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HomeMy WebLinkAboutBLD-19-001140 • op Vq� a jOfnoeVS"Only e C 0 IPernlle �R �y �, x iAmount 3S °ay4•w I. 4a s 1 Permit expires 180 days hoot !tissue dole 3u - tt 1C1- :90 EXPRESS BUILDING ?BRMtT APPLIC • - MINE 7 E D ' TOWN OF YARMOUTH ' Yarmouth Building Department AUG 23 2018 1146 Route 28 South Yarmouth, MA 02664 Bu,L E �9� (508) 398.2231 Ext, 1261 BBy -Q . _____ CONSTRUCTIONADDRES51' IN t `e454uis • - nnttm- ASSESSOR'S INFORMATION! Map: I Parcel: J OWNER: M i k, 1:- Wee • BERM DDRB • �� i' 75 TE CONTRACTOR! Henry Cessldy Cape Cod tnsuletIon is Ai rdon Cicely South Yarmouth 508.775.1214 AILING ADDRESS TEL,Si Residential 0 Commerolal ESL Cost of Construction S 3O6 'n) home Improvement ContrnotosLlo,H 153567 Construction Supervisor Lk,w 100988 Workmen's Compensation Insuranoe: (check one) 0 I am the homeowner- • 0 1 am the sole proprietor z I have Workoi"s Compensation!neural°, Inaaraneec°mpanyName, Atlantic Charter Insurance' Worker':Comp, WCE0043190k.,, WORK TO nE PERFORMED " ""Tent Duration (Fire Retardant Certincate attached?) Wood Stove !'!,!ding! H ofSquaros t,„Repic:cement windows: H Replacement doors! H Rooting! H of Squares ( )Remove existing* (max:2 layers). Inpsyulttion Old Kings Highway/Historic Dist ( ) Raplaoing Ilk°for like ( pool noa(v�"”"rt/ ' Thi Dee „ 2-W , D��Gi� ''sTlie debris wlll•be disposed or au (1 Akt Viiii 7 1. Location orrnc llty !titular/under penalties of porJusy that the etatolnents heroin ontolnod aro Irue and ocrreol to the best of my knowicdge And belief, I underslnnd That any folio amwor(s) will bo Just owe for denial or revoontlon of my name And for proseoullon under MA,L.Cli,20815591W 1, AVona Sgnhual Henry Cassiciy Hig.NicriP314 Dater 5,2 - I 8 Owners Signature( raltnthmeat) a DAteI Approved By; ;S / Dalot a 2 r/ ' Building 0'e- (or !f !oo EMAIL ADDRESS: ..-- o Zoning Dlsirloll w« Hlstorionl District, Cl Yes f,1 No Flood Plain Zona 0 Yes 0 No — Wator Resource Protection District: Within 100 R. of Wetlands: %%A. • 0 Yes Cl No 1 Yea Cl No • '" The Commonwealth of Massachusetts ' Department ofIndustrial Accidents tntT 'W 1 Congress Street,Suite 100 r- _:fj_ _y' Boston,MA 02114-2017 • • "�. .a• www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electriclans/Plumbers. TO BE FILED WITH TEE PERMITTING AUTHORITY. • Applicant Information Please Print Leeibiv Name(Business/Organization/Individual): Cape Cod Insulation Address: 18 Reardon Circle City/State/Zip: South Yarmouth,MA 02664 Phone#: 508-775-1214 Are you an employer?Cheek the appropriate boss 1. t am a employer with 48 Type of project(required): © employees(fuil and or part time),' 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.(No workers'comp.insurance required.) 3. 1 am a homeowner doingall work9. ❑Demolition ❑ myself[No workers'comp.Insurance required.)t 4.0 am a homeowner and will be hiring contractors to conduct all work on myproperty. !will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or esom le11.0 Electjcal repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 lam a general contactor and 1 have hired the sub•contacmra listed on the attached sheet 13.0 Roof repairs These subcontractors have employees and have workers'comp.Insurances 6.0 We are a corporation and Its oftiocra have exercised their right of exempdon per MO!.c. 14.0 Other Weatherization 152,11(4),end we two no employees,(No workers'comp.Insurance required.) 'Any applicantthat cheeks box el 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 cont actors must submit a new affidavit Indicating such. 1Conaaotors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contrectors have employees,they must provide their workers'comp•policy number. I 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.#; WCE00431902 Expirations Date. 06/30/201e1 Job Site Address: /42-f Ye %4 w f 'oto City/State/Zip: d'1U-/t .I 411r Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 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 WORK'ORDER 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 Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Henry Cassidy ---.-..-..L...--- •e3. Z'�• Ig ienaturc: Dat : 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 51 Plumbing Inspector 6.Other Contact Person: Phone#: • I C C e• Commonwealth of Massachusetts `�) Division of Profession's!Licensure •Bonrd of Building Regulations and Standards ConsVCth&lttl%ttmvi eor ;1 CS•100988 .J' liKi;11E Aires: 11/11/2019 • .• HENRY EOW5IDY:v;lt�={�1rr• K t 1 8 SHED ��( if WEST YARMOUTft MA•.0,878 b Ci. \ Commissioner w L/'w PrAe 9p9o4n4noazcyecde% ztany- � Office of Consumer Affairs and Business Regulation - ' 10 Park Plaza • Suite 5170 Boston, Mas busetts 02116 Home Improveme:t .otractor Registration r ldl r{;: Type: Corporation S."r' '+:';;`f, `✓`i''';%i;:•` ?; V Registration: 193587 Cape Cod Insulation, Inc CI :::;;, ,)t1,,•�..:.•::; Expiration: 12/14/2018 18 Reardon Circle i`[ ::.::c , �e So, Yarmouth, MA 02664 \;,.�'` ": _ ,;,1, .k4"cA',..til•F 41/ . "'l._..)'' Update Address end return card, Mark reason for change. ./•• loan n 40M•06/11 p�J..._.._...........,_--........_ ........ ..... . ..........._......._.CI Adr.ring..(:!-n.uMu7z:-Gtivr,Isymant-Cl sat tlarci r C 0 �pommta 6tuvreS u`Oerta aditraetn A Wilco of Consumer Nlairs a Business Regulation r,a"7 - • HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only • YF. Ty"pat Corporation before the expiration date. If foun• = urn to; _ ' Of floe of Consumer Affairs end': sl es Regulation r % ktu% 10 Park Plaza• e 5170 g ar;; ��'�,�, Il fig.dJ6 12!14!2018 Boston, •• Cape Cod Ins0l ti�'.�1 o ga;; ', Henry Cassidy'�, 1•; •m 1 y 18 Reardon ClrcV la, ,i+ ,..\12x49,1,-- /F. Lir So,Yarmouth,MAt0 01•S' i�% J .�_� _ •: Undersecretary (yCt el • houtsla etu • • 'I ..•••••"" 1 CAPECOD•27 AMAHLER A1,`O/t0' CERTIFICATE OF LIABILITY INSURANCE DATeImmloonYwl 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(ies)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 CAMiACT — J • Rogers&Gray Insurance Agency,Inc. PHONE FAX Not:(877)816-2156 SouthtDennis,MA 02660 (NC No,tall; s,;mall@rogersgray,com INSURER(S)AFFORDING COVERAGE NAIL a INSU_RERA:West American Insurance Company 44393 INSURED INSURERe:SafetY Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER O;Endure nee American Specialty Insurance Company 41718 18 Reardon Circle _INSURER D:Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02864 INSURER!; INSURER F I COVERAGES CERTJFICATE_NUMBEQ_ 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. /NSR ADDL SUER I TR TYPE OF INSURANCE INRD wvo POLICY NUMBER PIMMI ZD EFF 7 (Mp POLICY EXp I LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS-MADE X OCCUR EACH OCCURRENCE E 1,1100,000 BKW(19)53328281 04/01/2018 04/01/2019 PREMISEEBfFaoccurrence) $ 100,000 MED EXP(Any one person) E 5,000 PERSONAL a AIN INJURY E 1,000,000 �FMLAGGREGATE LI�MITTAPPLIES` 2,000,000 X POLICY U P LQU OFNERAI AGGREGATE E )( seeholderdacdp orapvetlone PRODUCTS•COMP/OP AGO $ 2,000,000 OTHER; B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT E FaaccMeml E 1,000,000 ANY AUTO 6232707 04/01/2018 04/01/2019 soolLY INJURY(Per person) $ AURTpODS ONLY X SCHEDULED 1.1 X AIM ONLY x AUTOa ONo? �'�OPERSODILY INY QAMJURY(AGE Per CCIdenG $ _ er ecclaenl E _ I C" UMBRELLALIAB X OCCUR EACH OCCURRENCE E 2,000,000 X EXCESS LIAO CLAIMS-MADE EXC10006635003 04/01/2015 04/01/2019 AGGREGATE E 2,000,000 N• DED RETENTIONS D WORKERS COMPENSATION pp E AND EMPLOYERS'LIABILITY PER FRH• ANYp� PROPRIETOR/PARTNER/EXECUTIVE WCE00431903 06/30/2018 06/30/2019 1,000,000 ImmCai�OryFin�i j EXCLUDED? NIA E.L.EACH ACCIDENT 5 Ilyyn deecnbe under^ 0€SE.L.DISEASE•EAEMPLOYEEE 1,000,000 LIRIpnONor OPERATIONS below BA.DISEASE•POI ICY LIMIT 5 1,000,000 ,l 1I •1 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,AddIllonel Remarks Schedule,may be attached If more space Is requIred) Workers Compensation Includes Officers or Proprietors. Additional Insured status le 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 ". �/[�/+ySEf /7 - ACORD 25(2016/03) ©1988.2018 Annan — • • • Ni,; Permit Authorization 3eYi 1.1- mass save Form Sten)'.TN,der,MYf jy f•r'S'4.IKy Site ID: 3432070 // Customer: Nancy A Cavanaugh AJn}n/E/ /f-• £a.✓a-r)at%h I, )L - dot� Q , a....-. ,owner of the property located at: (Owner's Name,printed) 124 Pleasant Street South Yarmouth. MA 02664 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. G� ' Owner's Signature: h < •-c y A-0-71.--ej-1- J r U Date: >( rs 'c/— FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Ca_ r. (ad 8- /v—�f Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: For Office Use Only Rev.102015