HomeMy WebLinkAboutBLD-19-001903 •
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RECEIVED
• EXPRESS BUILDING PERMIT APPLI'C • • 1
TOWN OF YARMOUTH OCT 1 — 2018
• Yarmouth Building Department
1146 Routo 28 sur est : -_0i r
South Yarmouth, MA 02664 By: it
(508) 398.2231// `` Ext. 1261
CONSTIWCTION ADDRZSSI' /0 btltrbZ lid„„„,, ,,„,,.;,,, 11 geek
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uTe . 'HenryCeorldyCepeCodlnruletat la
508.775. 1214CONTRACTORI
Residential 0 Commercial Bel.Cost orConstruction$ 508V pro
Nome Improvement Conlraotoc0Llo.x 153567 Construction euperylsorLb. x 100988
Wurkman'a Cumpensatlonjneurenoet (roheok one)
0 I an the homeowrraren CI I am the solo proprietor 0 I have WorkorIs Compensation Insurance
InsuranasCompenyNamo, Atlantic Charter Insurance' WCE0043I9
Worker's Comp polloyN 0
, . •
WORK TO BE PER 'ORMrrn
"Tent les Duration (Piro Rvtardanl Certipoa{e attavhsd7) .
Mood Stoll'tst,
Sidingt N otequeros I,,,Roplaoament windows) x�
Replacement doors) x
Rootlngl Hof Squares ( ) Amon ozls{Ings (max. 2layers), iL`
Old Kings Nlghwayalletorlo {71st R-3o ce/(u� Insula))
a ( )'Roplaving Ilko tel llko ke
rUl� en6sitit(- y � ��
•,, ' 'T1lddebrlitrlll'btdirpovrdofali • A _ 14 I 0 � ir hla� U
I. Lemon or Fee Hy
/ ' carved(
I dvvlary undnpooalllcl or prim that lift atalalnellls heroht 'onlolned ue true ww oeteel to the hal of my knowledge rued ballot I undomnnd Ihet u,y hiss onewori
wilt buJurt cowl for tenlal or revoontlon or my Iloene I end for proreoullon under M.0.4,011.2411 Seatlon I.
Cassidy P�”'°'"t 'I^"r"F
ApVlloenl7 Slanalunl Henryy 6 k,l¢"Id�nY'G;r tl�@,14;;t
is.�i nll•n.ru Date) —I Z.
Otruory Sltnnlurl(or etlnahmeot)
Approval Byl A- Dnlal
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:II • ng • Pr or or VIII j;�a . • 61 : I Dalol �•___l0 //.
Historical bletriotl CI ZYoctg0DIoNooll Floor— dp^ lein Zonal 0 Yes 0 'No w
Walor Resource Proteellon District' Within 100 R. orWestendsf t ti
• 0 Yoa CI No J Yos CJ No
r,
In
- The Commonwealth of Massachusetts
tp _ :.1=4= i Department of Industrial Accidents
C. _:Wit_ I Congress Street,Suite 100
Boston, NM 02114-2017 •
"' •4r" '4 www.mass.gov/dla
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electrlcians/Piumbers.
TO BE FILED WITHTHE PERMITTING AUTHORITY,
Applicant Information Please Print Leeibly
Name (Business/OrganizattoWIndivfduaf): Cape Cod Insulation
Address: 18 Reardon Circle
City/State/Zip: South Yarmouth,MA 02664 Phone#: 508.775-1214
Are you an employer?Clack the appropriate box:
Tf
I. I am a employer with 48 employees(full and/orpart•time).e 7. pe New constject(required):
construction 7. ❑New construction
2.01 am a sole proprietoror partnership and have no employees working for me In 8. 0 Remodeling
any capacity,(No workers'comp,Insurance required,)
7.01 am a homeowner doing ell work myself.[No workers'comp.insurance required.)t 9. E3 Demolition
4.0 I am a homeowner and will be hiring contractors to conduct ell work on my property. I will 10 0 Building addition
ensure that all contractors either have workers'compensation Insurance or an sole 11.0 Electrical repairs or additions
proprietors with no employees,
SCI am a general oontrector and I have hired the sub•contracton listed on the attached sheet, 12.0 Plumbing repairs or additions
'nese sub-contactors have employees and have workers'comp.insurances 13.0 Roof repairs
6.0 We are a corporation and l and ha officen have exercised their right of exemption per MOL a, 14,✓Other Weatherization
152,31(4),and we have no employees.[No workers'comp.insurance required.)
',Any applicantthatchecks box 01 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 contractors must submit a new atedavltIndioating such,
tContnetors that check this box must attached an additional sheet showing the name of the sub-contractors end state whether or not those entities have
employees. If the sub-contrectors have employees,they must provide their workers'comp,policy number.
