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Home My WebLink About0016 TOWNHOUSE COURT l(P -7—otO y-) (5 Ge.Se Ca uY-p 1 �� II 'I i ail, i I i I i 127 TOWN OF OARNSTABLF CAPE CCU, INSULAT1 6 PM �W] E i UI .n@ouss SiAMLESSaAMLELEs�SS N ym a+nEas E 1-800-696-66 To wn of Regulatory Services Building Division Address - Address 2 - Date:-.[ Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed& completed the insulation and weatherization work at the property listed below. Gape 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 Propertv Address Village C� Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings ( ) ( ) ( ) ( ) ( ) Slopes ( } ( ) ( ) ( ) ( ) Floors Walls ( ) ( ) ( ) ( ) ( ) Noui . &- oo rr 9 ire Are_S+ . 1�0C),� Sincerely s . He E Cassidy Jr, President Q'pe Cod Insulation, Inc. r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map V Parcel t Application # 106 ,2v Health Division Date Issued /O—/.S=I"( Conservation Division Application Fee S Planning Dept. Permit Fee _ Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address �// i��r/ ��1✓�� Village��Tx/ Owner C'A��i �'/1 pro e %2rr��rLS Address Telephone &7"�f ;ZZ4_"21 Permit Request fzTre �/ '��i%� ��G�, L�,� ZXza. Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation J WConstruction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ( Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes 4 No On Old King's Highway: ❑Yes P�No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including 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 _ Othp a , Zoning Board of Appeals Authorization ❑ Appeal # Recorded , 2 �iTO - --�- •- -- Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name �� 1,� ,��le�y1 b. Telephone Number —5-7- 7;2 f Address f� 2�f�.��,c� �� License # /D 1, �1�/1/�✓�y, Home Improvement Contractor# Worker's Compensation # O 6l ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# 1' DATE ISSUED .MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FRAME INSULATION i .,: ; FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. I HOus[ng Assistance Corporation Cape Cod HOME OWNER WEATHERIZATION WORK PERMIT&FUEL RELEASE: PLEASE FILL OUT AND SIGN THIS FORM IF YOU ARE THE APPLICANT'HOME OWNER. hereby consent to and agree that ' weatherization work may be done by the Weatherization Program of Housing Assistance Corporation ( herein after referred as ',Agency�� } on .the property located at: The weatherization work done will,be based on programmatic=priorities and availability of funding and it may include all or some of the following 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 the weatherization work'hto be done. at my home-1 agree to the following: 1. I 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 Corporation 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 agreement as listed and.,,freely.give ,d`tft y consent. ,Home Owner: (Signature) g , Date: 1. Agent: (signature) r` r Date: d* The Commonwealth of Massachusetts Print Form j -- Department of Industrial Accidents 1. I� Office of Investigations I — ; 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/Organization/Individual): Address: City/State/Zip: G2 hone#: Are you an employ r?Check the appropriate box: Type of project(required): 1.$am a employer with 4. ❑ I am a general contractor and [ employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition workingfor me in an capacity. employees and have workers' y p n'• 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]ui t c. 152, §1(4),and we have no q ] employees. [No workers' 13. Other/ J�J comp. insurance required.] *Any applicant that checks box#l 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. tContractors 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: , �G" Policy#or Self-ins. Lic. /G?�GQ<<j�5�9a/ Expiration Date: G / Job Site Address: �a�� u sf' l'� �� 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 fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations.of the DIA for insurance coverage verification. I do hereby certi der the paips aAdpenalties ofperjuiy that the information provided above is true and correct. Signature: Date: .f/ `/— Phone#: ��7�✓�j%� 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as ...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the 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, 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-contractor(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 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 permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town 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 burn 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 Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 7-2010 www.mass.gov/dia J CAPECOD-27 KLIGETT ... CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) Tlils 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(l)s)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 , iODUCER CONTACT ogers&Gray Insurance Agency, Inc, NAME; Barbara DeLawrence f4 Rte 134 PHONE ' a FAx —_ Huth Dennis,MA 02660. EAMA Lo Ex 1, AIC No; 877)816 2166 ADDRESS:bdelawrence@rogersgray.com — INSVRER S AFFORDING COVERAGE _ NAIC 4 S RkTp- - INSURER A:Peerless Insurance COmpany i INSURERB;COMMERCE INSURANCE COMPANY _ Cape Cod Insulation Inc INS UFIERC:Evanston Insurance Company � 16 Reardon Circle South Yarmouth, MA 02664 INSuRERD:ATLANTIC CHARTER INSURANCE GROUP_—INSURER E; - INSURER F 0 ERAGES CERTIFICATE NUMBER: REVISION NUMBER: INDICT IS IS TO CERTIFY INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD ATED. THAT THE POLICIES OF NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS C R;TIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, E Cli.USIONS AND CONDITIONS OF SUC__H POLICIES.LIMITS SHOWN MAY-HAVE BEEN REDUCED BY PAID CLAIMS. ....,_.-.... - ------------ -- q TYPE OF INSURANCE . POLICY NUMBER POLICY EFF POLICY EXP - X COMMERCIAL GENERAL LIABILITY MMIDDIY MMI DIY LIMITS CLAIMS-MADE X EACH OCCURRENCE $ 11000,000 ;. _...� L occuR CBP8263063 0410112014 04101/2015 �cR -- PREMISES(Ea occurrence) $_ 100,000 MED ExP Any one person) $_ ----�__ 6,000 PERSONAL&ADV INJURY _ $ 11000,000 G N'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,00.0,000 POLICY I 1 PRO- l J _ L__:.I JECT l J LOC _ PRODUCTS_COMPIOP AGG L. 2,000,000 � OTHER _ AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT ANY AUTO 14MMBCKVMK Ea acci�enl $ 1,000,000 �. ALL AUTOS OWNED X SCHEDULED 04/01/2014 04/01/2015 BODILY INJURY(Par person) $ - �( NON-OWNED BODILY INJURY(Per accident) $ AUTOS HIRED AUTOS AUTOS -- PROPERTY DAMAGE— $ — Per accide 1 X UMBRELLA LIAB X OCCUR $ EXCESS LIAR EACH OCCURRENCE $ 1,0�00,000 rANPEMPLOYERS' __ __ CLAIMS•MADE XONJ453514 04/01/2014 04/01/2016 X RETENTION 10,000 AGGREGATE $COMPENSATION Aggregate $ 1000000 OYERS'LIABILITY PTATE ERH.ANVRIEI'OftIPARTNERIEXECUTIVE YIN WCA0062690406/30/2014 06/30/2015y In NH)BER EXCLUDEp9 NIA E.L.EACH ACCIDENT $ 1,000,Q00 In NH)r . nder .L..DISEASE-EA EMPLOYEE $ ? 1,000,000 ION OF OPERATIONS below I I E.L.DISEASE•POLICY LIMIT $ 11000,000 it 9RIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101,Addlllon ISerl Compensation includes Officers or Proprietors, at Ramarka Schedule,may be attached If more apace Is required) 110 al Insured status Is provided under the General,Liability and Auto Liability when required by written contract or agreement with the Cortlflcate Holder. 3TIFICATE.HOLDER a Massachusetts _Depat'trri•¢'nt of PyUbltc Safety , '.1�6prd of Building Regw1alfons p•nd Standards Cunstnrction Supvrvisor Yr �k,,w: License: OS•100988 X.1'1?:NRY.R CASSI WE,ST Y kRM01P11.1 F i .Expiratto.n Commissioner 1111112015 - ., Office of Consumer Affairs and Business Regulation 10 Park.Plaza -,Suite 5170 Boston, Massaoh�}.setts 0211E F Io.me zmprtaveltent CQ actor R g str: tiia» • l•Yy�..A .S� � .:i Registration: 153507 TYPO. F'rival'e Corporation inn :. i:i 'i:: ;.i.:»f atian I2/15/2014 T0. 233a3VxpirCAPCOD INSULATION, INC NhY CASS H 18 RE*ARDON CIRCLE ':`, �`:.,�.�#•, -_ _._.,.._........ .. . AR.M02664 . r ...:,. :�0 Y OUTH 02664 � ..... �� ;., _..._..J..........._.......... ...�.. ,,;;•, .• ,�' '1lpdnte Addross anti return Citrtl, Manic ruasan I'ur vhnngc, .. ,:�. L�J ' p y ur,i u;:ri i Address D.R(!'(1.wnl, lt,tn to mt.rtt , Lust Cnrd '��ra �(�nair.•r�au�atutrctl�� c��2!' � . J� (/�tdJtZC'f(-tGJld��3 l.)I'fice urlbnausner rlrrnll's 13usifruss Rc�ulnl'iu❑ Lluens.0 of r'egNtrntion valid Ni'Ii.ldlvidtll use ()III), OME IMPROVEMENT CONTRACTOR boraro tho npirntlon date, it,round return to; oplatratlon: 1aaG7 Type, Office oFCansumer Affairs and Business ltobulntiun JO,xplradon; 12/1:K01 A Private Corporalio,i 10 Purk Pinza•Suite 5170 Hoston,KA 02116 r0 INSULA't'I.QN ,ASSIDY )ON CIRU .Llativrsec�rvrarY ,�of vnl' withu t not ru