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HomeMy WebLinkAbout1160 PHINNEY'S LANE (6) �i�;ram-Gze /�i+�-�#a�,3•�-��' . _ - _ _ ,\ - � II Division of Thielsch Engineering,Inc. R I .:S E 1341 Elmwood Avenue ENGINEERING Cranston,Rhode Island 02910. n - Wednesday, July 25, 2012 (v Town of Barnstable Thomas Perry, CBO 200 Main Street Hyannis, MA 02601 RE: 1160 PhinneY's Lane#213• Hyannis MA 02601 Arbor Terrace Co dos Barnstable Building Permit#: 201203868 _; v Dear Mr, Perry, This affidavit is to certifythat all work completed at 1166 Phifin6 s Lane#2B• Hy annis, MA p �irJ Y Y , 02601 (Arbor Terrace Condos), has been inspected by a certified Building Performance Institute (BPI) inspector. The following weatherization/energy saving measures were completed: Performed air sealing:measures to attic,are s�d conducted all appropriate blower door ;. g ,, _ tests, combustion safety tests and procedures. Sealing included attic chases, plumbing and electrical penetrations, bypasses accesslopenings, and other leakage points to reduce heat -loss through air infiltration. Includyd'weather stripping and insulating the ceiling access hatches,.weather strippingrand"installing sweeps to the front entry door, and sealing major penetrations througN'the"sill and the floor. _ Installed attic insulat on:,Furnished and installed approximately 9" of Class 1 cellulose R- 30 insulation to att c-Rat areas to achieve an approximate R-49 insulation"R"value; including soffit'baffles for ventilation as needed. All work erforme&meets or exceeds Federal and State Requirements. p � q _ 52 SmcerelY, -- a .�... �-- ;� � W== Erik J. Nerstheimer RISE-Engineering Residential Installations Department RISE Engineering; A Division of Thielsch Engineering CSL 1004591HIC 120979 401-784-3700 . 800-422-5365 . Fax 401-784-3710 ARBOR TERRACE - 81-12-1636 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION .Map :273 Parcel 089/OOF Application Health Division Date Issued Conservation Division Application Fee ! Planning Dept. Permit Fee yam_ 366 Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address UNIT # 2B ; 1160 PHINNEY'S LANE; HYANNIS, MA 02601 (ARBOR TERRACE) Village HYANNIS _ Owner ROBERT L.COHAN Address 1160 PHINNEY'S LANE #2B; HYANNIS, MA Telephone 508-771-2173 Permit Request PERFORM AIR SEALING MEASURES; INSTALL ATTIC INSULATION. SEE ATTACHED COPY OF JOB DESCRIPTION FOR MORE DETAILS. OWNER AUTHORIZATION ATTACHED. Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation $1,212.50 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 ❑ Oth er Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Paths: Full: existing new Half: existing new er ;°� Number of'3edrooms: 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: ❑`7 ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing © new; size_ 00 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 RESIDENTIAL Proposed Use SAME APPLICANT INFORMATION (BUILDER OR HOMEOWNER) RISE ENGINEERING; A DIVISION OF Name THIELSCH ENGINEERING Telephone Number 401-784-3700 EXT. 6133 Address 1341 ELMWOOD AVE. ; CRANSTON, RI 02910 License # CSSL-100459 EXP. 3/28/14 _ Home Improvement Contractor# 120979 EXP. 3/25/14 Worker's Compensation # 3730961-01 EXP. 1/1/13 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO YARMOUTH TRANSFER TATION• 50 WORKSHOP RD. ; SOUTH YARMOU H MA 02664 SIGNATURE _. GATE ERIK NERSTHEIMER FOR RISE ENGINEERING r r FOR OFFICIAL USE ONLY APPLICATION# .DATE ISSUED ,:.s. 3�`+ f -�►, .. � i i MAP/PARCEL NO. s ADDRESS VILLAGE r OWNER DATE OF INSPECTION: 1. t g . FOUNDATION'., i ' FRAME i INSULATION. FIREPLACE ' ELECTRICAL: ROUGH FINAL fl PLUMBING: ROUGH FINAL GAS: E ROUGH.%, FINAL h' N. ,FINAL BUILDING _ _ DATE CLOSED OUT. ? r , k ASSOCIATION PLAN NO. r 4 f The Commonwealth of Massachusetts Print Form 3 Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02119-2017 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. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.1 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#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. $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 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#26 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. 11 I do hereby certi nd a ains penalties o er'u that the in ormation provided abo a is rue and correct. i Signature: - _.:_....__ __ 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#: MASS. ,m� Town of Barnstable 'J Meg _- :_.. LIZ . ` Regulatory Services h D i •' irk �ti� Thomas F.Geiler,Director ' APR 3 0 2012 j!` BuildingDivision Thomas Perry,CBO -- ��'LL !' P Building Commissioner V 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 I, ROBERT L. COHAN ,as Owner of the subject property hereby authorize RISE, ENGINEERING; 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 2B;. HYANNIS, MA 02601 (Address of Job) e of Owner Date - ROBERT L. COHAN Print Name , If Property Owner is.applying.for permit,please complete the Homeowners,License Exemption Form on the reverse side: - . r ' C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 Sent by:Robert Cohan _ 3/8/2012_4.39:10 PM Page 1 of 2 i Arbor Terrace Condominiums nationalgrid PROGRAM SIGN-UP SHEET INSTRUCTIONS: Please complete this form to authorize the instal ation of a f t ist�ergy saving measures in your unit. You can choose any combination of mea ures. W udes enal and ainstallation. RISE Engineering will contact you to schedule appoin en 4 Return the completed form within 7 days in the enclosed postage par en op or fax it to RISE Engineering at 401-784-3710.,If you do not want to partici ate,you do not need to retur the fo m- If you have any questions, please contact eag an Quinn at RISE Engi eerin at 1-800-422-5365 ext.6131 or E- EnergyWisN mail: MQuinn @THIELSCH.COM. OWNER INFORMATION(Please pin t) / Owner's Name: 2r ��lL 4 A " Owner's Address/unit# Al �"� rJ Daytime hone .� V�r �� l !�yti p Evening phone J Cam/ lam' r� Air Sew ll n Attic Inaula'fion and`Hot liVater Conservation - (in a es-a -ma ena an insta ation----� e: ES 0NO Total Cost: $1,212.50 National Grid lncentive: $972:50--- Your Cost: Not to exceed 1240.00 billable upon completion • Air Sealing:Air seal attic chases, plumbing and electrical penetrations, . bypasses, access openings, transitions, ductwork and other leakage points to reduce heat loss through air infiltration. High quality foams, caulks, baffles, a 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 approximateR-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 be insulated. " MAW • Hot Water Conservation: Furnish and install hot water pipe insulation for the 1st 6' from the water heater,water saving showerheads and faucet aerators as applicable. A-.'F®9dBn stair Ins_talation and Air Sealin - mc u es all material ana installation): VES�i1N0 Total Cost: $166.5 NGrid Incentive: $83.25 —' Your Cost: Not to exceed $83.25 billable upon completion .:•=:: ; a Thermo-dome Cover: Furnish and install"thermo-dome"attic stair insulating cover. nYES-`NO for Digital/Programmable Low Voltage thermostats(No Cost) w' • Digital/programmable low voltage thermostats (Robertshaw RS6110 or exact equal) replace existing LManual thermostats in dwelling units Quantity of digital thermostats needed? By signing below. 1 agree to have implem nt the i o menu I have selected and agree to the associated c sts shown.8 Y 4 `- ✓ Owner(please sign) � Date 4 P 03/08/2012 THU 17:56 [TX/RX NO 63291 Q1001 THIEL-1 OP 10:-27 CERTIFICATE OF LIABILITY INSURANCE �4 0111 DMYY) 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 CONTACT The Preston Agency,Inc. 1350 Division Rd Suite 303- 401-885-1700 n/c°No Ext: Alc No PO BOX 810 E-MAIL East Greenwich,RI 0281&.0.810. -. ADDRESS: Judith A.Wright CPCU AAI ARM INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Zurich-American - INSURED Thielsch Engineering,Inc.Thielsch Group Inc. IN Thielsch Guarantee&Liability Hi Tech Realty Inc. INSURER C:Twin City Fire-Hartford Trent TherouX 195 Frances Avenue INSURER D:North American Capacity 195 _ Cranston,RI 02910 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF'INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDDIYYYY MM/DDNYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 11000,00 A X COMMERCIAL GENERAL LIABILITY X 3730962-01 01/01/12 01/01/13 PREMISES Ea occurrence $ 300,00 CLAIMS-MADE F OCCUR MED EXP(Any one person) $ 5,00 PERSONAL SADVINJURY $ 1,000,00 GENERALAGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMPIOP AGG $ 2,000,00 POLICY X PRO- LOCI Emp Ben. $ 1,000,00 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 2,000,00 A X ANY AUTO 3730963-01 01/01/12 01/01/13 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per $ AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE HIRED AUTO AUTOS Per accdent $ X UMBRELLA LI�N$ X OCCUR EACH OCCURRENCE $ 10,000,000 B EXCESS LIABCLAIMS-MADE AUC-4857188-01 01/01/12 01/01/13 AGGREGATE $ 10,000,000 DED RETENTIO $ WORKERS COMPENSATION -X VoC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N 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 EXCLUDE D9 -❑ NIA' (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 I(yes,describe under 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, 01/01/12 01/01/13 Prof Liab 2,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) 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. 200 Main Street AUTHORIZED REPRESENTATIVE Hyannis,MA 02601 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Details rage 1 of 1 Licensee Details Demographic Information rdl F 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: Doing Business As: Status Change: 18 - Prerequisite Information Licensee: NERSTHEIMER, ERIK S. Relationship: Attribute Of d License No: CSSL-100459 Discipline No Discipline Information Documentum http://elicense.chs.state.ma.usNerification/Details.aspx?agency_id=1 Mcense_id... 4/25/2012 Office of Consumer Affairs 6nd Business Regulation — 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 JUN ;Home Improvement Contractor Registration Registration: 120979 Type: Supplement.Card THIELSCH ENGINE ORING Expiration: 3/25[2014 1341 ELMWOOD AVE. CRANSTON, RI 02910 Update Address and return card.Mark reason for change. sCA 1 « 20M-05/11 Address Renewal Employment Lost Card dF/1e V1"11nzaarraerrl"1e'of'C/Ijtr�tcrc�uoe(l - ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation egistrationr:: ?0979;;_ Type: 10 Park Plaza-Suite 5170 Expiration 3/25/2014 Supplement Card Boston,MA 02116 THIELSCH ENGINEERING ERIK NERSTHEIMER :M / 1341 ELMWOOD AVE ` CRANSTON,RI 02910 Undersecretary Not valid without signature } Control No: 3 4 2 4 4 THE COMMONWEALTH OF MASSACHUSETTS b , DEPARTMENT OF LABOR DIVISION OF OCCUPATIONAL SAFETY 19 STANIFORD STREET, BOSTON,.MASSACHUSETTS 02.114 LEAD-SAFE RENOVATION CONTRACTOR LICENSING WAIVER RISE Engineering A Division of Thielsch Engineering, Inc. 1341 Elmwood Avenue Cranston, R102910 WAIVER: LW000672 EXPIRES: April 15,2015 IN ACCORDANCE WITH M.G.L.C. 111, § 197(B)(b)AND 454 CMR 22.03(3)(b), THIS LEAD-SAFE RENOVATION CONTRACTOR LICENSING WAIVER IS ISSUED BY THE DIV. OF'OCCUPATIONAL SAFETY TO THE CONTRACTOR ABOVE FOR THE PURPOSE OF PERFORMING LEAD-SAFE RENOVATION WORK. THIS LEAD-SAFE RENOVATION CONTRACTOR LICENSING WAIVER MUST BE MAINTAINED BY THE CONTRACTOR IN ACCORDANCE WITH M.G.L. C. i 111, § 19713(b)AND 454 CMR 22.04 WHEN PERFORMING LEAD-SAFE RENOVATION WORK. HEATHER E. ROWE,ACTING COMMISSIONER Printed on Recycled paper 9 v�1 �► TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map a`7 Parcel 6kol OOF Application # G� Health Division Date Issued Id , Conservation Division Application Planning Dept. Permit Fee Date Definitive Plan.Approved by Planning Board } Historic - OKH _ Preservation / Hyannis Project Street Address 1(00 Pin ► ,vie 6S L n. Village C . Owner R0be -� CoIIQ,n Address �QYY1� Telephone Permit Request Y1 k� 4b k% !Aoxyew qVV)JAJ makammey-)t Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay 00 Project Valuation 0Q 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 as V''a Historic House: ❑Yes C�`No On Old King's Highway: ❑Yes tiNo 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 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 _ Othe& Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ o Commercial ❑Yes ❑ No If yes, site plan review# CO Current Use Proposed Use : -- r- APPLICANT INFORMATION rn (BUILDER OR HOMEOWNER) Name / d> �S� ie- Telephone Number �7(D �`D Address /�/ �i�/�l/�,b��/ S�,P�o 1AA4)e License # 1'q A �li -7 ,61 1414 ff o &2 1 Home Improvement Contractor# 1(0A(40O Worker's Compensation # W-CI&AAA lSAa\a009 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO SIGNATURE DATE f� FOR OFFICIAL USE ONLY APPLICATION# F DATE ISSUED '. MAP/PARCEL NO. -r ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION t FRAME INSULATION FIREPLACE ! ELECTRICAL: ROUGH 'I FINAL PLUMBING: ROUGH I FINAL GAS: ROUGH FINAL 3 FINAL BUILDING DATE CLOSED OUT � r ASSOCIATION PLAN NO. t The Commonwealth of Massachusetts Department of Industrial Accidents Office.of Investigations 600 Washington Street Boston,MA 02111' ww».mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Orpnization/lndividual): C_ Address:_ o City/State/Zip: C ,�/�/i � �� Phone#: Are you an employer?Check the appropriate box:. Type of project(required): 4. El am a general contractor and I 1. I am a employer with 6. ❑New construction employees(frill and/or part-time).* listed on.the attached have hired the sub-cont sheet 7• ❑ Remodeling ractors 2.❑ I am a sole proprietor or partner- These and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition o workers' comp. insurance 5. ❑ We are a corporation and its [N 10.❑ Electrical repairs or.additions required•] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL ll.❑ Plumbing repairs.or additions myself. [No workers' comp. C. 152,§1(4),and we have no 12.❑ Roof repairs +\. insurance required.] t employees. [No workers'' 13.0 Other Re,01- W%»App� comp.insurance required.] ,Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infomiatiou: 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 their workers'comp.policy information. am an employer that 6 providing workers'compensation insurance for my employees. Below is the policy and job site nformation. ' nsurance Company Name,ADGrs ?olicy#or Self-ins.Lic. 7`��c►7140 ' Expiration Date: y-2 3.t lO lob Site Address: D City/State/Zip: kttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ailure to.secure coverage as required under Section.25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 )f up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of nvestigations of the DIA for insurance coverage verification. 'do hereby certify under the pains and penalties of perjury that the information provided above is true and correct ;i afore:. Date: V [� ?hone#: Official use only. Do not write in this area,to be completed by city or town official, City or Town: Permit/Llcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Issuing Phone#: Contact Person: i Client 0:9742 2BAKERAS ACORD,� CERTIFICATE OF LIABILITY INSURANCE s/is;� -- , PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION i D ONLY AND CONFERS NO Dowling 8 O'Neil Insurance RIGHTS UPON THE CERTIFICATE HOLDER.'THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ! Agency ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW i 973 lyannough Rd., PO'Box 19% Hyannis,MA 02601 INSURERS AFFORDING COVERAGE NAIL 9 INSURED INSURER A National Grange Mutual Insuranc Baker&Associates,lnc. INSURER Tf Associated Employers Insurance ^_ - - -- i P O Box 923 INSURt-H r Centerville,MA 02632-0071 NSURLN D INS(RWER t _J COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE NSUREDNAMED ABOVE FOR THE POLICY PERi(t)INDICATED NC)TWITH."�TANUItN(: ANY REtJUIREMENT.TERM OR CONOITION OF ANY CONTRACT OR OTHER DOCUMENT VITTH RESPECT TO WHICH T HIS CF.RTIFIC,ATE MAY BE L,SN-b�44 MAY PERTAIN,THE INSURANCE AFFORDEU BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS E XCLUSICINS AND(A NI)TI V ft n; '.if(>I POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �y TION LIM TYPE DE INSURANCE POLICY NUMBER pA DA POLICY Mi1DOMI I IMtTS A GENERAL LIABILITY MPJ7223M 04/19/09 04/19110 t AI:I l(IC(URRI NCI $11000 000 X M( I1AA1Ala TO RI Ni D $500 000 C(:MRC IN (AN[ I!A(Si111Y IS S I ... _.i.. (I.AIMS MARL U OCC(1R Mt O 1 Al, $10 000 -_- 0 RSONAI A ADV IN It W r $1 000 000 _ C.1_NI.RAI.ACI)HI I,A N s2,000,00 _ GI NI AGCRf GAT ILI Mn APF 11-S PtR 1'Huuuc I cc».w�(u'Ac(: s2 000 000 c'Fto (� UOC AUTOMOBILE LIABILITY COMht?41 I C,NI 11 i'M 1 1(.m'tlnnrll ANY AU 10 NI C 7WNtr 11 AU It 101)11+14;I114'+ l 1Pa(.Irscx� Scta:DtA I D A1,1`10S HIRI DAUIOS lil.)I)11'+'"it IRN' S IPw a:ddr+ll W)N UWNI I)At II S FRCtl1 Hl�I7AMA(71 ,, iPw ucdnfH�h GARAGE L1ABlITY 41.110(INI 1 A AI(_q)1 NI $ ---'—"- ANY ALIITI II(I H IHAN I A At.( EXCESSAJMBRELLA LLMWJTY I A{it(H:CIIRHI.Nt:1 UC(AR n CI AILLti MAGI A('.(:RI(All $ U(OC1C DBt t --- Ilk IENI iUN $ $ '------.. B WORKERS COMPENSAT11 N MID WCC5002454012009 04123/09 04/23110 X we TA IR w ;III -' EMPLOYERS'LIABILm I I I A1-14 A(I:rn 111 $100,000 ANY I'NC.AN11 rUWPAHI NI W(AFCW M - ........____... (it(ICI-WMEMPA R I XCLODF D? NO I t li IA•A I A I MIT 0-11 $1000W ._^. I•ios 00 itlu und& 41t CIA1,PR0VISIUN` r 1. I;IsI Ar,l PUI a:=I iM I $500 000 --- OTHER DE SCRIPTICJN OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENOORSEMENT I SPECIAL PROVISIONS ---_-'— Officers are included under the workers compensation policy. Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certilricate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Pa merit SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEI Lk UL(URI THI EXPWATKJN Town of Barnstable DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR 10 MAN 10 DAYS WNr(n N Thomas Perry NOTICE TO7HE CERTIFICATE HOLDER NAMED TO IHE LITI BUT tAll ORE TO DU SO SltuI 200 Main Street Ih POSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON 7TIE INSIJRC-R II S A(,r NTS I I Hyannis,MA 02601 REPRESENTATIVES._ AUTUOMZEDR�'PRESENIAT1VU i C. ACORD 25(2001/08)1 of 2 #S59110/M58469 `^' LS1 0 ACORD CORPORATION IN i -_ A62 te Board of Building Regulations and Standards One Ashburton Place Room 1301 � -> Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 162600 Type: Private Corporation Expiration: 3/26/2011 TO 282115 BAKER & ASSOCIATES INC. MARK BAKER P.O. BOX 923 CENTERVILLE, MA 02632 Update Address and return card. Mark reason for chant,. Address Renewal Employment Lust Cat G CAI 0 ,OM-04,'04-6 101216 y 1#;a�o.aa:#tuc°tt� - €��`#ttt-t�tt�.��i4 f►F #�tr#IIi�� � �����,� Brr�aa c# of Rui#tlin o Re-ul ations amI S(M)(13Cki Construction Supervisor License License: CS 74477 Restricted to: 00 BRETT J BUSSIERE 111 WAREHAM LAKE SHORE D h EAST WAREHAM, MA 02538 Expiration: 1/6/2011 8715 - -- Board of Building Regula ions and Standards _- One Ashburton Place - Room 1301 - Boston. Massachusetts 02108 Home Improvement Contractor Registration Reqistration: 162600 Type: Supplement Card Expiration- 3/26/2011 BAKER &ASSOCIATES INC. BRETT BUSSIERE 521 SHOOTFLYING HILL RD CENTERVILLE, MA 02632 Update Address and return card. Mark reason for ch: iwe- Address Renewal Employment Lust Car i 4 4 GA t C. 50M-01 04-G 101216 1HE Town of Barn-stable Regulatory Services 9 'i esi its` Thomas F.Geiiler,Director '` Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: S09-862-4038 Fax: 509-790-6230 Property Owner Must j Complete and Sign This Section If Using ABuilder as Owner of the subject property hereby authorize Q, (' as��pC1Q- �j/lC to act on.my behalf, m all matters relative to work authorized by this building permit application for: (Address of job) Signa e of Owner Date �ober't CoL�ca.,n Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. The Commonwealth of Massachusetts William Francis Galvin -Publ; 'qrowse and Search Page I of 2 The Commonwealth of Massachusetts f William Francis Galvin Secretary of the Commonwealth,Corporations Division One Ashburton Place, 17th floor Boston, MA 02108-1512 Telephone: (617)727-9640 BAKE-R & ASSOCIATES, tNC. Surnmary Screen 0 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 1/8/2.004 Entity Type: Domestic Profit Corporation Identification Number: 00052-2095 Old Federal Employer Identification Number(Old FEIN): 000000000 Date of Organization in Massachusetts: 01.101/1996. Current Fiscal Month I Day: 12.1 3.1 Previous Fiscal Month I Day:00/_00 The location of its principal office: No. and Street: 521_$HQOTFLYING 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 {,t+n //i•nrn cor ortntP ma us/corn/cornsearch/Corp Search Sum mary.asp?ReadFromDB=True... 3/25/2009 r September 21, 2009 Town of Barnstable Building Department Hyannis, Ma To Whom It May Concern: As the property manager of Arbor Terrace Condominiums located at 1160 Phinny's Lane in Centerville. This letter is to state that Baker & Associates Inc. has been approved to install replacement windows and doors at our complex. T nk You, George Bartlett