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BLD-19-002515 • . crj1 ._....._ .,,. , 1 ... _ _ 4.- . r:s ......... _ , 0.1 1...,,I 1 sic 4 _ O '�p ris 6 C�j •� 1 �(� tD CQ V' P Ij r =5 49 aCJ a , � N 13i; 3:^U_p E o ya = U a V 0 -43 } -pz •c 1 - o .7.- c 0. _ o C 2 Ili. o no - o v v o ni FA lab `o v o 0 0 F^� C N N - - (� o -y c -)-- ••• C> moo iris = -O t_ Ic. e utilea �- <N W pp CO _ Y O_ W Let s � o `� ro _O } pa -cc c o t-c� f- ,.. aR. e x -.-..- a0 _< _ - ra .3,- i E ° --lig -;±' li. ... �- .� • - - _ = a ter; _ _i z - TTh� O itz v co a 0 i m m �o e In r,y 5'-- v 6 C a m r- �0 9--2 n 0 3C> . _ R✓J ma. co- t+ Cep - cP F' 3 vs o •> ojtC oa� o s-t ac ... _` EC ra `__ M Co ' S.. e. - .17 o . 02 �. a o _p (o o S P =c n r . c v Ll - o c o �� la- t>: _ c ((� o'. U o C- C o C u c .ti E >'� o. rJ v V x a- V - a:V1 o g = - V ..2 o ) i m . h z r� _ _ W O x i F Q s •c- i_. • - G H _ = m _m - oma. — D Q o P E . i m Z - o-0-c m ....4. 81. O o z a a o e'er _ Z e c e as c > > ` c c' a_ P ,x _ ��/-lam/ U y 0 3 "a �-3 • • ] U ( dd C- b 6>" F r> m d v E O a w o C _u= of a �W. '- `O N I" e X r C Y 3 9 o O`�L �' O h O C o 3 a o 1-f-- a >7 a I OY- U -C O O = E vJ C - < 0 DocuSign Envelope ID:DD8440BD-B2E4.49E9-AE68-64BF18360943 Cape Light nm Compact : 5 Dupont Avenue South Yarmouth, MA 02664 , ,r1"11 ITU OWNER AUTHORIZATION FORM I, PETER SKORDAS . (Owner's Name) owner of the property located at: 160 Captain Small Road . (Street) South Yarmouth, MA 02664 . (Town, State,Zip) hereby authorize 1 Cie. C1, n,c, )( 6 (Subcontractor) _ J 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. The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. DocusWn.d by: c Q4 Mad A Cus(b' $ignature 5/7/2018 19:29 PM EDT -Sign Date 05/04/2018 • r • The Commonwealth of Massachusetts Department of Industrial Accidents —"a- " 1 Congress Street,Suite 100 S`= 7� Boston,MA 02114-2017 �•:1,=�,,4 www mass.gov/dia \Yorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. • Applicant Information Please Print Le¢ibly Name (Business/Organlzation/lndiv(dual): Cape Cod Insulation Address: 18 Reardon Circle City/State/Zip: South Yarmouth,MA 02664 Phone#: 508-775-1214 Are you an employer?Check the appropriate box: Type of project(required): 1.©t am a employer with 48 employees(full and/or part-time).* 7, 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling any capacity.(No workers'comp.insurance required. 301 am a homeowner doing all work myself(No workers'comp.insurance required.)r 9. ED Demolition CO I am homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5,01 am a general contractor and I have hired the sub•coatracton listed on the=ached sheet 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation end its officers have exercised their right of exemption per MOL c. I4.Ell Other Weatherization 152,11(4),and we have no employees.(No workers'comp.Insurance required.) 'Any applicant that checks box ill 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 tont:Rotors must submit a new affidavit indtoating such. tContrseton that check this box must attached en additional sheet showing the name of the euboontrectors and state whether or not those entities have employees. If the sub•contrectors have employees,they must provide their workers'comp.policy number. 1 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 Self-ins.Lie. WCE00431902A#: Expiration Date 06/30/2011 /n,��n Job Site Address: l�fNaly/s4 'a41 City/State/Zip:11l/ ll(//�1/s((1u, /!//�/ Attach a copy of the workers compensation policy declaration page(showing the policy numb* and expiration date). Failure to secure coverage as required under MGL a. 152,§25A is a criminal violation 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 WORKORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Ix{vestigations of the DIA for insurance coverage verification. I do hereby cerdfy under the pains and penalties of perjury that the information provided above isss/true pand correct. Henry Cassidy --^^•N� g Date: l�/Ll /i ,Signature: phone#: 508-775-1214 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): • 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5,Plumbing Inspector 6.Other Contact Person: Phone#: • /'m".4 CAPECOD-27 AMAHLER ACORD* CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDDTTYYY) 06/05/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on ' this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER �$��ADT Rogers&Gray Insurance Agency,Inc. PH NE FAX 434 Rte 134 (N No,Eel): lac,No):(677)816.2156 South Dennis,MA 02660 i"ttss.mail©rogersgray.com INSURER(SI AFFORDING COVERAGE NAIC s INSURER A:West American Insurance Company 44393 INSURED - INSURER 131WOW Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER G,Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER0:Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E; INSURER F I COVERAGES CERTIFICAJEJ4UMBER: 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. INER TYPE OF INSURANCE Aar IMOLIDYIYYYY) IMMLDNYYTI LIMITS LTR I p POLICY NUMBER A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE 0 OCCUR BKW(19)63328281 04/01/2016 04/01/2019 DAMA SFT lee NTEDDrel a 100,000 MED EXP(Any sine person) $ 5,000 — PERSONAL&ADM INJURY $ 1,000,000 GEN'L AGGR ELIMIT AP,E1,0PER: GENERAL AGGREGATE $ 2,000,000 POLICY jr LOO' PRODUCTS•COMP/OPAGG $ 2,000,000 X OTHER,Fee holder doscdp of operations B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Fe evident) $ 1,000,000 — AApNNyVYNNAUTO 8232707 04/01/2018 04/01/2019 BODILY INJURY(Per person) $ AIUpTEOQS ONLY X �ppjMppgULEEEDDp q X AUTOS ONLY X AUTOS N? BppgPDRYINJPAMAGracdtlenn 3 (Pcrr sed nDAMAGE j $ C* UMBRELLA LIAS X OCCUR EACH OCCURRENCE j 2,000,000 X EXCESSLIAB CLAIMS-MADE EXC10008835003 04/01/2018 04/01/2019 AGGREGATE $ 2,000,000 •• DED RETENTIONi D WORKERS COMPENSATION 3 AND EMPLOVERS'LIABILITY WCE00431903 sinrurF YIN 08/30/2018 06/30/2019 haw ANY PROPRIETOR/PARTNER/EXECUTIVE 1,000,000 OPFICERMtEMBER EXCLUDED? U NM E.L EACH ACCIDENT $ en etoryln ) 1,000,000 Ifyee deicdbe antler E L.DISEASE•EA EMPLOY S • DE$GIRIPTION QF OPERATIONS below E.L.DISEASE.POLICY LIM $ 11000,000 • • . / DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additlonet Remarks Schedule,may be attached If more apace Is required) Norkers Compensation Includes Officers or Proprietors. 4dditional 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_HDIDER 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 Zia ACORD 25(2016/03) 01988.2015 ACORD CORPORATION. All rights reserved, — i l��l e• - Commonwealth of Massachusetts Division of Professional Licensure .gourd of Building Re9ulatfons and standards Cons<;I,t:crhirl ISlreprvlsor iJ . ' CS•100988 ,:J' 3 Ey ires: 11/11/2019 . ... .,�.� jr`,iiil p. i ��frer • HENRY ECA9jSloy. : aj� e t _) BSHEDROWn �'+��1:o <( WEST YARMOGT/J MAIQ,B78 )C 4t.lis:,,fd011J .4. � 4 Commissioner . l/'w s 926 Vo/ vino4uoeco l2 M, . t f Office of Consumer Affairs and Business Regulation ti 10 Park Plaza • Suite 5170 Boston, Mag%ab�iusetts 02118 Home Improveme.g1 .0• tractor Registration 1'!:,:y1;.;:lr;.;..:• „1 ���,;. ;;. y;��,• ) Type; Corporation ("•r: '1'' `JiI'� `I ,r -:, ,. •'• 1' Registration: 153887 Cape Cod Insulation, Inc ;: ::4n .• t I•/•.: ! W Expiration: 12/14/2018 ti 19 Reardon Circle ( , b So, Yarmouth, MA 02664 � I: I/, Q Mt.l.1....r �V �••.� Update Address end return card, Mark reason for change. / ` 'CA. 0 200.1•06/11 _.._.__._-.___pp�� (_JJ..._........._... _---- /./... --.._... _..,... . ._........._..., (1.Metre a6..{ '-GLLSQ.v;.7:-GL"� p!o:/mar,R.L31as!^n.u. CiA\A Office of Consumer Alters A Badness Regulation NA p '• HOME IMPROVEMENT CONTRACTOR Registration valid for Individual Vs II only clr , T,yp et Corporation before the expiration date. If loun• , urn tot �l N rya ri;Ff1t+iilslretlon Fxnlrnllon Office of Consumer Allaire and'; al :as Regulation ``�, ,R1.1n. 10 Park Plaza• a 6170 ' 1;g;4:j�ifi0§6)1 12/14/2016 Cape Cod Insolatl''}1�1 0 ` •:1. r/' • Henry Cassidy'a, ;'' .:., 18 Reardon Clrc�' c {t,' ;, R-Cc9A T—•— • So,Yarmouth,MAa,C,,@,t;.!�'% Ci ' Is._ L '"' Undersecretary �t el • °'hout sle ata • t‘