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HomeMy WebLinkAboutBLD-19-001572 • , OV~ Only 4'Y (Office Uso t 0 1Parmlta le • ' 11 . (Amount �� K•4r ,W \\ (� g-- a Par. . •4$0 days from FtEC 6an...ta—• . t ' EXPRESS BUILDING PERMIT APPL( • Tign14 2018 ' TOWN OF YARMOUTH' Yarmouth Building Department e,,,�.,. a4E" •T,. — 1146 Route 28 — South Yarmouth, MA 02664 //`"J ($08) 398.2231 Bxt. 1261 / CONSTRUCTIONADDRES51' 31° 144l,{�be td vel ` QiU'atytC ASSESSOR'S INFORMATION! /, l Map! I Parnell OWNER! karat/ C t Cg-f zvt/ i• J ` o,—I 6Z /5�7 PRESENT ADDRESS • TB —H --- — CONTRACTOR( HanryCeaaldyCopt Cod gnauletton iiRrudonCirals IevlhYermovh 508.775.1214 AILING ADDRESS Ma • i Realdenllal 0 Commercial Ell.Coal of Conetruotlon$ ?DD 0/ Home Improvement Contractoeblo,N 153567 Conth'ucilvneupervlsorLlo, N 100988 Wurkmen'tCumpenoatlon Insuranoel (roheok one) o I am the homeown ?r • CII am the sole proprietor p I have Workor'e Componoatlon Insuranoe InaareneeCompanyName! Atlantic Charter Insurance' WCE004319 Worker',Comp. PolloyN 902, WORTS TO BlC PFCR t ERM I) . " "Tent „ Duration (Fir,(Fire Retardant COrtlf1Cale attached?) . , te, 'Wood Stove Slding! NotSquarot g,,Rvplaoomeltt window,! N Replacement doors) N Rooting! N of Squaras ( ) Remove existing* (max,2 layers). 21, t/ 4 Tnapla(Ion)' r Old Ring;Highway/Historic DIA ( )'Replacing llko for like Pool fencing`—, r ' Ire ` lTdd debrli wlll'bt disposed of elm f I. • • /� rLti / .... i� Locallon of Poo Ity I Javluru underperialllar of perjury that lime etatelnenta Wahl 'omolnod co true om1 cermet to the boat of my knowledge Md belief, I undoglnnd Ow any taloa onawor(a Will boJut aewa for nnlal or revoenllou of my Ilona,rid for prole yutton under MAL.Oh.COI,Seotlon I. AppliomriSlgnolunl Herlr Cassidy • 'his; �lbi1''ISTI.c1w.r�'kr�rs --` f, Dolal ?7t'1 rg OworriPlgnnlu (oranothmeot Approval tin �� . Onto; Eullding Olfleiel for onS000) EMAIL ADDRBS, �� " DAlol rj — r- 9— • YyM Zoning Iilttolioal Dlttrlotl CI Y 0 Noalt Plovn1 Nolo onol 0 Yes u No Water Roaouroe Protection Elalrin Within 100 ft. of Wetlands; a n 0 Yes CI No J Yos C) No RISE ENGINEERING' OWNER AUTHORIZATION FORM I, Karen C Pucciarelli (Owner's Name) owner of the property located at: 36 Salt Marsh Lane (Property Address) West Yarmouth, MA 02673 (Property Address) hereby authorize (Subcontractor) 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. Owner's S natu Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com _ I 6 tr • a Commonwealth of Massachusetts `�� Division olProlesalonalllcensure •Beard of Bulldlno Reyyulallons and Standards Cons lzcl; PlSrt lall•psrvlsor • 'I • Cs•looaee ,,,5' t'U ,'141 @?..pIres; 11/11/2019 HENRY E CA,,r, d;: plr• ' O t 11 8 SHED ROW!, . t:�{J�w% t•• t�f . WEST YARMOG.7H Mpt�O;�TB V0 � / /01,Vsipl0‘ • CommlaConor `6 el"" \ r.. d . kt.,,\I 4: b Office of Consumer Affairs and Business Regulation 10 Park Plaza • Suite 6170 Boston, Mag b�usetts 021168 Home Im roveme,.: ?0.o''tractor Registration 'jIfl '.i pti,,1!✓R'R .r, a 7AIYr`iv'i' .,14(j;j',;.1:j .----"11 CAPECOD-2T AMAHLER A�oRo CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDO/YVYY) 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 pollcy(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 en endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER E2kir Rogers&Gray Insurance Agency,Inc, PHONE 434 Rte 134 lac,No,lathSouth Dennis,MA 02880 Miss, FAX No(877) 816-2156 ADOREss,mall@rogeregray,com INSURER(S)AFFORDING COVERAGE NAIC/I INSURER A:West American Insurance Company 44393 INSURED '' INSURER B Safety Indemnity insurance Company 33618 Cape Cod Insulation,Inc, INSURER c I Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURERotAtlantle Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E: INSURER F I COVERAGES CERLFICATE 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, NOTWTHSTANDINO ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT LATH 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 INSD WVD POLICY NUMBER 1MMI D/YYYYLI JMMIDD /YYYYI LIMITS A X COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE a OCCUR BKW(19)63328281 04/01/2018 04/01/2019 DAMMGSEEDERENDenre) $ 100,000 MED EXP(Any one person) I 5,006 PERSONAL&AM/INJURY $ 1,000,000 SOIL AGGR E LpIMoIT.APP S PER: 2,000,000 X POLICY ria u LOS' GENERAL AGGREGATE $ amnionsPRODUCT$•OOMPIOP AGO 3 2,000,000 X OTHER, see holder deecdp of a I B AUTOMOBILE LIABILITY COMBINED eDOINGLE LIMIT $ lEa 1,000,000 ANY AUTO 66 pp 6232707 04/01/2018 04/01/2019 BODILY INJURY(Per person) f RUO$ONLY X gEppTYqOpp?ULEEED ,,, X AI)TDe ONLY X AVTOBNIY B00PERDILY NYVAMAGE RY(Per cGldenll $ _ P�erecclden1l 1 _ c. OCCUR UMBRELLA LIAR X ' S EACH OCCURRENCE S 2,000,000 X EXCESSLIAB CLAIMS-MADE EXC10008836003 04/01/2018 04/01/2019 AGGREGATE S 2,000,000 DED RETENTIONS D WORKERS COMPENSATION p $ AND EMPLOYERS'LIABILITY STATIITF FAH• ANY PRpOPREIETgOpRp/PARTNER/EXECUTIVE WCE004318W 08/30/2016 08/30/2019 gFFICCRIMEMNH)EXCLUDED? In NIA E.L.EACHACCIDENT S 1,000,000 II yes,describe under El DISEASE•EA EMPLOYEES• 1,000,000 DESCRIPTION OF OPERATIONS below EL DISEASE'P01 ICY LIMB, 5 1,000,000 ri• DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If mon space le 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 I �, 7/a _ ACORD 25(2016/03) ®1988-2015 ACORn CnRCnaATlnm. Au rink..en...,,.,., The Commonwealth of Massachusetts [r Department ofIndustrial Accidents F =ynt= I Congress Street, Suite 100 e= = y' Boston,MA 02114-2017 "�,,,Lo9F www,mass,doov/dip \Yorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibiv Name (Business/Orgenizatdon/lndlviduaq: Cape Cod Insulation Address: 18 Reardon Circle City/State/Zip: South Yarmouth,MA„02664 phone #: 508-775-1214 An you an employer?Cluck the appropriate box, - 1,©I im$employer with 48 employees(lull and/or pa t•ttme),e 7Type of Newco project(required): d): 2,01 am a sola proprietor or permership and have no employees working forme In . 0 construction nnletlon any capacity.(No workers'comp.Insurance required,) 8. ❑ Remodeling 5.0 I ems homeowner doing 01 work myself.(No workers'comp.Insurance required)? 9. ❑ Demolition Co I am a homeowner end will be hiring contractors to conduct all work on my property. 1v411 10 Building addition ensure that 01 contractors either have workers'compensation Insurance or are sola 11.0 Electrical repairs or additions proprietors with no employees. 5,[]1 un a general contractor and I have hired the sub•oontracton listed on the attached sheet. 12. Plumbing repairs or additions These sukontrectorshave employees and have workers'comp.tnrumnee.? 13. Roof repairs 6.0 We areaooryoradon end its officers have exercised their rightofexempdon per MOL o, 14, ✓�Other Weatherization 152,11(4),and we have no employees, [No workers'comp,insurance required.) 'Any applicant that checks box ill must ei so fill out the notion below showing their workers'compensation policy Information. t Homeowners vino submit this afildevit indicating they are doing all work and then hire outside contnotors must submit a new affidavit Indtoettng such 1Conraotors that:Mack this box must attached an additional sheet showing the name of the sub•oontractors and nate whether or not those entities have employees. It 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 sire Wormation. insurance Company Name: Atlantic Charter Policy ii or Self ins.Lio,H: WC,E004319022 Expiration Dater 06/301201'l 36 Job Site Address: ?J 1711444- (4 cQ.i City/State/Zip: t-l/ 61/ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MOL 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 WO 4c'ORDER and a fine of up to 5250,00 a day against the violator.A copy of this statement may be forwarded to the Office of Irivestigations of the DIA for insurance coverage verification, Ido hereby certify under the pains and penalties of perjury that the information provided abPpve is true and correct Signature; Henry Cassidy /I0 phone 44: 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 of:.Ilealth 2,Building Department 3.CitytTown Clerk 4. Electrical Inspector Si Plumbing Inspector 6.Other Contact Persons Phone#: