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HomeMy WebLinkAbout0014 CEDARWOOD ROAD i _�.•.,..i;:� :.._' ... :.. ...�.. ...... �...�.��.. _...ra; '... ., -^SY.tA.�qa� _ �'hI 'i.�K.YS'!ti.1. n+�+q•�..r.-.-++-� :eM TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION t Map TOWN OF SARNSTABI�,plication #�®���q ?6 V y Parcel Health Division 2012 11AR 15 Pal 3: ete Issued a� Conservation Division Application Fee Planning Dept " Permit Fee DIVISION ly Date Definitive Plan Approved by Planning Board G Historic - OKH Preservation / Hyannis Project Street Address 141 e�,O �wooyD Coil' Village a©ZLf Owner ,4-1�,4VGv ,52WeAddress Telephone Permit Request Square feet: Ist floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain _Groundwater Overlay Project Valuation Construction Type Lot Size O�� Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family :a---—Two Family ❑ Multi-Family (# unit )- Age of Existing Structure �� w5' Historic House: ❑Yes o On Old King's Highway: ❑Yes �No Basement Type: O Full tf Crawl 0 Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) C Number of Baths: Full: existing new Half: existing new Number of Bedrooms: c)2— existingonew Total Room Count (not inclu/ding-baths): existing new First Floor Room Count 7 Heat Type and Fuel: GC9' as ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes - o Fireplaces: Existing New 2 Existing wood/coal stove: ❑Yes Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION 7 � /� (BUILDER OR HOMEOWNER) Name �b // - Telephone Number Address �a�� License # i Y-4-V Home Improvement Contractor# &ILa21_ Worker's Compensation # Z_ D/ ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO /Q� SIGNATURE i (� � DATE Dz v 6 FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED s MAP/PARCEL NO. ' ADDRESS VILLAGE, OWNER: DATE OF INSPECTION: FOUNDATION t FRAME 0 - ►� INSULATION FIREPLACE r ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL r , -GAS: ROUGH :,- FINAL FINAL BUILDING. ..a �- a ll�- DATE CLOSED OUT . K ASSOCIATION PLAN NO.. 1 The Commonwealth of Massachusetts ,► ;^ I Department of Industrial Accidents I i >? Office of Investigations U 600 )Washington Street Boston,MA 02111 c www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Legibly Name fBusiness/Organization/Individual): Address: �r Q City/State/Zip: K 7Z60�O��r `Phone Are yo n employer? Check the appropriate box: F oject(required): I. I am a employer with—�� 4. ❑ I am a genera]contractor and I employees(full and/or part-time).* have hired the sub-contractors �Neconstruction 2.❑ I am a sole proprietor or partner- listed on the attached sheet deling ship and have no employees These sub-contractors have olition working for me in any capacity.. workers' comp, insurance. ing addition [No workers' comp. insurance 5. ❑ We are a corporation and itsrequired.] officers have exercised their cal repairs or additions 3,❑ I am a homeowner doing all work right of exemption per MGL ing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t. employees. [No workers' comp. insurance required.] 13.❑ Other ;Any applicant that checks box 9 I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. t6ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: 15 65705760�0�0% Expiration ate: Job Site Address: ( ��i�I"!,/2�/�/ //11 / ///� City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certff undo the pains andpenaltiessoof perjury that the information provided above is true and correct Signature: (_ _ _/x-� ; Ja-f yr i Date: - o7 Phone#: `� �(�ly �— LOth only, Do not write in this area,to be completed by city or town official n: Permit/License# hority(circle one): Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector son: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual, partnership,association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter- 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter info any contract for the performance of public work until