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HomeMy WebLinkAbout0062 WOLLEY ROAD eIOU t65, l I Town of Barnstable *Permit# '0�- Expires 6 months from issue date Regulatory Services Fee L►aN6TABLE, • 639. Richard V.Scali,Director �D Building Division � Tom Perry,CBO,Building Commission a 200 Main Street,Hyannis,MA 02601 n www.town-bamstable.ma.us FEB 2 Office: 508-862-4038 TO 9 2 9166 ax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESID MM�ONLY Not Valid without Red X-Press Imprint Map/parcel Number 2'70/I4"C' Property Address 62 WG It et, y Residential Value of Work$ Minimum fee lI of$35.00 for work under$6000.00 Owner's Name&Address w, 1116L h 6r I 106(G C— 0 Boy, , 2219 14",1virits , 04 02G 1 Contractor's Name / r(CA F.k/ m c.I p� Telephone Number 7 7 q -�� 736 �l Home Improvement Contractor License#(if applicable) /('O� �q Email: MM C ca r— rt aC) Construction Supervisor's License#(if applicable) C S el 6 ❑Workman's Compensation Insurance Chpck one: I 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 be taken to Re-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. ***Note: Property Owner must sign Property Owner Letter of Permission: A copy of the Home Improvement Contractors License&Construction Supervisors License is req�ued. _ SIGNATURE: � C:\Users\Decollik\AppData\Local\Micro indows\Temporary Intemet Files\Content.Outlook\2PIOIDHR\EXPRESS.doc Revised 040215 , r + BAWMABIX • MASS, Town of Barnstable Regulatory Services Richard V.Sca i,Director Building Division Y 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` I, 1%l.V l I I t CL m t I mo u t— ,as Owner of the subject property hereby authorize M6'K' Me►ey"- — - to act on my behalf, in all matters relative to work authorized by this building permit application for: Wolin 4 �n�. , ✓,/A (A dress 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. C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\2PIOIDHR\EXPRESS.doc Revised 040215 . y 27re Commonwealth of Massachrisetts Deparf►nent of Lulifsh ial Accide►rts Office of Investigations 600 Washington,Stmet Boston,MA 02111 ►vww.mass govldia workers' Compensation Insurance Affidavit:Builders/ContractorsMeeteicians/Plumbers Applicant Information Please Print Lezibly Name MusiueW0rganizMfi6attn&vidaai}: k f Address: `1'y City/State bp: arc SJ- )Ea 11770 2-3 g--l3, y Are you an employer?Checkthe appropriate boa: T of ect 4. am a general an ` Type p ro'I ( = I.El I am a employer with I enral contractor d I ❑ $employees(full and/or part-time).'° have hired the sub-contractors 6. ❑New construction 2.g I am a sole proprietor or partner listed on the attached sheet T- G!�Remodeling ship and have no employees Thy sob-contractors have S. ❑Demolition To working forme in any capacity.� i�and have workers' insurance . - [I!to workers comp.insurance ompn 9_ ❑Buildingaddition. hued-] 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 requited.]I c.152,§1(4),and we have,no employees.[No workers 13.0 Other ' comp_insurance required.] 'Any;appli:�t tharchecks boa#1 must AU out the section below.showing their woahere compensation policy infarmation. t Harneowners wbo submit this.af8dat•-it inificating they.are doing allwotk and then hire outside contractors must submit a new affidavit indicating mcb. lCoxtracttors that check-this box must attached an additional diset showing the name of the and state whether or not those entities base employee. If the subcontract—b——piweea,they=ut p-de their marks'gyp.pobcyaumber. I am an employer that is pro>MW ttworl ers'compensation insurance for my eaWWees. Blow is die policy and job site information Insurance Company Name: /n� Policy#or Self-ins.11c.4: Expiration Date: Job Site Address: 1'e f4 Ci /State/ e NA 0Z� tY �= h Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Suction 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 STOUP 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&u h pains and alder of penury that trite information provirded above is true and correct Si /�� � r Date: ?— Phone#: Official use only. Do not write in this area,to be completed by city or tmvn e0icial City or Town: Permit/License# Issuing Authority(circle one): L' .Board of Health 2 Building.Department 3.City/rown Clerk 4.Electrical Inspector S.Plumbing I%spector 6.Other Contact.Person: Phone#; 6 Vns ffaiac&Bu hcss Regulation,ell r License or registration valid for individul use onl Office of Consumer Affairs&Business Regulation g y OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: - ,egistiation. 160192 Type Office of Consumer Affairs and Business Regulation xpi ratio n: 7/2%2015_ DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 MARK MEJEUR CONSTRUCTION MARK MEJEUR 20 PARKER RD EAST FALMOUTH,MA 02536:' Undersecretary Not vali thout signature Massachusetts -Department of Public Safety Board of Buiiding Regulations and Standards ' Con."'ruc'.loll Supervisor _ License: CS-092961 MARK E NIE.TE1 ,. POBOX 682 EAST FA L.MOU PH Jar ` Expiration Commissioner _ 0410912017. CAPE CO® INSULATION Fq q N F 9 mreoEass sEpNEw frtlErrOAM susreeom rwrn auiros IMWtalroN attMos 1-888-696-6611 Town of Regulatory Services Building Division Address - Address 2 - Date: �_l .,.. Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance.Ipstitute (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. t Property Owner Property Address Villager �I��An•� G'E�Aowr Insulation Installed: Fiberglass Cellulose R-Value Restricted Unr strictedop • Ceilings Slopes Floors Walls ( ) A(. Sincerel Y He E Cassidy Jr, President Cape Cod Insulation, Inc. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION j ' Map Parcel A �4iI n Health Division Date Issued Z Z�—IS, Pr' Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis .Project Stre, t Address o Village lnriit l� Owner �`� � / Address Telephone Permit Request } _.z ZE Square feet: 1 st floor: existing proposed 2nd floor: existing proposed~ Totaf newo Zoning.District Flood Plain Groundwater Overlay Project Valuation Construction Type ` v Lot Size Grandfathered: ❑Yes ❑ No If yes, attach su porting OpcurpOntation. Dwelling Type: Single Family la' Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ 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 _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ N/O If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number ' U U` I I -Address L 1�(l License# � 0 0 oap Home Improvement Contractor# ff JCJ Worker's Compensation # fV ALL CONSTRUCTION DEBRIS RESULTING FRO THIS PROJECT ILL B TAKEN TO r / SIGNATURE AA DATE 2� I' FOR OFFICIAL USE ONLY �k APPLICATION# -DATE ISSUED iMAP/PARCEL NO. rs �r ADDRESS VILLAGE OWNER .g DATE OF INSPECTION: C' 6 li�1� _ , i=r t t' Afo,'jp- 1, �EFQUNDATLON :�•,�E._:,W ��!,���,:,�#.�s�� � � r FRAME - INSULATION_7._;: FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING. y j DATE CLOSED OUT i ASSOCIATION PLAN NO. 6 7 w Massachusetts - Department-of public Safety ':bo,ard of Building Regulations and Standards Construction Supervis6l, License: CS-100988., HENRY E CASSII)V 8 SBID ROW aa WEST YARMOU"rH ✓,�..� �11 jj51 Expiration Commissioner 11/11/2015 &Xe wammolmo" F 'i Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Con,tra�ctor Registration Registration: 153567 Type: Private Corporation- ""' Expiration: 1 211 5/2 01 6 Tr# 259188 CAPE COD INSULATION, INC HENRY CASSIDY ---- 16 REARDON CIRCLE -- - SO, YARMOUTH, MA 02664 Update Address and return card, Mark reason for change. ;CA1 0 20M•05r11 Address Renewal Employment Lost Card /e a»ur�zoauueulC/N�'C��/C�rataac/�raeCt 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: egistratlon: '1.53567 Type: Office of Consumer Affairs and Business Regulation i xplratlon:,.,-1.21:15/20.1,6 Private Corporation 10 Park Plaza -Suite 5170 t= ., Boston,MA 02116 CAPE COD INSULATI:b:N;;':INC° IENRY CASSIDY 18 REARDON 30,YARMOUTH. MA 02664 Undersecretar —— Y N valid wi ut sign e .77 y The Commonwealth of Massachusetts Department of Industrial Accidenis W Office of Investigations - a d I Congress Street, Suite 100 a'c oW Boston, NIA 02114-2017 www,mass,gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ff Please Print Legibly Name (Business/Or ' n/Individual)' (;Z `-�' L'{, Address; �4i) !Z40-vA. V �I ' City/State/Zip; �� �mn `�1, � Phone #; Are you an employer? Check he appropriate box; 1,�'I am a employer with 4, ❑ I am a general contractor and I Type of project(required); 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 working for me in any capacity, employees and have workers' [No workers' comp, insurance comp, insurance.t 9, ❑ Building addition required.] 5, ❑ We are a corporation and its 10,0 Electrical repau•s or'additions 3,❑ I am a homeowner doing all work officers have exercised their I I,❑ Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL insurance required.] t c, 152, §1(4), and we have no 12,❑ Roof repairs employees, [No workers' 13,[ Other comp, insurance required.] // Any applicant that checks box�1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this'ifffidavit 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 subcontractors 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 ,, .''Inform aflon. Insurance Company Name; &'� Policy# or Self-ins, Lic, #; Expiration Date; Job Site Address; City/State/Zip; > ,d��-_7 ti- Attach a copy of the workers' comp nsation policy declaration page(showing the policy nun er 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 forth 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, 1 do hereby cert�o n r pains and penaltles of perjury that the Information provided above Is true and correct, Signature: Date; � Z'� �� Phone 9: Officlal use only, Do not write In this area, to be completed by city or town of flclah City or Town; Permit/License # Issuing Authority(circle one); 1, Board of Health 2. Building Department 3, City/Town Clerk 4, Electrical Inspectol• 5. Plumbing Inspector 6, Other Contact Person; Phone#; 1 CAPECOD-27 KLIGETT CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 6/13/2014 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 Rogers&Gray Insurance Agency,Inc. NAME: Barbara DeLawrence 434 Rte 134 PHONE 0.N Exit: FAX A1C No (877) 816-2156 i South Dennis,MA 02660 ADDRESS: bdelawrence rogers ra .com INSURERS AFFORDING COVERAGE NAtC N INSURER A:Peerless Insurance Company INSURED INSURERB:COMMERCE INSURANCE COMPANY Cape Cod Insulation Inc INSURER C:Evanston Insurance Company 18 Reardon Circle INSURERD:ATLANTIC CHARTER INSURANCE GROUP South Yarmouth,MA 02664 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: T IS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD IN ACATED. 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 LTR TYPE OF INSURANCE DD BR POLICY NUMBER MMIDD�YY MM DD/1 YYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1.000,000 j CLAIMS-MADE a OCCUR CBP8263063 64/01/2014 04101/2015 PREMISES(Ea occurrence) $ 100,00. MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRO- GENERAL AGGREGATE $ 2,000,000 X POLICY 0 JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: _ Arx TOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 B Ea accident ANY AUTO 14MMBCKVMK 04/01/2014 04/01/2015 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED _ AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS X NON-OWNED AUTOS PROPERTY DAMAGE $ Per accident X UMBRELLA LIAR X OCCUR C EXCESS LIAB CLAIMS-MADE XONJ453514 04/0112014 04/01/2015 EACH OCCURRENCE $ 1,000,000 -- AGGREGATE $ DIED X RETENTION 10,000 Aggregate ORK $ 1,000,000 ERS COMPENSATION ND EMPLOYERS'LIABILITY . r PER OTH• YIN STATUTE ER D NY PROPRIETOR/PARTNERIEXECUTIVE WCA00525904 06/30/2014 06/30/2015 FFICER/MEMBER EXCLUDED? ❑ N/A E.L.EACH ACCIDENT $ 1,000,000 Mandatory In NH) -- f yyes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000 ESCRIPTION OF OPERATIONS below t' - E.L.DISEASE-POLICY LIMIT $ 1,000,000 r I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Norkers Compensation Includes Officers or Proprietors. 4dditional Insured status Is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate'Holder. CER IFICATE HOLDER CANCELLATION HOME OWNER WEATHERIZATION WORK PERMIT: PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER. ! hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation on the property located at: AL 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; air sealing; attic& basement insulation; exterior wall insulation; ventilation ' measures In consideration of the weatherization work to be done at my home I agree to the ! following: 1. I give permission to Housing Assistance Corporation the property with such equipment and materials as may be necessary to perform weatherization, ! 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for j 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 and give my consent. Home Owner(Signature) - ,�f;µl7 Date:: Home Owner email: ` Y� Agent:(signature) ` Date: Weatherization Contractors: Adam T the Cape Save All Cape Energy Frontier Energy Solutions Alternative Weatherization Lohr Home Improvement Buil ina Science Construction Resolution Energy Cape Cod�Insula!'or� Tupper Construction i Cape Save Inc O` BARN sTAM— 7-D Huntington Ayu . ,�r_ { South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 508-398-0399 3/17/13 Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main St. Hyannis,MA 02601 RE: Building Permits Dear Mr. Perry, This affidavit is to certify that all work completed for 62 Wolley Road,Hyannis has been inspected by a certified Building Performance Institute(BPI)Inspector. ' Basement: R-19 Fiberglass in bog sill All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey I TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Z J 0 Parcel d �5 Applid0on Health Division " Date Issued l Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Address wo { V &A Village V Man n I$ Owner_ W 1�{IO�,IY1 G- I I (`(� 0 1. ' Address Sac,rn P, Telephone Permit Request Ric s,�c.1 F le�c o\a.yl� {�c��� SS � H ax :S 1 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay _ Project Valuation VLO Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) p C) Age of Existing Structure 9 Historic House: ❑Yes ❑ No On Old King' Highway:_❑Yes-, ❑ No Basement Type: ❑ Full ❑ Crawl ❑ Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) r Number of Baths: Full: existing new Halfi.existing new Number of Bedrooms: existing _new v i Total Room Count (not including baths):'existing new First Floor Room Count Heat Type and Fuel: AGas ❑ 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 )d No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Q Name W. i MOO 1456 � p e &W, Telephone Number JC ` 3 8 — 0,3q " Address CRtkn fit NVE _ License # off. Tb YOXrho. 1ti 4 q Home Improvement Contractor# Worker's Compensation # `rUJG 3 1 9 9,g7�, ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO V— SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# ` DATE ISSUED MAP/PARCEL NO. r ADDRESS -- - VILLAGE OWNER - I _ DATE OF INSPECTION: I FOUNDATION FRAME S INSULATION) FIREPLACE f ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL h GAS:: ., ROUGH _. n , - FINAL ",,FINAL BUILDING„ . ;�•.� - 4 " x R DATE CLOSED OUT '; ASSOCIATION PLAN NO. 460 West Maoi Street OSJ ITaiis, 02i1-�698 `�"� ENERGY & HOME REPAIR T (508) 771-5400 F (508)790-2425 CORP ORATION TTY on all lines u .hrtcnr°'�e.Gl eCQd.tFB` HOME OWNER WEATHERIZATION WORK PERMIT& FUEL RELEASE: ' PLEASE FILL OUT AND SIGN THIS FORM IF YOU ARE THE APPLICANT HOME OWNER. " I Alai, hereby consent to and agree that weatherization work may be done by the Weat�on Program:of Housing Assistance Corporation ( herein after referred as "Agency") on the property located at: eng -- -d The weatherization work done will be based on prhgrammaric 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 F consideration of the weatherization work to be done at my home I 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 this agreement as listed and freely give my consent. Home Owner: (Signature) Dater Agent: (signature) Date: CA HAC approved'Weatherization Company: Caliber Building&Remodeling Cape Cod Insulation ape Save Creswell Construction Frontier Energy Solutions Lohr& Sons Peter Smith Resolution Energy Rock Solid Construction All Cape Insulation - • 's -M-5-41{i`.FTDi i--I' i The Commonwealth of Massachusetts ' Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgovi/dia orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aaallcant Information Please Print Legibly Name(Busineworpmation Individual):M t(' 1, C 14As I &,, Auk cft SAOC Address: I -C_ t�u r3'�1 nito'tD _ City/State/Zip: YA•RMogUj 640� 6&Z gone#: - 3 �- Are you an employer?Check the appropriate box: Type of project(required): I.(R I am a employer with--t'�------ 4. fait a general contractor and 1 .employees ull and/or.pari-time). have hired the sub-contractors 6 [3 New construction. (f 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employces •These sub-contractors have ' g. 0 Demolition working for me in any capacity. employees and have workers' 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 1 I.[]Plumbing repairs or additions myself.[No workers' comp. right of exemption per MGt_ insurance required.]+ .c: 152;j 1(4),and we have no 12.�Roof repairs i ' employees. (No workers' 13.®.Others � 0(1 ` comp. insurance required.] *Any applicant that checks box#1 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. tcantractors 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:.. I PmAn ell JnSoronCe Co ty1 Policy#or Self-ins.Lie.#: T W C 3% 9 / T" Expiration Date:. _ _0 e�I a.0 Job Site Address: W I,Lx, _ ` City/State/Zip:_ Viol S, Attach a copy of the workers'compen ation 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 covcrase verification. I do hereby certify under the pains d enahies erjury that die information provided above is true and eorrem S e' Date: Phone - L5'- tl- Official use only. Do.not►tirite in this area,to be completed by city or town official. { City or Town: PermitlLicense#' Issuing Authority(circle ode): r' 1.Board of Health 2.Building Depart 'eat 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector` 6.Other Contact Person:' Phone#• ' AC40 RQ® CERTIFICATE OF LIABILITY INSURANCE ioi2o/Zo�) 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 CAOINEACT Shannon Sperrazza Risk Strategies Company PHONE (761)986-4400 FAX WANG IF,, A/ o_(T81)963-4420 15 Pacella Park Drive - AIE LSS: Suite 240 INSURERS AFFORDING COVERAGE NAIC# Randolph MA 02368 INSURERA:Selective Insurance INSURED INSURERB:Safety Insurance Company 3618 Michael McCluskey, DBA: Cape Save INSURERC:Technol0 Insurance Company 7 C Huntington Ave INSURER D: INSURER E: South Yarmouth MA- 02644 INSURERF: COVERAGES CERTIFICATE NUMBER:CL11102041451 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. ILTR TYPE OF INSURANCE POLICY NUMBER MM/DDY� MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $ 100,000 A CLAIMS-MADE Fx1 OCCUR CPPS1994480 0/16/2011 0/16/2012 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY Ea BINEDISINGLE LIMIT 11000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 6208200 1/6/2011 1/6/2012 BODILY INJURY(Per $ AUTOS AUTOS ( ) X HIRED AUTOS X AUTOS-NED PROPERTY DAMAGE AUTOS- Per accident $ X Underinsured motorist BI split $100000 300000 X UMBRELLA LIAB X OCCUR CPPS1994480 , 0/16/2011 0/16/2012 EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE _ AGGREGATE $ 1,000,000 DED RETENTION$ $ C WORKERS COMPENSATION Executive excluded X WC STATU• OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N FC3297972. ow Coverage E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) 0/21/2011 0/21/2012 E.L.DISEASE'-EA EMPLOYE $ 500 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 r DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Issued as evidence of insurance. National Grid Corporate Services LLC d/b/a National Grid, d/b/a Boston Gas Company, d/b/a Essex Gas Company, Action Inc., and Housing Assistance Corporation are.listed as additional insureds .as respects General. Liability as required by written contract. CERTIFICATE HOLDER CANCELLATION (508)7 90-2425 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED .IN Housing Assistance Corp ACCORDANCE WITH THE POLICY PROVISIONS. 484 Main Street Hyannis, MA 02601-3698 AUTHORIZED REPRESENTATIVE Michael Christian/SMS :- ACORD 25(2010/06) ©1988-2010 ACORD CORPORATION. All rights reserved. INSn25 i7nin .;)n1 Tho ACr1Rr1 namo unfit inn^urn mnieforpf1 make of ARnon — = Office of Consumer Affairs and usiness Regulation i 10 Park Plaza- Suite 5170 ' .5 ` . - 4 Boston, Massachusetts 02116 + = Improvement Contractor Registration Home Registration: 164432 Type: DBA a CAPE SAVE Expiration: 10/6/2013 " Tr# 217656 MICHAEL McCLUSKEY ` 7C HUNTING AVE. I -S.-YARMOUTH, MA 02664 • r b : r Update Address and return card.Mark reason for change. _ ~ ^` Address F! Renewal .J Employment i Lost Card DPS-CA1 0 50M_m04-C,101216 ? office of Consumer Affairs&B mess Regulation License or registration valid for individul use only i ` HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 164432 v T Office of 0 Park Consumer Affairs and Business Regulation' ' y s n - Type: , - a _ Expiration: 10l6l2013 DBA Plaza-Suite 5170 v. *~ CAS SAVE Boston,MA 021.16 MICHAEL MCCLUSKEY 8201 S.HOURD CT _ _.. • CHAPEL HILL,NC 27516 Undersecretary of valid without signature . ', ll:issachusetts- Dep:u'tmcnt Of public afets ' Board nd of Building�. Re gulations itiun�and fi fandards _ , Construction Supervisor Specialty License ". License: CS SL 102776 Restricted to: IC WILLIAM MC CLUSKY " 37 NAUSET ROAD. WEST YARMOUTH, MA 02673 Expiration: 6/28/2013 ({anmi.�wner Tr#: ,102776 - f a , 08/25:2010 09:_3 919321295- PAGE O1 i 01 CME* 6AW Weatherization- .508-398-0398 August 22, 2010 To Whom It May Concern: William J. McCluskey is an employee of Cape Save. He is authorized to negotiate contracts and building permits for our.company. Michael MoCiuskey Cape Save—Owner , 919-593-5939 cell X Huntington Avenup,South Yarmouth,MA 026" J I M Town of Barnstable t *Permit#`?'S G 33 'Zie Expires 6 months from issue date Regulatory Services FeeMAM �� Thomas F.Geiler,Director Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 SSP Fax: 508-790-6230 T JUG 2 lr EXPRESS PERMIT APPLICATION - RESE DENTUL B �Fe Z00S Not dalid.withoutRed 8 Press Imprint g0 L, Map/parcel Number 7D Property Address 6 P (� GfResidential Value of.Workl ,4, Owner's Name&Address AA a2(oG� T Contractor's NameIL V 1'1 I (� �1 I7U ��VG 1 Telephone Number JZY 0719 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner U_I have Worker's Compensation Insurance / Insurance Company Name _ 1_Mj 14 lIZ!/l Workman's Comp.Policy# (,A)t - 3 G —t,1}/ Permit Request(check box) CeShoes) (�Re-roof(stripping old shi oes) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) -When 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. Home Improvement Contractors License is required. Signature Q:Forms:expmtrg Revise053003 ' �� Bo��ot"Ba�c�mgZ��u�iifti>�is�'ai��Ft� ` . • • License or registration valid for individul use only F HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: Registr 38ST-- Board of Building Regulations and Standards A piraIdU 8117/2005- One Ashburton Place Rm 1301 ~ Boston,Ma.02108 Type:,'private Corporation NICKERSON H ldtE;HM MARK NICKERSON ' 12 COMMERE DRIVE ORLEANS,MA 02653 Administrator Not valid without signature °Fs r Town of Barnstable " Regulatory Services saxtvSMBLr, vo MASS Thomas F.Geiler,Director °plEa i 9.�°�0 Building Diyision Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 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 liereby,authorizefi toact on my behalf, in all matters relative to work authorized by this building permit application for: (Ad ess of Job) V73, f 7 ta!ute of Owner -`—Date Print Name Q:FORMS:OWNERPERMISSION Ie ^V v' Liberty Mutual Group _ Mutual. y PO Box 7202 1W11,utual. Portsmouth,NE 03802-7202 Telephone(800)653-7893 Fax(603)431-5693 November 11. 2004 TOWN OF BARNSTABLE BLDG DEPT 367 MAIN ST HYANNIS,MA 02601- RE: Certificate of Workers Compensation Insurance Insured: NICKERSON HOME IMPROVEMENT INC PO BOX 2476 ORLEANS,MA 02653 Policy Number: WC2-31S-318102-03 Effective: 11/6/200 I Expiration: 11/6/2005 Coverage afforded under Workers Compensation Law of the following state(s): MA Employers Liability: Bodily Injury By Accident: $ 1.000,000 Each Accident Bodily Injury by Disease: $ 1,000,000 Each Person. Bodily Injury by Disease: $ 1,000,000 Policy Limits As of this date,the above-referenced policyholder is insured by Liberty Mutual Fire Insurance Co under the policy listed above. The insurance afforded by the listed policy is subject to all the terms, exclusions and conditions,and is not altered by any requirement,term or condition