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HomeMy WebLinkAbout0228 TREE TOP CIRCLE tee r t } r i r } I 1 I i t I i I 1 I I A .k it � � r �DfS��Fa1Y pO`y� Town of Barnstable `Permitru- Regulatory SeflCes Fee r� �a+ Mt 9 $A a63 •�1� Richard V.,Scali,Interim Director q r t� �A�NSTABLE "Building Division i lkitl 1, Tom Perry,CBO,Building Commissioner 200 Main Street Hyannis,MA 02601 �«vkv.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERN T A.PPLIC_A.TIOAI - RESIDENTIAL ONLY Not Valid without Red X-Press linDrint Map/parcel Number /a G D 33 �yl Propeity'Address as —7R�� /Op C/ t �,� �F)T�51Z101� i�/itlf Residential Value of Work S a 3� 6 7 8, Minimum fee of 535.00 for work under$5000.00 Owner's Name&Address- �CJ AA Contractor's Name_ n al,�_��};r�r s / Rr; ,'i ni snn Telephone Numberap1))Z29-q ffZO Home Improvement Contractor License--*.'(if applicable) /7 3 y S' Email: Construction Supervisor's License 1(if applicable) p Cj 5 7 n-, Q�Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I-am the Homeowner I have Worker's Compensation Insurance Insurance Company Name A G QT �.nS u<a yt Ce— Workman's Comp.Policy �rtlC�l $p ti 3`SZ 3 q y Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑ Re-roof(hurricane nailed)(not stripping Going over _ existing layers of roof) ❑ Re-side �O Replacement Windows/doors/sliders.U Value t 3 m 3 (maximu5)r ofwindo vs r of doors: - ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Eledhcal&Fire Permits required. Whe—re required. rssuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. "'Note: Property,Pwner must sigh Property Owner Letter of Permission. A copy o>j the Home Improvement Contractors License&Construction Supervisors License is regaired.� SIGNATURE: � Q%rPFILESIF0U1S1building permit fotmslEXPRESS.doc Revised 061313 '1 SOUTNEW-01 SHETTYSHT A�O' DATE(MMIDD/YYM CERTIFICATE OF LIABILITY INSURANCE 8/19/2015 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: Willis Certificate Center Willis of New Jersey,Inc. PHONE 877 945-7378 (FAX C/o 26 Century Blvd arc No Ext:l ) A/ No: 888)467-2378 P.O.Box 305191 E-MAIL SS:certificates llis.com Nashville,TN 37230-5191 INSURERS AFFORDING COVERAGE NAIC# INSURER A:Selective Insurance Company of Southeast 39926 INSURED INSURER S:OneBeacon Insurance Company 21970 Southern New England Windows LLC INSURER C:Argonaut Insurance Company 19801 D/B/A Renewal by Andersen INSURER D 26 Albion Road Lincoln,RI02865 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 SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/D MWD LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE PO OCCUR S 2029459 08/10/2015 08/10/2016 -DAMAGE TO RENT PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY PRO- JECT T LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: $ AUTOMOBILE LIABILITY EOMaB�INdEDISINGLE LIMIT $ 1,000,000 A X ANY AUTO S 2029459 08/10/2015 08/10/2016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED P BODILY INJURY(Per accident AUTOS AUTOS ( ) $ NON-OWNED PROPERTY DAMAGE X HIREDAUTOS X AUTOS Per accident $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE S 2029459 08/10/2015 08/10/2016 AGGREGATE $ 5,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY X STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 0000068028 08/21/2015 08/21/2016 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 C rrkers Compensation WC928058352394 08121/2015 08/2112016 See Attached DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule may be attached if more ace Is required) Y P reV ) 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 Evidence of Insurance �/-14 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations ' Q 1 Congress Stree4 Suite 100 Boston, MA 02114-2017 www massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): SOUTHERN NEW ENGLAND WINDOWS Address:26 Albion Rd City/State/Zip:Lincoln, RI 02865 Phone#:401-228-9800 Are you an employer? Check the appropriate box: Type of project(required): 1.9 I a a employer with 20+ 4. ❑ I am a general contractor and I employees (full and/or part-time).*.- have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL I2_❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13. Orer W/u�e)cd comp. insurance required.] p11 *Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy in ormation. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such- :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ARGONAUT INS. CO. Policy#or Self-ins. Lic. #:WC 928058352394 Expiration Date:8/21/2016 Job Site Address: re! dM d, o,,Le City/State/Zip: Mazzws p l[�,A T 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—,Uf 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 folpsurance coverage verification. I do hereby certi under the and penalties of perjury that the information provided above is true and correct c Signature: Date: L Phone#: 4012289800 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# I Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector b.Other Contact Person: Phone#: Southern New England Windows d.b.a Renewal by Andersen of SNE Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS4095707 BRIAN D DENMSON 7 II.AN=POND t1- s Charlton MA 0107 Expiration Commissioner 09/08/2016 V f2� �GLY��YrE%Q�ZI.(1E'CZ�ffZ�C�!�ZQQaG�Gi2U�P.� Office of Consumer Affairs d Business Regulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement.Contractor Registration Registration: 173245 Type: Supplement Card SOUTHERN NEW ENGLAND WINDOWS LL, E)Vratlon: 9/192016 DENNISON BRIAN ? -- 26 ALBION RD LINCOLN,RI 02865 ' � Update Address and return card.Mark reason for change. sCA1 o 2MA-05n1 0 Address ❑Renewal Employment ❑I.ostCard �iFo�osssnsow.�coldf cif mee of Conserver Affairs A Rosiness R alation License or registration valid for individul use only IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation ation: ii:iim Type. 10 Park Plara-Suite 5170 aelatr WErpiradon: 9Vlq t/10 Supplement.:ard Boston,MA 02116 SOUTHERN NEW ENGLAND WINDOWS LLC. RENEWAL BY ANDERSON DENNISON BRIAN t 26 ALBION RD r LINCOW.RI 02865 Usderscaeta7, Not valid without signature f 11/10 2M5 1©:45 STAOLE5 0166 PAGE W Y ' S1Ali m-817b= by,Wemf+.�,..,L 26 ANon Read- Laacvto,RI02865 Phone VA5M2235.1=401-W-6602- eaAcstTamftvessc" Sea born. twEz;I"'Wuml&*%LLC;dW- Rm,wd byAssdermm of SoatiawNew fEselaad 4aus70M Wm-,D0WAND DOORPiMODBFaNO AIQREBAMVT ear _.., —)r1�a �, S ��l•+� DFt=--ef#Wft.mc &ae{,p Save, Tgerb rrAtitme P�o /l�C� ` �/•G li.syei(s)hettby jwedy and se%wdy afm to p'-062-se the fs7a�-cb zmdhar senlocs of Scuthers'N" !Vta4vs %UC d/b/a.flenewah by Andeaca of SCi Ldtern New&-8k4(0Qontyacwn in aeoom;smce with the.Wens and omm&tiaa &ftc6btd on the Evans and fihe n6t1 m of Ffiabme �and-d�poeife�adon.3bM*)(coDeQi t�'A&recm jLj- O Ws orit ❑Condo o�Mf �odlbt„�.� p� maenad f'a�mrnL ot]1e tee oGen e©e ikfiseeWeA�S)- d t:hs&Qrdswo fordefrAka*-madman In-fthe ax Sam of jch � t'slmttts Cola Dorm ptelxt cross fPkoce cFe Gedfl tad )6Y did eft6 �j Aueet mv6 you adman+ =fin FaUrKe at Stan 000b end the Flt�tce on A inl./1��j�, A.79I' 6WmrA w�aref.l Conpk bn ofpb canxi ee elide by credo Camgletkrn cf job Qixyi ru d aid era 6t audk bF FFq-O da�bm*dM&arOeL SUyec(s)agrees and Understand■t➢at this Ags^eedwal;eaesefenttm the eatim mfderntanAing 16.tw.es4 eh.pard",and.that tid of te> o[•tAt Ba (wee ue eao Virbal WidesoadUa. a) (1)hn:.*ed this Agreement,onderstands the terms of this Agreenteat,and drip:seceive4 v comp seed,Qgned,aaad dated, mpy of thla fteeemeat,fschuHns the two a Notices ofnaaeDall Cgse,on the date first wtttteo above (2)was orally it7foemetl of BaFeias 40t to c�cel QtisAgeecwims DO 1rtOT SIGN'li'EM CONTRAC'P IF TH M AIMANY RLANS SP&CM. Made I.&.d 9.1 r 0.1)')Nolle+s to Buyers(1)Do aet.ip th6ASMe neat d my of the spesces mrtaaded fie the amad tl+e n . to&g etiteptof then avAanble iatfsrawden are kft hlmh.(2)Yei,ameadded tea copy of dda Agrectuentattbe tfma y m A34a It.(3)You maj at nay time pay oD'the ihil uap>eid batim6e die nnder this Ai eeinent,and In so doiogyern msy be eptided to i+rma.l a partial rzbste of the finance and j6mwzni,e cfi a et.(4)The'stlke lma na t46t to aa}awf°u y enter Vow paimises enmiait�y l:ic.eh of peace m repor�o as porckaeed tender tlila Agreemmt.(3)Yon may craned this Agreement. if it his not been sfgncd at the main®> ar a brejuk ec13Ce of the se[le,protruded you nm*'the seller is his or bw main of ce oe hr"ch om ace sbowa to the Agroamead:by reofftaredof exadWina 4 w"h9eh shaD be poi"»otl4cr tbau af the ddid calendar day afkni the day m vrhiah the bupnr sfpas to Agveenvm't, zeludlag Sunday and eny hoRklay ou wW& regmtatmaltdeliveriesarenctmadwseet5etieaompampfaigtloafceofoaneelhdoaformtoraa nadoa.ofwyeesriots. $ n9aon++Rt.B - paot�!£elm by Rhoda Isla ud C6a-bartun ReoArstina Bawd- $77tttr F,eaewal by of n. B&91—'d Bt. s) Brgvt(t5) By: or Panic Aisle of a rfaciagt r print Nana: PWai A?amc' XOIL.THE MJYER(b), MAY CANCEL TM9 TRANISAMON'AT ANY Ting PRIOR TO.NIIDA-11HI'Ti OF TM TWRD WSIIMM DAYAFTER THE DAIS Of TEUS 7 RAIAS tCT`ION.Sn Tnx ArucmM NOT XCE OF CANC$LIATION FORMS FOR AN gXPL gA,tION OP 7,2U9 RIOHT. x- - �— - - '^ �- • C� TIONI — — — — NQfi1GEOFeJNGEIrLnT10t�1, 1 Data OflMttttsaCtion.• 1* You inmr cv�cel' Dates ofTrarwtetkW .Y64 mt+y cancel this tratnaedon,vVl 4 . .pvnatty or'obfigatiai%vAthE f this tmnsietoion.without any petnalty ne abligatfors,within duets btti itlet'di)rs Aatn the above date:if lW ttiMW.any. 7 three 6i4ms days from dice above data.if ytru eas=4 w7. property trened ter.cityaVatim m� by you under the l propel'traded in,wW Paymentta r:,atd.by freer ender the Contact or.Sabo,and any nazot.+�fe irtstresnetst e+it a:ttted I Contract or Sale;slid any n_ ble fttstrutnWtt oxegreed by you win be r uoiteyd withttt ten fyutalnthas'days fbflowlng I M O � be ilk6w�ed wi e.n b4dit s'days folbwing reaetpt by the Seller oll`your,canoellation notice,and'any t ree ;m-br tho SQUer'of your,cancelfatlont notice,and any securfgr.b+earmt arching.out aid the &w%acdm.vA11 be t security •v w+=t•aridehz out o1 the. transaction wM be canceled.if you canoe4C�wUr must cicalae araib+hte t o the Sener. cum"If yyoot1tt ctwm4yyaouts must make available to tam Saw at your resident%hj substantially as good eondiden as when I al y�otlr resl�etea,.In substprttfally as good condition as when mcelved,any goods d4ver ed to ym colder.chit Contract cw I incWwd,arty goods delivered to you under this Contract or you op ye neap ifyou,.wlty c*mply with.tfm hutbruceinns of'I .Sa1Co r year hhtag4 if you wish,cvrrt4ly witlr tfrc Ghehls�iotts of the Jel'ler rt3gMng&.rett m thiptment of**good-at flee den Seller rezW&n=time return.lopmestt of th.goads as the Wlsr`e•�r .nsa and Ask.lf you do nuke the scrods available � Sene rli m�eerge and r18k.if you do tnalm the uva3lable to,tine fiollar and the Seller does not pfdt than UP wit!_d-n to thti sy[ter'and t!t®,Seiler d rat PlClt up.witUn twenty-days of His date of ttntltxUWan,you mxV main cr 1 twanbi of fire d►Ce of n a+tioty yacn avy e,t4hi�or dry of the goods%idvout anyJurth*r,obdi�on.if you I dose of the goods without 4my fbrdtcr ebiigstior>v(f you fl to rtwlm Ilia goody available to the Won or if you agree 1 fan ba malm the•Raodt siriiiabfe bo till SQIIK or if you a im to return th Q*to dice Seller and fad to tla.so.tltert you 1 eo rctam the pods to the Suter and fail to do s%than you vemoin.11able for prlbtrnance'of all obNgatt►ttti candor dha l remain liable for perfamance of all obllgadons under the CQntsact.To cancel thisi trMsaedon.male or delirer a sigrmd Conttact.To cancel"transaction;mail or delivers Ogned w4 dated CWr otr tftes•taseea8a+t�n nodes or.eery other I and dared coPfr.of;tfiis earroolattion not9oe or any --lay wgUw mdLe,or send a m t*PAnewal by n of I "written notie e,or send abdekram to Rtnewil byitnderen of Seer kern New In gland at 16AGb+an fired, p BS, f Southern Now Et1¢Iand at 26AlNon Itoadiineo6tl,R1 0.266S, �LATER THANIMfDNIGKT OF f� I NOT LATER THAN MUNIam OF (Date) 1 HAY CANCELTHISTRANSACTION: I i l*PftY CANCELTHISTRAN3AC•TION. b • lhrrteMa tlr.tvr. Ptitecrea.�o a t.f Pod Mere cam ftlall f Ayy.WMte Bt7W CapfP Yellow ftm Copf'K4 Cape Save Inc. 7-1) Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 508-398-0399 11/10/2014 Thomas Perry CBO Town of Barnstable Building Division 200 Main St. Hyannis,MA 02601 RE: Insulation Permits Dear Mr. Perry This affidavit is to certify that all work completed for 228 Tree Top Circle(#201400945) has been inspected by a third party Certified Building Performance Institute(BPI)Inspector. All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey NOISIIIIQ 11 h Z! Wd Z i 1AUIN 4116L t . " 319d1SM9 d0 N#.u-i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map f a�� Parcel O Application a( V s Health Division Date Issued Conservation Division Application Fee T�SAO Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation /-Hyannis Project Street Address C� Village 104VsfO4& Owner iQ Shl t�l-S Address S a etf Telephone (S—CYv — J� /7 Permit Request A4 4 /\ 10 twe 716__q �cc IM6 ! C� -�-o walls , Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 3 NO Construction Type S? o ZE Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting dodume%ation. Fa �n Dwelling Type: Single Family U/ Two Family ❑ Multi-Family (# units) g wCla t � Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: C_Yeses❑ No I ca 3i Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Others Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new y Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name a, uQ k e P,i vP lmr, Telephone Number 4oq to Address C 14U4 fc)4 4vc, License# ® �ar440�'" "�> `' � / Home Improvement Contractor# / V Email - Worker's Compensation #A/C 331 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 7 Q✓~" SIGNATURE DATE 7" / FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED `_'• MAP/PARCEL NO. ADDRESS VILLAGE OWNER " s l � � DATE OF INSPECTION: ` FOUNDATION ! FRAME I • INSULATION f FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING . DATE CLOSED OUT f ASSOCIATION PLAN NO. , G _ . J i Building Permit Authorization L'inda Stebbins ?' as owner '. hereby give my permission to Cape Save, Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Office: 508-398-0398 to take all necessary steps to obtain a building permit to perform work at my property located at 228 Treetop Circle Marstons Mills, MA 02648 Signed Date I 1 I - print Form J 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations V I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Please Print Legibly Applicant Information Name (Business/organization/Individual): Cape Save,Inc. Address: 7D Huntington Avenue City/State/Zip: South Yarmouth, MA 02664 Phone#: 508-398-0398 Are you an employer?Check the appropriate bog: Type of project(required): I.❑✓ I am a employer with 17 4. ❑ I am a general contractor and I 6 ❑New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. Remodeling 2.❑ I am a sole proprietor or partner- These sub-contractors have g. ❑ Demolition ship and have no employees employees and have workers 9. ❑ Building addition working for me in any capacity. + comp. insurance.+ [No workers' comp. insurance ME] Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs c. 152, §1(4),and we have no 13.0 Other Insulation insurance required.]t employees. [No workers' comp. insurance required.] •Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. not th t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new those entities have indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or n not os employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Technology Insurance Company T1NC 3353968 Expiration Date: 04/09/2014 Policy#or Self-ins.Lic. I�#: ✓ j� ° *0mb � City/State/Zip: I C Job Site Address: 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 certify under the aims and penalties of erjury t at the information provided abov is tru and correct. r_ Signature: - - - - -- - - - Phone#: 508-398-0398 Official use only. Do not write in this area,to be completed by city or town ojfciaL 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#: ® DATE(MMIDDIVYYY} Al� t' CERTIFICATE OF LIABILITY INSURANCE 10,22,2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. ONT PRODUCER NAME:CT Colleen Crowley Risk Strategies Company PHO E (781)986-4400 AAIC No:(781)963-4420 MIS-00,15 Pacella Park Drive A IL Spite 240 INSURERS AFFORDING COVERAGE NAIC t Randolph MAL 023611 INSURER A:selective Ins. , or America INSURED INSURERB:Safety Insurance Company 3618 Cape Save, Inc -INSURER C-.Technology Insurance Comany 7 D Huntington Ave INSURERD: INSURER E: South Yarmouth 16L 02664 INSURERF: COVERAGES CERTIFICATE NUMBER:CL13102268490 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. LTRR TYPE OF INSURANCE POLICY NUMBER MMIDO EFF MMIIDD EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,OOO X COMMERCIAL GENERAL LIABILITY PREMISES Ea ccurrencel $ 100,000 A CLAIMS4v1ADE FX_]OCCUR S1994480 0/16/2013 0/16/2014 MED EXP(Airy one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 21000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY X PRO JECTX LOC $ AUTOMOBILE LIABILITY Ea accident SINGLCOMBWED LIM 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 6208200 1/6/2013 1/6/2014 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS Peraccident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ HI 1994480 0/16/2013 0/16/2014 $ C WORKERS COMPENSATION Officers Included for X I &STATU- OTRH- Y LIMITS AND EMPLOYERS'LIABILITY ANY PROPRIErORIPARTNER/EXECUTIVE gJ Coverage E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? NIA 3353968 /912013 /9/2019 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 It yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Addttlonal Remarks Schedule,If more space Is required) Weatherization Specialists GL: Blnkt AI, Blnkt PNC, Blnkt WOS, Per Proj Agg, Per Loc Agg / GL Exclusions: Snow & Ice Removal/OCIP/Wrap Ups 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 �Ichael Christian/CLC ACORD 25(2010105) O 1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD �..a.d 0 f 3JiIG6iu C,%nsii u:iion Sup%.-,'a;'Spu-:i^.li_1" CSSL-'f027?G WILF.iAMJ MC C-LiTSKBY 37 NATUSBT ROAD VJestYarmouthMA 02673 675/77. Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Dome Improvement Contractor Registration - Registration: 171380 Type: Corporation _ Expiration: 3/14/2014 Trf/ 222184 . CAPE SAVE INC. = WILLIAM McCLUSKEY : 7-D HUNTINGTON AVENUE SOUTH YARMOUTH, MA 02664 - - Update Address and return card.Nark reason for change. Address : Renewal _; Employment Lost Card DPS-CAI`Qi 50h',0,U04-G101216 — — — ;,.. ✓fie'�c�x•�u�nuealf� c%.•L�as+uc�vrsel�`' Office of Consumer Affairs&Bdsiness Regulation License or registration valid for indivrduI use only __HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:-171380 Type: Office of Consumer Affairs and Business Regulation <` Expiration: 3/14/2014 Corporation 10 Park Plaza-Suite 5170 --` i Boston,VA 02116 CAPE SAVE INC. WILLIAM McCLUSKEY: 7-D HUNTINGTON AVENUE SOUTH YARMOUTH;•MPi'02664 Undersecretary Not valid wit 6 signal