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0037 RUDDER ROAD
3r7 2� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION . Map ��� Parcel l Application'# "" �- Vr�: �U0ry�^ Health Division Date Issued, Conservation Division ^v Application Few { Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Address � f`U. Village I VVn 1,C 00e 1' flfl Owner � iA (� Address Jl r(L f2o Telephone Permit Request 1 k (ZE0-K Ut' 'n Square feet: 1 st floor: existing proposed CD 2nd floor: existing ® proposed Total new Zoning District ( Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size 0,, oZ Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure VIC, Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: Mct Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) 9 Number of Baths: Full: existing_ new Half: existing new Number of Bedrooms: 13 existing _new Total Room Count (not including baths): existing S new First Floor Room Count Heat Type and Fuel: M/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;__ ZE Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ o Commercial ❑Yes ❑ No If.yes, site plan review# NO � Current Use Proposed Use ; Liu APPLICANT INFORMATION - - --rr.7 - (BUILDER OR HOMEOWNER) Name Telephone Number 074 Address ®`A `/ 1 \ (ed License # CS 0 I 1 l9% MA-1A- Home Improvement Contractor# 15-C 0 7 ll ti Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE ` DATE ` FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED ." MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION 1 FIREPLACE a ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. i _ r Lhpartweut a 1ndusb a[Ace aTentr e •600 Wasbmigton kstreet APPEcant��rkers' Caffipensaf�tmIns�ai� ����-B�der��fra�t-stFi � ' ers II Flea5e Print • 4 Na= C A r3 , n :Mi l ( Are you an employer?Check the appropriate bax: Type of pmaject(rae}uired}_ I_❑ I am a employer u 4. ❑I mn a peueral contractor and I 6. ❑New eanstructiun e agAoyeess(fsrll andibr part-time).* 1mve l iredilhe� 2.[K I am a sale pmpdetzw orpsrtner- listed on Ihe attached sheet 7- ❑R F d &g sbip and have:no employees S_ []Demolition wadtisg forme-many capacity_ emplayee a>Sdhave wadma- 9- ❑Building adriitiam INO wodonw camp-Einar-nce camp.msr curve 3 re7ireI ❑ We are a=poratim and its 16-❑Elec dca repairs or acl�ons 3 [:] lama�tmer doing all work officers have'emcis'd their 1 L 0 P3umbmgrepaig or additions Mys;der (M f[NO rra�s•�F- �y �t cif t 'og p M 1Z❑Rnofregais • inmxance reepuied-j 1 C.M§1(4�andwe Have ma play M[go 13_❑other cam-inmrame rt:quire&] •�ayspp���atcbe�'bas��stalsa�la�iietsectio¢bdawshas�g8les•wadcea-'ea®po+•�++rn•poTieyi�aem�� �rh � Id'n atdm sabnAl this ETU12si�ia�g deyatedai�ZUVXMI sad Bmnhi�aaisie4eeontaufosmact submit anema�dae -fine d%ecir tb is b=mast armed ca additi�sine�t sbox ag them aE the s -c ct�G�sty rrheths arnot�wse iesha� emphrJees.I€thesnb-cnna.s�UMhEve empICYW-%dsey—r-tpmnidrPuflEr Rode'camp.pGrmy amnlsez lam as�rrtpIr that is praucdufg Yvrtrkers'catperesatian irtsrirartce}or eplal Selaty is 1ltepaf anri jQ�iris e €r�,�atzrralioa . In.{umm e;Compaayi4ame: Paficg or Self-ins.Ii F�gi iaaDzlie Sob ffif a A&ke= CifglStatelg: Attach 2 copy of the w&rkere compe safionpoHry dechwation page(shawmg the policy amber and expiration date): Fad to secures coverage as regmreduuder Se chon 25A of MM e<152 can lead to the iauposi#ion of caimiEtai peimhaes of a fine up to$1Sa6 OU aniVorone-yearimprisonmenk as we11 as civil peuakies m ttie farm of a STOP WORK f]RDERand a fine Of up to$250M a dz against the violator. Be whiled&d a copy of this st aftzae t maybe foruarded to the Office of Izveftahow of the DSA for insmmace coverage venfic abna da lter y sr and '_ cx,�fget tt�y fhatflta a Para aprofi&d ahm a is tree and correct s1 LI. Prone Dffi:iat use wifj. 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Ro- :1■■ •r.Itl ■• a a11- •r■ t n 1 n••■ miss. • Ro" ■a a 1 n. ■. .i-:ka ■ ■■r 1• Ypass i■ •/ 1•.1■.7i'■ • ■■- 1 •l !••'/ Ro •- ■ •• • a n it" :Ro r ••:Ro. . •• a•. ■ L■•.• t■ 7• nun - ■ii■ss l • ►ila - 1' • .U e •1 Ross ." i71►• ■ I - _■ :• 7t■i1 ■■n - ••`a► •1 Ma■ /�±t ••trout ril■�- at •i'.■n 1 a• - ail [• Ja• .t Nolli+r. • r•n U i'. w •if•IRoI _ ••• ril■ • •:+an 1 u ■naa - �a : a r ilw■ll • �■w .■ n roue ..r a i■■. ■- O is • a ••+■ •1■tla ^•■ ■ .7- 1■ n.t■ ••r as • d■r' ■] •n r•••i'. .aa•n :n• low ■ •■• a_• .n• •■w■•L ■t V.:1 n•:aa :■al :n•I. a- -all an .1•■ r'.r ■nnf r i3 �•Gr.■ trt w-31 03 Iligli.•ittl ' • t r a t. ■I i ��.wtir n• •±t t �� 's a 2d_t .!: a a is 1 •••, to. ••r • ain ofs"ETo�,, Tgwn of Barnstable , 0 -Regulatory Services " � * Richard V.Sca14 Director Building Division Tom Perry,Building Commissioner 200 Main Street Hyannis,MA 02601 W W toym:tiarnstable ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Cornplete and Sign This Section If Using A Builder, 4 kAfz'Fn tH R U d (2.cr U .r ,as Owner of the subject property,- herebyauzhonze I(1 (Z( i'J VT to act on my o, SbehA in all'matters relative to work authorized bythis budding permit application for: (Address of Job) Pool,fences and ab='are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner of Applicant Print-Name Pent Name Date Q:FoxMS.OVR, MPERMlsSIO2,?OO s r' Town of Barnstable Regulatory Services Richard V.Scali,Director Building DIvWon crass Tom Perry,Building Commissioner p$j°rE%.o 5 ���� 200 Main Stream Hyannis,MA 02601 ww w.town.barnstable.ma_us Office: 50 8-862-403 8 Fax: 508-790-623 0 HOMEOWNM LICENSE MMIY ITON PIease Print DATE: JOB LO=OK-- nnmber shut village HOMEOWNER": . namc h—e phone# wow phone# 7 CURRENT IMAII.ING ADDRESS: cityftwn state" zip cods The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINIITON OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A!person,who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all.such woikperformed under the building permit (Section, 109.1.1) The undersigned`.`homeowner"assumes responsf0ity for compliance with the State Building Code and other applicable codes, bylaws,rules and regalations. - r The undersigned"homeowner"certifies that he/she ui dersfands the'Town of Bamstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Buii1dmg Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Coda Section 127.0 Construction Control. HOMEOWNER'S EXEAIP'ITON The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.11-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor- (see Appendix Q,Rules'&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a forth currently used by several towns. You may care t amend and adopt such a form/cerfification for use in your community. Q:IWPFMESIFORj*Mmldingparmitfo=M, MRBSS.doc Revised 661313 f �a'� ,�1u�: ���s�,�► S , axe jqf rxed Irc-)7(e 51- V, Al IV tip,. �� • 50,E o f _ s on Y f f t 1 a 45 VN tttlll� _ry w ` . C re ol Off ti T so 5 i Si X 5000 j. AA f song 4-u 3T Rx s Y - 11U �� • � IV P k r NEW ENGLAND LAND SURVEY Professional INSPECTION PLAN Professional Land Surveyors NAME KAREN A BUDREAU -� 710 MAIN STREET U' N.Oxford, MA 01537 LOCATION 37 RUDDER- ROAD 00 PHONE: (508) 987-0025 HYANNIS, MA FAX: (508) 234-7723 4 5 2016 SCALE 1"=40' DATE REGISTRY BARNSTABLE BASED UPON DOCUMENTATION PROVIDED, REQUIRED MEASUREMENTS WERE CERTIFY TO:ROCKLAND TRUST COMPANY MADE OF THE FRONTAGE.AND BUILDING(S) SHOWN ON THIS MORTGAGE ��{ OF 22768 254 INSPECTION PLAN. IN OUR JUDGEMENT ALL VISIBLE EASEMENTS ARE �t� DEED REFERENCE: / SHOWN AND THERE ARE NO VIOLATIONS OF ZONING REQUIREMENTS REGARDING DWELLING NG STRUCTURES TO PROPERTY LINE OFFSETS (UNLESS WARDEEORGE PLAN REFERENCE 232/125 OTHERWISE NOTED IN DRAWING BELOW). NOTE: NOT DEFINED ARE ABOVE o -� GROUND POOLS. DRIVEWAYS, OR SHEDS WITH NO FOUNDATIONS, ETC. v SMITH III N THIS IS A MORTGAGE INSPECTION PLAN; NOT AN INSTRUMENT SURVEY. NO. 38 8 WE CERTIFY THAT THE BUILDING(S)ARE NOT WITHIN THE SPECIAL DO NOT USE TO ERECT FENCES, OTHER BOUNDARY STRUCTURES, OR TO FLOOD HAZARD AREA. SEE FIRM: PLANT SHRUBS. LOCATION OF THE STRUCTURE(S) SHOWN HEREON IS EITHER IN COMPLIANCE WITH LOCAL ZONING FOR PROPERTY LINE OFFSET 25001 CO564J DID: 07/16/2014 REQUIREMENTS, OR IS EXEMPT FROM VIOLATION ENFORCEMENT ACTION UNDER MASS. G.L. TITLE VII. CHAP. 40A, SEC. 7, UNLESS OTHERWISE FLOOD HAZARD ZONE HAS BEEN DETERMINED BY SCALE AND IS NOTED. THIS CERTIFICATION 1S NON-TRANSFERABLE. THE ABOVE NOT NECESSARILY ACCURATE UNTIL DEFINITIVE PLANS ARE ISSUED CERTIFICATIONS ARE MADE WITH THE PROVISION THAT THE INFORMATION BY HUD AND/OR A VERTICAL CONTROL SURVEY S PERFORMED, PROVIDED IS ACCURATE AND THAT THE MEASUREMENTS USED ARE PRECISE ELEVATIONS CANNOT BE DETERMINED. ACCURATELY LOCATED IN RELATION TO THE PROPERTY LINES. RUDDER. ROAD 100.000, DRIVE; #37 ' 0 . � �6 ?Ro�oSP LOT 28 ►� 10)02J SF+ 1oo.000' ' 0' 20' ' 40' 60' 80' .120' . REQUESTED BY: GILL DEVINE DRAWN BY: DLM CHECKED BY: GES SCALE: 1'=40' FILE: 16MIP3181 716 SFT 2 1 All 8: 5 6, D1V1 01 Massachusetts Department of Public Safety - } Board of Building Regulations and Standards s License: CS-049696 Construction Supervisor CHRISTOPHER W COLBATH: 383 OLD MILL RD a - OSTERVILLE MA 02655 `��-- _ Expiration: ¢, Commissioner L 05/25/2018 W - • ��r f�%rilra7NrJ�rfilrr/�1 1141111rlr�rclG�/3 �. Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: registration 156038 Type: Office of Consumer Affairs and Business Regulation /expiration 5/29/201 Z 'Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 CHRIS COLBATH Y - CHRIS COLBATH 383 OLD MILL ROAD s OSTERVILLE,MA 02655d, c= - Undersecretary Not valid without signature Town of Barnstable *Permit G Expire 6 months Eton:issue date Regulatory Services Fee * •nxrtsTAai MAM Richard V.Scali,Director 039. Building Division Tom Perry,CBO,Building Commissioner` .200 Main Street,Hyannis,MA 02601 . www.town.batnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY �I ' Not Valid without Red X-Press Imprint Map/parcel Number -I (.