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HomeMy WebLinkAboutBLD-19-001344 ,r 61,Y44 iOfce Use Only 4 4 % Permitil t '!15 OI y- 'Amount j .`^"°O s:`8"• I Permit expires 180 days from t roc I 1 _/� 3g Y t issue date llJJll�� �Y{ 1Y� RECEIVED EXPRESS BUILDING PERMIT APPLICA I s ' TOWN OF YARMOUTH SEP 04 2018 Yarmouth Building Department 1146Route 28 Buller ap. IT , oz. South Yarmouth,MA 02664 C I! �/�/r,,/�y� (508) 398-2231 Ext. 1261 61), f� CONSTRUCTION ADDRESS: E�' `^u' 5O2 Alloy, `r W2/ mac. VM(/tc 1 — ASSESSOR'S INFORMATION: Map: Parcel: / OWNER: ti41L It 6- -�I me Z1 z. lilt NAME PRESENT ADDRESS TEL. M t CONTRACTOR: Henry Cassidy Cape Cod Insulation 18 Reardon Circle South Yarmouth 508-775-1214 NAME MAILING ADDRESS TEL.H R Residential ❑Commercial Est.Cost of Construction$ '✓t°6 . fl Home Improvement Contractor Lie.# 153567 Construction Supervisor Lie.# 100988 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor ' X I have Worker's Compensation Insurance Insurance Company Name: Atlantic Charter Insurance Worker's Comp.Policy#WCE00431902 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stoves Siding: #of Squares Replacement windows:# Replacement doors: #/_` Roofing: #of Squares ( )Remove existing*(max.2 layers) .. ..._I,. Insulation X 1S-/0 itilOiCgn lf30 l+4ehi Old Kings Highway/Historic Dist. ( )Replacing like for like 2 y r-) Pool farts lo 2 111 *The debris will be disposed of at: L/u. Y14 Ott divuy b lWu" Q!/ It 1 / ' Location of Facility I I declare under penahies of perjury that the statemrnu hekinadntained are true and correct to the best of my knowledge and belief. 1 understand that any false answer(s) will be just cause for denial or revocation of my license and for prosecution under M.O.L.Ch.268,Section 1. Henry Cassia ,._a Date:I Gili f 18 Applicant's Signemrc. e—=,_=�•«m °Pr Owner Dram (ora hmeeJt)� Date: �� Approved By: 61 /� Date: �>, • Building 0' 1i- lgnee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 7 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No ❑ Yes 0 No • I C2 • • i c• Commonwealth of Massachusetts \c. Division ol Profeulonal Licensure • •Bonrd of Building Re9ulallons and Standards Con S`gCttlSrl• ltpp;rYlaor i1 • os•10098s •.,S' t✓Z>gj.11 e fres; 11!11!2019 ��•+ • • HENRYECA�SIOy,yyF\ +p ;' O 8ENEDROW�• . 'II-}�(%P' <• ( yr WEST YARMOGT,i M1A•,0�878 ,b. N / uss Commissioner - Ci"" $.e... e:46 3520111411,041/40edg 16Aticidad1/6000, kt1�, Office of Consumer Affairs and Business Regulation 10 Park Plaza • Suite 6170 Boston, Mafibbusetts 02116 Home improveme:♦r+C.otractor Registration I ; ,.k:ly,:.;: ,�i,..,.;.;;.•.,., ) Typo; ('I% };;a (ft'yi i't''e$r'?;i�' ?; 0 Registration: Corporation5307 Cape Cod Insulation, Inc Ai:i: •�f. ,t'f'?,''i' 'W Expiration: 12/14/2018 18 Reardon Circle y : t, • So. Yarmouth, MA 02684 ';��'' '.:t. ;ctv.1" , tit,•tt\7 w `••••� Update Addrose end return card, Mork reason for change. Ca <> aoht.aun (J..q�r,•ams.,C •nssatr;n:_C1"� pl:t/.mant.Llloat ard. C 1Q�09/4MO CVQItek c/CY�rrddrtCttdotA So• Odic,ol Convenor Nlatre&Busmen Regulation • rpl •• HOME IMPROVEMENT CONTRACTOR Registration veils:forindividual use only T.pel Corporation before the expiration date. If faun• • urn tot pr.°Y 011los of Consumer Affairs and'= al :es Regulation tred grit �j14201a 10 Park Plaza9 • .; �;�\(�+'.�v�4;; . ori tznalzote a 5110 , \\�\C, 't ;$ Boston,MA • Cake Cod Ine61�t �iotl. $ !:, /f Henry Cassidy aon Clrc,'Ala t , j/ R.cG. So.Yarmouth,MAC,•,p$1.}fi' C� P /',_ L. • "•,i '• Undorsecretary t al • "hout sl, atu • • to 1. • ----- 1 CAPECOD-27 AMAHLER ACORD• CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDmrri 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 en 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 suchCendorsement(s).N PRODUCER NQME•CT Rogers&Gray Insurance Agency,Inc. PHONE Pp 474 Rte 134 (NC,No,Eat): (act,No):(877)816.2156 South Dennis,MA 02660 miss;mall©rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC 3 INSURER A:West American Insurance Company 44393 INSURED INSURER e!Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER C,Endurance American Specialty Insurance Company 41716 18 Reardon Circle INSURER 0:Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER a: INSURER F 1 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. INTR TYPE OF INSURANCE WSOp POLICY NUMBER POLICY EFF POLICY EXP 30/1MIDD/YYYYI IMMIDONYWI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 3 1,000,000 CLAIMS-MADE nOCCUR BKW(19)53328281 04/01/2018 04/01/2019 pRFMIs SlFeocwre,T,0 6 100,000_ MED EXP(Any one oereon) 3 5,000 PERSONAL a ADV INJURY $ 1,000,000 GEN'L AGGRE,GALE LIMIT APp—LIEIS PER: GENERAL AGGREGATE j 2,000,000 POLICY 5.& I Io- PRODUCTS•COMP/OP AGO $ 2,000,000 X OTHER.see holder descdp of operations B 3 AUTOMOBILE LIABILITY COMBINED eBINED SINGLE LIMIT S 1,000,000 ANY AUTO _ 6232707 04/01/2018 04/0112019 BODILY INJURY person) I A TU OS ONLY X AUTOSoULED — PM OM? pBRODILY INJURY(Peraccident) S II X PM ONLY X AUTOS ONL? (Pei:rI enI,AMAGE : 3 C• UMBRELLA LIAB X OCCUR EACH OCCURRENCE 3 2,000,000 X EXCESS LIAB CLAIMS.MADE EXC10006635003 04/01/2018 04/01/2019 AGGREGATE $ 2,000,000 •• DED RETENTIONS 3 D WORKERS COMPENSATION PER FRH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WCE00431903 06130/2018 06/30/2019 1,000,000 OFFICERS,IRMBER EXCLUDED? I I NIA E L.EACH ACCIDENT 3 1 antla ory n ( 1,000,000 Ryes,delete under E.L.DISEASE•EA EMPLOYEES 1,000,000 DESCRIPTION OF QPERATIONSSeIew EL.DISEASE•POLICY LIMIT $ / DESCRIPTION OF OPERATIONS I LOCATIONS/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• 7!/J�, ACORD 25(2016/03) ®1985.2015 ACORD CORPORATION, All rlahts reserved. The Commonwealth of Massachusetts ey Department of Industrial Accidents _ !s= 1 Congress Street,Suite .100 �_�= y' Boston,MA 02114-2017 4, www.mass.gov/clta Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aoollcant 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 An you en employer?Check the appropriate boxy l I am a employer with 48 Type of project(required): employees(full end/or part time).' 7. 0 New construction 2.01 em a tole 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.)t 9• ❑DemolItlon 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 ill contractors either have workers'compensation insurance or ere sole 11.0 Electrical repairs or additions proprietors with no employees. 3,01 am a general contractor end I have hired the subcontractors listed on the attached sheet, I2.❑P1umbIng repairs or additions These sub.confraetor,have employees end have workers'comp.insurance.: 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MOL o. I4. ✓�Other Weatherizatlon 152,11(4),and we have no employees.(No workers'comp.insurance required.) 'Any applicant that checks box CI must also fill out the section below showing their workers'compensation policy information. ?Homeowners who submit this affidavit indicating they are doing an work end then hire outside contractors must submit a new affidavit indicating such. 1Contrsotors that cheek this box must attached an additional sheet showing the name of the tub•oontractore and orate whether or not those entities have employees. !Mho sub-contractors 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.Lto.#: WCE004311/9,02, / Expiration Date 06130/201�'1�, Job Site Address: 66.1 �g105 C?d'1ile{j' �ic[✓ City/State/Zip: IV ' /10/6 ��L Attach a copy of the workers' ompensation policy declaration page(showing the policy numbe and expiration date). Failure to secure coverage as required under MGL e. 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 WORA'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 hivestigations of the DIA for insurance coverage vedflcation. I do hereby certify under the pains and penalties of perjury that the information provided ove is true and correct. Signature: Henry Cassidyra µt Phone#: 508-775-1214 Date; Official use only. Do not write in this area,to be completed by city or town off ciaL City or Town: Permit/License# Issuing Authority(circle one): • 1.Board of.Health 2,Building Department 3.City/rown Clerk 4. Electrical Inspector 54 Plumbing Inspector 6.Other Contact Person: Phone#: HOME OWNER WEATHERIZATION WORK PERMIT: PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER.�� I UVIV 6¢0Vj hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation on the property located at: 90 -6C—itsS Caweuc - I wi d/ moo 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(sionawreh AtI7 Home Owner email: Date: Agent:(sfgnature) Date: Agency Approved Weatherization Company All Cape Energy Alternative Weatherization Cape Cod Insulation Cape Save Cazeault Frontier Energy Solutions Q Lohr Home Improvement Agency Signature: Y+(b1 ( t�^Date: 6 '"Act I For Natural Gas Customers: I have received the National Grid Discount Rate Application form from my auditor. Customer Initials