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HomeMy WebLinkAbout0383 PITCHER'S WAY 3B3 ��cher5 W Feb 261910:56a DECLEANING 7744702907 p.3 Cavelvideli\ E}\fTERPRISESf* SITE WORK CONTRACT ;.P. Macomber&Son Since 1928 1�IOVEtVIBER 1 �J, Za 1.$ .4 Roberl R Our Co.,Inc. Compnrrr'Built on Trust" 153 Commercial Street,Mashpee,MIA 02649 PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT: I NAME: Geraldo Baracho ADDRESS: Same as opposite i ADDRESS: 339 Pitcher's Way Hyannis, MA 02601 ! PHONE: 508-737-5469 Capewide Enterprise proposes to furnish all materials and labor necessary to complete the following work at 339 Pitchers Way, Hyannis Work to include: • Front of wall to be disassembled to the two front comers,down to base blocks. • Excavate 3'-4'in from wall. ReseVreplace 40 mil poly liner. • Replace Title V sand as needed inside of liner. Re-assemble wall using existing blocks that are. not broken and replace blocks as needed, supplying all material, • Re-landscape top of wall as needed, as well as front of wall. The above work to be performed in accordance with the specifications submitted for above work and completed in a substantial workmanlike manner, for the sum of$9,265.00 With payments to be made as follows: $ 3,000.00 on signing $4,600.00 at start of work $ 1,665.00 at completion NOTE-This proposal may be withdrawn by us if not accepted within 30 days.Any alteration or deviation from above specifications involving extra cost will be executed only upon written order, and will become an extra charge over and above the estimate; payment for the extra is due in full before the change is made. All agreements contingent upon j strikes, accidents, or delays beyond our control. We are not responsible for any irrigation lines,trees, bushes, shrubs, or i plants unless specified in writing by Capewide. Capewide Enterprises is not responsible for driveway damage due to the- weight of equipment/machinery. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted, You are authorized to do the work as specified. Payments will be made as outlined above_ Customer Signature Date '" fJr- �cg Signature i Aut rized Capewide Enterprises Representative P Fax: 508,47 7.4977 w��.f.fapewidcEnterprises:core ®r,-CA P , . �- A„ ''�J z 5+ f INSULATION ,26 �a F-t I N �� 3 110.OawiS SlAMEf33 SPRAT FOAM 9USPENOEY .f[/T q 0.0.TT5 UYiTE0.5 INEYIAiION CEILINGS 1-800-696-6611 ' Town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, MA 02601 P Date: 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 4- ,�sui Nacci o 193 P t--s OWY A6nj4Y � Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings ( le) Slopes ( ) ( ) ( ) ( ) ( ) Floors Zt4s+5 Sincerely hECasJr, President on, Inc. I �� �, s _ � � ' Assessor's office(1st Floor): / Cy Assessor's map and lot!umber � v/ Q /�y•� i THE t Conservation — 9/ SEPTIC SYSTEM Board of Health( rd floor): Q INSTALLED IN CC . " I Sewage Permit number ' / G C � ses.tsranta . g WI°I H TITLE Engineering Department(3rd floor): House number - � LLB " ENVIRn0N1 ��'rAL C o �� ,r m Definitive Plan Approved by Planning Board t9 APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2-00 P.M.only TOWN OF BARNSTABLE h BUILDING INSPECTOR,, APPLICATION FOR PERMIT TO TO ?--, ,) &A Ll 10 "f jo, L_ TYPE OF CONSTRUCTION 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ` SCE `,C�'� 'VS W N-14 Proposed Use -Mc 1 o P�-s Zoning District ' Fire District �` a Name of Owner r0�. Q-�S IS AddressnA Name of Builder t" -l-1ll 7r 1 Address p2L- Name of Architect Address Number of Rooms I Foundation Exterior 4-�- ( � Roofing UJ CIO Floors t Interior Heating L,,�N o®& ; �oC>0 , Plumbing C\6 Fireplace Approximate Cost t, 00 d G Area S Diagram of Lot and Building with Dimensions Fee 0� OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS L�„� 1 hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. 2 Name C� Construction Supervisor's LicenseVO212��. EDWARDS, BRUCE SR. 4Sh . No35094 Permit For Built Accessory to Dwelling • r t. Location 383 a H annis 4 Owner t Bruce Edwards , Sr.- Type of Construction Frame Plot ` • Lot � �. •- � Permit Granted May 28 , 19 92 -I Date of Inspection 19 Date Completed �� _19 i e 14 e } • 3 t • Map, Page 1 of 1 s Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size Zoom Out In JPG Map: 269 Location: Owner: 2890$4 �; tis 206015001 _.._.�.._...._ __. 0393 k tggg4, Location In 25913$�, Map &Parce t9 Location Acreage ___..........._......... ___ « .n.. 290018003 current Ow 4 $0 i Mailing Addi z f71 r - 269693 4 do 0383 Appraised 2590$7 Extra Featur if 20� Out Building 290015002 tP 378 Land Buildings Total Apprai Assessed V � Extra Featur 80$9 w58-F et 2NON 260141? Out Building N 15 290418 Land k.36® Buildings Total Assess Set Scale 1" = 5g I Aerial Photos I MAP DISCLAIMER Copyright 2005-2008 Town of Barnstable,MA All rights reserved.Send questions or comm( BarnstableMA v1.2.3083 [production:) I http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=269093&ma... 10/24/2008 Taylor Design Associates, Inc. P. O. Box 1313 Forestdale, MA 02644 Telephone & Fax: (508) 790-4686 October 6, 2008 Ms. Doan Trinh 853 Pitcher's Way Hyannis,MA 02601 RE: Structural Inspection Family Room Addition 853 Pitcher's Way Hyannis, MA Dear Ms. Trinh:_ On October 4, 2008, I inspected the structural framing of the subject property. The framing meets the requirements of the Massachusetts State Building Code, Seventh Edition. Enclosed are calculations indicating that the framing members meet strength requirements. The inspected work indicates good workmanship. If you have any questions, please do not hesitate to contact me. IiA OF S er T LOA UA01C + 2TTM R. Grego yl �sAL Presiden Enc. X- J013 TAYLOR DESIGN ASSOC., INC. SHEET NO. OF P.O. Box 1313 - rl nATF.&XAAA&, FORESTDALE, MA 02644 CALCULATED BY TEL./FAX: (508) 790-4686 CHECKED BY A OF__ '?jdr..bAA 5 SCALE .......... ............. .......................... .............. ............. ....................... .............. ............. s A4.............K 0. . ............ .. ........ ........................ ........... ................. ........... ............ ............. .......... .............. ............. .............. .............. ........... ........... .......... .......... cl, ........... tt ..................... .............. ............................... ................ .......... ... .......... .......... ..................... ............ ... .......... ............ .......... ............ .......... ....................... ............... ............d ............. ........................ .......... .......... ............. .... ..................................... .................. ....................... ....... ............ ..................... t! ..................... ........ ................................ 1410J.............Ain ................ ............. ...................... .............. ----------........... ............ ............ .............. ............ .......... ............... ................. ............ a .............. .......... .......... ............ .................. ............ a. ................. c_ .............. .......... ........... ............ ............ ............. ............ .............. ............. ............. ........... ............. ..................... ................ ............ ............ .......... .......... .............. .......... .......... .............. ............. ................. .............. ........... ....................... ...................... .............. ............. ............. .......... ........... ........... .............. .............. ........... ...... .... ........... cv........ 15 ............. .......... ............. ............ ..................................... 714 ...................17 ............. ....... ....... ....... . p_ ........................... ...................................................... ....... 22� 4- ................. 9L ez ............ ............... ............. ......... . ..... ................................_ 1 ................................ ......................... ................... ..................... ipC-4 c(.......... ................ ......... 44" ................. .............. 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Box 1313 (---r DATE FORESTDALE, MA 02644 CALCULATED BY TEL./FAX: (508) 790-4686 CHECKED BY DATE 1 -T C-1A SCALE ....... ....... ............. ........... ............... .......... .......... ............. .......... .......... .......... ............ ........ ............ ............. ......................... .......... ...... ....... .......... ............ ........... ................ ........... .......... ....... ....-........ .............. .......... .......... . ..... ......................... ....... ..................... ......................... ............. .......... .......... .......... .. .................. ..... .............. ............- .............. ........... .......... .................... .............. .. ................................. ........... .............. .................... ................. 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PAMAICT M.1(Siffitft qwlql 2ffill Pawl YOU WISH TO OPEN A BUSINESS? 