� Property Address 3? C/L�A �C' Ol "\' Cth N1 ©VA residential . Value of Work$ 'okra' -5 Ub Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 1�2 L n n � \A P E al� Contractor's Name (z t C r J '. Telephone Number S ' ? 57- z26 7 b Home Improvement Contractor License#(if applicable) f 5 b Q 3 R " Email: Construction Supervisor's License#(if applicable)����b ❑Workman's Compensation Insurance Check one: I am a sole proprietor ❑ lam the Homeowner PERM ❑ I have Worker's Compensation Insurance JUL 012016 ' Insurance Company Name„ N OF BARNSTABLE Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ` ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers,of roof) ❑ Re-side .. ® Replacement Windows/doors/sliders.U-Value (maxiinum.32)#of windows �- u #of doors: �. Smoke/Carbon Motioxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *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. copy of th ome Improvement Contractors License&Construction Supervisors License is SIGNATURE: C:\Users\Decollik\AppData\Local\Microsott\Windows\Temporary Internet Files\Co6tent.Outlook\2PIOIDHR\EXPRESS.doc . Revised 040215 f ; INE anaxsrnsIX NAML Town of Barnstable , ��Via`` Regulatory Services Richard V.Scali,Director Building Division _ Thomas,Perry,CBO Building Commissioner - u 200 Main Street, Hyannis,MA 02601 - twww.town.barnstable.ma.us - Office: 508-862-4038 Fax: 508-790-6230, Property Owner Must Complete and Sign This Section If Using A Builder - I0A-�i 1 as Owner of the subject property c � 1 • hereby authorize ( ' P�". to act on my behalf, in all matters relative to work authorized by this,buildirig permit application for: 3? �ctd (Address of Job) 1 5' d f .6 Signature of Owner Dat F Coy A (2i Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.outlook\2PIOlDHR\EXPRESS.doc Revised 040215 I i `T)me Coninmonwealth of Massadiuseas Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 wtvw inass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legib Name(Business/organizationtladividoaw' Address: tVd r City/State/Zip: OS64 l UV l 4- - Phone 7 3 — �.d 7b Are you an employer?Check the appropriate box: T of project r 4. I am a general contractor and I • Type P 7 ( �= 1.❑ I am a employer with _. � g ' 6. New construction . employees(full and/or pact-time).* have hired the sub-contractors 2.'R 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 and have workers' working forme.in a�capacity-Y employees I 9. ❑Building addition . [No workers'comp.insurance comp.insurance ° .1. Electrical or additions required-] 5. ❑ We are a corporation and its ❑ s 3.❑ I am a homeowner doing all work officers have exercised their I LP Plumbing repairs or additions myself[No v�orkeis'comp. right of exemption per MGL 12❑Roof repairs insurance required.]i c- 152,§1(4),and we have no employees-[No workers' 13.❑Other comp insurance required.] - •Any appticsnt that checks boar#1 oust also fill out the section below showing their wo*eta'compensation policy information. 1 Homeowners wbo submit this affidavit indicating they ate doing all work and then hire aumide conttt ctars must submit a new affidavit m&cs=g sack tCoutracmrs that check this boot must attached an additional sheet showing the name of the sab-contractors sad state whether at not those entities have. employees. If the sub-couvactots have employees,they must provide their workers'comp.policy number. lam an employer that isprtwiding workers'compensation insurance for my employees. Below is the policy and job site ' information, Insurance Company Name: Policy 4 or Self-ins.lic.#: t Expiration Dater Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(shoeing 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 here VW, under e s and penalties of pedis#3 that the information provided above is trace and correct I Si Dater Phone#: SDP ? _I 2 07 Co . Official use only. Do not write in this area,to be campleted by can,or towit official, ,City or Town: PermitlUcense!# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other a r e �Pam��aa�uisea&/i Office of Consumer Affairs&Business Regulation j License or registration valul use ME IMPROVEMENT CONTRACTOR ; before the expiion date',If found for ,return to only rat egistration: 156038 a Type: I Office of Consumer Affairs and Business Regulation xpiration: 3%29/p� _, Individual 10 Park Plaza-Suite 5170 CHRIS COLSATH � Boston,MA 02116 CHRIS COLBATH 383 OLD MILL ROAD ' c OSTERVILLE,MA 02655 Undersecretary Not valid without signature Massachusetts Department of Public Safety Board of Building Regulations-and.-Standards License: CS-049696 Construction Supervisor CHRISTOPHER W COLBATH 383 OLD MILL RD OSTERVILLE MA 02655 '<'« Expiration: Commissioner 05/25/2018 I F l Town of Barnstable *Permit(p xpires 6 mo s from jssue e Regulatory Services E Fee s s ' +� BARNSTABLE. M"M1639. $ Richard V.Scali,Director . ArFD MA't A Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office:-t 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY � n Not Valid without Red X-Press Imprint Map/parcel NumberIM P t perty Address OZ a [Lkesidential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address j %x Y Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) OWorkman's Compensation Insurance Check one: 0 t ❑ I am a sole proprietor �1f [-am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) � ' ❑ Re-roof(hurricane nailed).(stripping old shingles) All.construction debris will be taken to QL� ,p i ❑ e-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows . #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. f ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: /f Q:\WPFILES\FORMS\ ding permit forms\EXPRESS.d c Revised 040215 r Ile Comynonivealth of Vcassaclrusetts Dep artrnent ca•fInrlastrial Accidents - f3,fface of Iirestigations 600 Washington street -� Boston,AM 02111 >F P v i n aarrrssgvWdia Workers'Compensatian Insurance Affidavit:BuildersiContracturs/EIecEricians/Plumbers Applicant InfmrmatiGn /J Please Print Le�bIX Nr7tYSP3us®ess,'Osgani2ationlIndiMdual}: off' /Address. //CityiStatcr _ 1'1 //t—' Phone 4 -15-0 R— i' Are you an employer?Check the appropriat.box: Type of project(required): 1.❑ I am a employer urittlr 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 street. 7_ ❑modeling shy p and lave no employees. These sub-contractors have _ g- ❑Demolition worizing far me in any capacity. employees and lm a wodoers' jNa i4CSrloerS'camp-;n�tranre comp_msurant�t 9. ❑.Burldtag addrtrart r d] 5. ❑ [fie are a corporation and its 10_❑Electrical repairs or a dditi outs 3. am.a hameo-amer doing all work officers leave exercised their 11_❑Plumbingrepaim or'additions myself[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required,]a c.152,§1(4h and we have na employees.[No wor=s' 13-❑Other comp.insurance .] •tLny 3ppP3ca tfut Checks box K mnst also McWthe sectioabelawshatsing dreirwo¢iseze compensatWnpolkyinformzdML I Fiameoemets who submit ffi s dffd.,t indicating they are doing all wad dad,dzen hire outside contractors amct suhnut anew affednst Mdsc=ag sarsi. . rGantnCtors thst d+ork This boa must attached au additional sheet showing the nmee of the sob-co=zctm:s and state whether or not those entities bane empiopees. Tfthesubtaatractorshave employees,treym=provide their workers'camp.policy number. I am art empfq-er that isprmzding workers'contperrsadon hmirance for uzy emplaives Heloav is the p Ucy and jobs to information. Insurance Company blame: Policy#or Self-ins.Lic_# F—xpirat oa Date: Job Site Address: City/State/2.p: . Attach a copy of the workers'compeusationp.olicy declaration page(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MGL c- 15—can lead to the imposition of criminal penatti s of a fine up to$1,50a 00 and/or one-yeir imprisonments as well as civil penalties Ju the form of a STOP WORK ORDER and a fine of up to S250.D0 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 i cation. I Afa Iit=reby certF;�1,ender the pains andpe ialtees ofpeg'my that the in;fbrwratian prm rted abm a is true and correct Sionatuie. Date: Ph6/f r Ufficial use only. Do itat write in tins area,to be winpleted bycity artoorn o fSciat City or Tomm: PerfmtlLicense if Issuing Authority(circle one): 1.Board of 331t2lth 2.Building Department 3.CityiTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other• Contact Person: Phone#: Information and hastructions Massachusetts Geheral Laws chapter 152 requires all employ=to provide workers'compensation for their employees: ?rasuaatto this st�ote,aa.employee is defined as.`-.every parson in the service of anoi3iea under any contract of bite, �+ express or implied,oral or writ[rn." An Troyer is defined as"an individual,parfnersbip,association,corporation or other legal entity,or any two or more of the foregoing engaged is a joint anterprise,and including tie 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 tie - dwelling honse of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurte ant thereto shall not because of such employment be deemed to be an employer." 1�4GL chapter 152,§25C(6)also states that"every stag or local licensing agency shall withhold the issuance or r_newaI 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 nuance.coverage requirecb" Additionally,MCrL chapter 152, §25C(7)staters"Neither the commonwealth nor wiry of its political subdivisions shall ent:es into any contract for the perfm==ce ofpnbhc work until acceptable evidence of compliance with the insurance.. rei moments of this chapter have been presented to the contracting suthozi:tj:" A-pplicants Please fill out the workers'compensation affidavit completely,by chmIciag the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), addresses)and phone numbers)along with their certifrcafe(s) of IDsu„-anc0. Limited Liability Companies(LLC)or Lnmithd Liability Partnerships(LLP)with no employees other than the members or partners,ale not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of instance coverage. Also be sure to sign and date the atmdavit The affidavit should be retnmed to the city or town that the application for the permit or license is being requested,not the Deparmeat of TnrdLt 'a .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-fi �rrance license number on the appropriate line. City or Town Officials f _ Please be srse that the affidavit is complete and pried legibIy- The Department has provided a space at the bottom of tie 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 is the peunitlIicense number which will be used as a mfercuce number. In addition,an applicant tha=must submit multiple penn&hc=r-applications in any given year,need only submit one affidavit indicatmg current policy infbmation(if necessary)and under"Job Site Address"the applicant should write"all locations>ii (may 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 fiat a valid affidavit is on file for fohnre 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 venue (Le. a dog license or permit to bum leaves etc.)said person is NOT rec�to complete this affidavit The Office of Investigations would at 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 nnnber. Th@ COMMMwealtir of Ma&E a6hu-,mitts . I1eg�ant of 1nd�tizal A�ci{ient� flue of blvegigatiow 600,washivm t Bost MA G21 I I ` eL 4 617-'27-4900 Qxt 4)6 or 1-�9 MASSAFE, Fax 9 617-727-7749 Revised4-24-D7 .m gavld33 Town of Barnstable Regulatory Services pUIK roy, Richard V. Scali,Director Building Division 1xrrsrnsrA ' Tom Perry'Building Commissioner hrass. 9 z639. ,�� 200 Main Street,.Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 - Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION , •DATE: Please Print /Z I sz S'� JOB LOCATION: num r street village "HOMEOWNER": nar. home phone# work phone# . CURRENT MAILING ADDRESS: - city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to'engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures.'A person who-constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned``homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Si ' of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. r HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to-do such work,that such Homeowner shall act as supervisor:" Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules &Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible: To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 040215 y r • • s • BARNSTABLE. * - 16 Town of Barnstable i639� ���' Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section. If Using A Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. QAWPFILES\FORMS\building permit fonvs\EXPRESS.doe Revised 040215 Cape Save Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 508-398-0399 1-11-14 Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main St. Hyannis,MA 02601 RE: Building Permits Dear Mr. Perry, cr, CIO This affidavit is to certify that all work completed for 37 Rudder Road,Hyannis has been% inspected by a certified Building Performance Institute (BPI)Inspector. Ceiling: R-30 cellulose Basement: R-19 fiberglass to accessible box.sill area (storage blocked some areas). All work performed meets or exceeds Federal and State Requirements.' Sincerely, William 4McCluskey • TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map. Parcel Parcel ��Q pcti 1n # Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 3 v,d At r Y o a, Village Owner -q i Ca►t pe n+e f Address 15 Q e n Lie C,o4cryr ,l lr, Telephone S 0 S R 9 U 8 II Permit Request I`�d� 1�` 1� 0 � W-. 3 0 well1 145e_ -i y -OV a i�c, �A - 3 0 c811�A,10 se o Ae— JI jor._. s 1 l any Al welne4-�" LA e, n ;n -toam Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 3 0 0 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single FamilyCl ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure I Historic House: ❑Yes ❑ No On Old King's Highway: Yes es❑ No o Basement Type: ❑ Full ❑ Crawl ❑Walkout 0 Other " - '.a� r7 Basement Finished Areas ft. Basement Unfinished Areas 'ft ; `�' ? Number of Baths: Full: existing new Half: existing' Number of Bedrooms: existing _new a;a .i Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size — Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes If yes, site plan review # Current Use - Proposed Use z - APPLICANT INFORMATION -- (BUILDER OR HOMEOWNER) Name W 11`t C �Ck SOV �' elephone Number Address- "� i l License # '�� �Jew Home Improvement Contractor# \ l 6 Worker's Compensation # 3 4 6 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE s FOR OFFICIAL USE ONLY t APPLICATION# 3 DATE ISSUED z MAP/PARCEL NO. ADDRESS VILLAGE OWNER r' DATE OF INSPECTION: t' ;,f0UNDATIQNjupq±:°dyy - FRAME INSULATION > FIREPLACE ELECTRICAL: ROUGH FINAL ec PLUMBING: ROUGH FINAL GAS: ROUGH FINAL t r FINAL BUILDING 5 _DATE CLOSED OUT ASSOCIATION PLAN NO. } t 'Aev maw _ 460 West Main Street a R,, c $ ` Hyannis, MA 02601-3698 Housing _ Tel: (508)771-5400 Fax(5 75-7434}„ Assistance , ; .,.. . di TTY on all�lines Corporation uvw w hw-nnr-nnar•nri nrn \` $L9L3��`�� : Cape Cad - Free Weatherization ! Your tenant has requested and is eligible for weatherization of your rental home " through government funding. This will be provided at no cost to you. Program regulations permit us to spend around $2,500 $7,500 in materials and labor per dwelling unit. Program regulations require us to weather-strip and caulk doors and windows; insulate attics, sidewalls and floors. All work is professionally done by established private contractors. . We will conduct a final inspection to make sure that all work is completed to specifications. If you request, you will be informed of the estimated measures before they are done and provided with a list of the actual measures and costs following the completion of the work. We also need proof that you own the property. .A copy of a CURRENT TAX BILL OR DEED listing you as the owner will satisfy this requirement. Please fill in all blank areas of the enclosed agreement and return with the proof of ownership as soon as possible. If we do not receive the enclosed form within two weeks, we will "do a basic energy audit of the home, but no weatherization work can be recommended or done. If you have any questions please call Mitzi Holmes at 508-771-5400, ext. 123. LANDLORD: ft CZ (i!� 2 'A TENANT: email: ('a Cil-S email: PHONE:(home).re9— PHONE: (home) (cell) (cell} t TENANTIPROPERTY OWNERIAGENCY WEATHERIZATiON AGREEMENT �0 1. The Parties to this Agreement are the following: ,; r,# 13 � C2O.FT (hereafter k rn as Tenant (print your name) �1 nus; t A,/Ig (hereafter known as P er)�, 1r�' (print your n me) and Housing Assistance Corporation (hereafter known as Agency). In consideration of the mutual promises hereafter stated,the Parties agree as follows: 2. The date of Agency's signature will be the effective date of this Agreement. 3. Property Owner and Tenant consent and agree that the Agency may do the following with respect to the property located at(street,town) S/ '� ®tea unit# ,and currently leased or rented to the r Tenant: ro 0 / a) Enter the premises for the purpose of performing a Weatherization inspection. b) Enter the premises to perform Weatherization work which the Agency determines in its discretion is necessary and appropriate as a result of the Agency's inspection of the property and in accordance with the appropriate priority list for the type of dwelling. The Agency and the Agency's contractors may also enter the appropriate common areas of the building for the purpose of accomplishing the Weathedzation work. The Agency and representatives of the Commonwealth of Massachusetts, Department of Housing & Community Development (DHCD) may further enter the property to inspect any and all work hereunder. The Agency will provide reasonable notice of the timing of the Weathedzation work and inspections. The Weatherization work will be performed in accordance with the Property Owner's consent as further specified below: i INITIAL ONLY ONE OF THE FOLLOWING I consent to performance by the Agency and its contractors of any Weatherization work determined necessary and appropriate by the Agency as a result of its inspection of the property. I understand that the Agency will provide a detailed statement of the actual work perfomled and the associated value at J the completion of work. I will provide a separate consent to performance by the Agency and its contractors of Weathedzation i work following my receipt of the Agency's inspection report and a statement of the estimated work and associated value. This additional consent will be sent under separate cover as Attachment A. I understand that the Agency will provide a detailed statement of the actual work performed and the associated value at the completion of the work. 4. The Property Owner understands and agrees that any and all work, including related repairs for which the Property may also be eligible, will be performed at the Agency's discretion_ The Agency estimated completion of the Weatherization work by the end of 2013. • 5. If the Property Owner is required to make repairs to the property prior to the commencement of Weathedzation work by the Agency,the Property Owner will be notified by the Agency and will be required to make the repairs as soon as possible. Except where the Property Owner receives a written extension from the Agency, time is of the essence in the performance of repairs by the Property Owner. . . L ' 6. The Property Owner and Tenant authorize the Agency to receive a statement from the fuel supplier/utility supplier as to the quantity of fueVublities used at the above address in each of the past three years and the future three years. The information is to be used. only to determine the cost effectiveness of the Weatherization improvements. 7. The Property Owner agrees that the rent for the dwelling unit will not be raised because of any increase in the value thereof due solely to the Weatherization work perfomred. ' 8. In consideration of the Weatherization work hereunder, the Property Owner further agrees that upon the effective date of this Agreement and during a period extending through 201312014, approximately one year from the time the work is completed, a) The present rent per month will not be raised for any reason. (The rent amount must be filled in). Heat included in rent?Yes No—'ate However,this Paragraph(8a)will be waived by the Agency in writing if,and only If,the premises are leased under a state or federal rent subsidy program, in which case the actual rent charged by the Owner shall conform to the standards of the rent subsidy program. Please state which Housing.Subsidy program your tenant is on and through which Agency: b) The Property Owner will not institute any summary process action for possession except in the case of non-payment of rent or other good cause related to the Tenant(or any successor Tenant). c In the event the Pro Owner decides to sell the remises Property Owner shall comply with one of Property p p rtY P Y the two requirements below: —The Property Owner shall.not sell the premises unless the buyer agrees(with a copy forwarded to the Agency) in writing prior to sale to assume all obligations of the Property Owner set out in this Agreement;or --The Property Owner shall pay the Agency an amount equal to the cost, as certified by the Agency, of the Weatherization materials installed and labor performed in the premises as of the date of sale. Said amount shall be paid to the Agency immediately upon sale. 9. (Applicable only if Tenant's heat Is Included in rental payment and blanks are filled In) At the end of the period set forth in Paragraph 8 above, the rent shall not be raised more than ` % per for an., additional period of one year, and the provisions of 8b and 8c above shall continue in effect for such period., However, the rent provisions of this Paragraph 9 may be waived by the Agency in writing if, and only if, the premises are leased under a state or federal rent subsidy program, in which case the actual rent charged by the Owner shall conform to the standards of the rent subsidy program. 10. The Parties agree that the terms of this Agreement are incorporated into any other lease or agreement between the Property Owner and the Tenant, and between the Property Owner and any successor Tenant, and if there is any conflict between the provisions of this Agreement and the provisions of such other lease or agreement, the provisions of this Agreement shall govem. However, if such other lease or agreement, including without limitation a lease or agreement under state or federal rent subsidy program, contains stronger protections for the Tenant, such stronger protections shall apply. 11. For breach of this Agreement by the Property Owner, the Property Owner shall reimburse the Agency in an amount equal to the cost,as certified by the Agency, of the Weatherization materials installed and labor performed on the premises, as well as attorney's fee and court costs. The Property Owner may also be liable for damages to the Tenant in accordance with applicable law, in such instance, the Property Owner shall reimburse the Tenant for attorney's fees and court costs. Without limiting the foregoing, the Agency may at its option terminate this Agreement, by providing written notice to the Property Owner and Tenant, in the event of breach by the Property Owner or Tenant 12. Performance of the Weatherization work hereund ��1 is contingent upon-the availability of funds to the Agency from the commonwealth of Massa and the ir*thi overnment,as well as the eligibility of the Tenant under WAP program requirements. ency iii ay termiis Agreement, by providing written notice to the Property Owner and Tenant, if the A y determines that milability of funds or ineligibility of the Tenant warrants termination. Cob c ' 13. The Parties acknowiedge that this Agreement is under seal It is intended by the Parties that the Tenant or any successor Tenant is the intended beneficiary of the Agreement and shall have a right of enforcement 0Property Owner's Signature: Date f D i Phone: Address: (� 4�� 4 Tenant Signatu4Weath Date �� Agency Approvion Company All Cape Energy I Adam T. Incorporated / Cape Cod Insulation Frontier Energy Solutions I I_ohr&Sons Inc. I Resolution Energy Agency Signature Date e. 1 Styr A r t The Commonwealth of Massachusetts ^-- Department of Industrial Accidents Office of Investigations ' ' I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly_ Name (Business/organizationAndividual): Cape Save Inc. Address: 7D Huntington Ave City/State/Zip: South Yarmouth, MA 02664 Phone #: 508-398-0398` Are you an employer? Check the appropriate box: Type of project(required): 1.0✓ l am a employer with 4. [] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6, New construction 2.❑ 1 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 � 9. � Building addition [No workers' comp. insurance comp. insurance.* 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 I LR 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' 13.0 Other Insulation comp. insurance required.] *Any applicant that checks box 91 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 and job site information. Insurance Company Name: Technology Insurance Company Policy#or Self-ins.Lic.#: TWC3353968 Expiration-Date: -04/09/2014 Job Site Address: 3 KysA t e r City/State/Zip: tin 1 �� Attach a copy of the workers' compensation policy declaration page(showing the policy number nd 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 S 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 certi under the pains and penalties of er' that the information provided above is true and.correct. Signature: Date a Phone#: 508-398-0398 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#: Aga CERTIFICATE'OF LIABILITY INSURANCE 10/22/2013013 D ' � /22 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(les)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 , NAME:ONTACT Colleen Crowley. Risk Strategies Company PHONE (781)986-4400 FAC No:(7e1)963-4920 15 Pacella Park Drive Suite 240 INSURER(S)AFFORDING COVERAGE NAIC# Randolph M 02368 INSURER A Selective Ins. OF America INSURED iNsuRERB:Safety Insurance Company 3618 Cape Save, Inc INSURERC:Technolo Insurance Company 7 D Huntington Ave , INSURERD: INSURER E: South Yarmouth NA 02664 INSURERF: COVERAGES CERTIFICATE NUMBER:CL13102268490 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 DESCR IBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTRR TYPE OF INSURANCE POLICY NUMBERMMfDD EFF MM`DD EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES a occurrence) $ 100,000 A CLAIMS MADE a OCCUR 1994480 0/16/2013 0/16/2019 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X JECTPRO X LOC $ AUTOMOBILE LIABILITY COMBINED accident SINGLE LIMIT1 000 000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 6208200 1/6/2013. 1/6/2014 AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ $ PDED UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 AEXCESS LIAB CLAIMS-MADEAGGREGATE $ 1,000,000 RETENTION Nil S1994480 0/16/2013 0/16/2014 $ C WORKERS COMPENSATION Dfficers Included for WCSTATU- OTH AND EMPLOYERS'LIABILITY YIN X T Y TS ANY PROPRIETORJPARTNERIEXECUTIVE F33r53968 age OFFICER/MEMBER EXCLUDED? NIA E.L.EACH ACCIDENT` $ 500,000 (Mandatory In NH) /9/2013 /9/2019 E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) Weatherization Specialists GL: Blnkt AI, Blnkt PNIC, Blnkt WOS, Per Proj Agg, Per Loc Agg J GL Exclusions: Snow & Ice Removal/OCIP/Wrap Ups , 'CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE chael Christian/CLC '� � ��=� ACORD 25(2010105) 1988-2010 ACORD CORPORATION. All rights reserved. INS025(20100s).01 The ACORD name and logo are registered marks of ACORD i . Massachusetts -Department of Public Safety . Board of Building Regulations and Standards,. Construction Supervisor Specialty License: CSSL-102776 WILLIAM J MC CLUSKEY,- '- 37 NAUSET ROAD g West Yarmouth rdA 02673 M. commissioner 06/2812015. r , _ Office of Consumer Affairs and eusness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration ' 'Registration: 171380 Type: Corporation Expiration: 3/14/2014 Tr# 222184 CAPE SAVE INC. WILLIAM iMcCLUSKEY f 7-D HUNTINGTON AVENUEZ. SOUTH YARMOUTH, MA 02664 Update Address and return card.Mark reason for change. - 1 Address 1 Renewal Employment ;j Lost Card =s-CA1 0 50M-04104-G101216 •�', ✓die-P�,�w�«alfl c .j[,c�laclir�sel�6 __,. . .__ . _ - Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: ..-171380 Type: Office of Consumer Affairs and Business Regulation 4070 RMS Expiration: =3%14/2014 Corporation 10 Park Plaza-Suite 5170 f,•yi - M/ Boston,MA 02116 SAVEINC WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE SOUTH YARMOUTH MA 02664 Undersecretary Not valid wit 6 signs