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HomeMy WebLinkAboutBLD-19-001357 A 0°^"�. Y FON. ` • omoOVs0Onl a 0 INS,' t!ti Qr +" liAnsount3s— _� s °Parmll ax Iran 180 do s from �C B l.l�'`q t P Y „a EIVED • EXPRESS BUILDING PERIVIIT APPLI•CAT • TOWN OF YARMOUTH SEP 04 2018 Ynrmoutb Building Depnrtment 1146 Route 28 °1114'/ ...' • '• 'TIE. South Yarmouth, MA 02664 _— `� /, �" (508) 398.2231 Bxt, 1261 CONSTRUCTIONADDRZ$$i' 26 £' 048-e, al" _liniCt ASSBSSOIV$lHrORMATIONI .. 9 _� Map: / Par* OWNERI AMB fibbt�ei ¢Sg6Y4 L� l oy ' J Se— 3ben 7. 9 PR858NTADDRB$a Te CONTRACTOR! HanryCa++IdyCap;Codln$uletlon IBRnrdonClrcbeouthY+rmovih 508.775.1214 AILING ADDREISS MN p Residential 0 Commercial Bet,Cost ol'Conetruotlon$ ✓`/'n • d'b Homo ImprovementContrnotokLloi 11153587 Conalruo(Ion auparvlsor Llo,H 100988 Workman's Cumpensallon Insuranoei (*hook ono) 0 I am Ihshomeowrro"r'^ CI I am the sole proprietor 0 I halo Workorr's Compensation !neuranoo InsuranoocompanyNamo; Atlantic Charter Insurance' poWCE004319 Worker's Comp, Hoy!! i I ' „ WORK TO13EPERFORMED • "Tent _° Duration _^ (Floc Retardant Certificate attached?) . Stoyo aNidingt NofSpiro; hoReptaoemontwindowetN Wood Replacement doom N Roofing) N of Squares ( ) Remote exletlllga(maxi 2 layers) �L d to T���fl n ui tion Old Him HighwnyfHlstorlo Dlst. 1 i�' ( )'Replacing Ilk*for Ilk* Pool fencing 61 a plc l�g •'•..,,:;r ON I. ' �Tdidebrliarlll'bgdhpaedorou (1111. ��� 30 {acos4 v.-, t, Location of PHI lty I dovlaru undo:ponaltla otporjuly Thal lho sleromonta horoln�tolnod on Iruo and oortoot to lho bail of my knowledge and boll r. I undorstond that any falso onawor(s) All bo Intl oawe for denlel or revooallou or my license and for proseooullon nadir M.O.L.Chi 260,Section I, Tien Cass Iciy ts.„t r,L�7 ,.,.. Appn0anrl$IgAahlr+l `� ✓ ` ttili"i`u�smt q ar ” DaI01 I OsrnarsSlgnnlura(o itnthmtot) Approved ayl % ��>� 01141 •u ''esr• noQ'oa o :. . . 011 ,, I .yY` Dalol �• L r w.o Zsg Historical Dletrlotl Cr YoatDl IsNoolt Flood Plain Zonor '] Yea 0 No .. Water Resource Protsollon District) Within 100 ft. of Wetlands; s 0 Yes CI No J Yoe Cl No s j U C • l a' Commonweallit of Massachusetts \ Division of Professional licensure .Board of Building Re ulations and SlnnUarUs Cons O•Hltkri' 1Stt 'nyrvlsor ,1 • CS.100988 •S ���y.1;1 e Aires: 11/11/2019 • HENRY E CAjSIDY•a�I 'pj" �' ( ) SSHEDROW�• : ' ��,t'/ r ;cc , ar . WEST YARMOG,T�i MA. O �TO ,b' 1011:2:10, �;. "•Ste. Commissioner l/'' • s9:46 �a/tivyno4ve lecd 2 0,Pj, • kV",) Office of Consumer Affairs and Business Regulation 10 Park Plaza • Suite 5170 Boston, MagSso usetts 02116 Home Improveme..t+C.o''tractor Registration .. I ,� :i;d; i�, 1..,..,.,.., ') Type: Corporation "if: t'•::.'111„?' •II ' i:' 1' Registration: 163687 Cape Cod insulation, Inc ' E,,,;'7', : Expiration 12/14/2018 18 Reardon Circle • 1 • hili t So, Yarmouth MA 02664 1 I{, ' ' cye:r:cyi ‘$°. 4,9 ••''‘......?� • Update Address and return card, Mark reason for°hangs. .' '\ PM a 201.1-06/11 \\ cy�... ............ .._. _....__ ,•_..•.,....... . ..........._••.....(;,7..Addy:ssa..(:',•Rsna.1..,A;_raPrr:picyment.L.11ast.C.aul . r ea rpowwuwawan14 a,Q aaurtekreetre groes of Consumer Melts&Business Regulation " � • HOME IMPROVEMENT CONTRACTOR a1�' ;,` :; � Registration valid for individual use only 3e4q 1!'0.• • T,j��pot Corporation betor,the expiration date, II foun• • urn tot lik y. 4 ,y px�lrnllon 01110,of Consumer Affairs and'= al ,ss Regulation • E1 i44 A 4 tion e 61T0 ;u,�'t;�: i>;a. a74 1Y114l201E 10ParkPlaae••l, \t,r•Ir '•. ;r, Boston MA . Cape Cod ins W1 h lc., t'4'' 1 Za f / _ So,Yarmouth,MAdi,ytr>> ' _� • Undersecretary t BI • hout at, atu = S\ • ..