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HomeMy WebLinkAboutBLD-19-1355 G Y iOfflosLiao Only • t, :n � O IPermhA R b — ��M M a . s A doom A,r.., O Pernlltaaplroa180dayahom r $CO-IT-b lleauedale • EXPRESS BUILDING PERIYII•c API'LICA R: C E I V E D TOWN OF YARMOUTH SEP 04 2018 Ynrmoutb Building Department 1146Route 28 a ,Ir•.'., e South Yarmouth, MA 02664 °Y ' (508) 398. .223„11. Ext. 12' 1261 36 17 ,7-0 / IAP (jAy v14444,0-2 ASSESSOR'S tNPORMATIONI Map; I Paroeli OWNER! 1 J r Q 9, • J 7 r ` PRESENT ADDRESS HenryCeaaldyCopecodInsulation TE ' CONTRACTOR! 11 Rs 608.775.1214 AILING ADDRESS TEL,N Residential 0 Commercial Eat.Cost of Construction$ `/6-06. 1 Home Improvement Conlrectoj Llo,N 153587 Construction SupervlJor LID,H 100988 Wurkmen'a Cumpenaation Insuranoei ('oheok one) 0 I em the homeowne"r" CI I am the Bole proprietor JO I hewWorkor's Companaatlon Insurance InsuraneeCompenyNamol Atlantic Charter Insurance' WCE004319 Workers Comp.PolloyN 0 , — ••.. • WORK TO BE PERFORMED '"Tent ._r Duration _ (Piro Retardant Certificate attached?) . ' H Sidingl of Squares ,,rReplaoamentwlndownN Replacement Stoveood !oral doom Roofing! Hof Squares ( )Remove existing* (max,2 layers). fc_ii do Old King,Highway/Historic. Dist, /clfr, ( ) Replacing Ilko foe like Pool fencing `aidr r cid 0peavek, l✓,C 5 y- ,, ' IT dabrli lvlll'b•e dhpond of oh .(4 a� ..Y I. , Low*orEn* fly I declare rntderpanallIar**(Jury that the atatotnonta heroin 'ontolnod ore true on cepa to Iho Uel or my knowledge and honor, I undorelnnel that any Mete anawor(a) wIll bo Juat oawa for dental or revoontlon of my Vomit r proseoallon under MA.L.Oh,268,Seollon I. Appllomre Slgnaluee . Cassid,� PIP I tiTlii"tc�f:.9yrfg _ a Fir,uu Dote! ) f Owner;Slgnntu (or altnahm,. r ' Dntol Approved Ey! ��r VVY Z Hlstorloni DIalrlot! CI yoanga No Novel Plood Plnln Zonot 0 Yea 0 'No w'1 Water Resource Protection Dlslriou Within 100 R.of Wetlands; a fg Yos CI No 1 Yes Cl No • ', U • l �• Commonwealth of Massachusetts c. Division ciProfessional llcensure •Bonrd of Building Regulations and Standards Con s<,g:Ctt&rl'I%11'pplevl s o r • CS.100988 ,;S' d .j E Aires: 11/11/2019 . Ih v' / ,+ HENRY E CA,�SIDY:,li ftli O f ) WEST YARMO8 SHED ROW GTfj M1+'0.�78 ,)C \ • Commissioner '1,- V'µ' 4 • y< U726 C(JaYI?/r�mma4?rcfleCY�4% a� tt1 r Office of Consumer Affairs and Business Regulation a 10 Park Plaza • Suite 5170 Boston, Mat$'blusetts 02116 Home Improvementgr tractor Registration viii. (?' Tri ) Type: Corporation 1' ttiai'�r:`'` / 9' Registration: 183887 Cape Cod Insulation, Inc f„ :1;;;;,?.�1�,,,, f.,_+:,:: 1; Expiration: 12/14/2018 18 Reardon Circle [;•-.;t., ,•aRil • So, Yarmouth, MA 02664 . ;i ,;,i .•t'tj4lit'.;;;;Ir t,.,•911 . `••.,.) • Update Address end return card, Mark reason for change. 7' '\ ;cm 0 20M•01/11 — \r- —'o�O�IMPROVvolav CONTRACTOR _ r7..Ad s.es..l t.n.iarlrrn:_I IP�r p! /mont.Clloat.^su onsumer s i ess 1„a' Registration valid for Individual use only ` , tat. Corporation before the expiration date, If foun- • urn tot ,' N tiltti:ji Exclrnllon Office of Consumer Affairs and = Si es Regulation �'*�' u /';a�°itQ.,,.���a� 12/14/2016 0oaton MA10 Park B• •• ea1T0 Cape Cod IneOi4ii ig -i: / Henry8591d k( /R /Ar"' Undersecreta C N ) t al •• h. sl, atu ' t‘ • ..---- 1 CAPECOD-27 AMAHLER ACOCERTIFICATE OF LIABILITY INSURANCE M' DATE(MMIDDYYI 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(!). PRODUCER NaPeCT Rogers&Gray Insurance Agency,Inc. PHONE (A/C,No,[sq: I FAX No1:(677)816.2156 434 Rte 134 South Dennis,MA 02680 Miss,mall@rogersgray.com INSURER'S)AFFORDING COVERAGE NAIC N JMILRER A'WestAmerioan Insurance Company 44393 INSURED INSURER 13:WON Indemnity Insurance Company 33618 Cape Cod insulation,Inc. INSURER C:Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER o;Atlantic Charter insurance Company 44326 South Yarmouth,MA 02664 INSURER C; INSURER F t COVERAOES CERTJFICATEJJJUMBER: 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. NOTLMTHSTANDING 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, LTRR TYPE OF INSURANCE DOL sUBR POLICY NUMBER POLICY EFF POLICY EXP .JLIMMIM'YYLIMMIDDpyYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE i 1,000,000 CLAIM$.MADE 0 OCCUR BKW(19)53328281 04/01/2018 04/01/2019 DAMSEEFREODene, 5 100,000 _ MED EXP(Any One person) 3 5,000 — PERSONAL&ADV INJURY I 1,000,000 GENT.AGGR ELIMITAPPI IES PER: GFNERAI AGGREGATE S 2,000,000 X POLICY L j T& I L09 PRODUCTS-COMP/OP AGO i 2,000,000 X •THER•set holder due prof operallons - B AUTOMOBILE LIABILITY i FaMaEcl DSINGLE LIMIT 1,000,000 FA acdeeml $ — ANY AUTO 6232707 04/0112018 04/01/2019 BODILY INJURY(Per rarer) i _ • AUTOS ONLY ONLY X SppTqq�ppgyWuLLEDp ,„ X AUTOS ONLY X AUTOS ONLY pBDqOPERDILY NYU MAGE RY(Per accident) i Leer scoldenI $ C" UMBRELLA use X OCCUR • s EACH OCCURRENCE i 2,000,000 X EXCESS LIAR CLAIMSMADE EXCISES/363E003 04/01/2018 04/01/2019AGGREGATE i 2,000,000 DEC RETENTIONS D WORKERS COMPENSATION pp S AND EMPLOYERS'LIABILITY PER FRS • ANY PROPRIETORIPARTNERIEXECUTIVE WCE00431903 06/30/2018 06/30/2018 ppF�FICERqIM M6Eq EXCLUDED? NIA E L EACH ACCIDENT $ 1,000,000 1mendatory In NN) ., II yes,describe under EL.DISEASE•EA EMPLOYEES 1,000,000 DESCRIPTION OF OPERATIONS below E L,DISEASE•POLICY LIMIT $ 1,000,000 / t/ 'I DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES (ACORO 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, • CERTIFICATJE.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 w �/Ly L 7a _ ACORD 25(2018103) 01988.2018 ACnpn nnvono a Timer a u e_,... doe......, — PatThe Commonwealth of Massachusetts Department of Industrial Accidents ='i�= I Congress Street, Suite 100 Boston,MA 02114-2017 • '1ejapio. www mass.gov/dia \Yorkers' Compensation Insurance Affidavits Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. ,4nolicant Information Please Print Leeibly Name (Business/Organizndon/Indlvidual): Cape Cod Insulation Address: 18 Reardon Circle City/State/Zip: South Yarmouth,MA 02664 Phone#: 508.775-1214 Me you se employer?Check the appropriate bort — I, I am a employer wttb 4 ti Type of project(required): © employees(full and/orpart•time), 7. New construction 2.0 1 am a sole proprietoror partnership and have no employees working forme in 8. ❑ Remodeling any capacity.[No workers'comp,insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.Insurance required.]1 9. Demolition 4.0i am a homeowner and will be hiring contractors to conduct all work on my properly. I will 10 ❑ Building addition ensure that ell contractors either have workers'compensation inidranc,or are sole 11,(J Electrical repairs or additions proprietors with no employees. S,❑I am a general contactor and 1 have hired the sub•contrector$listed on the attached sheet. 12.0 Plumbing repairs or additions These sub•contnctors have employees and have workers'comp.insurances 13.❑Roof repairs CO We are corporation and leeofficers have exercised their right of exemption per MOL c. 14, ✓®Other Weatherizatlon 132,11(4,and we have no employees,(No workers'comp.Insurancerequired.] 'Any applicant that checks ball must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they ere doing all work and then hire outside contractors must submit a new affidavit indicating such. ?Contactors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractor 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.uo.#: WCE00431902 Expiration Date 06/30/2017 Job Site Address: ✓4 -45P.lt Latta-- City/State/Zip 0 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 o, 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 WORN:ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Iivestigations of the DIA for Insurance coverage verification. !do hereby certify under the pains and penalties of perjury that the information provided ab vet true and correct. Signature: Henry Cassidy s q j j phone#: 508-775-1214 Date; Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): • 1.Board ot.$ealth 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5, Plumbing Inspector 6,Other Contact Persons Phone#: ft, RISE EMCMMfLMC OWNER AUTHORIZATION FORM p; 0110..1-04. f u ese 11 (Owner's Name) owner of the property located at Rv 35€ I ! Lone (Property Address) (Property Address) ll hereby authorize _ `.00A TYl_S u (Q r o N (Subconira �1 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. els Signature Date RISE Engineering 6 Dupont Avenue South Yarmouth,MA 02884