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HomeMy WebLinkAbout0084 BENT TREE DRIVE ,:� � �.,. � � _ .� ;;K,. ,z ., . .. .. .. , ,.. , ,, . . t � J � 4 .; .. 1 j. ,. ,. .. .. 1 �' r .. t .. �. _ .� + .. ..','. i _ .,. g .. � � iZ R :. ( ,o t .. � � � - '� ,a ,. .'4 .' ':,� Town of Barnstable Building 3 GLOWSra Post This Car.'d So That rt is Visible'From t:he Street Approved Plans Must be,Retained on Job and this Card Must-be Kept [Posted Until°Final Inspection Has.Been Made Permit Where a Certificate of Occupancy is Required,such Building shall Not.be Occupied until a Final Inspection has been made Permit No. B-19-465 Applicant Name: JAMES S PEACOCK Approvals Date Issued: 02/22/2019 Current Use: Structure Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 08/22/2019 Foundation: Residential Map/ -- �-Lot: 168-022 Zoning District: RC Sheathing: _',' Location: 84 BENT TREE DRIVE,CENTERVILLE Contractor.Name.*�,,JAMES S PEACOCK Framing: 1 a Owner on Record: GREGORY,SUSAN G&GAETANO Contractor License: CS 094500 2 Address: 1040 KENNEDY BLVD UNIT 602 m Est Project Cost: $20,000.00 Chimney: BAYONNE, NJ 07002 Permit Fee: $ 152.00 Description: Refit Master Bath New Vanity,Toilet,Shower(and Tile Floor. Insulation: Fee Paid ` $ 152.00 Project Review Req: NO STRUCTURAL WORK. Date. 2/22/2019 Final: Plumbing/Gas ter, Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permi i t s commenced within'six months after.issuance. All work authorized by this permit shall conform to the approved application and the,approved construction documentsfc r which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas: work until h completion of the same. " o ku t the p max. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building,and Fire Officials are provided,on this Permit. Minimum of Five Call Inspections Required for All Construction Work: ,,. Service: 1.Foundation or Footing 2.Sheathing Inspection Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Building plans are to be available on site Fire.Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: tHE Application Number. . ...... ................ 16"3 BUILDING DEPT. Permit Fee........................................Other Fee....................... gig , Total Fee Paid..............4.. .................... ...... . FEB 13 2 TOWN OF BARNSTABEIE Permit Approval by.... VIZ................... BUILDING PERMIT Map........... .................Parcel...... ................... APPLICATION Section 1 — Owner's Information and Project Location Project Address—' VillageL-eA4erv1 Owners Name-,S U ,<san t- ( n � anp ctaaca::14 Owners Legal Address—[ 04b Ke,Y)ne dU P) VA U h I Lo City —7 0(—DD— State IV zil) Owners Cell# H-te -3 1 S-J E-mail 7 2±0 Section 2'—Use of Structure Use Group_ F Commercial Structure over 35,000 cubic feet El Commercial.Structure under 35,000 cubic feet Single Two Family Dwelling Section 3 —Type of Permit ❑ New Construction Fj Move/Relocate [] Accessory Structure ❑ Change of use El Demo/(entire structure) El Finish Basement El Family/Amnesty El Fire Alarm Rebuild El Deck Apartment El Sprinkler System ❑ Addition ❑ Retaining wall ❑ Solar El Renovation ❑ Pool El Insulation Other—Specify Section 4 -,Work Description La U Last updated. 11/15/2018 Application Number......... Section 5—Detail " Cost of Proposed Construction 2-0 IDoD Square Footage of Project ca Age of Structure. g Dig Safe Number # Of Bedrooms Existing Total#Of Bedrooms (proposed) 110 MPH Wind Zone Compliance Method ❑ MA Checklist❑ WFCM Checklist ❑ Design . } Section 6—Project Specifics ❑ Wiring . ❑ Oil Tank Storage ❑ Smoke Detectors ❑ Plumbing, , ❑ , Gas ❑ Fire Suppression Heating System ❑ Masonry Chimney ❑Add/relocate bedroom Water Supply ❑ Public ❑ Private Sewage Disposal ❑ Municipal - t ❑ On Site Historic District ❑ Hyannis Historic District r ❑ Old Kings Highway Ji Debris Disposal Facility: CI r'r-nant ��U l I am using a crane ❑ Yes ❑ No - 1 � I Section 7-Flood Zone Flood Zone Designation Within or adjacent to a wetland, coastal bank? ` Yes ❑ No Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq. Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard` Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No Last updated: 11/15/2018 Barnstable Bldg.Dept. Appraved by: y Permit#c .._ ..�.9 U Gam'-'-2� __ .. ,� � -I�-,�,�.��,-,,���✓ � A4 � S ��,,, �� ' � v - +' .�. _ � _ . , - _� -. r ,, ... �. _ �� - .. �� � -� �� _ r� �..��� a � � — � _ �_ r e � � � w Y � � �� _ �U` w , �. W �.... 3 r -- .� � - - ,. �' N :.: _ �. T���_ . m �� - � _ ,. ,� � - f w a . _ . � . . �� . .. . , . . - , �. i'`- - ` . �� � � ���` s - � � � � � l e � � _ . : .� � , _ t � .- , ,z r : a , � a _ r r ry � e f r r e r r -n i ` M , 5 V - G.��-✓lam l _ s r,,:.� _ - �_, . ticz f WE Town of Barnstable Regulatory Services sn MASI iE - Richard V.Scali,Director W39 Building Division r Tom Perry,Building Commissioner '200 Main Street,Hyannis,MA 02601 r 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 l susAN GREGORY ,as Owner of the subject property hereby authorize. J.SCOTT PEACOCK to act on my behalf, in all matters relative to work authorized by this building permit application for: 84 BENT TREE DRIVE CENTERVILLE,MA 02632 (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed-and all final inspections are performed and accepted. Signa e of O ner Si tore of Applicant Z' SUW Print Name Print Name la - Date t _ I Conunonweaith of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructi'on'Supervisor CS-094500 Etpires:07/22/2020 JAMES S.PEACOCK _ 1046 MAIN Sf'.MNIT 7 P.O.BOX 171 :' OSTERVIU.E MA'-02655 Commissioner C ""- office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE::Comoration Registration . Expiration 151853 07/06/2020 SCOTT PEACOCK.BUILDING&REMODELING INC JAMES S.PEACOCK 1046 MAIN STREET SUITE 7: OSTERVII IE,MA 02655 Undersecretary The Commonwealth of Massachusetts 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 Applicant Information Please Print Legibly Name(Business/Organization/Individual):SC-01W PeelktioaL 1&U-1 I d is Re-M i OC4 , . n Address: f b, 6yx- )04G- Iwo n St SL ip City/State/Zip:U-C(ViI IP 0a(aS5 Phone#: SCIP-1 (4=a8 1(0C)6 Are you a-n employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with- 4. ❑ I am a general contractor and 1 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. 0 Remodeling ship and have no employees These sub-contractors have g• ❑Demolition working for me in any capacity. employees and have workers' comp.msuran0e 3 9. El Building addition [No workers comp.insurance P• required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their 11. Plumb' re❑ uig Pairs or additions myself o workers'co right of exemption per MGL Y Ll`l comp. 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers'. r 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 Homeowner;who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating suck rContractors 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 L�.i`l i f& ra i i LP,� Policy#or Self-ins.Lie.#: L� �` - )—� {'�C� Expiration Date: Job Site Address: f�e.Ylf Tree-- -b ( 1 Ve— City/State/Zip: U h k rO Ile 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 c Iunder the parrs penalties of perjury that the information provided above is true and correct Si ature: ° Date: c Phone#: 7 -2 (CCU Official use only. Do not write in this area,to be completed by city or town oj`iciaL. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: CERTIFICATE OF LIABILITY INSURANCE °ATE(MM/D°/YYYY' 1 07/19/2018 ' 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER CONTACT NAME: GermaniInsurance Agency PHONE _(508)428-9194 MAX C,No): (508)428-3068 908 Main Street ADDRESS: certs@geffnaniinsurance.com INSURERS AFFORDING COVERAGE NAIC# Osterville MA 02655 INSURER A: SAFETY INS CO INSURED INSURER B: Granite State-AIU Holdings Scott Peacock Building&Remodeling,Inc. INSURER C: P.O.BOX 171 INSURER D: INSURER E Osterville MA 02655 - INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: :_THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP— LTR TYPE OF INSURANCE POLICY NUMBER MM/DDJYYYY M /DD LIMITS « X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence $ . MED EXP(Any oneperson) $ A BMA0022118 07/05/2018 07/05/2019 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ Z000,000 POLICY1-1 PRO- JECT LOC PRODUCTS-COMP/OP AGG $ P OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea arxident ANY AUTO * BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS ONLY AUTOS ( ) HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY. Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 4EXCESS LIAR CLAIMS-MADE AGGREGATE, $ DED RETENTIONS $ WORKERS COMPENSATION PER OTH AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT. $ 500,000 $ OFFICER/MEMBEREXCLUDED? N/A WC005-81-5464 06/22/2018 06/22/2019 It yes,describe under under (Mandatory in EL.DISEASE-EA EMPLOYE $ 500,000 nd , DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE t THE EXPIRATION DATE THEREOF,.NOTICE WILL BE DELIVERED IN Scott Peacock Building&Remodeling,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. P.O.BOX 171. AUTHORIZED REPRESENTATIVE { -' I Osterville MA 02655 Fax:508-428-7625 Email:scottLpeacock@venzon.net 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD i f TOWN OF BARNSTABLE • PERMIT CHECKLIST Sip off hours for Health and ConservA on are 8-9s34 a.m. and 3:304:30 p.m, A complete permit application includesfilling all sons 1-13 1. NEW STRUCTURES/REMODELING/RENOVATION/ADDITIONS ❑ Site Plan showing setbacks of proposed and existing structures ❑ Commercial—One complete set of full sized plans one reduced 11"x 17" (plans may require a stamp by an architect or engineer). ❑ Residential - 5 Sets of floor plans no larger than 11"x 17" smoke/co detectors marked ❑ Worker's Comp. Affidavit and policy(if required) Res Check or COM check from the 2015 International Energy Cod Council(IECC) ❑Letter of financial Interest for new houses only(not required for rebuild after teardown) ❑ Performance bond made out for$4.00/foot of road frontage(new construction only) 2. DEMOLTION OF A BUILDING (NOT PARITIAL) ❑ Everything above plus shut off letters from following utility companies: ❑ Gas ❑ Electrical ❑ Water ❑ Sewer(if required) 3.-DECKS/PORCHES/GAZEEBOS/INSULATION/SOLAR/POOLS/SHEDS ❑ Site Plan showing proposed location ❑ Construction plans showing framing detail(if new framing), ❑ Pools—Barrier details,pool specs(engineers design) ❑ Workman's Comp Affidavit and policy(if required) FAMILY APARTMENTS ❑ Section 1 Plus: ❑ Family Apartments are subject to approval from the Building Commissioner. Agreement must be signed, notarized and recorded at the Registry of Deeds and returned to the Building Department. c Application Number........................................... I Section 9-Construction Supervisor i Name - S 0-0++- Ve a-W ' Telephone Number (o 0 ZD Address �, U. G I 1 City dsV o I�t_ State !