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EXPRESS BUILDING PERMIT APPt.I •'• c �.►- 1 V 1_
TOWN OF YARMOUTH
• Yarmouth Building Department OCT 1 — 2018
1146 Route 28
South Yarmouth, MA 02664 Fitt n P *a
(508) 398 2231 Mit' 1261 Y r� i
CONSTRVCTIONADDRESSI' 2Z1M�6a //
ASSESSOR'S NPORMATIONI
//. . I Map: I Parooll
OWNERI -{r1Z1�4g'l�Ll, (Lott 0 _ a /�
NAME : :•r . ,o. . ��/'g / ��OI/
TE ,NrnyCeesldyCrpCodlnsuletlon IIMdanVirah evuthYarmouth
508.775. 1214CONTRACTORI
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3 Residenllel 0 Commarolal bel,Coll of Conetruotlon s 6.500•D'VJ •
Home Improvement Conlrnot¢kblo,p 153567 CoarirvellonSupervirorIdle,N 100988
Workmen'?CumpeneetlorJln$"uranoel (ohaok one)
O I int the homeownnr"n , n am the eel,proprietor D I hove Worker's Compensation ineuremo
Imams Comply Atlantic Charter Insurance' WCE004319
Worker;Comp, POW/ -
%. ..„ WORK TO 9� PICRRO`RM_mn
Ten( ° Duration (Fin Retardant CgrVlpvata Bttavhad7) .
Mood 8tovo
e'Mldingl N otSquaree t,,,Roplaoament wlndowel N
Replacement d4o rt N
Roofing! U orsquarea,l `, ( ) Ramon exlaNng+ (max,2 layers). R'�Cdrs Z�O�t eel 4�
Old Kinge Nlghway/Nlslorlo 01st, _ 15 iv
5,ll sy�Cellon pp
( )'Rapinoingllkofot Ilko 3 pool n n¢5 f(G�tIit jed`
" •.'. , • ITllddebrliwlll'MtlIrposrdoron • , a IA ula r ••. t4rp fj -tiCK—k1 a p
LoonnoncrFor It), -.,: ,; n
., . . , , S
I deolure linen plAillot of pvr,luly Ihat Ills iie II1enle horoln .ontolned an No std oorriot to the Carl or nix knowledge and bolter, I und:Islnnd that my I so onnvon
vitt bv)ust ow;tardenlel or revoonllon of my Itoense and tor proleoulton under M.0 L, t,
Henr Cassid ;;r;�; IryIAy„w CI 248,eeolion I.
Applloenlh Vgnvtnnl y Y C 1V�r�P (iiy(;,,C,..�.,,a 77 0
Olnmrs elgnnlara(or ellnahmiot) _
Approved Byl Dntol
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II • h2 QprQr o1 nee e• ;aiir.,, I Dalai ���8
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H1/111•12181 Dirlriotl CI Ylt¢
o Il Nooh Floc~Zone' 'O Yes 0 *No .»„
Wator Reeovroe Protooilon l)IJtrloll Within 100 fl. of Wetlands; %%.m.
• f1 Yee Cl No 0 Yee Cl No
HOME OWNER WEATHERIZATION WORK PERMIT:
PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER.
J7f n114 C/ed`4C hereby consent to and agree that weatherization work
may be done by the Weatherization Program of Housing Assistance Corporation on the property
located at:
C�n21 /d 4 /� /cal
r,�
i 6n
. kAttcvh-,
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.
G
Home Owner(sIgnature) 6 z ttc o
Home Owner email: Date:
Agent(signature) Date:
Agency Approved Weatherization Company
All Cape Energy Alternative Weatherization
Cape Cod Insulation Cape Save Cazeault
Frontier Energy Solutions fLohr Home Improvement �j
Agency Signature: c` G�.L .Date: 9 .1 i l4
For Natural Gas Customers:
I have received the National Grid Discount Rate Application form from my auditor.
Customer Initials
1
• 1 0. Commonwealth of Massachusetts
OlvislonofProlesslonellicensure
•Board of Building RegulatIons and standards
Con s`w:OtU,rt'IStruly!aor
'1•
CS•100935 ,:S' 11 ,Yj,3i @sires: 1111112019 .
. .'.4031
fid 4\(1i , e
HENRYECA��SIOY;
S SHED ROW i. . jr• <! t fWEST YARMOG7fJ Ml� .O,;ATO �s0 f
•
• t1llSSitd00 A: . .' r•..w •
Commissioner "1- C/'k' /
C.
i ice,
1'.taH Office of Consumer Affairs and Business Regulation
a 10 Park Plaza • Suite 6170
Boston, Mas., d'btiusetts 02116
Home Improveme .p4pa• tractor Registration
.r •Y•alnl:.:.:r
I ar.. Type: Corporation
. („i.l '!Pi.1,:''1::).,';;j;•"_•;:;c f• Registration: 183587
Cape Cod insulation, Inc G! : ;:;,:'.f) ,,• . Ex18 Reardon Circle t Ir plratlon: 12114(2018
• So, Yarmouth, MA 02684 "`: - 4. '
•
t{ 1111'w•:• ,il
•
t-l. .tP Update Address end return oard. Mark reason for change.
/ '\ ;cm 0, 2e1/41•e6111
......._._..��__(}��...._............. ..� ..... ........_...... . ........,..._,... f 1.Ad cnsa...(7.r1Fne.ir;n!-rZPmplC/man1,.C1 l nat.Csre
eh fponott taiveriepU/04tauadetooleo
,�� Office of Sommer Mein&Dullness Regulalton
,f HOME IMPROVEMENT CONTRACTOR
• �t Registration valid on date, if b l use only
�., T•y.pel Corporation before the expiration date. If faun• • urn tot
” Of floe of Consumer Moire end'; al •ea Regulation
N «Yi•¢v
I 'r :• IIS%�ll• Exairnilon 10 Park Plass• e 6170
fir. I;'s G&1 12114/20tB •
'•'' 1q I twryT.4 Boston,MA •• •
Cape Cod InsOigl .� o Ilii, /'
Henry Cassidy "JJ (:°
18 Reardon Clrc�' e `til. ,, c .cc,G1,.••
So.Yarmouth,MA8t, 6646% , /4 to
ar
:.9"` Undersecretary i�t BI• 'mahouts to
•
i---1 CAPECOD-27 AMAHLER
ACORICY CERTIFICATE OF LIABILITY INSURANCE DATE(MM/ODIYYYY)
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 suchpp endorsement(s).NTNAMEA
PRODUCER CT
Rogers&Gray Insurance Agency,Inc. PHONE
(A/C, Ed): IFA% )
S4outh Dennis,MA 02680 ADDRESS;mail@rogersgray,com INC,No):(877 816.2166
INSURER(S)AFFORDING COVERAGE NAIC a
INSURERA:West American Insurance Company 44393
INSURED ^ INSURER9:Safety Indemnity Insurance Company 33618
Cape Cod InsulatIon,Inc. INSURER 0 Endurance American Specialty Insurance Company 41718
18 Reardon Circle INSURER o:AtiantIc Charter Insurance Company 44326
South Yarmouth,MA 02664
INSURER E:
INSURER F:
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 SUBR POLICY EFF POLICY EXP
ITR TYPE OF INSURANCE INSD WVo POLICY NUMBER IMMIDD/YYWI JMMIDD/YYYYI LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE E 1,000,000
CLAIMS-MADE n OCCUR BKW(19)63328281 04/01/2018 04101/2019 DAMAGE TO R ncwrmnrp) s 100,000
MED EXP(Any one person) $ 5,000
—
PERSONAL IADV INJURY $ 1,000,000
GEN'L AGGREE LIMIT AP S PER: GENERALAGGREGATE S 2,000,000
X POLICY j LOO'
PRODUCTS COMP/OP AGO $ 2,000,000
X OTHER:see holder dncrlp or operations -
$
B AUTOMOBILE LIABILITY COMBINEDI SINGLE LIMIT $ 1,000,000
(Ea accIdenANY AUTO 6232707 04/01/2018 04101/2019 BOOILY INJURY(Per person) $
AUTOS ONLY X AUIO?ULED
Xppp pN pSWMpp PBODILY INJURYT (Per accident) $
ALTOS ONLY X AUTOS ONLV {FRQPERO@nIQAMAGE $ —
C. UMBRELLA LIAB X OCCUR 1
EACH OCCURRENCE $ 2,000,000
X EXCESS LIAB CLAIMS-MADE EXC10006635003 04/01/2018 04/01/2019AGGREGATE $
2,000,000
DED LRETENTION$
D WORKERS COMPENSATION $
AND EMPLOYERS'LIABILITY YIN PERTUTE ER •
ANY PROPRIETOR/PARTNER/EXECUTIVE WCE00431903 06/30/2018 08/30/2019 E.L.EACH ACCIDENT $
OF 1,000,000
Ragging EXCLUDED? NIA U
�r� E.L.DISEASE EA EMPLOYE 5
1,000,000
If yes describe under E
• DESCRIPTION OF QPERATIONSbelow EL.DISEASE• 1,000,000
POLICY LIMIT S
. /
DESCRIPTION OF OPERATIONS I LOCATION!I VEHICLES (ACOR0101,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.
•
CERTIFLCATEJ{OLOER 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
ACORD 25(2018103) ®1988.2015 ACORD CORPORATION. All rights reserved.
S
- The Commonwealth of Massachusetts
l _-ky�t_: Department of Industrial Accidents
C. Elm1= 0 1 Congress Street,Suite 100
=: :1L- " Boston, MA 02114-2017 •
^4..,.,,''o www.mass.gov/dla
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY,
Annlioant 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
Are you an employer?Check the appropriate boat
12 l am i employer with 48 employees(full and/or pan•time),e Type of project(required):
7. 0 New construction
2.0 I am a sole proprietoror patmership and have no employees working for me 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,)t 9. CI Demolition
CO I an ahomeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contactors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no enpioyees.
5.0 I am a general contractor and I have hired the sub•contacton listed on the attached sheet. 12.0 Plumbing repairs or additions
These subcontractors have employees and have workers'comp.insurence3 13.0 Roof repairs
6.0 We ere a corporation and Its officers have exercised their right of exemption per MOL o. 14•l!tl Other Weatherization
152,11(41 and we hive no employees,(No workers'comp.Insurance required.)
'Any applicant that checks box*i must also fill outthe section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing dl work and then hire outside contractors must submit a new affidavit indicating such.
sContrecmrs that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees, lithe sub-contactors have employees,they must provide their workers'comp.policy number.
,. 1 am an employer that 4s 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.#: WCE00431902 Expiration Date 06/30/201'i ,t
Job Site Address: 22- MAIL,1/{) City/State/Zip: Qaibit1:4�1`4
Attach a copy of the workers' compensation yolicy declaration page(showing the policy numb r and expiration date).
Failure to secure coverage as required under GL c, 1521 §25A is a criminal vlolation'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 WORWORDER 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 l{vestigations of the DIA for Insurance
coverage verification,
1 do hereby certify under the pains and penalties of perjury that the information provided Bove tt�S true and correct
$iznature: Henry Cassidy :v. ^ 1.,»-. . . ..,.. _,m 1�7 I
phone#:
508-775-1214 Date: f r/ 1
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 Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5,Plumbing Inspector 1
6.Other
Contact Person: Phone#: