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HomeMy WebLinkAbout0022 RUSTIC LANE Lj� 10 W 11 OI 13arII8 Ldple Regulatory Services o Richard V. Scan,Director t Building Division $ Paul Roma,Building Commissioner t 200 Main Street,Hyannis,MA 02601 wvew.town.barnstable.ma.us'_ Office: 508-862-4038 ;* €. Fax:. 508-790-6230 Approved: Fee: 1 7 Y Permit#: HOME OCCUPATION REGISTRATION Date: L1,31 ` Name: AbdC QA � Phone t 'i*'+ $ - 5"b�3 Address: a Ru ahC Lh 14y ouin�S, Village: ally S Name of Business: P lu"'.na �1 bk-Aon S � Roqa 1A• f Type of Business:flo)YYl�j`� Map/Lot J INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling. there shall be no increase in noise or odor,no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes;and no increase in air or groundwater polIution After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. • ' Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in.excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other pardcnlar matter, odors,electrical disturbance,heat,,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. •' Any need for parking generated by sach-use shall be.met on the same_lot containing`the Customary Home. Occupation,and not within the required front yard • There is no exterior storage or display of materials or equipment ' • There are no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one tan capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation •' No sign shall be displayed indicating the Customary Home Occupation •. If the Customary Home Occupation is listed or advertised as a business,the street address shall not be inclu e L • No e on shall be employed in the Customary Home Occupation who is not a permanent'resident of the I,the.undersi a ead and agree with the above restrictions,for my home occupation I am registeriag. Applicant Date:.�E 1 Homeoc.doc Rev.06/20 6 , 4 pwzj �� , rN YOU WISH TO OPEN A BUSINESS? For Your Information:. Business.certificates (cost$40,DO for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to,the Town Clerk's Office, 1st Fl., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law: :M00 �- , 'DATE: Fill in please: APPLICANT'S YOUR'NAME/S: XrOM BUSINESS YOUR.HOME ADDRESS: a usAr L:n, l cznn=S, MA, og-w( . � �g- 4a2.-5U3 TELEPHONE # _. Home Telephone Number 60S - S-3&L4(p NAME OF CORPORATION: , NAME OF NEW BUSINESS_ Flu►' biNiG Salo ohs e.m fl 7 by 14r ytS A-4 TYPE OF BUSINESS_P h,6,%nQ IS THIS A HOME OCCUPATION? YES = NO ADDRESS OF BUSINESS Ln C, © 0 MAP/PARCEL NUMBER (/ U r 5�` (Assessing). When starting a new business there are several things you must do in order to be incompliance 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 COMMISSID�infeldffaZyper LE MUST COMPLY WITH HOME OCCUPATION This individual has b it equirements that pertain to this type of business .RULES AND REGULATIONS. FAILURE TO Authorized Sign Lure** COMPLY MAY.RESULT IN FINES. C ENTS: ! , 2. BOARD OF HEALTH This individual has been informed of the permit requirements that;pertain to this type of business. Authorized Signature** z COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) x This'individuaMas been informed'of the licensing requirements that pertain to this type of business. 4. Authorized Signature* COMMENTS: y _ Nr Ck n cl r�, d\ r }. t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel �� �, t _ t Application o � � I (0 Health Division R; A ' z Date Issued Conservation Division Application Fe Planning Dept. Permit Fee t : Date Definitive Plan Approved by Planning Board U ':_.1, Historic - OKH _ Preservation/ Hyannis Project Street Address Village Owner,.144 ,'go-Y Address Telephone i� �J� ,� ✓� Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay. -Project Valuation 4)Construction Type l Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family C Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes . No On Old King's Highway: ❑Yes -U-No Basement Type: ❑ Full 0 Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: 0 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 �i�T� /��/.�1'yk��/0':9 Telephone Number Address cam® License # /el D �1 T Home Improvement Contractor# Email Worker's Compensation # �� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE l T it FOR OFFICIAL USE ONLY {> 4 `APPLICATION# 4' DATEISSUED - 1, 4 e f MAR/PARCEL NO:. �I . i f t VILLAGE E. ADDRESS' ._. , OWNER s DATE OF INSPECTION: ; FOUNDATION FRAME INSULATION .k FIREPLACE 'M ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL r FINAL BUILDING URTE-CLOSED OUT AS.SO( TION PLAN NO: i R The Colrrnronwealth of Al' assuchuserts - -- -- _ Dggranent Qflndustrial accidents 'OjYice of Investigations 600 Washington Street Boston,MA 02111 wtww.ynass.gav/die , " Workers' Cowpecr-s do u Insurance Affidavit: Builders/Contiralctors/l�liet►trd�Y�insl�''Yatrzpl��rx � ;�. ►ttitl':urtt Y�txf�orry�atYt�r� Pleas �ri.t.tt l,e i1:►I� N4111C �l:IusincSxiUrbaitizatiart/ludivitl /' I _ T l /Yi -' Phone u c you 2111 eulployerr7 checic the appropriate box: -. a� Type of Project (required):' I 1 u a clitpluyer with 4, [] T anz a.betieral cpAtractor aril 1 _ _ I :tuplu}ecs (hill ruclfor part-ti-ri. have hired the sub eontractot� d ❑ uw 4uns4uitiou ant a sole proprietor or partner- listed on the attached sheet 7. [,] lhettaoclelinl; i 1 ;hip and have ao employes (These sub-contractors have . $. E] Demol.iulo working for me tax a:dy capacity: employees and have workers' ` (No workers' comp: insurance comp. insurance.t 9• ❑ Building; addition tryttirrd:) 5. We are a corporation and its Electrical repairs-or adilitionS horneow,ner douzg; ill-work officers have exercised their lrl,.[� PturribL'ng repairs or udditiogs Myself. [No workers comp. right of exemption per MGL _ iasau, ncereguirctl.] .r c. 152, §10), and we have no 12,E] Roof repair3 ULU a hotucowncr acting; " a employees. [No workers' 13,.M.Other �r J� � f , _z 01 �crlcral Col1Lr•SCt f or�r•Cer to `4) -r— ___ comp,insurance required.] 1�11y Ipphc:utt that cLccics txwz ff-t Wust also till out the Section below Showing thew workers'compcnsatiodi olicy iafotinutiou. ' iiuu,COwuc,Y wlw Yubrnit w aFhcluvit iaatlicutirig they arc doing all wart check thta b and then hire ouuidc contractors must submit a new affidavit indicating Such. �uuu utuey twc x[ntrxt uctut had an ttcidrtaunul Yheet sho\vtng the nnnw of the sub Uanuctar earl ytaw\Yheetxcr Uc uqt tliuxc eutitica twvc.i�q,iuycc,v. IC rho sulrcwtu'ua:torx.huvc culployccx;they must provide their workCtS'comp.policy uumbcr: - - - I tilts an employer that is giro vidinlr workers'compensation insurance for my employe ex ?l'dlory is the policy an(!jab site rr julrrra(!u!t 1t19111`411cG l;uutpatzy N rraac: /� 1'011L:y If ur 5c li=itts. C.tc. fl: / , ���' �- — !� � Expiration Date' 16L2�j I,iu>trr City/State/Zip` Aft;.Ch q copy of cite worke.rx' GoMpeusatlon policy declaration page(showing the policy rxQmber avid expiratlurt date). i'a'lc,c fo jccurG ti QYCI ag;c as,rcgWred under Section 25A of IVIGL c. 152 can lead to the imposition of cruniaa<tl penalties of a line t,p to S 1,.j0?.0Q and/or 6ne-year imprisonment, as well as civil penalties iu the form of a STQI' WORK°0FLDER and a tine ,i up to 2J0.00 a riay abairist the violator. Be advised that a copy of this statement may be forwarded to the Otfice of 1.nvcst1]atipp3 of chc D" for in iUraace coverrage-verification. I� l u'a rrcreby ecrriv,�rridKr the 7"Y1 �trrut penalties of perjury filet the inforralort proviaCeO abo'u is trueand collet tC f t . _ Date 1'n- a psi �7�� fl(jkii114Te only. Do not write in !%liar area, to be completed by city or town official t'itr ur l'uwtx: ^_ Permit/License# 153,w'q iutttority (circle one): t.lfo*rd of ficalth 2. Building Depurtuierit 3. City/To'wiv Clerk 4.Electrical Inspector S. Plinabing Inspector 6.other Phone#; u CAPECOD-27 CVANGELDER CERTIFICATE'OF LIABILITY INSURANCE 741112014 ,MMI°OnYYY) 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 Cape Cod Commercial ' Rogers 8 Gray Insurance Agency,Inc. NAME:PHONE FAX 434 Rte 134 A/C No.Exc: A/c N.:(877)816-2156 South Dennis,MA 02660 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE _ NAIC If INSURER A:Peerless Insurance Company INSURED INSURER B:COMMERCE INSURANCE COMPANY Cape Cod Insulation Inc INSURERC:Evanston Insurance Company 18.Reardon Circle IN SURERD: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 - e POLICY EFF POLICY EXP LTR TYPE OF INSURANCE �...�.;POLICY NUMBER', MMIDD/YYYY (MM/DDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY i •I v t s;: a: tt,.. t EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE OCCUR _,: CBP8263,063. '._' a ,04/0112014-.04/0112015 PREMISES(Ea occu_REWrrence) $ 100,00 ------ -. _ • .. •.,, � :., •, MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: 2,000 00 PRO ,•„yh,•,, GENERAL AGGREGATE $ , X POLICY L�jECjPRO LOC' " l ; PRODUCTS-COMP/OP AGG $ 2,000,00 ! s•< r i OTHER: r,ir.iiL $ AUTOMOBILE LIABILITY C M131NED SINGLE LIMIT $ Ea accident) E ANY AUTO 14MMBCKVMK 04101/2014 04/01/2015 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ 1,000,00 XX NON-OWNED ( PROPERTY DAMAGE HIRED AUTOS AUTOS Peraccidenl. $ $ X .UMBRELLA LIAR X ,OCCUR " EACH OCCURRENCE $ 1,000,00 C _ Excess uae CLAIMS-MADE R/O XONJ453512 04/01/2014 04/01/2015 AGGREGATE $ DED I X I RETENTION$ °10,000 Aggregate $ 1,000,000 WORKERS COMPENSATION PER ER STATUTE .AND EMPLOYERS'LIABILITY YIN "` - , D ANY PROPRIETOR/PARTNER/EXECUTIVE CA00525J04 r '06/3012013 06/30/2614 E.L-..EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? F NIA1,000,000 (Mandatory In NH) ,r r;, r+ i E.L.DISEASE-EA EMPLOYEE $ If yyas,describe under DESCRIPTION OF OPERATIONS below i, , �i, E.L.DISEASE-POLICY LIMIT $ 1,000,000 a` DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101;A'ddltlonal Remarks Schaduie,maybe attached if more space is required) Workers Compensation includes Officers or Proprietors. F ' Additional Insured status is provided under the General Liability and Auto Liability when required by written contractor agreement with the Certificate Holder. Ll CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EVIDENCE OF INSURANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN . ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. CORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Massachusetts -Depaftr nt of P�tbtic Safety Board of Building Regulations end Standards r Construction Supervisor . ., :. Licenser CS-10098$ HENRY E CASSEDV 8 SHED ROW s WEST YARMOUTH 2 ' `,�.•�..., Jj Expiration Commissioner . 11/11/2015 - Office of Consumer Affairs_ and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Co4tragtor Registration Registration: 153567 Type: Private Corporation " - ' Expiration: 1 211 5/2 0 1 4 Tr# 233831 CAPE COD INSULATION; INC " ,HENRY CASS I DY --- 18 REARDON CIRCLE- SO. YARMOUTH, MA 02664 Update Address and return card.Mark reason for change. .. [�SCA I,i) Address Renewal , Cniployment �� Lost Card 2UM-U5/I t .. . .lr rro>ru,reucztcll6-a�C�/l�ctadcccLtt�elt. ' \ Office of Consumer Affairs& Business Regulation License or registration valid for individul use only . P ' -." OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: gistration: .'1S3567 Type: Office of Consumer Affairs and Business Regulation xpiration: 12/15/201A Private Corporation 10 Park Plaza-Suite 5170 riL� ` Boston,MA 02116 CAPE COD INSULATEON,,I(J HENRY CASSIDY ° 18 REARDON CIRCLET SO.YARMOUTH, MA 02664 ` Undersecretar 1 Y otval witho tRN nat re M I r OWNER AUTHORIZATION FORM wn&s Name) owner of the property located at Ru5ti- Lram.n (Property Address) (Property Address) CQ hereby:authorize C �/ (Subcontracto, an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. r - Owner's Sion Date CAPE COD TOWN Of BARNSTABLE INS U L AT I ON 213 JP4 N3 P9 1177R OlAS> 7[AMLL77 SPRAT 70A[.1 747P7NP7p 7ATT7 G4TT70 IN74LATION UMNG7 " 1-800-696-6611 DIVISIOR Town of Barnstable I:egulatory Services Building Division 200 Main St Hyannis, A 02601 Oil Date: Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. perfonned & 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 Nrrarow aattttrx: ZrZ IZJfi'r C.4�►e hyq�•�o s /�� 0 t6e) Insulation Installed: Fiberglass Cellulose R-Value• Restricted Uiu•estricted Ceilings ( ) . (X ) (yL ) ( ) (x ) Slopes ( ) ( ) ( ) ( ) ( ) Floors cr"I W411S (X (X ) Walls ( ) (X ) ( 13 ) (X) ( ) Seal'1 Sincerely He y E C� sidy J , President Cape Cod nsulation, Inc. • TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel V Application # 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 Village Owner,, led,0,44/ 44 C�r��s�u Address ✓� Telephone 0 7F Permit Request rf.� ���, c2la/ l ��?�a�T,/ �� ®,�✓d /,e�?v//� &za,k Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation �fGW. d Construction Type i, ✓mac.®/ // Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family .2 Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes 2 no On Old King's Highway: ❑Yes ❑ No . Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Ea Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) `= = Number of Baths: Full: existing new Half: existing I new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count � Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ 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 /�/ ,J� �� 114&f -77�4 A® Telephone Number ,Address / /��'//�' �i 2, s/ n d l-Acense #/ Home Improvement Contractor Worker's Compensation ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE / �f� i f FOR OFFICIAL USE ONLY APPLICATION# �i t DATE ISSUED i MAP/PARCEL