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HomeMy WebLinkAboutBLD-19-701 • 0 ` • I One Oso only 441s. • e 0 IFermlla i' yy �4Amount• �S— ,0,54:4�y e I I Permit expire: 180 days troll) alssuo dote 6th— IG-bbII/a j • EXPRESS BUILDING P•ERIYI " ' APPLI• ATION 1 V E lb ' 'TOWN OF YARMOUTH — "— Yarmouth Building Department AlJS �3 Zp18 1146 Route 28 South Yarmouth, MA 02664 �trsr (308) 398.2231 Ext. 1261 e�.i� — CONSTRUCTION ADDRESS'. /4 V,, ,r'7-7_7/219 izemdif • ASSESSOR'S INFORMATION! Map: 1 Parool! J OWNBTU__ NA_ e/ /1/2A 14Y S He p MUNI'ADDRess . 4 �� 7�'aQ HenryCeseldyCepaCod!nsuhtlon TEL. b CONTRACTORI tome/doe South 608 775.1214 AILING ADMESS M.II p Rosidenllai 0 Commerolal Est.Cost of Construollon$ of le-e Home Improvement Contrncto,kL(o,n 153567 Construction auperyisorMot H 100988 Wurkmsn'sCompensation insurenoel (roheok ono) 0 I am the homeowner"n (1 I am the solo proprietor r,0 I have Worker's Compensation Insurance lnsuranoeCompany Namo; Atlantic Charter Insurance' Worker's Comp, PoneyI WCE0043190 -, .. ,... • WORK TO BE PERFORMED '"Tent _._a% Duration • (Fire Retardant Certificate attached?) . 'Wood Story a'';Siding! HofSquint I,,,Replacement Windowni f Replacement doors! N sts Roofing; N of Squares ( ) Remove exlsthnga (max,2 layers). Insulation • "• Old Kings HlghwayfFlistorio Dist, ( )Ropiaoin like for lIko • g Pool fencing 1. " •''• • 11.14 Maiwlllbtdisposed ofou 14 IS ti. 6 I. , Location of he Ity I deotare underporieltler of port 19111101...30' ern oroln •ontoinod so True atd 99(90110Ihe but of my knowicdgo Md boiler, I understand that any false onswor(a) will be Just owe for denial a A oeoonn p • . , r Md for pro:eoullon�u rider M O L.Ch.268,Seotion L APPlloent'eSignature ,,:f�r7 •SS !, ��1"i,IM1� G �; ;^ a.N',:g;fg Dater___42,421: 0nerlsites •re(oraltr ism/ wat) Approved eyt / De lot Building Orloa oyeks•noo EMAILADDRESSi Dalin ___ � . /� •• • WVYw Zoninl Districts Hlstorioal Dlstriott 0 Y03 0 NoFlood Plain Zonot 0 Yes 0 'No Water RoeouroeProtcotlonDistrict; Within 100 R. of Wetlands: a VV. CI Yes el No J Yon Cl No It • Pal The Commonwealth of Massachusetts ,,— title a Department of1'ndustrla4Aooidents ' 1 Congress Street, Suite 100 __{_{ r Barton, M.4 02114.2017 wwwimasAgov/dict \Yorkers' Companeatlon Insurance AffIdavflhBulldars(Contrtotors/Zlectrlelanafplumbers,' TO 13Z THAD WiTHTE&PBRM1Fh'PIi O At,1THOmy, oo{le ntir'torm ."v,'elno. Pleat! ?riot LetibNv Name (By,Uewolmitet(oNindlvidud)I Cape Cod insulation Addressl 18 Reardon Circle City/Stele/Zlpt South Yarmouth,MA 02884 phone Th ,508.776.1214 OM tin impleyert Cbeek the eppreprith belt 'Type of pro)eot (required): • 10I era mploytr with 4 8 employee;(NMI tndyor pirtitlm$),r 7, 0 New oonatruotlon t,[]I vn a tett proprstor et psrtnarahi and have employua wotklnt form; In tnyoepith/,(No worktra'oomp,tp;un unnet rtavind,) • 8, ❑ Remod611ng ICJ!yr,i homeowner delnt nll work myreltr(fo werktra'oomp,(mistime rigulrtd,)t 91 Demolition 4.0I ern a hom;ovmer end will be hiring eontnotora to conduct ail work on my ropey, I will 10 (] Building addition m;uu lh;l tit eentrtoton tither hive workout eempenettten iniunnee or vt;ole 11,(] Electrical repalra or td di popd;tot;withr. empty/eh, 12,C)PlumbIngtepathortddl trn a;mint*onototor EMI hen hind the;ubwontrtoton Ilitad onthi Ikeohid;hitt, Thu;;ubaontrtototi hen amployaa and hive workare'oomp,In;arano;t l J,[J Roof tepid (Q Wi vi o hpontientndltaottiainhtvttxtnludthat;HHghtoftx;mpdonperHobel • I 4. Other Weatherizetlo 1St,i i(q',end wt My'no employees,No wor''<,n'temp,mimes npulnd,) • 'Any%poi atnt'htt—to ••x I mvrs ;o ft ovt r nit onbr owl ow nt the rwoa rr; oompensa on policy(wormt4on I Hemowmn who i mtrittJrl.Mdtyit intrIotting threyy yr doh);tN work end then hits ovuidt ton76otore mutt tubmla a new ernervtt Indlnting Nor iVontnotantatohw1Nd;box Thum thaw to tddfdon;i,hitihowing'M nun;btthe;vbaontrtatoYa end ruts whtutu or not Oho+;tntluaa Mr,* tmpieyrn, Ili a rvbeonvto+on tuw tm 10 tea thry Thur rovlde theIr worker'Dom , Ile number, • !CM an employer that trprovidtngworkers'oompensalton inrurance farmy emptoy en, Below tr eh;Polley and lob st4 Imurt otc Atlantic Charter • insurance CompanyNamel WCE0043190Z m' PolloykorSelf•ins, Glorlat 8xpirationbata 00/30/201q • iobStteAddresslrler/i!garg..r/RJlid 2vn0 a Yrs Clty/&tate/Zipi 4 c"-L- Attaoh a oopyortheworkers' oompensalIoa oli aeiaraton gage(ahowl3)5the polioy number and expiration et: ?allure to IMO eevertg6 II required under MOL e, tS2, 12$A h t criminal v(olat(on punlshabie by t ane up to$1,500, '',,,, aijdlor.opelttr lmprlsonment, ea well al olvli penaltlei in the form of a STOP WORX ORDER and a tine of up to 5250, • day agetnstthe violator, A Dopy of Oil; statamfnt maybe forwarded to the OMoe of Investigations of the DIA for hewer ' "• eoveregeyeri8ottlon, I do hereby car under, • ns and marlin of perjury (hal lh6 hlformarion provided above la truce and correct, 2lgnature 't !; • i4 rttiurwwvvwwwaw,N nab., ✓��r nonak, 508. 76.1 14 Motel use only, Do nor virile in (iiia tires, to be oompteted by city or town offlatat City or Towne • Permit/Menet i! tailing Authority (otrete one)! 1,Botrdot1-fealth 2, Building Department 5, CItyPTown Clerk 4, Elaotrtatl InspeotoY'5, numbingInspecto ,6,Other • Control Parsons • • , \ A '1 CAPECOD-27 AMAHLER Ami CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 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(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 CgVT" Rogers&Gray Insurance Agency,Inc. PHONE FAx 434 Rte 134 lac,NO,EF11: tac,r40(877)816-2156 South Dennis,MA 02660 Miss,mali@rogeragray.com INSURERISI AFFORDING COVERAGE NAIC e INSURER A:West American Insurance Company 44393 INSURED ^ INSURERB:SafetV Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURERO:Endurance American Specialty Insurance Company ,41718 18 Reardon Circle INSURER o:Atlantie Charter Insurance Company 44326 South Yarmouth,MA 02684 INSURER E; INSURER P COVERAGES CERTLFICATEIIUMBER: 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 ADDL SUBR LTR TYPE OF INSURANCE JNSD bWD POLICY NUMBER POLICY EFF POLICY /MMIDp/YY1'YI fMMlOp/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE § 1,000,000 CLAIMS-MADE a OCCUR BKW(19)63328281 04/01/2018 0410112019 9AMAGER?RENTED 100,000 PRFMlSE Fa pccunBnrel $ — MED EXP(Any ens person) S 5,000 — PERSONAL&ADV INJURY § 1,000,000 GENII AGGREGAT LIMIT APP t $PER: GENERAI AGGREGATE $ 2,000,000 X POLICY PLA: LOP PRODUCTS COMP/OP E 2,000,000 OTHER: X Fee holder descdp of swallow; _ $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Fa accident) § _ ANY AUTO 8232707 04/01/2018 04/01/2019 BODILYINURY(Perpperson) $_ AOSDXpTEDUULLED — AUTONLY BODILY INJURY(Per accident)" X AUOS ONLY X ppOONY MRem4AMAGE $ — L` _ UMBRELLA LIAR X OCCUR E EACH OCCURRENCE 2,000,000 X EXCESSLIAB CLAIM$:MADE EXC10006635003 04/01/2018 04/01/2019 gAGGREGATE $§ 2,000,000 •. DEO RETENTIONS D WORKERS COMPENSATION p $ AND EMPLOYERS'LIABILITY YIN PER FRH TUTE ANY PROPRIETOR/PARTNER/EXECUTIVE WCE00431903 08130/2010 06/30/2019 1,000,000 Mira;M EXCLUDED? U NIA E.L.EACH ACCIDENT $ (MandeIory�n� j 1,000,000 II yes.descnbe under EL DISEASE•EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below EL.DISEASE•POLICY LIMIT $ 1,000,000 /, 1 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remark.Schedule,may be attached If more space Is requlred) Workers Compensation Includes Officers or Proprietors. Additional Insured status Is provided under the General Llabllity and Auto Liability when required by written contract or agreement with the Certificate Holder. Excess Liability Is follow form, CERTIFICATE HOLDER 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 p I G --i ACORD 25(2018/03) ©1988.2015 ACORD CORPORATION. All riahts reserved c \! • 1 C.• Commonwealth of Massachusetts L) Division of Professional Licensure 'Board of Building Regyulations and Standards Cons rr 1410N4p,rvisor CS•100988 /.f., �;;•/ P )re s: 11/11/2019 • HENRY ECA I p + 8$HEDROW �.��•��� � s� C WEST YARMOGT�M "' A�0 81D ?sC rt'f'1/Ssq..tO�1, ���.�} /� y1 i ir.tts. Commissioner leW y��"' itc,.. j U!22 �Poiwinon'ellecd 1 • . . Office of Consumer Affairs and Business Regulation 10 Park Plaza • Suite 5170 Boston, Mag#Pbiusetts 02116 Home Improvement+.C.o!!Mractor Registration Type: Corporatton Cape Cod Insulation, Inc C '' '""''� % � ''' '`'` I'' >, ! Regipiration: 1214/2 18 Reardon Clrcla " '"` 4 , W Expiration: 12/ia/2018 So, Yarmouth, MA 02654 !K,, . ,; 1 igi cna 0 'aom.osm �••-} Update Address end return eard, Mark reason for change, CRO�otmeararuualf el r7 ,t1dr;;,n.ar1.,(;!.11.s+aetrin:_f.Z a_tt:p!o.yrnar,R.I110.41.;`.a.rt!.. CY�rwurrC/rraet(J Odic.of Coneumer Nlelre&eueinen Regulation HOME IMPROVEMENT CONTRACTOR fl H,i Type: Corporation before the n valid fodatInde, If f use only �jnv%r' beforetheonsuerdate, end foun• • ur! tol Re o,�,{,r ,t,ur�_,;. kk Exelretlon Office of Consumer Affairs : %.N.� ,.er}3.reh 12/14/2018 10 Park Plaza• "sq Regulotion tI' -'' Boston MA • • e 8170 Cape Cod InsOIV l , ,,;,pg rt Henry Cassidy'% 1 18 Reardon Clrc So.Yarmouth,MAe3" /,r ��R`�C'"'P Undorseoretary t al • —��-! -- /li houtsl� atu': 5\ ) ..a. . v .;tip S4', O�1 : 042 4 , <jl, Ii Housingf' ` _ "t4 b,il a 460 West Main Street n, esj to Hyannis,MA 02601-3698 Assistance'g`fri aoiz, ;a v Tel:(508)771-5400 Fax(508)790-2425 Corporation ''( a D TTY on all lines Cape Cod -`J^�etzI i` Free Weatherization ! Your tenant has requested and is eligible for weatherization of your rental home through the Weatherization program at Housing Assistance Corporation. An average weatherization job is worth $4,500 and these services are provided at no cost to you. I The following weatherization measures area lied to the pp typical Job: air sealing in the attic and basement, insulation in the attic, basement and walls, woather-stripping doors. Bath fans may be Installed if necessary. We will test the efficiency of the refrigerator. All work is professionally done by licensed and experienced contractors. HAC will conduct a final Inspection to make sure that all work is completed in compliance with quality work standards. Prior to the work being done you will receive a letter from HAC showing the actual measures that will be installed and the total dollar value to the work. To confirm your ownership of the property, we will pull the appropriate town assessors report. If necessary, we may ask for a copy of your tax bill or deed to prove ownership. The work on your rental property will begin when we receive the signed copy of the attached Agreement if we do not receive the Agreement, HAC will conduct an energy audit but no weatherization work can be done without the signed Agreement. During the energy audit we will install energy efficient light bulbs and will test the efficiency of the refrigerator. If you have any questions please contact Suzanne Smith at 508-771-5400, ext. 123 or ssmith@haconcapecod.org LANDLORD: 90 Idip .' S TENANT: e► 1 m ialai. (9L rv..140r/A44 Ib fa.Tz. ler amici email:Muke@-Sol\As6)Re4,1510c•ORS email: 1 PHONE:(home) PHONE: (home) (cell) -7Zo- Z31- -moo (cell) MEM 14. The Parties acknowledge that this Agreement Is under seal. It Is Intended by the Parties that the Tenant or any successor Tenant Is the Intended�� beneficiary of the !�Aggg�reeemment and shall have a right of enforcement. Property Owner's Signature: fitt/ Date CoklanB Phone: 72q0- 231- 7000 Address: 62Z /,fla1NhT p/A// P.046srez ( NA ozfl70 . Tenant Signature " Date . Agency Approved Weatherizatlon Company Adam T. Incorporated / All Cape Energy / Alternative Weatherizatlon Cape Cod Insulation / Cape Save / Cazeault • Frontier Energy Solutions / Lohr Home Improvement / Tupper Construction Agency Signature Date ' 1 1?