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Home My WebLink AboutBLD-19-001901 • °N 0 4 C °N IJ "A 0 1dt1 Itpun119MJo1U 001 u11111M 110111014 00110910ild 0AJn000Sl1l01nM . °14, n 90A C, Iduo2 Old P°old ON t'1 06A 10 110111014 Iu01a01tIH 1101u1tia luiu62 .,..l 67.---n10111QI .: IA • • ,�' 0614119 Mjo.. . • Il: 101114PIRVar1111 p9Aalddy IG (IoIwgavu1Y 40)IJnluulls I.IOIIMO LZ ' 4 ul,;r�,iu;;'19!'jil�l' 1� � Ac ss3 Raua IUlptlulltmvouddy I0114140 agnlAn194141414141041411I 'Jollogpwo1p91Ato iujjejs'a41g010'P19punuollnouoldJo) pia ot140e1pwJo(101luooMA1Uto1494lobImiou (agIIIAt v4 Aw o td 641011491466 1491106 is 9nq 911 pwuloluo, Moloy iw6uloplt 9811141 Mlnllod Jo 19plouad bpi ernlnap I j� .... 411 loud Jo 1401114001 , II f J "I ' 7 110 Jo pltedgp l4•w ;pgop 4141 , " , CI,( �i Y12�0 2ulous; food ><II �toJ OW flu on do -- C99��nn ° I I 1i•( ) 1tIt1 aluo1aI}v,<uAt481J{ tlui>i PIo 0 uollnlncu Ma to/12 if tC- 11111.� Wahl 11 'MU) k8uinixo ototuo�J ( ) '—'caannbgJoq Isupooy .. p 10400 ltletueo Ides .-------"g ItMapulM Iuetuaooldov'm toAunbsJo p IlulplSr,I oAo1s Pooh. a; .. 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C dy�line 09920 VV4 'Ninoulati,�t{1no$ aZ 111 iBIOZ — I 100 waa udQ guIPUfl glnoluau,*, • , xinovsxVA do moL a 3 A 1 a F a - - (I ailddyzWU ad ONIIagin$ Ss2 MX • • Qb110-b( \ la 1 oOIVp Oltlli �Imx.uo4 aop Dot togdUtut'd1, il 11 1alunowyli o!mood1 \ \' .1:01SIImi ,Alup otnIOUJOj S The Commonwealth of Massachusetts Department ofIndustrialAccidents ; =Erring- I Congress Street,Suite 100 Boston, MA D2114-2017 • :k r.•o° www.mass.gov/dla Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FiLED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le¢ibly Name(Business/Organization/Individual): Cape Cod Insulation Address: 18 Reardon Circle City/State/Zip: South Yarmouth,MA 02664 Phone#: 508-775-1214 Are you an employer?Cbeckthe appropriate box? pr1E11 am a employer with 48 employees(full endNew lar part•time),e Type of co t(required): 2.01 am a sole proprietor or partnership and have no employees working forme In 87. 0enNCtlon any capacity.(No workers'comp,insurance required.) 6• ❑ Remodlillrig 3.01 an a homeowner doing an work myself.No workers'comp.Insurance required.)r 9. ❑ Demolition 4.01 am s homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contraoton either have workers'compensation insurance or ere sole 11.0 Electrical repairs or additions proprietors with no employees. 5.0 I am a general Contactor and I have hired the sub•contracton listed on the attached sheet. 12.0 Plumbing repairs or additions These sub-contractors have employees and have workers'comp.Insurance,* 13.0 Roof repairs 6.0 We Ire a corporation and Its officers have exercised their right of exemption per MOL o. 14, ✓�Other Weatherization 152,.11(4),and we have no employees,(No workers'comp.Insurance required.] 'Any applicant that checks box SI 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. 1Contraetcrs that check this box must attached en additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site information. Insurance Company Name: Atlantic Charter . Policy#or Selfins.Lio.#: WCE00431902 Expiration Dated 06/30/201/ _ Job Site Address: To %VIEW > City/State/Zip: ass Ni'tti, Attach a copy ofthe workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MOL c. 152,§25A is a criminal violation-punishable by a fine up to$1,500.00 andlor one-year imprisonment,as well as civil penalties In the form of a STOP W0Rc ORDER and a fine of up to$250.00 a day against the violator,A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification, 1 do hereby certify under the pains and penalties of perjury that the information providedbove/s true and correct 5ianature: Henry Cassidy v MSM .aDate: IGjZ7�f »-, Phone#: 508.775-1214 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 5s Plumbing Inspector 6.Other Contact Person: Phone#: • I U , • f 4• Commonwealth of Massachusetts lVDivision of Professional licensure • .Board of Building Rep9ulallone and Standards Co ns` ;CtN rl lE(1'ns,rvlsor • Yj • 08.100988 .,.;0' ,;r:d eyIres: 11/11/2019 • -;(111/.111/ t, l • �.�rr�`�G.n1^�.. • .c; e HENRY E CA�SIOY;,F 'r �o� eSHED ROW n Ill 11;' / "' WEST YARMOd.T MA,L'.O,.5EB 1+0' //1/0/(Seti:Cte\1, .+. w Commissioner +- C-2" • s`' Prhe no uaecdaa • L‘Itp Office of Consumer Affairs and Business Regulation 10 Park Plaza • Suite 5170 Boston, Magg°dbtiusetts 02116 Home Improveme,,:i:? o_�rNractor Registration !9i1'e• +^'/'" ) Type: Corporation ,. :•`r:_`•;`ll i1 I/ Re9istraIIon; 163687 Cape Cod Insulation, Inc l ""' ' ' r, Expiration; 12/14/2018 18 Reardon Circle ,v t"'' "'""'' •• So. Yarmouth, MA 02684 ��, },'r:" t, • t`:I..SIr j.1 • l•••••? Vpdete Address end return card, Mark reason for change. 1\ .._...,.........�[ ......._�.._....._..... . ........_._., ( .Addrsam.,C'-rl•u+alr;at_fZPmplcs/mont.r l last.Cs.rd . �0 700141{Me(Uef S o�Ct Y,(rrada.4rraat(J Mee of Conecmer Melee&Buelnen Regulation a" " HOME IMPROVEMENT CONTRACTOR 1 1 (mm� Registration valid for Individual use only y ., • Tjrpol Corporation before the expiration date, II Ioun• • urn lot ' 011loe of Consumer Altair,end'; el .es Regulctlon /r jnr;lne Exotrnau �.r '..11J;c"Ir'f+ iSb. ail 12114/2018 10 Park Plan• • e 5170 • • •.• \�14 i'i`i Boston,MA • Cape Cod insult P ottw t j I' • Henry CassldY'.\ I.' rf�Z�t g.t. to Reardon Circ(' v ` �,` ,c, R.ec..G so.Yarmouth,MA , , 84, so C� • JAIL_ 4 ,,y„i' Undersecretary t al, . �I, _ hout sle atu 0,01 • I.‘ • ..-- 1 CAPECOD-27 AMAHLE- A�Oe CERTIFICATE OF LIABILITY INSURANCE DATE 06/0512018 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 have ADDITIONAL INSURED provisions or 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�p endorsement(s).ry� .N PRODUCER B67EpCT Rogers&Gray Insurance Agency,Inc. PHONE FAX 436 Rte 134 (NC,No,no: (A/C,No(877)816.2156 South Dennis,MA 02660 p'rUiss,mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC N INsuRERA.West American Insurance Company 44393 INSURED ^ INaURERa:Satety Indemnity Insurance Company 33618 Cape Cod insulation,Inc. INSURER C:Endurance American Specialty Insurance Company 41718 18 Reardon Circle INsuRERo:Atiantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER I: 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. NOTLMTHSTANDING 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. IjNSR Tq TYPE OP INSURANCE ADDL SUER POLICY EFF POLICY EXP JNSD WVa POLICY NUMBER JMMIDDWYYY) IMMIDD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH�OCCpURRENCE $ 1,000,000 CLAIMS-MADE O OCCUR BKW(19)63328281 04/01/2018 04/01/2019 pRFMISPS(Pa oecurmncel S 100'000 — MEC/EXP(Any one person) I 5,000 - PERSONAL SADV INJURY S 1,000,006 GEN'LAGGR A LIMIT ARMS PER: GENERAL AGGREGATE $ 2,000,000 X POLICY LIj Sj LOP PRODUCTS-COMP/OP AGO S 2,000,000 X OTHER:sae holder dandy o/operations E B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I 1,000,000 — (Ea accidenANY AUTO p 8232707 04/01/2018 04/01/2019 BODILY INJURY(Perperson) S OWNED• UTONLY X AUTOSULED — XI TO UD1 oy�E PBgODILy INJURY(Per accident) S AUTOS ONLY X AUTOS ONLQ (PeoPEv 9AMAGE S I C UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 X EXCESS LIAB CLAIMS-MADE EXC10006635003 04/01/2018 04/01/2019 AGGREGATE $ 2,000,000 DED RETENTIONS D WORKERS COMPENSATION - p I AND EMPLOYERS'LIABILITY PERTUTE ERH ANY PROPRIETORIPARTNERIEXECUTIVE YIN WCE00431903 06/30/2016 06/30/2019 E.L.EACH ACCIDENT 3 1,000,000 �pFICERrtd MOEt EXCLUDED? u NIA (MantletaryFln ) 1,000,000 II yes,describe under EL DISEASE•EA EMPLOYEE S 1,000,000 • DESRIPTION OF OPERATIONS b.IOw EL DISEASE•POLICY LIMIT i • / DESCRIPTION OP OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be lashed if more space s required) Workers Compensation Includes Officers or Proprietors. Additional Insured status is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. Excess Liability Is follow form. CERTIFICATE HOLDER CAN.CELLATJON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. • AUTHORIZED REPRESENTATIVE ACORD 25(2018103) 01988.2015 ACORD CORPORATION, All rlahts reserved. DocuSigri Envelope ID:CC6853\ ,/ C,F-45E9-4080.8C6A-E0055663F35C Wd1 RISE ENGINEERING - OWNER AUTHORIZATION FORM I, Judy Scola (Owner's Name) owner of the property located at: 90 Seaview Avenue (Property Address) Bass River, MA 02664 (Property Address) hereby authorize Cape Cod Insulation (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property.This form is only valid with a signed contract rPocuelyruA by: •—Owne►4sosKJnatore 9/17/2018 I 6:06 PM EDT Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 I 508-568-1926 www.RISEengineering.com