of any or other documents with respect to which this certificate may be issued. This certificate is issued as a matter of information only and confers no right upon you,the certificate holder. This certificate is not an insurance policy and does not amend, extend,or alter the coverage afforded by the policy listed above. If this policy is cancelled before the stated expiration date,Liberty Mutual will endeavor to notify you of such cancellation. AUTHORIZED REPRESENTATIVE LIBERTY NIUTUAL INSURANCE GROUP This Certificate is executed by LEER I1 NTUTUAL INSURANCE GROUP as respects such insurance as is afforded by those companies. cc: Insured: Producer of Record: NICKERSON HOME IMPROVEMENT INC PIKE INSURANCE AGCY INC PO BOX 2476 PO BOX 1658 ORLEANS. MA 02653 ORLEANS. MA 02653 The Commonwealth of Massachusens Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 ° www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Alpplicant Information Please Print Legibly Name (Business/orp=ation/Individual)' N V f►/►.1-6h T Address: 11�h'1G�i� V7L City/State/Zip: M A. , Phone:#. �"�_g-� ap Are you an employer? Check the appropriate box:w• Type of project(required): r/ 4. [],1 am a- eneral contractor and I 1.[-11 am a employer withg 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 sheet. $ 7• ❑ Remodeling These sub-contractors have - 8. ❑ Demolition ship and have no employees working for mein any capacity. workers' comp.insurance. 9. ❑ Building addition o workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10,❑ Electrical repairs or additions required]- 11:❑ Plumbing repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL g ep c. 152,§1(4)i and we have no -12.- oofr airs myself:[No workers' comp. _ � t employees. [No workers' insurance required.] 13.❑ Other comp.insurance requited.] T 'Any applicant that checks box#1"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 their workers'comp-policy-information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy_and job site information. Insurance Company Name: z -�3 y j as Policy#or Self-ins.Lic.M LO L2—3 / S ,� .` 3 / Expiration Date: f/ Job Site Address: &2- LOO\\a` P-A City/State/Zip: fjV Is 0 Ze.a/ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500;00 and/or one-year imprisonment, as well as.civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u er the pains and penalties of perjury t: that the information provided above is true and correct Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. or Town: Permit/License# ing Authority(circle one): oard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector ther tact 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, 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 deein #o-Sean-MVivYer." 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. (7)states `Neither the commonwealth nor any of its political subdivisions shall Additionally,MGL chapter 152, §25C work until acceptable evidence of compliance with the insurance enter into any contract for the performance of public requirements of this chapter have been presented to the contracting authority. Applicants our situation an if e+.el b checking the boxes that apply toy d, . Please fill out the workers compensation affidavit completely, y g necessary, supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s) of p other the insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees oth than members or partners; are not required to carry workers' compensation insurance. If an LLC or UP does have sed that this affidavit may be submitted to the Department of Industrial employees,a policy is required. Be advi 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 shozld enter their self-insurance license number on the appropriate line. City or Town Officials Please be siie 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 if necessary)and under"Job Site Address"the applicant should write"all locations in - (city or policy information( 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 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAF'E Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia