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HomeMy WebLinkAbout1160 PHINNEY'S LANE (5) /l/Po ��ji fin •��,.�C �, �li�r� �' �� � � --- - - - - - - -- ---- - -- ---__-_ � .. e S=� C � �i � TOWNS OF BARNSTABLE R I S E Division of Thielsch Engineering,Inc. 2013 MAY 10 AMI H: 21 1341 Elmwood Avenue ENGINEERING Cranston,Rhode Island 02910 DIVISION May 1, 2013 Thomas Perry, CBO Town of Barnstable - Building Division 200 Main Street t ' , Hyannis, MA 02601 Vl Re: Insulation permits Dear Mr. Perry, This affidavit is to certify that all insulation work completed for 1160 Phinney's Lane, Parcel # 27308900D has been inspected by a Building Performance Institute (BPI) certified Professional. All work performed meets or exceeds Federal and State requirement. Sincerely, Erik Nerstheimer Supervisor of Installations, BPI certified Building Analyst Professional and Envelope Professional, RISE Engineering, a division of Thielsch Engineering, Inc. 1341 Elmwood Avenue Cranston, RI 02910 401-784-3700 •800-422-5365 •Fax 401-784-3710 ,ARBOR TERRACE - 81-12-1636 01 ISOTOWN OF BARNSTABLE BUILDING PERMIT APPLICATION. Map 273 Parcel 089/OOD Application #626GO-0 Health,Division Date Issued Conservation Division Appjication Fee i 5i. Planning Dept. Permit Fee _ 350 Date Definitive Plan Approved by Planning Board f Historic - OKH _ Preservation / Hyannis Project Street Address IT 1D 11�g�INNEY S LANE; HYANNIS, TEFtF�Fa) T == TNIS,— oa�e��nt�� t Village HYANNIS Owner BARBARA TURNER Address 1160 PHINNEY'S LANE #ID; HYANNIS, MA Telephone 508-771-3732 Permit Request OF JOB DES-CRIPTION FOR MORE TIFTOIT C OWNER AUT-1-10RIZAZIO 1 ATTA.01RD Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 41,212.50 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 Room Count Gb Heat Typeand Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other _ --i Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove;-❑Yea ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑=existing 9,-new__` Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: - ' Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ _21 Commercial ❑Yes ❑ No If yes, site plan review# Current Use RESIDENTIAL Proposed Use SSE APPLICANT INFORMATION (BUILDER OR HOMEOWNER) RISE ENGINEERING; A DIVISION OF Name THIE126H Telephone Number �i91_7B4_37nn EST, 6133 Address 4341 ET-I-wo-00-AVE. ; C AST N R! 02910 License # GSS, 100459 EXP. 9/28/14 Home Improvement Contractor# 12A979 EXP. 3/25/14 Worker's Compensation # 3730961_01 EXP. W,/T ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 02664 SIGNATURE — � DATE ERIK NERSTHEIMER FOR RISE ENGINEERINGARBOR S w ' FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED;;_ _c i. t t r MA_P/PARGEL_NO.,-, P ' 't } r ADDRESS VILLAGE OWNER f i7 I; I DATE OF INSPECTION: FOUNDATION;., FRAME INSULATION" ,IF _ FIREPLACE { ELECTRICAL: ROUGH FINAL t '. PLUMBING: ROUGH FINAL GAS: ; c:, ROUGH w,_- vz FINAL FINAL BUILDINGI;:+ :- i _. DATE CLOSED OUT ASSOCIATION PLAN NO. f The Commonwealth of Massachusetts Print Form` Department of Industrial Accidents Office of Investigations 1 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): RISE ENGINEERING;A DIVISION OF THIELSCH ENGINEERING Address: 1341 ELMWOOD AVENUE City/State/Zip: CRANSTON, RI 02910 Phone#: 401-784-3700 EXT. 6133 Are you an employer?Check the appropriate box: Type of project(required): 1.2 I am a employer with <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 working for me in any capacity. J 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.El Other comp.insurance required.] *Any applicant that checks box#I 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 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,INC. Policy#or Self-ins.Lic.#: 3730961-01 Expiration Date: 01/01/13 Job Site Address: 1160 Phinney's Lane,Unit# 1 D City/State/Zip:Hyannis, MA 02601 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 n th ains a enalties o _C!dua that the in ormation provided abov is true and correct. Signature:E _. _ _...... -- — _ __. - - -'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#: C � � lll9 i '� _ ■ARNBTABLE '• -a �— 09. ,e� Town of Barnstable i a APR 3 0 2012 i Regulatory Services Thomas F.Geiler,Director _ -----�- a i Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder r , at._ I, BARBARA TURNER , as Owner of the subject property RISE ENGINEERING;hereby authorize A DIV. OF THIELSCH to act on my behalf, in all matters relative to work authorized by this building permit application for: 1160 PHINNEY'S LANE, UNIT 1D; HYANNIS. MA_ 02601 (Address of Job) Az it 7 Z Q� OSV�4 �— e'-z 7—/11�1 Signature of Owner Date BARBARA TURNER Print Name If Property Owners applying for_permit,please complete the Homeowners License Exemption Form on the ` . _.. 're'verse side.r i C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 Arbor Terrace Condominiums i�� sir-= 0 - nationalgrid PROGRAM SIGN-UP SHEET INSTRUCTIONS: Please complete this form to authorize the installation of of the listed nergy vmg measures in your unit. You can choose any combination of measures. incl �t�al and installation. RISE Engineering will contact you to schedule appointments!. ple� he o S'. Return the completed form within 7 days in the enclosed postage paid eril I or fax it to RISE Engineering al •�'' 401-784-3710. If you do not want to participate,you do not need to retur 41he rm. If you have any questions, please contact Meaghan Quinn at RISE Engin erin - t} 2 5365 xx 6!1`3T'of E- mail: MQuinn @THIELSCH.COM. EnergyWise OWNER INFORMATION(Please print Owner's Name: a ar + rn ' t h e � , 9 Owner's Address 1 unit# e S — V i V Daytime phone 71 3 Evening phone S-AY►�C� ,.r— _-•^- � Air Seal'an Attic Insulation and-HotTWater Conservati-cW7 inc u es a -matena an costa anon �y r (�YES 5N0 Total Cost: $1,212.50 National Grid Incentive:197250"-"-' Your Cost: Not to exceed $240.00 billable upon completion ® Air Sealing: Air seal attic chases, plumbing and electrical penetrations, M bypasses, access openings, transitions, ductwork and other leakage points to ;. reduce heat loss through air infiltration. High quality foams, caulks, baffles, £ weather-stripping and other materials will be used to seal sources of air leakage. NOTE: a) Includes insulating and weather-stripping the attic access hatch, b) furnishing and installing weather-stripping and door sweeps on the front entry door, c) basement major penetrations through sill and floor. ® Attic Insulation., Furnish and install R-30, 9" of cellulose to approximately 5000 SF of open attic areas to achieve an approximate R-49 insulation value, including soffit baffles, as needed, for all flat ceiling areas. NOTE: Attic flooring and storage items may reduce the amount of area that can MORE kr'' be insulated. ® Hot Water Conservation: Furnish and install hot water pipe insulation for the 15'6' from the water heater, water saving showerheads and faucet aerators as applicable. : Attic Foldinq Stair Insulation and Air Sealin m u es a materia an insta a!on : OYES VNO Total Cost: $166.5 NGrid Incentive: $83.25 Your Cost: Not to exceed' H3.25 billable upon completion :' i '. Thermo-dome Cover: Furnish and install"thermo-dome" attic stair insulating ` 5 cover. . 