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HomeMy WebLinkAbout0277 FULLER ROAD Y p oK 10161 y Cape Save Inc. TO',711 OF B;' TABLF ' 7-D Huntington Avenue South Yarmouth, AM Ow266,4t°j 6 Art 1 : 0 6 Tel: 508-398-0398 Fax: 508-398-0399 r � it f f ' W 9/29/14 Town of Barnstable , Thomas Perry CBO Building Commissioner 200 Main St. Hyannis,MA 02601 RE: Building Permits Dear Mr. Perry, This affidavit is to certify that all work completed for 277 Fuller Rd, Centerville has been inspected by a certified Building Performance Institute (BPI) Inspector.. , Ceiling: R-31 cellulose; R-21 cellulose under decking; R-45 cellulose under decking Walls: R-14 densepack cellulose ' Crawlspace: R10 on foundation walls All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey C33s h2hV qq Town of Barnstable *Permit#� / b� Expi s 6 months from issue Bate Regulatory Services F r r . annrert+s�s, • — '� Richard V.Scali,Interim Director ' Mib ;j 14 Building Division Tom Perry,CBO,Building Commissioner y 200 Main Street,Hyannis,MA 02601 WN '� www.town.barnstable.ma.us Office: 508-5"624038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Yalid without Red X-Press Imprint Map/parcel Number 7,3 I Property Address o2 7 7 Residential Value of Work$ / �7� e Minimum'fee of$35.00 for work under$6000.00 Owner's Name&Address 1 I( "-- � IRA 0a6 B Contractor's N.,crAtA ! V�e�e-- Telephone Number Home Improvement Contractor License#(if applicable) ®d 6 9- 3 Email: Construction Supervisor's License#(if applicable) 7 O07 Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance f ® Insurance Company Name Workman's Comp.Policy# 0/76?/0 d Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders.U-Value ` 3 C) (maximum.35)#of windows c� #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,Le.Historic,Conservation,etc. ***Note: Property er s sign Property Owner Letter of Permission. A copy of H Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: TA EVIN D\Building Changes S RESS.doc Revised 061313 HOME IMPROVEMENT CONTRACT Sold,Furnished and Installed by: PLEASE READ THIS CONTRACT THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services 908 Boston Turnpike Unit 1,Shrewsbury,MA 1545 Toll Free 8779033768;Fax 8009863610 Branch Name: Boston South Date:4/20/2014 ME Lic#C 02439 RI Cont.Lic#16427 Branch No: 31 CT Lic#HIC.0565522 MA Home Improvement Contractor Reg.#126893 Federal ID# 75-2698460 Installation Address: 277 fuller road Centerville MA 02632 City State Zip Purchaser(s): Work Phone: Home Phone: Cell Phone: MIM mary to11 (508)775-1835 Home Address: 277 fuller road Centerville MA 02632 (If different from Installation Address) City State Zip. E-mail Address (to receive project communications and Home Depot updates):matolltt@aol.com Marketingemails will not be sent from The Home Depot. r Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,and THD At-Home Services,Inc. ("The Home Depot")agrees to furnish,deliver and arrange for the installation("Installati on")of all materials described on the below and on the referenced Spec Sheet(s),all of which are incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders (collectively,"Contract"): Job#:(Internal Reference) Products:' Spec Sheet(s): Project Amount 7483416 Windows 7483416 $1,973.88 Minimum 25% Deposit of Contract Amount h due upon execution of this contract Total Contract Amount $1,973.88 Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion Certificate(one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each. Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. Payment Summary: The Payment Summary# 7483416 ,included as part of this Contract,sets forth the total Contract amount and payments required for the deposits and final payments by Product(as applicable). GENERAL TERMS AND CONDITIONS Responsibilities: The Home Depot:will provide the Products identified above,make arrangements to have the Authorized Service Provider perform the Installation services in a professional and workmanlike manner,and arrange proper insurances. Unless otherwise expressly provided for herein,Authorized Service Provider will obtain required permits and provide permit numbers. Customer:will identify any property lines,easements,covenants,underground or overhead utility lines,pre-existing physical or 01-30-14SFC Page 1 of 11 I , �y=f f HOME IMPROVEMENT CONTRACT PLEASE READ THIS CONTRACT NOTICE TO CUSTOMER You are entitled to a completely filled-in copy of this Contract,signed by both you and The Home Depot,at the time you sign. Do not sign a Completion Certificate before the Installation is complete. Accentance and Authorization: Customer agrees and understands that this Contract is the entire agreement between Customer and The Home Depot with regard to the products and installation services and supersedes all prior discussions and agreements, either oral or written,relating to said products and installation.This Contract cannot be assigned or amended except by a writing signed by Customer and The Home Depot. Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has received a copy of this Contract Customer acknowledges receipt of the Notice of Cancellation,and that The Home Depot has orally informed Customer of Customer's right to cancel. Customer's signature below constitutes Customer's acceptance and execution of each of the applicable Contract Documents.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. You are entitled to a paper copy of this Agreement if you choose. If you consent to an entailed copy,your consent applies only to this Agreement.By contacting sales office (877)903-3768,you may update your email address,withdraw your consent,or obtain a paper copy of the Agreement at no charge. By signing below,you confirm the following: • You consent to receive only an emailed copy of this Agreement • You have access to a computer that can receive and open emails and PDF(Adobe Reader Version 10.1.4 or later)formatted documents. • Your email address is correctly listed on the Home Improvement Contract Submitted by: Sales Consultant Janice Campbell License Name. Telephone No. (877)903-3768 Sales Consultant License No. (as applicable) CANCELLATION:CUSTOMER MAY CANCEL THIS CONTRACT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS CONTRACT TO THE ADDRESS LISTED ABOVE. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. r� 01-30.14SFC Page 10 of 11 i\c:' rtl' I' M..."M n»ry toll (Apr 20. 2014. 12:04 PM) 7 k 4 JOSEPH ALV fld i '�`' d;�� SFr�,� S,� e�` T •_.k 5�."V� to ILI Ogee 61 COO �y x v. i 11EMAW4 y. g J & J Rem {sng �n° Duarte till } a Fall St,, A Wareham, 1'rla 02571 if ty gs � fin v� uincetse re n , r detgn t � U ©� ps. — wf fairs and usin, An f 7 y �• M. OS on Og A—i AR y r t o. i°without.3igna�"tire � �rill I t Tke Commonwealth of Massachusetts _ Department of Industrial Accidents Office of Investigations PC, I Congress Street, Suite 100 Boston, MA 02114-2017 A' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): IT' ki Address:_ CitylStatelZip:14i 4wwo,aWd Z39% Phone#: 7 71(- --2-3 25- Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I 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 ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees-and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised.their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy.information. t Homeowners who submit this 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 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 andjob site information. Insuranje Company Name: �V — Policy#or Self-ins.Lic.•#:. 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 under Section 25A of MGL c. 152 can lead.to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi y nder the a' s and en . ies of erjury that the information provided above is true and correct. Signature, ------___i Date: .____ Phone#: Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: e May 11, 2013 Barnstable Building Dept. The following is a list of our approved sub-contractors for The Home Depot: Ericsson Torres -,CSSL # 100546 HIC # 163528 Michael Viola — CSSL # 099403 HIC # 140993 Vincent Smith - CS # 106837 HIC # 165927 Timothy Thomas - CS # 51899 HIC # 152121 Ronaldo Solano — CSSL # 101027 HIC # 152206 Joseph Duarte - CS # 70077 HIC # 132349 Douglas Szynal — CSSL # 103950 HIC # 146142 Brian Laroche — CSSL # 100478 HIC # 152612 Joseph McKeon — CSSL# 98863 HIC # 132614 If you have any questions please contact Mike Bedard our permit coordinator at 508-962-6942 or myself at 617-438-9017.. S' erel uss one Bra Installation Manager THD At-Home Services, Inc. 908 Boston Turnpike• Unit 1 •Shrewsbury, MA 01545 Phone: 774-275-2139•Fax:508-845-6076•Toll Free:800-657-5182 Department of Industrial Accidents Office of Investigations _ s 600 Washington Street Boston,MA 02111 w ow.mass.gov/dia .Workers'.Compensation Insurance Affidavit: herders/Contractors(Electricians/Plumbers Apflicant Inf®r>rnatfl®tr f f / Please Print I et?ifl� Nagle(Busiriess/Organization/Individual): ) - , G) Address• - 5��ae-e S City/State/Zip: t1 33 Are you an employer?Check the appropriate x: TYpe,of project(required): 1.(_] I am a e n lo. er-with 4. I� lam,a general contractor and I � Y6. n New construction employees(full:and/or.part- time). have hired the sub-contractors Remodeling 2.[❑ I am a sole proprietor or partner- listed on the attached sheet. 2• [� . ship_and have no employees. These sub-contractors have 8. DemoLtion working for me in any capacity. „ employees and have workers'comp. ❑Building addition [No workers'comp.insurance comp.u�surance.x regtired:]' - 5. [] We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am abomeowner doing all work . officers have exercised their 11.®Pliirribing repairs or additions myself.[No.workers'coirip """' right of exemption per MfGL 12.C] Roof repairs ' insurance required:]t c..152,§1(4),and.we have no employees.[No workers' 13. Other (,t7/� d comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy Infrmatin. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide'their workers'comp.policy number. I am an employer that is providing w®rkers'compensation insurance for nay employees. Below is the policy and job site information. a Insurance Company Name: Mew 0-0 1*1 1.Policy#or Self:ins.Lic.M � 0 7 q ® / VV Expiration Date: f I Job,Site Address �7? City/State/Zip:Ajv�c)/ P 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,St?O.OrJ 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 DI f ' urance coverage verification. I do hereby certify and r pains tad penalties of perjuey that the information provided abov is tr a and correct . Signature: ��f/1 Date: .f — Phone#: �-7/ t% v Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of health 2.Building Department 3.City/'Town Clerk 4.Electrical Inspector 5.Plumbing Inspector ' 6.Other , Contact Person: Phone#: e ce o'� onsumer '"a4sel ton 10 Park Plaza - Smite 5170 Boston, Mwwhusetts 02116 ontractor Re 'sft ion 126693 v �. 1-�dme Imps ���� suppkm d Caw '' �+�� f..�� �;" fig'• �: flW014 The Home Depot.At-Home Servib� AidQREW SWEET` 289a CUMBERLAND PARKWAY1'�'F., '� 3'•!i, it ATLANTA, GA 30339 Up"Add"nd+r4ftm card.Mark n"ea for dmelp% ' [] Addr+sae 1IW Card OP34 M 0 lONh01104 1101a1e Om"�C4 � � Lfc M or ra��g a►vwm for kldlYw an G* MAP1tOVMN'r'QOi N1rtiAC7'OR w"a. r. f►efbire the expfratlea dale. It fil9ad tyre fst Am&*ef!Cwnmer A In and 3=6'w 11ePla O Tyw. 10 Park Ph=«f ft 5110 SuqWwmM Card fledea,MA►02116 c� 2 W V �, va�r�rdarr w r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION /\. k Map ParcelApplication a a Health Division Date Issued 617 a Conservation Division Application Fee r Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board 0Historic - OKH Preservation Hyannis Project Street Address a Village Owner /� � �! C' �S Address Sa�b'1 a-S 2JCP V'{) Telephone CI Permit Request �, � �- �� ��u u- z� o e- /A a r, AO-1. 7 14,1411, .Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Z/000s 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 Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing -new Total Room Count (not including baths): existing new First Floor Rco Count o Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other co Central Air: ❑Yes ❑ No, Fireplaces: Existing New Existing woodRd al stov�❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ e isting Ofew z izeCn Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: �0 Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use__ Proposed Use APPLICANT INFORMATION j � a (BUILDER OR HOMEOWNER) c Name KI�d� `�'''� G / "�` `- e SA, j .Telephone NumberAo l Address �J ' r �t I Ave - License # �a a UA yt�/-M 0 V�1 r� M4_ 6466'�l� Home Improvement Contractor# Worker's Compensation # IWC,33,-�r 3 Y6 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO Y4V^1 101,t4_/1 SIGNATURE DATE S {r FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED ,.t MAP/PARCEL N0. ADDRESS VILLAGE OWNER DATE OF INSPECTION: •FOUNDATION FRAME t INSULATION FIREPLACE J ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT 'E ASSOCIATION PLAN NO. Q _ I 1 I. �ri y f Y1 a J i �� � ... �..� �' `', ..eP• ash k ,�. _ � t /'AM'a aetla " C. Board of Y r a Building RegulationStandards s and ' s HOME IMPROVEMENT CONTRACTOR License or registration valid for indivtdul use on13 Req.stratlow before the ex g `fit 24310 piration date. If found return for ' �,-� 7007 Board of Building Regulation Y ,ividual One Ashburton Place sand Standards 3mes Curle i Boston,Ma.0210 1301x- ,. < Imes Curley f �. h 17 Fuller Rd. mterville, MA 02632 Administr ""� •- r ator , =Not valid without signature .. n ;3 • �, a n, • r. The Commonwealth of*Massachusetts Department of Industrial Accidents A c Office of Investigations 600 Washington Street Boston, M4 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): &LF If Address: • 0 X -4,S I _ City/State/Zip: 0-5LD b Phone #: 9® `t"S 16 Are you an employer? Check the,appropriate bozo -Type,of project(required): 1.ElI am a employer with 4. ❑ I am a general contractor and I ,Aftloyees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2J2 I am a sole proprietor or partner- listed on the attached sheet t 7. ❑,Remodeling ship and have no employees These sub-contractors have Be. ❑ Demolition working for me in any capacity. workers' comp.insurance. g, ❑ Building addition [No workers' romp. insurance 5. ❑ We are a 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.❑ P Bing repair_s or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12, Roof repairs insurance required.] t employees. [No workers' 13 ❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.' t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a 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.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: - Policy#or Self-ins,Lic. #: ` 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 under Section 25A of MGL c. 15.2 can lead to the imposition of criminal penalties of a fine up to$1,500,00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under he�ains enaltdes of per ury that the information provided a ve is rue and correct SSi afore: Date: Phone#: 1 ® ` 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 Insp-ctor I 6. Other Contact Person: �aFtMsr Town of-Barnstable wP o Regulatory Services BARNSfABLE, a' 9 MASS. Thomas F.Geiler,Director 039. �'ppenr�r•�°,0 BuRding Division. Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner bust Complete and Sign This Section If Using .A Builder frno 1 , as Owner of the subject property hereby authorize :3-L VIQS Q;W t to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) `7✓ 09— 4Sigaof OwnerL Date Print N4D le Q:FORMS:O W NERPERMIS SION a Town of Barnstable *Permit# �� /OL �Ll Expires 6 months from issue date Regulatory Services Fee 44j,5`• Thomas F. Geiler,Director /(�7 BuildingDivision ��/3joo Tom Perry, g CBO Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address �` J P [Residential Value of Work LTMinimum fee of$25.00 for work under$6000.00 Owner's Name&Address 1 ► 1� Contractor's Name -S Telephone Number Home Improvement Contractor License#(if applicable) 4310 Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance �� 4 Che one: e �_._;£ ms: R . T EYI am d �a�\.:h a sole proprietor ❑ I am the Homeowner APR 2 ® 2007 ❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) n ` 2/Re-roof(stripping old shingles) All construction debris will be taken to Q� ' ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) 4 *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'ItovemTfTntractors License is required. SIGNATURE: Q:Forms:expmtrg Revise071405 a= Massachusetts- Department of Public Safety Board of Building Regulations and Standards Construction Supervisor Specialty License License: CS SL 102776 Restricted to: IC WIL-LIAM MC CLUSKY 37 NAUSET ROAD WEST YARMOUTH, MA 02673 �i,•G--�� Expiration: 6128t2013 ('•mm�i>.i•,ucr Tr=: 102776 -70 _ r Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 ' Boston,Massachusetts 02116 Home Improvement Contractor Registration - -- Reoistration: 171380 Type: Corporation - Expiration: 3/14/2014 Tr# 222184 CAPE SAVE INC. WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE SOUTH YARMOUTH, MA 02664 ` Update Address and return card.Ndark reason for change. Address 7 Renewal f Employment _ Lost Card PS•CA1 Oa 501e,0404-G101316 /rsaNratc�zcr.�al!/ c:;:lla rurel License or registration valid for individul use only '. Office of Consumer affairs&B�ness Regulation b Y ---� - before the expiration date. If found return to: - --_ HOME IMPROVEMENT CONTRACTOR L� = Registratdon: 171380 Type: office of Consumer Affairs and Business Regulation -i 10 Park Plaza-Suite s170 �- Expiration: 3/142014 Corporation -� _ - Boston,iYGA 02116 CAPE SAVE INC. . ::._ WILLIAM MCCLUSKEY::.= : 7-0 HUNTINGTON AVENUE _ SOUTH YARMOUTH.MA 02664 Undersecrerar} Alot valid..with o signs ACCOM0® CERTIFICATE OF LIABILITY INSURANCE D /DDJYYYY) 4/9/29/2013 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 NAME: Colleen Crowley Risk Strategies Company PHONE E (781)986-4400 FAX ne11963-a4z0 15 Pacella Park Drive EMAIL c N° Suite 240 ADDRESS- INSUIREIRM)AFFORDING COVERAGE NAIC S Randolph NA 02368 INSURER A Selective Insurance INSURED iNsuRERB:Safety Insurance Ccamany 33618 Cape Save, Inc INSURER C:Technology Insurance an 7 D Huntington Ave INSURERD: INSURER E: South Yarmouth MA 02644 INSURERF: COVERAGES CERTIFICATE NUMBER:CL134960509 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 A DL S P LICY EXP LTR TYPE OF INSURANCE POLICY NUMBER PO POLICY EFF GENERAL LIABILITY MI LIMITS EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED— PREMISES(Ea occurrence $ 100,000 A CLAIMSAAADE Q OCCUR. S199449001 0/16/2012 0/16/2013 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO JEcT LOC $ AUTOMOBILE LIABILITY Ea accidenlSWGL LPAIT 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 6208200 1/6/2012 1/6/2013 AUTOS AUTOS BODILY 94JURY(Peracclderd) $ X HIREDAUTOS X NON-OMEO PROPERTY DAMAGE X AUTOS (Peraccideni $ Undennsured motorist BI split $ 10Q 000 A X U0.18RELLA LIAR X OCCUR 199448001 O/16/2012 O/16/2013 EXCESSLIAB EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION$ 1 $ C WORKERS COMPENSATION ff'cers Excluded from A STATU- OTH- AND EMPLOYERS'LIABILITY YIN X T Y �IM TER NIA ANY PROPRIETORIPAR7NERlDECUTIVE overage EL EACH ACCIDENT $ 500,000 OFFICERIMEMBEREXCLUDED? (Mandatory In NH) 353968 /9/2013 /9/2014 E.L.DISEASE-EA EMPLOY $ 500,000 If yn.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD tot,Addwor,al Re—k.su„dule,if--space is required) ' Issued as evidence of insurance. Issued as evidence of -insurance. National Grid Corporate Services LLC d/b/a/ National. Grid, Action Inc., Colonial Gas Company and NStar Electric are listed as additional insureds as respects General Liability as required by written contract. CERTIFICATE HOLDER CANCELLATION 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED ED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Cape Light Compact ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 427/SCH 3195 Main Street AUTHORIZED REPRESENTATIVE Barnstable, 1& 02630 chael Christian/CLC �� -- ACORD 25(2010105) 1 OO 1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD �Rnnt ForJn�`� The Commonwealth of Massachusetts � � Department of Industrial Accidents Office of Investigations ' I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Cape Save,Inc. Address: 7D Huntington Avenue City/State/Zip: South Yarmouth, MA 02664 Phone#: 508-398-0398 Are you an employer?Check the.appropriate box: Type of project(required): 1.❑✓ I am a employer with 17 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' Y P h'• 9. ❑ Building addition (No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LEI Plumbing repairs 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 Insulation employees. [No workers' 13.� Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this 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 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 lite policy and job site information. Insurance Company Name: Technology Insurance Company Policy#or Self-ins.Lic.#: TWC 3353968 Expiration Date: 04/09/2014 Job Site Address: a Y �� 1(e✓ X"�_ City/State/Zip: W ����` �(91�Q Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the pains and penalties ofpErLug tat the information provided abov is true,,and correctr— — Signature: - — --- — - —- - ---.._T_. =Date Phone#: 508-398-03982e Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person:. Phone#: Building Permit Authorization I, SToll as owner hereby give my permission to Cape Save, Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Office:508-398-0398 to take all necessary steps to obtain a building permit to perform work at my property located at 277 Fuller Rd Centerville, MA 02632 Signed U.IGv'�rn u ode Date M 2 , 20 13