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HomeMy WebLinkAboutBld-20-002884 (2) • • F;(Ra Commonwealth of Massachusetts`�� � �� Division of Professional Llcensure Board of F3uilcfing•Rec)ulallons and Standards Conolr,,,tCti'6,1{' 0pfrvlsor CS-100988 r~Kplres: 11/11/2019 • 1 �� t + l s r, HENRY S CA1 i3IDY ' iljt i { rt 6 5HLD ROW" �itl,l WEST YARM0u:rp I 0 '@73 CAP Commissioner /i l' 6 a/2?//i -c/?c'l'.(C� �� (/ %'�C/�- <l! 1� ?//) Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation CAP_ COD INSIfLATION, INC Re0letrefIon: 153567 • 18 PARDON CIRCLE Expiration: 12/14/2020 • SO YARMOUTH, MA 0266 Update Addreca and ilalur., . - inn,.;,. i% //z. i //,; onisa of Cons,nwrAflalro G Ourinws Rupulollon 110,,1E If,IPROV8MENT CONTRACTOR Ru IstratIon valid for Individual ucs only I 'PE;CorooraUon boforo lho oxpiralion(fato, If found rolurn to: SQC1 11s11.10.I) F DtfIliL41) Offc9 of ConsurnurAf/alra and Buclnoxc Ro0ulation 1'+507 12/14/2020 1000 Waohin91on Struot•Sulto 710, CARE COD INSU-,'i'I0N, INC l3ooton,MA 02116 lrl lJy fiC; lRY E.CASSIDI' REARDON cIRC;LG C.) r 4,11 (' so Y.nR mOlin-f,„,‘ 02GG4 Undorsecrola /a : i th Gt sl n< The Commonwealthof Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ' www,mass.gov/dia ' orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/organization/individual): Cape Cod Insulation Inc. 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.�—y I am a employer with 48 4. ID am a general contractor and I �c employees(full and/or pantime). • have hired the subcontractors 6. ❑ New construction 2,❑ l am a sole proprietor or partner- listed on the attached sheet, 7. ❑ 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.= required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers,' comp. right of exemption per MGL 12.0 Roof repairs insurance required.)t e. 152,§1(4),and we have noWeatherization employees.[No workers' 13. Other comp. insurance required.] *Any applicant that checks box N I must also fill out the section below showing their workers'compensation policy information. o Homeowners who submit this affidavit indicating they are doing all work and then hire outside canractors must submit a new affidavit indicating such. ' :Contractors that check this box must attached art additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the subconuacturs have employees,they must provide their workers'comp.policy number. I ant 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 i/or Self ins.Lic.h:;WC 100136900 Expirations Date;06/30/2020 ^ • Job Site Address:/L� lv/,/�S 16 IJ �/Z/4y ,R a( Ci `/ ate7`Lira /a AA D 24 41 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 tine 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 covers a verification. ' • I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: 744 -4 4' t- Date: 41 V/f — Phone ti: 508-775-1214 . .. _ - ._._ a.-- , 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): I. Board,of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector- 6.Other . Phone I: • CAPECOD-27 _.__ _TI-IQRNF_ CERTIFICATE OF LIABILITY INSURANCE DATEIMh1100r'YYY) 7(1612019 • CATE IS IS UED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS E DOES NO AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED _SENTATIVE OR PRDDUCER,AND THE CERTIFICATE HOLDER. ORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(Ios)must have ADDITIONAL INSURED provisions or be endorsed. f SUBROGATION IS WAIVED, sub)ect to the terms and conditions of the policy,certain policies may require an endorsement. A statement on ,r this certificate does not coffer rig is to the certificate holder In Ilou of such endorsements , (PRODUCER CONTACT Good Rogers&Gray insurance Agency, Inc. .PHONE PAx 434 Rle 134 NC No,Ext: 800)553.1801 (ac,Ne):(8%7) 8'16 215G South Dennis, MA 02660 �^ 55;mall@rogerscfray,com INSURERLSI AFFORDING COVERAGE __nkic e_____-, INSURER A:West American Insurance Company 44393 _ INSURED IN RERa Arbelia Protection Insuranco Company, Inc, 41360 __ Cape Cod Insula Ion,Inc, s c'Endurance American Specialty Insurance Company 41718 18 Reardon Clrcia IN amp:Atlantic Charter Insurance Company 44326____ South Yarmouth,MA 02664 INSURER F.: — ---- �____,• INSURER F: - __^__, COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT -HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANC ING 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. uNSrt ADDL SUER POLICY EPF POLICY EXP TR TYPE OF INSURANCE INSD WVO POLICY NUMBER „„ a� ��) pAIDDIYYYYI LIMITS-_,____ _ • A X COMMERCIAL GENERA,.LIABILITY ^' 1,000,000 EACH OCCURRENCE 10U,0001 l CLAIMS•MADE Xl OCCUR BKW 53328281 4I112019 4/1/2020 DAMAGE TO RENTED DAN ISEM olscq rence Ji__ _._ II E• XP(Any one person) $ -_---_- • I b,000 .J — PER59NAL_ADV INJURY a 1,00°,0001 GENt AGGRE ATE LIMIT APPLE PER: GENERAL AGGLtEGAT€ _y 2,000,000 . X i POLICY I I/P L LOC ' PRODUCTS•COMP/OP AGO 2,000,000 1 OTHER. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,0001 ' ANY AUTO 1020081008 4/1/2019 4/1/2020 BOD(FaILY ILY INJURY 2_ OWNEDSCHCDULED BODILY {Per•person) $ I • _ AUTOSFF ONLY v AUTOS BODILY pBOODILY INJURY7p Per accident $ T_______.___I X AUTOS ONLY X AU01 C S ONLY - (Herr acc'oenl)AMAOE $ C I UMBRELLA LIAR L X OCCUR EACH QQ QRRENCE S 2,000,U001 VX EXCESS LIAB C.AIMS•MADE EXC10006635004 4/1/2019 4/1/2020 AGGRECln•rF. _ _2,000,000 .,e D[D RETENTIONS S • ODM WORKERS COMPENSATION PER OTH• AND EMPLOYERS'LIABILITY Y/N • STAIttIE .■_ ANY PROPRIETOR/PARTNER:EXECVTIVE WCI00136900 6/30/2019 6/30/2020 - 1,000,000 .I OFFICER/MEMBER EXCLUDER? NIA E.L.EACH ACCIDENT ,_ _ __ ,(Mandatory In NH) 1,000,000 .11 yes,describe under E.L.DISEASE•EA EMPLOYEE_-__-______ 'DESCRIPTIONOFOPERATIONSbebw 1,000,000i ll E.L.DISEASE•POLICY LIMIT a l lI II -------'---'-1 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORU 101,Additional Romarke Schedule,may bo attached If more space Is required) • • _CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Information On y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE _I__ • ' iDr,<,-,Ii 77 a----,..._......... . ACORD 25(2016/03) I ©1988.2015 ACORD CORPORATION. All rights reserved. • 11/21/2007 00:06 5007551418 PAGE 04 • • RISE I.. ENGINEERING OWNER AUTHORIZATION FORM 1, MARIA J VASILIADIS (Owner's Nome) owner of the property located at. 1661Ivnslowgray Road (PYoperty Address) West Yarmouth, MA 02673 (PrOlitY ddreS8) hereby authorize (•i) _, (Subcontractor) an authorized eubcontraotor 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 4,44.41./ i ., Vat4X1L. Owner's Signature JJ q 1"4 )1 I 41 Date • RISE Engineering,a Division of Thleisch Engineering, Inc. 5 Dupont Avenue I South Yarmouth,MA 02664 1508-568-1926 www.RlSEenglneering.com