NO. E � ADDRESS VILLAGE _ OWNER r . DATE OF INSPECTION: y} :+ FOUNDATION i ' l FRAME INSULATION FIREPLACE id i ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL x i � 7 GAS: ROUGH FINAL FINAL BUILDING `r DATE CLOSED OUT ASSOCIATION PLAN NO. i V ---__- "- iw'tassachusetts - Department of Puitlic afet� Boar•tf of Builtlirtg Regulations and Standards, Construction Supervisor License LicenW; CS 100988u „t HENRY CASSIDY 8 SHED ROW, � k WEST 1ARMOUTH,, MA 02673 Expiration: 11/11/2013 ('unwiissiuncr Tr#: 7620 _� U !'l�G Q�y�•1�'TiGCIGCr�L;��'G � - C��Gl�/,L�G�C��G;lC����/,� ' == Office of Consumer Affairs and Business Regulation 10 Park Plaza,-..Suite 5170 - �--'`.q"ten Boston, Massachusetts 02116 Home Improvement Contractor Registration - - Registration: 153567 Type: Private Corporation Expiration: 12/15/2b14 Tr# 233831 CAPE COD.INSULATION INC HENRY CASSIDY 18 REARDON CIRCLE --------- --- SO. YARMOUTH, MA 02664 Update Address and return card.Marls reason for change. SC.4 t 2UM-05;11 Address ❑-Renewal 0,Employment I-] Lost Card ij / 1 �'.�lZC l(.O Jyt/IeIOY,000[!!✓�C����7JJCFGIGCWCC� ' L\_ Office of Consumer Affairs& Business Regulation License or registration valid for individul use only. OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 153567 Type: . Office of Consumer Affairs and'Business Regulation 5 • 10 Park Plaza-Suite 5170 . 4 xpiration: 12/1512014 Private Corporation aH, Boston,MA 02116 r CAPE COD INSULATION ZINC HENRY CASSIDY 18 REARDON CIRCLE -^ S0.YARMOUTHu MA 02664 Undersecretary of val' witho d t sifl,at re • — No, Client#: 4597 CCINSUL ACORD,,. CERTIFICATE OF. LJABILITY INSURANCE UA It(NINlItIL)m I Y) RTIFICA-VE IS j-,�.,jUEQ Zhi A�MAATTTEZR 07102120-12 ION GiNLY AND CONFERS NO RiGhTb UPON T�ili--CERTIFICATE LO710, 11 '�''C'' DOU�F, AFFIRMATIVELYINIC)'Y QR NEGATIVELY AlVii NT),EXTEND OR ALTERT�JE COVIERAG4 AFFORDED UY THE POLICIES CERTIFICATEOF INFORNIXI- 6r1Lovv THIS II­IIS CER'I'IFICATO OF INSURANCE DOES NOT CONS I 1-'UIF.A GONTRACTBEYWEEN THE 1%;,,�UING lN$URL;R(5),AU'ItIQRI1LL) RFPRC8E:N I*A'I'IVI:-'. Olk l"fiC)DUGF-R, ANlO THE CERTIFICATE nol"')LR, INbU v1,0 mr1durtioclitillL A alutollielil On* khi5 ck3j'jiIj(:kI(4 lit:O QI:,Swch ,'duLK.W.I k Ilul Ckllllel IIVhL-j tu(fic Glay llui- NAME Mai arct Y!OLI�11 434 RULI(Q I J4 PHONE INC,N ,Exll 508-760A602 )""t1i Oullltlk;, MA L2UUO -160-1 Lc N 1-616-21 ho 3�)U-/980 AfFORUING COVLfNjwL NAJ�6 IN4UJ+LR14:Pee-Floss 111sLIFIiico 1033,3--, Cape cact In!5uI"xtk)I) Inc INSURERfl:EVZ1114101i 11161JI'anCa COIkIl)4rIy ilss Yammuth klo"d Atlartile Eflatler lrl�ulrdllctt —---------------- fIV-1163, MA 0260-1 INJURIRq:C001111ercO In6urance Collipkily 34754 INJURER f: ('1ERFIFICATE NUMBER: c I'HAT REVISION NI.JIVft--jL-.ji; f-'L�' PUb-Y,'HAVE BEEN ISSUED 16'-ITI --D NAMED ABOVE FOR 1111- POLICYFIT--.M01) ANY ft(ILI(RENIFNT, I'HFN OR OF ANY CONTRACTOR OTHER D0CU&iEN*I WITH FZE,�OLC G To.wl IIC+j jjjle; lK1;f1CA1U. MAY kSt= IBSUED OR MAY PERTAIN. THE INSURANCt -U-rai\'OEQ BY THE POLICIES DESCRIBED HEREIN IS SUBJECT rO'ALI. ['11F. rrilthl5,- i-1\i,t1)SI()NS ANO CONUITIONS OF SUCH POLICIES. LIMITS 8l-io H61V9 IIECN REDUCED BY PAID CLAIMS. iTll OF IN$UHANG4 r�pol.