1 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 Selfins.Lie,#: WCE00431902
Expiration Date 06/30/201:1 _
Job Site Address: 10 City/State/Zip: ID a timet-ttia WP
Attach a copy of the worke s' compensation policy declaration page(showing the policy number tttd expiration date).
Failure to secure coverage as required under MOL 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 WO 'ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification,
1 do hereby certify under the pains and penalties of perjury that the information provided above//s true and correct ._
,Signature: Henry Cassidy �M"^M... ...,. ... _.. /R/Z��i,
Phone#:
508-775-1214 �- Date: "1 /1
Official use only. Do not write In this area,to be completed by city or town officlaL
City or Town: Permit/License#
Issuing Authority(circle one):
• 1.Board of Health 2.Building Department 3.City/rown Clerk 4. Electrical Inspector S, Plumbing Inspector
6.Other
Contact Person: Phone#:
1 C2
• .
•
• 1 z• Commonwealth of Massachusetts
o. Division alProlesalonallicensure
•Sonrd of Building Re9ldallona and Standards
Cons :0tMr1'I§0'nprvl6or
I1
03.100968 ,:5' „•;1E$ Iros; 11111/2019
,A 1rrC -
.�Ji '..4/j'
HENRY EOA�SIDY.:°• S yr.' ,1 i Pr i
eSHED ROW n . �•a')Sgi '1 ,, Cr I
WEST YARMOG.T/i MA.' r.\ )7'
IJ1'll5tiiplp�\, \ Jr.
Commissioner r V''- •
/a..--- '
•
s� Qrae Vo/x 2onwe&&% t a •
kailli
e��Ilas Office of Consumer Affairs and Business Regulation
a 10 Park Plaza • Suite 6170
Boston, Map,to usetts 02118
Home Improveme.,. . oy''traotor Registration
;4;l:l ;;;•,; /1, Type; Corporation
Cape Cod Insulation, Inc ' �r •VrO I:• i�',."'!r ; " Reglstratlon; 183807
11,, ,•f,r :: ; Expiration; 12/14/2018
18 Reardon Circle • .� ' .,, , , .er ' ,E
• So, Yarmouth, MA 02664 4 ` • `'
•, lt41, , , ,Tl •
y .r,:F ,,. "J
`'•."1' Update Address and return card, Mark reason Ior change,
. '\ tom 0 1041.06111
_._.. ._._ ..._..............._.•.....___ .._..,........ . ........._._•.., ._.a-Add:141•aa'e.f .n.4141.tr1-1:11thlp10./ment,.C14.024.Cr.rd .
— GM Wonfrmouuora e,/ agorae4u4oltd
C. Okks of Consumer Moire&Budnees Population
FI ci
, • HOMe IMPROVEMENT CONTRACTOR Reghlrallon valid Ior Individual use only
(t Am.• S'Ypol Corporation biter,the axplrollon data, It Ioun• • urn tot
11@4�• "" Oflloe of Consumer Metre and' al es Regulation
' yyty;tne Exolrnlloq
J "b•d�aa �0 e� 12!14!2010 10 Pork Plaza• : e 6110 ,
1� 'f•�It', bi5f Bolton,MA .
Cape Cod Ins01�1 }�i of ` ts, /j
Henry Cassidy'irx„ Y5I•J�1'`f;
18 Reardon Clrc e, ! i': 9 C�2 cc.� �-•—
So•Yarmouth,MAt,,,2)0t;N4'' r far,
Undorsecretery 141 el • —"hOut SI? atu-:
•
•
�----1 CAPECOD-27 AMAHLER
AC RO. CERTIFICATE OF LIABILITY INSURANCE DAT6IMM/DDIr8YY)
osrosrzot6
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 EJRAl cT
Rogers&Gray Insurance Agency,Inc, PHONE FA%
434 Rte
Dennis,MA 02660 igpfrss;mail@rogersgray.com
„mail@rogersgray.com lac "011877)816.2166
INSURERS)AFFORDING COVERAGE NAIL e
INSURER A:West American Insurance Company 44393
INSURED INSURERB:Safety Indemnity Insurance Company 33618
Cape Cod Insulation,Inc. INSURER c:Endurance American Specialty Insurance Company 41718
18 Reardon Circle INsuRER0:Atlantic Charter Insurance Company 44326
South Yarmouth,MA 02664
INSURER E I
INSURER F I
COVERAGE.$ 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. NOTWTHSTANDING 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 POLICY EFF POLICY EXP
ITR TYPE OF INSURANCE JNED WW1 POLICY NUMBER ,IMMIDOPM/YI IMMIDDNYYY) LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
1,000,000
CLAIMS-MADE ❑X OCCUR BKW(19)63328281 04/01/2018 04/01/2019 pRFMISEsIEeaCNrrOencel ; 100,000_
MED EXP(Any one person) $ 5,000
—
PERSONAL SADV INJURY ; 1,000,000
GEN%AGGREGALE LIIMIITA9rLIES PER: GENERAI AGGREGATE $ 2,000,000
X I POLICY I I TefII_11 LOP PRODUCTS•COMP/OP AGO $ 2,000,000
X OTHER.
is.holder dncdp of operations
$
B AUTOMOBILE LIABILITY COMBINEDISINGLE LIMIT ; 1,000,000
_ ANY AUTO 6232707 04/01/2018 04/01/2019 BODILYINJURY(Per person) $
OWN
OS ONLY X SCHEDULED
pp���� oN oSWNED BODILYRINJURYii (Per accident) ;
X ALlFa ONLY X AUTOS ONLY (Po?a<cROanIrAGE
$
$
C UMBRELLA LIAR X OCCUR EACH OCCURRENCE ; 2,000,000
X EXCESS LIAB CLAIMS-MADE EXC10006635003 04/01/2018 04/01/2019 AGGREGATE $
2,000,000
•• OED RETENTIONS S
D WORKERS COMPENSATION p pH•
AND EMPLOYERS'LIABILITY STATI ITE FR
ANY PROPRIETOR/PARTNER/EXECUTIVE vi WCE00431903 06/30/2018 06/3012018 EL EACH ACCIDENT f 1,000,000
• OFFICER IEMBER EXCLUDED? I NIA 1,000,000
1 andato n NNH))
EL DISEASE•EA EMPLOYEE $
If yyea decarlbe under
DESGIRIPTION OF OPERATIONS below EL DISEASE•POLICY LIMIT $ 1,000,000
•
/
DESCRIPTION OF OPERATIONS/LOCATIONS(VEHICLES (ACORD 101,Additional Remake 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 followform.
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 ',raa ' 7, —___
ACORD 25(2016/03) 01988.2015 ACORD CORPORATION. All rlahts reserved.
i ZIPN 460 West Main Street
Housing /4 S`il Hyannis, MA 02601-3698
Assistance I Tel: (508)771-5400 Fax(508)790-2425
Corporation TTY on all lines
Cape Cod .
Free Weatherization !
Your tenant has requested and is eligible for weatherization of your rental home
through the Weatherization program at Housing Assistance Corporation. An average
weatherization job is worth $4,500 and these services are provided at no cost to you.
The following weatherization measures are applied to the typical job: air sealing in the
attic and basement, insulation in the attic, basement and walls, weather-stripping
doors. Bath fans may be installed if necessary. We will test the efficiency of the
refrigerator. All work is professionally done by licensed and experienced contractors.
HAC will conduct a final inspection to make sure that all work is completed in
compliance with quality work standards.
Prior to the work being done you will receive a letter from HAC showing the actual
measures that will be installed and the total dollar value to the work.
To confirm your ownership of the property, we will pull the appropriate town assessor's
report. If necessary, we may ask for a copy of your tax bill or deed to prove ownership.
The work on your rental property will begin when we receive the signed copy of the
attached Agreement. •
If we do not receive the Agreement, HAC will conduct an energy audit but no
weatherization work can be done without the signed Agreement. During the energy
audit we will install energy efficient light bulbs and will test the efficiency of the
refrigerator.
If you have any questions please contact Suzanne Smith at 508-771-5400, ext. 123 or
ssmith@haconcapecod.org
LANDLORD: -JO 10-1 Cj l`-E TENANT: L4fli , O_ tf
10 "1e'"` v>� ib ✓, me Lv -u13
email: )S`Aj AkfctitAb Q WAIMML. (..0?• email: mifivskroct L•`um
• PHONE: (home) 5.1- 17)61E`• OK31 PHONE: (home) 1V\/t
(cell) N (cell) 613 2 ' 131 • at id
we
\\1\
14. The Parties acknowledge that this Agreement is under seal. It is intended by the Parties that the Tenant or any`
successor Tenant is the Intended beneficiary of the Agreement and shall have a right of enforcement.
Property Owner's Signature: . Date IC 1/ J 11.1/Phone: 5Ep31 - 61"3
Address: lb pl.(Lcyt Lin .
54.1r ..n1Oucw h1 .a2kG y
Tenant Signature te(t2L1- -h 4_ Date all Js'
Agency Approved Weatherization Company
Advanced Windows Inc I All Cape Energy / Alternative Weatherization
Cape Cod Insulation / Cape Save / Cazeault
.Frontier Energy Solutions / Lohr Home Improvement / MDH Construction, Inc
Agency Signature k4 {X.L Date 1 . 14 tig