 Licensee: RICHARD PATTON Signature -'/(��(� �jhl LIC. NO.: (Ifapplicable, enter "exempt" in the license number line.) Bus. Tel. No.,• 508-539-0200 Address: PO BOX 1525, MASHPEE, MA 02649 Alt. Tel. No. ZZ ""�� Td�Y. �� Sll�y ts1�4t�4tiri a W, � (A@t@1@ly V4@li'i@ tAf3I�l4%t11e�At. I and tkte (�tk one ®rn�er otavet'f a t. � PEBMIT FED• S 12S.t'0 I Q0 v Z` APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All ...nr4 m t.r nerFnrmrri in arrnrrianrr with the Massachusetts Electrical Code. (MEC). 527 CMR 12.00 Is this permit in conj tion with a building permit? 0 Yes C3 No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts New Service --kSn Amps 175D / of s Number of Feeders and Ampacity Location and Nature of Proposed electrical Work:_ Overhead Undgrd 0 No. of Meters Overhead Undgrd 2 ' No. of Meters_ Comnletion of the followine table may be waived by the Inspector of Wires of Recessed Fixtures No. of Ceil.-Sus . Paddle Fans No. of Total Transformers KVA o. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Above n- SwimmingPool md. md. No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection an Initiating Devices No. of Ranges Total No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: um er — — Tons — — — — No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Municipal Local Connection Other No. of Dryers ry Heating Appliances KW 8 pp Security Systems: No. of Devices or Equilivalent No. of Water Heaters KW No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or uivalent Attach additional detail if desired, or as required ny the inspector of wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may be issued unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same t?,lbc permit issuing office. CHECK ONE: INSURANCE [/] BOND OTHERC] (Specify:) Estimated Work to S I certify, t L VNA ee: (If applic� (Expiration Date) icalWork: (When required by municipal policy.) b Inspec 'ons to be reques d in aqcorfan e with MEC Rule 10, and upon completion. and en ti perju at the i o o t ' application is true and complete. LIC. NO. Signature LIC. NO. in the OWNER'S INSURANCE WAIVER: I am aware I below, I hereby waive this requirement. I am the Owner/Agent Signature [Rev. 04/00] line.) Bus. Tel. No.: t..., Alt. Tel. No.: ensee does not have the liability insurance coverage normally required by law. By my signature e) owner ❑ owner's agent. Q Telephone r • Commonwealth of Massachusetts °UscO01y _ Permit No. ' Department of Fire Services Occupancy and Fee Chect�) BOARD OF FIRE PREVENTION REGULATIONS . 11/991 ve bland/ Ir APPLICATION FOR PERMIT TO PERFORM ELECTRICAL W& 40 nc All cvmkto be pedotmed in accordae with the Massachusetts Electrical Code (MEC), 527 CMR �o 0 (PLWEPRUvTLVE-KORTYPE AU NFORAM770A9 Date: 61 City or Town of: YARMOUYH To the Inspector of Wires:. By this application the undetsigaed gives notice of his or her intention to perform the electrical work described Location (Street & Number) M7T7, POND VMLAGE, 121 Camp St Bldg # /cR Owner or Tenant Gatewood Homes/ Jeff Sollows TelephoneNo.508-7789669 Owner's Address 1600 Falmouth Rd., Suite 25, Centerville, Ma. 0263.2 Is this permit in conjunction with a building permit? Yes X❑ No ❑ (Check Appropriate Box) Purpose of Building single family residence Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ Na of Meters Number of Feeders and Ampariiy Location and Nature of Proposed Electrical Work Fire Alarm System (low voltage control panel) with baCl= battery.'centrally monitored. rAmnleHnm nfrhe fnllnwinv rahle may he ivnivalm the 1.r..wra+r ArWi,ve Na of Recessed Fixtures No. of Cer7.-Sq sP• (Paddle) Fans o. of OW Transformers KVA Na of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures SwimmingPoo1 d e • d. megNo. WE BatteryUni s�cy g Na of Receptacle Outlets No. of Ott Burners FIRE.ALARMR No. of Zones —1- Na of Switches No. of Gas Burners o. of metection.an 7 Initiating Devices No. of Ranges Na of Air Cond. Tons No. of Alerting Devices of Waste Disposers IleNo. t p Totals: um er. ' ohs et o Self -Contained Detection/Alerting Devices 7 No. of Dishwashers Space(AreaHeating KW Local 0 Conniption ® al Other No. of Dryers .. Heating Appliances KW etarnty gstems: e. No. o twices orE ivalent No. of Water KW Heaters o. o o. of Signs Ballasts Data Wiring: No. of Devices or uivalent No. Hydromassage Bathtubs No. of Motors Total HP -" econ.Wunrn:atrcns i.-sab No. of Devices or E uivilent OTBER: Attach aaataonar darart r)aertreq or as regWrad byVICbUpecrorOfWtr= INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE (0BOND ❑ 0T1:11ER ❑ (Specify), (Expiration Date) Estimated value of Electrical Work $750.00 (When required by municipal policy.) Work to Start Inspections to be requested in accordance with MEC Rule 10, and upon completion. rcerafy, under the pains and penalties of perjury, that the information on this application is true and complete FIRM NAME: Baltic Security, Inc LIC. NO.: 1178C Licensee: Jonas R Bielkevicius Signaturee LIC. NO: 49 D (If,W icvbk, enter "erentpt"in the Rome nwnbe Bus. Tel. No.50 • 8-833-0996 Address:_ PO Box .1609 Sandwxc�l �a. 02563 Alt, Tel. Na• 508�71�33 7 0WNEWS INSURANCE WAIVER .I am aware that the Licensee does nothave the liability insurance coverage normally repaired by law. By my signature below, I hereby waive this requirement I am the (check one) ❑ owner ❑ owner's agent Owner/Agent Signature. Telephone No. PERMIT FEE: $ 40.00 LOT 127 ' � . 22g.13' 2"E 1 EXISTING rn ' S FOUNDATION 90 VOL EXISTING ' FOUNDATION 2 ' 4y h I CERTIFY THAT THE FOUNDATION IS LOCATED IN FLOOD PLAIN ZONE C AS SHOWN ON FLOOD INSURANCE RATE MAP COMMUNITY PANEL NO. 250015 0005D AND THAT FLOOD PLAIN ZONE C IS NOT A SPECIAL FLOOD HAZARD AREA. ,ems �. TE REGISTERED PROFESSIONAL LAND SURVEYOR NOTICE 2 Unless and until such time as the original (red) stamp of the responsible Professional Engineer, or Professional Land Surveyor appears on this plan: (A) no person or persons, including any municipal or other public officials, may rely upon the information contained herein; and (B) this plan remains the property of Holmes & McGrath. Inc. � 3 E LOT 139 EXISTING .• s?, FOUNDATION r MAY 2107nn, I CERTIFY THAT THE FOUNDATION IS LOCATED ON THE LOT AS SHOWN, AND THAT ITS LOCATION CONFORMS TO THE MINIMUM SETBACK REQUIREMENTS OF THE 40B SPECIAL PERMIT. J yo Zo•�J DATE AEGISTERED P OFE SIONAL LAND SURVEYOR GRAPHIC SCALE ( IN FEET ) 1 inch = 20 ft. f AS —BUILT PLAN holmes and mcgrath, inc. `}N Of ,A OF LOT 126 civil engineers and land surveyors aWCH EL�'`y PREPARED FOR 362 gifford street e• MILL POND VILLAGE s fJIcGRATH y IN falmouth, ma. 02540 90 Na289M YARMOUTH, MA JOB NO: 201197 DRAWN: LMC SCALE: 1 "=20' DATE: 5-20-05 DWG. NO.: A2513A CHECKED: OF r TOWN OF YARMOUTH Building Department BUILDING (508) 398-2231 eA61 - It 4611PERMIT NO 8.05.----- - P ISSUE DATE ; _ 3/10/2005 _ ; PROPOSED USE PERMIT APPLICANT Frank --C-a-pra -----------'`' JOB WEATHER CARD , - P - .'` PERMIT TO New Construction ' AT (LOCATION) 100121CAMP ST Unit 126 ' 'ZaTITG DISTRIC R-25 Bldg. Type: Residential SUBDIVISION MAP LOT BLOCK 1044.21A.C126 I +BUILDING IS TO BE: LOT SIZE CONST TYPE 5-B USE GROUP R-4 new construction: 2 baths, 3 bedrooms, 1 diningroom, 1 kitchen, 1 livingroom as per plans dated REMARKS 02/09/05 and BOA # 3546. AREA (SQ FT) EST COST-($ $148,896.00 , PERMIT FEE ($) $543.00 OWNER IVillages @ Camp Street., LLC B ILDING DEPT BY ADDRESS 1600 Falmouth Road # 25 Centerville I MA 102632 Certificate Issue Date y,�(,.0 3cog �?a v3 --CERTIFICATE_of OCCUPANCY;t Departmental Approval for Certificate of Occupancy and Compliance Inspector Date Permit Number Approved By Remarks CONTRACTOR LICENSE 012430 Capra, Frank 1600 Falmouth Road #25 CentervilleMA 02632 5087789669 r��4 MIMS- To be filled in by each division indicated hereon upon completion of its final inspection. i� 'golof r� TOWN OF YARMOUTH Building Department g lJ I L DI N G �t (508) 398-2231 ext.29.1 PERMIT NO ---- ::--4_ ' PERMIT ISSUE DATE ; _ 3/10/2005 _ : PROPOSED USE - - - - - - - - APPLICANT Frank - --Ca-pra ------------------- , --------------------- JOB WEATHER CARD PERMIT TO New Construction ' AT (LOCATION) ZONING DISTRIC R-25 Bldg. Type: Residential 100121CAMP ST Unit 126 SUBDIVISION MAP LOT BLOCK 1044.21A.C126 BUILDING IS TO BE: CONST TYPE 5-B USE GROUP R-4 LOT SIZE new construction: 2 baths, 3 bedrooms, 1 diningroom, 1 kitchen, 1 livingroom as per plans dated REMARKS 02/09/05 and BOA # 3546. AREA (SO FT) EST COST ($ $148,896.00 PERMIT FEE ($) $543.00 OWNER lVillages ® Camp Street., LLC BUILDING DEPT BY ADDRESS 11600 Falmouth Road # 25 Centerville I MA 102632 INSPECTION RECORD CONTRACTOR LICENSE 012430 Capra, Frank 1600 Falmouth Road #25 Centerville MA 02632 5087789669 FIELD COPY Date Note Progress - Corrections and Remarks Inspector OF TOWN OF YARMOUTH Building Department Town Hall Yarmouth, MA 02664 (5W) 39&2231 ext.261 BUILDING PERMIT TRANSMITTAL Temp Permit No.: T-05-387 Applicant Name: Frank Capra Applicant Phone: 5087789669 Building Location: 00121 CAMP ST Unit 126 Owner's Name: Villages Q Camp Street., LLC Owner's Addres 1600 Falmouth Road # 25 Centerville MA 02632 Owner's Telephone: (508) 778-9669 REVIEWED BY: (OFFICE USE ONLY Recorded By: Ic Permit Fee: $0.00 Deposit Rec: $0.00 Payment Type: Check ChkNo.: 0 Net Owed: $0.00 Application Date: 1/31/2005 Issue Date: Expiration Date Comments: Map/Lot: 044.21.1.0 new construction: 1. WATER DEPARTMENT: DATE: N/A: 2. ENGINEERING DEPARTMENT: DATE: N/A: 3. CONSERVATION: DATE: N/A: 4. HEALTH DEPARTMENT:60 .(/ DATE: �Z iv'057— N/A: 5. BUILDING DEPARTMENT DATE: N/A: 6. FIRE DEPARTMENT: DATE: N/A: PLEASE NOTE COMMENTS: RECEIPT OF COPY: SIGNATURE OF APPLICANT: �„ p,{ /'` (�.t DATE: a Q� Date Printed: 1/31/2005 o . TOWN OF YARMOUTH Building Department ►. Town Hall Yarmouth, MA 02664 (508) 398-2231 ext.261 BUILDING PERMIT TRANSMITTAL Temp Permit No.: T-05-387 Applicant Name: Frank Capra Applicant Phone: 5087789669 Building Location: 00121 CAMP ST Unit 126 Owner's Name: Villages Q Camp Street., LLC Owner's Addres 1600 Falmouth Road # 25 Centerville _ MA 02632 Owner's Telephone: (508) 778-9669 VIEWED BY: 1. WATER DER ✓2. ENGINEERIN 3.CONSERVAT ✓4 HEALTH DEP 5. BUILDING DE 6. FIRE DEPAR COMMENTS: (OFFICE USE ONLY Recorded By: IC Permit Fee: $0.00 Deposit Rec: $0.00 Payment Type: Check ChkNo.: 0 Net Owed: $0.00 Application Date: 1/31/20 55 Issue Date: Expiration Date Comments: Map/Lot: 044.21.1.G new construction: ZONING APPROVED �. RTMENT: DATE: N/A: G DEPARTMENT: DATE: N/A: ION: DATE: N/A: ARTMENT: DATE: N/A: PARTMENT: DATE: N/A: TMENT: DATE: N/A: PLEASE NOTE RECEIPT OF COPY: SIGNATURE OF APPLICANT: DATE: Date Printed: 1/31/2005 oF'YAR ONE & TWO FAMILY ONLY - BUILDING PERMIT APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING s o y Town of Yarmouth Building Department IV „.r.,.Q„cai 1146 Route 28 • Yarmouth, MA 02664-4492 Tel: (508) 398-2231 x261 • Fax: (508) 398-0836 �"„s ,�`�,x�tOtf`ide �se'Oniy� x;,.�," ", PJa�rmkg 6oardfln#ncrnyat:an"°t.AssessorsYUepaifinec�'Infnm}aa�aotal�"�-�� r*" ��r'Kr3y ,^die"may [IIer/,yr�ay5 ^, GiiY I.o M. R 5 ;-..tynd `i � �>f' V*at!`3.4'M1il ✓ �t.r{"} '++hb�'Jil �{j$r�'n•Q',rdt{i`J.1'J.atGl k'a�" Rr5'15'v�*', i �'y�'m�[y�i��'4Zrv��'i��iYtr"��{n�^{�Ni'.°, `�.",? , -u.'Z? ,� i't~ G rT¢M:.t'l ]'.�5 s x+.Ii ,�.�, .L� rt F 4 5 i y,..yri 1 p.. M at^ratt"Z'Xi. Z k3e osit jrU,ZIP 9v "["'`�!iy�uv,'t<v� ten; bE1iY �.erni �-3 1 hE ' n T+ a vi nrea�cU., Trasntage 'fin>s it v a„v'.!°':�'*JQ`uo s:+5 e`C`:R:e.r s'aq'-•.M�+« }z3.z,�'.;:d r task->� ,.a=;:w .�;<• d ,w,,,,.;, ...x.+ �•*. a te .M .' _ �� tars eetlonl Q Affrce l e� r * em s [ ^ f�lr'ef.\�ZaFM��.J+� C. � uI'�. �W g3yG"['_ryp W 15ri ^S. S�M'S—A% C:a�F{aini �.{ �^':{i [ F" H -R rt.KY^' .l+ "t'4 � >;. 3`."a y LS:A• .ux i..!. y»�+�T^,.�,. .t^� �.Y'ii�/i'�1�x-tl'1x1+�`�L.JS��T%^. �Yf"xl r3}t•= iv..f`�'`(.Fl }fi'� TF'Y .�,.K.,iy g7, r �+, „�-..�...•... ,,,.�� r`Stafi!IrT9 ©ii{cii�lw,ar-`� � _. t+':�.,-,zn Ddie ern eke £�.r�^. ';�. € F; _ „- ;t...4 ��.:xy,�,,,�, , ,- S�e#iar1, -'te it rar3alon Use Group: R 4 Ty pe: 5-B 1.1 Property Address: 1.2 Zoning Information: a S' _ Des1 ot�,� �ca Vl Zoning District Proposed Use 1.3 Building Setbacks (it) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.4 Water Supply (M.G.L. c. 40. S 54) Sloo�rZonefiatO{m*ratio [Lflmtnents� Public Private Sec�An• ,�,Prb . � �: ,wr�ersfupfl'ot[�orized�ge�l 2.1 O j a Record: ijus LLC 0v M i V t , N me(}print� Mang Address 16��L SignatureSigna�re Telephone ouri0 Agent: / � Gj _ `�' Ol i G/ 0 O ✓`� JL�y ,6 f 4 �L S Name (print) Mailing Address �(\ j Hct zra Signature Tel grie I ,; I ! Fax I� econ� .atstrElct: e�ai{e ,n 3.1 Licensed Construction Supe LisUr. N ` 'a A icabIs ❑ nL —� license Number I I O \� o ✓I (a 0 ddre �(J - 77 y- 9G Expiration Date v C / 6 —Q gnature Telephone hrT r - �' � 5 3 2�E3e �`fsteie` �,,, LLr�e�ltaprouemerit^Co _ _ Company Name MAR 1 / Not Applicable ❑ 4 2 License Number Address By Expiration Date Signature Telephone 4 9-15-99 1of2 OVER Seaton ww.,+,rkers';;I✓orr�sad1��>rtsu�arr�ce A�dau(f �M �:i:.��Sz;S:�c.�s. Workers Compensation Insurance affidavit must be completed and submitted with this application. ,Failure'_, to provide this affidavit will result in the denial f the issuance of the building permit. Signed Affidavit Attached Yes ....,..... No .......... ectf l esci p„tt3nFoi3Plxtposed 1Norlc ct�e. a pi able}; New Construction No. of Bedrooms No. of Bathrooms Existing Bldg. ❑ Repair(s) ❑ Alterations ❑ Addition ❑ Accessory Bldg. ❑ Type Demolition Other Specify: p fy: Brief Description of Proposed Work: I v,�A—kvv-,*NsV1 f In "( Pw V 1 �ectfon6;Estrrtatetl �onsiructtotkCcisls�. Item Estimated Cost (Dollars) to be completed by permit applicant Check Below ❑ Conservation -Commission Filing (if applicable) ❑ Old Kngs Highway & Historical Commission approval (if applicable) 1. Building. o o a 2. Electrical �� J 3. Plumbing / Gas 0. V 5 4. Mechanical (HVAC) 0 5. Fire Protection o (o 6. Total = (1 + 2 + 3 + 4 + 5) ID S7 a 7. Total Square Ft. (new houses & adddions) Secti� 7a Outrrte�Afitlactor �. f3wner�s jl erlt=f�r.Contrac�rAppft�;, f6e onpletedWhe �or�Suiic7trlg,Pe[rit� ._ I, e--(- hereby authorize 6A e , a�owrier of the subject property � �' to act on m beh , in all matters elative to work authorized by this building permit ppl'dation. Signature of Owner Date I, as Qwner/Authorized Agent hereby declare that the statements and -information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. I k _AQr- Print n e 2�CL Signature of Owner/Agent Date EPA R 9-15-99 2 of 2 uo�A TOWN.OF YARMOUTH s BUILDING DEPARTMENT CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: Job Location: Num. berg � Street L GVillage Owner of Property: V ` Construction Supervisor: VA, 02L <:) 9�6 / Name �" �(� /� License No. Phone No. f / Address: / 50 ®� �'r " sU + -� /1 ✓� do PA A Da G 3 )C Licensed Designee: (If other than Supervisor) Name License No. 2.15 Responsibility of each license holder: 2.15.1 The license holder shall be fully and completely responsible for all work for which he is supervising. He shall be responsible for seeing that all work is done pursuant to the state building code and the drawings as approved by the building official. 2.15.2 The license holder shall be responsible to supervise the construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of building and structures only pursuant to the state building code and all other applicable laws of the commonwealth, even though he, the license holder, is not the permit holder but only a subcontractor or contractor to the permit holder. 2.15.3 The license holder shall immediately notify the building official in writing of the discovery of any violations which are covered by the building permit. 2.15.4 Anylicenseewho shall willfullyviolate subsections 2.15.1, 2.15.2 or 2.15.3 or any other section of these rules and regulations and any procedures, as amended, shall be subject to revocation or suspension of license by the board. 2.16 All building permit applications shall contain the name, signature and license number of the construction supervisor who is to supervise . those persons engaged in construction, reconstruction, alteration, repair, removal of demolition as regulated by section 109.1.1 of the code and these rules and regulations. In the event that such licensee is no longer supervising said persons, the work shall immediately cease until a successor license holder is substituted on the records of the building department. 2.17 The license holder shall be responsible for requesting all required inspections. Failure to do so may be deemed a violation of the permit conditions. I have read and understand my responsibilities under the rules and regulations for licensing construction supervisors in accordance with section 109.1.1 of the state building code. I understand the construction inspection procedures and the specific inspection as called for by the building official. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.152 Yes No ❑ If you have checked ygs, please indicate the type coverage by checking the appropriate box. - A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S I S CE.JWAIVE I am aware that the licensee does not have the insurance coverage required by Chapter 1 e M Gen Lawwodhd that my signature on this permit application waives this requirement. Check one: Signatur f Owner or Owner's gent Owner ❑ Agent ❑ Signature: Building Official Approval: k The Commonwealth of Massachusetts Department of Industrial Accidents i7fl effof/eresffosdsis 600 Washington Street Boston. Mass. 02111 Workers' Compensation Insurance Affidavit location- 14010 dQ Mn A --L O .. cn 0 1 am a homeowner performing all work myself. CD I.am a sole proprietor In a. ha,6e no one working in any capacity 1 am .an employer prop iding workers' compensation for my employees working on this job. Company name - add r"s - city- _tfhone 8 U-2 7 0.6 0 insurance co.CgAl eoliev # am a sole proprietor. general contractor. or homeowner (circle ones and have hired the contractors listed below aho ha%e. the following workers ;ompensation polices; city: phone # insurance co. polies # company name: address: one to secure cover age as required under Section 25A of MGL 152 nos lead to the imposition of criminal penalnn of a Bae ap.to S, 00 00 sainal and/or one vent' imprisonment as well as Civil penaldei in the form of a STOP WORK ORDER and a Bna of S100.00 a day against me. I understandthat a Copy of this statement may be forwarded to the OJI K15�f fuvestigatloes of the DU for coverage vei0eatim I do-herehy certify u er the pains Print name that the information provided above is true an eorr o2tp X p►tone K SO Q.... 779' fG gel otricial use only do not trite in this area to be completed by city or lawn official city or town: YARMOOT$ rmiNiccase # Pe nBuilding Department (] check if immediate response is required QI.Ieensing Board 261 Oselectmen's Ofree contact person: ❑Healtb Department phone#;_ i508) 398,2231 eat. nOther 1 TOWN OF YARMOUTH 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 Telephone (508) 398-2231, Ext. 261 — Fax (508) 398.2365 BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT BUILDING ELECTRICAL GAS PLUMBING SIGNS Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111.5, I hereby certify that the debris resulting from the proposed work/demolition to be conducted at 1 Work s is to be disposed of at the following location: 1O L✓►� dT�N%d �� Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. Signature o Applicant Permit No. Date w h C77- BOARD OF BUILDING REGULATIONS License:. CONSTRUCTION SUPERVISOR Number -:CS. 012430 &rtildate'06Cf6f1;940 Expj— 061-T 2006 Tr. not 25926 FRANK G CAPR/ 40 COPPER LN \ (7 CENTERVILLE, MA 02632 Commissioner 00.35,000denclosed space - J j (MGL C.112 5.60L) i 1A - Masonry _only - -� ' ? 1 G m I & 2 Family Homes Failure topossessa currentedition of the I Massachusetts State Building. Code - - - ! is cause for revocation of this license. DIG SAFE CALL CENTER: (888) 344-7233 — -- . _ F Ut3/U9/2UU4 Dy:11 _tit f-jrli-off4 JUrEY L.RUR'LG f rr UAL U♦ DATE (MMIOd.C4... -,.. CERTIFICATE OF LIABILITY INSURANCE 081 8n004 PROWLER 978.394-2253 DIRECT -' THIS CERTIFICATE IS ISSUED AS -A, MATTER OF INFORMATION ATLANTIC INSURANCE GROUP, INC. ONLY AND CONFERS NO RIGHTS UPON THE CEFTWICA-m- HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR AIP.LLC ALTER-THE-COVERAGE.AFEORDED BY THE POLICIES BELOW. 365 BOSTON POST ROAD PMS 203 INSURERS AFFORDING COVERAGE SUDBURY,MA 01776 -"' ""' INSURER A: AL NATIONFIRE &MARINE INSUREDRED GATEWOOD HOMES INC. WSUREA B: MA WORKERS COMP RESEARCH.BRD 16M FALOMOUTH ROAD usuRER---- I CENTERVILLE MA 02632 L.UUCKAk. w THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWtTYi9TAM04NC TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSU£0 OR ANY REQUIREMENT. 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. —. .. --.-.. __-......._.__ ._.. ..... PO�ICT EFFECTIVE ►OLICY EXYIRATIOl1 IJI11T5 TYPE OF INSURANCE I POLICY NUMBER I • �. OENE141L UABRITY I EACH OCCURRENCE f 1.00II000 A I X I CCMMERCW.GENERALUABIUTY 72 LPE 691943 I 4129/04 4129/05 FIRE DAMAGE tAAY Mefus: f 50000 - -- - ! CLAIMS MADE X I OCCUR I MEOEXP(ARYen_RPOrl") _ S . _ _10000 I _ I _ PERSONALAAOV INJURY S _;1000000 OENERALAGGREGATE f2000000L LGEN'L AGGREGATE LIMIT APPLICS PER: - LPRODUCTS-COMPUPAG'3 S - 1000000 PCLICY PRO.. L : Loo AUTOMDDILE LIABILITY II I COMBINED SINGLE LIMB IS j iANY AUTO ALLOWNEDAUTOS I I IBOD0.Y INAJRY I ' SCHEDULEDAUTOS HIRED AUTOS r I SOOIIY INJURY f C NCWOMEO AUTOS 1 lP� __ _ ... _... .�_ .... .. .__._.. I PROPERTY DAMAGE (Px AcT10M) i AUTO ONLY. EA ACCIOEN- IS OARAGZ LIAakJTY • ANY AUTO i OTHER THAN EA ACC S __•• _ 1 I AUTO ONLY. AGG f EXCESS LIABILITY I EACH OCCURRENCE f_ __ OCCUR ICL.LWS MADE _ AOGRECATE 1 I ,DEDUCTIBLE f RETENTION S S WORKERSCONPENITY AN D B POLICY UPDATE NUMBER TS I I 814104 814/05 ITORY LIMITS— •FIT dAPLOYERS'UABIUT' _ I EL EACH ACCIDENT._—_l3 DISEASE=EA EMPLOYE E 500_000 E.L. DISEASE . POLICY UwT f i OTHER I I _ DESCRIPTION OF OPEMYtONLLOCATK)NSNE)RCLELEXCLUSMS ADDED BY ENDORSEMENTISPEOUL PROYMONS PROJECT: MILL POND VILLAGE (VILLAGES AT CAMP ST. LLC - DBA) SHOULD ANY OF TIEABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION . DATE THEAEOP. TIE IMURIG INSURER WILL ENDEAVOR TO MA:L 60 DAYS WRITTEN NOTICE TD THE CERTIFICATE NOL MEP TO THE LEFT, OUT FAILURE TO DO EO SNALL TOWN OF YARMOUTH nfIOSE NO OBLIGATION OR RTT f ANY RIND UPON THE INSURER. R4 AGENTS OR BUILDING DEPARTMENT REPREEEMTA wmonLTEO n s Nr I AL.VKU AO-J IHB/Y V Awvnu'.vnrvR IIvn wuo Q D+r. CERTIFICATE Off' LIABILITY INSURANCE- DATE(MIv1/00/YY, PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eli%uxak Q�A,lhs=wrh ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. E%c 3/ HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. illcr�yr.-:_-�u7�ky�u�YP.: •?:] INSURED 11 1111 �_ I _. _ COVERAGFS INSURERS AFFORDING COVERAGE .. .I INSURER A_Ravid i.0 M.Itl1�. F1TL Im. m.. INSURER Bi$36g$ F LZ7 & ('L9 ty INSURER C: INSURER D: ' INSURER E: 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 OF MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OFSUCI- POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INDR, TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE LTR DATE h1M/DD/VY POLICY EXPIRATION T DATE IMM/DD/YY - LIMITS - GENERAL LIABILITY i I EACH OCCURRENCE COMMERCIAL GENERAL LIA6ILTY i FIFE DAMAGE (Any one nre) ' $ .. . �E - CLAIMS MADE I OCCUR , i r I ! MED EXP (Any one personi . PERSONAL & ADV INJURY 1 $ 1.A-W l Q GENERAL AGGREGATE _$ . . 2,0001 00 A • GEN'L AGGREGATE LIMIT APPLIES PER: ! r�r�r�� GO 0005933 04 I � �O-OrS-Q3 i , �aOS-Oi PRODUCTS-COMP/OP AGG I $-2jQQfWO i POLICY j PFOO LOC I AUTOMOBILE LIABILITY ! I j - ( ANY AUTO I I i COMBINED SINGLE LIMIT $ (Ea accident) I i ALL OWNED AUTOS BODILY INJURY $ -_ SCHEDULED AUTOS )- (Per person) ' ! HIRED AUTOS I I 6001LY INJURY $ I j NON -OWNED AUTOS i (Per accidom, j t PROPERTY DAMAGE I $ (Per accident) GARAGE LABILITY I AUTO ONLY_ EA ACCIDENT fr $_ ! ANY AUTO I ( i EA ACC f $ OTHER THAN I I I ) AUTO ONLY: AGG I S j EXCESS LIABILITY EACH OCCURRENCE • $ _ OCCUR I (CLAIMS MADE _ 1.-, .J _ AGGREGATE 1 $ DEDUCTIBLE I $ ! j RETENTION $ - i I j ! $ WORKERS COMPENSATION A7wm I WC STATU- UTH-I EMPLOYERS' LIABILITY I TORY LIMITS( t EACHP.CCIDENT $ 1,* 04-01-04 04-01-05 `L �EL ___ 1 E DISEASE -.ILA EMPLOYEE $_ , ' 1 00r0W B I 001630 E.L. DISEASE -POLICY LIMIT i $ 5oorobo OTHER I I i i I I DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER i 'I ADDITIONAL INSURED: INSURER LETTER: CANCELLATION E3msT 23=. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIOI 16DO al-...xi.h I DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEI 9>l� 25 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALI L{71��pr 0 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS Of -• REPRESENT ES. AUTHORIZEfFREbRESEffAUVX FYf�L 50$.718.5603 L ACORD 25-S (7197) © ACORD CORPORATION 198 ` ACORD- cHaJUKANGtGO CERTIFICATE OF LIABILITY INSURANCE °ATE,MM pD/Y, "R THIS CERTIFICATE IS ISSUED AS A MATTER OF INFOR$MAT10N Dowling & O Neil Insurance ONLY AND CONFERS NO RI GF{TS UPON THE CERTIFICATE Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 222 West Main St. PO Box 1990 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis, MA 02601 INSURED INSURERS AFFORDING COVERAGE EAI(C # Assurance Construction, Inc. INSURERA: Nautilus Insurance Company :::— A/O Assurance Excavation, Inc: INSURERB: 550 Willow Street INSURERC: West Yarmouth, MA 02673 INSURER D: COVERAGES THE PnI Ir.IFs na , E: ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE E MAYBE ISSUED OR THSTANDING 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. .TR NSR TYPE OF INSURANCE PIRATIO POLICY EFFECTIVE POLICY EXN POLICY NUMBER M/DD/YY EACH OCCURRENCE A GE;:ERAL LIABILIIR NC289301 DATE MM/DD DATE MLIMITS . 09/08103 09/08/DQ III 0.00 000 X COMMERCIAL GENERAL LIABILRY DAMAGE TO RENTED CLAIMS MADE O OCCUR PR I E100 000 X BI/PD Ded:1,000 ME13 EXP (Any me pemm) E5 000 PERSONAL$ ADV INJURY e1 nnn nnn GEN'L AGGREGATE LIMIT APPLIES PER: "rnc�L AUGREGATE POLICY JECT LOC PRODUCTS - COMP/OP A AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT ALL OWNED AUTOS (Ea aCdde[Y) ' SCHEDULED AUTOS BODILY INJURY HIRED AUTOS _ (Pa PersmI NON -OWNED AUTOS BODILY INJURY (Per asidenl) PROPERTY DAMAGE :ARAGE LIABILITY (PeraccJded) ANY AUTO - AUTO ONLY -EA ACCIDEN ' OTHER THAN EA ACAS XCESSIUMBRELLA LIABILITY AUTO ONLY: AG OCCUR CLAIMS MADE EACH' OCCURRENCE DEDUCTIBLE WORKERS COMPENSATION AND . I V/C EMPLOYERS' UABILITI' T ANY PROPP,IETOR/PARTNER/EXECUTNE E.L EACH OFFICER(MEMBER EXCLUDED? OTHER DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Operations performed by the named insured subject to policy conditions and exclusions. Gatewood Homes, Inc. Attn : Paula 1600 Falmouth Road, Suite 25 Centerville, MA 02632 ACORD 25 (2001/08) 1 Of 2 #35194 E S E S E E SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1!L 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 AUTHORIZED JV ACORD CORPORATION 1988 rax Server PRODUCER EMPLOYERS INS GROUP INC 281 MAIN ST STE 5 Ma(M61AbDIYY1 :..- to »a 08-04-09 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY. AND CONFERS NO RIGHTS UPON THE CER- RCA_TE—. HOLDER. THIS CERTIFICATE DOES -NOT AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. FITCHBURG MA 01420 COMPANIES AFFORDING COVERAGE " COMPANY 76HCK - A ROYAL INSURANCE COMPANY OFAMERICA INSUR COMPANY RESOURCE MANAGEMENT INC .B 281 MAIN STREET SUITE 5 FITCHBURG MA 01420 COMPANY - C ��1 /' SS U ra i 1 G� ac'eLV aL4' on COMPANY D COVERAGES s y .- . ,W a/ 'rW a N . —, .:. .n..:..:.w. 3. u.,u>.- •�.w :. w ....✓.. ......w .e+..... ro n ..a.. ... n THIS M TO.CERTIFY THAT THE POLICIES OF INSURANCE UST'ED BELOW HAVE BEE.N ISSUED.TO THE INSURED NAMED ABOVE FOR THE-PO11MC PERt02.. INDICATED, NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED CR 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. L O TYPE OF INSURANCE POLICY NUMDER POLICY EFFECTIVE DATE (MMND1ri) POLICY EXPIRATION DATE(MSMDWY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE s PROOUCTS-COMP/OPAGG. _ COMMERCIAL GENERAL LIABILITY CLAIMS MADE =OCCUFL _ ,ct< PERSONAL S ADV. INJURY : EACH OCCURRENCE s OWNERS a CONTRACTORS PROT. FIRE DAMAGE (Any one fire) f - MED. EXPENSE (Any one person) S AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT S BODILY INJURY ALL OWNED AUTOS SCHEDULED AUTOS (Per Person) - S HIRED AUTOS NON -OWNED AUTOS - BODILY INJURY (Per Accident) i PROPERTY DAMAGE $ GARAGEUABILTTY AUTO ONLY - EA ACCIDENT S OTHER THAN AUTO ONLY: ANYAUTO EACH ACCIDENT =.... - AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE S UMBRELLA FORM AGGREGATE S OTHER THAN UMBRELLA FORM A WORKER'S COMPENSATION AND EMPLOYERS LIABILITY (LIB-967X999-9-03) 11-20-03 11-20-09 STAMORY LMRS EACH ACCIDENT $ 100,000 THE PROPRIETORI PARTNERS'EXECUTIVE X INCL OFFICERS ARE: EXCL OTHER _ DISEASE— POLICY LIMIT $ 500 .000 DISEASE —EACH EMPLOYEE S 100,000 DESCRIPTION OF OPERATIONSfLOCATIONSNEWCLE&RESTRICTIONS'SPECJAL S COVERS EMPLYS LEASED TO ASSUR&}:F&—EXCAFtA- TORS 530'WILLOW ST W YARMOUTH MA 02673 THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. ERTiFICAT6}IQLUER;GANGEI .a...W...ci .Ytrw ..v.Vw , ,.cnn" Y.V w, LATtOAF. ♦ win-. a _•�'" , SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE GA.TEWOOD HOMES, INC. ATT:PAULA CENT FALMOURVILLETH ROAD —SUITE$ 25 CENTERVILLE MA 02632 EXPIRATION DATE THEREOF, THE ISSUING COMPANY WALL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOWERAApm T07"e— LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBUGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATRfE3: - AUTHORIZED REPRESENTATIVE .: ..<:;� ... ,...4 >• .x..�,dICORi'S�dRisORA �� 9_': • �� CERTIFICATE OF LIABILITY INSURANCE DATE(MMMDNYYY) 08/02/2004 PRODUCER- (508) 97-6061 FAX (508)991-3283 - THIS CERTIFICATE IS ISSUED AS,A MATTER OF INFORMATION Southeastern Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 662 State Rd. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 79398 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. N. Dartmouth, MA 02747 INSURERS AFFORDING COVERAGE NAIC # INSURED R J Bevilacqua Construction PO BOX 628 Forestdale, MA 02644 INSURER A: grbella Protection Insurance INSURER B: INSURER INSURER D: INSURER E: rnvvo nr_oe THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANOINI ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 FDDR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE 07/I5/2004 POLICY EXPIRATION LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE a OCCUR X Special Form 8500018147 -07/15/2005 EACH OCCURRENCE $ 1,000,00 1 DAMAGE TO RENTED $ 50, OO MED EXP (Any one Person) $ 5 , OO PERSONAL&ADVINJURY $ 1,000,00 GENERAL AGGREGATE $ 2 , 000 , OO GEML AGGREGATE LIMITAPPLIES PER: POLICY JEC7 LOC PRODUCTS-COMP/OP AGG $ 2, OOQ,OO AUTOMOBILE LIABILITY ANY AUTO 86852400001 02/21/2004 02/21/2005 COMBINED SINGLE LIMIT (Ea aocidenq § ALL OWNED AUTOS A SCHEDULEDAUTOS HIRED AUTOS BODILY INJURY (Per person) $ 250, 000 X X INJURY (Per accident) § 500,00 NON -OWNED WNED AUTOS X PROPERTYDAMAGE Per (Per accident) ( ACCIDENT $ 500,00 S . GARAGE LIABILITY ANY AUTO' EA ACC $ • AGG $ EXCESSIUMBRELLA LIABILITY OCCUR CLAIMS MADE EACH NCE § § DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY 9088680402 04/27/2004 04/27/2005 X WC STATU- OTH- CRY LIMITS E.L. EACH ACCIDENT A ANY PROPRIETORIPARTNER/EXECUTNE OFFICER/MEMBER EXCLUDED? $ 100,000 E.L DISEASE - EA EMPLOYE $ 100,000 H yes, tlesaibe under SPECIAL PROVISIONS below OTHER E.L. DISEASE -POLICY LIMIT $ 500, 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS or any and all operations performed during the policy period. Gatewood Homes Inc. 1600 Falmouth Rd Ste 25 Centerville, MA 02632 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WALL ENDEAVOR TO MAIL 10 DAYS WRrrTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES AUTHORIZED REPRESENTATIVE Pauline Desrosiers ACORD 25 (2001108) CORPORATION 19RR ,ACORD. CERTIFICATE OF LIABILITY INSURANCE o3/o9i2 0 PRODUCER (500 994-9688 FAX (508) 991- 5461 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rull OWSKI & KESTENBAUM ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 414 COUNTY STREET HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NEW BEDFORD, MA 02740 INSURERS AFFORDING COVERAGE INSURED Frank Capra INSURER A: Providence Mutual PO Box 664 INSURERB: OneBeacon West.Hyannisport, MA 02672 INSURERC: Continental Casualty Co INSURER D: 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. ILTRNSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE D MMIDDIY POLICY EXPIRATION DATEMIDD , LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE O OCCUR PPOO53131 01 12/13/2003 12/13/2004 1 EACH OCCURRENCE S 11000,0( X FIRE DAMAGE (Anyone fire) $ SO O( MED EXP (Any one person) S 5,0( PERSONAL & ADV INJURY $ 1, OOO , OC GENERAL AGGREGATE S 2,000,13 ( GENL AGGREGATE LIME. APRJES PER POLICYEJ JECT LOC PRODUCTS-COMP/OPAGG S 2.000,OC B AUTOMOBILELIABILITY ANY AUTOAUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS BXE48125 . .... ..... __ __.. _- 02/14/2004 .. . -: 02/14/2005 . COMBINED SINGLE LIMIT (Ea aw: w $ BODILY INJURY (Per pen) rso. S 250 , 00 X BODILY INJURY (Per accident) - S 500,00 PROPERTY DAMAGE (Per aecidenq AUTO ONLY -EA ACCIDENT S 100,00 S . ........ GARAGE LIABILITY ANY AUTO OTHER THAN EA ACC AUTO ONLY: AGG S S EXCESS LIABILITY OCCUR O CLAIMS MADE DEDUCTIBLE RETENTION $ ' EACH OCCURRENCE S AGGREGATE S S S S C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OTHER S59UB861X751604 _ 03/22/2004 03/22/2005 O TRV LIMBS ER EL EACH ACCIDENT S 500 , 00( E.L. DISEASE- EA EMPLO S 500.00( EL DISEASE -POLICY LIMIT S SC♦0,00( DESCRIPTION OF OPERATIONSILOCATIONSA EHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER I I ADDITIONAL INSURED: INSURER LETTER CANCELLATION Gatewood Homes Inc 1600 Falmouth Rd Ste 25 Centerville, MA 02601 25-S(7/97) FAX; (508)778-5603 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY If1MC'IIPORi OF ANY IZ COMPANY. ITS AGENTS OR-RBPRF!s N Ax q ACORD, CERTIFICATE OF LIABILITY INSURANCE EA'NM'°°""''PRODUCER SOS-398-6033 FAX 508-760-1667 /09/2004 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eastern Insurance Group LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1 Atlantic Ave ALHOLDER. TE E H9COVIS ERAGE AFFORDED BY THE POTIFICATE DOES NOT LICIES BELOW. So Yarmouth MA 02664 7_0RS AFFORDING COVERAGE NAIL # INSUgED Cape Cod Custom Floors A: Arhel la Protection Ins Company 762 Falmouth Road B: HartfordHyannis MA 02601' C: : THE POLICIES OF INSURANCE LISTED BELOW HAVE; BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDIN 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 15 SUBJECT TO ALL THE TERMS. EXCLUSION5 AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR DD' TYPE OF INSURANCE POLICY NUMBEq POLICY EFFECTIVE POU Y EXPIRATION GENERAL LIABILITY LIMITS 7500000373 12/13/2003 12/13/2004 EACHOCCLRRFNCG s I;OD"0;0( X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED CLAIMS MADE a OCCUR S 50,0( A MED EX► (Any we perms) S OIL GENL AGGREGATE LIMIT APPLIES X POLICY n JEGT I 1 I AUrOMOB%E LIABILITY ANYAUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS E IABILITY CLAIMS MADE f WORKERS COMPENSATION AND EMPLOYERS' LIABILITY (; ANY PROFRICTOWPARTNEWEXECUTIVE OFFICERJMEMBER EXCLUDED? If yaT deGmbc undo! SPECIAL PROVISIONS below OTHER ADDED BY CNDORSEMENT l SPECIAL PERSONAL A ADV INJURY s 1,000,00 GENERAL AGGREGATE S 2,000.000 PRODUCTS -COMPIOPAGG S ?-non non COMBINED SINGLE LIMIT (Ea ac 4") S Y INJURY $ r5pn) Y INJURY S 6,19 n)RTY DAMAGE_deal) SNLY-EAACCIDENT S THAN EA ACC 4AA =NLY: AGG SCCVRRENCE SGATE SSSS E.L UCH ACCIDENT IS -L OISEASE.EAEMPLOYE S of Insurance for work performed within the Insured's scope•of normal operations Gatewood Homes 1600 Falmouth Road *2S Centerville, PIA 02632 ACORD 25 (2001/08) FAX: (508) SHOULD ANY OF THE ABOVE DEBCRMCO POUCIES BE CANCELS - EXPIRATION DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMEDi09Metnr'— ISUT FAILURE TO MAIL SVCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OFANY KIND UPON THE CACORD CORPORATION 1988 ACOBDL ' CERTIFICATE OF LIABILITY INSURANCE 8/2/220o 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 INSURED Casperson Overhead Doors Box 517 East Falmouth, MA 02536 f`n%=RAl:FC INSURERS AFFORDING COVERAGE NAIC# INSURERA: Worcester Insurance Company INSURERS: National Grange Mutual INSURER C: INSURER D: INSURER E: 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. JMR VTR o•L NSRO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DD POLICY EXPIRATION DATE MM/DD UMTTS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMSMADE 7 OCCUR CB 2J1973 - 05/28/04 05/28/05 EACH OCCURRENCE $ 1 OOO,OOO PREMISES Ea occurence S 100,000 MEDEXP(AnVonepe n) 5 10,00 PERSONALAADVINJURY s 1,000,000 GENERAL AGGREGATE SL OOO f OOO GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JEo-F1LOC PRODUCTS-COMP/OP AGG s 2,000,000 AUTOMOBILE LIABILITY ANYAUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNEDAUTOS COMBINED SINGLE LIMB (Ea accident) S BODILY INJURY (Per peson) S BODILY INJURY (Peracadent) S PROPERTY DAMAGE (Peracadent) E GARAGE LIABILITY ANYAUTO . AUTO ONLY-EAACCIDENT E OTHERTHAN EAACC AUTOONLY: AGG S S EXCESSIUMBRELLA LIABILITY OCCUR CLAIMSMADE DEDUCTIBLE RETENTION E EACH OCCURRENCE E AGGREGATE $ S S $ B WORKERS COMPENSATIONAND EMPLOYERS' uAsam ANY PRO PROPRIETOit/PARTNER/E%ECUTNE OFFICERIMEMBEREXCADED? Ifyes,descnbeunder SPECIAL PROVISIONS belay CP48352 02/22/04 02/22/05 X TIC ITATI ORYLIMITS - ER E.L. EACH ACCIDENT E 500 006 E.L. DISEASE - EA EMPLOYE S SOO O00 E.L. DISEASE -POLICY LIMIT S 500,000 OTHER DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES / EXCLUSIONSADDED BY ENDORSEMENT/ SPECIAL PROVISIONS - Gatewood Homes, Inc. 1600 Falmouth Rd., Ste. 25 Centerville, MA 02632 ACORD25(2001/08) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIOI` 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 REP S T T @ACORD CORPORATION 1988 ACO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODIYYYY 11/06/2001 PRODUCER .(SOB) 790-1919 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Sandpiper Ins. Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER'. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 12 Enterprise Road ALTER THE'COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis MA 02601- INSURERS'AFFORDING COVERAGE I NAIC # INSURED INSURERA Zurich Small Construction CENTURY PAINTING AND DRYWALL, INC CENTURY PAINTI INSURERS PO BOX 2903 C-Le cod/ INSURER C: INSURER D: HYANNIS MA 02601-7903 INSURERS Cf)VFRArZFS THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING AN REQUIREMENT, TERM OR CONDIMON 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 ANC CONDITIONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR DO'L INSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE(MMIDDIYY) POLICY EXPIRATION DATE (MWDD/YV) LIMITS GENERAL LIABILITY - / / / / EACH OCCURRENCE s 1,000,00 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE ❑OCCUR SCP034309873 12/18/2002 12/18/2003 DAMAGE TO RENTED PREMISES aoccurrence s 300,00 MED EXP An one rson S. 10,00 PERSONAL 3 ADV INJURY s 1,000,00 GENERAL AGGREGATE $ 2,000,00 / / / / GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JEC LOC PRODUCTS-COMMOPAGG S 2,000,00 AUTOMOBILE LIABILITY ANY AUTO / / / / COMBINED SINGLE LIMIT (Ea accident) s ALL OWNED AUTOS SCHEDULED AUTOS - / / / / BODILYINJLRY (Per Persm) S HIRED AUTOS NON -OWNED AUTOS / - / / / BODILY INJURY (Per accidentl $ PROPERTY DAMAGE (Per axbent) s GARAGE LIABILITY AUTOONLY -EA, ACCIDENT' - $ ANY AUTO / / / / OTHER THAN EA ACC $ AUTO ONLY: AGG $ E%CESSIUMBRELLA LIABILITY / / / / EACHOCCURRENCE s AGGREGATE S OCCUR CLAIMS MADE s DEDUCTIBLES / / / / s RETENTION s S WORKERS COMPENSATION AND EMPLOYERS LIABILITY TORY UATU- ER EL EACH ACCIDENT S ANY PROPRIETOR/PARTNER/EXECUTIVE - OFFICER/MEMBER D(CLUDED7EL. If yes, describe under DISEASE- EA EMPLOYEES E.L DISEASE- POLICY LIMIT s SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS PAINTING S DRYWALL a.crt r rnasl I c nLlLu�n CANCELLATION ( ) - (508) 778-5603 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 GATEWOOD HOMES FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE 1600 FALMOUTH RD SUITE 25 URER, ITS AGENTS OR MPR�NTATNES. ACORD 25 (2001108) n INS025 (D1D8).os MA 02632- ELECTRONIC LASER iQ_RMS,;AC. - (8M327-0545 © TRD CORPORATION 1981 1 Page 1 of: Ac®RD CERTIFICATE OF UABIL iY-t �ifrf E PRODUCER ' Spllivan, Garrity & Donnelly 508-754 -1767 10 Institute Rd -.PO Sox 15010 Worcester MA 01515-o010 THIS CERTIFICATE IS ISSUEQ AS. ONLYAND CONFE- IS NO RIGHTS HOLDER. IS CE1. ATE DOE ALTER THECOVEFAG;LAFFOROE — INSURERS_AFFORDIIIGCOVERAGE Phone:508-754-1767 Fax:SOB-754-1885 INSURED NSURC•RA Hanov Er Insurer INSURERS: Arch Lnxurance Crowell Construction, Inc. PO Box MA 02660 INSURERQ INSURER0: COVERAGES INSURER E: PON THE. CERTIFICATE NOT AMEND, EXTEND OR BY THE POLICIMBELOIAL^._ . 22292 THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERT D BIDICATED. NOTwrrHSTANdnn;t ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CEF' RFI' ATE MAY BE ISSUED OR I MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUI: Oft' AND CONDITIONS OF ajdH POLICIES. AGGREGATE LXOTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. y LTR NSR INSURANCE POLICY NUMBER I FF TIV pq E MMMD LICY E: PIRA 1 DATE MI UEVYY LIMITS A GENERAL X LIABL UA811.lTY COMMERCIALGENERALLIABILITY CLAIMS MADE ®OCCURMED ZHM007141 05/01/04 05/ Il/OS EACH g(A $1000000 PREMIce1 $100000 EK AI j 5000 PERSONAL j AryW WilJITF 31000000 GENERAL AQOiL.E{A7'6 S 2wovw... ' GENT AGGREGATE ROM APPLIES PER: POLICY .ECT LOC PRODUCTS -A"XI,A)I_AC40 $ 2000000 AUTOMOBILE LIABILITY _1'-"- A ANY AUTO " AEK7001142 05/01/04 05/ 1/OS COMBINED SINfV-9 LVMF (E3'cdcluni) ! y^^' f ALL OWNED AUTOS BODILY B1JURy I (Pew OMPA) I S1000000 X SCHCOULED AUTOS X ' HIRED AUTOS - X BODILY INJURY I (Per 20%dW) j 1000000 NON.OWNMAUTOS - PROPERTY DAWJSE (Pare ldeMl j $00000 GARAGE LIABR.ITY ANY AUTO AUTO ONLY -EA.tdCIIK7JT S OTHER THAN E'I ACC. AUTO ONLY: I ^. A.30 S S EXCESS:7B ELLA UAB6JTY occuR CLAIMS MADE EACH OCCURREJICE f _ AGGREGATE j DEDUCT01.6 - ^ S RETENTION S WORKERS COMPENSATION AND 8 EMPLOYERS' LIABIL1IY ANY PROPRIErOWPARTNEPJEXECUTIVE IRWC100100 03/22/04 OFFICERIMEMBER EXCLUDED? TORY LIMBS -[ I Fri 03/: 2/05 ELEACHACCIDE:NT - 9500000 RyeA.deacnbeanaor E.L. DISEASE -EA EMPIAWS SPECIAL PROVISIONS trelw E.L. DISEASE - POLICE LIMIT OTHER — _ OESCR6'TION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED By ENDORSEMENT / SPECUJ, PROVISIONS As per policy forma, Conditions and exclusions. $500000 S SOOOOO CERTIFICATE HOLDER CANCELLATION GATrW00 SHOULDANTOFTHEABOy IDE.=RMEDPOLIWESBECANCE;LLEDBEFORE-TNE DATE THEREOF. THE =UIV; B,AURER WILL ENDEAVOR TO LIX.L 10 DAYS WRITEN Gatewood Homes, Inc. NOTICE TO THE CERTIFTex?HI;LDER NAMED TO THE LIFT. INJT FAILURES 1600 Falmouth Road Suite 2S IMPOSE NO OBLIGATION OF: Lot BILffy OF ANY KIND UPON Ti.S DNURER ITS AGENTS OR Centerville MA 02632 REPRESENTATIVM ACORD 25 (20011D6) — ACORD,y CERTIFICATE OF LIABILITY INSURANCE MARK SYLVIA INSURANCE AGENCY 969 MAIN STREET OSTERVILLE MA 02655 INSURED PETER J. GOVONI DBA P. GOVONI LAND SERVICES 20 OPEN TRAIL RD. SANDWICH, MA 02563 cnvcoAr_ec AND CI R. THIS I- DATE(MMIDO/YYYY) 08/04/2004 �S A MATTER OF INFORMATION iHTS UPON THE CERTIFICATE DES NOT AMFNn FYrcun nc INSURERS AFFORDING COVERAGE D: NAIC # 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 DD TR POUCYNUMBER POUCYEFFECTIVE POUCYEXPIRAT10N A I GENERAL LIABILITY LIABILITY X COMMERCIALGENERALAL1OCCUR CLAIMS MADE I 2OO1L62O2 LIMITS EACHOCCURRENCE 05/31/2004 05/31/2005 PREMISES Ea oxurenx � f 1,000,000 f S 5000 OCCUR MEDEXP(Anyonspelson) PERSONAL a ADV INJURY S GENERALAGGREGATE GEN'LAGGREGATE UMITAPPUES PER: f 2,000,000 S 1,000,000 PRO> POLICY LOC PRODUCTS, COMPA)P AGO AUTOMOBLLE UABILTTY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) f ALL OWNED AUTOS S SCHEDULEDAUTOS . BODILY INJURY (Perpen,w) HIREDAUTOS ' NONeOWNEO AUTOS BODILYINJURY.(Peraccident) PROPERTYDAMAGE . .. (Peratadent) - - - S .._..__... . �� GARAGELIABILITY. ANYAUTO . ... .. . . .. . . .. '' AUTO ONLY iEA ACCIDENT S' I I I EXCESSIUMBRELLALIABILITY _ OTHER THAN EA ACC' AUTOONLYc ",qGG S I OCCUR CLAIMS MADE _ EACHOCCURRENCE AGGREGATE S S S DEDUCTIBLE S RETENTION $ ' S A WORKERS COMPENSATION AND EMPLOYERS'LUBIUTY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDEDi TO BE ISSUED WCSTATU> OTH, 07/04/2004 07/04/2005 TQRXLIMITS X ER E.L. EACH ACCIDENT S 1,000,000 Des. describe under SPECIAL PROVISIONS below I E.L. DISEASE, EA EMPLOYEE S 1 000 000 OTHER E.L. DISEASE,POLICY LIMIT S 1,000000 DESCRIPTION OF OPERATIONS l LOCATIONS IVEHICLES/ EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS LOGGING AND LUMBERING, TREE PRUNING, STREET CLEANING SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN GATEWOOD HOMES, INC. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL 1600 FALMOUTH ROAD #25 IMPOSE NO OBLIGATION OR LIABILITY OF-AWt* < M-"ON-T}(HNSU Mfk-IT3AGENn OR CENTERVILLE, MA 02632 REPRESENTATIVES. I T_ AUTHORIZED REPRESENTATIVE _ 1 ACORD 25 (2001108) ) 'ACORD CO RATION 1988 f .....................::.::::.::.... ......:..:... ...... Da ( ro 7E MM ` • .............,.....................................:.:....:..w..:,:::..,M.:::.:,.:::.,:.N.:r::::::;.:;.::r;:.r:.::.r;::s:::<::<rr::;.::r:::;:;::;:.::>:s>_::::::::;::;:a:::::r:;:z:::rzr:::_::; ..v........ _.......:::.::::r::.:::::.::::.:,>..r;<8 03 04 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HAROLD H WILLIAMS INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 81 BASSETT LANE ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE HYANNIS MA 02601- COMPANY . (508) 775-3366 ( ) — A MERCHANTS INS CO OF MA INSURED COMPANY STEPHEN M CHILDS B 145 CAMMETT ROAD COMPANY C MARSTONS MILLS MA 02648- COMPANY (508) — D 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. - CO LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM/DD/YY) - POLICY EXPIRATION DATE (MM/DD/YY) UNITS A GENERAL LIABILITY GENERAL AGGREGATI " $6 0 0 0 0 0 X COMMVCIALGENEPALLIASIUTY CCP8567749 04/28/04. 04/28/05 PRODUCTS -COMP(OPAGG s600000 ..., CLAWS MADE X❑ CCCUR PERSONAL & ADV INJURY 000000. OWNERS & CONTRACTORS PROT EACH OCCURRENCE • s3 0 0 0 0 0 ' FIRE DAMAGE (Any one fire) S MED EXP (Any one person) $S O O O AUTOMOBILE LIABILITY , COMBINED SINGLE LIMITS ANY AUTO ALL OWNED AUTOS BODILY INJURY $ SCHEDULEDAUTOS (Per person) HIRED AUTOS BODILY INJURY S NON -OWNED AUTOS (Pa ecciden4 ' PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S ANYAUTO / / / / OTHER THAN AUTO ONLY _ EACH ACCIDENT $ - AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE S UMBRELLA FORM / / / / AGGREGATE $ OTHER THAN UMBRELLA FORM S O WORKERS COMPENSATION AND TWCRYST MIT✓ F EMPLOYERS' LIABILITY EL EACH ACCIDENT $ THE PFOPFUETOFV INS EL DISEASE- POLICY LIMIT S PARTNEAS/EEXECUTIVE OFF CERS ARE . EXCL EL DISEASE - EA EMPLOYEE $ OTHER DESCRIPTION OF OPERATIONSA.00AMONSNEHICLES/SPECUIL ITEMS ELECTRICAL WIRING Gatewood Homes Inc. 1600 Falmouth Road Ste 25 Centerville MA 02632 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, TITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE — .A i —xt i, � �� "`£ � f ..+-K . 3N y> 4� �- l a, if wP."aSS 'sy F• 4'"'-am JY S' � h. x �w �tI -i 4 .+. ^t" � .. CER2IFICATE OF I f ISSUE DATE (MM/DD... / c afr .. .: k. v,''+ �.r, . .vx. ,.:F ,.0 ,N,. _... .a'"'i''rp$'x,.' {`n '-*, -. ,k. w .. } �• _ >.} 1 £F£ 08/03/2004 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND Harold H Williams Ins Agcy Inc CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE . DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE 81 Bassett Lane P OLICIES BELOW. Hyannis, MA 02601 COMPANIES AFFORDING COVERAGE INSURED Stephen M. Childs COMPANY A A.I.M. Mutual Insurance Co 145 Cammett Road Marstons Mills, MA 02648 40(t may}, �(�(,} _s- a@, �. - ''�E T ': 'cx*-.cla,s�,"^ r u„• .t -, J u 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 RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY TIM POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPI8AT10 I.II11I1'S . DATE(MMIDD/YY) DATE(MM/DD/YY) GENERAL LIABILITY GENERAL AGGREGATE S PRODUCTS-COMP/OP AGG. S COMMERCIAL GENERAL LIABILITY MS MADE�DCCUA PERSONAL&ADV. INJURY S EACH OCCURRENCE S OWNER'S & CONTRACTOR'S PROT. FIRE DAMAGE (Any one fire) S ED. EXPENSE (Any one person) S AUTOMOBILE LIABILITY SINGLE S ANY AUTO DINED ALL OWNED AUTOS BODILY INJURY S SCHEDULED AUTOS (P.P..) HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS Per=idem) GARAGE LIABILITY PROPERTY DAMAGE S LESS LIABILITY - EACH OCCURRENCE S BRELLA FORM GGREGATE S HER THAN UMBRELLA FORM WORKER'S COMPENSATION AND X WC STATU- OTH--'- EMPLOYERS'LIABIL, S A THE PROPRIETOR/ 7015793012003 12/13/2003 12/13/2004 EL DISEASE —POLICY LIMIT S 5W OW PARTNERS/EXECUTIVE INCL OFFICERS ARE: X EXCL EL DISEASE —EA EMPLO-EE $ I OO OOO OTHER DESCRIPTION OF OPERATIONS/LOGITIONS/V MCLES/SPECIAL ITEMS CERTIFICATEOLDER , _ CANCEL LATION ter- r?r r 4 z SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE GATEWOOD HOMES, INC. i' EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL, ENDEAVOR TO -`-' MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR 1600 FALMOUTH ROAD, SUITE 25 JIA ILITY OF ANY KIND UPON THE COMPANY, ITs AGENTS OR -5' REPRESENTATIVES. CENTERVILLE, MA 02632 x' AUTHORIZED REPRESENTATIVE --------------------------- .. �. ram. '-L '.... ,... ..i3'+e wY•F �-wY '...x. +[I+v `c'}.m.. .eL'.,.'�L°1fA o�.i. . ��-..r-2.�--S�"-T .._'w p_.._c .L �v .. 'E�'.+. ... A. CO.Ra CERTIFICATE OF LIABILITY INSURANCE 8/2/2004 DATE(MM/Da'V- ) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Mc Shea Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON .THE CERTIFICATE 749 Main Street Suite#H HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Osterville, Ma.I02655 508-420-9011 INSURED . Casperson Overhead Doors Box 517 East Falmouth, MA 02536 508-563-5633 INSURERS AFFORDING COVERAGE wsURERA: Worcester. Insurance INSURERS: Natinnal fora n,re. NAIC# THE POUCIES 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 LIMITSSHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSRrAGGREGATE LTR E INSU7F-1 POLICY NUMBER pOAL MEEMfDOCTNE PDATE MM/DI D nONK LIMBS ITY RENCE E 1,000 C AL GENY Dccvence S 100 OO MADEUR one per;Dn) S 10,00ACB 2J1973 05/28/04 05/28/05 DVINJURY S 1 000 00, GREGATE S 2 OOO, OOI TE LIMER: OMP/OP AGG S Z, OOO OOI Pe T LOC ANYAUTO ALLOWNED AUTOS SCHEDULEDAUTOS HIRED AUTOS NON-OWNEDAUTOS GARAGE LIABILITY tANYALITOLLA LIABILITY CLAIMSMADE E S WORKERS COMPENSATIONAND EMPLOYERS LIABILITY ANY PROPRIETOR ARTNERfMCUnVE B OFFICER/MEMBER EXCLUDED? Ifyes•desWbeundef SPECIAL PROVISIONS bebw OTHER COMBINED SINGLE LIMIT (Ea accident) IS S " BODILY INJURY (Per Pa ) S BODILYINJURY (Peraccident) E PROPERTY DAMAGE (Peraccident) • AUTO ONLY-EAACCIDENT $ S OTHERTHAN EAACC AUTOONLY: - AGG E EACH OCCURRENCE E AGGREGATE S - E S E x TORYLIMITS OER 8352 02/22/04 02/22/05 E.LEACHACCIDENT E 500,000 • EL DISEASE- EA EMPLOYE $ SOO 000 EL DISEASE. POLICY LIMIT E 500 000 IISION3 Anl1Fr1 RV FNl PQ=\/CATIcovn... ............�.._ _ Gatewood Homes, Inc. 1600 Falmouth Rd., Ste. 25 Centerville, MA 02632 ACORD25 (2001/08) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO 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, fTS AGENTS OR AUTHORIZED 1988 AC =7 CERTIFICATE OF LIABILITY INSURANCE DATE(MKVo/n-M 08/02/2004 - PRODUCER (781)431-9800 FAX (781)431-0222 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Cochrane & •Porter Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE o Renaissance Alliance Ins. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR CIALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. g81 Worcester Street Wellesley, MA 02482 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: OneBeacon American. Ins. Co. 20621 Cape Cod Ready Mix, Inc. INSURERB: Commerce Insurance Company 34754 300 Cranberry Highway INSURERC: Zimmerman Specialty Insurance ZSI001 Orleans, MA 02635 INSURER D: INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTW ITHSTANDIN, ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY A ICIES, THE IN E LIRANC SHOWN AFFORDED BY THE BEEN RIES DESCRIBED PAIDHEREIN IS CLAIMS- SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH INSR ADDI TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION 01/01/2005 LIMBS A GENERALUABILITY - X COMMERCIAL GENERAL LIABILITY CLAIMS MADE I I OCCUR - CBR817036 01/01/2004 EACH OCCURRENCE S 1,000,00 DAMAGE 70 RENTED S 100,00 MED EXP iAny one person) S 5' 00( PERSONAL C ADV INJURY $ 1 , 000, 00( GENERALAGGREGATE $ 2,000,00 GENT. AGGREGATE LIMIT APPLIES PER POLICY JECT LOC PRODUCTS -COMPIOP AGG S 2,000, 00( B AUTOMOBILE LIABILITY ANYAUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS XY9014 - 01/01/2004 01/01/2005 COMBINED SINGLE LIMB (Ea accident) S 11000,00( BODILY INJURY (Per person) S X X BODILY INJURY (Per accidert) $ X PROPERTYDAMAGE (Per acadelt) S GARAGE LIABILITY ANY AUTO AUTO ONLY. FA ACCIDENT $ OTHER THAN EAACC AUTO ONLY: AGG -S S -C EXCESSIUMBRELLA LIABILITY X OCCUR ED CLAIMS MADE DEDUCTIBLE RETENTION S BE9744481 01/01/2004 01/01/2005 EACH OCCURRENCE s 1,000,000, AGGREGATE Is 1.000.000 SIR s 10.000 S $ WORKERS COMPENSATION AND EMPLOYERS' UABILITY ANY PP.OPRIETORIPARTNER'EXECJT'VE OFFICFJLMEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below WC 5i:ATU- OTH- F—L EACH ACCIDENT S E.L DISEASE - EA EMPLOYEE S EL DISEASE- POLICY LIMIT s OTHER DESCRIPTION OF OPERATIONS I LOCATICNS I VEHICLES EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Gatewood Homes, Inc. 1600 Falmouth Rd. Suite 25 Centerville, MA 02632 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NA14D TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL STROBE NO OBLIGA OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS CR REPRESENT S. AUTHORIZED REPRESENTATIVE .. If 25 (2001l08) ,,- %'ORD CORPORATION 1988 V. C -EUL CERTIFICATE OF LIABILITY INSURANCE DATE(MWCD(YY) PRODUCER�� 08/02/04 The Fel et (berg Company THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY 222 Milliken Blvd. HOLDER.NTHSO NFER CERTIFICATE (DOES NOT AMEND,CEEXTENDA R P.O. Box 3220 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Fall River, MA 02722 INSURERS AFFORDING COVERAGE INSURED - Cape Cod Ready Mix Inc, wsURERA: Construction Industries Compensation PO Box 399' INSURER B: " Orleans, MA 02653 INSURER C INSURER D: nnven. r.INSURER E. THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDIN( ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED Of MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCI POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. SR fR TYPE OF INSURANCE POLICY NUMBER PCUCY EFFECTIVE POLICY EXPIRATION GENERAL UABIUTY DATE M/D DATE M/DDIYY LIMITS COMMERCIAL GENERAL LU1B ILrIY EACH OCCURRENCE § J CLAIMS MADE FIRE DAMAGE (Anyone fire) § OCCUR I� MED EXP (Any one Person) S PERSONAL, ADV INJURY § GENL AGGREGATE LIMITAPPLIES PER- GENERAL AGGREGATE S OMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS GARAGE LIABILITY ANY AUTO I ' EXCESS LIABILITY OCCUR CLAIMS MADE L IDEDUCTBLE . RETENTION § A I WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OTHER COMBINED SINGLE UMIT (Ea accident) S BODILY INJURY (Per person) $ BODILY INJURY (Per accident) S PROPERTY DAMAGE Is (Per accident) AUTO ONLY - EA ACCIDENT S OTHER THAN EA ACC S AUTO ONLY: 01/01/04 I01/01/05 X WC STATI EL EACH ACC E.L DISEASE EL DISEASE DESCRIPTION OF OPERATION57LOCgTiONSNEHICLEStEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Gatewood Homes Inc. 1600 Falmouth Road Suite 25 Centerville, MA 02632 ----------------- SHOULD ANYOFTH E ABOVE D ESCRIBED POLICIES BE CANCELLED BEFORE TH E EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL3Q_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDERNAMEDTOTHELEFT, BUTFAILURE TODOSOSHALL IMPOSE NO OBLIGATION OR LIABILITY OFANYKIND UPON THE INSURER,ITS AGENTS OR ACORD 25-S (7/97)1 of 2 4S61300/M55627 CL3 0 ACORD CORPORATION 1988 Aur(13-04 02:42pm F rom-A I G 273-316-6903 T-270 P-002/002 F-481 2 ZVF�- -'* �-lltwt .-%t. ATE-01 ANS• j.. ... . �RT" PRODUCER THIS C Th ICATE IS ISSUED A MATTER OF INFORMATION ONLY AND ( ONFERS NO RIGHTS UPON THE CERTIFICATE 0 Dias Ins Agency Inc HOLDER. TI- IS CERTIFICATE DOES NOT AMEND, 535 Brayton Avenue ALTER r: EXTEND OR 1E ALTER THE.:OVERAGE ;OVERAGE AFFORDED BY THE POLICIES BELOW - Fall River, MA 02721 COMPANIES 'AFFORDING INSURANCE INSURED COMPANY GRANITE STATE INSURANCE COMPANY Ela Carpentry Inc 100 West Main Street, St lo Hyannis. MA 02601 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED ;tLuw HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOT WITHSTANDING ANY REAL REMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TOWHICH THIS CERTIFICATE MAYS; ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED THE-.. POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. E -CLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED By PAID CLAIMS. Lm YkRs* U`4BILrry PROPlummm 0 EXCL 0 C Group . 1 0085615 %a ApprK* to MA Opa uOwy. CERTIFICATE HOLDER GATEWOOD HOMES 1600 GALMOUTH ROAD. SUITE 25 CENTERVILLE. MA 02632 7/24/2004. 7/24/2005 ACCIDENT SE POLCY LWT CANCELLATION "ULD ANY OF THE AOC /E DESCRIBED POLICIES BE CANCELLED Pn BEFORE THE O(PIPATION GATE THOU )F. THE ISSUING COMPANY WCLL ENDEAVOR To MAX.,, DAYS WRrn'N NOT" 7 'THE CFRTWICATE HOLDER NAMED To THE LEFT. BUT FALURE To MAR SUCH K' RICE SHALL IMPOSE NO OQL)GATK)N OR LIABILITY OF ANY )ONO UPON THE COL 'ANY. ITS AGENTS OR REPRESENTATIVES. ----------------- AUTHORIZED REPRt S /E S ltj* V V. L7I V: 1V.VV .•n,� JUO/DUuaY`J bULVX N ASSOC Al�flS7f�CERTIFICATE 7 i� LIABILITY s17�{.i i�i�rEDATEIiAABOtnvy"r. ra ■ y a aayv CSR a3 VV 23 04 GwDti50 ^ P OLD #N13 CER7�€ICAS£-I^s!3$l!$D tSS.46VkxFEPt CF )ue �u VINANCI & A330CIrs I I275II3ANC8 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE RZNIA;TCZAL 38Ai7ZCS3 IN.-. HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR 933' #iuTmD iN- D s ALTER-TWV FYAMvIS w 02601 ' Phomsf50a-775-6alQ J."S7;mRsAFFORDING CaVERAGE fNgIII 6, INBUOC^ -- INSURERA: ESSEX INSURANCE ee VmRBR e: AZi'a k- '—j mL lxsu: is w4c3 CO. O DwI llb OVATIONS INCBOX L+suaERt: ¢8a=^MDT 93AC3 MM-L 02562 INSURER e THE POLICIES OF INSURANCS LISTED BE10W HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NOICATEO. NOTWITHSTANDING ANY RE�-UIREMe4T. TERM OR COND=N CF AW CONTRA^T OROTl-.R oocLr4SM WITH RE$PE.-T TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THM NSURANCS AeFQ=ffD BYTE E^L== DESCBBED GEgs :S ,WB,M1CT TGALL THT. TEML% DMUS -NSA=000 DiTrMS C-r S1CH POLICES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN R[DUCEDBY PAID CLANS LTR TYPE OF MSI.•iA/1C8 IPDUCYNUM89T DATEffIE•DO/WI DATE LIMITS A DEtNERAL'LLAmui7 Y COMMERCIAL GENERAL LIABILITY 7-wDts MADc ®occua 3CH2718 - 12/12/03 12/12/04gGREPAL EACH OCCURRENCE 13100ocoo Aomranexi 550000 •m Pm ) 45000 ACV •1AIRY f l000O00 GREGATE s 20-000TTQ-. GEWL AGGREGATc LIMIT APPLIES PER POLICY ( JECT I LOC PRODUCTS-COMMOPAGG S 1000000 ADTOMOBLE UAB•JTY ANY ALL OWNED SCHEDULED AUTOS AUTOS NREDAUTOS NO N1iGiNF3 AUTOS(Pr . COMBINED SINGLE LIMIT fEi icdmO S IRV 00 134) _ BODILY N.AIRY acld•nti S PROPERTY DAMAGE I � e-4G-9�IILJ S ....G.. :E t7AmLITY A.UYdLlTC I AUTO C;.'lY-EA ACCIDENT S CTHERTHAN EAACC AUTO ONLY: EGG S 9 E%QMKMQR6j_4A U AA LRY OCCUR CLAIMS MADE DEDUCTIBLE RETENTION i EACH OCCURRENCE S A66G�[TE S f f B WORKER! COGI EMUTION AND FLIPLOYERS LIABILITY AwrRGeRr. ,rr„�P- „vnY, OFFICERIME BE't. EXCLUDED?trm '=Unszs 1oiw #16007016018012004 01/03/04 01/03/05 1 TM UNITS ER EL EACH ACCIDENT 9100000 El DISEASE-EAEMPL s SOOaOa' E.L. DISEASE-rOLICr LIMIT s500000 17 ER— - — CEBORI�bN�OPERAYlON3/LDCAYION3/{rceiiCLe'%IEACiIEdTiNiSADCs7i BY cNBtiR9Ei.cNi/SPECIAL PROiTIi7ii9 GATZWOOD IMMIMS INC FAY 508-798-5803 1600 F..:..n"" Tz ROAD CSNT]MVILLN 14A 02632 G&qn a .HIMI DA.:70E THE .-4^YEMESCItME11 ECG,= Co. CA---V- D=�f.T'M7 DATE THEREOF- THE I56lENG USURER WILL=4DE&VOR TO N!!L 30 DAYS WRITTEN NQMA TO THE ieL0VICATS POWER NAAK9 TO THU LEM BUT FAILURE TO go ea-M4ALL IMPOSE NO OBLIGATION OR LIABILRY OF ANY WIN UPON THE I1$IiIRER� R� A(�EM� ( ACORD 25 (2001/OS) CI ACORD CORPORATIOWIM b/4/U4 'L::il': 35 NM 4154 ® 02/03 coRQ CERTIFICATE OF LIABILITYINSURANCE DATE (4/2o04 •RODUCER'(508) 540-2400 FAX (S08) 760-1988 - Murray & MacDonald Insurance Services 406 Jones Road Falmouth, MA 02540 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE " HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # Douglas MacDonald MSURED TRACY HOWERTDN PO BOX 15S1 MASHPEE, MA 02649 INSURERA: Hartford Fire Ins co 196g�" INSURERS: Liberty Mutual Ins Corp INSURER C. INSURER R INSURER E. !`AVCaACCC THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PEMOD INDICATED. NOTWITHSTANDING: ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY SE 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 UAAITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION A GENERAL UABBITY COMMERCIAL GENERAL UABIUTY CAMS MADE ❑ OCCUR 08SOAKR7945 10/02/2003 1 LIMITSs0/02/2004 EACH OCCURRENCE § 500" DAMAGE TO RENTEO § 300 MED EXP (MY we pusue) § 10'. PERSONAL SADV INJURY § 500 " - GENERAL AGGREGATE § GEN AGGREGATE L APPLIES PER POLICYPFO_ POLICY 0. .IPT LOC PRODUCTS-COMPIOP AGG § 1 000 AUTOMOBILE LABRI[Y ANr AUTO - COMBINED SINGLE UMIT {Ea ecdeenl} § ALL OWNED AUTOS BODILY INJURY (Per parson) § SCHEDULED AUTOS HIRED AUTOS BODILY INJURY (Per aorsfenit § NON-0WNED AUTOS � PROPERTY DAMAGE (Per nddenU § GARAGE LIABILITY ANY AUTO AUTO ONLY -EA ACCIDENT S OTHER THAN EA ACC § AUTO ONLY: AGG § EXCES&UMBRELLA LNBLAJ OCCUR C CAMM S MADE EACH OCCURRENCE § AGGREGATE § § DEDUCTIBLE RETENTION S § WORKERS COMPENSATION AND EMPLOYERS' LIABILITY WC131S317310021 10/OS/2003 -10/05/2004 WC STATU• OT B ANY PROPRIETOR/PARTNER/FXECUTNE OFFICEWMEMBER EXCLUDED? E1. EACH ACCIDENT § 100, E.L. DISEASE -EA EMPLOYE § 100 ITYM des .antler SPECIAL PROVISIONS ae1W E.L. DISEASE -POLICY LIMIT § S00, OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATF 1In1 nFa GateA'Cod Homes Jeffrey SolioMs 16 Falmouth Road Suite 25 Centerville, M4 02632 ACORD 25 (2001/081 FAX: (508)778-S603 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _lO _ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, SLIT FAILURE TO MALL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY MIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. AUTHORMEDREPRESENTATIVE Claudine Wrighter/COW 24�&A 1515 40AGOHD CORPORATION 1988 K 1 Vtlf K 15K 51- tC; I RL I STS RIDER RISK SPECIALISTS INSURANCE AGENCY, INC. P.O.BOX 115 1 508 564 7272 P.01i02 -,.,,:^ QATEIEEMmelrrl a.� 07/28/04 TE IS ISSUED AS A MATTER OF INFORMATION INFERS NO RIGHTS UPON THE CERTIFICATE CERTIFICATE DOES NOT AMEND. EXTEND OR CATAUMET, MA 02534-0115 A SCOTTSDALE INSURANCE COMPANY INSURED __:.... 7COIAPANY� MONUMENT INSULATION, INC. .. .. �- RICAN HOME INSURANCE COMPANY 223 COUNTY ROADBOURNE, MA 02532 COMPANY THIS IS TO CERTIFY THAT THE POLICIES Of INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORHE POLICY PERIOD INDICATED, MAY B { ISSUE NO 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-kEREW-.IS_$OgjECT-TO-AI I IH TERUS EXCLUSIONS AMC) CONDITIONS OF SUCH POUCIES. UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO LTR TYPE Di NIELMAAICE POLICY NUMBER POLICY EFFECTIVE_. ~._. GENERAL LIABILITYGATEBMMIDDI DATEtMMIDDrM VIII X COMMERCIAL GENERAL LIABILITY GENERAL AGGREGATE. 61,_000, 004 CLAwE MADE rvi PRODUCTS: COMPIOP AGO $500, 000 2T+OWNEq'SB CONTRACTOR'S PROT CLSS OO17O5 PERSONAL a ADV INJURY 6500,000 3/30/04 3130/05 EACHOCCVR--CE :SOO, 000 ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS GARAGE LUMILITY 71 ANY AUTO EXCESS LIABILITY UMBRELLA FORM OTHER THAN UMBRELLA FC WORKERS COMPENSATION AND CAKOYERIP UAIR TTY B THE PROPRIETOR/ �y PARTNERSIEXICUTIVE I-=`. INc, I WC 768 29 54 Exa j FIRE DAMAGE IAAY OAS Rrq I E 5 0. 0 0 6 MEC EX IAA"OM pR{OnjF7s- COMBINED SINGLE LIMITBODILY III IJBY LPN POISONBODILY INJURY tPm .mamm PROFERTY DAMAGE AUTO ONLY - EA ACCIDENT OTHER THAN AUTO ONLY: ~� EACH ACCIDENT -' F AGGREGATE F EACH OCCURRENCE -... EL 3/5/64-.. 3/5/OS EL .IOENT S1OO. POLICY LIMIT EA EMPLOYEE 21 fln _ GATEWOOD HOMES SHOM ANY OF THE ABOVE DESCRIBED ►DUCTE3 BE CANCELLED BEFORE THE 1600 FALMOUTH ROAD #25 EXPIRATION DATE THEREIF' THE 133MG COMPANY. WALL. ENDEAVOR TO MAIL CENTERVILLE, MA 02632 10 DAYS WRITTEN NOTICE TO THE cram ICATE HOLDER NAMED TO THE LEFT. BUT FAIWRE TO MAIL SUCH NOTICE SEIALL RKPOSE NO OBLIGATION OR LIABILITY OF ANY KIND USeN rue -- VV .VVVGyJ 6UL,UXAN ASSOC PRODIXER t. (�ERTIFICATE OF LIABILITY INSURANCE R,rg- do ASSO� =AT8S =SURANC$ CSR As A SlnM: CSS �C 3 TACSR THIS CERTIFICATE IS ISSUED AS A I�MTTER OF NrF ONLY AND CONFERS NOOtTHA).HOLDER R. 026 )1 THIS C RIGHTS UPON THECERT ALTER THE CO ERTffiCATE DOES NOT ASAEND6 ��r'E �-775-6010 Faxa508-790-0249INSURERS CORDED BY TH AFFORDING COVERE INSURER A: L`HA C10 SiANZCAL SYST8FS5wsI+RERe: 80)IDgR I,ANE y _ INSMERa. -INS CO TMA 02668 COVERAGESTHE DISURER D: lTSURER E: POLO" OF: ANYREOUIREMS rt SVRAt �E MISTED BELOW HAVE BEEN L93UED TO THE wSURED NAME° N E FOR MAY PES. THE e15uw NCE THE POLICY PERIOD INDICATED, NOTWTIHSTANOING 8V THE PCOOL�iGES Oq GTHER DOCITMENT WTIN M'DlIGES. AGGRf GATE LB IT5 SHOWN MAY HAVE °ESCMOM HEREIN IS SUB.IECTR Tp A TO WNICN THIS CERTIFICATE KA ' BE 1BSUED �� M LTR BYPAD CLAMS TYPE O ' NSURANCE OR THE ��S. e=LLSCUS AND CONDITIONS OF SUCH t GEHEWIL HABIT TY POLICY M1NeER DATE MllflD } r A X CCIMERCULGENERALLIABIUTY iFL8172 DATE AMID UNITS EACH CLAM MADE a) OCUMIR 11/21/03 11/21/04 e�ena S MED E71P WW idle peson) s. GF1fL AGGREGA uMR PERSONABADNRRYI 5 pm. PC PRO. JE�CT LOC GENERALAGt,'itEGATE S: AUfOM2ME Iy M-ny - PROOU;7S. COMROP AGG S; AN AUTO AU. OWNEL AUTOS - COMBIINESINGLE LINO l SCiEOULE[ AUTOS MINIM= S BOOIL+aenINJUR l i NCNpWNE IAUTOS - rj —� BOO,LY OWAY (Peral:cieenq S GAAAG f LLMW y PROPERTY DAMAGE l ) ANYAUTO AUTO ONLY. FA ACCIDENT �... Rise AAMREE LALIABILTTY OTHERTHAN FAACC S OCCUR CLAWS MADE AUTO ONLY: AGG S-... . EACH OC�� l DE]UGTIBL AGGREGATE .L ... RETENTIONWORKERS S S IONAND S B EMPLOVERSa.1q AFFjC RIEIOPJP,I+NFp ^unvE �7278A84903 oFFICE(LMEr ( l TOHvuMrtS ER 05/03/04 IMCI ■ eesabe SIO MTMansroNSIy,, 05/03 /OS EL EACHACdDENT s10C arm" ortlER E1 p156ASE-EA EMPI°y lion t f Q02 OR NAIC III 00 .Gr ULUt I f ATION GATSSFOOY OFTFEABOVEDE4CRIBmOF. THE ISSUING INSURER WRl I3IDEA °B�O�THE ExPIRATroN GATBWOIID HONESINC Yet TO MAIL 1a1600DAYS *11ITTEN FAX 5F:-778-5603 "TAMED TG TMLEFTORLtMUTy ,�F,yLURE TO pp�� S+MODT$ ROAD REPRESENTATNE&ANY 1ORDWDN THE IN3UREICMTSATERTS U1t_. CENTER SILS 02632 PROPERTY ADDRESS; %a/ camos� ALCULATION FOR PERAiT COST TYpE OF ROt EZ.0 2 =_ �,� • $3 2 Z Q�. �o ADDITION 6S ALTERATIONS BATH �lJ• BED ROOM CERTIFICATE OF OCCUPANCY " COMPUTER ROOM �. QECK naCw� MMOLITION DEN DINING ROOM FAMILY ROOM FIREPLACE FOUNDATION ONLY GARAGE NO.OF BAYS E GREAT ROOM KITCHEN LAUNDRY ROOM LIVING ROOM _ . MUD ROOM .OFFICE PORCH CLOSED PORCH OPEN REROOFING SUN ROOM NO a TOWN OF YARMOUTH WATER DEPARTMENT 99 Buck Island Road West Yarmouth, MA 02673 Telephone: (508) 771-7921 • Fax: (508) 771-7998 Letter of Water Availability Date of Issue: February 2, 2005 1. Single Family Dwelling X 2. Duplex Family Dwelling 3. Condominium Dwelling 4. Commercial / Industrial 5. Other (Specify) Reference; Massachusetts General Laws Chapter 40, Section 54 To: Town of Yarmouth Building Inspector Please be advised that the Town of Yarmouth public water supply is available to service lot / parcel (s) 21.1 C/126; Street: 121 Camp Street, W. Yarmouth As shown of Assessors sheet / map 44. Issuance of this Letter of Availability is subject to the following provisions / restrictions: (1) The property owner agrees to comply with all federal State, and Local Laws, Rules and Regulations as they pertain to the use of the public water supply. (2) The Yarmouth Water Department shall have exclusive rights as to the size, number, type and location of all water service lines, fire service lines or appurtenant items connected to the water distribution system. (3) The Yarmouth Water Department reserves the right to require, at the property owner's expense, the installation of water mains and appurtenant items to meet water demands requisites within any structure relevant to this Letter of Availability. (4) This Letter of Availability will expire 180 days from the date of issue I have read and understand the provisions / restrictions of this Letter of Water Availability. Owner (sign) Am toN:\Water Availibility\121Camp#126.doc of TOWN OF YARMOUTH _ Building Department Town Hall Yarmouth, MA 02664 (508) 398-2231 ext.261 BUILDING PERFAIT TRANSMITTAL Temp Permit No.: T-05-387 Applicant Name: Frank Capra Applicant Phone: 5087789669 Building Location: 00121 CAMP ST Unit 126 Owner's Name: Villages Q Camp Street., LLC Owner's Addres 1600 Falmouth Road # 25 Centerville MA 02632 1 Owner's Telephone: (508) 778-9669 (OFFICE USE ONLY Recorded By: IC Permit Fee: $0.00 Deposit Rec: $0.00 Payment Type: Check ChkNo.: 0 Net Owed: $0.00 Application Date: 1/31/2005 Issue Date: Expiration Date %.V111111C11L5: new construction: REVIEWED BY: 1. WATER DEPARTMENT: c DATE: N/A: 2. ENGINEERING DEPARTMENT: DATE. N/A: 3. CONSERVATION: DATE: N/A: 4. HEALTH DEPARTMENT: DATE: N/A: 5. BUILDING DEPARTMENT: DATE: N/A: 6. FIRE DEPARTMENT:. DATE: N/A: PLEASE NOTE COMMENTS: RECEIPT OF COPY: SIGNATURE OF APPLICANT: U44.21.1.0 DATE: Date Printed: 1/31/2005 001 lul tl jGWN R) m0.4' ' LOT 2 I�JJ•- n�30'00 PROPOSLATERAL SEWER ZZ PROPOSED HOUSE EU ETi G . 16 LOT 127 '+ 55:. 55.00 ' 226.13 �N80'21 42"E GRAPHIC SCALE 10 0 20 ( IN FEET ) 1 inch = 20 fk r.�lcku -- �70.00 C, 36.91 26 . N L PROPOSED ( 0PL �G 3;6` �.,. 1 LET 126 W 61.23' _80.21I It / NOTE: ® SEWER LATERAL SHALL BE SLEEVED IN ACCORDANCE WITH TITLE$1�IFj WITHIN �IDFTI- WA1�E MAIN. R= L= PLOT PLAN holmes and mcgrath inc. OF LOT 126TIMOTHY tip. `� a civil engineers and land surveyors -IF sANTos PREPARED FOR U N0.45078 , 362 gifford street A CIVIL MILL POND VILLAGE Po 9Fc s7EF�° IN falmouth, ma. 02540 �F YARMOUTH, MA JOB No: 201197 DRAWN: LMC SCALE: 1 "=20' DATE:12-29-04 DWG. NO.: A2513 CHECKED: 7nl. MAScheck.COMPLIANCE REPORT I I Massachusetts Energy code I I MAScheck Software Version 2.01 Release 2 I Permit # I I 'I I Checked by/Date I CITY: Barnstable I STATE: Massachusetts HOD: 6137 CONSTRUCTION TYPE: 1 Or 2 Family, Detached HEATING SYSTEM TYPE: other (Non -Electric Resistance) DATE: 4-21-2004 DATE OF PLANS: 04/21/04 TITLE: The Egret PROJECT INFORMATION: Mill Pond Village 1600 Falmouth Road Unit #25 Centerville, MA. 02632 COMPANY INFORMATION: Northside Design ASSOC. 141 Main Street Yarmouth Port, MA. 02675 COMPLIANCE: PASSES Required UA = 216 Your Home = .123 Area or cavity Cont. Glazing/Door ---------------------Perimeter--R_Value R-Value U-Value UA ---------------------------62-- CEILINGS 832 30.0 30.0 14 WALLS: wood Frame, 16" O.C. 1409 15.0 15.0 GLAZING: Windows or Doors 87 0.340 30 GLAZING: Windows or Doors 40 0.340 14 DOORS 40 ----------------------------------------- 0.086 3 ---------------------------- COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans,. specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate, has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the design load as specified in Sections 780CMR 1310 and J4.4. Builder/Designer Date Massachusetts Energy code MAScheck Software version 2.01 Release 2 The Egret DATE: 4-21-2004 Bldg.l Dept.I use I I CEILINGS: [ ] I 1. R-30 + R-30 I Comments/Location I I WALLS: [ ] I 1. wood Frame, 16" O.C., R-15 + R-15 I comments/Location I WINDOWS AND GLASS DOORS: C ] I 1. U-value: 0.34 I For windows without labeled u-values, describe features: I # Panes Frame Type Thermal Break? [ ] Yes [ ] No i Comments/Location C ] I 2. u-value: 0.34 I For windows without labeled u-values, describe features: I # Panes Frame Type Thermal Break? [ ] Yes [ ] No I Comments/Location DOORS: C ] I 1. u-value: 0.086 I Comments/Location I I AIR LEAKAGE: [ ] I joints, penetrations, and all other such openings in the building I envelope that are sources of air leakage must be sealed. When I installed in the building envelope, recessed lighting fixtures I shall meet one of the following requirements: I 1. Type IC rated, manufactured with no penetrations between the I inside of the recessed fixture and ceiling cavity and sealed or I gasketed to prevent air leakage into the unconditioned space. I 2. Type IC rated, in accordance with Standard ASTM E 283, with no I more than 2.0 cfm (0.944 L/s) air movement from the the i conditioned space to the ceiling cavity. The lighting fixture I shall have been tested at 75 PA or 1.57 lbs/ft2 pressure difference and shall be labeled. I VAPOR RETARDER: [ ] I Required on the warm -in -winter side of all non -vented framed I ceilings, walls, and floors. I I MATERIALS IDENTIFICATION: [ ] I Materials and equipment must be identified so that compliance can I be determined. Manufacturer manuals for all installed heating I and cooling equipment and service water heating equipment must be I provided. Insulation R-values and glazing u-values must be clearly I marked on the building plans or specifications. I. 7 'dUCY INSULATION: Ducts shall be insulated per Table J4.4.7.1. DUCT CONSTRUCTION: All accessible joints, seams, and connections of supply and return ductwork located outside conditioned space, including stud bays or joist cavities/spaces used to transport air, shall be sealed using mastic and fibrous backing tape installed.according to the manufacturer's installation instructions. Mesh tape may be omitted where gaps are less than 1/8 inch. Duct tape is not permitted. The HVAC system must provide a means for balancing air and water systems. TEMPERATURE CONTROLS: Thermostats are required for each separate HVAC system. A manual or automatic means to partially restrict or shut off the heating and/or cooling input to each zone or floor shall be provided. HVAC EQUIPMENT SIZING: Rated output capacity of the heating/cooling system is not greater than 125% of the design load as specified in Sections 780CMR 1310 and ]4.4. SWIMMING POOLS: All heated swimming pools must have an on/off heater switch and require a cover unless over 20% of the heating energy is from non-depletable sources. Pool pumps require a time clock. HVAC PIPING INSULATION: HVAC piping conveying fluids above 120 F or chilled fluids below 55 F must be insulated to the following levels (in.): PIPE SIZES (in.) HEATING SYSTEMS: TEMP (F) 2" RUNOUTS 0-1" 1.25-2" 2.5-4" Low pressure/temp. 201-250 1.0 1.5 1.5 2.0 LOW temperature 120-200 0.5 1.0 1.0 1.5 steam condensate any 1.0 1.0 1.5 2.0 COOLING SYSTEMS: Chilled water or 40-55 0.5 0.5 0.75 1.0 refrigerant below 40 1.0 1.0 1.5 1.5 CIRCULATING HOT WATER SYSTEMS: Insulate circulating hot water pipes to the following levels (in.): PIPE SIZES (in.) NON -CIRCULATING I CIRCULATING MAINS & RUNOUTS HEATED WATER TEMP (F): RUNOUTS 0-1" I 0-1.25" 1.5-2.0" 2.0+" 170-180 0.5 I 1.0 1.5 2.0 140-160 0.5 I 0.5 1.0 1.5 100-130 0.5 I 0.5 0.5 1.0 ----NOTES TO FIELD (Building Department Use Only)-------- Loti,a� Oho-3 &PRODUCT SPECIFICATIONS GMS 9/GCS 9 SERIES 93 % AFUE Multi-P Single -Stage/ Gas Ft Heating ( 46,000-115; Standard Features • Corrosion -resistant, aluminized -steel tubular heat exchanger and stainless -steel recuperative coil for maximum efficiency • Designed for multi -position installation—GMS9: upflow, horizontal right or left; GCS9: downflow, horizontal right or left • Energy -saving, reliable Hot Surface Ignition system, featuring a Norton® Mini -Igniter with patented adaptive learning algorithm to maximize igniter life • Aluminized -steel inshot burners • Energy -saving PSC, multi -speed, direct drive blower motor • Quiet, corrosion -resistant induced draft blower assembly • Integrated furnace control with improved -diagnostics • Low voltage terminal blocks • Multiple flame roll -out switches, blower door safety switch, outlet air -limit switch and pressure switch for proof of combustion air • 40VA transformer for heating and air conditioning control service • Combination redundant gas valve and regulator • Top venting is standard; alternate flue/vent located on right side • Completely assembled, factory run -tested furnace for heating or combination heating/cooling application • All models comply with California NOx Standards • Suitable for direct vent (2-pipe) or non -direct vent. (I-pipe)applications 0101010010 Air Conditioning & Heating The GMS9/GCS9 single -stage, multi -speed gas furnaces offer installation versatility. Cabinet Construction • Heavy -gauge, reinforced, fully insulated steel cabinet with durable baked -enamel finish • Attractive architectural gray paint finish • Foil -face insulation -lined heat exchanger compartment • Coil and furnace fit flush for easy installation • Convenient left or right connection for gas and electric service • Bottom or side air inlet (GMS9) • Removable, solid bottom block -off (GMS9) Accessories • L.P. Conversion Kit (LPT OOA) • L.P. Gas Low Pressure Kit (LPLPOl) • High Altitude Natural Gas/L.P Kits (HANG11, HANG12, HALP10) • High Altitude Pressure Switch Kit (HAPS27) • External Filter Rack (EFROI) • Horizontal Concentric Vent Kit (HCVK) • Vertical Concentric Vent Kit (VCVK) • Internal Filter Retention Kit upflow, horizontal (RF000180) • Internal Filter Retention Kit—downflow (RF000181) • Thermostats Blower Motors (CHT18-60, CH70TG, CHSATG, H20TWR) SS377D w .goodmanmfgxom 6/04 PRODUCT SPECIFICATIONS .Nomenclature LG M S 8 070 3 A N A Goodman® Brand Revision M: Upflow/Horizontal D: Dedicated Downflow C: Downflow/Horizontal H: Hi Air Flow S: Single Stage/Multi-speed V: Two Stave/Variable-soee 8: 80% 9: 90% .t r*D'un 045.45,000 071- 7D,000 090:90,000 115: 115,000 140: 140,000 NOx A. Imbal Release B: to Revision N: Natural Gas C: 21d Revision X: Low NOx. Cabinet Width A: 14" B: 17�fi" C: 21" D: 2*1" Maximum CFM 0.5" ESP 3: 1,200 4: 1,600 5: 2,000 2 C. C PRODUCT SPECIFICATIONS t Performance Ratings " v od a ._.; a u aias 7« ._fx�`'Naural U$E n` x ..+> is aciH {r ,r CPS ° / UE.�r""TssA,Pempr31tur �� 3 a0'�ESP!`;e✓an GMS90453BXA 46,000 42,800 37,200- 93.0 3.0 35-65 GMS90703BXA 69,000 64,400 55,800 93.0 3.0 35.65 GMS90904CXA 92,000 86,000 74,400 93.0 4.0 35-65 GM591155DXA 115,000 106,500 93,000 93.0 5.0 35-65. GCS90453BXA 46,000 42,800 37,200 93.0 3.0 35-65 GCS90703BXA 69,000 64,400 55,800 93.0 3.0 35-65 GCS90904CXA 92,000 86,000 74,400 93.0 4.0 40-70 GCS91155DXA 115,000 106,500 93,000 93.0 5.0 40-70 t For altitudes above 2,000', reduce input rating 4% for each 1,000' above sea level. z DOE AFUE based upon Isolated Combustion System (ICS). Specifications wllw� es .t' Wwo 10" x 7" HP��fera 1./3 4 �t 2" f 33ufh�� .yfptr 2 e �_rat3?htp 288 1Ze, �iM£.�e,vi 5 n'�rtt [fsposab e;p?ttyPotec�ho ey%axt%iar. rs�llldXiillUtr ar� -yh'.t" $q'•` weigh GMS90453BXA 576 9.0 15 132 GMS90703BXA 10" x 8" 1/3 4 2" 3 282 564 9.0 15 135 GMS90904CXA 10" x 10" 1/2 4 2" 4 376 752 8.9 15 158 GMS91155DXA 11" x 10" 3/4 4 2" 5 470 940 12.2 15 175 GCS9D453BXA 10" x 7" 1/3 4 2" 2 288 576 9.0 15L 132 GCS90703BXA 10" x 8" 1/3 4 2" 3 282 564 9.0 15 135 GCS90904CXA 10" x 10" 1/2 4 2" 4 376 752 8.9 15 156 GCS91155DXA I 11"x 10" 3/4 4 2" 5 470 940 12.2 15 175 n Installer must supply one or two PVC pipes: one for combustion air (optional) and one for the flue outlet (required). Vent pipe must be either 2" or 3" in diameter, depending upon furnace input, number of elbows, length of run and installation (1 or 2 pipes). The optional Combustion Air Pipe is dependent on installation/code requirements and must be 2" or 3" diameter PVC. z Minimum Circuit Ampacicy = (1.25 x Circulator Blower Amps) + ID Blower amps. 3 Maximum Overcurrent Protection refers to maximum recommended fuse or circuit breaker size. NOTES: • All furnaces are manufactured for use on 115 VAC, 60 Hz, single phase electrical supply. - • Gas Service Connection rah" FPT • Important: It is required to size overcurrent protection device and wives properly and make electrical connections in accordance with the National Electrical Code and/or all existing local codes. ` PRODUCT SPECIFICATIONS GMS9 Dimensions 3/4 {�19"S —►{ 1R 34 (DISCHARGEAIR) 4 VENT/FLUE PIPE I R R I21 PVC PIPE 21/16 2PVC I AIR 1 2' PVC I ALTERNATE ALTERNATE 47 C 2 W16 .l AIR INTAKE LOCATION GAS SUPPLY I Q- CONDENSATE STANDARD GAS HOLE - DRAIN TRAP SUPPLY HOLE M 314' PVC HIGH VOLTAGE 41I8 DISCHARGE ALTERNATE ELECTRICALHOLE 13'4 RIGHT ORLEC�AION LE LEFTSIDE 1q 4 LEFT SIDE) DEAN LINE HIGH VOLTAGE I&B i ELECTRICAL HOLE HOLES RIGHT SIDE 112 TRAP 21 /t 71DRAW DRAIN LINE �� TRAP HOLES R 301 /9 Me Q ELECTRLOW VOLTAGE 2 LOW VOLTAGE 14 SIDECCCAT-MOLE t9 B o. 113M I ELECTRICAL HOLE SIDE CUT-0UT 13'4 •r� 1t y4 185I8 32t 1 IIy,F SIDE CUT-OUT t W4 L J L J 130 OM _OUT LEFT SIDE FRONT RIGHT SIDE WEW VIEW VIEW +.- Q. �a. GMS90453BXA GMS90703BXA 3:X �'b,` _ 174" ,w -•-: =$7 ,�« 16" �. ..°�" ',K'. >�:'.f'.s�'-11 � -�, 12'/e" z^ a ��s.y"zq�:4;i), .n��.�''-.:. 12'/e" GMS90904CXA 21" 19W, 16%" 14%" - GMS91155DXA 241h" 23" 20'/e" 18%" NOTES: 1. Installer must supply one or two PVC pipes: one for combustion air (optional) and one for the flue outlet (required). Vent pipe must be either 2" or 3" in diameter, depending upon furnace input, number of elbows, length of run and installation (1 or 2 pipes). The optional Combustion Air Pipe is dependent on installation/code requirements and must be 2" or 3" diameter PVC. 2. Line voltage wiring can enter through the right or left side of the furnace. Low voltage wiring can enter through the right or left side of furnace. 3. Conversion kits for high altitude natural gas operation are available. Contact your Goodman distributor or dealer for details. 4. Installer must supply following gas line fittings, according to which entrance is used: Left —Two 909 elbows, one. close nipple, straight pipe Right —Straight pipe to reach gas valve Minimum Clearances to Combustible Materials `� z <.Q id�fi zRea� font r- v FOR � U flow 0"1 0" 3" C I 0" 1" Horizontal 6" 1 0" 3" C 1 0" 4" C = If placed on combustible floor, the floor MUST be wood ONLY. NOTES: • For servicing or cleaning, a 36" front clearance is recommended. • Unit connections (electrical, flue and drain) may necessitate greater clearances than the minimum clearances listed below. • In all cases, accessibility clearance must take precedence over clearances from the enclosure where accessibility clearances are greater. 0 4 C PRODUCT SPECIFICATIONS � r GCS9 Dimensions LEFT SIDE VIEW FRONT VIEW RIGHT SIDE VIEW 3/4 1R12 PIPE -I I �M2' . .(RETURNA1R) PVC%� 2 8 r , CONDENSATE r DRAIN TRAP i LOW VOLTAGE 134 LOW VOLTAGE W3/4'PVC DISCHARGE ELECTRICAL HOLE ELECTRICAL HOLE-- 40 (RIGHT OR HIGH VOLTAGE LEFT SIDE) "6EUECTRICVALL J M/FLUE J 16 HIGHVOLTAGE 28}/18 61/8 LOCATION ELECTRICALHOLE211/18ALTERNATE DRAIN 19718 I + AIR INTAKE LOCATION TRAP 2 &Bat ¢ I yg = 1813/1 PC LEFT SIDE 15112 DRAIN LW - RIGHT SIDE MOLES t11R O 2 14 DRAIN LINE HOLES 11 STANDARD GAS SUPPLY HOLE 41 91 8 O 81/4 9 y4 7 39+I ALTERNATE GAS SUPPLY HOLE HOLE �a-�{I UNFOLDED FANGES 513 C D UNFOLDED FLANGES IS AIR FOLDED FLANGES DISC^�EJ FOLDED RANGEB DISCHARGEAIR " " a e GC590453BXA - 171/1" y_ Y �.,.. 16" 12%P' 141/i" 16" GCS90703BXA 17%" 16" 12%" 141%" 16" GCS90904CXA 21" 191i4" 16%" 18" 191h" GCS91155DXA 241A 23" 20%" 21Y2" 23" NOTES: 1. Installer must supply on% or two PVC pipes: one for combustion air (optional) and one for the flue outlet (required). Vent pipe must be either 2" or 3" in diameter; depending upon furnace input, number of elbows, length of run and installation (1 or 2 pipes). The optional Combustion Air Pipe is dependent on installation/code requirements and must be 2" or 3" diameter PVC. 2. Line voltage wiring can enter through the right or left side of the furnace. Low voltage wiring can enter through the right or left side of furnace. 3. Conversion kits for high altitude natural gas operation are available. Contact your Goodman distributor or dealer for details. 4. Installer must supply following gas line fittings, according to which entrance is used: Left —Two 909 elbows, one close nipple, straight pipe Right —Straight pipe to reach gas valve Minimum Clearances to Combustible Materials �?a3s ta_ SiOe �a sAnt#> nttofttr�'u Y 0" T a rt Downflow 0" 0" NC_ Horizontal 6" 0" 1" C 0"1 4" C = Combustible: If placed on combustible floor, the floor MUST be wood ONLY. NC = Non -Combustible: A combustible floor subbase must be used for installation on combustible flooring NOTES: • For servicing or cleaning, a 36" front clearance is recommended. • Unit connections (electrical, flue and drain) may necessitate greater clearances than the minimum clearances listed below. • In all cases, accessibility clearance must take precedence over clearances from the enclosure where accessibility clearances are greater. 5 PRODUCT SPECIFICATIONS Blower Performance Specifications e'iir1�z b �eta15MtE , TitaCes(dterCoTutnhjsa+ e r�e'1* M- CIS . jdx 1tiS�; cC ? FtTSE� FY1l "6RIS1 ' ,LkMr t)5E Ci M LFM E#Ar G_S90453BXA HIGH MED 3.0 2.5 1,352 ------ 1,214 ------ 1,318 1,172 •----- ------ 1,260 1,123 -•---- ------ 1,202853 1,064 -- 93j (LOW) MED-LO 2.0 997 -•---- 994 ••---• 960 35 923 361'31��j �y[( LOW 1.5 757 44 753 44 734 45 704 47fi20a1q �4 G S907036XA HIGH MED 3.0 1,449 36 1,409 37 1,326 39 1,273 41 MED-LO 2.5 1,192 43 1,172 44 1,141 .45 1,094 47 9 (MED-HI) 2.0 981 53 962 54 943 55 917 563 G4a'6 LOW 1.5 750 ------ 730 --•--- 714 ------ 692 ------ 620 7iY; ©_ HIGH 4.0 1,970 ---•-- 1,874 35 1,757 38 1,667 40gq G_590904CXA MED 3.5 1,713 39 1,650 40 1,572 42 1,510 4433 11(MED-LO) ,7fl-I MED-LO 3.0 1,439 46 1,412 47 1,370 48 1,327 509LOW 2.5 1 183 56 1 155 57 1 122 59 1 108 60 dlsfgy," i1GH MED 5.0 4.0 2,134 1,678 40 51 2,103 1,643 40 . 52 2,029 1,643 42 1,941 44 '- 5V g �71�flxj�MllG_S91155DXA 52 1,577 54 (MED-HI) MED-LO 3.5 1,453 58 1,440 59 1,426 59 1,363 62 LOW 3.0 1 259 67 1 239 68 1 220 70 1 181 2 a NOTES: 1. CFM in chart is without filter(s). Filters do not ship with this furnace, but must be provided by the installer. If the furnace requires two returns, this chart assumes both filters are installed. 2. All furnaces ship as high speed cooling. Installer must adjust blower cooling speed as needed. 3. For most jobs, about 400 CFM per ton when cooling is desirable. 4. INSTALLATION =S TO BE ADJUSTED TO OBTAIN TEMPERATURE RISE WITHIN THE RANGE SPECIFIED ON THE RATING PLATE. 5. The chart is for information only. For satisfactory operation, external static pressure must not exceed value shown on the rating plate. The shaded area indicases ranges in excess of maximum static pressure allowed when heating. 6. The dashed ( ---- ) areas indicate a temperature rise not recommended for this model. 7. The above chart is for U.S. furnaces installed at 0' - 2,000'. At higher altitudes, a properly de -rated unit will have approximately the same temperature rise at a particular CFM, while ESP at the CFM will be lower 6 Accessories LPT OOA L-P. Conversion Kit i ✓ ✓ LPLP01 L.P. Gas Low Pressure Kit i ✓ ✓ HANG11 High Altitude Natural Gas Kit 1 1 1 1 HANG12 High Altitude Natural Gas Kit 2 2 2 HALP70 High Altitude LP. Gas Kit 2 3 3 3 3 HAPS27 High Altitude Pressure Switch Kit 3 3 3 EFR01 External Filter Rack 3 ✓ ✓ ✓ DCVK•20 Horizontal/Vertical Concentric Vent Kit (2") ✓ i DCVK•30 Horizontal/Vertical Concentric Vent Kit (3") ✓ ✓ Available for this model (1) 7,00l'to 9,000, (2) 9,001' to 11,000' (3) 7,001'to 11,000' ' • Note: Ail installations above 7,000' require a pressure switch change. For installation in Canada, furnaces are certified only to 4,500'. Downflow Floor Base: When the GCS9 model is installed directly on a wood floor a downflow floor base must be used. Those model numbers are: CFB17, CFB21 and CFB24. Thermostats ♦ _'3' k'far .ik3 .s a� .r,�..&'f.#'{ �l-f'�' .D�S.Cf �t10 { •"`�IVE7A7 CHT18-60 Cooling/Heating, Mechanical �^ CH70TG Cooling/Heating,. Digital, Non -programmable f CHSATG Cooling/Heating, Mechanical \'— H20TWR Heating Only, Mechanical 7 G TOWN-OF-YARMOUTH j �, r= II. Jill! OCT 05 7' 6U:'_G,'s C=FT. Builain9— Al : Location New LY Plans Submitted APPLICATION FOR PERMIT TO 00 GASFITTING r(OFOCE USE ONLY) Fee: $ ---- - - - - PERMIT NO. Owne Namerb. Renovation IJ Yes "; No i� Type of Occupancy-z':r-1�-^ Replacement D IL 2, m LU W t z ti O1 ai 11 I LZIO H Z Wor7i iyz j J f' r S O is = u. O SUB•BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RO FLOOR tPRiN1 OR TYPE) Check One: Installing Company Nam?___UAL/ Corp.... Address ..__t.0._-_C-_.>�}J93. ...—s .i`f-1Partnership ��_��.---_.----�-• !.�t�/YL�$r._...—_.. __.__...... Q_..Z._%�1.—_...—__._. "7 Firm/Company-_----.-.---._. L I .. Business TelephoneQ-7•�.�.-(�`L_._—___._ Name cf Licensed Plumber order INSURANCE COVERAGE: Check One I have a current i abrhty insurance policy or its substantial equivalent. Yes Er�No 0 :f you nave checked yes, please inoicate t e type of coverage by checking the appropnere aox. A liability insurance policy Other type of indemnity IJ Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage requaed by Chapter 142 of the Mass. Genera! Laws, and that my signature on this permit application waives this requirement. Check One; _..........._.. _.__..__ ._---- --- _�___.... Owner ❑ Agent Signature of Owner or Owner's Agent t hereby certify that all of the details and information i have submitted Signature o Licensed (or entered) in above application are true and accurate to the best of Plumber or Gasf4tter my knowledge and that all plumbing work and Installations performed %„r ��5 ' under permit Issued for this application will be in compilance with all pertinent provisions of the Massachusetts State plumbing Code and License Number • ... - rvoc 1 if`CUCC•