HomeMy WebLinkAbout0023 INDIAN TRAIL _} }� r� u x -•. �- ':G..''Etrp ± -fi •� ., vie .:,�. i .r; •+ .d. 'c .�5 r
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. A Town of Barnstable Building
1 �`�� r � ^' -.� a �,• .z"�`�g,�a 4,\'��..� � .. c„�� � ';ti��a s� � `, & _.xrm* <�::'. �.,y't 7+ � .\ \� �F
e: Post;Th�s Card S9�That"�tyis��V,�sible�From the Street :A roved:,PlansrMust be:Retasned�on•Job;andthis,Card Must be Ke' t � ,_ "'
ra+" Whece a.Certificate of:Occu ancise`aired a<such,-Buildm shallrNotube Oecu iedu^t'I aFinal`:Ins ection has�een made Permit
Permit No. B-18-1056 Applicant Name: MID CAPE ROOFING Approvals
Date Issued: 04/10/2018 Current Use: Structure
Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 10/10/2018 Foundation:
Location: 23 INDIAN TRAIL,CENTERVILLE Map/Lot.:,, 190-091 Zoning District: SPLIT Sheathing:
Owner on Record: MCKENNA,WALTER D&EDNA C Contractor'Name ` MID CAPE ROOFING Framing: 1
Address: 23 INDIAN TRAIL Contractorcense 161458 2
CENTERVILLE, MA 02632
Est Protect Cost: $7,400.00 Chimney:
Description: reroof(stripping old shingles) �P`ermit Fee: $37.74
Insulation:
Project Review Req: y Fee Paid: $37.74
j�Date 4/10/2018
40
Final:
xi
Plumbing/Gas
Rough Plumbing:
Ali .,
Buildin Official
g Final Plumbing:
This permit shall be deemed abandoned and invalid unless the work authorize`•dby th s permit is commenced within six months after issuance. Rough Gas:
t 1 �..
All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted.
Final Gas:
All construction,alterations and changes of use of any building and struct fAe [shall be in compliance with the local zoning by laws and codes.
This permit shall be displayed in a location clearly visible from access street o road and shall be maintained open for public m�spectio`n for the entire duration of the
work until the completion of the same. � Electrical
\ Service:
The Certificate of Occupancy will not be issued until all applicable signatures`by the Building and,. it Officals are provided on this permit.
Minimum of Five Call Inspections Required for All Construction Work: Rough:
1.Foundation or Footing �,,. ,ram .,_ •
2.Sheathing Inspection Final:
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough:
5.Prior to Covering Structural Members(Frame Inspection)
6.Insulation Low Voltage Final:
7.Final Inspection before Occupancy
Health
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations.
Work shall not proceed until the Inspector has approved the various stages of construction. Final:
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department
Building plans are to be available on site Final:
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT
W e
.j Town of Barnstable *Permit'#
O� Tres 6 months from issue date
- Building Department
BAMSTABIA : Brian Florence,CBO
Building Commissioner 4)1
R.
'0�o Mpr 200 Main Street,Hyannis,MA 0260�O�/f/ 1 02 �z 4��ir
www.town.barnstable.ma.us 6
Office: 508-862-4038 ��/�� �x� j 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
_ j / •fir
Property Address3 ".11?A� �s� / Ce.�r�✓+� /�'e
[9esidential Value of Work$ CAD,ca Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address
Contractor's Name: 04t -e< Telephone Number
Home Improvement Contractor License#(if applicable) Email:
Construction Supervisor's License#(if applicable) b 2-'V�12 f
D orkman's Compensation Insurance
Check one:
[g-t'am a sole proprietor
I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name -71,✓4 L,4 le- p-f
Workman's Comp.Policy# Ci l L f'� Z04o N3�
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
g-Re=roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to X964A
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows
#of doors:
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
*** .ote: , Propervowner must sign Property Owner Letter of Permission.
caj�y of the Home Improvement Contractors License&Constr'uction Supervisors License is
required.,
SIGNATURE:
QAWPFILESTORMEXPRESS2017
The Commomveakh qfMassadlrttselfs
Dep whment r f IndustrialAccid,=&
Office o,fInITStigadmu
600 Washington Street
Boston#MA 02111
minumamgovIdia
Workers' Cumpensattian Immn Wince Affidavit BaderslC mft-ActursMecl ricianslPlumbers
AmUcant InfarII]atiou 7 Please Print
Na=4BusmessflOrgsnizzatit}allntfrviduaI //�l/ D c�f
,Q �r
Addre= L( l^[/ �SbMA
Are you an employer?Check the appropriate box: Type of project' (required)-
etparetl):
I.❑ I am a employer with. 4. ❑I am a general contractor and I 6. ❑New oonsauction
Pees(fall an&or part-timer* have hired the surf-combat-toes
2. a sole proprietor or partner- listed on the attached sheet. 7- ❑Remo g
ship and have no employees Them=b-contactors have S..❑Demolition
worsting far me in any capacity. employees and hn a wodwn' 9_ ❑Budding adziitioer
INo svorkmrs'comp insurance camp-i„surane J
reg3lire -] 5. ❑'We are a-corp oration and its 10❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their . 1 L❑Plumbing repairs or additions.
myseli[No worms'camp- eight-of exemption per MGL 12.❑Roof repairs
+nmnmmerequired 3 ,c.152,§1(4�andwe have no
employees-[No wo&M, 13_❑other
comp-insurance required_]
*AnyWHcntMatchedrsbos#lmastalsoMo t*esectimbgawsho n�Sxvo&eWcompensatimpark-yi tz-
t Eamevamss who submit dais zMwft mdkzhzLj dzey ate dam.-ag wait and&eahae aatdde coats =zmst submit anew affidzuk indi—in sacfi
rCanttactms eheck tlgs boar mast emdie d as additional sired shoxing the name of&a sub.cmxtwm¢s sad state whether ar aatf mse entities hwe
empioyees.I€thesnb-caa.�esba�e empIo�Zs,dier�> � '�P•F�F a�tre�
lam an ftzmrance,for my employ a= Below is t7te pv cy and job srte
irrformatiota. /' -
Insurance Company Name: / ,c -�.
Policy g or Self-ins.Lic-4 N 3 FxpirationDate: .2
Job Site Address: CitYstatelztp- a vz� T °,-V
Attach a copy of the work-ere compensationpolscy 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 imposi ion of criminal penalises of a
fine up to$1,50D.OD andfor one-year in4misotmtenk as well as civil peualties.in the form of a STOP WORK ORDE$and a Ene
of up to$ O-00 a day against the-violator. Be advised that a copy of this statement maybe fiorwarded to&e Office of
Investigations ofthe DIAL for ics=m=coverage verifixatio .
ldo lietasby remit axukr thepains andpgnalfies P'arjury fhatfhe io�ornzatimPrI t ii&dabut%!I bus and correct
Signature: Date:
Phone ik
Ojsid use anE. Do not writs in saes Brea,to be=npfeted by city artown affirms
City or Town: PermitUcense�
ISSuing Authority(circle one):
L Board of Health 2.Building Departmeat 3.Citp Town Clerk d.Electrical Inspector 5.Phanbing ILsltecter
6.Other
Com tact Person: Phi#-
6
formation and Instructions
Massachusetts Gdam-9 Laws chaff M regnaes all employers`bo provide workers'campensaf'im for their employees.
F ro this statrne,an MTlayee is defined as.6_.avmy peasdu in the service of another under any.confrart of hire,
e egress or implied,oral or write."
An employer is defined as"an indix4idua partnership,assoiEian,Mxporation or o-ff3=legal entity,or any two or more
of the foregoing m aJ ,ands legaluesenfatives of a deceased employer,or the
receiver or trustee of an mdividml,partnership,association or other legal entity,employing employees. However the
owner of a dweIIing house having-not more t3aa three apartments and who resides therein,or th'.e occ¢pant of the -
dwelling house of anol er who employs pessoms to do maims ce,construction or repair work on such dWeIImg house
or on the grounds or building shaRnotbecanse of such employme3:tbe deemed to be an employer."
MOL 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 bwld xgs is the commonwealth for any
applicant who has not produced acceptable evidence of cdmp&ance wi($the insurance.coverage required."
Additionally.MGM chapter 152, §25C(7)states'Neither the com ngawealth nor any of its political subdivisions shall
enter into any contract for theperformauce ofpmblio wolicuntl acceptable evidence of compIiancevMh the;nm„ mce.
requirements of this chaptrr have been presented to the Contracting aufhoiity."
APPHcan-ts
Please 01 oht the workers'compensation affidavit completely,by checl the boxes ghat apply to your situation and,if
mmessary,supply sab-contractorr s)name(s), address(es)and phone mumber(s)along with their certificate(s) of
msm-Emce. Limited Liability Compames(LLC)or Limited Liability Partnerships t7 LP)with no employees other,than the
members or pmtaers,are not rbquaed to cagy workers' conopensaiion.insuranm If an LLC or LLP does have
employees,a policy is rmpired. B e advised that this affidavit may be submitted to the Department of Industrial
Accidents for confnmation of inmz?nop coverage Also be sure to sign and date the affidavit The affidavit should
berretrJmed to the city or town that the application for the permit or license is being requzestA not the Department of
LridmstriaI Accidents- Shonldyou have any questions regarding the law or if you are;required to obtain a workers'
compensation policy,please call the Department at the nnmbea listed below. Self-rosined eampauies should ear their
self msaranm license n=aber on the appropriate lime
City or Town Officials
t
Please be sine that the affidavit is complete and pnccbe .le�ly. The Depa tmenthas provided a space at the bottom
of the affidavit for you to fib out is the event the Office oflnvesf'igations has to contactyou regarding the applicant
Please be sure to fill in the peunhlliceuse member which will be used as a reference member. In addition,an applicant
that must submit Multiple p=itllicense applications is any given year,need only submit one affidavit indicafmg cuirmt
policy mfo=mation(if necessary)and under"Job Site Address"the applicant should write:"all locations in (c'Ly or
town)."A copy of the-affidavit that has been,officially stamped or maiimd by the city or town may be provided to the '
applicant as proof that a valid affidavit is on file for futai permits or licenses- Anew affidavit must be filled out each
year.Where a home owner or,citizen is obtaii.g a license or permit not related to any business or commercial ve<ntu'e
(Le. a dog license or peunit to burn Ieaves etc.)said person is NOT regrind to complete taus affidavit
ike to thank you in advance for your cooperation and should you have any questions,
The Office of Iuveslig�ons would l
please do not hrsitate to give us a ca1L
The Department's address,telephone and fax number:
TIC *of Massachusetts, ,
Degadmmt of tTi�al Accidents
ice of��. tio�
�o11�fA E�IIF . ,
D,L 4 61� -490G cmt 4€16 Qr I-M MASSAFR
Fax#617 727'749
Revised 4-24-07 ¢�
Y
A:i ' MID CAPE ROOFING
11 RUSSO ROAD
WEST YARMOUTH, MA 02673
508-775-3799/508-385-8801
Barry Merrill &Paul Merrill
... .Job Site Address Mailing Address
~Name: Name:
Street: 3 1t-'4A--J 'A74—1 Street:
City: C�v� L Z(�Twwa- City:
Telephone: ��r� Telephone:
We hereby propose to furnish all the materials and all the labor necessary for the completion of:
roof replacement of the dwelling at the above address. Mid Cape Roofing proposed to remove
and dispose of the existing roof. The roof will be replaced with CertainTeed Landmark shingles.
Aluminum drip edge will be installed along the gutter line. Ice&Water Shield installed on bottom
edges to protect ice back-up. 15 pound felt paper will also be applied. The shingles Will be
installed using 1% inch roofing nails. New pipe vent collars will be installed. Ridge vent will be
installed along the ridgeline of the roof to provide proper venting of the attic space.
Mid Cape Roofing guarantees the workmanship for a period of 10 years. All walls and
landscaping will be protected from damage;the property will be raked and cleaned of all debris.
All material is guaranteed to be as specified and the above work is to be performed in accordance
with' specifications submitted for above work and completed in .a substantial workmanlike
manner for the sum of: .00—All discounts have been applied.
Payment made as follows: •`
Deposit of: vo 00 the day job is started and remainder paid on completion.
Any alteration or deviation from the above specifications involving extra costs will become an
additional charge over and above the estimate and will be discussed.with the homeowner.
Respectively Submitted by Mid Cape Roofing
NOTE: This.proposal may be withdrawn by Mid Cape Roofing if not accepted within 30 days.
Acceptance of Proposal
The above prices, specifications and conditions are satisfactory and are hereby accepted. Mid
Cape Roofing is hereby authorized to perform work as specified with payments made as
outlined above.
Accepted: �-
Massachusetts Department or public.S 4fy
j
ulations and Standards-
Board of 13uiiding Reg
LJcgnse: CS-054>;<28 Y
Construction Supervisor
BARRY B MERRILL
312 SKUNNKETT RD,."
CENTERVILLE MA 02ii32
j Expiration:
1" 05/2'V2018
- Commissioner
. �Lce�an7rrrzonwea��a o���4�F�.%Qe�li:
:,�+.\ �Y;i':Z•^;GOf:<r<^.-s!';+i7a:a$,- L R'saf: ul�•,
3— 40ME lk-1-'i„:-lE1AFNT i�tdif?tiL
Type: r'_rtnership
ration
RooJ'A
Con dtidrrr,Sypervisor -, '
Restricted.to
Unrestricted ;Buildings of any use group whichcontain
less than 35,000 cubic feet(991 cubic meters)of.
