Loading...
HomeMy WebLinkAbout0140 OAK NECK ROAD �o Cad nbc �5 6d INSULATION SEP fil 10' VCJ IIYlY S[<NML[ [HST fg4k !u[eaHDaq MMRS YURLYi INi YIAfIpN Ci1lINOi 1-800-696-6611 Town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, MA 02601 Date: Dear Building :inspector ` Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed rs,. 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 (BP'I) inspector. All work preformed meets or exceeds Federal & State Requirements, Property Owner Property Address Village 4 tj Insulation Installed: Fiberglass Cellulose R-Value Restricted" ` -Unrestricted Ceilings ( ) (�) (35Y ( ) Slopes ( ) ( ) ( ) ( ) ( ) Floors Walls apt fr5lC ( ) ( ) ( /y) ( ) (de) Sincerely He ry L Cas: y Jr; President �'`' e Cod I , ulatiori, Inc. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map-. • 3-n Parcel Z� Application # Health Division Date Issued 7—G`!Y Y Conservation Division Application Fee S Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 'Al eGe_ jZ Village Owner �� �� /���� Address .� Telephone��� 7 � 7 Permit Request /� �' .11,dw fZS"/ G�i9✓�� / CG/�v ©S� - /�l�C pl�.0/Z :.,�c?4-1 451 x TIeie /nCli Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation a2�d a, of construction Type�� Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family P-"' Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes W-Ko On Old King's Highway: ❑Yes JLWo 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 MCI- �. Total Room Count (not including baths): existing new First Floor K1100 CouniN Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other - Ga Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood oal sto a ❑Yos ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ .xisting new size ;. Q Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: 4 Zoning Board of Appeals Authorization ❑ Appeal # Recorded 0 Commercial ❑Yes ❑ No If yes, site plan review# Current UseT__ - - -- Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name A,4�L' Cv�,�®.�.�U/�1�s� Telephone Number Address Z 4f License # Z o cAN9�&-V 1 Home Improvement Contractor# Email Worker's Compensation # AYJ, ,M ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE 117 DATE A�,V- FOR OFFICIAL USE ONLY A AO-PLICATION# DATE:ISSUED MAP.:/PARCEL N0. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL "r GAS: ROUGH FINAL FINAL BUILDING, , DATE-:CLOSED OUT ASSOCIATION PLAN NO. T � 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 At)nlicant Information Please Print LeLYlbly Name (Business/Organization/Individual): Address: City/State/Zip: 2 T� >> . o ,Rhone #: � ' Z j 411- Are you an employer? Check the appropriate box: 101 am a employer with �� 4. ❑ 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 2.❑ 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 workers' comp. insurance comp. insurance.t 9. ❑ Building addition required:] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their t l.❑Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no 12•❑ Roof repairs 3a.❑ I am a homeowner acting as a employees. [No workers' 13.Q OtherZ,,_� igeneral contractor(refer to#4) comp.insurance required.]. 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensationpolicy 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, tContmcton 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 olic 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: Policy#or Self-ins. Lic.#: Expiration Date: J /.� Job Site Address: 1212t ,�,f//,cf/S City/State/Zip: .rl�i7 �j zG 7rj 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 of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office f d a fine Investigations of the DIA for insurance coverage verification. I do hereby certify u '�J#er the pains and penalties of perjury that the information provided above is true and correct Sizna Date: 7L` Phon 0•fj9cial use only. Do not write in this area, to be completed by city or town officiaL City or Town: - PermitlLicense# 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#: Massachusetts -Depattn)4.nt of f'ljblic Safety .Board of Building Regulations end Standards Constritchon Supervisor License: CS-100988 1.Is HENRY E CASS11ft 8 S11ED.ROW WEST YAR111O11'1.11 .�. i Expiration , Commissioner 11/1112015' P - Office of Consumer Affairs and Business Regulation F 10 Park Plaza - Suite 5170 r Boston, Massach>.1 setts 02116 . .. Home Improvement Col oor Registration ' Registration: 153567. l ; J. Type: Private Corporation . Expiration: '12/15/2014 TrW 233831 CAPE COD INSULATION INC HENRY CAS S I DY 18 REARDON CIRCLE s --=-- _.__._.._._........._ - -.._........ --.-. _... SO. YARMOUTH, MA 02664 --- --------- I,} - 'Update Address and return card. Mark reasun for change. _ ❑ Address Renewal L� L:mployment [ Lost Cnrd I '���%`f(icl.i/r.r�r.clirtnc;trll�c��G�.`�c,i;�ac6ie�c3lt � . t)triec of C'unsuwer At't'airs& Business Regulatiu„ License or registration valid t'or individul use only - , OME IMPROVEMENT CONTRACTOR before(lie expiration date. lt'found return to: epistratioil: 153.�67 Type: Office of Consumer Affairs and Business 12el;ulation xpiration: 1.2/15/2014 Private Corporation' 10 park Plaza-Suite 5170 ,` Boston,MA 02116 'E(OD INSULAT1QNl1,ilNQ, .. VRY CASSIDY :EA MON CIRCLE YA1 NIOUTH, MA 02G64 — KrO Underseitretary, of Val' witho t I CAPECOD-27 KLIGE TT CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) s/13r2o14 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Rogers&Gray Insurance Agency,Inc. PHONE Barbara DeLawrence 434 Rte 134 (A/C No.Ext)� IA No 877)816-2156 South Dennis,MA 02660 E-MAIL ; ADDRESS:bdelawrence@rogersgray.com INSURERS AFFORDING COVERAGE NAIC# ---- ---------- INSURER A:Peerless Insurance Company INSI RED — INsuRERB:COMMERCE INSURANCE COMPANY_ Cape Cod insulation Inc INSURER C:Evanston Insurance Company 18 Reardon Circle INSURERD:ATLANTIC CHARTER INSURANCE GROUP South Yarmouth, MA 02664 — - INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS C�R;TIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, E C(USIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY-HAVE BEEN REDUCED BY PAID CLAIMS. N7R TYPE OF INSURANCE A Tf6R POLICY EFF POLICY EXP - - -- _ POLICY NUMBER MM/DD/YYYY PO Y LIMITS A X COMMERCIAL GENERAL LIABILITY - EACH OCCURRENCE $ 1,000,000 1 CLAIMS-MADE L X� OCCUR CBP8263063 04/01/2014 04/01/2015 MBE TO RrRT:o-- - PREMISES(Ea occurrence)_ $ — 100,000 — — -- — --- MED EXP(Any one person) $ 5,000 ' I — ------- ----- PERSONAL&ADV INJURY _ $ 1,000,000 G1,N'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY I PRO- X_ LOC —� PRODUCTS-COMP/OP AGG $ 2,000,000 r OTHER — $ AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT Ea accident $ 1,000,000 3 ANY AUTO _ 14MMBCKVMK 04/01/2014 04/01/2015 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED _ AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS X NON-OWNED AUTOS PROPERTY DAMAGE $ Per accident $ X UMBRELLA LIAR X IOCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAR_ CLAIMS-MADE XONJ453514' 04/01/2014 04/01/2015 AGGREGATE $ DED X RETENTION$ 10,000 Aggregate $ 1,000,000 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WCA00525904 06/30/2014 06/30/2015 11000,000 OFFICER/MEMBER EXCLUDED? JI N/A E.L.EACH ACCIDENT $ _ (Mandatory in under E.L.DISEASE-EA EMPLOYEE $ 1 000,00 If yas,describe und - � DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 ( ESC)RIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) orl�ers Compensation includes Officers or Proprietors. 1d7t1al Insured status is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. I ERTIFICATE HOLDER CANCFI I ATION OWNER AUTHORIZATION FORM I, (Owner's me) owner of the property located at /�zo C, )C n-e c (Property Address) -, Cthn �, ,,7Z 7 , (Property Address) -� fi)nShca �;o hereby authorize. �'" _ 'v (Subcontra or) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. r . O neris Signat e z ( 14 Date