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HomeMy WebLinkAboutBLD-19-001358 p'f YA°s 10111oe Uso Only �1 �e O PornIIN 4?'' �iAmoun%_3S`� �M4'.„ 0 1# , 1 is ,. 1Permllexpires 180days from dole .. UJ-1 G� l�e) 13s u!:ene • EXPRESS BUILDING PERIYTtc APPLZC'=•: .: • TOWN OF YARMOUTH E I V E D Yarmouth Building Department 1146 Route 28 SEP 04 2018 South Yarmouth, MA 02664 (508) 398.2231 Bxt� 1261 BUS ' R' 17Ord. u w � viltCONSTRUCTIONADDRES51 ASSESSOR'S INTONATION! I�, � Mapi Pero!! crawl " kt v 360 7tg/ PRE BIT •DRB ' TEL, CONTRACTOR! HenryCessldyCope Cod Insulation reRitchie CM, aoulhVermouth 508.775.1214 AILING ADDRESS TEL,8 R Residential 0 Commercial Bat,Coat of Conatruotlon$ 7130-3 Home Improvement Conlrnot% bloc H 153567 Conghruotlon Supervisor I,Ie,H 100988 Workmen's Compensation InJuranoet (roheok one) 0 I em the homeowne"r'• CI 1 am the solo proprietor z 1 hevo Worker's Compensation Insurance Atl In:uranoyCompenyNamer antic Charter Insurance' Wo • WCE0043190 rker a Comp,PolloyN .,, . • • WORK TO BE PERFORMED '"Tent " Duration, . (Firs Retardant Cartifloato attached7) . "„ Wood 3lovo `Siding! H of Square. "Replacement windows! H Replacement doors! H Roofing! H of Squares__ ( ) Ramona exlstinga(max,2layers). li—3D {vt y8 +g. taion - •a' Old Kings Highway/Hlstorlo Dist, ( )Replacing like for Ilko J 'fa 63°P9ifen s /0 ,11 • • '• 1. . ITS'Mai wlll'btdUpoiedoPolra 44 IL „�, / ..� & �L1JZ(G5 �v ° / Location of Fee try I deolury Enderpenallies of polar/1111114 statement:herein�tolnod In true and conto%to lbs boil of my knowledge end bollof. I undoreland%her an false enswor s Will bolus;oaustfordenlelorrevooalionofmylloensewsdforproseoullontinderM,O,L,C11,20Seotton1, Y ( ) a . -nry Gas Cs." tlhhl4�1°I7r N , i / fit Applloenle3l nein! II"dn il{idjifif.M.s"� Dater Owners Slgnar $(or Agee meet) Approved Dee I �, Dntor Btang •li •e ITN .•) EMAIL ADDRESS! DOM ��i' Historlonl Distrlotl Cl ZYesngt)IsNoot� Flood Plain Zonis! '3 Yes ID No Wator Rosouroe Protcollon District! Within 100 ft, of Wetland:: s w • el Ye: CI No D Yes Cl No ,,, ' HOME OWNER WEATHERIZATION WORK PERMIT: PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER. I hr.,ah, j hereby consent to and agree that weatherization work may be done byothe Weatherization Program of Housing Assistance Corporation on the property located at: I n 0ge dip ip..�t-t J We 1/4-015b kit The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures: Weather stripping; air sealing; attic& basement Insulation; exterior wall insulation; ventilation measures In consideration of the weatherization work to be done at my home I agree to the following: 1. I give permission to Housing Assistance Corporation to access the property with such equipment and materials as may be necessary to perform weatherization. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five (5) years after the weatherization work is completed. I have read the provisions of this agreement and give my consent. Home Owner(signature) ri ter Home Owner email: Date: Agent:(signature) Date: Agency Approved Weatherization Company All Cape Energy Alternative Weatherization Cape Cod Insulation Cape Save - Cazeault Frontier Energy Solutions " Lohr Home Improvement r/ —tce Agency Signature: %14A ,IA) Q �Date: '',AC i For Natural Gas Customers: /, I have received the National Grid Discount Rate Application form from my auditor. Customer Initials I U • 0.). Commonwealth ol Massachusetts Division of Professional Licensure 'Bonrd of Building Regyulations and Standards Cons`�;0tttlri tt11pprvlsor • CS•100988 .:S' w s si, 2sires: 11111/2019 . •'[I4irt jti,�, .. V . 6ENRYROW,I0Y; . K, t IHENRY E . :WEST YARMOGSrJ MVO,' � S� rtrC'1r5Sd:10\\, \ �.r. a • Commissioner w 0'4— '``,i�l ' Office of Consumer Affairs and Business Regulation b 10 Park Plaza • Suite 6170 Boston, Mag&tusetts 02116 Home Improveme:.00oNractor Registration ITI'F e.iW1:gt::R.. 1 ,�?: ) Type Corporation . ('‘'i! I.k1, l.A/ •J'' T.`' a: 0' Registration: 183587 Cape Cod insulation, Inc YI :;;:•:.:,) ,•%.. „ Expiration: 12/14/2018 18 Reardon Circle it ';;:;-: , • So. Yarmouth, MA 02664 \l, 1 ..F9iqii t d u.i:r.nc'ay 1• • •,„,^ .. .,.Y ",......, ' Update Address end return card. Mark reason for change. \ ICA,/ a 201,0011 l ._..._....�.�..__....___ ,._...__..... . ........_._........(;LAddra.aa..( .n.se mag_R"nrplo:ymant.r.aost.C..r.rd. — ?o C atINJeal6rVarF/[JY a`CVIICOaaree/troat(u CN Mee of Comely Metre&Business Regulation rglk ify. • HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only I' 1. • Zy"pol Corporation bolero the expiration date, II foun• • urn tot I“ Oar slretlon rxplrntlo0 OIIIoe of Consumer Aflalre and'' al •a Regulation 0 a] 12/1412018 10 sionPark MA • = 1 6170 :-.P.1::•.11•1„• � • � a„! Boston,MA . Cape Cod Ins0„*.t•I . I iii��c"':,, - Henry Cassidy'r?, '.'/ ti, lava /er_ 5 ' Undersecretary .t al • 'mahout at. atu•: • • ----am1 CAPECOD•27 AMAHLER, ACORD• CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDDIYYYY) 06/0512018 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 E2klieCT Rogers&Gray Insurance Agency,Inc. PHONE (AIC,Ne,lath/ jae,Ne):(877)816.2166 034 Rte 134 South Dennis,MA 02660 fmist mall@rogersgray.com INSURER(S)AFFORDING COVERAGE NAICC INSURERALWeat American Insurance Company 44393 INSURED INsugp ie:Safety indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER c I Endurance American Specialty Insurance Company ,41718 18 Reardon Circle INSURER a:Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E: INSURER F: 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 WMTH 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 ;im SUep POLICY NUMBER POLICY EFF POLICY EXP IMMIDDIVYYYI IMMIDDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEp $ 1,000,005 CLAIM&MADE E OCCUR BKW(19)63328281 04/01/2018 04/01/2019 PREM SFR fFeoormrencal $ 100,000 — MED EXP(Any one person) S 5,000 — PERSONAL SADV INJURY $ 1,000,000 SI'L AGGREGATE,8IIMIITAP,LIES PER: GFNFRAL AGGREGATE $ 2,000,000 X POLICY II_JI PE ,, II LOCI. 2,000,000 w holder dentin of operations PRODUCTS•COMPJOP AGG $ X OTHER; $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 Ira acddem $) _ ANY AUTO 6232707 04/0112018 04/01/2019 BODILY INJURY(Per person) $— AOSUTONLY XCUULLED BODILY INJURY accident) $ __X AIM ONLY X ACTOSOIEp PEfte5NPRdTeYnt4AMAGE S — S C UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,000,000 X EXCESSLIAB CLAIMS•MADE EXC10006636003 04101/2018 04/01/2019 AGGREGATE S 2,000,000 •• DED RETENTIONS D WORKERS COMPENSATION 9 f AND EMPLOYERS'LIABIUTY STATUTE FRµ ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WCE00431903 06130/2018 06/30/2019 1,000,000 OFFICER 4En6ER EXCLUDED? u NIA E.L.EACH ACCIDENT f ( an ato NN) 1,000,000 II yes,describe under E.L.DISEASE•EA EMPLOYEE f 1,050,000 • DESCRIPTION OF OPERATIONS below EL.DISEASE•POLICY LIMIT $ / DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addlllonet Remarks Schedule,may be sached If 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. CERTIELCAIF 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 • ACORD 25(2016/03) 6)1988-2015 ACORD CORPORATION. All rlahts reserved. • •w The Commonwealth of Massachusetts M fit-=t Department of Industrial Accidents 1 Congress Street, Suite 100 =Si= _y' Boston, MA 02114-2017 • 'La," www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers, TO BE FILED WITH THE PERMITTING AUTHORITY, Applicant Information Please Print Leelbiv Name (Business/Organization/Individual): Cape Cod Insulation Address: 18 Reardon Circle City/State/Zip: South Yarmouth,MA 02664 Phone#: 508-775-1214 An you an employer?Check the appropriate boat 1, lamaemployerwtth 4e Type of project(required): © employees(full end/orpart-time),' 7. 0 New construction 2.0 I am a sole proprietoror partnership and have no employees working forme In 8. 0 Remodeling any capacity.(No workers'comp,insurance required,) 3,0 1 an a homeowner doing ell work myself.(No workers'comp.Insurance required.)t 9. El Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contncmn either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. S,❑1 am a general contractor and I have hired the aub•contrecton listed on the attached sheet. 12.0 Plumbing repairs or additions These subcontractor,have employees and have workers'comp.Insurance.? 13.❑Roof repairs 6.0 We ere a corporation and itofficers have exercised their right ofexemption per MOL o, 14. Other Weatherizatlon 152,11(4),end we have no employees, [No workers'comp.Insurance required.) 'Any applicant that checks box 11 must also fill out the notion below showing their workers'compensation policy Information. t Homeowner,who submit this affidavit indicating they are doing an work and then hire outside contreotors must submit a new affidavit Indicating 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, 1f the sub-contractors 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-Ins.Lio.#: /W�CE00431902 Expiration Date 06/30/2011 (9' Job Site Address: iq L1i4tt-' City/State/Zip: w' alefu'rct Attach a copy of the workers' compensation policy declaration page(showing the policy numbeand 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, es well as civil penalties in the form of a STOP WORtS,•'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 Idvestigations of the DIA for insurance coverage verification, 1 do hereby certify under the pains and penalties of perjury that the information provided abPPpPv is,true and correct. ,Signature: Henry Cassidy qlt Date' Phony#: 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,Heaith 2, Building Department 3.City/Town Clerk 4. Electrical Inspector S, Plumbing Inspector 6,Other Contact Person: Phone#: