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Home My WebLink About0045 BUCKWOOD DRIVE ys �6uefcwaa� �D2 . 11 Application number ! ...... .... .^. .!... - ►�7!!! Fee .............................................................................. OCT 3 1 2018 HAM Building Inspectors Initials..... Ak Date Issued.......to......................v..... .. 4-1 ov Map/Parcel............ .Tek . ................................. TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/W1NDO W S/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: (/ (�(� � � Alz�vl,1-1,5 NUMBER STREET VILLAGE Owner's Name: 4A419 I-A L U�C L�/ —SU 1,i 'hone Number `5� (0 C) 4,:;-) $ Email Address: Cell Phone Number 50 :bo F-D Project cost $ •Soo, &0 Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above roe I hereby property Y authorize to make application for a building permit in accordance with 780 CMR Owner Signature: c Date: )0` a2,6 r pZ0 I TYPE OF WORK Q Siding 0 Windows (no header change) # 0 Insulation/Weatherization 0 Doors (no header change) # Commercial Doors require an inspector's review Roof(not applying more°than 1 layer of shingles) Construction Debris will be going to W!�M,Ow # �q%S/ -i& CONTRACTOR'S INFORMATION Contractor's name L>lV/` Home Improvement Contractors Registration(if applicable) (attach copy) Construction Supervisor's License# q Q �` (attach copy) Email Hof Contractor f_5 E 6O I-[h17&orm,&.Goi-I ' Phone number y 93 6 & 5 ' ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS/N A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER ............................................................ *For Tents Only* .. .._Date'Tent (s) will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent Fuel source being used LP tank 201bs. or> Yes No , if yes, a gas permit is required. Natural Gas Yes No , if yes, a gas permit is required. If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date 6. APPLICANT'S SIGNATURE r L 0 Signature Date 3l 8 All permit ap ieations are subject to a building official's approval prior to issuance. . . Town of Barnstable Building ,Post This Card So That rtis visibleFrom the Street:A , ~roYetl;Plans Must�beRetam`ed on Job„and this-"Card MusL=be;Kept BAR*SIITAn'. . S z, M Posted°UntilF�nal Inspection HasBeen Made t � Q Where a Cert Permit ijllt Permit No. B-18-3616 Applicant Name: ADILSON SEGOLINI Approvals Date Issued: 10/31/2018 Current Use: Structure Permit Type:.. Building-Siding/Windows/Roof/Doors Expiration Date: 04/30/2019 Foundation: Location:' 45 BUCKWOOD DRIVE,HYANNIS Map/Lot: 272 100 Zoning District: RC-1 Sheathing: Owner on Record: JULIAO,MARIA L ; Contractor NameY ADILSON SEGOLINI Framing: 1 Address: 45 BUCKWOOD DRIVE Contractor License: C55L-099907 2 stPrJtCost: Chimney:HYANNIS, MA 02601 Description: ReRoof Permit Fee: $35.00 Insulation: Project Paid.: $35.00 Review Req: Date 10/31/2018 Final: Plumbing/Gas un •^ y, n Rough Plumbing: ... t Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved appl cation and the approved construction documents for whichahis permit has been granted. All construction,alterations and changes of use of any building and structures,shall,be incompliance with the local zonmg`by laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or roadand shall be maintained open for}publ c Wsspectidn for the entire duration of the work until the completion of the same. P Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Buildihg and:Fure Officials are'provided,on ti s permit. Service: Minimum of Five Call Inspections Required for All Construction Work i . 1.Foundation or Footing r Rough: 2.Sheathing Inspection 3.All fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation \7.Final Inspection before Occupancy Low Voltage Final: _ Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work"shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons.contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Buildingplans are to be available on site p Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT T> i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual); Address:��iZ /y/�i�/�i✓ ,�,AI�/E City/State/Zip: W. A4,t6jr Phone#: g 6,9?5 Are you an employer?Check the appropriate box: Type of project(required): 1.[B—I am a employer with 4. I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 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 workingfor me in an capacity. employees and have workers' Y P h'• $ 9. ❑Building addition [No workers' comp.insurance I 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 12.❑Roof repairs insurance required.]t c.152, §1(4),and we have no employees. [No workers' 13.❑Other comp. insurance required.] *Any applicant that checks box 41 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 the policy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: /14 17- Expiration Date: l y' Job Site Address: 146- 0C t wo00 p2 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 certify under the pains and penalties of perjury that the information provided abov is true and correct Signature: Z Date: b l Phone#: 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#: I 7, 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 into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this 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 certificate(s)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 burn 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 Boston,MA 02111 Tel.#617-727-4900.ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 • wvvw.rnass.gov/dia ACORD�Z� -I r CERTIFICATE OF LIABILITY INSURANCE DATEosr27rM 9�s� 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 have ADDITIONAL INSURED provisions or 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; JIM HINDMAN Schlegel&Schlegel Ins Broker PH NE 608-771-8381 No: 608-771-0663 34 Main Street West Yarmouth,MA 02673 0 schl el[nsuran mail.com INSURE AFFORDING COVERAGE NAIL# INSURERA: NGM INSURANCE COMPANY 14788 INSURED INSURERS: AIM MUTUAL Adilson Segolini INSURERC: DBA SEGOLINI CONSTRUCTION INSURER D: 117 Minton Lane W Barnstable,MA 02668-1818 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FORTHE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I.INSR POLICY EXP TYPE OF INSURANCE 'POUCY NUMBER fVPW9--rM IMMIDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAJMS-MADE ®OCCUR PREMISES E oS�e— $ 500,000 MED EXP one $ 10,000 A MPT8486U 05/07/18 05/07/19 EERSONALBADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMMAPPLIES PER GENERAL AGGREGATE S 2,000,000 POLICY❑JE LOC PRODu COMProPAGG S 2,000,000 OTHER $ AUTOMOBILE LIABILITY INGL9 LIMIT S eeei eM ANY AUTO BODILY INJURY(Per pencn) 9 OWNED SCHEDULED BODiLY INJURY(Per acciderd) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY GE $ AUTOS ONLY AUTOS ONLY S UMBRELLA UAS OCCUR EACH OCCURRENCE S EXCESS LU1B HCLAIMS-MADE AGGREGATE S DED RETENTIONS S WORKERS COMPENSATION RTUTE H AND EMPLOYERS'UABIUTY I RA ANY PROPRIEMPJPARTNERlEXECUTVEYIN E.L EACH ACCIDENT S 100,000 B OFFICERIMEMBEREXCLUDED? ® NIA AWC-400-7026025-2016 051=18 08123/19 IMandatory in NMI E.L.DISEASE-EA EMPLOYEE S 10,000 N yes,dasaibe under 500 000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is requited) ADILSON SEGOLINI HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN SEGOLINI@IOTMAIL.COM, ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REP Ave 0 2015 ACORD CORPORATION. All rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks dVACORD Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Individual `� Y Expiration before the expiration date. If found return to: ReaistraElen Office of Consumer Affairs and Business Regulation 05/14/2020 1600 Washington Street-Suite 710 ADILSON SEGO Boston,MA 02118 DB/A SEGOLINI_C: _ STR`UGTON ADILSON SEGOL NI / E`er ,^117 MINTON LAN Y WEST BARNSTABLE,MA 02668 Undersecretary Not valid without signature Commonwealth of Massachusetts Division of Professional Licensure r 'Board of Building Regulations and Standards' Constr. ctVo , } ;Specialty` CSSL-099907 45X jres:•10/14/2019 ADILSON SEGO ENI li `117 MINION r w. WEST BARNS LE;MA-i126 tcmmfssioner. .{ https://www.cifraclub.com.br/pentatonix/iittle-drummer-boy/imprimir.htm1 12/4.116,4:04 PM Page 3 of 3 C Cape Save Inc. TOWN OF BARNSTABLE 7-D Huntington Avenue South Yarmouth, MA 02664 2012 01-C ( e Tel: 508-398-0398 Fag: 508-398-0399 12/11/12 Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main St. Hyannis,MA 02601 RE: Building Permits Dear Mr. Perry, This affidavit is to certify that all work completed for 45 Buckwood Drive, Hyannis has been inspected by a certified Building Performance Institute(BPI)Inspector. Ceiling: R-11 cellulose All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map— a�d� too _� � Parcel Application i Health Division Date Issued I O Z Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Address 45 Box V,Woo f I& Village I-+Ya�n I y Owner Norma. W ,t new Address Telephone 501 �''�J - C,2, Permit Request NA Q - I I all)Alue +0 4e MAIY. -Lftcr"Oe ic ven+ilafian c-ode, w14 5104 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation�l op 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 19 l 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 ti Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: N Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes �No Fireplaces: Existing New Existing wood/co I stove: ®Ye No Detached garage: ❑ existing ❑ new size Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑n6w ;fie Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size — Other: Y ' Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes �No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) ii ��, i Name W1IIi m �, Tf1c, Telephone Number 508 Address �D 00, a License# Mr d- 1 Home Improvement Contractor# 38b Worker's Compensation # I WC 33 hol ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO 1(U.1 m,01A SIGNATURE DATE I a-W FOR OFFICIAL USE ONLY `APPLICATION# DATE ISSUED MAP/PARCEL NO. i ; ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL t GAS: ROUGH FINAL FINAL BUILDING it DATE CLOSED OUT ASSOCIATION PLAN NO. 4+,60 vest IRain S-ti:eet Hy-his,MA 0260;-3698 Assistance 3 TY on-AR lines HOME OWNER WFATHERIZATION WORK PER3#iIIT&,FUEL RELEASE: PLEASE FZI OUT_AND.SIC,N`iMS TORM IF YOU ARE THE APPLICANT HOME Off_ I N o r mop 'i-pee - her`eb-y consent to and agree that weatha zatiou work may be . done by the Weathaizati n Program of Housing Assistance Corporation{ herein after refesed as "Agency") on the property located at N 5 )r ueod U f i r - The weatherization work done will be based on programmatic priorities and availability of fa ceding and it may M' dude all or some of the following measures= ` Weathhe±-stlipprug&canik;Y,g of windows and doors,insulation of attics, sidewalls 8�basements,attic, and other ventilation mea=cs and ossxblp replacement of badly detexaoxated wzndows_ n consideration of the weatherization work to be done at my home I agree to the following 1_ I give permission to the `'Agency" its.agents and employees to travel onto or across said property with such equipment and mat enals;as may be necessary to perform Reatheriza-tion work on said pro-pert- 2_ The Housing Assistance Corporation reserves the light torinspect the fael or utility bill for the weatherized unit on au ongoing basis for no more than five(5)years after the Weatherizatiola work is completed I have read the provisions of this agreement as listed and freely,gye my consent. If '_.. Horne Ownci= (Signature) Datel r Agent (signature) - - - II J Date RAC approved Weatherization Company Caliber Budding&Remodeling. Cape Cod Insul�fion Save Creswell Consi-mctioia Frontier Energy S_omons - Lohr-&Sons -Peter Smith Resohition_Eiaergy- Rock Solid Cowiniction, All-Cape hs ala#i-on The Conztnompealth ofMassa' clzrrsetts . Department of Industrial Accidents , Office of Investia ations 600 Washin;ton Street Boston,MA 02111 1v)vw-mass.g ov1dia Workers' Compensation)nsurance Affidavit: guilders/Contractors/Electricians/Plumbers A licant Information Name(Business/Organization/Individual): C '`� Please Print Legribly LA J-n , Address: D H A,ntin 4-on . City/State/Zip:-5 o� t�+ �aC-mo ;-t-�1 �A Oa66 Phone#: 5 g._ 3 9 $ - 3 9 g F2. re you an employer?Check the appropriate box: I am a employer with—'�— 4. 0 I am a general contractor and I Type of project(required):- ❑ employees(full and/or part-time)•' have hired the sub-contractors 6- ❑NeW construction . I am a sole proprietor or partner- listed on the attached sheet. 7. []Remodeling ship and have no employees ' These sub-contractors have working for me imany capacity. employees and have workers' �' ❑Demolition [No workers'comp.insurance comp,insurance." 9-' 0 Building addition required.] 5. D We are a corporation and its 1.0:0 Electrical repairs or additions 3•❑ I am a homeowner doing all work officers have exercised their myself.[No workers'comp. = rio 1 I.0 Plumbing repairs or additions p right of exemption per MGL insurance required.]t c. 152, §1(4),and we have no 12 0 Roof repairs employees.[No workers' Other I"U.k V,p comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing T Homeowners who submit this affidavit indicatin the are doing '�1eu workers'compensation policy information. n hire de contractors must *Contractors that check this box must attached an additional sheet howing th name of the sutb contractors and state wt�etherit a eor nowt thosedavit,entities have employees, If the sub-contractors have employees,they must provide their workers'comp.policy number. such. I am art employer that is providing workers'compensation insurance for sty employees. Below is the policy and job information, cy l site Insurance Company Maine: -Teo�not 0 .s►S uv,-an Gel G Policy#or Self-ins.Lic.T: T�A� c331ao �' Expiration Date: Job Site Address: 1� �a c� �r,v City/State/Zip: 0.r�iS Attach a copy of the workers'compensation policy declaration page(showing the policy num er and expiration Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminap enal • date) 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 penalties ofa of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Im�estiQations of the DIA for insurance coverage verification. 1 do hereby cet10 under the pants and penalties of perjun t/rat the infnrnzaiion provided above is true and correct. Si$nature: + Date: Phone 3 8 _ 0396 — Official use 0110. Do not re rite in.Phis area,to he completed by city or towil official City or Tovvn Permit/License Issuing Authority(circle one): 1. Board of Health 2.Building . Inspector Department 3. City/Town Clerk 4.Electrical Inspector 5 Plumbing I ect 6. Other p or -------------- Contact Person: Phone F i iE CERTIFICATE OF LIABILITY INSURANCE DAion oi� 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 COONNTACT Risk Strategies Company . Risk Strategies Company PHONE (781)986-4400 C o..(781)963-4420 15 Pacella Park Drive E-MAIL ADDRESS: Spite 240 INSURERS AFFORDING COVERAGE NAIC# Randolph MR 02368 INSURERa:Selective Insurance INSURED INSURERB:Safety Insurance Company 3618 Cape Save, Inc INSURERC-Mechnology Insurance Company 7 D Huntington Ave INSURER D: INSURER E: South Yarmouth MA 02644 INSURERF: COVERAGES CERTIFICATE NUMBER-CL125948081 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE L POLICY NUMBER MM/OD MOIDDIYYW LIMITS ' GENERAL LIABILITY 1,000,000 EACH OCCURRENCE S GE TO X COMMERCIAL GENERAL LIABILITY PRA REM EaENTED occurrence) S 100,000 A CLAIMS-MADE 5x-1 OCCUR PPS1994480 0/16/2011 0/16/2012 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,no,000 ' GENERAL AGGREGATE S 2,000,000 GEN'LAGGREGATE LIMIT APPLIESPER PRODUCTS-COMPIOPAGG S 2,000,000 X POLICY JFCT PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Es accident) S 1,000,000 ANY AUTO BODILY INJURY(Per person) $ B ALL OWNEDSCHEDULED 6208200 AUTO 1/6/2011 1/6/2012 BODILY INJURY(Per accident) S X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS X Underinsured motorist BI solit S 100,000 X UMBRELLA LIAB OCCUR r EACH OCCURRENCE $ 2,000,000 A EXCESS LIAB CLAIM84AADE AGGREGATE S 2,000,000 --TOED I I RETENTIONS CPP91994480 0/16/2011 0/16/2012 $_ C WORKERS COMPENSATION Z WC STATIh OTH- AND EMPLOYERS'LIABILITY YIN 'sToll ANY PROPRIETOR/PARTNERIEXECUTIVE EL EACH ACCIDENT $ 500,000 OFFICERIMEMBF-R EXCLUDED? N NIA - (Mandatory in NH) C3318007 /9/2012 /9/2013 EL DISEASE-EA EMPLOYEE $ 500,000 If yes,desaibe under , DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES Attach ACORD 101,Additional Remarks Schedule if mores ace is re Issued as evidence of insurance Issued as evidence of insurance. uired q ) Thielsch Engineering, Inc. is listed as additional insured as respects General Liability as required by written contract. CERTIFICATE HOLDER' CANCELLATION msong@capelightcompact.org SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Cape Light Compact - ACCORDANCE WITH THE POLICY PROVISIONS. Pitts: Margaret Song PO Box 427/SCH s AUTHORIZED REPRESENTATIVE 3195 Main Street Barnstable, M 02630 �yh Michael Christian/HAM ACORD 26(2010105) 01988-2010 ACORD CORPORATION. All rights reserved. INS02517n1naslnl That ArtnR11 namat nnfi Inns prat rnnieforori mark*of Arnpn r ti:ts:achusctts-Dcpartincnt of Public Safm 9 Soard (of Buildin!, Rcl ulations and Standat•tls ConsLNCticin Super;risor 3 ecialty License , License: CS SL 102776 _ Restricted to: IC ' WILLIAM MC CIUSKY ! ! f 37 NAUSET ROAD ` F WEST YARMOUTH, MA 02673 r" Expiration: 6128/2013 . ('.nuroi..i„nrr Tr=: 102776 Office of Consumer Affairs andeusness Regulation `+ k / 10 Park Plaza Suite 5170 Y Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 171380 ' _ Type: Corporation . - _ Expiration: 3/1412014 - Tr# 222184 CAPE SAVE INC. WILLIAM MCCLUSKEY 7-D HUNTINGTON AVENUE SOUTH YARMOUTH, MA 02664 Y - _ Update Address and return card.Mark reason for change. s Address . Renewal J Employment ii Lost Card PS-CA1 is SOW04/04-G101216 ' ✓fe�ami»to�tcue¢��•c ,.l�a•uacfurelt� • . Office of Consumer Affairs&B siness Regulation License or registration valid for individul use only n l;_HOME IMPROVEMENT CONTRACTOR before the expiration date If found return to: Registration:_:171380 Type: Office of Consumer Affairs and Business Regulation a" 10 Park Plaza-Suite 5170 Expiration: 3/1412014 Corporation Boston,MA 02116 6V SAVE INC. WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE-- SOUTH YARMOUTH,MA`02664 Undersecretary Not valid wit o signa