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HomeMy WebLinkAbout0120 WALNUT STREET /��D �v�}-fur- .s�-- P 'l e:-!1i.q. r.R... ._�..: _....-_..... ,.. .a..M.,-,....,.,.;a.._ -,.,^-. —.s-�'1 v.�-�.,.;....-nw„- _-='---- - ,_. �__�-��,.r�._..�.- .�.. ew�w...raw�a...F ��s.--Q.�-�.s.. _ _ - - _ref��� Cape Save Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 508-398-0399 12/29/15 Thomas Perry CBO Town of Barnstable Building Division 200 Main St. Hyannis,MA 02601 RE: Insulation Permit 201507754 Dear Mr. Perry C � This affidavit is to certify that all work completed for 120 Walnut Street,Marsto s Mills"has bey,.n inspected by a third party Certified Building Performance Institute(BPI)Inspector. i �' cA All work performed meets or exceeds Federal and State Requirements. m r Sincerely, William McCluskey TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map / 0_5 8 0141N OF BARNSTAB Parcel LE Application # dnG��S Health Division ?r!,S ft!"V I r� h1 f; Date Issued L 2. �O L;� Conservation Division Application F Planning Dept. ��. n,, Permit Fee W ' 10rS,, " Date Definitive Plan Approved by Planning Board ��/` Historic - OKH _ Preservation/ Hyannis i Project Street Address �d W al/q 14 Village OwneAimig /V ay l e t4A ed C°V" Address S Telephone % ` q /('�`���( Permit Request il- -S f Gl I 4 �T i�C ei e Lt/ ���1' `� f✓.c v Q/!/� densc o a cF e C e//u_/&sc -a jtm ee jA �D Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District ll // `' Flood Plain Groundwater Overlay Project Valuation`"_c7c (f� lJ Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ 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 ❑ new size_Pool: ❑ existing ❑ new size _ Barn: O 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) ge Name VL' Q,� � C M Telephone Number 03 v Address *ve License # c,l ! / a yG fin' 0"t (a k Z/ Home Improvement Contractor# Email Worker's Compensation # L' �✓�- 3002 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Y at M L � Z SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# ` DATE ISSUED MAP/PARCELNO. ADDRESS y VILLAGE OWNER DATE OF INSPECTION: FOUNDATION + ' FRAME r INSULATION FIREPLACE ELECTRICAL: ROUGH - FINAL , PLUMBING: ROUGH FINAL. GAS: ROUGH FINAL e FINAL BUILDING r DATE CLOSED OUT I - ASSOCIATION PLAN NO. — r. i '. AM Waechter 508 428 0392 p.4 Towu:of Bannrstable y _ R gul ory SLw ices Rtebwd V.Sc"Duredw Bo►iklimg Division Tom Perry,strip CM A".ouer 200 Man Smeet,I1*uW:z6 MA 02601 wwwmwa.balrnstablelaa as 01�=.56$-162-4018 Fax: 508r7904130 ProPexty Owner Must Compleie:and Sign Tbb Section S AB� ' de ' �, �,� �►I►c. 1�' 1[�t�� �/ z �+� �l•�� t t� ,�s(�avner.�fthe•s�bJecc'P�P�Y hmbpaudw&e ( c�, J-e ,, 4C w act on.mybeb&, in aU m2nters m6fxe to work by this but7ding p=k application for. s ... "`*Pool fences and alarm's are the mponsNilayof the appfim= Fools acre nbt to 3e:filled Or utilized befo=fenee.is:installed and all final. -.inspections are,performed and acceptad. it $juat[ue Owner L Sig�naQuce of 'taut l�laboe Pm'tName Date s�aowrrooiS The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):Cape Save Inc Address:7-D 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): 1.❑✓ I am a employer with 20 employees(full and/or part-time).* 7. New construction In I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling 3.[:] any capacity.[No workers'comp.insurance required.] I am a homeowner doing all work myself.[No workers'comp.insurance required.] t 9. El Demolition 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑1 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.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑✓ Other Insulation 152,§1(4),and we have no 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name:Wesco Insurance Company Policy#or Self-ins.Lic.M WWC3136274 Expiration Date:04/09/2016 d. r?(,t , W,3 o Ilk,Job Site Address: /�� City/State/Zip: � �s J*tW e--,9 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under th pains andpenalties of perjury that the information provided above is true a c(o'r�rect Si afore: Date: �/ w Phone#:508-398-0398 Official use only. Do not write in this area,to be completed by city or town official City or Town; Permitlicense# 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#: ACO® DATE(MMIDDIYYYY) `�. CERTIFICATE OF LIABILITY INSURANCE F10/14/2015 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 pollcy(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. PRODUCER CONTACT COME: Colleen Crowley Risk Strategies Company PHA E (781)986-4400 FAC No:(761)963-4420 15 Pacella Park Drive ao�SS:ccrowley@risk-strategies.com Suite 240 INSURER(S)AFFORDING COVERAGE NAIC• Randolph MA 02368 INsuRERA:Selective Ins. of America INSURED INSURERB Allmerica Financial Alliance Ins Co 10212 Cape Save, Inc INSURERC:Wesco Insurance Company 7 D Huntington Ave INSURERD: INSURER E: South Yarmouth MA 02664 INSURERF: COVERAGES CERTIFICATE NUMBER:CL15101402127 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. LLTR TYPE OF INSURANCE POLICY NUMBER MMILICY EFF MMI�EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE X�OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 S1994480 10/16/2015 10/16/2016 MED EXP(Any one person) $ 10,000 PERSONAL&ADVINJAJRY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY�ACT �LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY nt $ 1,000,000 Ea accide B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED Ix SCHEDULED AWBA46796600 11/6/2015 11/6/2016 BODILYINAIRY(Peraccident) $ AUTOS AUTOS X HIREDAUTOSNON-OWNED PROPERTY DAMAGE $ AUTOS Per...dent $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ Sil S1994480 10/16/2015 10/16/2016 $ WORKERS COMPENSATION Officers Included for X PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE Coverage E.L.EACH ACCIDENT $ 500,000 OFFICERWEMBER EXCLUDED? NIA C (Mandatory In NH) WWC3136274 4/9/2015 4/9/2016 E.L.DISEASE-EA EMPLOYE $ 500,000 It yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached It more space Is required) National Grid Corporate Services LLC d/b/a National Grid, Action Inc, Colonial Gas Company and NStar Electric are all included as Additional Insureds with respects to the General Liability coverage of Named Insured as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Housing Assistance Corporation THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 460 West Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE Michael Christian/CLC �� 'c--oe=� O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) i Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 171380 Type: Corporation - Expiration: 3/14/2016 Tr# 249649 CAPE SAVE INC. WILLIAM McCLUSKEY - - - 7-D HUNTINGTON AVENUE _ SOUTH YARMOUTH, MA 02664 -- - N: Update Address and return card.Mark reason for change. SCA 1 0 20M-05111 Address ❑ Renewal Employment Lost Card