----"Th CAPECOD-27 AMAHLER A�oRo CERTIFICATE OF LIABILITY INSURANCE DATE IMM/DO/YYYY) 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 3341IACT Rogers&Gray Insurance Agency,Inc. PHONE - I(A/C,No,Ext): jnlc,N°I:(877)816.2156 434 Rte 134 South Dennis,MA 02660 Lobs;mall©rogersgray.com INSURER'S)AFFORDING COVERAGE NAIC a INSURER A:West American Insurance Company 44393 INSURED -" muses e: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 02684 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. 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 OFINSURANCE p SUER POLICY NUMBER POLICY EFF POLICY fl P IMOLIC YIPOLIC YEXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS•MADE a OAMAGEAATpO OCCUR BKW(19)53328281 04/01/2018 04/01/2019 RENTEDnre) $ 100,000 — MED EXP(Any one person) s 5,000 PERSONAL SADV INJURY ; 1,000,000 _GE_ AGGREAT,,E LIMIT AP S PER: GENERAL AGGREGATE ; 2,000,000 X POLICY n jR LOP PRODUCTS-COMP/OP AGO ; 2,000,006 X OTHER:see holder demi))o/operations s B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea arcldenn S _ ANY AUTO _ 6232707 04/01/2018 04/01/2019 BODILY INJURY/Per Demon' ;_ AOSXAOSULED —AUTONLVBODILY INJURY accident/ AI ONLY X AppNNppOEp roPadeYnyAMAGE j _ _ S C UMBRELLA LIAR X OCCUR EACH OCCURRENCE s 2,000,000 X EXCESSLIAB CLAIMS.MADE EXC10008636003 04/01/2018 04/01/2019 AGGREGATE $ 2,000,000 DED RETENTIONS D WORKERS COMPENSATION p 0 ; AND EMPLOYERS'LIABILITY VlN STATUTE FRH • ANYPROPRIETORIPARTNER(E%ECUTIVE r WCE00431903 06/30/2018 06/30/2019 1,000,000 gram EXCLUDED? L_I N/A E.L EACH ACCIDENT $ indc Ory " 1,000,000 Ifyee deaodbe ureas, E.L.DISEASE EA EMPLOYEE $ OF EdRIPTION OF OPERATIONS below E L.DISEASE•POLICY LIMIT $ 1,000,000 I, ( DESCRIPTION OF OPERATIONS I LOCATIONS I 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 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 ACORD 25(2016/03) I ®1988.2016 ACORD CORPORATION. All riahts reserved. C • The Commonwealth of Massachusetts _ .W, Department of industrial Accidents 74.17410&--- l Congress Street,Suite 100 Boston, MA 02114-2017 • •-•..�•°� www.mass.gov/dia Workers' Compensation Insurance Affidavits Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. • Applicant Information Please Print Leeibly 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?Cheek the appropriate box: Type of project(required): II ama employer ere with 48employees(full and/or part-time),* 7. 0 New construction 2.0`aam a asoce proprietor or parmership and have no employees working for me In 8. ❑Remodeling wacky.[No workers'pomp,insurance required.) 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.)s 9. ❑ DemolitIon 4,0 I am a homeowner and will be hiring contractors to conduct ell work on my property. !will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or we sole 11.0 Electrical repairs or additions proprietors with no employees. 5,❑I ems general cannetor and I have hired the aub•cont actors listed on the attached sheet. 12.0 Plumbing repairs or additions These subcontractors have employees and have worker'comp.Insurance.: 13.❑Roof repairs 60 We an a oorporation and Its officers have exercised their right of exemption per MOL 0. 14.9 Other Weatherization 152,11(4),and we have no employees.(No workers'comp.insurance required.) *Any applicant that checks box II must also fill out the notion below showing their workers'compensation policy Information. t Homeowners v.4w submit this affidavit Indicating they are doing all work and then hire outside cont'so:ors must submit a new affidavit indicating such. :Contrsomr that cheek this box must attached an additional sheet showing the name of the eub.00nonotors and state whether or not those entities have employees. Mho sub-contractors have employees,they must provide their worker,'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 Self4ns.Li #: WCE00431902 Expiration Date 06/30/2019 Job Site Address: 2g fil finktoe City/State/Zip: GO i& t& Attach a copy of the'workers' compensation policy declaration page(showing the policy numb 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 WORI('ORDBR 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 Livestigations of the DIA for insurance coverage verification. l do hereby certify under the pains and penalties of perjury that the information provided Bove is true and correct ,Siznature: HenryCassidy alit-,4.; -. ... ...- ., 9 Phone#: 508-775-1214 Date: Official use only. Do not write in this area,to be completed by city or town officlaL City or Town: Permit/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 Persons Phone#: • rn 460 West Main Street Housing e' k ' Hyannis,MA 02601-3698 Assistance i Tel: (508)771-5400 Fax(508)790-2425 Corporation TTY on all lines • Cape Cud - Free Weatherization ! Your tenant has requested and is eligible for weatherization of your rental home through the Weatherization program at Housing Assistance Corporation. An average weatherization job is worth $4,500 and these services are provided at no cost to you. The following weatherization measures are applied to the typical job: air sealing in the attic and basement, insulation in the attic, basement and walls, weather-stripping doors. Bath fans may be installed if necessary. We will test the efficiency of the refrigerator..All work is professionally done by licensed and experienced contractors. HAC will conduct a final inspection to make sure that all work is completed in compliance with quality work standards. Prior to the work being done you will receive a letter from HAC showing the actual measures that will be installed and the total dollar value to the work. To confirm your ownership of the property, we will pull the appropriate town assessor's report. If necessary, we may ask for a copy of your tax bill or deed to prove ownership. The work on your rental property will begin when we receive the signed copy of the attached Agreement. If we do not receive the Agreement, HAC will conduct an energy audit but no weatherization work can be done without the signed Agreement. During the energy audit we will install energy efficient light bulbs and will test the efficiency of the refrigerator. If you have any questions please contact Suzanne Smith at 508-771-5400, ext. 123 or ssmith@haconcapecod.org LANDLORD: to•I E 1 . 1\4iaruit - at– TENANT: cu. –_. � 7 ov 6, r��13' 1 blP/YL�JJG{ u-2� frindWiLaryz e ail: / t yaw. LAIR Dix C� e Ner email: . , ly.. t� ® -St l4owt PHONE: (home) �— PHONE:(home) (cell) S'e{– 367 3f00 (cell) .'14T/a�a t 6E52 14. The Parties acknowledge that this Agreement is under seal. It is intended by the Parties that the Tenant or any successor Tenant is the intended beneficiary of the Agreement and shall have a right of enforcement c �/ Property Owner's Signature: 4/- 1 Date t�/�� Phone: SOS 3C ---,15-00 Address: 7 ,L 8 is C L r4- • 42114D1 -7/Y0dlz-7 "44._ o /?2, 675'. ;. s q .. +, Tenant Signature Date e¢—0 I It Agency Approved Weatherization Company Advanced Windows Inc / All Cape Energy / Alternative Weatherization Cape Cod Insulation / Cape Save / Cazeault Frontier Energy Solutions / Lohr Home Improvement / MDH Construction, Inc Agency Signature Date R- 2tc b