4 V(YES ONO for Digital/Programmable Low Voltage thermostats(No Cost) ® Digital/programmable low voltage thermostats (Robertshaw RS6110 or exact equal) replace existing manual thermostats in dwelling units 4Quantity of digital thermostats needed? ___�__� -toe.®;` ,.� --------------------------------------------------------------------------------------------------------------------------=------------------------------------ By signing below, I agree to have ou immplement the improvements I have selected and agree to the associated costs shown. ✓ Owner(please sign) _Date3—12 -/Z r — - THIEL-1 OP ID:-27 CERTIFICATE OF LIABILITY INSURANCE DAT01/1 DNYYr, 01/_13/12 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). PRODUCER 401-886-8000 NCNTACT AME: The Preston Agency,Inc. FA 1350 Division Rd Suite 303- 401-885-1700 acNro Ert: A/C No PO Box 810 E-MAIL East Greenwich,RI 028184810. ADDRESS: Judith A.Wright CPCU AAI ARM INSURERIS)AFFORDING COVERAGE NAIC p INSURER A:Zurich-American INSURED Thielsch Engineering,Inc.Thielsch Group Inc. lNsuRERB:American Guarantee&Liability Hi Tech Realty Inc. INSURER c:Twin City Fire-Hartford Trent TherouX 195 Frances Avenue INSURER D:North American Capacity 195 _ Cranston,RI02910 INSURERE: 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 ADM SUEIR TYPE OF INSURANCE POLICY EFF POLICY EXP - LTR POLICY NUMBER MMIDDNYYYI (MMIDDIYYYYI LIMITS GENERAL LIABILITY EACHOCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY X 3730962-01 01/01/12 01/01/13 pREMISEs Ea occurrence E 300,00 CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 5,00 PERSONAL BADV INJURY $ 1,000,00 GENERALAGGREGATE S 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY X PRO` Loc Emp Ben. $ 1,000,00 AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT Ea accident $ 2,000,00 A X ANY AUTO 3730963-01 01/01/12 01101/13 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per $ AUTOS AUTOS ( ) HIREDAUTOS NON-OWNED PROPERTYDAMAGE AUTOS Per accident $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 B EXCESS LIAB CLAIMS-MADE AUC-4857188-01 01/01/12 01/01/13 AGGREGATE $ 10,000,000 DED RETENTION$ $ WORKERS COMPENSATION WC STATU OTH- AND EMPLOYERS'LIABILITY Y I N X T RY LIMIT- ER A ANY PROPRIETOR/PARTNER/EXECUTIVE 3730961-01 01/01/12 01/01/13 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED9 N I A (Mandatory In NH) If yes,describe under E.L.DISEASE-EA EMPLOYE $ 1,000,00 DESCRIPTION OF OPERATIONS below E-L.DISEASE•POLICY LIMIT $ 1,000,00 C Property Section 02UUNHE6930 01/01/12 01/01/13 Property see belo D Professional Liab DVL000026802 01/01112 01/01/13 Prof Liab 2,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is requlred) When required by a written contract. CERTIFICATE HOLDER CANCELLATION TWNHARW SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Division ACCORDANCE WITH THE POLICY PROVISIONS. ZOO Main Street AUTHORIZED REPRESENTATIVE Hyannis,MA 02601 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Details F'age 1 of 1 Licensee Details_ Demographic Information Full Name: ERIK S. NERSTHEIMER Gender: M Owner Name: License Address Information Address: 228 Gleaner Chapel Rd. Address 2: City: North Scituate State: RI ipcode: 02857 Country: United States License Information License No: CSSL-100459 License Type: CSSL-IC- Insulation Contractor Profession: Building Licenses Date of Last Renewal: 4/24/2012 Issue Date: 5/6/2009 Expiration Date: 3/28/2014 License Status: Active Today's Date: 4/25/2012 Secondary License: T Doing Business As: Status Change: 18 Prerequisite Information Licensee: NERSTHEIMER, ERIK S. Relationship: Attribute Of License No: CSSL-100459 Discipline No Disci line Information Documentum http://elicense.chs.state.ma.usNerification/Details.aspx?agency_id=1&license_id... 4/25/2012 ' Office of Consumer Affairs d Business Regu2 _ 10 Park Plaza - Suite 5170 7 Boston, Massachusetts 02116 ;k JUN ; Home Improvement Contractor Registration Registration: 120979 Type: Supplement Card THIELSCH ENGINE 'RING Expiration: 3/25/2014 1341 ELMWOOD AVE. CRANSTON, RI 02910 Update Address and return card.Mark reason for change. SCA 1 C., 20M-05/11 Address Renewal n Employment Lost Card dF/1e W.nzo.,mveall/I&I1/-j"C/"uel ce of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: e Office of Consumer Affairs and Business Regulation gistratio. 10979 Type: 10 Park Plaza-Suite 5170 VffiExpirati0h:��'ji26/1614 Supplement card Boston,MA 02116 THIELSCH ENGINEERING i ERIK NERSTHEIMER v / 1341 ELMWOOD AVE: CRANSTON, RI 02910 Undersecretary Not valid without signature Control No: 34244 Fa mom(13 THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF LABOR c DIVISION OF OCCUPATIONAL SAFETY 19_STANIFORD STREET, BOSTON,MASSACHUSETTS 02114 LEAD-SAFE RENOVATION CONTRACTOR LICENSING WAIVER RISE Engineering A Division of Thielsch Engineering, Inc. 1341 Elmwood Avenue Cranston, RI 02910 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. HEATHER E. ROWE,ACTING COMMISSIONER 0 Printed on Recycled paper - - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 6P ri 3 Parcel Application #Z �;vD�COs Health Division Date Issued c v Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Address 114o h r, 1s tie ® ` Village C eA 7-C r=_1s r LL e Owner ? ycti Address Telephone . 4 3S!( Permit Request e_ L_J 4 I Lu e. Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation j. o0OC40 Construction Type sk i Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. �elling 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 �1 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 wo d%coal stove': ❑,ems ❑ No Detached garage: ❑existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑;existing -0 neW= size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: v Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ c� J Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use I APPLICANT INFORMATION (BUILDER OR HOMEOWNER) .Name Telephone Numbers 7)7ev� Address License # `7 q u -7 CA,1!2d na.. �/A-�S1 O � g' Home Improvement Contractor# lbw Worker's Compensation # ��� ? ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATES 7, � FOR OFFICIAL USE ONLY ' @' APPLICATION# .1 `> s DATE ISSUED MAP/PARCEL NO. ti _ ADDRESS VILLAGE OWNER DATE OF INSPECTION: 'FOUNDATION':' FRAME j INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL j GAS .iP� ROUGH FFOAF --4E' FINAL r FINAL BUILDING''-; t #-DATE CLOSED OUT 4 { ASSOCIATION PLAN NO. 1 i 1 The Commonwealth of Massachusetts Departmi-7it oflndustrial Accidents t9 ` �. Office of Investigations 600 f6'askingtora Street ww, Boston,J A 02111 ttInFyt:raaass.gov°ilia Workers'Compensation Insurance Affidavit:Buiklers/Con#motors/Electricians/Plumbers Applicant Information Please Print Lezibh Name M i gauizatiorrtlntiividtal)- N Address: L S' a a�1144 C-xtylState p. °l1 Phone A a an employer?Check the appropriate box: Type,of project(required): 1.Are a employer with_Q 4- ❑ l am a general contractor and 1 & ❑New construction employees(full andlor part-time)-* have hired the suer-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet- T ❑Remodeling 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.1 rewired] 5. ❑ We are a corporation and its l Q.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work: officers have exercised their I LE]Plumbing repairs or additions myself o workers'co right:of exemption per MGL m5' � comp.. 12.[-1Roof repairs and insurance required.] c. 1527§1(4),a we have no employees-[No workers' 1 XOther W,, nn n (1/J comp_insurance required-] ;Any appl catu that checks box*1 mast also fill out the:section below showing their workers°compensation policy inforat"son.. Homeownets who submit this afgidda-it in&ratmg they are doing all wank and thea hire oxide t outtactors mast mbmit a rtew affidavit indicating such- .Contractors that check this box must attached an additional sheet showing the name of the sub-cwtractors and state whether or not those entities Mare employees. If the sub-connectors have employees,they must provide their wakkeeis'comp.policy number.. I aam an enipioyer that ix proWding workers'compensation insu ance for a Jy err€I W—ees. Below is die policy and job,site information. Insurance Company Name: L:,IG Policy#or Self-ins-Lic.#: a L/D d a 6 () Expiration Date: �l - a� 3 - l� Job Site Address: n e4w ✓ /�-� Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data). 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 an&lor one-year imprisonment,as well as chit penalties in the formm of a STOP WORK ORDER and a fine of up to$250-00 a day against the violator- Be,adiwed that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification- Ido hereby certi ¢wider thepains anad penalties of perjury that the information provided above is true and correct CS'" iris:. ` Date:. Phone#: Official u.se only. Do not mite in this area,to be compteteed by city or town official City or Town: Permit/License Issuing Anthorit:(circle one): 1.Board of Health 2.Building Department 3.City.(I`own Clerk 4.Electrical Inspector es.Plumbing Inspector 6.Other Contact Person: Phone# 6 Date, 9/19/2910 Times 1t29 PM Tot M 9,15083626115 Page. 002 Client#:974 2BAKERAS ACOR& CERTIFICATE OF LIABILITY INSURANCE o8;9"010 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling&O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES AND,EXTEND OR Agency ALTER THE COVERAGE AFFORDED BY NOT HE POLIES BELOW. 973 lyannough Rd., PO Box 1990 Hyannis,MA 02601 INSURERS AFFORDING OVERAGE NAIC# INSURED INSURER A: National Grange Mutual Insuranc Baker&Associates,Inc. INSURERS: Associated Employers Insurance P O Box 923 INSURER C: Centerville,MA 02632-0071 INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NsRd TYPE OF INSURANCE POLICY NCR DATPOUE EFFECTIVE OLICY DATE EXPIRATION LIMITS ITS GENERAL UABILmr MPJ7223M 04119/10 04/19111 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDencal $500 000 CLAIMS MADE Q OCCUR MED EXP y one parson $1 Q 000 PERSONAL.&ADV INJURY $1 00Q 000 GENERAL AGGREGATE s2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG s2,000,00 POLICY � LOC AUTOMOBILE LIABdlrY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per pers-) HIRED AUTOS BODILY INJURY (Per acddeni) $ NON-OWNED AUTOS x PROPERTY DAMAGE $ (Per acddeni) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ _ ANY AUTO OTHER THAN FA ACC $ AUTO ONLY: AGG $ EXCESSAIABRELLALIAIMM EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WC STATU- OTH- B 1worip"scomPENsATmAw WCC5002454012010 04/23/10 04/23/11 X EMPLOYERTL.IABILITY E.L.EACH ACCIDENT $500000 ANY PROPRIETORIPARTNERIEXECUTWE OFFICER/MEMBER EXCLUDED? NO E.L.DISEASE-EA EMPLO $500 000 If yes,describe under E.L.DISEASE-POLICY LIMIT $500 OOQ SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHLCLES I EXCLUSIONS ADDED BY ENDORSEVANT I SPECLAL PROVISIONS Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCR13ED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAL IQ_ DAYS WRITTEN 200 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAIURE TO DO SO SHALL Hyannis,MA 02601 IMPOSE NO OBLIGATION OR UABBITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. AUTHOR=9E0 PRESENTATIVE ACORD 25(2001/08)1 of 2 #S71887/M68180 LS1 ® ACORD CORPORATION 1988 Board of Building Regula ions and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 162600 ' Type: Private Corporation Expiration: 3/26/2011 Tr# 282115 BAKER & ASSOCIATES INC. MARK BAKER �; � _,.� ---------------- -- ----- ---- - P.O. BOX 923 � CENTERVILLE, MA 02632 Update Address and return card.Mark reason for change. oPs-cAi 0 50M-04/04-G101216 - j Address (_; Renewal Employment Lost Card Nlatssatchusctts Dcpai-t ent of Public '+atfM Bt-ntrd taf Building Regulati4)ns and Standards ads Construction Supervisor License License: CS 74477 Restricted to: 00 BRETT J BUSSIERE h l ' 111 WAREHAM LAKE SHORED EAST WAREHAM, MA 02538 Expiration: 1/6/201 7r4: 8715 a Board of Building Regula ions and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 162600 F Type: Supplement Card d Expiration: 3/26/2011 BAKER & ASSOCIATES INC. BRETT BLISSIERE 521 SHOOTFLYING HILL RD - CENTERVILLE, MA 02632 Update Address and return card. Mark reason for change. DPS-CAI 0 50M-04/04-G101216 , Address j 1 Renewal Employment ! Lost Card The Commonwealth of Massachusetts William Francis Galvin -Publ; Browse and Search Page I of 2 The Commonwealth of Massachusetts f� William Francis Galvin Secretary of the Commonwealth,Corporations Division r - One Ashburton Place, 17th floor s. 1r~ Boston, A 02108-1512 ''`' M F a �-_,��`; Telephone: (617)727-9640 BAKER & ASSOCIATES, INC. Summary Screen O pit;;;:,•„h ft._fomn Request a Certificate The exact name of the Domestic Profit Corporation: BAKER&ASSOCIATES,INC. The name was changed from: BAKER CUSTOM ALUMINUM&VINYL COMPANY,INC. on 1/8/2004 Entity Type: Domestic Profit Corporation Identification Number: 000522085 Old Federal Employer Identification Number(Old FEIN): 000000000 Date of Organization in Massachusetts: 01/01/1996 Current Fiscal Month I Day: 12/31 Previous Fiscal Month/Day:00!00 The location of its principal office: No. and Street: 521 SHOOTFLYING HILL RD. City or Town: CENTERVILLE State: MA Zip: 02632 Country: USA If the business entity is organized wholly to do business outside Massachusetts,the location of that office: No. and Street: City or Town: State: Zip: Country: Name and address of the Registered Agent: Name: No. and Street: City or Town: State: Zip: Country: The officers and all of the directors of the corporation: Title Individual Name Address(no PO Box) Expiration First,Middle,Last,Suffix Address,City or Town,State,Zip Code of Term PRESIDENT MARK BAKER 521 SHOOT FLYING HILL CENTERVILLE,MA 02632 US TREASURER CAROL BAKER MRS. 521 SHOOTFLYINGHILL ROAD CENTERVILLE,MA 02632 US SECRETARY BRETT BUSSIERE MR. 521 SHOOTFLYINGHILL ROAD CENTERVILLE,MA 026323 US DIRECTOR MARK BAKER MR. 521 SHOOTFLYINGHILL ROAD CENTERVILLE,MA 02632 US http://corp.sec.state.ma.us/corp/corpsearch/CorpSearchSummary.asp?ReadFromDB=True... 3/25/2009 I IME BmmsrnstE, Town of Barnstable s6gq ♦� 039. �fD MA'S A Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder Jr. ad 4-- , as Owner of the subject property hereby authorize —Re,kr C to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address o Job) Signa re of Owner Date B4Ci�l��cs� Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. t C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\4STGU5QO\EXPRESS.doc Revised 090809