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HomeMy WebLinkAboutBLD-19-001173 OT Y� \irorae.alae Only letr(11(4 Permit!! er: �(y Amotmt_ Permit expires 180 dogs from !tleaue dote EXPRESS BUILDING PERMIT APPLIC • R• E i E D • TOWN OP YARMOUTH Yarmouth Building Department AUG 271018 • 1146 Route 28 a BUILDING OEPgR7MENT South Yarmouth, MA 02664 (, 08) 398.223/1 Ext. 1261 ~ CONSTRUCTIONADDRESSI. 'Al it "0 eI 'Sr ihr 6 " /` /cytew 1 , a''� . 1 ' ti j aLaG ASSBSSOR'S INFORMATIONt Map; Parcel; tU1i WNBR; A la A lI U�737 kyQ� O PRE'E T DORE TEL CONTRACTOR! Henry OaasldyCaps Cod lnaulatlo0 IaRurdonClrcM1 South Vermouth , • ••• 508.775.1214 . NQ TE . ' g Residential 0 Commeroisl 153567 Bs'.Cost oPConatruvtlonS Nome Improvement Contrnetokl,lo,N 1 0988 Couah'uctlon Suparvlaor Lied/ Workmen's Compensation Insuranoel (oheok one) 0 I am the homeowner Cl I am the sole proprietor W 1 havo Workor'e Compensation Insurance InaurenoeCompanyNamo; Atlantic Charter Insurance. WCE004319 Worker's Comp,Po11oyN WORX TO BE PERPORME0 '"Tent " Duration (Fire Retardant Certificate attached?) ,ye Wood Stove ;Sldingi HotSquaros a,eReplacemontwlndowslN,•_� Replacement doorst N Roofing! N otSquares ( )Remove existing* (max,2layers). Tnsuiallony4 Old Kings Highway/Historic Dist ( )ReplacinJ V-{(s Replacing like for like Pool Lacing / AV RID si '',, sTtle debris evill'bt disposed of oh kis • a ... (�,�1��� I' Location orpneIIty '\-ry I deviare Under Wallin of porjuay that the itatomonie heroin °mined ere true rind oorreot 10 the bon of my knowledge and proposition under boiler, I understand that any false annvor(a) will bejust owe for denial nr revooetlon of my license and for F ,� �� n r M.01.,Ch.268,Saotlon I. Applloanl's$lgnah;ret H- enry Cassidy `7/t'!'(7� ". • ,� Dvlet 4" Zi - 1 Owners518nmure(or attachment) Approved Ey; / Ontoa vp :u • ng •- o8 or es gnoo ;. . .•D I Dato; 01"12 -/L Hlstorionl Dlstrlotl Cl Zoning ngC)District' oFloo_ Plain Zone; O Yes 0 No .. Walvis Resource Protection District: Within 100 ft, of Wetlands; s A • 0 Yes CI No 0 Yes 0 No •--. The Commonwealth of Massachusetts Department of Industrial Accidents r __ +►_ 1 Congress Street,Suite 100 :f n Boston, MA 02114-2017 "�,�..�� www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly 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?Check the appropriate box: Type of project(required): 10 l amaemployer wlth 48 employees 7. ❑New construction 2.01 ant a sole proprietor or parmership and have no employees working forme in S. Remodeling any capacity.(No workers'comp.insulters required.) 3. I em a homeowner doingall work 9. ❑Demolition ❑ myself(No workers'comp.insurance required.) 4.0 I am a homeowner and will be hiring contractors to conduct all work onroe I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or mye i sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 f am a general contactor and I have hired the subcontractors listed on the attached sheet. 13. Roof repairs These subcontractors have employees and have workers'comp.insurance,' 6.0 We are corporation and its officers have exercised their right of exemption per MOL e. 14.9 Other Weatherization 152,11(4),and we have no employees.(No workers'comp.Insurance required.) *Any applicant that checks box NI 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 contractors must submit a new affidavit indiosting such. :Contractors 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-contnutors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy andfob site information. Insurance Company Name: Atlantic Charter ' Policy#or Self-Ins.Lk.#: WWC/E00431/9,0��2 Expiration Date06/30/201'? Job Site Address: ig cS I4 f/ "` City/State/Zip: (J d arucnEt ,t'tA Attach a copy of the workers' compensation policy declaration page(showing the policy numb 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 WORKORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Ix{vestigations of the DIA for insurance coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. ,Signature: HenryCassidY v-^=.�-•---.... .....r-w fa.�7. j(J Phone#: 508-775-1214 Date: D Official use only. Do not write in this area,to be completed by city or town of ciaL City or Town: Permit/License# Issuing Authority(circle one): • 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S,Numbing Inspector 6.Other Contact Person: Phone#: • f e' Commonwealth of Massachusetts lDivision of Professional Licensure .Board of Building Re utations and Standards Cons`q{I,Cf r♦'tthpdrvisor Cr • CS-100986 �y i a4�ty ti @�Ires: 11111/2019 HENRYEDAteilDY..,,4 t.1 O r .$ 8 SHED ROW.-. /, WEST YARMOUTH Mpb 678 C � ��f • Commissioner CL P.,2e Wt9470noauoecda •k 4 �J ' 3, Office of Consumer Affairs and Business Regulation 10 Park Plaza • Suite 5170 Boston, Mas$tf usetts 02116 Home Improvemen0aitractor Registration �,.1,1 :Y;t�y''1TV)c,::.:; . /r' , Type: Corporation Cape Cod Insulation, Inc0. ;:-..,X1/1f;; Registration: 153587 18 Reardon Circle - W Expiration: 12/14/2018 So, Yarmouth, MA 02664 ai I>` • l :.Rte:: f • icna s1 aoM osnt t••.. Update Address end return card, Murk reason for change. la-,Ai1r,;:a.ae..r n. a taeleeetwuucalryo�0liftaara.troe!!u uutr:tt._!�rp!O.ymsr.R.�.1.nel..^.t!r�. wiles of Consumer Nfelre&Duel,,,,,Regulation I'1 HOME IMPROVEMENT CONTRACTOR i,, • Type: Corporation beforeRegistrationa valid for Individual use only I�• �/ �'cr,.���6olstretlon before the expiration date. It four• • urn tot r ExRlrotlon Office of Consumer Affairs and : al :as Regulation ' ''1./¢A+�lfi,3$a7 10PsrkPleae• - ;,t(,;` '(1,6 :i,v,t 12/14/2018 a a1T0 Cake Cod InsuISI cy 1l pit rt Boelon,MA HenryCessidy';a, .s2i..lpp.4, 1.' _a; 1/4& j/{fa ot ' t c•6. �" PUndorsocretary /V?f6thoutsle at • ..----"i CAPECOD-27 AMAHLER A�Ro CERTIFICATE OF LIABILITY INSURANCE DATE 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 en 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 MR" Rogers&Gray Insurance Agency,Inc. RHONe 434 Rte 134 (Arc,No,E.q: FAX No):(877)816.2156 South Dennis,MA 02660 •E ji,,R,mail©rogersgray.com INSURERISI AFFORDING COVERAGE NAIC e INSURER AIWestAmerican Insurance Company 44393 INJURED `^ INSURER B t Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER a 1 Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER D;Atlantle Charter Insurance Company 44326 South Yarmouth,MA 02684 INSURER E; INSURER F I COVERAGES C_ERTIFICATE 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 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 OF INSURANCE ,1NADOL SUER POLICY EFF POLICY EXP EC UVO POLICY NUMBER IMM/Dorman JMMIDD!YYVY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE j 1,000,000 I CLAIMS•MADE jX OCCUR BKW(19)53326281 04/01/2018 04/01/2019 DMQi?FREoNTDencel S 100,000 _ MED FXP(Any one Perm/ $ 5,000 — PERSONAL 6ADV INJURY j 1,000,000 SN'LAGGRE LIMIT AP�p�E$PER: 2,000,005 X POLICY P l.__I LOS' GENERAL AGGREGATE ; _ ne aldvdacnp of opentlane PRODUCTS•COMP/OP AGO ; 2,000,000 X OTHER: B AUTOMOBILELIA8IUTY COMBINEDSINGLE LIMIT E Fe ecrldeml $ 1,000,000 — ANY AUTO 8232707 04/01/2018 04/01/2019 BODILYINJURY(PerDer,on) S AUTOS ONLY X 2Up7N5rVvLNEEOp ." X lAtra ONLY _X AUTO09S ONLY • pBOpOPERDILY INVUo AMAGE RY(Per accident) j — leer ecgdenlQ j — "O' UMBRELLA LIAR X OCCUR I X EXCESSLIAO CLAIMS•MADE EXC10008835003 04/01/2018 04/01/2019 EACH OCCURRENCE $ 2,000,000 DED I I RETENTIONS AGGREGATE $ 2,000,000 D WORKERS COMPENSATION 1 ooTT E AND EMPLOYERS'LIABILITY (STATUTE I IfRH ANYQ� PROPRIETO�R�/PARTNER/EXECUTIVE WCE00431903 06/30/2018 08/30/2019 1,000,000 OFrCQEto4EAEER EXCLUDED? NIA F.L.EACH ACCIDENT $ IIIMpyer deudbeunear EL DISEASE•EA EMPLOY E 1,000,000 DESCRIPTION OF QPERATIONS below EL DISEASE•POLICY LIMI E 1,000,000 0. DESCRIPTION OF OPERATIONS(LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers Compensation Includes Officers or Proprietors. / Additional Insured status Is provided under the General Liablilty and Auto Liability when required by written contract or agreement with the Certificate Holder. Excess LlebIlity 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• UT� REPRESENTATIVE ACORD 25(2018103) ©1988.201R Armen rnoDnoATlna, •,,.,_,.._.____,__ • • c• ; Permit Authorization Y�, C mass save Form s.. .VW",ern.gy."xr.nry Site ID: 3350040 Customer: Alison j Adams FTI_(S0ii H'pRMS ,owner of the property located at: (Owner's Name,primed) 63 Seaview Avenue 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. Owner's Signature: Date: 1120 l'8 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: (?APG Com .LII cut A*Tiv1 '7/90/!? Participating Contractor D#te Name: RISE Engineering Phone: 401-784-3700 Email: For Office Use Only Rev.102015