} Zip 0abS'S_ License Number 0�1 Lf SV& License Type Expiration Date 1 Contractors Email S t o t+: De CQ.aj-Lf4 'i✓r 1-zon,n t Cell# 50?1 3Co+)_3 I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation r quired by 780 Ca and the Town of Barnstable.Attach a copy of your license. Signature Dated I Z (�C Section 10—Home Improvement Contractor Name_ 3N YYu' ✓ �-, AbWe, Telephone Number Address City State Zip Registration Number 'I`j 1 85 Expiration Date °1 (P I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code.I I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your H.I.C... Signature Date t Section 11 —Home Owners License Exemption Home Owners Name: Telephone Number Cell or Work Number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMA and the Town of Barnstable. Signature Date APPLI T SIGNATURE Signature - Date Print Named - S C DD Pe-c Ccc4— Telephone Number 5))R- q D.!9-1&00 E-mail permit to: -1` L L e yset 17 r1, n e-+, Last updated: 11/15/2018 1 Section 12 —Department Sign-Offs 7!e Health Department ❑ Zoning Board(if required) Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ Conservation ❑ For commercial work,please take your plans directly to the fire department for approval ' Section 13—'Owner's Authorization I, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of j ob) Signature of Owner date Print Name Last updated: 11/15/2018 s Town of Barnstable 1REGE112t MAM200 Main Street, Hyannis MA 02601 508-862-4038 ' 6;p. Application for Building Permit Application No: B-17-1510 Date Recieved: 5/16/2017 Job Location: 84 BENT TREE DRIVE,CENTERVILLE Permit For: Building-Siding/Windows/Roof/Doors Contractor's Name: TROY A THOMAS State Lic. No: CSSL-099913 Address: CENTERVILLE, MA 02632 Applicant Phone: (508) 328-1635 (Home)Owner's Name; DUBOIS, GREGORY F& SUSAN G Phone: (177)423-8863' (Home)Owner's Address: 84 BENT TREE DRIVE, CENTERVILLE,MA 02632 ,q y 'Work Description: Strip& install of siding on front of home only 10 t CIO Total Value Of Work To Be Performed: $2,900.00 Structure Size: 0.00 0.00 0.00 Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have, been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: Troy Thomas 5/16/2017 (508)328-1635 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost : $2,900.00 Date Paid Amount Paid Cheek#or CC# Pay Type Total Permit Fee: $35.00 5/16/2017 $35.00 XXXX-XXXX-XXXX-1 Credit Card 3286 Total Permit Fee Paid: $35.00 THIS IS NOT APERMIT }CoPa . _ ,., ,.. .� 11/14/14 Thomas Perry, CBO Town of Barnstable Building Division 200 Main St Hyannis, MA 02601 RE: Insulation Permits Dear Mr. Perry, This affidavit is to certify that all work completed for insulation work at 84 Bent Tree Drive (application#201206994) has been inspected by a certified Building Performance Institute(BPI) Inspector. All work performed meets or exceeds federal and State requirements. Sincerely, Conor McInerney ., - _ ConserVision Energy 3 376 ROUTE 130,SUITE C SANDWICH,MA 02563 508-833-8384 WWW.CONSERVTODAY.COM t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee a 2 Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address@cad .e Q,c�. Village Owner Address benc� Telephone Permit Request TXCW\ U% w� Osc -6 y o\ ��• Ns(- �5 C aW c. Q &�mUnX. Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation A\ 06 Construction 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 ❑ No On Old King's Highway: ❑Yes ❑ No v Q Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other cl ` Basement Finished Area (sq.ft.) Basement Unfinished Area (sq ft , _n 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- ( g ) 9 I Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No p g 9 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 Telephone Number Address _ � S UL.� _ b License# `1T6 �r t,JQ�CT 6"A71, Home Improvement Contractor# Worker's Compensation # W�, � � °1 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE yilGll ►2, 'Fl FOR OFFICIAL USE ONLY APPLICATION# y DATEISSUED ` MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: , FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL { PLUMBING: ROUGH FINAL i GAS: ROUGH FINAL FINAL BUILDING ' z DATE CLOSED OUT ` ASSOCIATION PLAN NO. , 1 PrlFclrttrf� The Commonwealth of jilassachusetts Department of Industrial Accidents .= Dffiee oflnvesiigations ' h Congress.Street,Suite 100 Boston, MA 021.1 -201.7 - ivww.mass.gov/dia Workers' Compensation Insurance AM davit- Builders/Contr:actors/Electricians%Plumbers Applicant Information Please PrintLegibly. Name(Business/OrganizationIiftdividual):CONSERVE ENERGY INC. d.b.-a CONSERVISION ENERGY Address 376'ROUTE 130, SUITE C City/State/Zip. .S,ANDWLGH, MA 02563 Phone#`: 508-833=8384 Are you an employer?C,heck_:the,appropriate box; Type of prgject(required).: L I 'i am,a-employer with 6: 4: !Q Vain a general contractor and I r employees(full and/or part-time); have hued the sub=contractors 6. ❑ New construction 2.Q I am a sole proprietor.or partner- listed on the attached sheet. 7. Remodeling slop and Have no employees These sub-contractors have. 8. [Q Demolition working for me in any capacity., ernployees and have workers' [No:workers' comp. insurance Icomp. insurance.+ 9. ❑ Building addition required.]: 5. ❑'. We are a corporation and its 10.7 Electrical repairs or additions 3.0 1 am a homeowner doing all'work. officers have'exercised'theii I.l.❑Pititnbing repairs or additions myself.[No workers' comp, right ol'exemption per MCL 12.❑Roofrepairs insurance required..]t c. 152,��I(4),and we7mave no EATHERIZATION employees. [No workers' 13•© Other - W comp. insurance required:] *AnyApplicant thatchecks box#1 must-also fill out the section belowshowing.their workers'compensation policy intonnation'. #Homeowners who submit this affidavit mdtcating they ure.doing all.work and then hire onside contractors must submit a new atficiavit indicating such. $Contractors that check this box must attached an additional sheet showing the.name of he:sub-contractors and state whether or not:those entities'have employees. lithe sub-contractors have employees,they must provide their workers'cotitp.policy number. .lam an employer that;isprovitleng'warke&:'egmpensatioir insurance for-fury:employees Below is.thepo/icy andfnb site information: Insurance Company Name: SELECTIVE INSURANCE COMPANY OF THE SOUTH' Policy#`or Self-ins. Lic.#:WC7956539 Expiration Date°3/15/13 Job Site Address: City/State/Zip: .Attach a.copy ofthe,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 fine tip-to$1,500.00 and/or one-year imprisonment;.as well as civil penalties in the form of a STOP WORK ORDER and afine of`up to MOM a day against the violator. Be advised.that a.copy of,this statement may be forwarded to the Offce.of Investigations of the D.IA:for insurance coverage verificati in I do hereby certi under the. sins and, enalties o er`ur that the in.nrmatian:,provided above.is true and.correct Signature, Date: _. Phone M 50&833-$384 Offi a!use only, .Do n4l write-in this area,to be completert by city or t t.wn off ciul'._ City ar Town' pooll(Jue-o ise Issuing Authority(circle one): l:.Board of Health 2 $sliding Department 3.City/Town Clerk 4:Electrical;lnspector a,Flumning^inspector 6.Otlier Contact Person Phone#: i f Client#'68880 CONSER A:CORD. CERTIFICATE OF LIABILITY INSURANCE DATE(NM/ODIYYYI) _ 63115t2612 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON'THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER,THE COVERAGE AFFORDED,BY.THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),,AUTHORIZED REPRESENTATIVE OR.PRODUCER;AND THE:CERTIFICATE HOLDER. IMPORTANT:,If the certificate holder is an ADDITIONAL INSURED,,the policy(ies)must,be endorsed.If SUBROGATION IS WAIVED;subjecYto- the'terms and.conditions Of the policy,certain policies may require an"endorsement:A statement'on this certificate does not Coflfer rights to the certificate holder In of such endorseinent(s). PRODUCER NAME, ACT - Rogers 8 Gray 19surance.Agency:.Inc. FPHoNE Fax dAA/C No E, :508 398 7980 (AIC Noj:_ 