acceptable,evidence of compliance with the insurance requirement's ofthis chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s),address(es)and phone number(s) along with their certificates)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would Like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The.Commonwealth of Massachusetts , Department of Industrial Accidents Office of Investigations 600 Washington Street Gaston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-9-77-MASSAFE Revised 5-26-05 Fax # 617-727-7749 wwwmass..gov/dia DATE CERTIFICATE OF LIABILITY INSURANCE �TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 3MATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. MMERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACY BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE �UCER,AND THE CERTIFICATE HOLDER. T>1NIFINT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions tdl@j&y,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). =wR CONTACT NAME: PHONE---- -----------'---- I FAX Risk Insurance Services, Inc. (A/c,No.Ex1y (-87-7)-23.4=442-0�1(AIC•No) (-8-7.7-)-234=4421 Old Mill Rd E-MAIL 41P+ 113E 68154 ADDRESS: PRODUCER CUSTOMER ID# (877)234-4420 INSURER(S)AFFORDING COVERAGE , NAICI 1111111111I INSURER A: -Cont inental—Iademni.t-y—Co--- 2.82511 =oNx, Carey INSURER B: -- — r Buildiw and Relttodeling INSURER C: -�Allibx 1080 INSURER D: 3lft, MA 02635-1080 -- —--- — -- INSURER E: CTL 1273 579907 INSURERF: FMMGES CERTIFICATE NUMBER: REVISION NUMBER: PTO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY ffiWANDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO 33nt,IS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL CMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IKY2 ADDL SUBR: POLICY EFF I POLICY EXP 13& TYPE OF INSURANCE INSR I WVD I POLICY NUMBER MM/DD/YYYY i MM1DD/YYYYl LIMITS LMERALLIABILITY EACH OCCURRENCE Is COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED CLAIMS PREMISES(Ea occurrence) _S j MADE F1 OCCUR I ! I MED EXP(Anruneperson) S - -- � I PERSONAL 6 ADV INJURY IS E GENERALAGGREGATE S E11.,,,c%3ATE LIIniI APPLIES PER: ! PRODUCTS-COMP/OP AGG IS ,POLICY PROJECT( ILOC Is YAM110BILE LIABILITY i ! j COMBINED SINGLE LIMIT XIJY AUTO (Ea accident) PJ-L OWNED AUTOS ! 1BODILY INJURY(Per person 1'--S _ SCHEDULED AUTOS _ :BODILY INJURY(Per acciaent) ,S 'PROPERTY DAMAGE ' j ,ERRED AUTOS l(Per acd , IS _ `NON•OWNED AUTOS I S -- I — ,UMBRELLA LIAR OCCUR ;EACH OCCURRENCE____ IS 'EXCESS LIAB ICLAIMS-MADE —) ;AGGREGATE jS DEDUCTIBLE -- ------- i - _. S JtETENTION S i i ----- --- - -- --is--------- 1-TIM.9MERS COMPENSATION I s ' S'LIABILITY X`WC STATU•Si iOtN-i �MEMPLOYER T RY LIMIT iER I '3!(NOPRIETOR/PARTNER/ I - 4XEC JTNE OFFICER/MEMBER N/A I I I E.L.EACH ACCIDENT Imo- -0-,-0-0-0— @ kIDED? i _---I46-805700-01-04 �08/31/2011 08/31/2012 '(Rsulalory in NH) E.L.DISEASE-EA EMPLOYEE IS llym describe under ! j If F:SPECIAL PROVISIONS below I E.L.DISEASE-POLICY LIMIT IS IJI LiI 1 ffi�W*PTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach Acord 101,Additional Remarks Schedule,if more space is required) CEFMFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Omer Ehli ldinc7 and P"nodelira EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH PO B= 1080 THE POLICY PROVISIONS. Wit, NA 02635-1080 AUTHORIZED REPRESENTATIVE Atta: Project Manager ACORD25(2009/D9) The ACORD name and logo are registered marks of ACORD pt -2009'CORD CORPORATION. All rights reserved. Town of.Barnstable • Regulatory Services t uAs.& g Thomas F. Geiler,Director �'°rEo►�'` Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-8624-03 8 Fax: 508-790-6230 Property OwrierMust Complete and Sign This Section If Using A Builder as Owner of the subject.prvperty hereby authorize to act on ray bebalf' in all matters relative to work authorized by this building permit application for. (Address of Job) S, er D to le Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:F0RMS:0 WNERPERM1SS1DN Town of Barnstable Regalatory Services L uMSTABts, Thomas F. Geiler,Director MLq g 16.1 .� Building Division `rEoy k Tom Perry, Building Commissioner 200 Maig-Street,_Ayannis,MA.02601 nmtown.barnstable-ma_us Office: 508-862-4038 Fax: 509-790-6230 HMMOGVNER LICENSE EXEMPTTON Pleare Print DATE: JOB LOCATION: number street village "HOMEOWNER'': name home phone# work phone# CURRENT MAILING ADDRESS: cityhown state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six Units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFUCnON OF HOMEOWNER Persons)who owns a parcel of land on which he/she resides or intends to reside, on which thrre is, or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constrilcts more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on.a form acceptable to the Building Official. that he/she shall be responsible for all such work performed under the building hermit. (Section 109.1.1) T:kc undersigned"homeowner"asm es responsibility for compliance with the State Building Code and other . applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that.he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Ohara] Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOwI1ER'S Ex3-vmmON .The Code states that: "Any bomeownerr perfomung work for which a building pmniit is required shall be exempt fmm the provisions of this section.(Sectioa I D9.1.1-L.icensifig of construction Supervsors);provided that if the homco�yner engagrs a persons)for hint to do such world that such Homcowna shall act as supervisor.^' 4any homeowners who use this exemption are unawart that they an assuming the responsiblities of a supervisor(see Appendix Q. Auks&Regulations for Licensing Construction Supervisors,Section 2.15) This lank of awarenrss often results in serious problems,particularly when the homeowner hues unlicensed persons' In,this case,our Board cannot proceed against the unlicensed person as it Wrould with a licensed Supervisar. The:home rowncr acting as Supervisor is ubirmtcly responsible. To ensure that the homeowner is My¢ware of his/her n sponsrbilities,many communities requae,as part of the permit application, that the homeowner certify that he/she nnderstffinds the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certfflr ion for use in your conmrunity. Q:forms:homccxcmpt I Legend: C 0- Guy Anchor p o utility Pole Light Past /_ •-�^: •,��•. 17 CB/DN Concrete Bound a M w/drill hole �r.- S�;i-•�\i,. ,,, Deciduous Tree q% 1 j;'• 4 A0w1 giyn.tt \ i� Coniferous Tree \ \ ^� —_w—— Motor Contour ' •; � Cotuit \ —oRw— Overhead Wires l Location Map N85'W15'E \ 1000BFhd ' ov M �� 1�!-zaoos i \ \ \\ Cot I `a' ASSESSORS REF.: 8 \ \ ;\41,90835f d' Map 020, Parcel 128 „ ZONE: RF Area(min.)87,120 SF(RPOD) \ \ a E ' Front (min) 150' \ Existing �a .. oqo 1G p/ a r�l Setbacks: b \ \ \ \ t ' Fron t 30' Site 15' `\° h" a� / Rear 15' try Cal 'u/b,;:' FLOOD ZONE. \ P\ ❑ Zone C ❑ m Community Panel No. \r \ \ \\ A ❑ 4 �' P50001 0018 D \ 51--�i tn. July 2, 1992 OVERLAY DISTRICT: \ \` +: ❑ a \ AP — Aquifer Protection District K Hood R.t 1 \ ❑— \ 4— �2--• -� \ \'. SEmsr r.+� Stare\ 1049L C.- � Road Cedarwoo (� Wide — Public Wby) m+ — a» = 05 10 15 20 M 40 FErr Sheet @ Title: Prepared For: Notes/Revisions: 4 Existin `Conditions Plan CapeSury Scale: =20' 1.)The topographic information shown was 9 Corey Grover obtained by an on the ground survey 1 oil At 14 Cedarwood Road 7 Porker Road Dote: Po Box 1080 performed an 06/JAN/11. G11 Oster 14JAN11 vdle MA 02655 � � CotuJt MA 02635 2.) The elevation datum used is approximate Bamstable(cotuioMass• (508)120-399+(508)420-3995f. pwg; MSL based an the Town of Barnstable GIS ti rowswvaopec»dnet C413_391 data. s i EX i,5T t N 6- H O V.S 6' .I � r T P �W 9 Q x I' @ O --- 11 �Xc�W9 SON o�f�V �S . 