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HomeMy WebLinkAboutBLD-19-001353 ,o7'Y R �l\0 (Oran Uso Only '�A; !Permit$ ij e,5,:"4,. Amount__ Permit expos 180 days holo B C'✓—top4701 3. 4Issue data • EXPRESS BUILDING PERMIT APPLICA so 304 I&C E I V E D TOWN OF YARMOUTH SEP 04 2018 Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 aY ettr+ps ftw-- ^,, .. (508) 398.2231 Ext, 1261 CONSTRUCTION ADDRESS!' i$ 1//.40(5 - 14 , Ai,•wri,u ASSESSOR'S INFORMATION! I Map: Parcell OWNER! ' Go og1t/ at • 770'1P 3y 1 VE ' PRESB`T DOW' TEL, q CONTRACTOR! Henry Cassidy Cope Cod!minion 10 Rs rdon ClreM1 somh Yermoulh 50$•775.1214 N. .; TEL, ' Resldenllel 0 Commercial 153567 Eat.Coat ofconatruotlonS 206 n Home Improvement Contrnvto4Lloi N 100988 Construction Suparvlsvr Lk.q Workmen's Compensation insurenoet (theok one) 0 I am the homeowner'. CI I am the solo proprietor 0 I havo Workor's Compensation Insurance Inauranev0ompenyNamo; Atiantic Charter Insurance' Worker's Comp, PolloyN WC$0043190i2 , WORK TO BE PICRFORMED • "Tent ^` Duration (Fire Retardant Certificate attached?) Wood Stora 'IN, '°;ISlding! NN ofSquaros w.Roplaovmont windows! _ Replacement doors! N Roofing! Not Squares ( ) Remove existing e (maxi 2 layers). x� tfencing an Insulation • a• Old Kings Highway/Historic Dist. {� ( ) Replacing like tel like Pool tencin e `4 4 l/3 lf! 4-0 find debris kite disposed ofotr 1 •674 04'1L A *l C t10 i, Locatioi Fls ao / ••�l Ity G (�( 1 deuiery ander penalties of por)u;y that the siatemvnls heroin ontoinod are!rue rM oorrvol to the boil or my knowledge and boiler. I undors;and that any NNiso answor s All be just oeuve for denial or revocation of m liven A I Cass Ile d for promotion under M,O,L,Ch.268,Seotlon L I i PV loam a Slgnaluret a • P'I ;6lit_;dt l �Sq 'i11i.iroTN DatelI D OwuersSlgnntury .1.Minch at) i ''/ Dnlos Approved Dr a .../ u • nY �c a ort v i. i ! Date; i I. Dle Hlstorioni District; CI ZYosngU Nocll Flood ?kin"_—,_---ono; '3 Yes 0 No Wator Rosouroe Protection District: Within 100 ft. of Wetlands: t • 0 Yes CI No 1 Yes Cl No •a ` I • u • lc Commonwealth of Massachusetts �( l�l Division of Professional Licensure .Board of Building Regulations and Standards Cons<U'CtAS,rfISt1'pi;,visor �f ' C3.10095a ,:S' 1,:Si, E: Ires: 11111/2019 14,4,01/ CAU�.�. f. ' • HENRY E CA0js4DY.lg„011.:l . t 1 8 SHED ROW�• : ', `r ' ., (• WEST YARMOGT}4 M , 0$73 >C Commissioner w l '{' C. — .. `' esk 3520/tiino4u ca4 , i 'p. ' Office of Consumer Affairs and Business Regulation 10 Park Plaza • Suite 5170tb�i Boston, Ma? usetts 02116 Home improveme:t:+C•o tractor Registration ,17:rn7..:i41:II:-..,:,:::r-r tv. ':., i>:' t`, ., )) Type: Corporation '�i: '.;;i,!'^il�'.rl rl ?,;'': � i; //' Reglstral On; 163567 Cape Cod insulation, Inc cl,. • t,,1 ( W Expiration: 12/14/2015 18 Reardon Circle ''' t • • So, Yarmouth, MA 02664 J V • • lfrj � "••• �'' Update Addroea end return card, Mark reason for changer ' '\ IP'.e 0 a0M•06111 •'•- \\ ......._.__ _0_o?A-m..w,o._/m...i.m....e....clbe...r.a.o_a_ck�a.o._en... .. .._.. . ._.-......._r... ' rrana.•D.nsa ;n,_ l° p!a.y snt.r-Aerat^ert . C Office of Consumer Moira&evilness Regulation ,I op, HOME IMPROVEMENT CONTRACTOR Reglalrelion veiltl for Individual use only °+ ., • by""pet Corporation before the expiration date, It foun• • urn tot au•g Pxnlrntion Office of Conaumar Allelrs and'= al :as Regulation ;•:;�e, ' 10 Park Plaza. = 18170 ; ,;t,�o�17'•3,h�e4 12/14/2018 Boston,'MA . ;r t4 r't� ;:, 1. Cape Cod Insdeti'- Henry Cassidy'1'4\, 1�1 o to 1, 7/ soR ardon Yarmouth, 0 Oa ' C,Q cc, 1L .a_ Ii — '10) Undersecretary yCt al . 'mahoutele atu'= • ...-----1 CAPECOD-27 AMAHLER ACERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY1 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 NneCT Rogers&Gray Insurance Agency,Inc. PHONE p 434 Rte 134 (AIC,No,EMI! I ,Nol:(877)816.2156 South Dennis,MA 02680 Mess:mall©rogeregray.com INSURERIS)AFFORDING COVERAGE NAIC e INSURER AJWest American Insurance Company 44393 INSURED •"' INSURER B,Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc, INSURER O I Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURERDIAtlantle Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E I 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. INSR ADDL SUER LTR TYPE OF INSURANCE INSR Wvo POLICY NUMBER JPMMO➢Y�I JMMODY/YEYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY 1,000,000 CLAIMS-MADE 0 BKW OCCUR 53328281EACH�OCCTpURRENCE ; (19) 04/01/2018 04/01/2019 PREMIRFS IPaoecu rDencel ; 100,000 MED EXP(Any one Perm) $ 5,000 — PERSONALSADV INJURY S 1,000,000 GEN'L AGGREyATIE LIMIT API IryS PER: 0,0 2,0000 OTHER:POLICY IJ rEL I I Le. GENERAI AGGREGATE S _ X we holder dm pf•-of eperetlone PRODUCTS•COMWOP AGG ; 2,000,000 B AUTOMOBILE LIABILITY S _ FEORMa nIl GLE LIMIT $ 1,000,000 04/0112018 04/0112019 BODILY INJURY(Per person/ $ ANY AUTO 8232707— oB ONLYXAUOULEDBODILY INJURY(Per cdene $l X AU ONLY xpo0WNpp PPUe RTenl?MAGE S C UMBRELLALIAS X OCCUR 2,000,000 X EXCESS LIAO CLAIMS•MADE EXC10006635003 04/0112018 04/01/2019 EACH OCCURRENCE $ DED I IRETENTIONi AGGREGATE s 2,000,000 D WORKERS COMPENSATION EE Op 3 • AND EMPLOYERS'LIABILITY I STATI ITE I ERS ANY PROPRIETOR/PARTNER/EXECUTIVE n WCE00431903 06/30/2018 06/30/2019 1,000 0 OFFICER4EnBER EXCLUDED? NIA E.L.EACH ACCIDENT S , 00 ( mde o NMS Il yes deacdhe under E L.DISEASE•EA EMPLOYEE 5 1,000,000 O SGIRIPTIONOF OPERATIONS below EL.DISEASE.POLICY LIMIT $ 1,000,000 1/ 'I DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101,AddIllonal Remelts Schedule,may ho attached If more apace 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. CERTIFJCATE HOLDER CAN9ELLATION 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) ©1988.201s Annan rrn RRn RA?.Incl •u.r_u. -_.._. - • PIM The Commonwealth of Massachusetts Department of industrial Accidents �= • ,c � 1 Congress Street,Suite 100 , _i4 y' Boston, MA 02114-2017 • tat www.mass.gov/dla Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY, ' Applicant Information Please Print Legibly Name(Business/Organizatiowlndivldual): Cape Cod Insulation Address: 18 Reardon Circle City/State/Zip: South Yarmouth,MA 02664 Phone#: 508-775-1214 An you an employer?Clack the appropriate bon I. 1 am a employer wltb a a Type of project(required): © employees(full andlor part-time),* 7. 0 New construction 2.01 am a sole proprietoror partnership and have no employees working forme In 8. 0 Remodeling any capacity.(No workers'comp,insurance required.) 3,0 I em a homeowner doing all work myself.(No workers'comp.Insurance required.)' 9. ❑ Demolition 4,0 I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11,0 Electrical repairs or additions proprietors with no employees. 5.01 em a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.0 Plumbing repairs or additions These subcontractors have employees and have workers'comp.insurances 13.❑Roof repairs 6.0 We area corporation and Its officers have exercised their sight of exemption per MOL e. 14, ✓�Other Weatherization 152,11(4),and we have no employees,No workers'comp.Insurance required.] *Any applicant that checks boxtll must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit Indicating they are doing all work and then hire outside torn:rea rs must submit a new affidavit Indicating such. 'Contractors that cheek this box must attached an additional sheet showing the name of the sub.00ntnotors and rate whether or not those entities have employees. If the subcontractors 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.#: W,C,E00431902 Expiration Date. p,. 066130/201 Job Site Address: r / ` (. "t' l/ R( City/State/Zip: w'I /1741tI4$ Attach a copy of the workers' compensati6n policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c, 1521§25A Is a criminal violation punishable by fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WOR,WORDBR 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. Ido hereby certify under the pains and penalties of perjury that the Information provided bo Ig is true and correct $knature: Henry Cassidy ;„-y- .W�-Y-MWnwM / ��� Phone#: 508-775-1214 Date: Official use only. Do not write In this area,to be completed by city or town ofyiclaL 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#: , row Permit Authorization mass save Form Senn\rrrar r^'.r.ly e.'<xercy Site ID: 3448146 Customer: Carmen Comite (7'j2rAl: VIrimr ,owner ofthe property located at: (owners Name,primed) 18 Lewis Bay Road West Yarmouth, MA 02673 (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: (2auii1b4 0 NI Date: '1\4)6 Jq 24 y,. g FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: (Sten— Co ck SJ °v) cY/ Z7423 Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: For Office Use Orly Rev.102015