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• EXPRESS BUILDING PERMt" APPLICA1
TOWN OF YARMOUTH 6 2018
Yarmouth Building Department SEP —
1146 Routa 28
South Yarmouth,MA 02664 Dirte `: `le`gry1T
(308) 398.2231 Ext 1261
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CONSTRUCTION ADDRESSI l6 'Oa V/�-----t
ASSESSOR'S INFORMATION
Mapt I Panel; I
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Ong r.. dPAM T AODRE$S TEL
HenryCeaaldyceps Cod Insulation IIKurdonCtrela South Yarmouth 508.7754214
• CONTRACTOR' AILIN6AODRESS TEL N
R Residential 0 Commerolal Est.Cost of Construotton$ c250 • a
Home Improvement Contracto bio,N
153567 Construction Supervlser Lie, N 100988
Workmen's Cvmpensetlon 1nurenoet (oheok ono)
0 I am thshon+norme.i CI I am the sole proprietor III I hevo Workor's Componaation InsuraCE004 3190 .,
InsuranoaCompenyNamo; Atlantic Charter insurance. Worker'aComp.PolloyN
WORK TO BE PERFORMED '
"Tani Duration (Fin Retardant Certificate attached?) Mood Stove
...'';Sldingt N of Squaros t,,,Replaoement windows; N Replacement doors' N
Roofing' N of Squares — ( )Remove exlstlug* (max.2layers)Cvatih,D Z70' In�lail
_Old King;Hlghway/Hlstorlo Dist. ( ).Replacing Into for Ilko P of ten g 10 D�
G (� riQ •
lvo1/Qvati ireheI
„ '1. ;TA debrh wlll'ba dlapored of ort t Location of Enc llty CCht--
I devlary under porialdae of porJuly that the statement'horoln ontolnod to uve and moot to the Volt of my knowiadgo turd olio r. I undorstnnd that any(Rho 0
L•CI sde / g
will1,0J I%Dewe for denini sr revocation of my roams and for proavoutlon under M.O, , t, ,Saot on , f/
Henry Cassidy ga."s�1!i4s!;�ii 'tr v:�,ra b r
Applicant's Slgnaluret t u',nnn,wfas Dale:
antra Signature(or nlnthmeut) yy Dolor /
Approval Ey: Data; 9�7C77
Drilling of Coo) DDRESS: •••�
Zoning Dlatrlcli
Historical District' CI Yoa C1 No Plood Plain Zeno' 0 Yes 0 No
Wator Resource Proteollon Dlririoh Within 100 ft. of Wetlandc a
• CI 541 CI No 0 Yos 0 No •
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•
• l °• Commonwealth of Massachusetts
t. Division of Prof esslonal Licensure
•Board of Building Re9ulatlons and Standards
Cons`,g:* riiS11'jp1vlsor
it •
• C3.1d0988 ;S' tivr:HI ♦;Arcs: 1111112019
. !; .'.4� �(.4ii.. �,
HENRY BOW..., ;v;: 11�j'.r • %
eSHEDRCWA• . 111/1 ;'r ,
WEST YARMOGTHMA, O•; E0 >;' \ /
Commissioner '- C24-.
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`' W e �a�;nmcw2.criea
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"��t ` Office of Consumer Affairs and Business Regulation
b 10 Park Plaza • Suite 6170
Boston, Masattusetts 02116
Home Improveme,. .o 4ractor Registration
s.., % r•\ +st•74frii'.:'F:,,i'1h ' kt
usv'. ) Typo:
„pl , ..,,I:''i`' `;li°'t'.'>r:.:::` t, ( yP Corporation
,, ;';;:_,;;,;J,�;I' } r Y Registration: 103887
Cape Cod Insulation, Inc i ,1.1 .1..,.,r IW Expiration: 12/14/2019
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18 Reardon Circle ,r "r!i IS ;
' So. Yarmouth, MA 02684 ""`' £'
•
"V...�. Vpdele Address end return card. Mark reason foe chimps.
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a"• Office of Conavm$r Alf airs&susinesa Regulellon
F"A
�I�� yt�� '• HOME IMPROVEMENT CONTRACTOR Registration Vella lee Individual use only
(` T,ypol Corporation before the expiration date. If Nun. • urn tel
� N i;nrly Pxnlrnlloq 011loe of Consumer Affairs end'= el •es Regulation
'' 41if�•ri }:�a7� 1211412018 • tOPark Plaza. ea170 •
'�. \1�C}trt1 .'. L� Soeton,MA •• .
Cape Cod Insoi ti;.' ( ' ,e.0 r\ L• HenryCaseldula O„”��ti
, 18 Reardon CI v t J,' S-c-ta
So,Yarmouth,MA ,Q `Q,:119 •�� 1S .L. „
i ' Vndorsuoretary •1.t al • 'mahout sit atu :
•
.-------Th CAPECOD•27 AMAHLER
ACRO' CERTIFICATE OF LIABILITY INSURANCE DATEIMM/DO/YYYYI
0610512018
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 WCT
Rogers&Gray Insurance Agency,Inc. PHONE FAX
434 Rte 134 Ia. c,No,cal): (ac,No1:(677)816.2156
South Dennis,MA 02680
Miss:ss:mailcrogersgray.com
INSURER(SI AFFORDING COVERAGE NAIL N
INSURER A:West American Insurance Company 44393
INSURED ^ INSURER a: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 P,
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. NOTWTHSTANDING 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 TYPE OF INSURANCE p SMg. POLICY NUMBER POLICYm/DDEFF POLICYM/DDEXP
IMYEFF ( EXP LIMITS _
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
CLAIMS.MADE QX OCCUR BKW(19)53328281 04/01/2018 04/01/2019 DAMA pRgENTEOnee1 s sumo"
MED EXP(Any one person) $ 5,000
—
PERSONAL a ADV INJURY $ 1,000,000
_GEN'L AGGR A ELIMIT AP I S PER: QFNERAL AGGREGATE $ 2,000,000
X POLICY LI 5& LOP
PRODUCTS•COMP/Qp AGG $ 2,000,000
X mholder dew
OTHER;
S
B AUTOMOBILE LIABILITY COeMecddenlBddentl NGLE LIMIT $ 1,000,000
l _
— OWNED O 6292707 04/0112018 04/01/2019 BODILY INJURY(Per person) $
AUTOSANY Ipp� ONLY X 233TNO.p??UULNEEDpRY _
X ONLY X AUTOS ONLY BODILY
OOPERNYUAMAGE accident/ _
P�oreec, en$ $ _
1
C• UMBRELLA LIAR X OCCUR EACH OCCURRENCE S 2,000,000
X EXCESSLIAB CLAIMS•MADE EXC10008635003 04/01/2018 04/01/2019 AGGREGATE $ 2,000,000
•• DED RETENTIONS
D WORKERS COMPENSATIQN $
AND EMPLOYERS'LIABILITY PER ppTUTE ERH
ANY PROPRIETOR/PARTNER/EXECUTIVE WCE00431903 08/30/2018 06/30/2019 1,000,000
FICE�2AIEMBER EXCLUDED? NIA E.L,EACH ACCIDENT S
ands cry n ) 1,000,000
If yyes descdbe under EL DISEASE•EA EMPLOYE 5 1,000,000
•DESCRIPTION OF OPERgiIONSDeIow E L DISEASE•POLICY LIMIT $
•
/
DESCRIPTION OF OPERATIONSI LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It 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.
CERTIFICATENOLDER 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 REPRESENTATIVE7
I �,Waf/SE
ACORD 25(2016/03) (01988.2015 ACORD CORPORATION. All riahts reserved.
PIM
4a\ anownwie
The Commonwealth of Massachusetts
=1.011?= Department of Industrial Accidents
1 Congress Street,Suite 100
€t! h' Boston, MA 02114-2017
4,
www.massigov/dla
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individuaq: 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 bon -
Type of project(required):
I. t am a employer with 48 employees(MI and/orpart-time),'
7. 0 New construction
2.01 am a sole proprietor or partnership and have no employees working for me In 8. 0 Remodeling
any capacity.(No workers'comp,insurance required,)
3.0 I am a homeowner doing all work myself(No workers'comp.insurance required.]r 9• ❑Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees,
6,❑1 tuta general contractor and 1 have hired the sub-contrecton listed on the attached sheet. 12.❑Plumbing repairs or additions
These sub-contractors have employees and hive workers'comp.Insurencat 13,❑Roof repairs
6.0 We are a corporation and Its officers have exercised their right of exemption per MOL , 14. Other Weatherization
152,11(4),and we have no employees,(No workers'comp.Insurance required.)
*Any applicant that checks boxgl 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 contnotors must submit a new affidavit indicating such
:Contractors that cheek this box must attached en additional sheet showing the name of the sub-oontraotors 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.m W CE/00431902 Expiration Date 08/30/2014 _
Job Site Address: lb to die City/State/Zips 7kO4/, 09-
Attacha copy of the'workers' co pensation 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 31,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WOR$'ORDER and a fine of up to$250,00 a
day against the violator,A copy of this statement may be forwarded to the Office of Irivestigations of the DIA for insurance
coverage verification.
Ido hereby certify under the pains and penalties of perjury that the Information providedhove Is
true and correct.
,$(¢nature: Henry Cassidy r at fir•. --.... .... .r,» T'Jhf)9
phone#:
508-775-1214
Data: h()9
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#:
RISE E
ENGINEERING'
OWNER AUTHORIZATION FORM
1, Karin U Sieland riLel S(c ' i. el ,
(Owner's Name)
owner of the property located at:
16 Eldridge Road ,
(Property Address)
Bass River, MA 02664
(Property Address)
hereby authorize (Ape CO J .../41 Sv In 'f- 1 c)n ,
(Subtontractor)
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.
I Ap'
-1.
Owners ignatur
',/17/zb16
Date
RISE Engineering,a Division of Thielsch Engineering, Inc.
5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926
www.RlSEengineering.com