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HomeMy WebLinkAbout0621 MARINER CIRCLE l ,. ,'$rR'.�:;r'!,.�"� •%",'�-"T�'.x';.Lfi;`...:C...1..7C,..:... ,.-�- J .,.gr,ei..,. ++'•?ia.� s i.;p,".S`S sv r..'„rC"ur, iu!F aid-:MF`.r?�YKw'f.�..�„tt i,„f at'6x'.Sx.�R �'+,P r.•P� i i n iR ll WWW 1•.;. s ? Zv . 11N +'e sr id :l'(a- '� , �n ate'•� �° Ni Via �1 � _ : � x r•' ,�+�'t` `\ Al Aof p i t .•. a ru -ioi 4 tics } / cg*rW.if TWIT T�fs f *T,1 A , S z• b�, .t R - .c h.J a{ `P t I t '3�a yv�: ,�.. A'LW �� •t V.i �� `Y' � ,'_ _T kT'r�, t�S�l^f ,tij4�� t �P.. X' ..- .. ,. e�wAWnq�. � rs letn" Ir r "k •v/ z '•v �.5 �, �V •<. 'J.. *'{�'"�'i' 4 �» F,. '� " �' " .ry a iA x f`'J u ` �t�d i�flr'C+ .. ,e »Y"t.,a4�a"-+Ar,;.tit c w 1 E'.�. $Y:. �, '',',� �p�jx. ��. 2i,Y" .F} ..; P� +, u+v { t Y y � hr S.g. F" �a- "6• } "`�Qy�y,�s 43"'''C�� �i� ky �,,,�s.F s ` s' y-�- r .� �' r A j :, t s d;.i ,� ±t. }�i +e<„•es.� "�i,,. 2 � �,i �, .j a �, e' _%� � '�:7 '� �r r• --r rAk r���irJ Assessor's map and lot number .... ....:a.., ...r� t s �`_ . ........ 4V11tlST BE �QyOFTNET0�4. Sewage Permit number c9Q.-.. ..3.:......C�.....� a SEPTIC�SYSTEM � 3 . � .�•...9�.L:�-.o INSTALLED /� IN COIv11'LIANC = E1EanSTADLE, i House number � 01-� WITI♦ TITLE 5` 90............ .......................................................... p ENVIRONMENTAL CdDE AND �EpMOR TOWN OF B ARNI'T9A EEP"s • BUILDING INSPECTOR APPLICATION FOR PERMIT TO ........aj.. .&............................................................................................. TYPE OF CONSTRUCTION ....G J.P .... /. .. . .......... 9........ a ..................9. � TO THE INSPECTOR OF BUILDINGS: ' The undersigned hereby applies for a permit according to the following information: Location .G!.'.......Z ..... / ..!.Q' ..... ....... It.. ....... ProposedUse ......l..l. ..... .............. ...................................................................................................................................... Zoning District �. .....Fire District ..... ..... .... .... Name of Owner .. ......... . ..... ..................Address ...........-..... ...................... Name of Builder ..... ......... ..... ......Address R. Nameof Architect .........:...................:....................................Address ............. ................................. Numberof Rooms ...................6...........................................Foundation .. .................. .......................................... �..Exterior ..�/��!�....����:�"�! ' .......... . ..........................Roofing .....,r���/4Z//. . ....... ........................................ Floors ..... Cl. / ............................Interior ..... . . .G ...................................................` C; ............... / , . JHeat'ing ` ...... ...'� ....... ..:..........::....Plumbing ...........1 .............. . . Fireplace ................... ./........... Approximate Cost ...��. .f. ............................. Definitive Plan Approved by Planning Board -____-�9 _--__1_-_ v . Area ....,,[..�� ...,5: .'.....- Diagram of Lot and Building with Dimensions Fee. .................... ......................... SUBJECT TO APPROVAL OF BOARD OF HEALTH �OI� u �y)oa I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. , Name .. ... ....... ...................... THEO CONSTRUCTION � r No 226.2.7..... Permit for Qzte.. t.QrY Single„Family Dwelling yF ........ r Location ..Lot #28 621 Mariner Circle .............................................................. Cotuit ✓ i ............... ............................................................ S ero Theoharidis Owner ......}?......................................................... Type of Construction Frame ....... ..........•.....•...............•.........•..................................... • 1,� 1 f Plot ............................ Lot t Permit Granted .........October 3'0................................19 8 0 ' Date of Inspection ....................................19 ' Date Completed ........ 19 :HERMIT REFUSED ........�. '�a. ...... 19 ► , ..n. ..._. ....... Q ..y:: ..... n ................................................... , ........` (.r............ ..................................................... - • i Approved ... 19 ............................................................................... AsseSsor's map and lot number .... ,,`.y. AFT ETO Seyage Permit number sL f 1 1 � Z BASBSTJIDLE, i House number ................`...j....................................................... 9 rasa Op 1639. `00� Q YPt TOWN OF BARNSTABLE 4 BUILDING INSPECTOR APPLICATION FOR PERMIT TO ..........�.a..td ...................................................................................................... TYPE OF CONSTRUCTION .... : ..flt?'> ltii:'P.....7)1v ` 6, ..................................................... U .............. .......... �....:� ..............19.�t 0 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit 1 according to the following information Location ... 1u 1"6 lo / f �/:� , .... C; ;ff� ... . :::....:....... .. ..................... ProposedUse ........ ' t ! ° ! .................................../............................... ................................................................ Zoning District .....................................Fire District dam« .................................... ............. .................................................................. .Name of Owner .... ..5r�!`�t��� ! - ............Address 1 Name of Builder ? �... f/�{!!Pt rfl!fti �......Address ............................................. ... ..................................... Name of Architect ...... ..... ....-.......................................Address ...................�.�/............... ............................................ Number of Rooms .................. r'?...........................................Foundation ... ................................. Exterior ............................Roofing ....... !d............ ....... ........................................ Floors ..... //„�....5.... ..........................................Interior ......Ae.AWav ............................................ ... .:.. raj. �q 4 Heating (�..............................................Plumbing .............:.......................................................... ......... Fireplace / Approximate Cost .... .�!.,:. ' ..... ?................................ .... .. Definitive Plan Approved by Planning Board ------ -------19__+� Area ' .................. .......... Diagram of Lot and Building with Dimensions Fee µ'.>. �.� ................................... SUBJECT TO APPROVAL OF BOARD OF HEALTH `ham t u� I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ............ THEU CUNSTuUCTT,-Om ee=��-�* . j ^ . . . ' . . . ` Mo 2.2` 2.7-. Permit for [}aIg...StPKY............ __ ..g ..Dvve ............... Location ..bgt...#.Z8...G2l...marine.r...Cir.cle .................Q.Qtniir.............................................. CJvvnar .......T j!PD...Q.Q7lPtK.U.Q.tj,.Q.IR.----.. Type of Construction Xx ' ^ Plot .....................' Permit Granted / October 30,...,9 80 uore or Inspecti/n ....................................19 Date Completicd/A,..............................19 U PERMIT REFUSED _,-. --.-------. lA � ---' -- -' --------- , . '--..��m....�� --f-+-~'--------. '---^^^^^------^'~^^^^--^^~^^---` '-'-----'~~^^~^^^'-'--'-^'~^^^'----'- Approved ------------.---.. lQ -------'---~-^--'--^^^-'-~^^^^^' -------'^--'----^^^--~^^^'~'-~^- | - �_. . .. . IL f a 3 - --� §o o •� E4ko. � o ' = FLAN SHO ING FOUNDATION LOCATION o ' 31.T, MAS CHUSE T T S. . ', „ awe .8y= 7'u4 L nt �" v 'T c�J r 1C! f SCALE Vtw 54 ', . WE- O&T, E 15, i.1� ; K : `-r �� G° 6STERD:LAND SlIRYWYOR . 1 mERFBY CERTIFY THAT'_THIS .FoLhvl Artom is L ATEQ 4N'MULO .'AS SHOWN AND ,WKkVAfS TD THE TOWMI- ` F BI NSTQBt'E ZO+AtPNb `RE60LA `IONS REGARDING � yG o ROAM; SFT� f" E:T.ia RAYlV ON y C-11 svR. 4 TOWN OF BARNSTABLE Permit No. __22G2'7 Building Inspector � rua Cash ------ --- 16ia. .. 00CUPANCY PERMIT Bond XX �F6 No building nor structureshall be erected, and no land, building or structure.shall be used for a new, different, changer or.enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall'be occupied until a. . certificate of occupancy has been issued by'the Building Inspector." Issued to Theo Construction Address South Yarmouth Lot #28 621 Mariner Circle Cotuit Wiring Inspector ��,,fw, Inspection date r , Plumbing Easpector Inspection date r _ q Gas Inspector -�' Y f �� �YZ -� - Inspection date 4 3pr`- C: " VEngineering Department . 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. SO jq_�At l/ Building Inspector / Eng-inep�Dept. (3rd floor) Map 0.Z.,3 Parcel C, Permit# / . - House# Q Date Issued Bo d of Health(3rd floor)(8:15 -9:30/1:00-4:30) o�S�op CA44 : . = 1?` Cons ation Office(4th floor)(8:30-9:30/1:00-2:00) cb J F Slip s �qp� , INE 19 �r ^vs,? BARF53A9J,iEJ' �.FA�:t v TOWN OF BARNSTABLE Building Permit Application Proje LAddressVil _ Owner Address Telepho — d? Permit Request le X First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ /a 02) CIZ� Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure ,,2-6 --- Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: ;Z7 ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing Z New No. of Bedrooms: Existing_ mot-- New Total Room Count(noZincl ing baths): ExistingNew First Floor Room Count Heat Type and Fuel: ❑Oil ❑Electric ❑Other Central Air ❑Yes l Fireplaces: Existing _New Existing wood/coal stove ❑Yes p'No Garage: ❑Detached(size) Other Detached Structures: ❑Pool( ' e) ttached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name A ,eJL Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO t SIGNATURE DATE �?/7 6 BUILDING PERMIT ENIED FOR THE FOLLOWING REASON(S) I f ?, n nw"'" :::!�"ma'a}:.:�� °F tHE u, The Town of Barnstable 1m� Department of Health Safety and Environmental.Services 1659. Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. /Type of Work• �T st.Cost /Address of Work: Owner's Name Date of Permi Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,00d Building not owner-occupied Owner pulling own permit Notice is.hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Contractor Name Registration No. Date OR Date Own 's Name s* a = +` The Conttnonhealth of 4fassachusettt Departnunt of Industrial Accidents 1 1- • � OfliceofINY9st/921/offs _'•; ':.:_ , '' 600 {i ashinrtoit Street Bosto►t,Afass. 0 111 Workers' Compensation Insurance Affidavit it an an rm i n• _ I � - ` ./C,t• ✓city —� nhone{I �(�v�, 1 am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity •ter rr r.�,-��;� .�..,� � --.....�-_ �-- �--•+-----�..--�,•-ter-•- I°am an employer providing workers' cuimpensation for my employees working on this Job. company name: address• city: phone#: insurance co. policy# I am a sole proprietor, general contractor, or.homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: comnanv name: address: cih•• nhone#• insurance co nolicv# �- - .. __ ._... �..e,ri,«' ':71�av:^.rr^r..:_'T•.'�,e.tr:L'��_' � re••--ra��'�• �;�'y'7's!J.,�w!!!' u'::r,".,.:.—• ::�.:.^+r...�•.ymoi-^'e.r-•'^_••.e. comnanv name: address city: nhone#• insurance co policy# ,.. �Attach additional shcef if tiecessaty,•�"+�-a-;��,..ti�r.,r�'� .:•{• •«•'•�� �"•.�•��� •• >'t � °A+•�•••.�• Failure to secure coverage as required under Section 25A of 1NGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 andior one years'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of 5100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereht certifj•tut the pants and penalties ofneryun•that the information provided above is true and correct. [j Si=nature Print name �(315�T-- Za�&OK•-S Phone# 4' official use onh• do not write in this area to be completed by city or toA official city or town: permidlicense# r Building Dcpirtment Licensing hoard I]check if immediate response is required [3Scicctmcn•s Office [311calth Depa tment contact person: phone#; rlOther ti i 4. t (re%ised 3f9;PJ.ai information and Instructions ' Massachusetts General Laws chapter 152 section 25 requires all emplovers to provide workers' compensation for their employees. As quoted from the "law", an emph ree is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An entph rer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more the foregoing enLaged 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 Navin- not more than three apartments and who resides therein, or the occupant of the dwcllin�(, house of another who employs persons to do maintenance , construction or repair work on such dwelling_ hous or on the _rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that even-state or local licensing agency shall withhold the issuance of- renewal of a license or permit to operate a business or to construct buildings in the commonwealth for anv applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance'with the insurance requirements of this chapter ha� been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavit-s 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. Cin• or 'Towns 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. Pleas. be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. Tile Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. .. - ... •.. •{�». +:� Try :F• Tile Department's address. telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax #: (617) 727-7749 phone 9: (617) 727-4900 ext. 406, 409 or 375 • TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print / DATE ... .�3 9w •• ' . •• JOB• LOCATION : 'Number Street address Section of town "HOMEOWNER" �' r • ' •_.. Name Home phone Work phone PRESENT MAILIN G ADDRESS Air. Cj.ty town State Zip c: The current exemption for "homeowners" was extended to include owner-odic: dwellings of six units or less and to allow such homeowners to engage an dividual for hire who does not possess a license, provided that the owne: acts as supervisor. DEFINITION OF HOMEOWNER: Person(sJ who owns a parcel.. of land on which he/she resides or intends tc side, on which there is, or is intended to be, a one to six family dwell: attached or detached structures accessory to such use and/or farm structL A person who constructs more than one home in a two-year period shall not considered a homeowner. Such "homeowner"• shall submit to the Building Of on a form acceptable to the Building Official, that he/she shall be resno for all such work performed under the building permit. . (Section 109.1.1) The undersigned "homeowner" assumes responsibility for compliance with th, Building Cpde and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and'requiremE: and that he/she will co ly with said procedures and requirements. HOMEOWNER'S SIGMA APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35,000 cubic feet, or larger, will be requir to comply with State Building Code Section 127.0, Construction Control. HOME OWNER'S EXEMPTION The code state that: "Any Home Owner performing work for w1ich' bu: Permit is required shall be exempt from the provisions of this sectic (Section 109.1.1 - Licensing of Construction Supervisors) ; provided i Home Owner engages a persons) for hire to do such work, that such He shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are as: the responsibilities of a supervisor (see Appendix Q, Rules and Regu: for .licensing Construction Supervisors, Section 2.15) This lack of often results in serious problems, particularly when the some Owner I unlicensed persons. In this case our Bard cannot proceed against ti inlicensed person as it would with licensed Supervisor. The Home Owr: as. supervisor is ultimately kesponsible. :•!. .•• To ensure that the Home Owner is fully aware of his/her responsibilit communities require, as part of the permit application, that the Home certify that he/she understands the responsibilities of a supervisor. last page of this issue is a form currently used by several towns. Y care to amend and adopt such a form/certification for use in your com r:. `� ;�� ,� • , I , 1 �f � I � l 1+ I r 1 r ' " P k t ision 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 621 Mariner Circle (application#201404892) has been inspected by a certified Building Performance Institute(BPI) Inspector. All work performed meets or-exceeds Federal and State requirements. Sincerely, cs� Conor McInerney n ConserVision Energy 376 ROUTE 130,SUITE C SANDWICH,MA 02563 508-833-8384 WWW.CONSERVTODAY.COM r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map oz.'s Parcel n-4,4 Application # Health Division Date Issued S �y Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address t_*z: .., t,;L c..Z Village, Owner Address 6 i.. Telephone _ Permit Request ��a�����z alp o►`, CC Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new ,Zoning District Flood Plain Groundwater Overlay e� Project Valuation +�` Construction Type :Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Ur"" Two Family ❑ Multi-Family (# units) Age of Existing Structure \,ck g 0 Historic House: ❑Yes ❑ No On Old King'-� tghway:�,Q Yes-�❑ No ��. t� Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other + Basement Finished Area (sq.ft.) Basement Unfinished Area (sq:ft .'J Number of Baths: Full: existing \ new Half: existing new Number of Bedrooms: Z existing _new Total Room Count (not including baths): existing ��_new First Floor Room CountS rr Heat Type and Fuel: YGas ❑ 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 n"C:SL,+—k-%Zbu Telephone Number ao-t- -%V&- Address %mac_ '31: License # �13,19 Home Improvement Contractor# \-A\ i3z Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO q%�-►� �. SIGNATURE DATE '-7 Z4 FOR OFFICIAL USE ONLY IkPPLICATION# DATE ISSUED MAP/PARCELNO. k ADDRESS VILLAGE OWNER DATE OF INSPECTION: ' FOUNDATION FRAME F , y INSULATION f , $' FIREPLACE ELECTRICAL: ROUGH a FINAL PLUMBING: ROUGH FINAL I!, GAS: ROUGH . FINAL ! FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. s t Teaarm . i rtgal�to2 &Aiim eese qr r istr€xtion:ua[iii A rind Odul use Only r before the:es[3 irationdatc If found return to: - - ME IMPROVEMENT CONTRACTOR istration: 171251 Type.. Owleg-o€Consumer Af['airs aad Business Regulation iration: 31112016 PnitGPsip: If}Pork P[axa Suite 5t7t1, Easton. IA 0211 . CON-SERVE ENERGY DONOR i CINERNEY 376 ROL i E 130 SUITE C SAPJl'M!!GFl,"AA 02553 Underseereury Not valid trithout signatttse 39 S QNSET jNUVl akd-Ampu B1 atM,t 32 P $ t ..F+.w—,-nw�...�.._.-..:_.-+va......�...�u..e::....n...4........-.-.�.,.r...-.e-.r.:J.e..ny.,..:«.u�+...y.w.n_�.o-'wu�wr..ri.r.•w:•:.a.+..•win•+•!u.,kwa..u•m•s»r�.:W.:S+^ ....:nbW.. �..:n'.+n...n ....m.t. � M1 The Commonwealth of'Massachusetts Department 0j Adustrial Accidents' Office o, Investigations 600 Washington Street — Boston,MA.02111 wwmmass gov dia Workers' Compensation Insurance Affidavit::Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly f°nvsc.ar�!'z+irtaz trsstavrst . €1t33Limmu j Nets"K.--An lgs�rp t W-1381.V{ Address: 376 Route 130 Suite G City/State/Zip: Sandwich, MA 02563 Phone r4k 508=83.3-83 Are you an employer?Check the appropriatebox: Type of project(re+gaaired}: 1. 1 am a employer with 8 4. ❑ i am a general contractor and I 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 C]Remodeling" ship and have no employee These sobl3 ontractors have. 8. T.-1 De noiition working for me in any capaet€y.: �v&Kerss` 9— uil Bfliltg additiotr: [No workers'comp,insurance 5• ❑ We area corporation and its- required.] officers have exercised their 10..� Electrical repairs or additions 3.❑ I am a homeowner doing all work; right of exemption per.MGL . 11.[]Plumbing repairs or additions myself [No workers comp: C. 152, 1(4)5 and we have no I D Roof repairs insurance.required_1 t employees.-[No workers' , n�t:e UUput#wfi, comp. insurance required.) ,L, *Any applicant that checks box#1 must also fill out the section below showingtheir work'ers'compensation.policy information. t Homeowners who submit this affidavit indicating thcy arc doing all.work and then hire outside contractors must submita new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policysnformation: I am an employer.that is providing workers'compensation insurance for my employees .below is the pnlaey and jo$site information, Insurance Company Name CS&S/WORKCOMPONE. Policy#or Self-ins,Lie.#: 6011316349 Expiration Date: Q311112015: Joh Site Addre_sc City/State.lZip: Attach a copy of the workers'compensation policy declaration page(showing the.policy:nu bet 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 inve-stipgatiom,of the DIAfh inz ranrr c-tsvc ss Lertf ati st_ _�— _--_ I do hereb .j3' er t p 'ns nd pen allies of per,jury that the inforrnratiwn provided above is;frue and roprecA Signature: Date ,7, N `�- ipl�nna:f�- Official use only. Do not write in this area,to be completed by city or town official City or Town: Issuing Authority(circle one): 1.Board of Health 2.Bm`fd€ng Department 3.City/Town Clerk: 4.Electric al:latspe olr S .Pluanh deg ipspeetvr: 6.Other Contact Pers on: Phone#.. i o CERTIFICATE OF LIABILITY INSURANCE 03/1712014. 'I'MIS CERTIFICATE IS tMED AS A(MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT kFF9,P_RLI 1TiVELY OR 49--ATRfFL LtltEINM EY E"D OR ALTER THE COMPAGE AIFFORDlzD:RYTi�EPOLICIRS.MLOW T10EI4 CERTIFICATE-OF INsURAMCF NOT CONSTrrUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER„AND THE CERTIFICATE HOLDER. IMPORTANT: U the certificate holder is an ADDITIONAL INSURED,the palley(les)must be endorsed, if SUBROGATION IS:WAIVED,subject to the ternt.s_and conditions of the policy,certain polities may require on endorsement• A statement on this cergfflcate dos not confer+Ights.to the oer"cate holder in Aeu of su4fi e+ldareem@nt(SI• PRODUCER CONTACT .. . CS&SfWORKCOMPONE NAME: PO 13OX 946580 PHONE Tax ftAf t!► i3 FL 327 € Phone-877-124-2669 11° Fax-877-763-5122 INSURER(5)AFFORDING COVERAGE . NAIC# `Continental Casv Company INSUR€R A. Pa 20443 INSURED INSURER 8: CONSEWSION ENERGY 376 ROUTE 130 INSURERC.: SUITE C I; ERo:Continental Casualty Company. 20443 fi!SANDWICH,MA 02563 INSURER E Continental Casualty Company 20443 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,TERRA 0R CONDITION OF AMY CONTRACT OR OTHER DOCU6IENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRS9ED HEREIN IS SUBJECT TO ALL THE TERM$,EXCLUSION$AND tCONDfROMS OF!h4H€oust€S,.LIMITTTS SHOWN MAY'HAVE B€€N:R€@UeEb BY PAID CLAIMS. rmE cr to kAncr ...._.. ..INSR _ - _:.. POU:Cr m7%BER N"MNY�_ .. UOTS GENERAL LIABILITY EACH OCCURRENCE $1smm , CfMMERCiAt GENERAL LIABILITY DAMAGE TO RENTED $300 000 PREMISES(Ea occurrence) # CLAIMS MADE OCCUR MED EXP JAny one person): $10,000 A Y P1 6tt11316336 OW1112014 03M I12015 sera s AUti P1aL�zY $1,000,000 GENERAL AGGREGATE 2,000,0.0 GEWA AGGREGATE LgaT APPLES Peg: PR4DUCTs-G�dPr{3P.Af�fa �2s��r--- POLICY .P7ERCTT R L" AUTOMOBILE LIABILITY- _. . . COMBINED a1NGLE LIMIT $1,000,000 - (Eia"accident) ANY AUTO _ BODILY IN,NRY(Per Per—) ALL ODD SCHEDULED (Per 5c�i3eitl A _ AUTOS AU D N N 6011395335 03111120`14 (j 03IM20`15 Safi Y i"33URY ) HIREE3 AUTOS AUTOS s' PROPERTY DAMAGE UMBRELLA LIAi3 OCCUR EACHOCCURRENCE 1,000,0 D EXCESS LIAR GAMS-MADE N N 6$11M6353 03/11 2014 03/11/2015 AGGREGATE 1,000,000 DM RETENTION$ 101900 A .. �m EMPLOYERS`LIABILITY TORY LIMITS ER i ANY PROPRiE7rOR{PAR7NER/EXEeUTiVE YIN E L:EACH ACCIDENT $21008 OFRCERAAEMBER EXCLUDM7 id M 601'13163�19 D31. 03/1112014 1112015 jMari>>>u'in NH) .. . If yes,aesa(be under E.L.018EASE=-EAEMPLDYEE Mum DESCRIPTION OF OPERATIONS below e-L.DISEASE-EDLICY LtMffL $500,000 DESCRIPTIm Of OPERATIONS I LOCATIONS t VEHICLES(AllitchACOR11 101,AddNt nW Rem Sdwdul%d awre space isre%*sdl. Certificate Holder is added as an additional insured as provided in the bianket additional insured endorsement. CERTIFICATE HOLDER __ CANCELLATION tSE _Engine enng SHOULD ANY OF THE ABOVE DESCRIBED POUICIES BE CANCELLED BEFORE 1341 Elmwood Ave THE EXPIRATION:DATE THEREOF,NOTICE WILL BE DELIVERED IN Cranston,Rl 02910 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All fights reserved. ACORD 25(2010106) The.ACORD name and logo are registered marks of ACORD eadass OWNER AUTHORIZATION FORM s—" (Owner's Name) owner of the property located at �! �/s^ ��¢ (Property Address) (Pr party Address) hereby authorizeoew�'S' (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my beW to obtain a building permit and to perform work on my property. Cate