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HomeMy WebLinkAbout0060 CAPTAIN COOK LANE s .�.�. .. A� F Application number........ I e ff ; Date issued..............L ........... ..1 t. ........ IIARNSTABL£, m �w71w,' OCT C Building Inspectors Initials. TOWN T252016 T0► 1�6 � e MapJParcel.. .OA.Q.....!................. RNSTABLE TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDINGAVINDOSJ►WS/DOORS/TENTS/STOVES/WEATIBRIZATION ]PROPERTY EVORMAT>iON Address of Project: Ln (�0 k NUIVIBE STREET 'VILLAGE Owner's Name: �o� f� ,�ay.nC� Phone Number_ 5o&-Zpo- O t i ck Email Address: Cell Phone Number Project cost S 2 , O 5 9 — Check one Residential Commercial OWN EW S AUTHORIZATION HORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: _See A4ad,BQ Date: TYPE OF WORK ❑ iding ❑ Windows (no header change)# ❑ Insulation/Weatherization Doors(no.header e char # t Commercial Doors require on inspector's S ) q review LD Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION TION Contractor's name A 3JZ / Pe� �- Home Improvement Contractors Re 'stmdon Cif aP licable)# /!Z 7 5 (attach copy ) Construction a ervisor's License# O7 t� attach p - ! ( copy) Email of Contractor e c,--► Phone number -1,/o/-7 i1/-(3 :�9 ALL PROPERTIES THAT HAVE STRUCTURd OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. 5 APPLICATION NUMBER.................. *For Vents OnIV* Date Tent(s)will be erected Removed on Does the tent have sides?Yes number of tents total No (If yes please attach floor plan with exits marked) Dimensions of each Tent Additional tent dimensions can be attached on a separate piece of paper. 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 te nt df food it being served at your event please obtain a Health department approval between the hours q��:00ar�-9:30 am or 3:30 pm-4:30pm, Co�ramercial events may require Fire Department a rovaL g j i pp YWOOD�COAL/PLLLET STOVES x Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front_back . __left side right side HOMEOWNER'S LICENSE EXEMTTION Homeowner's Name: Telephone Number Cell or Work number I understand ffiy 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?S0 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNAT Signature Date All permit applicati are subject to a building officiaps approval prior to issuance. SPECIAL.SERVICES CUSTOMER INVOICE Page.1 of 5 NO. H2612-89455 wy , Store'.2612 HYANNIS Phone: (508),778-8948 INDEPENDENCE A 1 .�. ,. 65 INDE NCE DRIVE CCSC HYANNIS MA 02601 Reviewer: VXG1123 Name Phone 1. • FORSBERG JAYNE (508)280.0148 REPRINT .Add`ess 60 CAPTAIN GOOK`LANE Phono2 Company Name City CENTERVILLE. Job Description patio"doge install 2018-09-25 14:01 State MA Zip 02632 "'"ty BARNSTABLE We reserve the right to limit the quantities of merchandise. INSTALLER DELIVERY #,1 MER:CHANDISE AND SERVICE SUMMARY 5oldtocustomers i REF# 101 STOCK MERCHANDISE TO BE DELIVERED: REF it I SKU OTY �Uml DESCRIPTION "PI TAX I EAW EXTENSION R03 0000 254.294°. '3 60 €A 3/4"X5-1/2"W PVC.TRIM/ A o: W.98 $68.94 1 7 R04 0000-458-056 24.00 LF 11/16 X3.1/2`PFJ WM444 CASING/. $1.94 $46.56 R05 1001-787-1221 1.06 EA 2X4-8FT#1 PT WEATHERSHIELD GC/ Y $4.67 $4.67 R06 0000-734-834 1.00 EA PHENOSEAL ALL PURPOSE WHITE:10.1'OZ/ A Y $5.58 $5.58 R07 1002-961-477 1.00 EA 6"X50'WINDOW& DOOR SEALING'TAPE/ A Y $17.97 $17.97 R06 00M.715-499 1.00 RL MULTI-PURP 16"X48" ROLL INS0L-5:3SF/ A Y $5.48 $5.48 R09 1001-861-475. -1'00 EA 1/2'X 4-1/2"72".WW472 OAK SADDLE/ A Y' $23.98 $23.98 R11: 1000=049-619 1.00 EA PS510L FRAME WHT PART ONLY./ A 'Y $205.0011 . $205.00 R12 1000-049=622 1.00 EA1 PS510L OPER PANEL WHT PA A Y $2M.00 $272.00 R13 1000.049.621 1.00 EA PS510L STAT'PANEL WHT -Y/ A Y $272.00 $272.00 R14 0000-321-257' 1.00 EA SCREEN FOR 206 e 51 R WHITE JA Y' $139.00 $139.00 R15 0000-570.469. 1:00 EA DO.OR'HARD 0/400-GLIDING WHITE/ A Y $5900 $59.00 r. w w - �. as a $1 .120.18 DELIVERY INFORMATION:. DELIVERY DA gftT iER WILL SCHEDULE 1 INSTALLATION#101 AT TIME OF INSTALLATION.. INSTALLER WILL DELIVER`MDSE T "`► I f't` I !' C"I ,`"'.CONTINUED ON NEXT PAGE"' O Check your Current.order,st4tus online atU()tvww.homedepot.dom/ordersta,tus /4{`/'�J � 0 (� .Page 1 of 5 NO. H2612-89455 Customer Copy � � - SPECIAL SERVICES CUSTOMER INVOICE- Continued Name: FORSBERG Page 5 of 5 NO. H2612-$9455 INSTALLATION #2 (Continued) ° REF#102 THE PERMIT IS PAID FOR,WC9RK ON THE PERMIT ASSEMBLY BEGINS IMMEDIATELY.CANCELLATIONS WITHIN 72 HRS.WILL BE REFUNDED END OF INSTALL#2 TOTAL CHARGES OF ALL MER6HANDISE & SERVICES Policyld (PI): o ' o '� © 51,989:19 A:90 DAYS DEFAULT POLICY; SALES TAX S70.01 TOTAL $2,059.20 PAYMENT TERMS : BALANCE DUE $.1,396.20 Refer to the Horne Improvement Agreement for payment terms 'The Nome Depot reserves the right to limit/deny returns. Please see the return policy sign in stores for details.' END OF ORDER No.H2612-89455 Customer's Signature \ .: ' J { Date Page 5 of 5 No. H2612-89455 Customer Copy Ors# of ;It �u.� e � 74247 # � i's f: NJ Mu' 7A .' f47�'liiilR!i iMl'B � �f6�3$tf;� �t � •C �' r� 3 y e 11 � -.'� � �• �` k a ne Commonwealth of Massachusetts �.�.: . Department of IndustrialAccidehis 2 �3tFE Office .f g o Invesfi ations I Congress Street,Suite 100 r 75 1�OStO�i 11IA 02X 14 2017 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information t Please Print Legibly Name (Business/Organization/Individual):?r $.Li Address: ! - = t1 S iL;=- �'� City/State/Zip: #E3; ` . C-13�= Phone#: Are you an employer?Check the appropriate box: El am a general contractor and I Type of project(required): 1.❑ [ tun a employer with 4. ,Zemployees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2.LJ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have. .8. ❑Demolition Working for me in any capacity. employees and have workers- [No El 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 I I.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL IZ.❑Roof repairs insurance required.] C. 152. §1(4),and we have no employees. No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box 91 must also rill 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 tivorkeis'comp.policy number. I ain an employer that is providing workers'compensation insurance for nzy employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.-#: Expiration Date: F Job Site Address: 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 ce-IfI&under the pares and penalties of perjury that the information provided above is true and correct e, Date.'__...-....--'-- ----- ---- - - - 7-1 Phone#: s• Official use only. Do not cT&C in this area,to be completed by city or town,offciaL Cite or Town: Permit/License# Issuing Authority(circle one): I.Board of health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other 'Contact Person: Phone#: r The Commonwealth of Massachusetts Department of Industrial Accidents Office ce of Investigations ; 1 Congress Street,Suite 100 Boston,JU4 02114-2017 www.massgov/dia Workers'Compensation Insurance_kMdavit: Builders!ContractorsMectricians/Plumbers APPEcant Information `�'� Please Print Le 'blv Name (Business!Clrgain nomTndividual): 0 ei J/ D _ Address: (B f g o S J'bN / y QNP/& City'State/Zip: 9Xf*0sd N • olvnr Phone#: 7 VY: ,?-75' - /S�5— Are you an employer?Check the i4propriate,be%: Tvpe of project(required): ]t employer with 7. 4. 6G 1 am a general contractor actor and I `I am a #, have hired the sub-contractors 6. ❑New construction .J employees (full and/or part-time). ! I am a sole proprietor or partner- These on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have g• ,Demolition l Notdm- for me in anv caps emoiovees and have workers' o ry I 9. U Building addition �o workers' zom insurance comp.IIsurance.= �] p 5. ❑ We are a corporation and its � 10❑Electrical repass or additions 3.[ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions, myself iNo workers' comp. right of exemption per iVIGL 12.❑ oof repairs t c. 152,§1(4),and we have no irsulrance required.] 13.�ther i i emplovee�. [No workers' i comp.insurance required] ..•. r.v applicant rha::hecks box s71 must also 511 out the section below showing their workers'compensation policy information. .rlomrownim who mbmit this affidavit indicatine they are doing a0 worl:and then hue outside contractors must submit a new affidavit indicating such. :Coat-worn that check this box must attached an additional sheet showing the name of+dir sub-contractors sad stare whether or not those entities have_ =pine. s the sub-contracmzc have employers,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 sire information_ L-[simmce Company dame: Policy 9 or Self-ins.Lic.0: X W l I o % Expiration Date: 3 ` Job Site Address: l0 I Cl i/1 �o n Y LR nl� City,Stawzip: 0Pn�Cr✓����'oz_ M 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 un to$1,500.00 and/or one-ye imprisomnent,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to M50.00 a day a st a lator. Be advised that a copy oft his statement may be forwarded to the Office of Irvestigations of the DMT 0surAce coverage verification. I do hereby terrify un e i at the information provided above is true and correct Si ate: Date: [n �.Z Phone T: d 77%iard ly. Do not wrue in this area,to be completed by city or town offrciaL or : Permit'License rity(circle one): l . ealtb 2.Building Department 3.City/Town Clerk 9.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: f :yi t I .;•�.F 7� j �l.�J t!'�' R S ! }I: {.� • (-n v�l,-♦ .." C{.�- f e at ,t' �'.f l��C" Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Supplement Card HOME DEPOT USA INC Registration: 112785 2455 PACES FERRY RD C-11 HSC Expiration: 04/22/2079 ATiAN`'TA,GA 30339 Update Address and return card. Mark reason for change. El Address ❑Renevra! El Employment ❑ Lost Card -_-- Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE SuoQlemeni Card before the expiration date. If found return to: Registration Expiration , Office of Consumer Affairs and Business Regulation i 12755 04i22/2019 10 Park Plaza-Suite 5170 -TOME DEP07 USA INC Boston,MA 02115 ANDREW SWEET 2455 PACES FERRY RD C-11 HSC ��• ATLANTA,GA 30339 Undersecretary d ithou Signature r 1 DATE(MWDDmYY) A C>RD CERTIFICATE.OF LIABILITY INSURANCE 02122QDIB ihkTHIS 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 terns 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 endomement(s). PRODUCER CONTACT MARSH USA,INC. NAME: TWO ALLIANCE CENTER PHONE FAx AlC Noll: 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA.GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIC 0 CN101642069-HoneD-GAW-18-19 INSURER A:Old Republic In uranceCo 24147 INSURED THE HOME DEPOT,INC. INSURER 8:New Hare Ins Co 23841 HOME DEPOT U.S.A.,INC. INSURER C:HlurleRlSk Cwwe Insurance Company 2455 PACES FERRY ROAD INSURER D: BUILDING C-20 ATLANTA.GA 30339 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: ATL-004353430-16 REVISION NUMBER: 3 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. tNSR ADDL SUB POLICY EFf POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER fMM1DD1YYYY1 (MMfDwYYYYL A I X I COMMERCIAL GENERAL LIABILITY MWZY312717 0310112018 03I01/2019 EACHOCCURRENCE S 9•000•000 DAMAGE TUREWED CLAIMS-MADE OCCUR PREMISES Ea occurrence S 1.000,OOD LIMITS OF POLICY XS I EXCLUDED MED EXP(Any one person) :S OF SIR:S1 M PER OCC PERSONAL 8 ADV INJURY S 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 9.000.100 POLICY E]PRO 7 LOD PRODUCTS-COMPIOP AGG S 9,OQC.000 X JECT S OTHER: .' A 'AUTOMOBILE LIABILITY MWT6312718 031012018 0310112019 C OMBINED QDISINGLE LIMIT S 1,000,000 X ANY AUTO LY INJURY per person) S OWNED SCHEDULED I SELF INSURED AUTO PHY DING LY INJURY(Per accident) S AUTOS ONLY AUTOS I 1 HIRED NON-OWNED ERTY DAMAGE S I AUTOS ONLY AUTOS ONLY ccident I I S I UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LU18 CLAIMS-MADEJ AGGREGATE S DED I I RETENTIDN S S B WORKERS COMPENSATION WC014122577(AK,NH,NJVT) 03ID72018 03/D12019 X STATUTE ER B AND EMPLOYERS'LIABILM YIN WC 014122578(WI) 031011201E 03/01/2019 5,C00,0m ANYPROPRIETORIPARTNER/EXECUTIVE _ E.L.EACH ACCIDENT S OFFICERIMEMB£REXCLUDED� NIA $,000,0M (Mandatory In NH) E.L.DISEASE-EA EMPLOYE s n yes.describe under Conuntled on AdliNonal Page E_L.DISEASE-POLICY LIMIT S 5,00000 DESCRIPTION OF OPERATIONS below C ExcesS AUIu 297-1-10011-00-2018 03101/2019 03101/2019 Unit: 4.000.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLJCIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING C-20 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA.GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee —Mauoo' L ©t98S-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101642069 LOC#: Atlanta AC ADDITIONAL REMARKS SCHEDULE AGENCY Page 2 of 3 Iv1ARSH USA.INC. NAMED INSURED THE HOME DEPOT,IHC POLICY NUMBER HOME DEPOT U.SA.,INC. 2455 PACES FERRY ROAD BUILDING G20 ' CARRIER ATLANTA.GA 30339 ! NAIC CODE ADDITIONAL REMARKS EFFECTIVE DATE. THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of LiabilityInsurance Workers Compensation Continued: Carrier:Indemnity Insurance Company of North America Pdicy Number WLR C647o3191(AL,AR,FL,ID,IA,KS,KY,LA.MS.MO.NE t4f:;.ND,OK,SC,SD,TN;lNV,WY) Effective Dale:031012018 Expiration Data:03101/2019 (EL)Unit:S1,000,000 Camer New Hampshre Insurance Company Policy Number.WC 014122576(DC,DE.HLIN.MD.MN.MT,NY,RI) Effective Date:031012018 Exoiration Date:03/0112019 (EL)Lirmt:S1,00o,o00 Carrier ACE American Insurance Company Policy Number.WCU C64783221(QSI)(AZ,CA:IL,NC.OR,VA,WA) Effective Dale:03/012018 Expiration Date.031012019 (EL)Lim C S1,00D,000 SIR SI-000,000 SIR for the states of AZ.CA IL.NC,OR,VA,NA Camer.Nation!Union fire Insurance Company policy Number.XWC 4595580(OSI)(CO.CT,GA,ME,MI,NV,OH,PA,UT) Effective Date 03/012018 Expiration Dale:0310112019 (EL)Umil:S7,000,000 51.000.000 SIR for the states of CONEAV,1141,OHRA,UT S750,000 SIR for the slate of GA S350,000 SIR for the state of CT Carrier-.National Union Fre Insurance Company Pdicy Number.XNC 4595581(QSI)(MA) , Effective Date:031012018 p Expiration Date:03/012019 nIY (EL)Limit.S1,o00,00D r YL SIR 5500,00D TX Empoyers XS Indemnity C31'rier.0linios Union Insurance Company Policy Number.TNS C4916693A(TX) Effective Dale:031012016 Expiration Date:03/012019 (EL)LircaC SID.000.00D SIR.S i,000,C00 ZORD 101 (2008101) The ACORD name and logo are registered marks of ACORD CORPORATION. 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Historic - OKH _Preservation / Hyannis Project Street Address 60. Captain Cook Lane Village - -ry , , ye�..a►: 3 Jayne Forsberg same Owner Address Telephone 508-775-2048 Permit Request Air sealing, r-31 insulation to attic_ attic tbermodorme v®ntilatiep a totes Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation i 243 72 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: ❑'existing Oanew:-size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: t Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # ' � r Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name, RISE Engineering Telephone Number 401-784-3700 EXT 161 Address 1341 Elmwood Ave, Cranston RI 02910 License # 100459 Home Improvement Contractor# 120979 Worker's Compensation # 3730961-01 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO RI Resource Wove SIGNATURE DATE C /( Erik Nerstheimer for RISE Engineering { i FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED R MAP/PARCEL NO., ADDRESS VILLAGE OWNER ` DATE OF INSPECTION: FOUNDATION FRAME INSULATION, ` fi•Ja ul,e- FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ti':!,' ROUGH 4: r> FINAL r _ �1 FINAL BUILDING,, sfl-' r DATE CLOSED OUT t tF ASSOCIATION PLAN NO. 4 ' f w The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 www.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrician's/Plumbers lug Applicant Information Please Print Legibly Name(Business/Organization/Individual): RISE Engineering `a division of Thiel ch Engineering Address: 1341 Elmwood Avenue City/State/Zip: Cranston, RI 02910 ` Phone#: (401)784-3700 or . 1=800-422-5365 Are you an employer?Check the appropriate box: Type of project(required): 1. 0 I am an employer with. 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part time).* have hired the sub-contractors ❑Remodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have 8. ❑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 perm MGL insurance required] t c. 152,§ 1(4),and we have no 12. ❑Roof repairs employees. [no workers' 13. N Other Insulate comp.insurance required.] *Any applicant that checks box#1 roust also fill out the section below showing their workers'compensation policy information.. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contactors that check this box must attach 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: The Preston Agency Policy#or Self-ins.Lic.#: 3730961-0 1 Expiration Date: 1/1/12 Job Site Address: 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 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 $250.00 a.day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certi and the in enalties.ofperjury that the information provided above is true and.correct. Signature: s Date: Print Name: Erik Nerstheimer Phone#:(401)784-3700 or 1-800-422 5365 ext133 Of 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 Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#: OP ID:31 ACOROm DATE(MM/DD/YYYY) `..� CERTIFICATE OF LIABILITY INSURANCE 12/30/10 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 endorsements. - PRODUCER 401-886-8000 CONTACT NAME: The Preston Agency,Inc. 401-885-1700 PHONE FAX 1350 Division Rd Suite 303 A/C No Ext: AI--,No): EMAIL PO BOX 810 ADDRESS: East Greenwich,RI 02818-0810 cusTOMER ID u:THIEL-1 T INSURER(S)AFFORDING COVERAGE NAIC S- INSURED Thielsch Engineering,Inc INSURER A:Zurich-American Ins Co. elsch Group Inc. Hi INSURER B:American Guarantee&Liability Hi Tech Realty Inc. INSURER C:North American Capacity 195 Frances Avenue p ry Cranston,RI 02910 INSURER D:Hartford Insurance Company + - INSURER E: - 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. i INSR TYPE OF INSURANCE POLICY EFF POLICY EXP - LTR - POLICY NUMBER MM/DD/YYYY MM/DDNYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE. $ .1,000,00 A X COMMERCIAL GENERAL LIABILITY 3730962-01 01/01/11' 61101112, PREMISES Eaocamence $ 300,00 CLAIMS-MADE K OCCUR MED EXP(Any one person) $ 10,00 PERSONAL BADVINJURY $ 1;000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: • PRODUCTS-COMP/OP AGG $ •2,000,00 POLICY X PRO- JECT LOC lEmp Ben. $ 1,000,00 AUTOMOBILE LIABILITY 'COMBINED SINGLE LIMIT- $ 2,000,00 A X ANY AUTO 3730963-01 01/01/11 01/01/12 (Ea accident) BODILY INJURY(Per person), $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY(Per accident) $.- PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NONdWNED AUTOS $ e $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $- 10,000,00 EXCESS LIAB CLAIMS-MADE, AGGREGATE $ 10,000,00 B.., AUC-4857188-00 01/01H1 01/01/12 DEDUCTIBLE' $ RETENTION $ _ $ WORKERS COMPENSATION - X STATU-- OTH- AND EMPLOYERS'LIABILITY Y/N *' TWC Y I T R -A ANY PROPRIETOR/PARTNER/EXECUTIVE 3730961-01 01/01/11 01/01/12 E.L EACH ACCIDENT $ 1,000,00 OFFICERIMEMBER EXCLUDED? N I.A _ _ - (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1,000,00 If yes,describe under - - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 C Professional Liab DVL000026800 (14101110 04/01111 Prof Liab 2,000,00 D Leased/Rented Eqp 02UUNTD5678 01/01/11 01/01/12 Equipment 100,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,A more space is required) CERTIFICATE HOLDER CANCELLATION TOWN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN i ACCORDANCE WITH THE POLICY PROVISIONS. ' AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION:,All rights reserved. r ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD r a THiEL-1 PAGE 2 NOTEPAD INSURED'S NAME Thielsch Engineering,Inc OP ID:31 DATE 12/30/10 29r:. RI E Enameerinfq,a division of Thielsch En mpenni ,Inc. �a kell Associa es a divisloR f,Thiels h qn ineenhg9,Inc. A Laborato ,a c11v}s on o }elsch n }n6erin ,jlnc. Eg �¢or�tor i,a divaslgn,oifgsc� nimeenng,Inc. ngmee nq 2 wpia, �g sch ng�nee m ,Inc. �►�►ater Mariagemer�f Services,a division of Thielsch Engineering, Inc. i r V ; 91te nsumer fail; an usines�sleg on _ 74 Off ce o o g 10 Park Plaza - Suite.5170 Boston, ssachusetts 02116 Home Improve ontractor Registration Registration: 120979 " Type: Supplement Card Expiration: 3/25/2012 THIELSCH ENGINEERING m ERIK NERSTHEIMER 1341 ELMWOOD AVE. a CRANSTON, RI 02910 Update Address and return card.Mark reason for change. Address ['Renewal Employment n Lost Card DPS-CAI 0 50M-0004-G101216 • ,per � �1e -�io�.vizo,xiuea.�./ o���aaecuL..uae�a . `Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation ` Registration`s ' 79 _ TYpe: 10 Park Plaza-Suite 5170 Expira -- 12 Supplement Card Boston,MA 02116 THIELSCH ENt L 1 'ERIK NERSTH 1341 ELMWOOD CRANSTON; R1 029 f %' Undersecretary Not valid without signature - Control No: 34244 THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF LABOR b ' DIVISION OF OCCUPATIONA' SAFETY 19 STANWORD STREET,BOSTON,MASSACHUSETTS-02114 LEAP-SAFE RENOVATION CONTRACTOR LICENSING WAIVER RISE Engineering A Division,of Thielseh Engineering, Inc. 1341 Elmwood Avenue ' Cranston, RI 02910 WAIVER: LW000672 EXPIRES:: April 15,2015 IN ACCORDANCE WITH M.G.L. C. 111, § 1970)(b)AND 454 CMR 22.03(3)(b), , THIS LEAD-SAFE RENOVATION CONTRACTOR LICENSING WAIVER IS , ISSUED BY THE'DIV. OF OCCUPATIONAL SAFETY TO THE CONTRACTOR ABOVE FOR THE PURPOSE OF PERFORMING LEAD-SAFE RENOVATION' . :t WORK. THIS LEAD-SAFE RENOVATION CONTRACTOR LICENSING WAIVER MUST BE MAINTAINED BY THE CONTRACTOR IN ACCORDANCE WITH M.G.L. C. 111, § 197B(b)AND 454 CMR 22.04 WHEN PERFORMING LEAD-SAFE RENOVATION WORK. HEATHER E. ROWE,ACTING COMMISSIONER Printed on Recycled Paper Licensee Details Page 1 of 1 The Official Website of the Executive Office of Public Safety and Security(EOPS) Mass.Gov Home Public Safety Department of Public Safety Licenseef Complaints License Type Construction Supervisor License# 100459 x Restriction WS,IC Name Erik Nerstheimer City,State,Zip North Scituate,RI,02857 Expiration Date 3/28/2012 Status Current No complaints found for this Licensee. Back'ro Search -. •t. ail http://db.state.ma.us/dps/licdetails.asp?txtSearchLN=CSLIQ0459 1/7/2011 F P. r, c y .10 FIAT-24531 - 1 y > 1 � f RISE ENGINEE) INS Federal ID#06-0405629 RI Contractor Registration No 8186 A division of Thielsch Engineering MA Contractor Registration No 120979 CT Contractor Registration No 620120 1341 Elmwood Avenue,Cranston,RI 02910 1 (401)784-3700 FAX(401)784-3710 CON 6 I%MC e �t Page I S PROGRAM THIS CONTRACT IS ENTERED INTO BETWEEN RISE CLC-RCS ENGINEERING AND THE CUSTOMER FOR WORK AS ENGINEERING DESCRIBED BELOW CUSTOMER PHONE DATE _ Client# Jayne E Forsberg (508)775-2048 09/28/2011 120463 SERVICE STREET - BILLING STREET 60 Captain Cook Lane 60 Capt-cook Ln SERVICE CITY,STATE,LP. BILLING CITY,STATE,ZIP - Centerville,MA 02632 Centervil,Ma 02632 JOR DESCIIPTIOloT Provide labor and materials to seal areas Of your home against wasteful,excess air leakage. This work will be performed in concertwith the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of air exchange and indoor air quality. Materials to be used to seal your home can include caulks,-foams,weatherstripping and other products. Primary areas for sealing include air leakage to attics,basements;attached garages and other unheated areas(windows are not generally addressed.) , $385.00 Provide labor and materials to install 2"polyisocyanurate foam board insulation,that meets the sections R-316.5.4 and 316.6 requirements of., building code,to 32 square feet of kneewall area. Seal all seams with FSK tape. $88.32 Provide labor and materials to install a 9"layer of R-31 Class I Cellulose added to 385 square feet of open attic space. $492.80 Provide labor and materials to install an easily moved,insulating cover for the attic access folding stair. A small flat surface of plywood will be created around the opening within the attic. This will allow the.cover's integral weather-stripping to restrict air leakage. $220.00 Provide labor and materials to install ventilation chutes in(18)rafter bays to maintain air flow. $57.60 RISE Engineering will apply all applicable,eligible incentives to this contract. You will be billed only the Net amount. Currently,for eligible measures,the Cape Light Compact offers a 100%incentive. $385.00 RISE Engineering will apply all applicable,eligible incentives to this contract. You will be billed only the Net amount. Currently,for eligible measures,the Cape Light Compact offers 75%incentive,not to exceed$2,000 per calander year. -$644.04 OCT- 12 2011 AGR � Y TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF' ***Two Hundred-Fourteen&68/100 Dollars $214.68 UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL.INTEREST OF 1%WILL BE CHARGED MONTHLY ON ANY UNPAID BALANCE AFTER 30 DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AUTHORIZED SIGNATURE-RISE ENGINEERING CUSTOMER EP NCE69 NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN OF ACCEPTANCE t7 ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE S-�`/) DAYS. SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE s OWNER AUTHORIZATION FORM (Owner's Nam ) owner of the property located at (Property Address) (Property Address) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to-perform work on my property: + eCs gnature Date , [EO-E0IVE D OCT 12 2011