3 �3 Pit For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR N ME in town (which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) DATE: a' /S- 07 �. s, Fill in please: - APPLICANT'S YOUR NAME: (Soo# /f-aVe-r,2 BUSINESS YOUR HOME ADDRESS: pwa �d8 ME-96/(o rY.* eov/ ,:b V TELEPHONE # Home Telephone Number8 5�S/-900 �/ �-,y�.�c t. jNAME:,F:NEWBU51EST ..,;:. NO ��. .Vic•: € i.�r '� .at., �y ::,: t?;p ..P;Y'., ,�.- �. �� -�� r ��-f- u`. T � a= z c±�. , - .ate' .. .< s- 's` � �` I rs` 45.. .:# �Cx�a. j o� 3t•. - R �= - �.� ��' �• ._. ';�►DDRESS. F�USINESS�s+�,-;�0.�-=l.?._ : .:; . : _ �� �1,��:� �. .!�. �I�/. .. Y. P�3RC�EL,NUMBED a�_�_�£�_ ��._x.:�n When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OF This individual h n infor a of any permit requirements that pertain to this type of business. Authorized Signat * COMMENTS: 2. BOARD OF HEALTH This individual ha n info f he p rmit requirements that pertain to this type of business. Authorised gnatur ,COMMENTS: 3. CONSUMER AFFAIRS [LI G AUTHO TY) This individual has be rmed of a requirements that pertain to this type of business. ho ized Signature* COMMENTS: Town of Barnstable *Permit#�C)(2 Expires 6 months rom issue date Regulatory Services Fee - _) U Thomas F. Geiler,Director Building Division om Perry,CBO, Building Commissioner Qif 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press.Imprint y� c ✓Iap/parcel Number 7'- Iroperty Address 1 O Residential Value of Work Y' 'al Minimum fee of$25.00 for work under$6000.00 )wner's Name&Address es 1 contractor's Name ,6 C z �D t! Telephone Number,fow` /7 g :come Improvement Contractor License#(if applicable) K 7 a construction Supervisor's License#(if applicable) �orkrnan's Compensation Insurance Check one: Po'I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name A. Norkman's Comp.Policy# CJ'la / `7 d(91 Ok 0as �opy of Insurance Compliance Certifica a must be on file. ?errrvt Request(check box) 9, Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders. U-Value (maximum.44) "Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of e Home Improvement Contractors License is required. SIGNATURE: �Torms:expmtrg Zevise061306 NOTICE NOTICE TO TO EMPLOYEES EMPLOYE]. 1S The Commonwealth of Massachuset-'s DEPARTMENT OF INDUSTRIAL ACCID E 1 41 600 Washington Street, Boston, Massachusetts 02111 617-7274900 As required by Massachusetts Gemal Law,Chapter 152, Sections 21,22&30,this will givt . ,:)u notice that 1(we)have provided for payment to Out injured employees cinder the above menti( : :d chapter by insuring with: ASSOCIATED WDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE C£?MPANN NAME OF INSURANCE COMPANY 54 THIRD AVENUE,P.O.BOX 4070, BURLINGTON,NIA 01303<0970 ADDRESS OF INSURANCE COMPANY V/C 5010142012005 K 12/08/2005 - 12/C: 2005 POLICY NUMBER EFFECI`IV .i1ATES Rogers&Gray Insurance Agency MO Route 132 Inc Hyannis, ILIA 02501 (5059 7 i, 0011 NAME OF INSURANCE AGENT ADDRESS PHONE John A.Leboeuf 35 Princess Pine Rd Hyannis, MA 02001 EMPLOYER ADDRESS 11/17/2005 EMPLOVEWS WORIKERS COMPENSATION DMCER(IF AIM MMWAL The above roamed insurer is required in cases of personal injuries arising out of and In the course of employment t, i;.rnish adequate and reasonable hospital and wedieal urvim in armor th the providow of the workers Compera: b.m Act. A copy of the First Report of Injury must be given to the Injured employee. The employee may select his or her oe physician, The reasonable cost of the servicm provided by tote treating physician will be paid by the Insurer,if the treatment>• e eeessary and reasonably connected to the work related injury, In caves requiring hospital attention,employees are hereby! a fled that ON imnrer bas arranged for anch attention at the NEAREST AND BEST MEDICAL FACIUTY NAMEOFROSPITAL ADDRESS TO BE POSTED BY EMPLOYER • �\ 1/�G I+VIIt/nVIS I►cas�al• v� i1i KYYMY.�r.Y�--.r , \ Department of Industrial Accidents ? Office of Investigations 600 Washington Street Boston,MA 02111 . www.mass.gov/dia Workers' Compensation•Insurance Affidavit: Builders/Contractor-s/]EIectricians/Flumbers A_•pplicant Information Please Print Legbly Name (Business/organization/Individual): Address'--,off ?/ c' £SS• 631)z- City/State/Zip: Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1•❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction 2. 61yees(full and/or part-time)-* have hired the sub-contractors 0 sale proprietor or patner- listed on the attached sheet$ 7• ❑ Remodeling ship and have no employees These sub-contractors have Demolition working for me in any capacity. workers' comp,insurance. g, ❑ Building addition ' Comp.insurance 5, ❑ We are a corporation and its II`la workers 10.❑ Electrical repairs or additions required.] ' officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plam ing repairs oT additions myself.[No workers' comp. c. 152,§1(4),and we have no 12:5Roof repairs insurance required.] t employees.[No workers' 13.❑ Other comp.insurance required.] 4 *Any applicant that cheelm box#1 must also fill out the section below showing their workers'compensation policy infonvation ' t Homeowners who submit this affidavit indicating they ere doing all work andthen hire outside contractors must submit anew affidavit indicating such lContmctom that check this box must attached an additional sheet showing The name of the sub-contractors and their workers'comp•policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance CompanyNanne:,4 ,,, Policy#a Self-ins.Lie.#: rSCI�C�'/ �t�141.0 Expiration Date: lob Site Address: ~-� % E��'� rx!�'' City/State/Z;p: > .A(J- ' Attach a copy of the workers' compensation pelicy decla anon page(showing the policy numb 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 maybe fniwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby cetli u er he pai nd p 1#es of perjury that the information provided above is true and correct Si afore: --le Date: Phone#; 00 7 • 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.Electricai inspector.5.Plumbing Inspractor 6.Otther Contact Persona: Phone#: 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 for6going 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 employmentbe deemed tobe 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 fire 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-contractors)name(s),address(es)and phone numbers)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. Se advised that this affidavit may be submitted to the Department of industrial Accidents ibT confirmation of insurance coverage. Also be sure to sign and date the afifidav% 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 maybe provided to the applicant as proof that.a valid affidavit is on file for future pemi is or licenses. Anew 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 bum 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=ber: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, l+✓IA 02111 Tel. +617-727-4900 ent 406'oa-1-o77-M.ASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/eia _ i v°SIMI Town of Barnstable Regulatory Services CAB $ Thomas F.Geller,Director �O�FD NU►i�,� Building Division.' ,f Toth Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 ww mtown.b arnstabl e.ma.us office: 508-862403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign TWs Section. •If Using ABuilder I, a y1 �(k) ,as.Owner of the subject property hereby authorize G'� L. CaLtJ to act on my behalf, in all matters relative to work authorized by this building permit application for. r P Lic )ro 0 1 1(b n-�;� (Address of Job) Signature of Owner Vate Print Name Q:FO3LMS:0WNERPERNMS1QN TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 04 Parcel (J"/J Application /s Health Division Date Issued l� Conservation Division Application Fee �d Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address VillageiI �J� Owner .� �r'� �!� U���� Address 10, Telephone ;7 2- 4- 0 Permit Request ,/Z.P,4_/ � �� / �y✓`� � � �r� `� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new ® -� Zoning District Flood Plain Groundwater Overlay Z g P Project Valuation 3 L awl, ® Construction Type��6� � v { Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting`abcu antation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) �o Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway:❑YR )No ri M 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 bat—)): 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 Telephone Number Ca , Address,Jt�, �/�� �/ �'�/� License # /40 9c', Home Improvement Contractor# Worker's Compensation ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE I,� FOR OFFICIAL USE ONLY �! t APPLICATION# DATE ISSUED f• MAP/PARCEL NO. L " ADDRESS VILLAGE OWNER F% C l4 A DATE OF INSPECTION: FOUNDATION FRAME ' INSULATION 'r FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING Y DATE CLOSED OUT ASSOCIATION PLAN NO. t I , ,1 i � t 1Iasx.u'husclts - I)c r l-olrcol of Public tial'cls Ku;.u'tl ut Buililin„ 12r�111a1iolls anti `+t:urrl:u'tls constrl.tption Supervisor License w. ,. Licen '.CS 100988 rH a :.�•� fy JJJ,,a�: rYf tG� f 6,¢ HENRY CASSIDY 8 SHED ROW1a WES, 'JARMOUTH, MA 02673 .-._�_.--____.._ ____/_.`_'�_• Expiration: 1 1/1 11201 3 l . nuui,si5uicr Tr4: 7620 \ ���LL�.' 1��C2-��l,�ydl�C��2•ll.�P�li�/'l� C���i�L CY:J:1C�<_.'61.�i!�!.:�C'��1 IL OffiCe of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: '153567 Type: Private Corwration Expiration. 12/15/:?bl4 Trk 23,3831 CAPE_ COD INSULATION, INC FIE:NRY CASSIDY 18 REARDON CIRCLE __.... _..__.. _._ SO. YARMOUTH, MA 02664 _......... ...-__ ..._ Update Address and rcturu card. Marts reason for change. L� Address ❑ Renewal _) Isrnployme-ut Lust C;ud � r �l`j'rrrr.arr rrrr"P'rC(l� I'"TJJmliuJe lJ unire ui Consumer Alfairs Business Itegulatio„ License ur registration valid for individul use only 111UME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: eyistration: 153567 Type: Oft-ice of Consumer Affairs and Business Regulation jExpiration: 12/15/2014 Private Corporation 10 Pork Plaza-Suite 5170 Boston,MA 02116 ('.01)1WSULATI0N;,IN�' .' UndersecrcrarY t Val' it to t nat re I The Commonwealth ofMassaehusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation In surance nsurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizadon/Individual): n, ,i1j' Address:_ City/State/Zip: > � f2��J /r1�% one#: S Are you an employe ?Check the appropriate box: I am a general contractor and I Type of project(required): 4.1.❑ I am a employer with' ❑ g employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.[1 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' [No workers' comp. insurance comp. insurance.: 9. ❑ Building addition 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 1 I.❑ 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 3a.❑ I am a homeowner acting as a employees. [No workers' 13.1;6`0ther general contractor(refer to#4) comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compcnsatiod# olicy 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. tContracton that check this box must attached an additional sheet showing the nano 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 I am an employer that is providing workers'compensation insurance for,ny.employees. Below is the policy and job site information. Insurance Company Name:�� �.c��G Policy#or Self-ins. Lic.#:� Expiration Date: Job Site Address:34F3 '" /State/Zi •Ci 7 ty p._, . D 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 u der the parts and penalties of perjury that the informailon provided above is true and correct i Date, Phone#: OMcial use only. Do not write in this area, to be completed by city or town ofciaL City or Town• Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Othee ` Contact Person: Phone#: CAPECOD-27 MYOUNG CERTIFICATE OF LIABILITY INSURANCE 1 DATE 7IYYIY) /8/20/2013 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 License#PC-514062 - CONTACT Margaret Young Rogers&Gray Insurance Agency,Inc. PHONE Fax 434 Rte 134 A/c o xt: AIC No): South Dennis,MA 02660 ao RESS:myoung@rogersgray.com INSURERS AFFORDING COVERAGE NAIC# INSURERA:PEERLESS INSURANCE COMPANY INSURED INSURERB:COMMERCE INSURANCE COMPANY Cape Cod Insulation,Inc. INSURERC:Evanston Insurance Company 18 Reardon Circle INSURER D: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 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 TYPE OF INSURANCE A BR POLICY EFF POLICY EXP LIMITS LTR I SR WVD POLICYNUMBER MMIDD MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 URENILLI A X COMM ERCIAL GENERAL LIABILITY CBP8263063 4/1/2013 4/1/2014 PREMISES Ea occurrence $ 100,000 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 Ea accident $ B ANY AUTO 13MMBCKVMK 4/1/2013 4/1/2014 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS $ X HIRED AUTOS X AUTOSWNED PER AFC DAMAGE DEN $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 C EXCESS LIAB I CLAIMS-MADE XONJ453512 4/1/2013 4/1/2014 AGGREGATE $ 1,000,000 DED I X I RETENTION$ 10,000 $ WORKERS COMPENSATION VvC STATU- OTH- AND EMPLOYERS'LIABILITY TOY LIMITS D ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N -WCA00526904 6/30/2013 6/30/2014 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? a N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) _ Workers Compensation includes Officers or Proprietors. Addtional Insured status is provided under the General Liability when required by written contract or agreement with the Certificate Holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Cod Insulation,Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN p ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE i ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD i OWNER AUTHORIZATION FORM (Owner's Name) owner of the property located at 4 v3 (Property Ad s) (Property Address) C. hereby authorize , (Subc ntractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. -'Owner` Signature Ib 13 Date 3