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HomeMy WebLinkAbout0038 STETSON LANE �� d`� ��� ���`� C Town of Barnstable *Permit# Expires 6 months from issue date " MIT Regulatory Services Fee v� M^S- Thomas F.Geiler,Director P i639 �� E Building Division Tom Perry,CBO, Building Commissioner 1fIV�F�A NSTi� tL 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Valid without Red X-Press Imprint Map/parcel Number ®, Property Address jt \ ❑Residential Value of Work$ -6-60n. Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ,r Con` actor's me Telephone Number CConst5;Zon me I Contractor License# ica ) Email: Supervis 's License applicable) Workman's Compensation Insurance Check one: ❑ am a sole proprietor I 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 betaken to ❑ roof(hurricane nailed)(not stripping. Going over existing layers of roof) �Re-side Replacement Windows/doors/sliders.U-Value (maximum.35)#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. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&.Construction Supervisors License is required. SIGNATURE:_ QAWHILESTORWbuilding permit forms RESS.doc Revised 060513 4F E m ail i The Commorittteakh ofMassachuse tts Deparmtent of lndksoial Accidents D,w--of1m atigadons 600 Washington&reet Boston,MA 02111 anass.goWdia Workers' Campensatian Insurance Affidavit:BuilderslContractors/Flec� tricianslPlumbers Applicant Infarmation Please Print Legibly Name(E 'om/lndividmo: Address_ S CitylStaWZip: 0 Phone#: Are you an employer?Check the appropriate b06 Toe of project(required): /4. am a contractor and I ❑ f_❑ I am a employer with I �� 6_ Neva aomsFiuc#ion employees(full andlorpart4ime)* L—� have hired the sub=contractors. 2.❑ I am a sole proprietor or partner- listed on the attached sheet +- ❑Remodeling ship and have no employees These sub-oontractors have g- ❑Demolition w for me in an c ci �- employees and.have workers' or�ng Y � t3 9. F]Building addition [No Workers' comp.iwu ante comp.irmu anoe t reTtire5. ❑ re We a a corporation and its 10..❑Electrical repairs or additions r3.❑ I dhomeowner doing all work officers have exercised their ILE]Plumbing repairs or additions myself.[No workers'cep. right of exemption per MGL 1Z. c.152, 1 and we have no ❑Roof repairs ins;umwe required-]1 (4' 13-❑Other employees-[No workers' comp-insurance required-]! *Amy Wbcw t that checks ban#1 rmst also 511 out the section below showing itek woodrere compensation poliry information. T Homeowms who submit this affidavit imdxating they am doing all vok sad then lie outside contractors mast sabmir anew albdsrit indicating mcl>_ tractors that rhea this boc mast attached sn additional sheet showing the name of the sub-eonLtacbxt and state whether ornot those eatilks have ezWkyees. Ifthe m*-coatractars have employees,they mi, provide their workers'comp.policy number. I am an employer that is protiNng workers'compensation irnwrimce for azy employees. Below is Ste paM7 and job site information. Insurance Company Name: Policy 9 or Self-ins-Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach acopy of the workers'compeasati m policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredimder Section 25A of MGL c. 152 can lead to the imposition oft riminal penalties of a fine up to$1,500.0a andlor one-yearimluisonment,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 forwarded to the Office of Investigations of the DIA for insurance;coverage venficatitm. I do Hereby certify render thepains aetdpenattt'es ofperjury that the information pros ided abaw is bus and corrects AN Stature: - l Gt f Date: G� _Phone 0: ' O WaI use only. Do not write in this area,to be completed by city or town of jSciaL City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto 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 foregoing 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 employment be deemed to be 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 the 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-coatractor(s)name(s),address(es)and phone number(s)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_ Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation ofinsun nce coverage. Also be sure to sign and date the affidavit. 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 permitilicense 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 may be provided to the applicant as proof that a valid affidavit is on file for future 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 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 number. The Cornmanwealth of Massachusetks Depaitnent of Industdal Accidents Office of lavest gatfons 600 Washington Sfz�eet Boston,IAA 02111 Tel,#617-727-4940 at406 or 1-977 MASWE Revised 4-24-07 Fax#617-727-7749 www.massgov/dia Town of Barnstable Regulatory Services rIEB; Thomas F.Geiler,Director ��Eo.19. Building Division Tom Perry,Building Commissioner 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 V G� �•.. JOB LOCATION: 1.9 \ r L CLS�G number `1 l street illage "HOMEOWNTER": name Lhome phone# work phone# CURRENT MAILING ADDRESS: ti S 44 ri G -4 city to state zip code The current exemption for"homeowners" 'as 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 ang that he/she will comply with said procedures and requirements. 'Sign re of o caner 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. N 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. C:\Users\demllik\AppData\Loca]Nicrosoft\Windows\Temporary Internet Files\Content0utlook\QRE6ZUBN\EXPRESS.doc Revised 053012 -� THE r Town of Barnstable Regulatory Services �� Thomas F.Geiler,Director � Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property ProP a Owner Must _ Complete and Sign This Section - If Using A Builder I, /awuet the subject property hereby authorize to act on my behalf, in all matters relative to work authorized building permit /alaa of job **Pool-fences he responsib 'ty of the applicant. Pools are not to be fillfore fence is ins ed and all final inspections are accepted. Signature of Ow r Signature of Applicant Print Name Print Name Date QTORMS:OWNERPERMISSIONPOOLS 62012 F. The Cbmmoyrivealth of Vassachusetts Departinent oflrirdustiiul Accidents QKwe offmest gations s 600 Washington Street Boston,MA 02111 wuri anassgovIdia orke.t-s' Compensatiuulnsurauce 4Lffidavit: Builders/CantractorsMectricianslPlumbers ApplicantInfannation / Please PrintLe?_ibly Name(Easiness/Ozymization/Individnal): �J Address: <30 f Mew 00 IA Ific�� City/Sta&Zip: Phone#: 5-Gk Are you an employer?Check the appropriate box: a contractor s Type of�o - . ki ari I �ectr(required): I..[I I am a employer with 4 ❑ I s 6- ❑New oamsEruction ployees(full and/or part4ime).* have hired the sub-contractors_ 2_YJ I am a sole propfietor orpartner- listed on the attached sheer~ . ❑Remodeling These sub-contractors have ship and have no employees $- ❑Demolition w for.tne in an capacity- employees and have workers' orkiag y apa. ty. I 9. ❑Building addition [No workers' comp.insurance comp-tnsuraftce 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 LE]Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12_�; of repairs- insurance 3 c_152,§1(4},andwelra•��eao R return `] employees- o workers' 13_Vther comp.insurance required]: *Amy sppUcyon that checks box#1 mast also fill out the section below showing their wodsere compensetion policy infinnud®.. T Someovnms who submit this affidavit indicating they are doing all wait and then hue outside contactors Est submit anew afdaM indicating suc1L lContmcmrs that check this box mast 9ttached an additional sheet showing the name of the sub-caarxmrs and state whether ornot those emfities hsve employees. If the sob-contactors hale employees,theg must ptuvide their workers'comp.policy number. I am an employer that isprm idrrrg nwrkers'compensation insurance for rrry errrplayees Below is the policy andlob site information. Insurance Company Name: Policy 9-or Self-ins.Lic_4: `1 Expiration Date: Job Site Address: � �� �I�N e Cityi'StatdZip: Attach a cop} of the workers'compensation policy declaration page(showing the polic),number And-expiration date}. Failure to secure coverage as required under Section 25A ofMGL c. 152 can head to the imposition ofaiminal penalties of a fine up to$1,500.00 and/or one-year itnprisoament,as well as civil penalties in the form E:of a STOP WORK ORDER.and a fine. of up to S250-00 a day against the violet . Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA liar insurance overage�erifcatiorr- _.__ I do Irereby cerhfy,u t its dpena as afperjury that the information prinided abmre is bus and correct Phone# 01WAl use only. Do not write in this area,to be coampleted by city,or town officsaL City or Town: PermitUcense# Issuing Authority,(circle one): I 1.Board of Health 2.Building Department 3.City-frown Clerk 4.Electrical Inspector S..P•hrmbing Inspector 6.Other Contact Person: Phone 9: Information and. Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto 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 foregoing 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 employment be deemed to be an employer." F k 1� MGL chapter 152,.§25C(6)also states that"every state or IocaI licensing agency shall withhold the issuance or renewal of a license or permit to operate a business o'r to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally,J1VMGL chapter 152, §25C(7)states"Neither the commonwealth not 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 the 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 number(s)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. Be advised that this affidavit may lie submitted'to the'Department of Industrial, Accidents for confirmation of insurance Coverage. Also be sure to sign and date the affidavit. 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 perm-it/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 may be provided to the applicant as proof that a valid affidavit is oa file for future 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 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 number: The Commonwealth of Massachusetts Depar9meEtt of Industrial Accidents Office of JavestigatiGm 600 Washington Street Boston,IAA 02111 Tel. 617-727-4900 ext 406 or 1-877-MASS AFE Fax#617-727-7749 Revised 4-24-07 www.imassgov/dia 4 N Bill Inquiry- Munis [TOWN OF BARNSTABLE] Ble Ed51 Tools Help —Year/Type/Bill No, Customer Account Information History 16641 Detail Property Information LIEBERMAN,BEWERLY TR 141 STETSON LANE TRUST - Parcel ID 306-065 i 141 STETSOhJ LN Orig Bill Alt Parc HYANNIS,MA 02.601 effective Hate: Prop Loc 38 5TET5ON LANE Q;Special ConditionslNotes I (- Installment Information Scan Bill Int Dt Billed Abt/Adj Pmt/Crd Interest Unpaid bal Quick Entry 08/02/12.. .L.. _....._845.84 00 _....._.......,,._,.. ..,._.'0 74 50 920,34 11/02f12 845 83 QO ,00 93 63 939 46 ' Utility Acct _. .. . __ .._-------- T , _...._ _._ _..._ _._n._.... 02/OZ113 93Q 23 _._...' 00. ...,,.. d !,_.._. ._,..,._..BZ 43 1 021 66 Customer 05/02j13 ,.,.939 23_ ��.......,.. 00., _ w00 ' 1..... ...... .. 5734 996 57 j .----- Name Fees/Pen .... 00 ' 15.00 " .00 0015.00....... -. Totals 3,570 13 ' - 00 = 3,893,03 ...._......__....._F ...... 30790_..__... _....._.___._.__........._._..._ Parcel Prop Code Notes/Alerts _ - - Due lOf 15:2013 3,893 03 . j Bill Dates JAN 1 Owner: LIEBERMAN,BEVERLY T Per Diem Int.Paid 100.12 Bill Audits Total Paid 100.12 23'G iea'M prior Lu-tpa:c Ks: Bill Events ' Reprint _. Preferences,._. �41 *PQg0 I Diagnostics ...." .:,. ......._ ._2.-...of..2 - _... ..:,..�.��: ......" _ Attachments 0) Maintain the effective dote i TOWN 0 CAPE CC® INSULATION 1112 i= f'1 . 2 r ri8 BATTS %�l .„:5 SPRAY NSULATI 9 ON CRILINGS 49>•R u--e2 :at.,^��_-. ^"' 1-80G-696-6611 T rS?'fit; - Town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, MA 02601 f _Date Dear Building Inspector Please accept,this Affidavit.as documenL a ion that Cape Cod Insulation, Inc. performed & completed the insulation and weather zation 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 Ac dress Village go v�Ictc-( Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings ( ) ( ) ( ) ( ) ( ) Slopes ( ) ) ( ) ( ) ( ) Floors ( ) ( ) ( ) ) ) walls ( ) ) ) I l (� I ) o0A � < < . .Sincerely He y E Ca -idy r, President Ca e Cod sulation, Inc. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map . Parcel plion # -` Health Division Date Issued a4 l L Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _Preservation / Hyannis Project Street Address Village A� ZXIIZ J Owner ;;, �/��2�/ Zi C111ff 4W4V JAddress Telephone ? 7/ L,1' 34-/ Permit Request " /�i�/�9 X iZ;�z ;0J 9ic/ /eL zzr/,�,�Z'd,-d Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new; Zoning District Flood Plain Groundwater Overlay Project Valuation D D 1, U d Construction Type ,7-10 / Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family .L;K Two Family ❑ Multi-Family(# units) q Age of Existing Structure Historic House: ❑Yes ;I-No On Old King's H:i;ghway: ❑-Yes EPNo Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) ' Number of Baths: Full: existing new Half: existing newrQ 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 l��l°� �Uo/�ysy�/-/i i Q�/ Telephone Number c 77,4�0 / j Address f c� %2�� �o w C'i License # o d Home Improvement Contractor# /0 u?J, 4 Worker's Compensation # �/C ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TO SIGNATURE DATE t FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP PARCEL NO. ` ADDRESS VILLAGE OWNER 'DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL 4 PLUMBING: ROUGH FINAL J GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 460 ldest Main Street HOUSING � Hyannis, HA 02601 ASS_TSTAN'CE ENERGY H011E REPAIR T (508) 790-7105 K (-'--08) V-QO- CORPORATTON 2425 HOME OWNER WEATHERIZATION WORK PERMIT& FUEL RELEASE: -- - F+L-L---U-T-AN�H+S+G4:Z4t F Y(D43-A-RE jj THE APPLICANT HOMEOWNER. � hereby consent to and agreethat weatherization work may be done by th eatherization Program of Housing Assistance Corporation ( herein after referred as "Agency" ) on the property located at: 3 8� _ e wit' 0. 01 Theweatherization work donewill be based on programmatic priorities and availability of funding and it may include all or some of thefbllowing measures: Weather-stripping& caulking of windows and doors, insulation of attics, sidewalls& basements, attic and other ventilation measures and possibly replacement of badly deteriorated windows, In consideration of theweatherization work to bedoneat my home I agreeto thefollowing: 1. 1 give permission to the"Agency" its agents and employees to travel onto or across said property with such equipment and materials as may be necessary to perform weatherization work on said property. 2. The Housing Assistance Corporati on reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five(5) years after the weatherization work is completed. I have read the provisions of this agreement as listed and fr ee! give my consent. Home Owner: (Signature) Data. 3 / 2 Agent: (signature) Date: HAG approved Weatherization Company : CAPe EC2 _y)';_J A All Cape Energy, Caliber Building&Remode LCappeCcodlnsuilat)�iorn, CapeSave, Creswell Construction, Frontier Energy Solutions, Lohr&Sons, Peterse on Energy, Rock.Solid Construction 10 Park Plaza - Suite' 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 153567 Type: Private Corporation Expiration: 12/15/2012 Tr# 206433 CAPE COD INSULATION, INC , HENRY CASSIDY 455 YARMOUTH RD. HYANNIS, MA 02601 pdate Address and return card.Mark reason for change. =t .'•' Address F Renewal L] Employment Ej Lost Card DPS-CA1 rp 50M-04/04-G101216 .. " Office o�`'mer Affairs us ne Itegul lion License or registration valid for individu! - HOM RSMffl�1 �7Ccd before the expiration date. If found return to: - = Registration: 153567 Type: Office of Consumer Affairs and Business Regulation , Expiration 12/15/2012 Private Corporation 10 Park Plaza-Suite 5170 `. Boston;MA 02116 OD INSULATION INC HENRY CASSIDY. 455 YARMOUTH RD; HYANNIS,MA 02601 Y Undersecretary t alid ith t pture , '�- IMiissachusetts-Department of Public Safety' Board of Buil'din Regulations and Standards' �. i► Construction Supervisor License License: CS 100988 HENRY CASSIDY 8 SHED ROW. WES,ST'YVARMOUTH;`MA 02673 Expiration: 11/11/2013 Tr#: 7620 A " No. 1605 K i Client#:4597 CCINSUL ACOW. CERTIFICATE OF UABILITY INSURANCE DATE(MMIDDffm) 07/02/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFQRMATION 0iN-LY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMk:ND,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 PRODUC)=R,AND THE CERTIFICATE HOLIA�.11. IMPORTANT:If the cerllHcota holder is an-ADDITIONAL (he policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subJect to the terms and conditions of the policy,Cartaln Policies may rugDlre Sri endorsement.A statement on this certificate does not confer rights to the certificate holder in lien of such endorsemenl(s), PRODUCER NAME: Mal" 8fet YOu.1 Rogers&Gray Ins.-So.Dennis PHONE 508-760-4602 r CN 8774116.2'156 434 Route 134 rvc Na Exl: Arc Na -- E-MAIL South Dennis,MA 02660-1601 50a 398-7OSQ INSURERS)AFFORDING COVERAGE NAIL N INSURER A:Peerless Insurance 18333 INSURED INSURERS:Evanston Insurance Company Cape God Insulation Inc INSURER GAtlantic Charter Insurance 455 Yarmouth Road Hyannis,MA 02601 IN9URERD:C4rnnierce Insurance Company 34754 Hy INSURER E: _ IN6URER F: COVERAGES CERTIFICATE NUMBER, REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LI$TI=O L{ELOVY HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR GONNT'ION OF ANY COIJTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFRhr,DEO BY THIS POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN 1',1Ar'HAVE BEEN RGDUCED BY PAID CLAIMS. sR - ADOL 5UBR POLICY EFF POLICY E1( R TYPE OF INSURANCEWVI) POLICY NUN+_uLR MMIDD/YYYY) tMMjOD!YYYY1 LIMITS q GENEFiALUA81uTY GBP8263063� 41,01/2012 04/01/2013 EACH OCCURRENCE $1 000000 X COMMERCIAL GENERAL LIABILITY pq�gC,E 7 ENTEO - PREMISES .�otturrence $1DU�l)() - CLAIMS-MADE N OCCUR MED EXP(Anyone pereon) $5 000 PERSONAL,&AOV INJURY 0,000,000 OENERALAOOReGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS-GOMPIOP AGG s2,000,000 POLICY PRO LOG $ p auTOMOBtLE uA6ILITY 12MMBCKVMit 4/0112012 041011201 EQMB CD1SINGLELIMIT 1 000 000 ANY AUTO BODILY INJURY(P.,person) $ ALLOWNED SCHEDULED _ AUTOS X AUTOS BODILY INJURY(Por ioddont) $ „X HIRED AUTOS X NON-OWNED PROPERTY Ww GI� S. AUTOS $ H X UMURFLLA LIAE OCCUR XONJ453512 4101/2012 04101/201 EACH OCCURRENCE $1 000 000 EXcf_gy L.IAB CLAIMS-MADE AGGREGATE $1 00O 000 DED X RETENTIorl 00000 $ C WORI(ER$COMPENSATION WGA00625!U2 6J3O/2012 06/30/201 'X WCSTATU• OTI* AND EMPLOYERS'LIABILITY YIN E ANY PRO PRRIM7 PgqR011"0N6l) ECUTIVfca E.L,EAON ACOI()kNT 1 O0U 000 OFFICERIMEMBER E}(GI IJDE � N(A (MaAkaty in NH) E.L.DISEASE-EA QiPLOYE6 $1 00O 000 Ir yea,de&cfta under DESCRIPTION OF OPERATIONS beluw _ E.L.DISEASE,POLICY LIMIT $1 000 000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Allaah ACORD 101,Addlllanai