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Home My WebLink AboutBLD-19-1151 • Y.� One Use Only '� � 4A•Rtr . O iPermita * K , StAn,aum cab J '+Ga �Permit expire:180 days from"4«,,, c" 4ch.:r, B(4)— ltli _ Obi ISIImo Onto • • • EXPRESS BUILDING PERMIT APPLIC • '» ft ' E I V E D TOWN OF YARMOUTH Yarmouth Building Department 1146 Route28 AUG 23 2018 South Yarmouth,MA 02664 BUILD •e Jr, •Ase kg.- } � /(05/08)) 398-2231 EEx�t. 1261 CC Ti / CONSTRUCTION ADDRESS!' 6 N it ""'f /0 vim' " ASSESSOR'S INFORMATION! Chet/hike //tM•ap; Parcel; �O t'J, OWNER! __ ( ora4) PRESENT ADDRESS TeL,`k /r' 73Y'� CONTRACTOR! Henry CeasldyCep,Cod tnsulattos logo ordon VW, South Yarmouth 508.775.1214 NAME MAILING ADDRESS TEL,Ara R Residential 0 Connerolal ESL Cost otConstruodon S 3a0- Home Improvement Contrnctmlilo.N 153587 ,ConstructionSupervisor Glc,II 100988 Workmen'sCompensation Insuranoe; (oheok one) 0 I am the homeowner% 0 I am the sole proprietor itt I hero Worker's Compensation Insurance Insurane,CompanyNamo; Atlantic Charter Insurance' Worker's Comp.Pelloyf WCE0043190L.,, WORK TO BE PERFORMED • '"Tent in Duration (Fire Retardant Certificate attached?) Wood Stove hiding) N otSpa ros t,,Replacement windows! N Replacement doors! k Roofing! If of Squares ( ) Remove existing*(max,2layers). Insulations/ Old Kings Highway/Historic Dist, ( ) Replacing Iwo for like Pool fencing I. 1Tlid debris wlii bt disposed of ott t11,1'V14 ACP( Oc(,(,l,Gy,V I. Location of Facility I declare under permutes or imply that the statements herein ontolned axe true and correct to the boil of my knowledge and belief. I understand that any false answer(%) svIllbeJust cause for dental or mention of my license and for prosecution under Mat.,CIL 2d8,Section I, t HenryCassid`, !;;A,� W rniMle.. APPlloentYSlgnaluret ✓ ✓ lmda.;rIt %,Mr""°""� Date) 6 e/ ' Owners Signature(or nttnchmeat) I/' Onto; /� Approved Dyt DAM Tj H�9/7'/E 131111d1n;Offlo r oo EMAIL AD, : •we totting Districts Historical Distriott CI Yea f3 No Flood Plein Zone; 0 Yes 0 No •. Water Resource Protection District; Within 100 A,of Wetlands; .v,1. • CI Yes U No J Yes a No • N RISE '5 ENGINEERING OWNER AUTHORIZATION FORM 1, Charlotte Grant (Owner's Name) owner of the property located at: 86 Nantucket Avenue (Property Address) South Yarmouth, MA 02664 ((Property Address)n hereby authorize ` ca>a qhs,>\,-.1o\r) (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's t t istur � • Oat RISE Engineering,a Division of Thielsch Engineering,Inc. 5 Dupont Avenue I South Yarmouth,MA 02664 1508-568-1926 www.RISEenglneering.com pits The Commonwealth of Massachusetts pi• =7.1-jr..t. Department of lndustrialAeciderrts +�1= I Congress Street,Suite 100 Boston,MA 02114-2017 • "'a,,..• www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. • Applicant Information Please Print Leeibly Name(Business/Organization/indivtdual): Cape Cod Insulation Address: 18 Reardon Circle City/State/Zip: South Yarmouth,MA 02664 phone#: 508-775-1214 An you an employer?Cluck the appropriate bon employer Type of project(required): t. lama with 4a employees and/orperttime).e 7. 0 New construction 2.01 am a sole proprietoror parmership and have no employees working forme In 8. ❑Remodeling any capacity.(No workers'comp.insurance required.) 3.0 I am a homeowner doing all work myself(No workers'comp.insurance required.)t 9. ❑Demolition 4.❑1 am a homeowner and will be hiring contractors to conduct ail work on my property. I will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or ere sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions S.❑I am a general contactor and 1 have hired the nub-contractors listed on the attached sheet 13.0 Roof repairs These sub-contractors have employees and have workers'comp•insurances 6.0 we are a corporation and its officers have exercised their right of ev_emptlofl per MOL . 14.0 Other Weatherizatlon 152,11(4),and we have no employees.(No workers'comp.insurance required.) 'Any applicant that checks box Yl must also till 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 contractors must submit a new affidavit indicating such. tContmeton that check this box must attached an additional sheet showing the name of the sub-oonnactors and state whether or not those entities have employees. If the sub-contractors 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.#: W /00_4/31902 Expiration Date. 06/30/201'1 Job Site Address: b I a CEfl4t(Leo( City/State/Zip:1' aavncfcc!D nil- Attach a copy of the workers' compensation policy declaration page(showing the policy num r 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 signature: Henry Cassidy -73- le Phone#: 508-775-1214 Date: lJ 4t' Official use only. Do not write In this area,to be completed by city or town official City or Town: PennIt/License# Issuing Authority(circle one): • 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: • 1 6 • ( t r Commonwealth of Massachusetts l�l Division of Professional Licensure Board of Building Regulations and Standards Cons :CPil;r ISbOy;rvisor /.1' CS•100988 .4' ieutlai a Tres: 11/11/2019 • HENRY E CASSIDY,,;,�rlicctiV: . 'I f _f 8SHED ROW/' : r es WEST YARMOU,V M(i"A,,Q70�D' \'� Commissioner V /� .1•• '' • S� Q.726 ircvn 4noiuoecd4 C (i(/y • a'(: r Office of Consumer Affairs and Business Regulation a 10 Park Plaza • Suite 5170 Boston, Mapihtusetts 02116 Home improvemeiPC.otractor Registration ( Type: Corporation t''•� ''_i:::#71 'i•` r: ',:: ! Registration: 153587 „ �...... Cape Cod Insulation, Inc „ ;�,,,, j. • •: `w Expiration: 12/14/2018 18 Reardon Circle ;t , It So, Yarmouth, MA 02664 r` . . :i; < ,;,r t„ Yr",1 r+,'v� , ' -I••..•1" Update Address end return card, Mark reason for change. ,cna o xon,.osm p)) p� , r� _.......G7-Addy*.na..Cr.l-Thew:,rn:_f1°Tp!o.yment-al.aal.Co.rxi.. • !_«`elm rponantenaruon�2 of4YV addctCA1(44llJ «•• ---- • Office of Consumer Nleirs&Business Regulation l'I jy, m • HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only I • T'?pe: CorporationJr 0before the expiration date, If foun, ' urn to; ` 1st„�,, gait/don Office of Consumer Affairs end • al -se Regulation v'a • 10 Park Plaza• - e5170 • kat eh 12114/2018 Boston MA tlh::,' Cape Cod IneOleti.Mi)no ,tn:; r` / - Henry Cessldy't?, ,,, Y t' a. 18 Reardon Clrc t ti � ' /' R•-ccot—^ So,Yarmouth,MAN,4$'.+fi' C� • iL�_ /�i� _ Undersecretary t dl • hout Ste ales : ' tt • ..-----"Th CAPECOD•27 AMAHLER A� CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDDTYYWl 06/06/2018 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 pollcy(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 C ACT — Rogers&Gray Insurance Agency,Inc. PHONE 434 Rte 134 South Dennis,MA 02660 (ac,No,Eat); INC,No):(877)816.2156 [Albs!.mall@rogera gray,com INSURER(SI AFFORDING COVERAGE NAIL 0 INSURER 'West American Insurance Company 44393 INSURED •^• INSURER BISafety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER 0 I Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER o:Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER!I INSURER F I COVERAGES CERTJFICATENUMBEQt 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. INTR TYPE O►MSURANCE ADDL SUER POLICY EFF POLICY EXP INSD Wvo POLICY NUMBER _IIM(DD IMM/DO/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS.MAOE QX OCCUR BKW5332EACH OC7C $ 1,000,000 (19) 8281 04/01/2018 04/01/2019 PRFMISER(7pURRENCE Ea occurrence) $ 100,000 MED EXP(Any one Demon) i 5,000 PERSONAL SADV INJURY 1 1,000,005 LAGGREGAT LIMITAP,EL7g,S PER: 2,000,000 X POLICY SRO• I I L GENERAL AGGREGATE $ X see olderde.crip eroperatlene PRODUCTS•COMP(OP A00 S 2,000,000 OT ER; B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S Fe ectldenll 1 1,000,000 ANY AUTO 6232707 04/01/2018 04/01/2019 BODILY INJURY(Per Demon! i AIUIJppT�O�S ONLY X �ppTNN�jppgWWULNNEEEDpp pPBpOpDILY INJURYT (Per eccldenli $ 111 X AUTOS ONLY X AUTOSONIY IPe�eCcpdvrMAGE i _ C' UMBRELLA LIAR X OCCUR i X EXCESS WAD CLAIMS.MAOE EXC10006635003 04/01/2015 04/01/2019 EACH OCCURRENCE $ 2,000,000 CED I I RETENTIONS AGGREGATE 1 2,000,000 D WORKERS COMPENSATION EE p S AND EMPLOYERS'LIABILITY I STATIRE I I FRH ANY) pPROqPREIETgO�Rp/PARTNER/EXECUTIVE WCE00431903 06/30/2018 06/30/2019 1,000,000 IMFFICE ryInBK)EXCLUDED? NIA EL.EACH ACCIDENT S Ifyesdeecrlbe under E L DISEASE•EA EMPLOYEE S 1,000,000 'J• DESCRIPTION OF OPERATIONS Below EL DISEASE•POLICY LIMIT $ 1,000,000 .. 1 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If mere pecs Ie 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 7'//�/ ACORD 25(2016/03) 01988.2018 Ar.npn r`.no oneA t,na, A,,.,_,.._...._...,— TOWNOF5YARMOUTH BUILDING:DEPARTMENT 1146 Route 28;South"I'arniouth; MA 02664 508-398-2231 ext 1261 Fax 508-398-0836 FINAL AFFIDAVIT FOR SOLAR INSTALLATION I, -ISM -Shc*c Lic. # (3 Ckricl mats . W&.e/ Property Address Rio - Vt- QOOS 9 111 • Permit # Have installed the permitted solar system according to the manufactures specifications and the Mass. State Building Code. I do certify under pains and penalties of perjury that the information provided is true and correct. 1.00A 04K Pe ft holder sign here ' RECEIVED AUG 23 2018 BUILDING DEPARTMENT By.