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'Permae
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C101 ,a IAmounl .7)--C"....7)--C"...cM1,, **Y�l �/� IPermit eaplrerISO day, from
,{lastly date
EXPRESS BUILDING PERMIT APPLICATION..
'TOWN OF YARMOUTH R E C t i �, l I,
I Yarmouth Building Department — 1
1146 Route 28 AUG 13 2018
South Yarmouth,MA 02664 I
(508) 398.2231 Ext, 1261 y cr/ i
CONSTRUCTIONADDAMSI' /I , i?42c' &G.ck' „By IL �A�
ASSESSOR'S INFORMATION!
Mapi I Pasoell
OWNER! . I : J 1 J�/'� 7 r .`3.5 7 `�/
N i; PRE E` •DR•
HenryCessldyCapeCodInsulation TB ' q
CONTRACTOR! la nitre* 508.775.1214
AILING ADDRESS TEL,II
1 Residential 0 Commercial Est,Cost of Contruotlon$ 7•f G.O, O
Home Improvement Contractokblo,N 153567 Construction$uparvlsorLio,N 100988
Workmen'sCompensation lnsurenoei (Check one)
0 I am the homeowltt"r CI I am the sole proprietor 0 I hevo Workor's Compensation Insurance
in,aranaecemp,nyNamel Atlantic Charter Insurance' WCE0043I90 n
Worker's Comp,PolloyN
WORK TO BE ptERF_ ORM�D
"'Tent " Duration_, (Fire Retardant Certificate attached?) .
•;h„ Wood Stove
Sidlll¢t N of Squaroe ,,r Replacement windows! H
Replacement doors' H
Roofing! #of Squares ( ) Removeexisting* (max,2layers).
Insulation
^. Old Kings HlghwayfHistorlo 01st, ( ) Roplaaing like for like
Pool fencing______
„ ' rTllddabrtdsviPbpdhpondofou • (� ds
I. Location of Pay
lty /
I daclaro Ilnderpe iallka of per u y!h 11,0.i�i vola heroin ontolned an live and ooneci to the Veal'slimy Imowledgo and honor, I Ilndorslrmd that My rake onswor(s)
will bo lug oaun tordenial or , 7 Prr • 4••ens and for roseoullon under MAL, n,
1 ,.,/, i,+ d' ° p ww LCI 268,Seopon
Appllo,nl'rSign,tnrel s • �iy • r�tldtt ,,lr L'117n,, ,a.n ,J O
b�i,i ran i,bi rerw Date!`�egaile
Omen Signature(or ntlashmeoQ
Ditto!
Approved Eli Daly; - 7,.
Build', ,e or rsignoc B ILADORESSI
to
Historical Dlstrlott 0 Yoa gtl District'
Flood Plain Zone: 0 Y6s 0 No •.
Water Roeourve Proteolion District! Within 100 R, of Wetlands; , ^t
• 0 Yoe CI No 0 Yes C1 No
11.11.1
• ,. ,
^---
000(\- ' The Commonw¢alfh of Massachusetts.
),Ea—;-711r=:—
' ' � ' beparlmenfo JXndusfr(a lriooldorsrs
=,'��^�•
e' I Congress Slre¢f, Sluile 100
A �= nos(an, 1104 021142017
tk- www,mcoss,gov/dla
1Votkers� Compensation Insurance Aft1davltt•Auliders/Contractors/ZIectrlotans/Plumbers,
TO 9E PILEC WITH THE PitIWITTIhs3 Milli.
Adollcant!'norm: a . , :; 'c
Name (9vaUssa/OrgenleeHo IndlvIduaglCape Cod Insulation a
Address, 18 Reardon Circle
City/StatelZIpl_ South Yarmouth, A 02884 phone rel .608.776.1214 •
•
• Amp's it umploysrt Click fin spproprlott bore
elm;umpioyrrwith 4s smplo'us(atillanllorpsnllme),r Typo of prolog (required)
LO tint sols propdator orpistol rohlp end hove no smloysn worklnt forms In 7, 0 New oonstruodon
soy orpnity,(No workva oomp, lrourenee remlred,) 8, 0Itomodel.ing
LO I em m homtowner doing ell work myselt'INo workers'Qom)).Immo raquittd,)t 9, (] Demolition
4,0I am s homnumr and will bi hiring eontnoton to conduot iii work on my propany, I will 10 0 Building addl{lon
mnun Vitt Ci oonaaoton either havr worksr vomptimtion Inaunno or vu ooh
(rwlVt no anployan' 11,0 alootrloel repairs or addil
proprlalo
s,d I ins s,rntnconl ono,and 1 hero hind the aub•vonasoton lined on the utaohad ahaet, 12,❑plumbing repairs or addh
Thinaubaonbaoton have employail and hove workers'oomp,Ian.' 13,[]Roof repair,
e.[]wsvrsearpontlenandltaohlvanhevaaxarolaadlhairr{ghtofaampdonparWA,v, 14, ✓[DOlher WentherIzatlo
IntilMi and wi haus no employ,rr, (No worken'oomp,Inauranosnpulnd,)
IHoYmepwn nlwho`iubmfilh.lnrtadarlt Ilndivatln6atheeayynot al dolnt CIwork r thin ni thhits ovin'
id,oonaiotors mutt ru mit i naw ettldavlt lndlosttm such
IContrsoton Q tohnk WI lox mwt atuohed an eddltlonal ahnt ahowing Vu sols btths auMventnotora and hats wh,War or not thou rntltlaa have
empley.n, If she rSoono,aton ruvs um en th mutt •.
I stn an employer Thal G provldtn8 worker-II oo rev dr Mir workarr vol •.Iso number,
mpenamron Insurance/or employee:I Below is the policy and lob sir
t fnjormattan,
lnsurbnoacomptnyName, Atlantic Charter
t' hilly 0 or self•Itts,LI if WCE00431902
Expiration bate 08/301201Q
Job Slte Address, ;c✓ „ ST 4-
� pelNexpiration
" ' . Attabtcopy orheworkrroompnsattoapolicy declaration pap( owl ;thpolcynumber dpl a de
n', •;;., Falluro to,sours oovarega es required under MOL o,
"')ft. tujdror.opetyear Imprisonment, w wallas olvll remittal In the folrm of a $TOPorlmIntl I Wton punishable by a e up to Sl,sso,
day agslnsl the violator. A oopy of th1e stat.emint may be forwarded to the Oftloe of 1 ye s t on of the Dof IA ufor In ur,r
oovorage verlfioation,
I do hereby oar dean s and penatltes oof�perjury (had the Wormatlon prov dad above Ir true and correct
'1•
H.i ' {•Mini 11.1 r .tut awvuvNwuw,n W,M '
608- 76.121 ' //s 8'
Metal use only, bo not write an flats ma, robe completed by city or town official
City or Town, •
Cssuing Authority (olrcle ono), PermlVLloense fl
i, BoiOthrd of Idealth 2, Bundling bepartmont J, CltylTown Clerk 4, Ecotrioai inspecto>+'Si Plumbing Cnzpecto
d,Other
Contact Persons
-
W �^
-----'1 CAPECOD-27 AMAj1LER
ACORO' DATE(MMIDD YYYY)
c------ 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 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 22 ACT
Rogers 8 Gray Insurance Agency,Inc. PHONE FAX
434 Rte 134 IANC,No,Ext: I(AID,Noy(877)816.2156
South Dennis,MA 02660 iffilhss,mall@rogersgray.com
INSURERS)AFFORDING COVERAGE NAIC N
INSURER A:West American Insurance Company 44393
INSURED INSURERS: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. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WMTH 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 ADOL SUBR
LTR TYPE OF INSURANCE lenD Wm POLICY NUMBER IMM/IDDDIIYYYYI IMM/DDY�I LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE { 1,000,000
CLAIMS-MADE a OCCUR BKW(19)53328281 04101/2018 04/0112019 PRFM16FsIEecxTurence) $ 100,000_
MED EXP(Any one person) $ 5,800
—
PERSONAL S ADV INJURY $ 1'000,000
GENLAGGR GATE LIMITAPP IES PER: GENERAL AGGREGATE $ 2,000,000
POLICY I j�T LOO PRODUCTS•COMP/OP AGO $ 2,000,000
X see holder descrlp of operations
OTHER:
B $
AUTOMOBILE LIABILITY Me COMBINEDSINGLELIMIT $ 1,000,000
— ANY AUTO _ po 6232707 04/01/2018 04/01/2019 BODILY INJURY Person) $
AUTO ONLY y AUTOgULED —
ITO UN.pWNEp BODILY INJURY(Per accident) $
. X AUTOS ONLY X AUTOS ONLY (Pe�accRdentQAMAGE
$
$
C UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000
X EXCESS LIAB CLAIMS-MADE EXC10006635003 04/01/2015 04/01/2019 AGGREGATE $ 2,000'000
.. DED I RETENTIONS
D WORKERS COMPENSATION $
AND EMPLOYERS'LIABILITY �1,�N PERTUTE ERµ
ANY CPROpPREIETgO�RqIPARTNER,E%ECUTIVE I� WCE00431903 06/30/2018 06/30/2019 EL EACH ACCIDENT $ 1,000,000
IllOF,ICEERMTn8ER EXCLUDED? NIA1,000,000
yet,descrlbe under E.L.DISEASE.EA EMPLOYEE $
• DESCRIPTION OF OPERATIONS below EI.DISEASE-POLICY LIMIT $ 1'000'000
•
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space I,tequlnd)
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 C� L I7
ACORD 25(2016/03) ®1988.2015 ACORD CORPORATION. All rights reserved.
•
I,
•
���o• Commonwealth of Massachusetts
Division of Professional Licensure
•Board of Building Regulations and Standards
Constr,deAr09I1pyrvis or
08.100988 ;$ �/
,,}I, ! Ir es: 11/11/2019
HENRY E CA ID. ,v sn"
BSHED ROW'Y Y•'u/'a��jr1•' <
WESTYARMOGT�JMA'.0p >
c �
t'ci;nr:tot-•
\—j, •
Commissioner-1- Cat'
s, /
2e l(JLzfyt nc2/146J'ec 1
kill;
Office of Consumer Affairs and
10 Park Plaza • Sui a 517pss Regulation
Boston, MagAttusetts 02116
Home ImprovemeO+C.e?tractor Registration
Cape Cod Insulation, Inc
t,',1
' `'" '' I !` •'? f'' Registration:
corporation
P ,, ;.i.:7:.: :..),�;'' /' Re Ipiration: 193687
18 Reardon"Circle ( IW Expiration; 12/14/2018
• So, Yarmouth, MA 02684 ' `
c
ICAs O zoM'osrrt c �...( /Update Address end return card, Mark reason for change,
,
ego 31cmmoraraonac r7•Ad rasa..f�.
�cz2(ruurrc%rraettu nsruav;rt.-Caprr;p!aymart-CJ.aar Caro.
„ v Officeof Consumer Affairs&Budneee Ragvlellon
rtgI1 1,�;(r! HOME IMPROVEMENT CONTRACTOR
i od . Ly1i Corporation before ellon valid for Individual If
use only
rd ..r�, f„i,�;�,� before the expiration date, II lours• * un to;
`� :•`F.r ,. 1,� 12/1EX14/2018 �011oe PorkPlaaeeumarAffairsand - Regulation
?rn•L'�.�,Ctg 9 ; si e '
i `i'j''(I• `•"'4 Bolton,MA .• e6170
Cape Cod IneOlatil'fitij o 5,•r•, •
Henry Cassidy'r?, la . J¢¢
18 Reardon Clrc�'k� ff3� 4. 2„c /
So.Yarmouth,MAl„ Q1@f, +; �� �'"R
Vndorsecretary j $1� AlledillP —...
% t al • hout al- lifts
RISE
ENGINEERING'
OWNER AUTHORIZATION FORM
I, Glenn Mayo
(Owner's Name)
owner of the property located at:
16 Braddock Street
(Property Address)
Bass River, MA 02664
(Property Address)
hereby authorize Cie-ca 2 cr\P�
(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.
71111
7/ P
ture ,19
Date
RISE Engineering,a Division of Thielsch Engineering, Inc.
5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926
www.RlSEengineering.com