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HomeMy WebLinkAboutBLD-19-001356 opY lomoavaaonly :. i 0 IPernahfl �e ib- IG-bnI354, "peranmoitaxplroadale 180days Cons ila RECEIVED • EXPRESS BUILDING P•ERMt•T APPLI CAir1'r— TOWN OF YARMOUTH SEP 04 2018 Yarmouth Building Department 1146 Route 28 eau rr,l , South Yarmouth, MA 02664 e Y: (508) 398.2231 Ext, 1261 CONSTRVCTIONADDRE551' Ana (0 (xov1�ekc� ASSBSSOR'S INFORMATION' `. g��, Q /� I Map' I Parcell J OWNER' 1 °1 ti °G 64,fr1 ' ifi ben /� • 0 NAMd -AB BIT PORES' r HenryCaaeidyCepaCodInsulatlon TB ' CONTRACTOR' I0 RI circle tooth Yarmouth 508.7751214 AILING ADDRBSS TEL.ii 1 Residential 0 Commercial Bat.Coat of Construotlon$ o277• M Home Improvement Contrneto•el,lo,n 153567 Construction 5upervlsor Llo,N 1 0988 Workmen's Compensation Insurenoei (oheok one) o I am the homeoverri ^ Cl 1 am the sole proprietor 101 hews Workov'a Compensation Insurance !nsuranee0empanyName' Atlantic c Charter Insurance' Workera Comp, Fo11oyN WCB0043I9 0 ., .. ,, •'I' „ WORK TO 13E PERFORMED • 'Tent la Duration (Fin Ratardant Cartlflcato attached?) . awood St0Y0 s Sldingl NotSelma; s,rRaplaclement windows! HReplacementdoorsl M Roofing' Sot Squares ( ) Ramona existing* (maxi 2 layers). o fa {4Ba Ipsulallo Old Kings Hlghway/Hlstorla Dist' AM ( )Ropinoing like for Ilko �/ aw S ova . �/ Pool fencing 11 • ' ''•,,••"Wild debrti arlll' e disposed of oh 0 - I / �pit % g"WS ' l L 30 OV�u°4Q i, LiL tlIS Fn; Ity fo YyGlf mfr I declur underporiallla,of por)usy ovum,atatetnolns haroin�tolnod are True slid cornea Io the Vast of my knowledge and belief. I undorstnnd that any false answer(s) svIli bo Just came tor dental or revocation of my license and tor proseoulton under MAIL Ch,201,Seollon I. Applicanl'l5Ignalur,i Hen Gazaidy p41iMil,li1,.r�rt,z,a;;ry C a (0Are Dater ) / OwnaraSl sentare Ilnehma• �i '- Onto! Approved By! = /�►/ �� ��„� 'll • al •`ea or _mit :• . . •. :• 1 Dn101 �Y Historical Dtatrlctl Cl ZYoaagDistrict!' C)) Noolr Flood Plain Zone,' 0 Yea 0 •No Wator Resource Protection District' Within 100 ft. of Wetlands; a • 0 Yes CI No 0 Yes Cl No • PIMP • The Commonwealth of Massachusetts j;=a i14- t Department of Industrial Accidents aa+it= 1 Congress Street,Suite 100 Boston, MA 02114-2017 �.„ ��o www.mass,gov/dla }Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FiLED WITH THE PERMITTING AUTHORITY. ,4DDlicant 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?Cbeck the appropriate box; - I, 1 am a employer witb 4x3 Type of project(required): © employees(full and/or paratime),e 7. 0 New construction 7•0I am a sole proprietor OF partnership and have no employees working forme In 3, 0 Remodeling any capacity.(No workers'oomp,insurance required.) 3.0!em a homeowner doing all work myself.(Na workers'comp.insurance required.)r 9. El 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 contactors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. S,0!am a general contactor and!have hired the subcontractors listed on the attached sheet. 12.0 Plumbing repairs or additions These subcontractors have employees and hive workers'comp.insurance.: 13. Roof repairs 6.0 We ere a corporation and Its officers have exercised their right of exemption per MOL a. 14.Ell Other Weatherization 152,11(4),and we have no employees,(No workers'comp.insurance required.) 'Any applicant that checks box ill must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached en additional sheet showing the name of the suboontnetors and elate whether or not those entitles have employees. If the sub-contactors 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.#: WCE00431902 Expiration Datta 06/30/2011 gyp_ Job Site Address: a k' 4k Le, Ate_., City/State/Zip w - aU,n fr'; 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 WOR7'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 vestigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided ab ve is true and correct. Signature: Henrycessidy ?•�^- --^��--�—^ Date: I i f ig Phone#: 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 it 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#: • ..--'11 CAPECOD•27 AMANLER A`O/zo CERTIFICATE OF LIABILITY INSURANCE m• DATE(MMIDoYYI 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 CN�liACT Rogers4 134 Insurance Agency,Inc. reC,No,Eet): FAX Nol:(877)816.2156 South Dennis,MA 02660 as,mall@rogeragray.com INSURER(S)AFFORDING COVERAGE NAIC P INSURER A/West American Insurance Company 44393 INSURED '"• INSURER a'Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER c I Endurance American Specialty Insurance Company 41718 18 Reardon Circle messy;Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02684 INSURER E I INSURER Fr COVERAGES CERTIF(CAtEJJUMBER., 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 CONTRACTOR 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. jNTR TYPE OF INSURANCE ADM SUER POLICY EFF POLICY EXP INED WVD POLICY NUMBER .JMMIDDIYYYY) /Moo/rem LIMITS A X COMMERCIAL GENERALLIABILITY 1,000,000 CLAIMS MADE X OCCUR PEM SFS fEACH OCCURRENCE S BKW(19)63328281 04/01/2018 04/01/2019 &RPq occurrrence) I 100,000 MED EXP(Any one person) $ 5,000 — PERSONAL SADV INJURY S 1,000,005 SI,AGGREGATE LIMITAP S PER: 2,000,000 X POLICY TS t09 GENERAL AGGREGATE E X see holder due p of operations PRODUCTS•COMP/OP AGO { 2,000,000 OTHER: B AUTOMOBILE Limo? COMBINED SINGLE LIMIT E we accident) {1 ,000,000 — ANYAUTO6232707 04101/2018 04/01/2019 BODILY INJURY(Perpereon) I AIUIRRTEEOppS ONLY X AUpoTNr.IOppgWU7LyEDpp pBORDILY INJURY(Per accident) S .I' X AM ONLY L AUi050NFY pPamh IQAMAGE E UMBRELLA LIAR X OCCUR E EACH OCCURRENCE S 2,000,000 X EXCESS LIAO CLAIMS-MADE !X010006835003 04/01/2018 04/01/2019 2,000,000 AGGREGATE { DED RETENTIONS — D WORKERS COMPENSATION p S AND EMPLOYERS'LIABILITY I STATIITF I IORH ANY CPROPRIETORIPARTNER/EXECUTIVE WCE00431903 06/30/2016 06/30/2019 g�Fgsfa EM EXCLUDED? NM E.L.EACH ACCIDENT 3 1,000,000 IM tl Pry In NH) Ilya describe under E.L.DISEASE•EA EMPLOYEES 1,000,000 DESCRIPTION OF OURATIGN90elow — EL.DISEASE.POLICY LIMIT $ 1,000,000 I/ ii ., DESCRIPTION OF OPERATIONS/LOCATIONS(VEHICLES (ACORD101,Additional Remarks Schedule,me)/be attached If more epics la 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_HOLOER 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 �AW+�/ G �� ACORD 25(2016/03) 01988.2018 Amnon nnoono torrent A„.,_,.._.____._., " I L • 1 • l °• Commonwealth of Massachusetts \) Division of Profession!licensure .Board of Building Regulations and Standards Cons` totttr,rtIStIpf;rvlsor it • • 03.100988 .4' Uzi. EI e pires: 11!1112019 • • HENRY E CAV IDY,���1} t 0 %It 8 SHED ROW WEST YARMOGT MA.;O„470 V Commissioner "z- C-2- ' s. e �ainoQuaetzi 2 t� a AiC . 'I( Office of Consumer Affairs and Business Regulation 10 Park Plaza • Suite 5170 Boston, Mag. °£ usetts 02116 Home Improveme,.$tCo'tractor Registration ji;i ,y.•.. C.C. s u f i..1 .ir .•,"i,,,... ) Type: Corporation .• (''4t �!,;;!;,;r,';'� J • ' •,+:. a !1' Registration: 153587 Cape Cod insulation, Inc t! '..;. ,�... I ,I'I.,Ia ;, Expiration: 12/14/2018 16 Reardon Circle •ti..� , So, Yarmouth, MA 02664 ,• +` mii r' ' I:r' , ,\ fi ` \ , • \fit• � `I •.(:"..Y Update Addrose and return yard. Mark reason for change. }` ions a NM Ohl j...�._...........__....___ .._...__...... . ....._.._._........t,1..Addrana-C'•n'xnosemt_r_7 arr.p14,mtment.Lllaat.Cart!.. . 9)4rpamcmwarueale.elbeedQa*rraolto • Vika of Consumer Metre a euslnees Reguletton 14 •• HOME IMPROVEMENT CONTRACTOR Reglsteallonvalid for Individual ueeonly 4,4; y ,, ' Type: Corporation %afore the expiration date, II foun• • urn tot ' " Cities of Consumer Affairs end'; ci ,ss Regulation ycy,jue Exolrotlon a E170 / 9 `�;i°vt.;.ci8.�,8� E.EDIC 2018 10 Park Plaza ' '��t`,,,l , ,r^h'.>,4 Seaton,MA • Cape Cod Ins00 Ir oii '" t� / j Henry CHEWY Vyr,S f � it 18 Reardon Clrc' $ l; ��2 cc. '- / ` ^ • So,Yarmouth,MAli Oaf et: a.. /�_ _ Undersecretary t el • "hout sl• eh/•: • • • ' 10, gls ' 460 West Main Street Housing l 11 Hyannis,MA 02601-3698 Assistance' a` Tel:(508)771-5400 Fax(508)790-2425 Corporation TTY on all lines Cape cod • 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:, i l 9.1 ^ Q'itri'fit. aG. TENANT: (J t.J c ,',)fl7c 74 1GG/ i}ved64/IZ& c -c) * I. CA*04 rirrno, iVC— e ail: %'fW-wt. I01x Cow c4 t . parr email: C/aJ oCieb TYA/2-- cCt-i . PHONE:(home) — PHONE: (home) (cell) 5.11—31.7`3COO (cell) SDS- 36O -w9?3 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 Property Owner's Signature: .�/ ant_mer Date Vtii r Phone: .SDS-36 7- 3 E00 Address: 49 /es/i t✓ yv-raru urAtazc,T. 11 ,02475 Tenant Signature est1.0,ec&Gl 14fl ,tt Date V/ct ,( Agency Approved Weatherization Company f f Advanced Windows Inc / All Cape Energy / Alternative Weatherization Cape Cod Insulation / Cape Save / Cazeault Frontier Energy Solutions / Lohr Home Improvement I MDH Construction, Inc Agency Signature 514Date 1S 'X' ' 10