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Home My WebLink AboutBLD-19-001354 • e1/41:6:1:1SPktd) • OfrloeVsoOnly jParmliH. r !:111,17211:1:11- S' — :Permit expires 180 days from r A DLO -v1CI - bb13 . EXPRESS BUILDING PERMIT APPLICATI• \ TOWN OF YARMOUTH• E C E ► '/ e u • Yarmouth Building Department 1146 Route 28 SEP 04 1018 South Yarmouth, MA 02664 F',. . G� (508) 398.2231 Ext, 1261 8�ijzo•y. .T. , CONSTRUCTIONADDRESS( c3 ttv/ti — C �� g 6a ASSESSOR'S INFORMATION; II �j I MemI Faroe': OWNER; jII Uk :cat/ /*1 i ""B PRESENT ADDRESS TEL, Z / CONTRACTOR; HonryCassidy Ceps Cod Insulation Ii RsordonCuret outhYarmouth 508.775.1214 AILING ADDRESS TEL ii p Residential 0 Commerolal Est,Cost of Construotlon$ / 01 ' rt)Home Improvement ContractopJLle.H 153567 ConstructionSuperelgorLlo,H 10088 Workmen's Compensation Insurenoe; (oheok one) 0 I am the homeowne ^ Cl I am the Jole proprietor 113 I have Workor's Compensation Insurance InsuranoeCompanyNamo; Atlantic Charter Insurance' WorkerWCE0043190rn Worker's Comp, PoiloyN 0A„ • ••.. WORK TO BE PERFORMED • '"Tent IP Duration (Fire Retardant Certificate attached?) Mood Stove as';Sldingl H otSquaros I,„Replacement wlndowstH Replacement doors; II Roofing; HotSquares ( ) Remove existing* (max,2 layers). `/ Insulation +7� .'4' Old Kings Hlghway/Historlo Dist, ( ) Replacing like for like h Pool fencing Qng tv 5t tJ fencing „ ' keu r'rT�e debrli wlll'bp disposed of on § /- ZitrK� a • s4BLa. f 4••• g./ rV. at, t• / Location or Pact lty I dcularo non mow orporjuty that that statements heroin •onteined an Ire,and OVUM to the best ormy Immo*and boiler, I undorrland Ilial eny false answor(s) will be Jun cows for denial or revocation of myIloenseandfor rosaeuttonunderM,O,L,Ch,268 S,ollon I, Applloanl',sivi lnr, He.�.. Cassidy/ p `M i,' yr( �T'r'"'tni q'I/I 0 o-1 a'i,.,+ra,a Dow V/I Owners Slimmers • aitnehhm S Doter Approved Byt _.,/ ,��i �' :u . n •- oa or '•'07" :. • • 11. 1 Data; s�Lr��/, VY4W Zoning Ish Historical Distrlotl Ci Yed U NooFlood Plain Zone; 0 Yes 0 •No w. Water Rosouro,Proteollon District: Within 100 ft, of Wetlands; A • 0 Yes CI No J Yes Cl No • l o Commonwealth of Massachusetts } Division of Professional Licensure • •Board of Building Regulations and Standards Cons<OVIS4prvisor 1 • cs•1d0988 •r ¶1 .at e Aires: 11111/2019 . • �p •..,,1'i {t /gip,.. s, . • . HENRY E CA$�SIDY. \k �,fl . C •f • 8SHED ROW c. : ' �1f. (Jr•' , "• WEST YARMOUTH MA.lqeVois •9r8 >C Commissioner "w ✓'w C. ' , so— e 52panalvcrsecdtPAi ki:ni op ' Office of Consumer Affairs and Business Regulation 10z it Park a k Pla, a • Suite 5170 Boston, Ma�St tusetts 02116 Home Improveme;.4o dractor Registration ( 1 ie a1 ir' Type: Corporation •i: :;:( IT,Vli I +�;;..,�;r a; if Registration: 153557 Cape Cod Insulation, Inc (a ::;.:;,:,. .fit ,�7:•;;.7 '012, Expiration: 12/14/2018 18 Reardon Circle .y -;:`)' £, So, Yarmouth, MA 02664 \;)' i'i!''i`; l.h �..... Update Address end return card. Mark reason for change. f' \ ICA., f) eeM•06111 .....t.J•Adr„;'a.ns••f�•n.saetrn;_I�.P�t:plc:/manL.Lllast.^.r..rd 92o 709/14110461MIS u�caRM(lt�traaflJ C. OHM of Consumer Metro&Business Regulotion i f • HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only '.a ': Spot. Corporation before the expiration dote, If loun• • urn tot Q(`( alt � I;;tj P)nlrnllon Office of Consumer Affairs and'' ai .Ca Regulation @, . r ,, , 10 Park Plata• - e8170 • :' 1Jk,11�.1��.�,8�4 12114/2018 Boston MA ' Crape Cod Insgl�t '4 otl '1\; ,, •j HenryCassldy'•,,::, '� i i/y. 18 Reardon Clrc� 1` }1k,' }; AR eCG1l—•-- So.Yarmouth,MA„401.0)r.ler • f,, /�L t•.9^' Undersecretary 't al • "hout SI, atu • • • tos • �1 CAPECOD-27 AMAHLER Ai�R� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYYI 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 NgTACT Rogers&Gray Insurance Agency,Inc. PHONE Fac,No):(877)816.2156 434 Rte 134 (NC,No,axe); South Dennis,MA 02660 ItIckIstmall@rogersgray.com INSURERISI AFFORDING COVERAGE NAIL e _ INSURERA!West American Insurance Company 44393 INSURED T^' INSURER a!Safety Indemnity Insurance Company 33618 Cape Cod InsulatIon,Inc. INSURER c I Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER°AAtlantic Charter Insurance Company 44326 South Yarmouth,MA 02684 INSURER!I INSURER F I 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. NOTVATHSTANDING 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. !NSA TYPE OP INSURANCE IHsDL SWVOIDE POLICY NUMBER POLICY EFF POLICY EXP _1p1MIDD/YYYVIJMMIO10/YWY1 LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE j 1,000,005 CLAIMS•MADE ID OCCUR BKW(19)63328281 04/01/2018 04/01/2019 OMGSEIOEoEEDaapel $ 100,000 MED EXP(Any One Perm) $ 5,000 PERSONAL a ADV INJURY j 1,000,000 LAGGREGATEPIMIIT APEL1,Si GENERA! AGGREGATE j 2,000,000 X POLICY IILLJJII CC�i UU X OTHER.lee hewn dosedp of operations PRODUCTS•COMP/OP AGO S 2,000,005 B AUTOMOBILE LIABILITY OMBINEDSINGLE LIMIT I FFeecclaeml $ 1,000,000 — ANYAUTO6232707 04/01/2018 04/01/2019 • OWNJS ONLY X p33oTNqg3ULLEppDDD BODILY INJURY(Per Denonl S in X AUTOS ONLY x AUiO50PoLY • pBpORDILY INJURY(Per sodden() S _ IPor seal entQAMAGE $ C UMBRELLALIAB X OCCUR EACH OCCURRENCE j 2,000,000 X EXCESS LIAR CLAIMS.MADE EXC10006835003 04/01/2018 04/01/2019 AGGREGATE j 2,000,000 OED RETENTIONS — D WORKERS COMPENSATION S ANO EMPLOYERS'LIABILI11 STATIITE oofl FRH ANY PROPRIETOR/PARTNER/EXECUTIVE n WCE00431903 06/30/2018 08/30/2019 OFFICE�IyinBER EXCLUDED? N/A E.L.EACH ACCIDENT S 1,000,000 (Irvee do and 1,000,000 If yes,describe under E.L.DISEASE•EA EMPLOYEE S DESCRIPTION OF OPERATIONS below E L.DISEASE•POLICY LIMIT $ 1,000,000 //// v DESCRIPTION OP OPERATIONS(LOCATIONS/VEHICLES (ACORD 101,AdditIonel Remarks Schedule,may be attached If more space IP required) Workers Compensation Includes Officers or Proprietors, Additional Insured status Is provided under the General Llabllity 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 REPRESENTATIVE7 I L ACORD 25(2016/03) 601999.2018 AClpn pow The Commonwealth of Massachusetts • %j l_47 Department of In dustrialAcciden es C. WISH- 0 I Congress Street,Suite 100 -it =;U ;i Boston, 11/L402114-2017 . '1.x.00 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/plumbers. TO BE FiLED WITH THE PERMITTING AUTHORITY. * /Applicant Information Please Print Leelbly Name(Business/OrganIzationi{ndividuaq: Cape Cod Insulation Address: 18 Reardon Circle City/State/Zip: South Yarmouth,MA 02664 Phone#: 508-775-1214 An you an employer?fleck the appropriate box: Type of project(required): Itr,l{emtemployer u4tb 48 employees end/or 7. 0 New construction 2.01 am a sole proprietor or partnership and hive no employees working forme In $. Remodeling any capacity.(No workers'comp,insurance required.) 3,01 am a homeowner doing all work myself.(No workers'comp.insurance required.)t 9. El Demolition 4.0 I am a homeowner end will be hiring contractors to conduct all work on my property. I w111 10 Building addition ensure that all contracton either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no anployees. 12.0 Plumbing repairs or additions S.0I am a general sontnetorand I have hired the sub•eontrscton listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurances 13.0 Roof repairs 6,0 We tre t corporation and Its officers have exercised their right of exemption per MOL c, 14.0Other Weatherization 152,11(4),end we have no employees,(No workers'comp.Insurance required.) 'Any epplicent that cheeks box ilI must also fill out the section below showing their workers'oompensation policy Information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside convectors must submit it new affidavit ingesting such. sContnoton that cheek 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-oontnctors 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 andJob site Information. Insurance Company Name: Atlantic Charter ' Policy#or Self-Ins.Lio.#; WCE00431902 Expiration Date• 06/30/201'1 Job Site Address: 53 (' wilt -Kt, /}City/State/Zip: I ' , / "''/ Attach a copy of the workers' compensation policy declaration page(showing the policy number ad expiration date). Failure to secure coverage as required under MGL o. 152,§25A Is a criminal violationpunishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORIt,'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 Investigations of the DIA for insurance coverage verification, I do hereby certify under the pains and penalties of perjuty that the information provided bgve is true and correct $ianature: Hen 'Cassidy a'; ;`^' • ------ ' " g iV 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.Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5,Plumbing Inspector 6.Other Contact Person: Phone#: 404494e Permit Authorization mass save Form 5a «enegY entener Site ID: 3451360 Customer: Paul Stanton I, 1301 'i-ktit h ,owner of the property located at: (Owners Name,printed) 53 Geneva Road South Yarmouth, MA 02664 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature: >? Date: X o—Zl — l& FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: For Office Use Only Rev.102015