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HomeMy WebLinkAboutBLD-19-002600 r jjjjg m4 � � � _ 1° w N p • CO C7 c� ,� a w W J' 11 1 x. Ng4 IL_ 5 r rte- o U �__ Cr �� m m -c c9 a :.14'..4' o O E O J o` I. es _ c R la_i__ .J a d E n .O _ -p n` n _ "W C0. 0 �+ �I •� N CO Q II) Y6 �N ,e2(W(�,� W QD J - V 5 ca e Y \� o� • ti— )+ -a Ki N : • _C O S O !L i7�RO � EN� ra�� Vm Ica cc, vel o o_.s -S 1 apz.T� V ; _ IS 0 yC6 E" E a v_ -- 1 .A O o h a o h W 9 4 =: • N} Z air oma. _ d O - > F. vs —.-. E o S c a y _ .- I O2 - e o L 0 a v `�` _ o Y '> a co a o a o _ �- PQ = Co a sem-. '-- o .� - a rc: e� CO o-c sG v A _ o c. Q a.z LoaY- o� n- .�� d E v _ o Z3 = C O o oG- eo 1`0 2 h z G fi ` Cf �• es o o `M1 co• - t i _ JI !\o ea C 0 .� _ /o_ O 1 C E Es` e o ` v := _ • �"� E h O _ i n E c' iii Lift C> h o o f:. y lir- - • stop The Commonwealth of Massachusetts = ,_ Department of Industrial Accidents =1.111_ 1 Congress Street, Suite 100 _" — Boston, MA 02114-2017 e' _ w • ww.mass.gov/tile. 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?Meek the appropriate box: Type of project(required):I, i am employer with aa employees (full end/orparbtime),s 7. ❑ New construction 2.0 I em a sole proprietor or partnership and have no employees working for me In any capacity,(No workers'pomp,insurance required.) g• ❑ Remodeling 3.01 em a homeowner doing ell work myself.(No workers'comp.Insurance required,)t 9. ❑ Demolition , . 4,0 I am a homeowner and will be hiring contractors to conduct ail work on my property. 1 will 10 0 Building addition ensure that ill contractors either have workers'compensation insurance or are sole proprietors with no employees, 11.❑ Electrical repairs or additions 6.[]I am a general oonnotor and I have hired the sub•oontrectors Ilsted on the attached sheet, 110 Plumbing repairs or additions These sub-contractors have employees and have workers'comp,Insurance.; 13,❑Roof repairs 6.0 We are t corporation and Its officers have exercised their right of exemption per MOL o. Ica Other W eatherizatlon 132,11(4),and we have no employees,(No workers'comp,Insurance required.) Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy Information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit Indicating such. 'Contractors that check this box must attached en additional sheet showing the name of the eub.00nuaotors and state whether or not those entities have employees. Mho subcontractors 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 k or Self-ins.Lie,h; WCE00431902 Expiration Date 06/30/201q Job Site Address: ld Wit z lYDOL City/State/Zip: W �aV , �j '-- Attach a copy of the'workcompensation policy declaration page(showing the policy numbe and expiration date). Failure to secure coverage as required under MGL e. 152, §25A is a criminal vlolation'punishable by a fine up to$1,500.00 and/or one•year imprisonment, as well as civil penalties in the form of a STOP WOR)cpRDER and a fine of up to$250.00 a day againstthe violator,A copy of this statement may be forwarded to the Office of r{vesdgations of the DIA for Insurance coverage verification, !do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. ,$lanature: Henrycassldy �,. ^� ^• /0/31/1 OIn /`1 � .,..-w...,.....M...«.r, Data• / 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 it Issuing Authority(circle one): • 1.Board of Health 2. Building Department 3. City/rown Clerk 4. Electrical Inspector 5f. Plumbing Inspector 6.Other Contact Person: Phone#: C • • • t' Commonwealth of Massachusetts t1Division of Professional Licensure Board of Building Regulations and Standards ' Cons`r;' iVCthrtl%Gpyrvisor p. • CS•100988 J' I yi• . E Tres; 11/11/2019 . i '' .1:11 P`>'r n • HENRY E CA�$JSIDY.'I I a7; ' a i,` 8 SHED ROW i .1 � Iji,, • Si • WEST YARMOGSMA`IO236'13 rC )' 't • • Commissioner "- saef-Ae Vag; 2a4vcie044 9W,6,6 czal z of ler I VAry, Office of Consumer Affairs and Business Regulation tl, 10 Park Plaza . Suite 5170 Boston, Mas,$b�usetts 02116 Home Improveme.,.f. .o-tractor Registration c,n,m�1wII nr.RMVR-r. m.. "',.'.1.'9.,1;•",1.'. (, nl .,;..,:,, ' ��+"'�;,:;r:,a:'r •l TYPO. Corporation Cape Cod Insulation, inc '"` ii fill r '^it�'•m ;l P Registration; 153567 4e/ •;'+;•`'' , Expiration: 12/14/2018 xn•,j 18 Reardon Circle t" ' ;;,,;;;,: So, Yarmouth, MA 02604 • t tti \ea `• ,mai! 6 ,,'r:,, \"i',•{ i rill • �'•••�5� np UpdateAddroesandreturncard: Mark reason for chomp IMe Cr11 ?OMA I; . 1` ....,....._._.._.. (� �� �__�::_..:....... . •........,.._,.:,.,..C,�„Adr;uaam..f�.R•enc.lr;n!_I:Z°.n:plo�/m'an1..L.l.Lc,.a.!;err. 00 IPO WIWI4WvIb4{u�cYleadoer.r/rreatfu •°i Vile,of OomumtrPJlelts I. auelneea Repvletion 't'4 ; • HOME IMPROV!M8NT CONTRACTOR Registration velld for Individual Uia only @i'41., • L.ypol Corporation boiora the expiration date, It Igyn• a urn tot N • 1uu,a; pxp,�nllen C1110*of Oonaumer Affair, and': al -a, Regulation °j'�' ti7:1W.t)e ,� 12114/2018 0 8110 .. ' 8,7 10 Park •r. rv�•I Dolton,MA . 11+ ' Cape Cod Ins01�10 ISHo ry C eCodIldY'c;� p 1 ' /• 18 Reardon Clro � �t�St," 2.cG, �. . / So,Yarmouth,MA ,Q; ,ptib„ pt C� Off' -- _ C:1 Vndorsecretary ��t rd.-- housi slu ; -----'1 CAPECOD-27 AMAHLER A`--- DATE(MMIDDN'YYYI CERTIFICATE OF LIABILITY INSURANCE 06/05/2018 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 pollcy(les)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 endorsement(s). PRODUCER NAPII€AcT Rogers&Gray Insurance Agency,Inc. PHONE I FAX NpI;(877)816.2156 434 Rte 134 INC,No,Eat South Dennis,MA 02860 min;mall©rogersgray.com INSURER'S)AFFORDING COVERAGE NAIC e INSURER A:West American Insurance Company 44393 INSURED ". INSURER B:Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER c:Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER D:Atlantic Charter Insurance company 44326 South Yarmouth,MA 02664 INSURER E; INSURER F I 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. II TR TYPE OF INSURANCE IANSL SND POLICY NUMBERPOLICY EFF POLICY EXP IMM/DD/Y1'YYI IMMIDDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1 1,000,000 CLAIMS•MADE O OCCUR BKW(19)53328281 04/01/2018 04/01/2019 DAMAGE TOR ENry anal $ 100,000 MED EXP(Any one person) $ 5,000 — PERSONAL It AIN INJURY $ 1,000,000 LAGGR GAT LIMIT APP I SPER: G NERAL AGGREGATE $ 2,000,OOD POLICY�jR Lov PRODUCTS AGO 3 2,000,000 X OTHER see holder descdp of operations $ B AUTOMOBILE LIABILITY (FOseocldenll NGLE LIMIT $ 1,000,000 — ANY AUTO _ 6232707 04/01/2018 04/01/2019 BODILY INJURY(Per person) $ AUgTpOpS ONLY X AFil�ilIi uLLEEDpp ' X AUTOS ONLY X AUTOSONLY BpOOPERTYDILY UAMAGE RY(Per accident) $ (NCr accident, 3 — •C. $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 2,000,000 X EXCESS LIAR CLAIMS-MADE EXC10006635003 04/01/2018 04/01/2019 AGGREGATE $ 2,000,000 •. DED RETENTIONS _ D WORKERS COMPENSATION $ ANO EMPLOYERS'LIABILITY PERTUTE I I FRD ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WCE00431903 06/30/2018 06/30/2019 1,000,000 gFFICERrMEMBER E%CLUOEW u NlA EA. EACH ACCIDENT $ (mandatory In NNI 1,000,000 If yes describe under E.L.DISEASE•EA EMPLOYEE $ 1,000,000 • DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT 5 • • DESCRIPTION OF OPERATIONS I LOCATIONS,VEHICLES (ACORD 101,Addltlonel Remarks Schedule,may be attached If more area Is required( / Norkers 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_NOLDER CANCELLATION 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 I 7%X ACORD 25(2016/03) 01988.2015 ACORD CORPORATION. All rights reserved. DocuSign Envelope ID:F37E2892-0247-4143.87F9-E494A611AFCE RISE ENGINEERING OWNER AUTHORIZATION FORM I, Bernadette M Archambeau (Owner's Name) owner of the property located at: 36 Town Brook Road (Property Address) West Yarmouth, MA 02673 (Property� Address)l_ hereby authorize Cc') a- e-cr,-- ono Jct cA \ (Subcontracto}) 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. ,-DocuSiyned by: I t�Gl QI/1.0.U. •--flwnerlmslgnature 10/18/2018 I 10:29 AM 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