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Home My WebLink About0246 BISHOPS TERRACE P ,,;� f S s l CAPE TOWN of BARNSTABLE INSULATION 101q jUL -S 0 8; 39 .IIY PlAY1' )[A M[CSS 3PqT fGAM 7YSPENOEp ATT) Jurtf YS INiYSAi1PN CCICIN05 - 1-800-696-6611 DIVISION 1'o4vc� of Barnstable Regulatory Services Buildli-ig Division 200 Main St llyannis, MA 0260.1 Date: - • Dear Building Inspector r _ Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. perforined & 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 peralit application. All work has been inspected by a cerr,fied'BuiIding Performance ins ti'tate (BP,I) inspector. All work preformed meets or exceeds Federal & State Requirements. 1 PropertOwner Property Address Villag-e. 1(aV-J�W SMjjjt<n c ay4 Disl o��Tr en t'2 j,g�s'��✓. Insulation Installed: Fiberglass , Cellulose R-Value Restricted Utu•estricted Ceilings Slopes ( ) ( ) ( ) ( ) ( ) 1"loors Walls ( } ( X) Sincerely l He ry L as, y Jr, President (:.' e Cod Ir ulation, Inc. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map- � Parcel Application # /` V 37?q Health Division Date Issued Conservation Division Application Planning Dept. Permit Fee ; Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address Village�ZZ; 9Z/.S Owner Address ---I" Telephone :2 .3 6 Ste! Z Permit Request 10 :e:z NO Square feet: 1 st floor: existing proposed 2nd floor: existing proposed- Total ewe? Zoning District Flood Plain Groundwater Overlay Project Valuation a 7!>D , D Construction Type �� a� . Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documgntation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ANo On Old King's Highway: ❑Yes XNo 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: ❑ 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 � iJ �� /��s/�,L �/ Telephone Number ;.S7Jf 27`!62- / Address f /GG' ltfi �zA"O, zj,/,g5- License # Home Improvement Contractor# Email Worker's Compensation # 401 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE /��f FOR OFFICIAL USE ONLY APPLICATION# ,R DATE ISSUED MAP]PARCEL NO. ADDRESS VILLAGE a +; OWNER 7 DATE OF INSPECTION: r FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING, s - . ;t DATE CLOSED OUT kSOC,IATION PLAN NO. Massachusetts -Depaftr4rit of P�blic Safety Board of Building Regul .0ons?nd Standards Construction Supervisor a License: CS=100988 FIN HENRY E CASSD 8 SHED ROW s WEST YARMOVfH ` 2 Expiration Commissioner 11/11/2015 -- Office of Consumer,'Aairs:_and.Business Regulation 10 Park Plaza Suite 5170 . .Boston, Massach> setts 02116 Home Im rovement CO",'tractor Registration Registration: 153567- 1 € ; Type: Private Corporation Expiration: 12/15/2014 - -Tr# 233831 CAPE COD INSULATION, INC - HENRY CASSIDY 18 REARDON CIRCLE SO. YARMOUTH, MA 02664 H - .. Update Address and return card.Mark reason for change. SCA 1 0 20M-05/11 Address Renewal. Employment (� Lost Card .. � � - c��e epurrerie<vrecaeczl!�i o�C�/�l �ucleCls '_ , ' ' �_ Office of Consumer Affairs&Business Regz�caculation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR " before the expiration date. If found return to: " gistration: _53,567 Type: Office of Consumer Affairs and Business Regulation xpiration 1205/201.4 Private Co�poratian 10 Park Plaza-Suite 5170 �,`r ,,.. Boston,MA 02116. CA E COD INSULATION, INCH HE qRY CASSIDY 1 i ..i, 18 REARDON CIRCLE SO YARMOUTH, MA 02664 Undersecretary of val witho t 4,atfre �I h CAPECOD-27 CVANGELDER CERTIFICATE OF LIABILITY INSURANCE DATE 4/11/2 DIYYYYI /112014 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. f 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: Cape Cod Commercial Rogers&Gray Insurance Agency,Inc. PHONE Fax" -- 434 Rte 134 IA/C.No.ExtL AIC No): (j 877)816-2156 South Dennis,MA 02660 EMAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC q __._......._.._._.._—___.— _ INSURER A:Peerless Insurance Company _ INSURED INSURERB:COMMERCE INSURANCE COMPANY Cape Cod Insulation Inc INSURER c:Evanston Insurance Company 18 Reardon Circle INSURER D:ATLANTIC CHARTER INSURANCE_GROUP South Yarmouth,MA 02664 INSURER E: INSURER F: - V 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 - AOUL SITE POLICY EFF POLICY EXP I LTR TYPE OF INSURANCE JNSQ WVD POLICY NUMBER MMIDDIYYYY MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 _I CLAIMS-MADE 1X J OCCUR CBP8263063 04/01/2014 04/01/2015 AWA_G_ETO-RENTED 100,000 PREMISES Ea occurrence $ MED EXP(Any one person) $ 5,000 — PERSONAL&ADV INJURY _ $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ — 2,000,000 X POLICY(( PRO- I l_.--^I JECT U LOC PRODUCTS-COMP/OP AGG $ ^— 2,000,00 I OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO 14MMBCKVMK 04101/2014 04/01/2015 BODILY INJURY(Per person) $ — T ALL OWNED .X SCHEDULED BODILY INJURY(Per accident) $ 1,000,000 AU70S _ _ AUTOS I X X NON-OWNED PROPERTY DAMAGE _ $ HIRED AUTOS AUTOS Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 C EXCESS LIAB CLAIMS-MADE R/O XONJ453512 '04/01/2014 04/01/2015 AGGREGATE_ .$ I UED X RETENTION$ 1'0,000 Aggregate $ 1,000,000 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE D ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WCA00525904 06/30/2013 06/30/2014 E.L.EACH.ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? a N/A -- '--- (Mandatory In NH) E.L.DISEASE-EA EMPLOYE- $ 1,000,000 It yas,oescnbe under DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) . Workers Compensation includes Officers or Proprietors. Additional Insured status is provided under the General Liability and Auto Liability when required by written contractor agreement with the Certificate Holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EVIDENCE OF INSURANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. - - AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD r � The Commonwealth of Massachusetts Department of IndustrialAccidents u W Office of Investigations J d l Congress Street, Suite 100 ' Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): Q, Tf� Address: (�11� City/State/Zip: 'dbtA G�W&Mffkt66 Phone#:' �'�0� ' -71 (2 A e ou an employer? Check the appropriate box: ,�,�(� Type of project(required): I.f� t am a employer with 2r7 4. ❑ I am a general contractor and I have hired the sub-contractors 6. ❑New construction employees (full and/or part-time). 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. msurance.x 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 I LEJ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] 't c. 152, §1(4),and we have no: �'J employees. [No workers' 13.[�Other1 JV5 J(i171 y w 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 anew affidavit indicating such. tContractors 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: �� G(/V�"��i�� Policy#or Self-ins, Lic. #: Expiration Date: f/ ,;2)6 Job Site Address: -5 City/State/Zip: a 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: 1 do hereby cer tfy the pains and penalties of perjury that the information provided above is true and correct. Si nature: p Date: U � " Phone#: 0 V2 s /Z 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#: 4 r , OWNER AUTHORIZATION FORM Calr (owner's Name) owner of the property located at y� f isk us —r"ra.al (Property Address) is (Property Address) hereby authorize 1 nsU D n , (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. Ane 's Signature Date II