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1302 BUMPS RIVER ROAD
30�• c P TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel 0 0Application # Health Division Date Issued C Conservation Division � -;Application Fee Planning Dept. , Permit Fee Date Definitive Plan Approved by Planning Board • V , Historic - OKH Preservation/ Hyannis . Project Streets Address 1 3 ® °a- um p S �(��� R P Village C --�✓U I f "� 'Owner o 4 4 11 revAddress 130_ 5UMPS RIVEll R b Telephone 77 /- 6 `if G S� �t fr?v 11 j II44 P Permit Request `R-e U I k C-e- e X i d r m i e ck i o,S ®;I U e-c 1` Le. � Xi`✓ ��rtc� � ee a 4r1ok7 Square feet: 1.st floor: existing proposed 2nd floor: existing proposed Total new Zoning District RV " / Flood Plain � ° Groundwater Overlay N Project Valuation 5t 0 D V Construction Type W 00 t, r/E,4 M 4 Lot Size �'c Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family : 3 Two Family ❑ Multi-Family (# units) Age of Existing Structure I f 4 Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: Cull ❑Crawl ❑Walkout ❑ Other Basement Finished Areas .ft. Basement Unfinished Areas .ft Number of Baths: Full: existing .2- new 0 Half: existing new Number of Bedrooms: .3 existing ®new Total Room Count (not including baths): existing 7 new D First Floor Room Count Heat Type and Fuel: 3, as ❑Oil ❑ Electric ❑Other - Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove--D Yes-,❑ No Detached garage: ❑existing ❑ new size_Pool: ❑existing ❑ new size _ Barn: ❑existing ❑new size_ Attached garage: LI/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 1?f i filet'i* "J l yt y It r4m Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name !' S+W u m S 0, Telephone Number Address 1 0 Ox t 4 ) License # G B y 2.1 4 a1)1 �3A tM 1 4 4 7 V d `� i Home Improvement Contractor# Worker's Compensation # llJ C C 4 Sy y 32 0 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO U tj 1'fe d QUA Jre SIGNATURE DATE 14 f FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO; :: r y ADDRESS VILLAGE OWNER- DATE OF INSPECTION: f t.`-FOUNDATIONS'_• ` FRAME ' INSULATION: #" FIREPLACE ELECTRICAL: ROUGH FINAL .k PLUMBING: ROUGH FINAL lF ,GAS: ROUGH 4r .._ FINAL a -:';FINAL B_UILDING':y ® G lohc j y DATE CLOSED OUT } ASSOCIATION PLAN NO. t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,M.4 02111 www.mass gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information Please Print ILtgibly Name(Business/Organization/individual): Z��_{fin` Z-1 �t O ri n' —I MR R t y ue tve J4 7.v Address: 4i A) t,t -h1 ,Z1l:7 1Z 1v City/State/Zip: C o'u 4 i A44 6263s, Phone#: `i 5-1; Are you an employer?Check the appropriate box: Type of project(required) 1.[ am a employer with t>�0 ' 4. [� I am a general contractor and I 6. ❑ a,construction employees(full and/or part-time).�' have hired the sub-contractors 2.Q 1 am a sole proprietor or partner- listed on the attached sheet. 7. [n Remodeling shipand have no employees These sub-contractors have P Yew 8. []Demolition working for me in any capacity. employees and have workers' corn msurance.t 4. ❑Building addition [No workers'comp,insurance comp. required.] 5. Q We are a corporation and its 10:0 Electrical rep airs'or additions 3.❑ I am a homeowner doingall work officers have exercised their l 1. Plumbing re❑ g Pairs or additions myself.[No workers'comp. right of exemption per MGL 12•❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 1311 Other' comp.insurance required.] 'Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy in&rrnation. t Efomeownets who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheet showgtniofhu -connh tractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees Below is the policy and fob site information. d Insurance Company Name: N y C A S'tA9 L y Policy#or Self-ins.Lic:#. j At C C g 59 41 3 Lt:��� Expiration Date:_ i �•: � �� , �!J Z% 13 ox. 15vm 12;l/ea.l1 Job Site Address: �, U. City/State/Zip: � `i�l 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.60 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby unde=sins and penalti f perjury that the information provided above is true and correct Sianature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town orcial City or Town: Permit/License# Issnigg Authority(circle'one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector'5.Plumbing Inspector 6.Other Contact Person: Phone#• f. Client#:47298 CAPIHOM ACORD. CERTIFICATE OF LIABILITY INSURANCE DAE(MMIDDIYYM THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS.WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). ARooucER CO NAME:CT. Karen Walther Rogers&Gray Ins.-So.Dennis PHONE F Alc No Ext:508 398-7980 Alc,No):. 434 Route 134 E-MAIL P.O.Box 1601 ADDRESS: Waltherka@rogersgray.com South Dennis,MA 02660-1601 CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED Capi$i Home Improvement,Inc. -INSURER A:National Grange Insurance CO. Capizzi Enterprises,Inc. INSURER B:ACE Property&Casualty Ins.Co INSURER C: - 1645 Newtown Road COtult,MA 02635 INSURER D INSURER E - INSURER F: _ - COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM,OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DL UBR POLICY EFF POLICY EXP - L S6WD POLICY NUMBER MM/DDIYY`M (MMIDDIYYM LIMITS I A GENERAL LIABILITY MPB1075H 06/08/2010 06/08/2011 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY - DAMAGE TO RENTED . PREMISES Ea occurrence s500,000 CLAIMS-MADE 51 OCCUR 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 17 POLICY F PRO- LOC $ A AUTOMOBILE LIABILITY - BPO10786 06/08/2010 06/08/2011 COMBINED SINGLE LIMIT - A ANY AUTO M1 M28044 06/08/2010 06/08/2011 (Ea accident) $500 000 " ALL OWNED AUTOS BODILY INJURY(Per person) $ - .- :. . ^. � BODILY INJURY(Per accident) $ X SCHEDULED AUTOS - - - PROPERTY DAMAGE - - X HIRED AUTOS - (Per accident) $ - - X NON-OWNED AUTOS �.. - -U1 - s250/500,000 X Drive Other Car U2 $250/500,000 A UMBRELLA LIAB X OCCUR CUB1076H 06/08/2010 06/08/2011 EACH OCCURRENCE $5 OOO 000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5 000 000 - DEDUCTIBLE X RETENTION 10000 - - $ B WORKERS COMPENSATION NWCC45843208 12/25/2010 12/25/2011 X WC STATU- .I OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE - E.L.EACH ACCIDENT $1.,000,000 OFFICER/MEMBER EXCLUDED? - � .NIA - (Mandatory In NH) -yes,describe under E.L.DISEASE-EA EMPLOYEE $1,000,000 - If DESCRIPTION OF OPERATIONS below - - E.L.DISEASE-POLICY LIMIT $1 000 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)" - Workers Comp Information Included Officers or Proprietors CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town Of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE BLA ©198 -2009 ACORD CORPORATION.`AII rights reserved. ACORD 25(2009/09) 1 of 1 The ACORD name and logo are registered marks of ACORD #S61971/M61970 MEE i Page 7 of 7 CAPIZZI HOME IMPROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT OWN THE PROPERTY LOCATED AT 13o�- IN C�� v�.t ,MASSACHUSETTS. I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR,THE MASSACHUSETTS STATE BUILDING CODE. I GIVE MY PERMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR,THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: � a OWNER'S ADDRESS: OWNER'S TELEPHONE: { LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit,MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: ✓tie "var«�zaoeuseatt�z ay✓vca:wczcsaugeua Office of Consumer Affairs&Business Regulation g License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and sin-es.- Regulation Registration';100740 Type: 10 Park Plaza-Suite 5170 Expiration`_672312012 Supplement Card Boston,MA 02116 CAPIZZI HOME IMPROVEMENT.-INC: JACK STRUNSKI 1645 Newton Rd Cotuit,MA 02635 Undersecretary Not valid without signature ' Nlassachusetts- Department-of Public Safety ° Board of Building Rey „7ulaiions and Standards Construction Supervisor License 'License: CS 64817 JOHN T STRUMSKI.,. PO BOX 861. 43UZ7ARD$_BAY,`MA 02532 : T Expiration: &18/2012 ('onlrHiwsiuncr" Tr#: 10573 , BOG �R O Op, MBLU 188 046 002 1302 BUMPS RIVER ROAD BARNSTABLE, MA o PROPOSED DECK, REBUILT IN PLACE 40'x12' EX. DWELLING w h� �. C •�`o TANK Q ? PIT O _a 6s 05, FROMCSEPTISYSTEM PLOTTED NF RMAPON PROVIDED BUMPS RIVFR ROAD BY OWNER, CONTRACTOR TO VERIFY. CERTIFIED PLO T PLAN MACALLISTER RESIDENCE I CERTIFY THAT THE IMPROVEMENTS SHOWN OF As 1302 BUMPS RIVER ROAD HAVE BEEN LOCATED WITH, AN INSTRUMENT ��,�� s90 BARNSTABLE MA SURVEY. y� DRAWN: RBS DATE: 5-3-1 1 ROBB r„ JOB #: E00919 c SYKES SCALE.?'=50' DWG. CPP No. 35418 v' EASTBOUND LAND SURVEYING, INC. ROBE SYKES, P.L . DATE P.O. BOX 442 FORESTDALE, MA 02644 1 c.i n14 _b 6L. 6,-To- F124MrE 7T_"Orrl _ O - ape V _ ---.. ro 0.1H ram. Town of Barnstable *Permit# � Expires 6 nrontlrs from issue date 7 BAxxsTAMASS.BLE « Regulatory Services Fee �1 00 439• � Thomas F.Geiler,Director ArFD MA']A , Building Division Tom Perry, Building CommissionerX-PRESS PERMIT 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 j DEC 2 8 2006 r{ Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ON OF NLY���A�LE Not Valid without Red X-Press Imprint Map/parcel Number Property Address Residential Value of Work ► oul—D Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address �� � Contractor's Naame_ p f , /� ,tom l o? CI �Yl D �-1� Telephone Number Home Improvement Contractor License#(if applicable)_ 1 Construction Supervisor's License#(if applicable)_ C)P��nV ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor g k ❑ I am the Homeowner I have Worker's Compensation Insurance Insuranc Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) 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) *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. Home Improvement Contractors License is required. >ignatur ?Torms:expmtrg ',evise063004 s r The Commonwealth of Massachusetts Department of Industrial Accidents ^ a , Office of Investigations d 600 Washington Street Boston,MA 02111' ww'Minass.gov/dia Workers'Compensation Insurance davit: Builders/CoractorsElectricinsPlun mbers- Applicant Information Please Print Leizibly Name(Business/Organizationadividual): rx 0 122Y1 n►�.1 Address: ® o C City/State/Zip:Mp� Phone.#: Are you an employer? Check the appropriate box: :Type of project(required) 1,El am a employer with 4. ❑ I am a general contractor and I 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 shi .and have no employees ese s -contractors have PThese ub 8, ❑Demolition: � '�yorking for me in any capacity, employees and have workers' 9. ❑Building addition [No workers' comp,insurance comp,insurance. $' requited.] 5: ❑ We area corporation and its 10,❑Blectricai repairs or additions '3.