434 Route.134 E-MAIL - "- ADDRESS: South Dennis,MA 0266.0 -- 508 398-7980 ��_-.... - INSURER(S)AFFORDING COVERAGE - NAICl� _ INSURER -- fi INSURED A•Selective Ins.Co of the Sout 7 INSURER$: t Con=Serve Energy;Inc:.. J - INSURER.Ca,_ INSURER I) Sandwich,MA 02563 INSURERS: _ -- --- - _ INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED',BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE. FOR THE POLICY PERIOD .INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN; THE INSURANCE AFFORDED BY THE POLICIES'-DES611MED HEREIN IS SUBJECT TO ALL THE TERMS; EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS.SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS, INSR LTR TYPEOFINSURANCE aADDLSUER POLICY'EFF POLICYEXP _ IINSR WVD POLICY NUMBER. MM(DD/YYYYy i(MMIDD/YYW1�_- UMITS: . - __ A GENERAL LIABILITY X 5201,1299. 3/1 4/2 01 2 10 0 3tEACHOCCURRENCE IS1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED I i i PREMISESIgaoccurrence S100,000 _(.. CLAIMS-MADE I .Aj OCCUR' I # M 7 EXP(Any ono erson) $1 O OOO - - - -- 1 PERSONAL&ADV INJURY_ 'y$1:DO0,0O0'.. GENERAL AGGREGATE_ S3 OQO,OOO GEN.L.AGGREGATELIMITAPPLI_ESPER: 'i E PRODUCTS-CgMPIOPAGG.$3,000,000- X:POLICY' i ---- _ JER T F LOC. s. i �` „S .. _.... ..... ._...,__... ..__.._- .... _ _...... ____ . AU7OMOBILE+LIABILITY I COMBINED SINGLE LIMIT ,I s - - - S Ea accatlenil d S I _ ANY AUTO _ BODILY rvJURY(Per person} .�S ALL OWNED i,SCt}EDULED AUTOS ' AUTOS- BODILY INJURY(Par acddem) S 1 NON-OWNED .:.:..... _..—_ _._ ._._W 111 t �PROPcRTYOgMAGE :HIRED AUTOS I AUTOS i - 1Per acadent) _I S A UMaRELLA GIAE X, OCCUR X! 920,11299 311412012 3 120"1 EACH OCCURRENCE: !$1,000 060 _XdEXCESS LIAR CLAIMS-MADE - AGGREGATE �$3,000,GOD . { DED X t RETENTION$0 S A WORKERS COMPENSATION. I WC7956539 3/14f2012�03f14J2013X lWCSTATU 1 oTH- AND EMPLOYERS-LIABILITY Y t Ni ----LOR-Y-1-Iw-T+g.__ 1.E ANY PROPRIETOR7PARTNER/EXECUTIVE'[ N l A. I OFFICER/MEMBER EXCLUDED i Y, I E EACM ACCIDENT g1 OO1DD0 {1MyaansdatooaryLtn�aver '-' E 1.DISEASE-EA EMPLOYEE S1 OO 000_ DESCRIPTION OF OPERATIONS below .....:..._.... ....:.......... ................. .... .__: .... .. E.L.DISEASE-POLICY LIMIT,.:.S50O,000 DESCRIPTION OF OPERATIONS I LOCATIONS!:VEHICLES(Attach ACORD.101;Additional Remarks Schedule;if more space i5:required) Excluded officers tender Workers'comp Con or and Courtney MClneiney: Blanket additonai insured'coverage appli'e.s under CGL CERTIFICATE HOLDER CANCELLATION ihielsch Engineering,Inc. SHOULD ANY OF'THE'AB'OVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL: BE DELIVERED IN 195 Francis Ave. ACCORDANCE WITH THE POLICY PROVISIONS: Cranston,_R1 02910 AUTHORIZEDREPRESENTATIVE ©1SB -2010 ACORD CORPORATION.All rights reserved. ACORD 25'(2010105) -1 of 1 TheACO.RD-name and logo are registered marks of ACORD #5788991M7889$ DDR r Massachusetts -Departmem of Public Safety 9oa.ra of Building Rerluia ions area Standards e`ianstrurti�u Sulter�r�rr�peciiilh License CSSL-102778 -. CO1\OR D 51CINF;RINE- Q r . 39 SIASCONSIET DRIA SACANIGRE dB1 A;CH iwA 02502 Czxn ir3a,sianr;.. 08/1912014 ✓f . :w.czf/ r �f.rrc er� Office`o/kons�imer r�(rira1ry. `gi ines ]Ccgula of o License or registration vaiid for i divid I use only HOME IMPROVEMENT CONTRACTOR, before the expiration date, if found return to: Registration: 171251 Type: Office of Consumer Affairs and Business Regulation Expiration: 3/1f2014 Partnership t0 Park Plata-Suite 5170 Boston,MA 02116 CON-SERVE ENERGY CONOR MCINERNEY t t 376 ROUTE 130 SUITE C �� 'a! ( f SANDWICH,MA 02563 r tluderwretary Not vshd Without signature f ` F: OWNER AUTHORIZATION FORM (O er's Name) owner of the property located at Cv, VJTt�—(e- k L- 1� (Property Address) 1 (Property Address) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. Ovine s Aignature 1a ') r2 Date