qT��ncnnicaracaeulG�o����clanrl ce;e//' - - . - Office or Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: egistration: 171380 Type: Office of Consumer Affairs and Business Regulation U'VExpiration::; 3/14l2016 Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 I CAPE SAVE INC. WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE SOUTH YARMOUTH,MA 02664 Undersecretary Not vali ithout signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards t-OnSti iiii�OA aurii:i�No ouccialt_v License: CSSL-102776 WILLIAM J MC au 37 NAUSET ROA6 I IF West Yarmouth 113A Expiration Commissioner 06/28/2017 I I OVVIIIOM PtP1E\ '�,lplf"Tr�n ca r,v ae CAPE COD INSULATION � C�' 9: 94 PIBLS OIASS SEAMLESS SPRATFOAAl SUSPENDED BATTS OUTTIRS INSULATION CEILINOS 1-800-696-6611 v Town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, MA 02601 Date: a-- Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. Property Owner Property Address Village Antwlkfi� dJa,&h kr /,�v Maku. S� /I S�vns �lls Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings ( ) ( ) ( ) ( ) ( ) Slopes ( ) ( ) ( ) ( ) ( ) S Floors (X ) ( ) ( 10 ) ( ) (X9 Walls ( ) ( ) ( ) ( ) ( ) CIb11a C-il, !'oA,--. +NSraCGld dVVU-7d 11%.v= .0t 0� Cv►q�µt,� cvl 1 rfef0 41L (�Qt�II't rt I Sincerely He y E C sidy , President Cape Cod nsulation, Inc. �W TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ParcelLD Applicio I q Health Division Date Issued 61a� Conservation Division Application Fee c� Planning Dept. Permit Fee J Date Definitive Plan Approved by Planning Board �. Historic - OKH _ Preservation / Hyannis Project Street ddress t Z ,D/�,, �/I r�u f 9 i> �T Villa e ��f� l'15 V �'�1���' Owner w/rt u!/tl vl Gc WA&C4,k Address IZ11 Telephone Permit Request T� LL 1%�� %rUP�CL 1 z 6w 3 W'm-hm6 afar wllm 6� T &VW , Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type (ak Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Z( Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No © o —4 Basement Type: ❑ Full U Crawl ❑Walkout ❑ Other N Co Basement Finished Area (sq.ft.) Basement Unfinished Area (sq ft) o o # Number of Baths: Full: existing new Half: existing f ne'w : a Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Roodn 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: 0 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 4 (BUILDER OR HOMEOWNER) Name " I Telephone Number �*2D�— Address License # h ~ Home Improvement Contractor# -3 567 Worker's Compensation # aV - ALL CONSTRUCTION DEBRIS RESULTI G FROM THIS PR=T WILL BE TAKEN TO SIGNATURE DATE r+b l f4 ' 1 y FOR OFFICIAL USE ONLY y, APPLICATION# I � DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER R Y DATE OF INSPECTION: FOUNDATION r FRAME f } INSULATION y. FIREPLACE ELECTRICAL: ROUGH FINAL o z i PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL.BUILDING t s, DATE CLOSED OUT ASSOCIATION PLAN�NQ-- t '111C l �rtiYllFQ -= 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Iome Improvement Contractor Registration Registration: 153567 Type. Private Corporation Expiration: 12/15/2012 Tr# 206433 CAPE COD INSULATION, INC HENRY CASSIDY 455 YARMOUTH RD. ---- ----"-- --�"- HYANNIS, MA 02601 ;Update Address and return card. Mark reason for change. " Address C� Renewal L, I L mlaloyntcnt L.� Lost Card )PS-CAI 0 b0NI-04N4-G101:?1ti (11'lice� u1 Sumer Afrairs Bus ne�''/Regul it') Liccuie or registration valid for individu! use HOM8 1191Pb� fflF�`fJ`(�t01V1`�,1YCTC�Wu1uu>�CGs before the expiration date. if found return to: f r,fY_ Registration: 153567 Type: Office of Consumer Affairs and Business Regulation Expiration: 12/15/2012 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 E? OD INSULATION, INC HENRY CASSIDY 455 YARMOUTH RD.. HYANNIS,MA 02601 Undersecretary Atalid ith t si ture '= aChusel(s-)cllartmcnt of Public Sall ct% Board of B(iilding Rcgulations an(I Stalldal-ds,. " Construction Supervisor License License: CS 100988 HENRY CASSIDY 8 SHED ROW WEST YARMOUTH, MA 02673 Expiration: 11/11/2013 ('unuui,.i•ncr Tr#: 7620 LVI rIVI No. 1605 P. I Client#:4597 CCINSUL ACOR&, CERTIFICATE OF UARILITY INSURANCE DATE(MMIDDIM-0 07J02/2012 THIS CEkTIFICATE IS ISSUED A5 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 CONS"rl'I UTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the cerllflcaI I holder ie an ADDITIONAL INSURED.the policy(ies)must be endorsed.If SUBROGATION 13 WAIVED,SUb)oct to the terms And conditions of the policy,certain policies may ruqulru an endorsement.A statement on this certificate does not corder rights to the certificate holder in lieu of such endorsernent(s). PRODUCER Rogers&Gray Ins.-So.Dennis NAME: . Margaret Youli 434 Route 134 In i a Exl:508-760-0602 ac Na: 817-816.2156 E-MAIL South Donnis, MA 02660-1001 500 398-7980 INUURFR(B)AFFORDING COVERAGE NAIC N INSURERA;Peerless Insurance 18333 INSURED Cape Cod Insulation Inc INSURERB:Evanston Insuranco Company ' 455 Yarmouth Road INSURERC:Atlantic Charter Insurance Hyannis,MA 02601 INSURER D:.Com,nerce Insurance Company 34754 INSURER E; _ INSURER F; COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTFD hCLOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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. 1�SN TYPE OF INSURANCE ADDL SUER - POLICY EFF POLICY EY POLICY Ntlp1ocry MMIDD/YYYY MMIDBN*YYY LIMITS A GENERAL LIABILITY CBP8263063 4101/2012 04/01/201 EACH OCCURRENCE $1 000000 X COMMERCIAL GENERAL LIABILITY ENTER � �aocurrcnce $1 OO OOU CLAIMS-MADE F X]OCCUR .MEO EAP(Any one pereon) $5 000 PER80NAL tt AOV 1HJuRY 51 000 000 GENERALAOOReoATs $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG s2,000,000 POLICY PRCT O LOC $ Q AUTOMOHILEUAdWT'Y 12MMBCKVMK 4/0112012 04/01/201 j CEOM�B_I,INdEoDSINGLELIMIT 1000000 ANY AUTO BODILY INJURY(Pa person) $ ALLOWNEO X SCHEDULED _ AUTOS AUTOS BODILY INJURY(Par aacloent) S X HIRED AUTOS X NON-OWNED PROPERTY OA AUTOS S 9: B X UMeR�LLALIAB OCCUR XONJ453512 4/01/2012 04/01/201 EACH OCCURRENCE $1 000 000 El(cEs6 LIAB CLAIMS•MAOE AGGREGATE $1 OOU 00O oEo X RETelvnorl 10000 C AND EMRS COh)S'LI A ILITION WCA00525901 6/30/2012 06/30/201 X we srnru• OTm $ — AND EMPLOYERS'LIABILITY Y N E oFFlcEwn E n�° Exc�do �SieCUTwe E.L.EACH ACCIDENT 1 000 000 NIA ( ory n NHJ Y8d.d If yee, aecnee under E.L.DISEASE-EA EMPLOYCe $1 00O 000 DESCRIPTION OF OPERATIONS bola& E.L.DISEASE,POLICY LIMIT 1$1 000 000 7 DESCRIPTION OF OPERATIONS I LOCATIONS I VENICLES(AUaah ACORD 01,Addliloml Rw .,k.Schedwe,I(More apace 16 requii9a) "Workers Comp Information"* Included Officers or Proprietors Certificate Holder is included as an additional insured undor General Liability when required by written contract or agreement. CERTIFICATE HOLDER CANCELLATION Cape Cod Insulaliorl,lnc SHOULD ANY OF THE ABOVE DESCRIBED POLICIES RE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOVICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVIsION9. AUTHORIZED REPRI=SENTATIV6 0190 -2010 ACORD CORPORATION,All rights reserved. ACORD 25(2010/05) 1 Of 1 The ACORD name and logo ara registered marks of ACORD #S03849/M83848 MEY The Corr moll 1, d1h of kfassach-useits Departmeti t o, 'whistrial Accidents 0jfiCt, ,ii,!)I vestl gatt ons 600 14-ii-viiington Street B o,� VIA 02111 lV H"I I INS,go v1dia Wort'Lior's cotupetislitiou 111sunnice Affiu_:i: BLiii(iei-s/Coiiti-actors[L?Iectriciatisj.['ILlik.iL)(,t-.s Please 1JI-illt legibly Y1 C. yto Pd, Plioneft: 61 L-4/zl/ L Arc.voli all eloPlUYCr'? (A)CCI'L dkC uPpropriate box; I'Ype of Project (required): .ill a C!Inrloyel. with 4* 0 1 arn*a 6..1 contractor and I have New COnSt rLICtion El (I:Llll WId/(jr hired flic. ails ,owractors listed on 7. Rerikodelingo the attar lwi] 1tc.. c[.T 1)cuprieuor or partnership These sui-.,-_wr,-,ctors have 8. El Deniolit)o n rind have IlQ clllployt:es working for eniploycv,:,,,,I have workers' comp. 9. Ej Building addition "Ic Ili any capacity. [No workers' insUrallkV.: 10. a Electrical it-Imirs oi-additiuns Wllil)HUSUI-WIL.-C rCqUirrd.j 5. E] We arc:i c-illoi-aiion and its 1.1. Pluiribing repairs ur addlitolls officei's lix,.-cxi�rcised their riolit of I�1111 a hullwowlier cluing all work exenipiwit 1;cr MGL c. 152§(04),and 12, hoof repairs "tVISVII: [M) workers' comp. we have Ik,CHII-lloyees. [No workers' COMP. 11111;1:111CC required.) F. 11I)IJ11"itnt that chocks box #I roust also fill out the section below showl".•dwir workers'compensation policy inforn-kittlork. 1c,-%,uct,w I w-;I[I..I IIII t I I i S it Ft'i d u V i t i rid i C u ki 118 t 11C Y at C doing a I I wo,1,au,l i,,-it hire outside contractors must subniii,a new affiduyit indiCUting JIUCII. ji'111liack.-I,that chcck-this box IIII.I.St attach an additional sheet showing of[ha sub-contractors and state whether or not those entities,have 1i lh<'tit.c.nwarturs have ctllployCr.S. dtCY IIILISE provide their workw'coitq, ituniticr. wit au employer that is providing workers'etmispensatio n it,"„ pure for my employees. Below is the,policy arts job site 1-111,11ick- Company Narrie: A 0 M Ae�- C- Poll'-Y it of Ncl I-I It's. Lic. it: ,�Q_)f A (5 fLC4_0 L— Expiration Date: Job Sit(.. Oki City/State/"Lip: 4koIW47 AA AL AtLidt a copy ot'the worlCerb;, compensation policy declaration pat;,- the policy nuntber and expiration date). I-Attic w�,Cuic covortl6c its mqUiMd UIjdCj'Section 25A of MGL c. I'5-' 1,;ad to 1110 imposition of criminal PCnaltios of u fine up it)$1,500-00 ani.Uui LIS well its Civil penalties in the form of a STOP\\.I ji<i\*ORDER and a fine Of Lip to$250.00 a day against the violatur.13e:0vised Irui c orwarded to the Office of lnvesti,,w­11,of the,DIA for insurance coverage vorification, �wa I du here c if' under the iris and penalties qj'pet.-I.my that the injnrttiation provided above is true and eorrect. Date: Ullicial use only. 1.)uIlot write its this area, to be official City ol-Towll: # Issuing Authority (circle otte): 1. hoard OfFlealtli 2. Building Department 3.Ci t /Ti) i I I Clerk 4.Electrical Inspector S.Pltuikbhkl;luspector I 0.Other Contact Persull: Phone#: _j f M OWNER AUTHORIZATION FORM 1, Hnna Mgr%'o, WCktG��� (Owner's Name) owner of the property located at la0 W�A- ln� � skrPef (Property Address) (Property Address) � � f hereby authorize cod 1C,6 , (Subcon r ctor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. Owner's Signature Date 4 i 1 r.