N,n—ks EShoduls,I(rngre SpAQe IB regUlrsa) "Workers Comp Information Included Officers or Proprietors Certificate Holder is Included.as an additional insured ungor Gonoral Liability when required by written contract or agreement, CERTIFICATE HOLDER CANCELLATION Cape Cod Insulatiort,Inc SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLF0 BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN AGGORDANCE WITH THE POLICY RROVISIONS. AUTHORIZED REPR@SENTATIVP 4 ®199 -2010 ACORD CORPORATION,All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo aru ro0lsleredlnarks of ACORD #SB3849/M83848 MEY The Comtnoint,. llth of Massachusetts Department ,,l.Industrial Accidents rye. _ r Office, Investigations �I - Fw 600 Vl/o.S/ i11gton Street Bosli,�. i11A 02111 w a MI'I1.1'i:iss.govldlCl Worket-'s col"Pelisation Insurance At'tiai..r:ii: Builders/Contractors/El lectricians[Plurnbers Applicallt Information I'IeaSe Print Legibly e Nautc (I),usines /0r;ani.z4tti oil/l.ndividual): P t'itJ'%�I21lt illp:_ ��YC ?55 /6 Yr 7 (�c ��''U ( `1 --- ----- _ ` d Phone#: ` r-2� y2 k Are YOU an employer? Check tine appropriate box: _ Type of project(required); l l ant a employerwidr-. �l El un a,; n is l ontractor and I have 6. ❑ Mew construction - ©-- erriplvyecS (full and/or hart-tinge).* hired the ;ni::contractors listed on 7. Rerruxlr.littg the'atta�:h: I :heet.� l dill a sole;proprietor or partnership These SuiI ntractorS have 8. ❑ Demolition an(l have: K)errtploYecs working for etnploy&s:iuJ have workers' comp. 9. ❑ Building addition me it any capacity. [No workers' irisuralw,.I 10, ❑ Electrical repairs ur additiuns co mp insurance reduirect.] 5. ❑ We are;i il)ouMionand its It. rirbing repairs or adclitiotis officers I�:n� �ercised their right of ❑ Plu ' ❑ taut a horileowtter doing all work. exemptiiin I :-i NIGL c. 152.§ (4),and 12. Roof repairs niyse.if. INo workers comp. we have lio:utployees.f No workers' / insurance rec aired-. 13. Other Y l API ZG1�lC� 1 .I 'I� camp. insur;�u«required.) -Ally i wlicant that checks box lit must also till out the section below showin..+licit workers'compensation policy information. t l{J4,CU1PUCiS who suhuiit this 41*66avit indicating they are doing DO wo,k:u h6n hire outside contractors❑lust submit a new affidavit indicating such. Ci 111hW[Ul:S that check this box must attach an additional sheet showing il,, n:iuz:of the sub-contractors and state whether or not those entities have employers.It the xib-contructurs Ilave employe9-,they must provide their workers comp pcdt v number. rent an employer that is providing workers'compensation iusm-once for my employees. Below is the policy and job site iu/innuttion. Ius Maher.Company Nante: A t y l'uhry#ur Self-iris. l.ic. #k: 02 A 00 � - _. Expiration llate: .lob Site Address: L� �J�s/%�d�Q ;�f ---- City/State/Zip: .2 G Attach a copy of the worl�ers' compensation policy dechiration pagoj�,iiowingthe policy.number and expiration date). failure to secure coverage as required under Section 25A of MGL c. 152 :aw load to the imposition of criminal penalties of aline up to$1,500.00 auXui uttc-year iutprisomi-It,as well as civil penalties in the Norm of a STOP 1•bt il:l:ORDER and a fine of up to$250.00 a day against the violator. Be advised th<u a copy of this statement triay,4e forwarded to the Office of Invests^:,ii,-m of the DIA for insunrnce coverage verification. 1 do here c if under the iris and penalties oj'per�rny that the information provided above is true and correct. . ligrtaturc: Date:_ Ujjicihl use only. Do not write its this area, to be completeel bi ;;ii�or town official City or Town: _. l'crinit/License# Issuing authority (circle one): 1, hoard of Health 2. Building Departulent 3.City/'loran Clerk 4.Electrical luspector S.Plunluirtg lrlspector -b.Other Contact Person: Phone#: