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HomeMy WebLinkAboutBLD-19-001397 ' ► • \OfaoetlanOnly I � ' ,� fit Amount 3S— .; �wtAntonl eaplrae 180 days hom ��NC«w 1 100 1 Ina MO EXPRESS BUILDING PERMIT APPL fl" itovrvED TOWN OF YARMOUTH • 6 2018 • • Yarmouth Building Department ' SEP 1146 Rout°28 South Yarmouth, MA 02664 s •r !fl t;'it ip ' �Ir �� (508) 398.2231/// ,, Ext, 1261 Y. �`c�� � • W�kl„ ,,,V Z CONSTRUCTION ADDRESS'. ASSESSOR'S INFORMATION' Mop; paroah I W(C' t. 'n° ' • Zvi- lib& 14465”OWNERI a 1 FRES NT ADDRESS TEL, r / Henry Canldy Cepa Cod lnauletlon IS Rs erdon Circle Inch Vermouth 508.775.121 4 • CONTRACTOR' AILIIT6A15bRESS TELA I Est,Cost of Construotton$ Z ' .�ResldentlRl CCommal'olal 100988 Home lmprovomvnl ContrnctokLlo.H 153567 ConstruollonSupervisor IA,N Workmen's Compensation Inatlrenoat (thaok one) 0 I emlhehomowner'^ 0 I am tho solo proprlator SI I heveWorkorls Componsatlon lneunatos43190 ., Immo*CompanyNamol AtTantiC Charter Insurance' Worker's Comp.Polloyg • WORK TO BE PERFORMED • "Tent _. :s Duration (Fire Retardant Certipoata attached?) 'Wood Stovo �'';Stdlltgl ii of$quaros _ prReplaoernallt windows' ff Replacement doom • Roofing' if of Squares ( )Romova existing* (max.2layers). (tfizfrovt,?r,.,djsulatl a OW� Kings Highway/Historic Dist. ( ) Replaoing Itko for Ilk* S Pool fen�� K ;r; a O '. „ ' lig;debda wllPb,B dlepoeed of vll 1 Location of Pnc Illy tl! I dvolare under poraltta of parjuly Ihat the atalmnenta horoln ontolnod aro true and conact to lho belt of my knowledge rod bo`IaG undorolond That my roll.*a wilt bo Mt*atUl for dental or revooRlton of my Nome and for pr gyeontIo tinder KU,Oh,268,Seotlon I r// Applloenl'a SIBnahuel Henry Cassidy f"?;it Ii.t4t,,VP•ti:: 4 Datel q 6 i a 0rr1101$1gnelure(oretlnohmaat) Dntol rJ x `r DWI / ,-- ApprovedByl sD u • II/0aP' el =y/ • e• : 1 •••� Zoning Dlalrloll Historical Dlstriott CI Yoe 0 No Flood Plain Zeno' 0 Yes 0 'No Watt)?Rosouroa Protection District' Within 100 R. of Wetlands; % • 0 Yea CI No 0 Yos Cl No • • a• Commonwealth of Maveachuselts `�� Division of Professional Licensure •Board of Building Re9yulatlone and Standards Don st`yl:Ott>yrittB'ppvlsor i/ CS.100988 ,;,'' U , qI gslres: 11/11/2019 • • i :3•'14,10,0•1" 7,, • HENRYECA IOY; . ttfr ((q," SSHED ROY; ti'\11,,, r a' � f • WEST YARMo x MF1` 8 fib° Commissioner "s• M- --' \ . • s 926 Wa/i;/malvcoe04 2 • alal ,1 • • tIiI r Office of Consumer Affairs and Business Regulation 10 Park Plaza • Suite 5170 Boston, Manacusetts 02116 Home Improveme.:.1•0.oMractor Registration l,,t) :p;p;: t ilii:ir;ai'::;r: 1,'? Typo: Corporation r. :!;a:y,l1/):` 1 :;g:p.iit� 1 Registration; 183887 Cape Cod Insulation, Inc H ;; ? , `2.7. Exit 18 Reardon Circle ; ;i141 t''' •••':•`�',.• Expiration: 12114/zo13 So. Yarmouth, MA 02684 ''"''''k G r • `•••••� Update Addroee end return card, Murk reason for change. / '\ ICA J 0 'MA{.06!11 (�addra as..(� ........._._�._._�/) _....�.,._........,.,..._-.r,...__ '�.,...,........ . ............_•..,,....•, �,,,.tl.zna.tr;n:_f.Z4.mplay.man6.LlJ.�.at.^.exr! ta _�• Office of Conwmer Nlelre&Suelnese Regulation p•I"I HOM2IMPROVSMENT OONTRtton Registrationvslld forIndividual use only Spot Corporationbefore the expiration date. If lours• • urn tot Oilloe of� jc�jeii?;?v ols1re11en Pxnlrnlleq 10ParkPeta• •Consumer 5170rae.9 ,• el :es Regulation C. \.41..3.fi5`a4 12/14/2018 Sordoni MA • ' ll' q r• Cape Cod Insr.41 ' .� o t1� ••�, j • Henry Cassidy'r , t, t, 18 Reardon Clrol' a ffc, ), 2.cc,0,,, ' So.Yarmouth,MAl', Q5 .�t' �� �^ /' ,,a,•b Undersecretary 1 al ''hou� to • N • --.."-1'1 CAPECOD•27 AMAHLER A�� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDOlYYYYI 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 £2t ±CT Rogers 8 Gray Insurance Agency,Inc. HONE A 436 Rte 134 �uc,Ne,!xi): (pa ,No):(877)816.2168 South Dennis,MA 02880 Fitgfis ,mail©rogersgray.com INSURERS)AFFORDING COVERAGE NAIC e twsunan*iWest American Insurance Company 44393 INSURED - INSURERS tSafety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER c:Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER IX:Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E I INSURER F 1 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 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 AD SSU R POLICY NUMBER POLICY EFF POLICY EXP Q IMMIDOTYYYYL•IMMIDO/WYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS•MADE EX OCCUR BKW(19)63328281 04/01/2018 04/01/2019 FRFM4RIoFenNwr°Me1 § 100,000 — MED EXP(Any one orlon) $ 5,000 PERSONAL SADV INJURY $ 1,000,000 GEIN'LAGGREGALEJIIMIITAPPLIE`POE(R: OFNERAL AGGREGATE $ 2,000,000 POLICY U PELT I I PRODUCTS2,000,000 w holder doe Ap or operations COMP/OP AGO $ X OTHER' � E B AUTOMOBILE LIABILITY COeBBINEDtSINGLE LIMIT $ 1,000,000 ANY AUTO _ 6232707 04101/2018 04/01/2019 BODILY INJURY(Per Demon) $ AUTOpS ONLY X AUUTT1OSSWULNE¢DpRY _ '' X 'Ms ONLY X AIM ONLY BODILY OROPERNYU AMAGE accIdent) $ _ - /Per e�aaenlQ § E C' UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 X EXCESS LIAB CLAIMS-MADE EXC10006835003 04/01/2018 04/01/2019 AGGREGATE § 2,000,000 •• DEO RETENTIONS D WORKERS COMPENSATION § AND EMPLOYERS'LIABILITY PER FR • ANY PROPRIETOR/PARTNER/EXECUTIVE 0813012018 08/30/2019 E 1,000,000 FICE mt M EXCLUDED? NIA E.L.EACH ACCIDENT $ anaa�oryPln NIl) 1,000,000 , livge, describe under E.L.DISEASE•EA EMPLOYEES 1,000,000 • DESORPTION OF OPERATIONS below EL DISEASE•POLICY LIMIT S . / DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,AddIllonel Remarks Schedule,mey be ttached If more specs Is required) Workers Compensation includes Officers or Proprietors. Additional Insured status Is provided under the General Liability and Auto Liability when required by written contractor agreement with the Certificate Holder. Excess Liability Is follow form. CERTIFICAIE_HQkDER 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 �,NJr// L ,ared _ ACORD 25(2018/03) 491988.2015 ACORD CORPORATION. AU rlohts reserved. pis The Commonwealth of Massachusetts Department of Industrial Accidents „ere_ a1 �I y Boston, s Street, Suite 100 'w ^ MA 02114-2017 • '4 www mass.gov/dta 1Yorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. • TO BE FILED WITH THE PERMITTING AUTHORITY. Aoolicent Information Please Print Le¢ibiv Name (Business/Organizadowlndividual): 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 boxy Type of project(required): I.©lams employer with 48 employees(full end/or part•time).' 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees working forme In g, 0 Remodeling any capacity,(No worker'comp,Insurance required.) 3.0 I am a homeowner doing all work myself.(No workers'comp.Insurance required.)t 9, ❑Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contactors either have workers'compensation betimes or are sole 11,0 Electrical repairs or additions proprietor with no employees. 12.0 Plumbing repairs or additions 5,01 am a general contractor and 1 have hired the sub•contncton listed on the attached sheet. 13.Q Roof repairsTltesesub-contractorshave employees and have worker'comp.insurance 6.0 We are a corporation and its officers have exercised their right of exemption per MOL o, 14. ✓�Other Weatherizatlon 152,11(4),and we have no employees.(No workers'comp.Insurance required,) *Any applicant that checks boxel must also fill out the section below showing their workers'compensation policy Information. Homeowners who submit this affidavit indicating they are doing all work end then hire outside contaoton must submit a new affidavit Indicating such. 'Contactor that check this box must coached en additional sheet showing the name of the sub•oontraotors and nate whether or not those entities have employees. If the ab-oontractors 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 and Job site information, Insurance Company Name: Atlantic Charter • ' Policy#or Self•Ias.,Llc,#: WCE00431902 Expiration Date• 06/30/2011 _ Job Site Address: 24 0 6 • VZ City/State/Zip Gam' A� it�1 Attach a copy of the workers' cora ensatlon policy declaration page(showing the policy numb r and expiration date). Failure to secure coverage as required under Mat 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 WOR1S;'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 Ir(vestigations of the DIA for Insurance coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided a ove is true and correct .M,/Y•ryMWQ I / f $fanature: HenryCassldy w:,;.�„�'�'-•-----.-........-..... pate: I/(/ I��d Phone#: 508-775-1214 Official use only. Do not write in this area,to be completed by city or town official. City or Townt Permit/License# Issuing Authority(circle one): • 1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector Se Plumbing Inspector 6.Other Contact Persons Phone#: .Doc*Sign Envelope ID:E790D150-CC3C 4F9G9680.32BCD549FEC8 OWNER AUTHORIZATION FORM Patricia Brown (Owner's Name) owner of the property located at 248 Camp St, unit V-2 (Property Address) West Yarmouth, MA 02673 (Property Address) hereby authorize C--2_1.e„ G>ck "r\ \o_7C1o\(1 (Subcontractor) J an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. rDocuSigned by: f"Aida &room, Owner's Signature 8/30/2018 1 10:44 AM EDT Date