:'.enclosed space.
,. IV; '
�.'FaduieX&possess a current edition of the Massachusetts•.-,
N State Buil4jmg Code is cause for revocation of this license
SDP.. Licensing information visit: WWW MASS G 1DP§
ration vai i a sst or individual use , r.r
l before the expira;i n date. f mound re';: n
Off ica of Consurn,r Affairs ancf Busirw�
J F:Pic Plaza Sa: a 5170
{ Boston;MA 0211',...
i �
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION a,
Map Parcel plication 4t
Health Division Date IssuedIL
Conservation Division Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project,Street Address
Village
Owner ,�J�1J19 ni � ��� Address
Telephone J 0,f 7
Permit Request 1D `� � 12 fs'
Square feet: 1 st floor: existing proposed 2nd floor: existing - proposed Total new
Zoning.District Flood Plain Groundwater Overlay
Project Valuation 4e:� Construction TypeJc
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family IK Two Family Li Multi-Family (# units) e-a a C
Age of Existing Structure Historic House: ❑Yes 4No On Old Kings ighway: YepAgNo
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other ' �s
Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing new Half: existing i newer '
C.> M
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 Telephone Number 77, Z V_
Address �`2�;9//I�� trlo License# f DD f'
0U�, Home Improvement Contractor#
Worker's Compensation # GvQ�IJ
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE �����
FOR OFFICIAL USE ONLY
APPLICATION#
DATEISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
AFOIJNDATI_ON3u�r� a
FRAME
INSULATION:!+.A; :;1."_'..� �'xi� VA
FIREPLACE
•
ELECTRICAL. - ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
`. FINAL BUILDING —•'�
DATE CLOSED OUT
ASSOCIATION PLAN NO.
a The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
•www.mass.gov/dia
Workers' Compensation Ins urance'Affidavit: Builders/Contractors/Electricians/Plumbers
Apolicant Information
Please Print Legibly
Name (Business/Organizadonindividual):
Address:1�
City/State/Zi : /� T� t� o ,,Vhone #:71Areyou employer? Check the appropriate box:
p y 4. ❑ I am a general contractor and IType of project(required):
em to er with�-�'yees (full and/or part-time).* x 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 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp, insurance - comp. insurances 9. ❑ Building addition
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 p
3 a.❑ I am a homeowner acting as a employees. [No workers' 13.2 Other/,��/�'%
general contractor(refer to#4) comp,insurance required.].
'Any applicant that checks box 111 must also fill out the section below showing their workers'compensaticrtpolicy 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-contracton 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:
Policy#or Self-ins. Lic.#: Expiration Date: a
Job Site Address: f�City/State/Zip: Lo J Z �
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 cernfy u
..,!!#r the pains and penalties of perjury that the information provided above is true and correct
Si a
Date:
Phone#:
Official use only. Do not write in this area, to be completed by city or town official
City or Town• PermitJLicense#
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#:
III/
A C� " CAPECOD-27 KLIGETT
CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYy)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS Np 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(les)must be endorsed, If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy, certain policies may require an endorsement. A stas certificate does not confer rights to the
certificate holder In Hem(If such endorsement s). � tement on this
PRODUCER
N0gers&Gray Insurance Agency, Inc. NAMeACT Barbara DeLawrence
134 Rte 134 PHONE FAX iouth Dennis,MA 02660 IA/c.No. xt -�A/c No; 877)816.2156
AD AIESS'bdelawrenc@ ra ers ra ,com
INSURERS AFFORDING COVERAGE �—
r - -- INSURERA;P@@rI@ss InsUranCe Company NAICp
NS RED —
1I ' IN BICOMMERCE INSURANCE COMPANY �—Cape Cod Insulation Inc INsuRERc;Evanston Insurance Company
jJ 18 Reardon Circle INSURERD:ATLANTIC G
South Yarmouth, MA 02664 HARTER I NSU RANGE GROUP.
INSURER -
A ERAGES INSURERF;
CERTIFICATE NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO--THE NA REVISION D A 0"VE FOR THE POLICY PERIOD
I< DICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
C R;TIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
E CLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY-HAVE BEEN REDUCED BY PAID CLAIMS.
R TYPE OF INSURANCE POLICY EFF POLICY EXP
X COMMERCIAL GENERAL LIABILITY POLICY NUMBER MIDO/YYYY MMI Dly
_ LIMITS
1 CLAIMS-MADE L X]OCCUR CBP8263063 EACH OCCURRENCE $ 1,000,000
04/01/2014 04101/2015 TO RC -- -
__.. PREMISES(Ea occurrence) 100,000
MED EXP(Any one parson) g 6,000
G N'LAGOREGATE LIMIT APPLIES PER: PERSONAL&ADV INJURY_ $. 1,000,000
POLICY I—l JE C LOC GENERAL AGGREGATEO
$_ 2,00.0,000
OTHER PRODUCTS•COMP/OP AGG $ 2,000,000
AUTOMOBILE LIA8ILITY $ —'
t COMBI ED SING E LIMIT
( ANY AUTO 14MMBCKVMK Ea accident $ 11000,000
ALL OWNED 04I01/201 --
_ SCHEDULED 4 04/01l2016 80D -
:.. AUTOS X BODILY' INJURY(Par parson) $
AUTOS BODILY INJURY(Per accident) $
AUTOS
HIRED AUTOS X NEO. ^--- -
AUTOS PROPERTY pAMAGE
Per accident $
X UMBRELLA LIAa X OCCURJ. $
EXCESS uas EACH
cLAIMs•M 04/01/2014 04/011201
AOE XONJ453514 OCCURRENCE $ 11000,000
DED X R $ETENTION 10,000 v AGGREGATE $
WORKERS COMPENSATION Aggregate $AND EMPLOYERS'LIABILITY 11000,000
ORH ANY PROPRIEI.OR/PARTNER/EXECUTIVE y/N WCA00525904 8 T TE
OFFICER/MEMBER EXCLUDED? N/A 06/30/2014 06/30/2016 E.L.EACH ACCIDENT
(MandatorylnNH) $ 1,000,000
0 yes, IPTI be under • E.L.OISEASE-EA EMPLOYEE $ - 1.000,00.
DESCRIPTION OF OPERATIONS below
E.L.DISEASE-POLICY LIMIT $ 1,0001000
�RIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule, '
Sera Compensation Includes Officers or Proprietors. may be attached If more space Is required)
to"al Insured status is provided under the General.Liability and Auto Liability when required by written contract or agreement with the Certificate Holder,
I
ITIFICATE HOLDER
CANCEL I ATI(1W_
Massachusetts -Depaftni*'nt of Public Safety
ro
-Board of Building Reg ulations;p•nd Standards
Cunstmction Supemsor, ; >.
License: CS-100988 :;:
HENRY E CASSU).Y
8 SHED.ROW
WEST YARMOV1`11 2 ;
..� Expiration
Commissioner 11/11/20115
is
C?��t/cr.�t�•ac�����-E����il-
_ Office of Consumer Affairs and Business Regulation
>' 10 Park Plaza - Suite 5170
Boston, MassachLISetts 02116
-lame Improvement Co-,traQtor Registration
4
,J Registration: 153567
Type: Private Corporation
Expiation: '12/15/2014 Ti-# 233831
CAPE COD INSULATION, INC { r
HENRY CASSIDY
18 REARDON CIRCLE -----
S0. YARMOUTH, MA 02664
:..: "Update Address and return card. Marls rwoun for change,
ii .!I IRI Owl I
[� Address Renewal lnlplUynlerlt I. 1.U5tCard
.1�
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cunsumer Affairs& Business Regutatiuo License or registration valid for individul use only
" OME IMPROVEMENT CONTRACTOR before the expiration data. If found t'etut'n to:
epistration: 153.567 Type; office of Consumer Affairs and Business Regulation
xpiration: 12/1-5/2014 Private Corporation 10 Parlc Plaza-Suite 5170
Boston,MA 02116
'E(00 INSULATI.nN,�;,Iol _t;r. .
VRY CASSIQY
lEA DON CIRCLE
YA NIOU1 -1, MA 0294
Undersecretary it
witho t nat re
OWNER AUTHORIZATION FORM
1 c
(Owner's Name)
owner of the property located at ,
:&2Z,2
(Property Address)
'(15ropeYty Address)
hereb .authorize
Y ,
(Su con ctor)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building
permit and to perform work,on my property. T
Owner's Signature
Date
S