1 r � L4 C o-f-L) ;4 -, M►+, e� GQavEe2 a��►` 2� 6u;14 i� C Il p, )M tl ii Q �T' X �S o►� /�` _�pau�a�An �v sea"` Zr p t �o(z Re 601)d �I{ eedc-4I ,too v6� II fr: III SEX i,5T OJ G- H 0 us 6 r� r rr t ii �Xc�sf+wq SoN o-f v $�S k 4--, wt e� G2ovc:e2. � " reek 2m 6-A r iy 8 �I Y rj µ 4 V IL Zr- ------------------ .Fv2 Re bps �r�o V6 I _ _ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map- Parcel TOWN OF BARNSTAB E Application # Health Division Date Issued LN S'-P 27 PH 12: 116 Conservation Division Application Fee Planning Dept. d.,e Permit Fee T. Date Definitive Plan Approved by Planning Board''1gjCYq Historic - OKH _ Preservation / Hyannis Project Street Address I 4 Ca ob r v--%ma 2 d (v4v,+ M A 33- Village �ftj Ca Owner F,`� 0IZGk1r e_ Address 14 Cau C,-Ev,* nA :zs Telephone (Q 11 - N47 - 07g2 Permit Request Ar Sp�l�.c , 2 ''n�„yl �f�h, -!4 fa -z"OE, F,IQalw�f�le.�c 4 cr-?,Ase3ew_ Z" Gra«+1spaCX Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Flood Plain Groundwater Overlay Project ValuatX A 7 1 .92 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family J.2r Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing 0 new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑.new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use I APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name %lad Telephone Number 6-08— Address Y10 erotic Sf License # (QS9-6, Home Improvement Contractor# Email Worker's Compensation # X4,1 5LY1&7 4l ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO k, 4'c SIGNATURE DATE r ` FOR OFFICIAL USE ONLY k APPLICATION # DATE ISSUED i MAP/ PARCEL NO. j ADDRESS VILLAGE OWNER DATE OF INSPECTION: ' FOUNDATION FRAME INSULATION FIREPLACE ' ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS. ROUGH FINAL FINAL BUILDING . DATE CLOSED OUT ASSOCIATION PLAN NO. r. , DEBRIS FORM In accordance with the provisions of MGL c.40,s.54,a condition of BullIding Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c. 111,s. 150A. This Debris will be disposed of in: Republic Services Dumpster: 1080 Airport Rd Fall River, MA 02720 (LOCATION OF FACILITY) Signature of Permit Applicant /Z2�r'� • Date IF DUMPSTER IS USED IN EXCESS OF SIX (6) CUBIC YARDS A P.ERMIT`FROM THE FIRE DEPARTMENT IS REQUIRED 6 FOR COMMERCIAL, INDUSTRIAL, INSTITUTIONAL AND MULTI-FAMILY RESIDENTIAL OVER 20 UNITS DEMO, RENOVATIONS OR ALTERATIONS OF THE EXISTING BUILDING: °^ CIRCLE ONE HAVE YOU-SUBMITTED THE AC206 NOTIFICATION TO THE MASSACHUSETTS DEP? YES NO F The Commonwealth of Massachusetts x Department of Industrial Accidents a I Congress Street, Suite 100 Boston, MA 02114-2017 www.tnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. 'f0 BE FILED WITHTii:EPERMI'iTI\G AUTHORITY.Applicant Information Please Print Lecibly Name(Business/Organization/individual): Insulate2Saye Inc. Address: 410 Grove Street City/State/Zip: Fall River MA 02720 Phone M 508-567-6706 Are you an employer?Check the appropriate box: Type of project(required): I.❑x I am a employer with 20 employees(full and/or part-time).* 7. ❑New construction 2.❑t am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.(No workers'comp.insurance required.)t 10❑Building addition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors eidter have workers'compensation insurance or are sole i LE] Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions � 5.❑I am a general contractor and i have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance? 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑X Other Insulation 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box N I must also fill out the section below showing their workers'compensation policy information. 1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. Irthe sub-contractors have employees,they must provide their workers'comp.policy number. /ant art employer that is prowling workers'compensation insurance for my employees. Belo►v is the policy and job site information. Insurance Company Name: Liberty Mutual Insurance Policy#or Self.-ins-Lic.M XWS 56418741 Expiration Date: 12/10/2017 t• Job Site Address: I t'( Cad rc.-a-r-J City/State/Zip: & M A 016,33— Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under�� s am et ties of perjury that the information provided above is true and correct. Signature: /(((/,,, Date: 9 1 Phone M 508-567-6706 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical.Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: r PAL j - Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvemen Q ntractor Registration Type: Corporation Registration: 180747 INSULATE 2 SAVE , INC. Expiration: 12/28/2018 410 Grove St Fallriver, MA 02720 ° w •9 5�0 Update Address and return card. Mark reason for change. iCA 1 Ca 2OM-05111 (]_Addr_Q�s_O Renew_al 0 Employment O.Lost Card (92. U,V Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: T`firatio Office of Consumer Affairs and Business Regulation #egir lion Expiration 180:7� 1y iratioS 10 Park Plaza-Suite S170 Boston,MA 02116 INSULATE 2 SAVE .NC:. Roland Langevin 410 Grove St Fallriver,MA 02720 ,_ j� Undersecretary Not valid without signature - tip• Commonwealth of Massachusetts I ® Division of Professional Licensure Board of Building Regulations and Standards Constr� (;riSpgrvisor CS-103861 ' E Aires: 08124/2019 J ROLAND LANGEVIN 0 56 HIGHCRESTjRO I) FALL RIVER MA}02720 i Commissioner µ ®ACOR CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDD/YYYY) O' 12/8/16 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Anthony F. Cordeiro Insurance PHONE 508 677-0407 A,X N0; (508) 677-0409 171 Pleasant Street E-MAIL ADDRESS: hsouza@cordeiroinsurance.com Fall River, MA 02721 INSURE S AFFORDING COVERAGE NAICIf INSURER A:Liberty Mutual Insurance INSURED INSURER B: Insulate 2 Save, Inc. INSURERC: 410 Grove St. INSURERD: Fall River, MA 02720 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER M/DDN MM/DDVYYYY LIMITS A GENERAL LIABILITY Y Y BKS 56418741 12/10/16 12/10/17 EACH OCCURRENCE $ 1,000,000 DAMX COMMERCIAL GENERAL LIABILITY PREMIS zTORENTED occurrence) $ 300 000 CLAIMS-MADE aOCCUR ME D EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER PRODUCTS-COMP/OPAGG $ 2,000,000 X POLICY PRO LOC $ JECT A AUTOMOBILE LIABILITY Y Y BAA 56418741 12/10/16 12/10/17 EOMB�Ndart) GLELIMR $ 1,000,000 ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS X AUTOS NON-OWNED PROPERTY DAMAGE $ X HIREDAUTOS X AUTOS Peraccdent $ A X UMBRELLA LIAB X OCCUR Y Y USO 56418741 12/10/16 12/10/17 EACH OCCURRENCE $ 2,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10,000 DED RETENTION$ $ A WORKERS COMPENSATION XWS 56418741 12/10/16 12/10/17 X I WC'RySTATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y� N/A E.L.EACH ACCIDENT $ 500,000 OFFICERMIEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yyes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) "For Insurance Purposes Only" CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: RISE Engineering RISE 5 Dupont Ave,South Yarmouth,NIA 026" ENGINEERING' CONTRACT 508-568-1926 FAX 508-SW1933 Page 1 PROGRAM Tests coNTRAcr is ENreaEo arro aErejmN R= CLC-HES ENAWEERaip Ate THE CUSTOMER FOR VMK AS oEstRtemea:rnv cuSToWaR PHONE OATS CU04T4 WORK 617DER EILEEN OROURKE (617)447-0792 02/24/2017 213738 26005 SERVICE STFM SMUNO STREET 14 Cedatwood Road 17 Puritan Lane SERVICE CRY,STATE.UP 811JNy MY.STATE,aP Cotuit,MA 02635 Swampscott,MA 01907 JOB DESCRIPTION AIR SEALING:Provide labor and materials to seal areas of our home cost wasteful,excess air y against leakage. This earl:will be performed $I60.00 in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams,weatherstripping and other products, Primary areas for sealing include air leakage to attics,basements,attached garages and other unheated areas(windows are not generally addressed.) (2)working hours: A reduction in cubic feet per minute(efrn)of air infiltration will occur,but the actual number of cfrn is not guaranteed. BARRIER Your ceilings are constructed of a lightweight cardboard composite material. These ceilings cannot support the additional weight.of blown-in insulation or air sealing measures,the tiles could be dislodged due to movement of workers in the attic and cause damage to the ceiling tiles. Until.you renovate these ceilings,we will only insulate with rolled out fiberglass batt insulation. This is being brought to your attention to identify it as a prt-existing condition to the weatherizatio work planned for your home.Your signature is your acknowledgement of these conditions and agreement to proceed. ATTIC ACCESS:Provide labor and materials to insulate the back of(1)attic hatch with 2"rigid Thermax board_Weatherstrip the $42.50 perimeter. BASEMENT CEILING:-Provide labor and materials to install(64)linear feet of R-19 unfaccd fiberglass insulation to the perimeter of $140.16 the basement ceiling at the house"sill. CRAWLSPACE:Provide labor and materials to install(418)square feet of 6 ml polyethylene over open ground in designated $321.86 erawispscdearthen basement areas. CRAWLSPACE:Provide tabor and materials to install (208)square feet of 2"rigid board with the required fire rating to the crawlspace $842A0 perimeter wall up to the sill and against the band joist. • i • • i i i 1 i i i i i i i RISE Engineering RISE 5 Dupont Ave,South Yarmouth,MA 02664 ENGINEERING' AC CONTRT 508-568-l926 FAX 508-568-1933 f4P14s Page 2 PROGRAM xN INTOT6CONTRACISEE auTouER EwAEaCLC-HES G A mcpameaow CUSTOMER PHONE DATE CLIENT 0 WORK ORDER EILEEN OROURKE (617)447-0792 02!24/2017 213738 26005 SERVICE STREET SKA1NG STREET 14 Cedarwood Road 17 Puritan Lane SERVICE CRY,STATE,ZIP BLUM CRY,STATE,ZIP Cotuit,MA 02635 Swampscott,MA 01907 JOB DESCRIPTION INCENTIVE:RISE Engineering will apply all applicable,eligible incentives to this contract You will be billed only the Net amount $I65.00 Currently,under.the landlord Incentive,for eligible measures,the Cape Light Compact offers 100%incentive not to exceed S4,000 per calendar year and an incentive of 100%for the Air Sealing measures.To participate in the Landlord imxrttive,please return a copy of this contract signed by both Ord and the tenant, 1 as a copy of the year-round rental agreement. TENANT SIGNATURE DATE- 1 For the safety and health o ur home's indoor air quality,we will be conducting a blower door diagnostic of the available air flow in your home both before the work is begun,and after the weatherization work is complete.We will also conduct a diagnostic assessment of the combustion fumes in the exhaust flue of your heating system and water heater.This has a value of S90 and is at no cost to you. The Permit.will be secured by the-insulation contractor.This has a value of$75 and is at no cost to you.It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. { • i l i I 's t i t • I • I I i I i f i Total: $1,671.92 Program Incentive: $1,671.92 !!� Customer Total: $0.00 WE AGREE HEREBY TO FURMSH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***00/Dollars $0.00 UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERWO.CUSTOMER AGREES TO REMIT AMOUNT DUE RI FULL AREREaT OF 1%VALL BE CHARGED . UNPAID BALANCE AFTER 30 DAYS.SEE REVERSE FOR GCPORTANr INFORMATION ON GUARANTEES.RIGHTS OF RECISION,3CHWLV#J,AND CONTRACTOR AUTNORIZED-SIGNATURE-RISE EnSLwninp- TOME.ACCEPTANCE . NOTE:THIS.CONTRACT MAY BE WITHDRAWN BY US IF NOT EIRECVTED WITHIN DATE OF ACCEPTANCE ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE 30 DAYS. SATISFACTORY TO US AND ARE HEREBY ACCEPTED,YOU ARE AUTNORMED TO DO THE WORK . AS SPECIFIED.PAYMENT WULRiE MADE AS OUTLINED ABOVE'- f R151.IE 5 Dupont Avenue South Yarmouth,MA 026641 508-568-1926 ENGINEERING www.RISEengineering.com Efficicncy Energized. OWNER AUTHORIZATION FORM I Eileen Orourke (Owner's Name) ' owner of the property located at: 14 Cedarrwood road (Property Address) -' Cotuit MA. 02635 (Property Address) Insulate 2 Save hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building i permit and to perform work on my property. This form is only valid with a signed contract. Owner's Signature Date