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EXPRESS BUILDING FERMI APPLICATION
TOWN OF YARMOUTH 12 E C E ! V E 'i:° '
Yarmouth Building°apartment
1146 Routo 26
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AUG13 2018 jSouth Yarmouth, MA 02664 __ 1
(508) 3984231 Ext, 1261 qui _ " NluY _ - -
.
CONSTAUCTION ADDRESSI' •
ASSESSOR'S RNFORMATIOM
Mapt k Parcell I
i •, le CZ 3 Z Z 2
OWNENI ' "
f AV FM e`T •DDR' S TEL,
Hang,caaaldyCepa Cod lnaulatWI laMufti collo aovthYarmouth 508.775.1214
• CONTRACTORI AILING ADDRESS TEL'il
D Commercial Eat,Cost of ConetruoUon$ ��6O, e#-O
41 Aesldentlal 100988
Home Improvement ContrnotokLN lol
153567 Construction SuperYlsor LW.N
Wurkmron'a Cumpensallon Ineyrenoel ('oheok ono)
D1amthe homnownerCI lamthe soleproprietor IhevoWorkor'sComponsattonInsurezoo
WCE0043190 .,
IneuranooCompanyNamol Atlantic Charter Insurance, Worker's Conlp,Polloyfl
WORK TO BE PERFORMED •
'"Tent ,�` Duration (Fire Retardant Certificate attached?) •Wood Stove
�a';Sldingt N of Squaros s,,,Replaoement windows) N Replacement doors) N
Roolingt N of Squares, ( )Remote existing* (max,2layers). Insulation
•.%. _Old King;Hlghway/Historio Dist, ( ).Roo/pitteiinggvikoIIWoo for 11ko Pool fencing
1.
I aTdd dabdnvllCbt dlepond of oil i Location of Fact Ity
I deoWN under pieties orperlu that the eta tw Ia horoln ontoined art true hied ooncot to the boil of my knowledge rend boilcL I undorstend that any(also a
will Wort oawafor danidor .7000tlro, r•seandforprttootInunderMOd. Oh. Q ,Seetlon I.
r ' > •f°f % ,o1mztt
Apua$ISnonnel a Datet ��b/ {
Onn0111 Slronmura(or
allneha Ontm
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ApprovodByl Dal �r
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/Ba' la •r calgnoo EMAILADOI
n+,.
Zouing Dlstrioh
Hlalorloal Dletrlotl CI Yoa 0 No Plood Plain Zonot '3 Yea D No
Wator Rosouroe Proteotion Dislrloh Within 100 ft. of Wcttenda; ,
• U Yee el No J Y o e Cl No
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,—......, The Commonwealth of Massachusetts
s- a Department of InduslrlalAooldeists
"' id 1 Congress Sereer, Suite 100
-P— EBoston, M.4 02114.2017
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w ,masrtgov/eta
llrorktrs' Compensation Immo,Afndavltl,BullderslContrtotore/Electriolans1Plumbers,'
TO BE MED WITH THE PEPMITTI?W AUTH019,T,Y,
Aoollesntlirtormgti4n ''c"t•A,,,, Pleaserint twerlbiv
Name (9urinw/OrgtnletHonrindlvldua1)t Cape Cod insulation
Addressl 18 Reardon Circle
City/State/Zip! South Yermouth,MA 02884 phony #1 .1508.77.6.1214
• An yea totmpleytriChtel,thtspproprltttbeet Type of'poitot(requlrad)1
•
fel gni tmploytryeah 48 tmployasa(MI Indio ptrtdlme),' 7, ❑ Ntwoonstruotion
1,0 I em a NI proprlotot or pertnenhltp and MY;no tmployiis workln! (or mi In 8, (] Remodeling
trywpaoty,(tioworkvr oomp, ntunnet renulred,)
• tin I tm themeowner dolnr all work myseltr(1oworker,'oomp,Inunnoe raquirtd,)t 9+ ❑ Demolition
Curt t homovmer and will be hiring tontnoton to oonduot UI work on my proptny, t will 10 CI Building addition
emtun+htl tit eonteemon 'War have workers'aompannhon Inaunnot or vi roll 11,0 Blootrioal repaln or eddltl
proprielotrwIO no employnt, I2,0Plumbing repairs or eddltl
So I em a pmni oont*aotot er+d I have hired Ott rvb'oonbroton 11894 on til INeohod,hut, •
Thera rup4ontraoton hent employees and have workers'oomp.Inrurtnood 1 S,0 Roof repair,
iiusteerport ononoItoweinevt
hexsrolrutheirrlOiortxempdonperMino, 14, ✓QOthar Weatherizattor
it wills
171,11(1);and wt htvt no employtet,roto workers'oomp,Immo,mauled,)
+Anyoppl eantNat6'na •.x'I mit tleo :il oul i sut on •s ow i ow no the rworkors'oomptrua on polio)*tt tormttlon.
1 Homtewmn who,Omirth'ar9de ell Indicating they on doth!on work end thin hire ovule,oonaeoten mutt!Omit a now atridavtt tndlotttn;:uon,
1Contnotorr thrt cheek Kr hex must etuohed us eddldont rhett ohowing tt neuro loth,tub•oontnoton and:tato wh,ther or not thou,mitre;Mn
empieytn, Itch:aub•4;ontreoton Iwo employ,newejtmurt provid,thtir worker,'oemp,peltty number,
1 am en employer Ora tr providing workers?oompen:anon Insurance for my employees, Below fs the pottoy and Job site
ii Inforrnatton
„ lnsuranoeCompanyNamei Atlantic Charter
" Polio),Si or 5elf•ins,Llo,ill t Expiration Data. 0813012014Th. al
M$11e Addrsui 3t y 'J Ye' aVP 71 l' ayno1,f C)ty/Stats/Z1pi f/Z//9
• Attach.a copy of the workers' compensation policy d oration page (thowingthe policy num ban and explrttion dee
Page to scour: coverage ss required under MOL o, 1520 125A Is t orlminal violation puntsmble by a v4,3‘,11,to st,soo.,
•. ';'" :'''kl• er\dlor.o,netyear implement, u well eta *II penalties In the form oft STOP WORK ORDER and a tins of up to$2$0,0
day egdnst 1111\1011+w, A Dopy of this stttcmpnt mey be forwarded to the Ofttoe of Investigations of the DLA for Insuranc
• ooverageYertottlon,
/do hereby Der - n r,A1'e�r cans and pen&Ntes of perjury that the hU'ormation provided above is true and cornet
• . ? r, . / w , ' ¢
,,{tnattlrel H, 4 ., /. ,,, 'S1'w.w,.«wlbroNaw.rw,a Dat 1 ho ie
Pliers:gi 508• 5.1 4
Mold at only, Do not write in Uric area, to be oempteeed by city or lown oflota4 i
„
City orTownl • Permit/License #
lrsuing Authority (circle one)i
h Soerd of Health 2, Building Department J,Clkyt'Town Clerk 41tleotrloal Inspeotol''Si Plumbing Inupeetor
6,Othtr
Contact?troll! aa,,,,,. Li.
i---, CAPECOD-27 AMAHLER
A a CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DEVYYTY1
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 N%I€ACT
Rogers&Gray Insurance Agency,Inc. PHONE FAX
434 Rte 134 lac,No,EON I lee,No):(677)816-2156
South Dennis,MA 02660 d1Nbas:mail@rogersgray.com
INSURER(S)AFFORDING COVERAGE NAIC H
INSURER A:Weet 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:
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. NOTIMTHSTANDING 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 POLICY EFF POLICY EXP
I TR TYPE OF INSURANCE LNSD WVD- POLICY NUMBER ,IMMIDDYYYYI IMMIDDIYYYYI LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE ; 1,000,000
CLAIMS-MADE n OCCUR BKW(19)53328281 04/01/2018 04/0112019 DAMMISETORENTTrrencel S 100,000
— MED EXP(Any one person) ; 5,000
—
PERSONAL&ADV INJURY ; 1,000,000
GEN'L AGGREGATE LIMIT AP 1 S PER: GENERAL AGGREGATE t 2,000,000
X I POLICYLI Pn Loa PRODUCTS-COMP/OP AGO S 2,000,000
X OTHER see holder dourly of operations
B _ CC S
AUTOMOBILE LIABILITY fPa ecceldeDISINGLE LIMIT I 1,000,000
ANY AUTO _ 55 EE 6232707 04/0112018 0410112019 BODILY INJURY(Perperoon) S
• TU OS ONLY X A�TOSULED —
ooNNopyWyNN¢¢op pBpODILY INJURY(Per accident/ $
X AL ONLY X AUTOS ONLY (fge�ecEdg nIPAMAGE 3
. $
C UMBRELLALIAS X OCCUR EACH OCCURRENCE $ 2,000,000
X EXCESSLIAB CLAIMS-MADE EXC1000663S003 04/0112018 04/01/2019 AGGREGATE S 2,000,000
DED RETENTIONS
D WORKERS COMPENSATION p 3
AND EMPLOYERS'LIABILITY STAQTTUTE ERH
• AApNNFY PRgqOPREIIETggO�RRp/PARTNER/EXECUTIVE WCE00431903 06/30/2018 08/30/2019 1,000,000
(mincatory IMNHI EXCLUDED? NM E,L.EACH ACCIDENT 3 1,000,000
If yes,describe under E L.DISEASE•EA EMPLOYEE S
DESCRIPTION OF OPERATIONS below EL.DISEASE•POLICY LIMIT 3 1,000,000
. I,
/
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more apace Is 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 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 �,Wa!/ 7� _
ACORD 25(2016/03) ®1988.2015 ACORD CORPORATION. All riahts reserver).
., t.
•
l t' Commonwealth of Maseachusetts
`} Division ofProf essionelLicensure
•Board of Building Regulations and Standards
Constryl:Cttt1t11'ppvisor
Cs•1l)0988 <f
•
r , .„•,�4",:.4;I, eXplres: 11/11/2019
D
HENRYECA,S' IDY,�i� 9
WEST YARMOIJT�J MA1{b�r,0.5
iIt'lISS4C011xJ!
•
Commissioner % CAL 4”
So-
4'
le
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CP t 1 Office of Consumer Affairs and Business Regulation
10 Park Plaza • Suite 5170
Boston, Ma?,,�° btusetts 02116
Home Improveme:.Pp.o gractor Registration
..Vk;l'::
Cape Cod Insulation Inc t' `` "'�'tr.II '`^'' ' ReglstraTllon: 16387 tion
18 Reardon•Circle '
y ,,:,,,, • W Explratlon: 12/14/2018
So, Yarmouth, MA 02664 ':'„ciglIkte. .;. —'
.e:
t'Vrpf'f T��
cn4 t1 sonr.oent ° *t•••..)' Update Address end return card, Mark reason for change,
& Z Vowon(ofervordekoF 4 _ Add.^sal..(n.n•tnr.tr:n;_fSPc; rte,
aa,Regulation ploymsnl L:1.,1•ant.arard..
Office of Consumer Nfelre&Dullness Regulation
Fr' )4 HOME iMCONTRACTOR •
' T• pe; Corporation Registration valid for individual If
use only r
4'4i •r E titre t1 " _tretlon beforeOffice
the onaumer date. If faun•
,,�„• „v • urn to:
' t iti fl3 a Ofllce of Consumer Affairs end = el a Re
r, ���;`��1( '„�t„� r�t 12/14/2018 10 Park Plaza• e 6170 1 Regulation
Cape Cod Ine01�11''ry�j pi ' rt Bolton,MA •
Henry Cassidy'(a, ?:i ,. `' ' "'
18 Reardon Circe\/�� /`' IS..
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t al • hout sl• atu
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RISE
ENGINEERING
OWNER AUTHORIZATION FORM
1, Dr Elizabeth Knowles
(Owner's Name)
owner of the property located at:
34 Turtle Cove Road
(Property Address)
South Yarmouth, MA 02664
(Property Address)
hereby authorize ze:_. Gm& CAI")
(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.
Owner' Signatur
-�- � v
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926
www.RlSEengineering.com