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HomeMy WebLinkAboutBLD-19-001904 p CI'�q 10fRoe Vso Only • "'U i Amount,cr rry, ^, ��-1^, —Mel r4 °Perntll esplror l s0(Joy; hon �a Vr/ vl , Imo duo RECEIVED , I • EXPRESS BUILDING PERMIT APP • Ye ATION • ' TOWN OF YARMOUTH OCT 1 - 2018 • Yarmouth Building Department 1140 Route 28 a U i_ �iC- T South Yarmouth, MA 02664 (30- �8) 398.2231 Ext, 1261 .2-1,CONSTRVCTIONADDRESSI' t58 r t 5-rmit ip,, qtai . .IIIIIIII 11111 III"Iii1•.., VI ASSESSOR'S INFORMATIONI 1a Mapl I Pam!! owNEnl �4, ' ''Oji -is., no6L�. CONTRACTOR! Monty Ceraldy Cope Co. Inrulellon II Amon Cull? Jovth rirmouih 608,775.1214 AILINO ADDRESS TEL A 1 Resldenllel 0 Commerolel Eel. Ocelot construction S 3'21V- VS liome Improvement Conlroelo, Llo�H 1 535 67 ,�'a Coueh'upAon9upervlsnr 41118100988 Wurkmon'aCvmpeneetlorjnsuronoal (check one) 0 I em the homeowner""" " CI I am the eole proprietor p I hove Workor4 Compensation Insurance inaurano.CompenyNemel Atlantic Charter Insurance' WCE0043I9 Workcr'a Comp, polloyNi ., • WORK TO B� FERRO_ reRm__ ° '"Ten{ Duretlore (Pin Retardant Certificate attaehed9) . •Wood Stove sI°SIdIngl N otSquares I,NRoptooemen! wIndowei N Replacement doom N Roofdngl ItotSquaree ( ) Remove exlslinge (maxi 2layers). 9° lC-30 �e/3�Z �p a L ,,I� nsulall n ^• Old Kings Highway/Historic Met, ) q Pool �u� �,n/ ( )'Replacing Ilko for Ilk* av l Pol fencing Mid debrlt tvlll'bt dlrppnd or oh , , 4 SL a. /I Salo& j. i• 0 LocellonorPro Ity I daalurp under po-eallles or{Jeffry'Willa etelalneme heroin ntelned rya Irtie wW mill to Iha Carl ormy knowledge Md Collar I undarslnnd IN my rets° onrwoi' wlllb9NAM(tor danletnrrevoemlonormylloanseandfor proreoullonundrrMAL, 1, Hent Cassld »( , ,( .� CI 268,Seollonl. Applloent'asgnmmn Y Y °.t1(rff;4, „r.,•,I1 r�,.�,„,m "r�lAl, " ' l'��IIrN Dclel C/1, if Oernrrr Slfnnlun(or ellnahmeot) ��� Dolor Approval by! •n • ng .`p :rot PI P109 I Niel /Gy�� // I., — • Z Hlatorloal Dlstrletl Cl Yoe CI Noh No Floc plain Zonal 0 Yea 0 'No ,..,, Walor Rerouroe Proiaollon DIslrloll WIIhIn 100 ft orWellende; ti N. ' re Yee CI No J Yoe C! No .,, sag The Commonwealth of Massachusetts i Department oflndustriaiAccldenis l Congress Street, Suite 100 ' Boston, MA 02114-2017 • ' t.�..+' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY, Applicant Information Please Print Leeibly Name (Business/Organization/Individual): Cape Cod Insulation Address: 18 Reardon Circle City/State/Zip: South Yarmouth,MA 02664 Phone#: 508.775-1214 An you an employer?Cheek the appropriate boxi I. t em a employer ere with 9 t3 Type of project(required): © D Y employees(thll and/orparteme),' 7. 0 New construction 2.0I ant a sole proprietoror partnership and have no employees working forme In 8. Remodeling any capacity.[No worker'comp,insurance required.) 3.01 am a homeowner doing all work myself.(No workers'comp.insurance required.)t 9. Demolition , 4,01 am a homeowner and will be hiring contractor to conduct all work on my property. 1 will 10 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 ant a general contractor and I have hired the sub•eontractor listed on the attached sheet, 12.0 Plumbing repairs or additions These subcontractor have employees and have worker'comp.Insurance.! 13.Q Roof repairs 6.Q We ere a corporation and les officers have exercised their right of exemption per MOL e. 14,0 Other Weatherization 152,{1(4),and we have no employees,(No worker'comp.Insurance required.) 'Any applicant that checks box MI must also fill out the section below showing their workers'compensation policy information. 'Homeowners who submit this vitaavi!indicating they are doing all work and then hire outside eonnotors must submit a new affidavit Inducing such. :Contractors that cheek this box must attached an additional sheet showing the name of the subcontractors and 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 Self-ins.Lic.#: WCE00431902 Expiration Date• 06/30/201x1 Job Sita Address: ZZ . "' t" """e City/State/Zip: �V� "! �► 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 a, 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 WOR)C 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 IS{vestigations of the DIA for insurance coverage verification. 1 do hereby cert{fy under the pains and penalties of perjury that the information provided t/�hove s true and correct Sianature: Henry Cassidy it:M`^zq.. .. .w..,....., q/�7 /� phone#: 508-775-1214 Date: I 1 w 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 6.Other Contact Persons Phone#: • • 1 • • . • nc. Commonwealth of Meecachuaalls Division olProfession'alLicensure •Bonrd of Building Regulations and Standards Cons`yt,[Cl'Itr,r�ISU'psfVl s 0 r Kt CS.100988 ;S' 41• eAires: 11(1112019 4'J WEST YARMOGTiMl, 0;QE0, aC \'•f 1\44/58ifdo,1 Commissioner "4 CA' / e--- U ac 262/xiv nc4velieGd�i% ! jy . . ji� ,'Ito/al-.1 aOffice of Consumer Affairs and Business Regulation 10 Park Plaza • Suite 5170 Boston, Meq,%%attusetts 02116 Home Improvems.nito Ftractor Registration ,gcNIYI'.R':d:',111@TC1l,:1`9, ... I ••,'kl')•;';: /4'tl iii::, '� Type; Corporation 11 <o.lra'%,'' ,,, f Registration: 183987 Cape Cod Insulation, Inc • ,,, ll )I1,0.1\::1•• t.;j, .;' Expiration: 12/14/2015 18 Reardon Circle • ,y i 1', ; r( • So, Yarmouth, MA 02684 4 , "'' ""'t"` ;r.7 '.1r','y "1/4.....P Update Address end return oard. Mark reason for change. 1` CA 4 0 70A1.06/II ........._.__.�._._-__...,.._............,.....---..-....._..... . ........_._.........ta.Adr,!ramm..h.rune.lrra!!-GlP.mplo//mant.L.11aat.Gr.rd.. eta alone•u,weraon/U o,/eYa(addraa eeleddttu •��- Office of Consumer Alleirs &Bvelnese Regulation 'jj}ys ,11� HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only ' ., • T.y".pot Corporation before the expiration dale, If loun• ' ern tot )r i?!�;jis PxnlrMlon Office ofOonaumerAffair,and'' al •eeRegulation J • '' '!1'c,t"ti 89 12!14!2018 10 Park Plaza. • e5170 b g 'e Bolton,MA • Cape Cod Ina01lI`'.' I 0 .\'^: !:• HenryCaseldy'ri`,�\}\ • d. k it• r� . 18 Reardon Gird',,, `i' 1 extQ.r ____",:t �_ 4 i ' Undersecretary t BI • "hoot sl• atu 1.,, • CAPECOD-27 AMAHLER A`C:PR Oe CERTIFICATE OF LIABILITY INSURANCE DATE 06/05IDD/YYVY) 0 610 512 01 8 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 MACY Rogers&Gray Insurance Agency,Inc. PHONE FAX Soug (N0,No,Ext): th Dennis,MA 02680 mall ro ers ra Qom lac,Npl:(877)816.2166 INSURERISI AFFORDING COVERAGE AMC s INSURER A:West American Insurance Company 44393 INSURED ^ INSURERS Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER C;Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER o;Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E: INSURER F I 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. NOTNATHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP JOSE/ WVO., ,IMM(DOp'YYYI (MMIDD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ❑X DAMA OCCUR BKW(19)53328281 04/01/2018 04/01/2019 Mg TORENTEnnce) i 100'000 MED EXP(Any one Person) $ 5,000 PERSONAL3ADV INJURY $ 1'000'000 AGGRE,ME LIMIT AP SPER: GENERAL AGGREGATE ; 2,000,000 X POLICY jEef I LOG PRODUCTS.COMP/OP AGO ; 2,000,000 X OTHER,see holder donde of operations E B AUTOMOBILE LIABILITY COMBINEDSINGLELIMIT IF S 1,000,000 _ ANY AUTO 8232707 04/01/2018 04/01/2019 BODILY INJURY(Per person) S OWNEDTONLY X SCHEDULEDAUTOS XIpEo oN oVyNEp pBRODILY INJURY(Pr accident) $ AUTOS ONLY X AUTOS VNLV (PeOPERTYPAMAGE S C UMBRELLA LIAR X OCCUR EACH OCCURRENCE ; 2,000,000 X EXCESS LIAB CLAIMS-MAGE EXC10008835003 04/01/2018 04/01/2019 AGGREGATE E 2,000,000 '• DED RETENTIONS _ D WORKERS COMPENSATIONp _ AND EMPLOYERS'LIABILITY STATUTE FRH ANY PROPRIETO�Rq/PARTNERIEXECUTIVE YIN WCE00431903 06/30/2018 06(3012019 1,000,000 • OFFICER 1EABER EXCLUDED? L NIA E.L.EACH ACCIDENT S an sto I NN) 1,000,000 Mystdescribe under EL.DISEASE•EA EMPLOYEE f • DESCRIPTION OF OPERATIONS below EL DISEASE•POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be aaached If more pics le required) Workers Compensation Includes Officers or Proprietors. AdditIonal Insured status Is provided under the General Liability and Auto Liablllty when required by written contract or agreement with the Certificate Holder. Excess Liability Is follow form. CERTIFICATE.HQLDER 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(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. DocuSign Envelope ID:D817BD1A-BESC 4323-8913-5E3F63FA34D2 RISE ENGINEERING' OWNER AUTHORIZATION FORM I, Roger Raymond (Owner's Name) owner of the property located at: 22 Brae Burn Lane (Property Address) South Yarmouth, MA 02664 (Property Address) hereby authorize Ca r.,a -iso\ao- (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. LDoeusgn.a by: oasSure 9/13/2018 17:46 PM EDT Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RISEengineering.com