❑ I am a homeowner doing ill-work . officers have exercised their H ❑Plumbing repairs or additions ' myself [No workers'comp, right of exemption per MGL 12,❑Roof repairs . insuranm required.]t c. 152, §1(4),and we have no employees, [No workers' 13. Other_110 n l 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. :Contractors that check this box must attached an additional sheet showing the name of the gub-contractors and state whether ornotthose entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. lam an employer.that is providing workers'compensation insurance for my employees. Below is.the policy and job site'' information. Insurance Company Na'm� c (1(� ' �- Policy#or Self-ins.Lic,#: l�� ` I Expiration Date: Job Site Address: City/State/Zip- Attach a copy of the workers' compensation policy declaration page'(showing the policy number and expiration date). Failure•to secure coverage as,required tinder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 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 bU for insurance coverage verification. .1 do hereby ce ify under the pains•and penalties of perjury that the information provided above is true and correct. Si afore: Date; 3� ��. _ Phone#; oo— L 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 r Contact Person: Phone ' { lU�'II1d L�S)11 UHU .L IMI UULIU113 ' 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 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 ehapter.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 compl anc. vyithtlie insurance' requirements of this chapter have been presented'to the contracting authority." Applicants ,r Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-confractor(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 ti r 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 Towli 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. . d 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 (cityor 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:: Thc COMMOUWe .th of Mmachusotts ; DQpUtmect of ladwtnal A.4czdlcks. Off lec of 600 Washingtori Stet , B$astCn�,MA 02111'' r Tel.##617-727 000 ext 406 or 1477-MASSA.FE Fax 4 617-727-7749 Revised 11-22-06 WWW.m -gov/dia f Binder for Workers' Compensation and Employers Liability Insurance r\ i ®i e-Commerce Specialty Workers' Compensation Member of American International Group, Inc. December 22, 2006 To the Employer Through the Producer Capizzi Home Improvement, Inc TPA INSURANCE AGENCY, INC. 1645 Newtown Road 10 NEW ENGLAND BUS CTR DR Cotuit, MA 02635 ANDOVER, MA 018101096 FEIN: 800014011 Phn: 978-691-2470 Reference Number: 1651-19DEC06 Fax: 978-691-2477 A Workers Compensation policy for your insured has been bound with policy number 1764953 and based on the quote issued with above Fein, for the 12/25/2006 to 12/25/2007 policy period . Please reference this policy number on all future correspondence, Binding is subiect to the following: • Any changes in rates and/or experience modifications by any entity having jurisdiction over this policy. • Final premium will be determined at the end of the policy period after payrolls have been audited and applicable rates and experience modification have been applied. • Receipt of a completed signed Acord Application and experience modification worksheet within 48 hours. PLEASE BE ADVISED, this binder has been prepared based on the information provided by you and your insurance representative(s) in your application. If any of the information provided in the application is incorrect, outdated or otherwise should be changed, please provide the updated information to us. This offer of insurance may be rescinded or revised because of changes in (1)the information from the application, (2)applicable rates, (3)the experience modification factor or(4)other reasons, The changes may be reflected in a revised proposal or when we issue your policy. The final premium will be determined after policy expiration and completion of a payroll verification audit in accordance with the terms and conditions of the policy. Notice about the Office of Foreign Assets Control (OFAC) This proposal or resulting binder, the continuation of any bound insurance, and payments to you, to a claimant or to another third party, may,be affected by the administration and.enforcement,of U.S. economic embargoes and trade sanctions by the Office of Foreign Assets Control (OFAC), if we determine that any such party is on the "Specially Designated Nationals.or.Blocked Persons"list maintained by OFAC. Member Companies of American International Group Inc. American Home Assurance,Inc.,AIU Insurance Company, Granite State Insurance Company,Illinois National Insurance Co., New Hampshire Insurance Company,National Union Fire Insurance Company,Insurance Company of the State of Pa ,..Services As an AIG Specialty Workers' Compensation policyholder you now have access to the Partners in Productivity® website, www.ai.gswc.com, at no additional charge. This site will provide links to the following policyholder services: • First Notice of Loss, this online claim reporting system allows you to report claims via the internet—reducing processing time for individual claims and engaging claims management capabilities on a more timely basis. Claims services are delivered by the AIG Companies'Primary Claims unit. • AIG RiskTool System®, our online loss prevention and risk management tool, can assist you in managing the risks your company and employees face every day. Use the tool to build loss prevention programs tailored to your needs. • Request and receive loss runs electronically. • Locate medical service providers. • Submit voluntary payroll reports. • Research general information on Workers' Compensation insurance. These valuable services are only available to current inforce policyholders and their brokers. First time users of the website will need to have the following information, which can be found in your workers' compensation policy, on hand for the online registration process. • Policy Number • Agent or Broker Number • Issuing Company The Employer is urged to refer to the policy(ies) immediately upon their delivery for a complete description of the scope and limitations of coverage and other details including premium determination and payment plans. You may also report claims by calling our toll free claim reporting line at(888)-393-6828. If you need any additional information, please call our Customer Service Department at(800) 645-2259, Monday through Friday, between the hours of 8:30A.M. and 6:OOP.M. Eastern Standard Time. Member Companies of American International Group Inc. American Home Assurance, Inc.,AIU Insurance Company, Granite State Insurance Comp any,pang,Illinois National Insurance Co. -New Hahipshire`7n'surance Company,National Union Fire Insurance Company,Insurance Company of the State of Pa 0/ Board of Building Regulations and Standards - One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration, Registration: 100740 Type: Private Corporation Expiration: 6/23/2008 CAPIZZI HOME IMPROVEMENT, INC. Thomas Capizzi, jr. 1645 Newton.Rd. Cotuit, MA 02635 - Update Address and return card.]!lark reason for change. oPS-CA1 Ir, 5OM-04/05-PC8698 Address •E] Renewal R Employment Lost Card /ze �om��io�u.�reat� o�',�/�aeaac/zctQeCla. - J Board of Building Regulations and Standards License or registration valid for individuI use`only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ?_ ,•" Registration: 100740 Board of Building Regulations and Standards Expiration: 6/23/2008 One Ashburton Place Rm 1.301 Type: Private Corporation Boston,Ma. 02108 CAPIZZI HOME IMPROVEMENT,INC. Thomas Capizzi,Jr, 1645 Newton Rd. �� ` .�Evalid - Cotuit, MA 02635 Deputy Administrator without signature 5 ✓die&o� v ✓!/LaGGa czude i -- 130ARD OF BU1LDIN R GCIL;gT10fl1S license: :�A NS7RUCTION 5 ':f` i Numb er`;>CS 057032, ' 1 rChdate',i19/2G�1 iEKpii=�sJ't�i3/26/20D7 i . .`v • i I�estr4tl--ctec7—�Dp i r:>��. �,t '4j 7HOMASX CAPI V::,y. ti1a3�f�d�.:' i 1695 NEWTOWN COTUIT, MA 02636�� colh 11s8iotrier f - . PAP IZ G; �1 Home Improvement Inc. - .. .. .. :-:..... .- -....s..-. „.. ':..x!.+w...,.....r.:cY 3. .�.1w.., ' _amv ..ya»Y ron+-.r.-....i ..-•".au. .-' .ar1+.^v.-s. tRa _ _ - __ _ _ — . I, Thomas Capizzi Jr., owner of Capizzi Home Improvement,hereby authorize Lisa Haworth,'to sign on my behalf for permit applications filed through the town. Signed: 66,2 Thomas apizzi, r: Date: aworth Date: 1645 Newtown Road Cotuit, MA 02635 (508) 428-9518 (800) 262-5060 FAX (508) 428-1547 CAPIZZI HOME IMPROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS ..LETTER OF_AUTHORIZATION TO APPLY-TOR A BUILDING PERMIT I,BOB MACALLISTER, OWN THEYROPERTY LOCATED AT 1302 BUNTS RIVER ROAD,IN CENTERVILLE,MASSACHUSETTS. I HAVE AUTHORIZED. CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR,THE MASSACHUSETTS STATE BUILDING CODE. I GIVE MY PERMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT IN AC , RDANCE WITH 780 CMR,THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER(S): OWNER'S ADDRESS: 1302 BUMPS RIVER ROAD, CENTERVILLE,MA 02632 OWNER'S TELEPHONE: 508-776-0017 LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: C( APPLICANT'S ADDRESS: 164 ewtown Rd.,Cotuit,MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE.OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: s° TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map_ l Parcel 4`� 0 Permit# f � { 4 r Health Division Date Issued a/"'/0 L�Z&D Conservation'Division i :. Fee Ads Tax Collector ` YTreasurer /!�/20VO Planning Dept. ' t I Date Definitive Plan Approved by Planning Board , Historic-OKH Preservation/Hyannis Project Street Address - Villagefie D wyv4. Owner C Ail,11 S �—c�2 ; Address Telephone ' A Permit Request kc !Ln� ✓v-� Square feet: 1 st floor: existing proposed 2nd floor:existing proposed Total new Estimated Project Cost B000 Zoning District Flood Plain Groundwater Overlay Construction Type r)� Lot Size Grandfathered: ❑Yes 0 No If yes,attach supporting documentation. Dwelling Type: Single Family bl� Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full ❑Crawl 0 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 O Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No ' Detached garage:0 existing ❑new size Pool:0 existing ❑new size Barn:-❑existing 0 new size Attached garage:O existing ❑new' size Shed:O existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded O Commercial ❑Yes ❑ No If yes,site plan review# Current Use 'Proposed Use BUILDER INFORMATION Name ERASER CONSTRUCTION BON Telephone Number Address 71 TARAGON CIR. License# . Home Improvement Contractor# /a 5_3 b f Worker's Compensation# (NCB S t S L! 5 a- 36 S i)i F ' r ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO-� SIGNATURE DATE 1 6-0 FOR OFFICIAL USE ONLY 4 � a '# � '`" �! r.. A^" # re •t :t •'b y _� �. 'y TM _ r f's , `, Y.. - f m 4 " PERMIT NO. - t DATE ISSUED MAP/PARCEL°NO. ADDRESS' ,_' VILLAGEF 45 OWNER DATE OF INSPECTI FOUNDATION � FRAME INSULATION . Y FIREPLACE ELECTRICAL: ROUGH FINALS PLUMBING: ROUGH FINAL GAS: ROUGH FINAL [ � FINAL BUILDING_ � . �� ... ` __ � ° . = ` -� • •3 ., ' , • DATE CLOSED-OUT j h ASSOCIATION,PLAN NO i The Commonwealth of Mossachnsd& Department of&&u*W Acvldcnrs \ OMcs�I�i� goo Washington qw!w,Maas. 02ZZI Workers' Ca Nos Iowrance AtA"t FRASER CONSTRUCTION - 71 TARAGON CIR. ❑ Iama S i am a r yumEdgm and have no one workin in anv ca N I am an for my mqdoyelli wafts an this ice... COUIT MA• 02635 '' ` % •f'S 5.: N•, '' ..::•.•: J.:i. , .,n�... .. .'.';1y3;:•a :.k,:;:.: 8aar!!iS � - J.(808) 428=2292 ------------------------ ----——---------I i mwoxl I am a sole proprietor,pa►eral Contractor,or homes(ckck on#said haw hired Cho l: =ctors listed below who haw the following workers'compeasation polices.• .......... mmusu amp., dy4•R.:,^•: f'y .ti.'?�,r:.,:JJ..• •:i�,:.}#.h�{•! .'.wi.. �. ^ J.JN •Mt�••.4..^'' .y¢J., yi+rw },J' gin.3 ^� �•• @'fWl:".,•w: ..:. w,ri: ^ J.•. :3�: w:�i`•�N' :. .nj 'i' �%; i.A''r ..pR�.r.• ....�J... ':4'i'.}t�iM1•A••}tt•'• •:•i Y\T'.d:'+0004v. Addms � •.,A. .;iawjMi•. �• - %c5 x,.•ew?i ;; b toeue a t�sera0e a Ngolnd tmdv duWa lSA of MtiI.1D=on iri to tY otatadut peadtla of a 8a UP to Sid00.00 MU*r aw yaw U WA" Ml p�la tfa toffs Ora sm wolz t3R sad a a�orSt00.�a day a taa t uuaier,bad Clot s wpy ot14V abs�wq►ba tMtnnndd to�C'Nltee orinvatlptloCn otthe D1Ati�t�aada rertseatl� Ido ,�, „nP s—of paJpry dYat the blormakn pmWded#bow b mr andcorrea gigue L60 OLO-a9.62 C Phou p [13 twono►� mwdkDapuulw pt'°uw�m'rmeklflaa►ed�rrapawbt q�dt d aot puson: v „ HOME IMPROVEMENT CONTRACTORS REGISTi2ATION oard of Building Regulations and Standards One Ashburton Place — Room 1301 Boston, Massachusetts.,02108 HOME " IMPROVEMENT CONTRACTOR - - -Registration_ 112536 ExPiratio-n 04/06/01 - ----------- --- ---=- -- --- - - - - - .. Type -� UBA \ f , .. NONE ilRrOUBTTRACTOR, Registration 112536 FRASER CONSTRUCTION co Type _ OBA DEAN C. ,FRASER 1 TARRAGON CIR COTUIT MA 02535 t FRASER CORSTROCTION co i OEM C. ERASER 61MA6OR CIR. AMOGST OM . iUIT �i 02635' r/ s '." he Town of Barnstable. . kAAL Department of Health Safety and Environmental Services - Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crosson Fax: 508-790-6230 Building'Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires th the"reconstruction,alterations,renovation,repair,modernisation,conversion, improvement,removal,d molition,or construction of an addition m any pre-existing owma+occupied building containing at l one but not more than four dwelling units or to stnteatres which are adjacent to such residence or buildi be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: Estimated Cost' Address of Work: Owner's Name: Date of Application: — lkcle) I hereby certify,that: Registration is not required for the following reason(s): E3 Work excluded by law E3Job Under$1,000 Building not owner-occupied QOwoer pulling own permit Notice is hereby given t at: OWNERS PULLING EIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME MMOVENIENT WORK DO NOT HAVE ACCESS TO THE ARB11MATION PROGRAM OR GUARANTY FUND UNDER MGL a 142A. SIGNED UNDER PENALTIES OF PMUURY I hereby apply for a perm it as the agent of the owner: Dam Contractor Name Registration No. OR Date Owner's Name q:fomu:Affidav r 5 I + or's map and tot number..... ...../ y C.Q� /(ram /n_ ��� & /�`� YHs Permit number ........�.�:.....5.SEP .P 9TOD E , ". House number ....:.t i3O. -.. ...4 INS` ALLED ICI C0I��I�L€.=$ �'��"e a � ITHI TITLE 5 'Ai�o 3yAr T O-W N O F, ;=BAR N NO � � I };§ ff� r BUILDING'11) NSPECTOR , APPLICATION FOR PERMIT TO ....y.......................... TYPE' OF CONSTRUCTION.............. .................4' / ...... t ' ......................... . ............... 1 ....................ZI/L! ......................19.. ! TO THE INSPECTOR OF BUILDINGS: The:undersigned hereby applies for a permit accordind,.to the following information: Location !CUt .....d............''� �'?• '` ......��!. ....... .d.....�......��,w��'.�v`G.. .............. ProposedUse ......%� � ...:.h g �'�,Y......f-/G�E.... ............................................................:............................ Zoning District ................. .' : .Fire District ......��!`.:�:...vST........... ........................ .. Name of Owner .. .......: .... .. ......... .' �'.... .... .......Address,..... .. ...... ... ................................................................ ' C"C�.v ' Nameof Builder ....................................................................Address .............................................................:......................... -C' Name of Architect ......................:.Address ;s ............ ...... ............ ...........................f................ ....:.................... ....... / Number of Rooms ....SP.v� -......`...................................Foundation ....,P.0.1. ��—�"a'.....�Q't'� �-r��................. Exterior` ........ ..... ...� .'9 .... ��'.`�!��' 5,...Roofing .......!S`.5 ?.6r�' `�.7............................ t Floors � ' a.��......................:..................`:.Interior .....fir �! ..4................................................... Heating .... ..�`�. �.�..Y.... .. ..... ...............Plumbing .`....a. .._ ....8.9-�� �......: ................... g :Fireplace ............:.Approximate. Cost .fOU�00�'....... Definitive Plan Approved by Planning Board --- - 19 -____. Area r,( .. . ... . ... . Diagram of "Lot and.. ,with Dimensions ' Fee ..�C/.../..:! .. .. ... SUBJECT TO APPROVAL OF BOARD OF HEALTH A. OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS - - �B�`.Fr�•'�if�c5skcrsTer' I hereby agree to conform to all the Rules and Regulations.of the Town of Barnstable regarding the above construction. . Name .. ......... �e .. �. ................. -....... I , Construction Supervisor's ., �� ..........i v ..... -120,3?- Al Nz ...... Permit for 12 Story.......... .. l Single Farm y ...................... . - Location t..2 r....1302 Bs 'River Roads Owner David Building..I'Y! t..... ........: ' Type of Construction". .. .Fr. ................. ++.-^ ........................ Plot Lot'--.-" Permit Granted r� • ..June..25 r .... ... :19 84 . >; :�; Date of.l . r^ r Date Completed "'�.. .. ...... .. 19 . 6 ITta - '"`� r� • s �• it a! 4 +��E M }ry ^T �µf :� /„�� T„�„"'"'._... ..y(,' �_...� �9 1zfi :a rltt � !j �. W � - : .. � �•t�� .V�r� �. 41 : .AZI x�� 'i�A�s..r �1i�4"""'°"` �__,'�,"«f. %.�-...�t+'�az�,qY i � is,�• .. ' _ �a r 7 .. _ _ _ ;!,! Y��� a � I 'Y;[•;+' e � '�i• i/ k.='.i:-- '. *�� 'y,�" � r^ ,. �, �t,/t .�j /� .�C _ - y'`,,�^' r• ". . // '_�'� J1 � � r J / y,� Assessor's mapjanrl lot number .:.. .. ..... (_�, �/r /' %Y ETo rr - • ., P Sewag?: ermit' number -.. .��-...., 2....................... \ Z BARNSTSDLE, i Housenumber .........................:........a.......:.....:.........:........... ' 9�p 2639. :•^ � �0 YpY�'' -TOWN OF �BARNSTABLE r ; BUILDING INSPECTOR APPLICATION FOR PERMIT TO '.....'..Siy9 w �P :TYPE OF CONSTRUCTION ............'...lN ���1.....,f°F:....... ............................................................................. f !, . .�....1� ...... ...........19.. � TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: .... � rt,s ... ............................c.Gr.....a............. ' .......................................................................... .............. ....................... Proposed Use ......�2�¢. 124 ...... /: 'y f-/Get............................................ ZoningDistrict .`L� �..............................................Fire District ......��....T.....oST......................................... .... Name of Owner ....cu:Gdi�vlr'.../�!G67Address .. d G � 'P.✓........C1.......�.�..'A... ol Nameof Builder ....................................................................Address .................................................................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms SF'v�"".........................................Foundation ....,�,�..rJc�2.........�'O'i'.'2.r. ' ............... ....... ......................................... Exlerior ....... ` ...... ...... .h.v.�i4�!.5....Roofing .......�fSoG1�9c.. .................................................. Floors /7 %10LuOO..'�O.D............................................. ..... �" 9 ................................................... O�/. !v• BY !�i� mbing ....... .........Heating .... s........................................................................Plu rig`S........................................ Fireplace .......................................................................Approximate. Cost .............................................. Definitive Plan Approved by Planning Board ________________________________19________. Area .......................................... Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH �. OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Names „1,, C-?-C. .:..4. .:% .......... 0 Construction Supervisor's License .................................... DAVID BUILDING TRUST op t> No � - -7( -- Story ....... Permit for A..§:�2-KY................. .Sle FamilY...Dwelling.......................... Location Bumps..River Road........... ...... .............. 1.1.e..................................... Owner ..David...Building Trust................... ..David Building. Type of Construction ..ftallr'P............................ ................................................................................ Plot ............................ Lot ................................. Permit Granted ...:June 25. ..............19 84 ................... Date of Inspection ....................................19 Date Completed .......................................19 TOWN OF BARNSTABLE Permit No. Building Inspector cash OCCUPANCY PERMIT Bond _._--------- Issued to ig llistM Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date Board of Health Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. ....................................................... 19......_._ ................_........._.........._............................._...................................._.... Building Inspector TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map l Parcel D Application # 2� 1 ldb `t Health Division Date Issued Conservation Division Application Fee I� Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic OKH _ Preservation/ Hyannis Project Street Address LAMPS Village C ell •{ /) Owner 61)b eK4- MGtM I I fs r Address' Telephone Permit Request D) ; �vrl CSC (n -3o Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 37 CIO Construction Type _a Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) M0 Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway.'13 Yesa ❑ No 4� Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other - ? Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) , ;= ki, 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 ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name RISE Engineering Telephone Number 401-784-3700 Address 1341 Elmwood Avenue License# 100459 Cranston, RI 02910 120979 Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE --- DATE I �V I 1 Erik Nerstheimer for RISE Engineering FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED s - r MAP/PARCEL N0.- — C ADDRESS VILLAGE OWNER z r 1 ; DATE OF INSPECTION: t FOUNDATION; f FRAME INSULATION 0 !Ql« FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH - h FINAL DATE CLOSED OUT _E ASSOCIATION PLAN NO. I ITM i i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,.Mdss. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectricians/Pluulbers Applicant Information Please Print Legibly Naitte(Business/Organization/Individual){ RISE Engineering a division of Thielsch Engineering' Address: 1341 Elmwood Avenue City/State/Zip: Cranston, RI 02910 Phone#: (401)784-3700 or 1-800-422-5365 Are you an employer? Check the appropriate box: Type of project(required): 1. N I am an employer with 4.. ❑ I am,a general contractor and I '6. ❑New construction employees(full and/or part time).* have hired the sub-contractors ' 7 ❑Remodeling 2. ❑ I am a sole proprietor or,partner- listed on the attached sheet: ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' : 9: ❑Building addition [No workers'comp.insurance comp.insurance. $ required] 5.0 We area 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 perm MGL , insurance required] t c. 152;§ 1(4), and we have'no 12. ❑Roof repairs employees. [no workers' 13. Other Insulate comp.insurance required.] . *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContactors that check this box must attach 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: The Preston Agency Policy#or Self-ins'Lic.#: 3730961=01 Q\/ Expiration Date: 1/1/12: Job Site Address: I",)Ll moS 1 lI Y�-R d ' 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 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 $250.00 a-day against violator.Be advised'that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. r I do herby certi and the ins enalties ofperjury that the information provided above is true and.correct. Sign ture: ` Date: Print Name: Erik Nerstheimer K Phone#.(401)784-3700 or -:1-800-422-5365 extI33 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 Heath 2..Building Department '.3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#: OP ID: 31 ACOROM DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/30/10 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 endorsements. PRODUCER 401-886.8000 CONTACT NAME: The Preston Agency,Inc. PHONE 401-885-4700 FAx 1360 Division Rd Suite 303 ! E MA�o xt Alc No): . PO BOX 810 ADDRESS: ER East Greenwich,RI 02818-0810 PRODUC ' K CusroMER to a:THIEL-1 INSURER(S)AFFORDING COVERAGE NAIC# INSURED Thielsch Engineering,Inc INSURER A:Zurich-American Ins Co. Thielsch Group Inc. INSURERB:American Guarantee&Liability 195 Frances Avenue Tech Realty Inc. a INSURER C:North American Capacity - Cranston,RI02910 INSURERD:Hartford Insurance Company' INSURER E: - INSURER F: ' COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT;TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE.POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.C LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iLT R TYPE OF INSURANCE - POLICY EFF POLICY EXP - LTR POLICY NUMBER MM/DD/YYYYI 1MM/DD/YYYYI LIMITS - GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY 3730962-01 01/01/11 01/01/12 DAMAGE TO PREMISES RENTErence $* 300,00 CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 10,00 PERSONAL 8 ADV INJURY $ 1,000,00 GENERAL AGGREGATE - $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY X JECPRo- Loc Emp Ben.' " $ 1,000,00 AUTOMOBILE LIABILITY - - - - COMBINED SINGLE LIMIT - (Ea accident) $. 2,000,00 A X ANY AUTO 3730963-01 01/01/11 01/01/12 ALL OWNED AUTOS BODILY INJURY(Per person) $. BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON•OWNED AUTOS $ $ UMBRELLA LIAB X OCCUR- . ' EACH OCCURRENCE $ 10,000,00 EXCESS LIAB CLAIMS-MADE '` AGGREGATE $ 10,000,00 13 ., AUC-4857188-00 01/01111 . 01/01/12 DEDUCTIBLE $ RETENTION $ $ WORKERS IMAND EMPLOYERS'L ABILITY Y/N X Fl STATU- OTRH- - -A ANY PROPRIETOR/PARTNER/EXECUTIVE 3730961-01 01/01/11 01/01/12 E.L.EACH ACCIDENT $ 1,000,00 OFFICERIMEMBER EXCLUDED? NIA - , (Mandatory In NH) E.L.DISEASE-EA EMPLO YEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below a E.L.DISEASE-POLICY LIMIT '$ 1,000,00 C Professional Liab DVL000026800 04/01/10 04/01/11 Prof Llab 2,000,000 D Leased/Rented Eqp 02UUNTD56" 01/01/11 01/01/12 Equipment 100,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) + CERTIFICATE HOLDER CANCELLATION TOWN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE -THE EXPIRATION DATE THEREOF, NOTICE WILL BE' DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved.. - I ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD r ,r`j Mt THIEL-1 PAGE 2 NOTEPAD INSURED'S NAME Thielsch Engineering,Inc OP ID:31 DATE 12/30/10 Al RI gr:n ineering,a division of Thielsch En ineerin ,Inc. Ga kell J�ssocial9es ad' f ThielsNn h Ineen�i ,Inc. BA Laboratory,a c�ivlsjon o � Ielsc In�erin , orptory,a alvlsign,o IgJsc n grin Inc.CCC ngmeenn Ivlsmn NfhigIs ngmee I ,Inca atera�agemer�> lervices,a division ofhlelsch Engineering,Inc. • J _ �onsuWer4Z(a4nul�s�mss�egu onO ice o , .. 610 Park,Plaza- Suite 5170 Boston, ssachusetts 02116 Home Improve ontractor Registration Registration: 120979 ? :Type: Supplement Card <. Y y F w Expiration: 3/25%2012- THIELSCH ENGINEERING m f ERIK NERSTHEIMER ro 1341 ELMWOOD AVE. CRANSTON, RI 02910 Update Address and return card.Mark reason for change. r Address Renewal Q Employment Lost Card. - DPS-CA1 0 5OM-04/04-G701216 ✓/ze �ooranzovurseai oaaaac`a welt_ Office of Consumer Affairs&Bu mess Regulation p� License or registration valid for individul use only OME.IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration,�1=979 Type. 10 Park Plaza-Suite 5170 F Iry 12 Supplement Card Boston;MA 02116 _ THIELSCH EN&, �y ERIK NERSTH 1341 ELMWOOD C c CRANSTON,R1 Undersecretary Not valid, without signature x Licensee Details '' Page 1 of 1 The Official Website of the Executive Office of Public Safety and Security(EOPS) Mass.Gov Home Public Safety " Department of Public Safety Licensee Complaints License Type Construction Supervisor.. License# 100459 Restriction WS,IC Name Erik Nerstheimer City,State,Zip North Scituate,RI,02857 Expiration Date 3/28/2012 Status Current No complaints found for this Licensee. , Back'ro Search f http://db.state.ma,.us/dps/licdetails.asp?txtSearchLN=CSLI00459 1/7/2011 A ti ' yj 4 Fi k� `'.4��4 hR%��h �"+�i t'n "w4 � 4 � •N NAT-24531 - 1 A K m A , Control No: 34,244 THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT of LABOR a , DIVISION OF OCCUPATIONAL SAFETY s° 19 STAMFORD STREET, BOSTON,MASSACHUSETTS 02114 u LEAD-SAFE RENOVATION CONTRACTOR LICENSING WAIVER RISE Engineering A Division of Thielsch Engineering; Inca' 1341.Elmwood Avenue ^ Cranston, R102910 WAIVER: LW000672 EXPIRES: April 15,2015 IN ACCORDANCE WITH M.G.L. C. 111, § 197(B)(b)AND 454 CMR 22.03(3)(b), THIS LEAD-SAFE RENOVATION CONTRACTOR LICENSING WAIVER IS ISSUED BY THE DIV. OF"OCCUPATIONAL SAFETY TO THE CONTRACTOR ABOVE FOR THE PURPOSE OF PERFORMING LEAD-SAFE RENOVATION WORK. THIS LEAD'SAFE RENOVATION CONTRACTOR LICENSING WAIVER MUST BE MAINTAINED BY THE CONTRACTOR IN ACCORDANCE WITH M.G.L. C. 111, § 197B(b) AND 454 CMR 22.04 WHEN PERFORMING LEAD-SAFE RENOVATION WORK.` y HEATHER E. ROwE,ACTING COIYMSSIONER LJ Printed on Recycled paper _ RISE ENGINEERING . 'Federal ID#06-6405629 RI Contractor Registration No e9 81 A division 86 d �soBof Thiels ch Engineering g eermg MA Contractor Registration No 120979 CT Contractor Registration No 620120 1341 Elmwood Avenue,Cranston,RI 02910(401)784-3700 FAX(401) 10 CONTRACT �y- 1� 1 Page 1# THIS CONTRACT IS ENTERED INTO BETWEEN RISE 1 .1�ICa���� 1�� 111.���� _ _ ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW CUSTOMER S .. . I 'GJ PHONE DATE- Robert D Macallister �w client# (508)771-0465 11/10/2010 114484 SERVICE STREET _ 1302 Bumps-river Road BILLING STREET 1302 Bumps-river Rd SERVICE CITY,STATE,LP - BILLING CITY,STATE,ZIP Centerville,MA 02632 Centervil,MA 02632 JOB.DESCRIPTION. RISE Engineering will provide labor and materials to seal areas of your home against wasteful,excess air leakage. This work will be performed in concert with the use of special tools and diagnostic tests to assure that your.home will be left with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams,weatherstripping and other products. 1 Primary areas for sealing include air leakage to attics,basements and other unheated areas(windows are not generally addressed.) RISE Engineering will provide labor and materials to install 2.25"R-10 semi-rigid fiberglass board insulation to 656 square feet of kneewall $1,188.00 area RISE Engineering will provide labor and materials to install:a 9"layer•of R-30 Ctass 1 Cellulose added to 640 square feet of open attic space. $1,771.20 RISE Engineering will provide labor and materials to install insulation and.weatherstripping to 1 attic access hatch(es). $704.00 RISE Engineering will provide labor and materials to insulate the back.of 1 existing kneewall access hatch(es)with 2.5"rigid fiberglass board $25.00 insulation,and seal the edge of the hatch with weatherstripping. RISE Engineering wilfprovide labor and materials to install RA3 faced fiberglass to 15 square feet of wall:place. Insulation will be fastened in $85.00 RISE Engineering will apply all applicable,eligible incentives to this contract.'You will be billed only the Net amount. Currently,for eligible $17.25 measures,the Cape Light Compact offers 75%incentive,not to exceed$2,000 per calander year. . -$3,138.80 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF *"-*Six Hundred Fifty-One&651100 Dollars $651.65 UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF 1%WILL BE CHARGED MONTHLY ON ANY UNPAID BALANCE AFTER Ep DAYS,SEE REVERSE FOR IMPORTANT INFORMATION.ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES ALIT QED S -RISE ENGINEERING CUSTOMER ACCEPTANCE NOTE: CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN ,\\ DATE OF ACCEPTANCE ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE DAYS. - SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE t Pxh J) •�j Z7. 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