=R A LiLNLKAt-LIA11101 y .1 TO Y 'I- CBP826306" 04101/20'12 4 1201 EACH QCCURIFIENCIE, t:�JhlhltNCLAL G-Nff�AL( — -1 JAE11LITY F (A.AIM-i MADE OCCUR lelft)f.At'(Ally wl,)poNaill s5 001) "FA$Qf'lAt-N AOV IN JUtiY 41 000 000 ........... OFW: ''iQl AGG s2000000 "TOMOL11L 14 LIAlaiLl I'v IN SINGLIC LIMIT— 121VIMBCKVivj); —T4I!JIF2�12 0410/29011" I AIA-UVVNt0 Au I CIS x - AUTQ3 X jjjHL0 AU,[(J5 X NON-0VvNhL) AUro5 LJMdNl,-1.LA LIA QCCUR XONJ45351 tXLE"k.LIAU fiACH 00 GLAIMS-M — --- ACORLECATC C (:()NIrtNdA'I ION AND IFY ANY I R 11 N 061301-9011, x �'i I2J'ru'tF1' I"6xc ol,vN NIA C,L,CAVO Acc-101'ml' 1'w rL NM) NI A� IiAL I 111 'U""""" -A I 1 U" C'L C_' C.L. t1P SNIP(ION OF UPC ()N-s C.L.DI:XASIZ 0UU"u­6-0, Workers Comp Infoitriatloat 111(�'klkivt1 OttictorQ Qr PrQprietoni, j-'j inaluclvd a3 an additional illSlLlfdd U0061 6u(10ial LwOtlity W11011 roquirod'14y writton contract Or :F1'I"IFICATEHOLUER ................... CANCELLATION capQ cuo'liluutactuJI'llic SHOULD ANY OF THE AQQVL OLSCRIUEO I1QLICIk1,i 13E GANChIll-J)Whl:Uk THE EXPIRATION DATE THEREOF, NOTICE WILL HE ul7'I-IVl:kCLI IN ACCORDANCE WITH THE POLICY PROVIUIQN.']. % AU MORULL)REPRESEN I XCIVE 01qnA--2D'IQAC0RD CORPORATION,Alt 1, of File ACORD RL"I'd d"d 1000 6ru rcg1sWrod marks ofAlCORD mky The Commonwealth of Massachusetts ­Rrint-,Fcirm71 tr -`' ` Department of'Industrial Accidents. . ` - Office of Investigations f I Congress Street, Suite 100 : :,4 7 Boston, MA 02114-2017 ej2r www.nmss.gov/dia , Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individuaa�l): l Q - Address: la vdoGL ( �1VU City/State/Zip:: Vila IN1 A' Phone #: ' -_2D� Are you an employer? Chec4te ppropriate box: Type of project(required): l. 1 am a employer wiih 2,O 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. n Remodeling shipand have no These su -conracorsave Lib-contractors h ` employees P yees ese 8. [] Demolition . I working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. 9. ❑ Building addition 5. We are a corporation and its 10.❑ Electrical repairs or additions required.] ❑ p >.❑ I am a homeowner doing all work officers have exercised their 1 L❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof re a'rs insurance required.] t c. 152, §1(4), and we have no �j �e��f� employees. [No workers' 13Y Other comp. insurance required.] *Any applicant that checks box#I must also till out the section below showing their workers'compensation policy information. . Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. k'ontnactors 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- II'the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: k'o�, Policy#or Self ins: Lic. #: We zz Zij qol Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine 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 tine* . Of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA'for insurance coverage verification. I do Hereby ce fit ler the pains r nrd penalties o er'ury that the in ormation provided above is true and correct. Si nature: Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# ' Issuing Authority(circle one): ` I-Board of Health 2. Building Department 3. City/Town Clerk' 4.Electrical Inspector 5. Plumbing Inspector' 6. Other ,. Contact Person: Phone#: ' a OWNER AUTHORIZATION FORM �2 6G� wner's Name) owner of the property located at p p a fzu5-ti, c, L �,.n (Property Address) (Property Address) hereby authorize COJ , t7 (SubcontractCY an.authorized subcontractor for RISE Engineering, to act on my behalf to obtain a:building permit and to perform work on my property. `Owner's Si n ture Date x