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EXPRESS BUILDING PERM!,,' , APPLI'C►•:r- in- .
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TOWN OF YARMOUTH VE(}
' Yarmouth Building Department
I 146 Rout,28 OCT 1 — 2018
South Yarmouth, MA 02664
(308) 398.2231 Ext, 1261 aPYu : eg °Tjnnrao _p_ r
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ASSESSOR'S INFORMATION!
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CONTRACTOnI Hinny Caaaldy Cepa Cad Insulation IB Muden PIM; savlh Ynmovlh
608 775.1214
g Residential 0 Commercial Bs!, Cog of Construotlon $ 30ot
Horne Improvement Conlrnelokb(o,it 153587 Coustl'uo(Ion3upervlsorLio, A 100988
Workmen's Cumpsmatlon,insuranoel (check one)
o I am Ihehomeowrrar" C1 I am the sole proprietor p I WI Workor's Componsatlon Insurance
insuranceCompanyNamo! Atlantic CCharter Insurance' WCE004319
Worker's Comp; FolloyN 0%_-,
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"Tent Duration (Fin Retardant CartlOeato attaohed7) .
4;Sldingl N „
orSquaros t, Roplaoement windows! N 'Wood 5tovo
Replacement doors! b
Roofing! Nct$quaras ( ) Remove existing* (max,2layers), at 1 Iallon cum
Old Rings Hlghway/Historlo Dist, ( )'Rspinoing ilko for llko ' R Ci McI,
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I davlary 111161pooalllal of porjuly(hat the seatemen!,heroin•onlolnad are True sill cone;to the Vol or my knoveled;e rod bollcr I undorsmnd that any(also onawo'
will DOM own for lanial or revocation of my Homo wad for prowullonvundar M.O,L,Oh,268,Notion L
Apalloraasgnmu,al Henry Cassidy 1'1'�Is,;t;Ii�lJ;t�e'r,4„'r;' 61 .L7
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Ownara elBnalure(or erinchmaot)
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Water Rosouroe Proteollon Dlalrlols Within 100 R, of Wetlands1 %%/4,
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RISE ��
ENGINEERING
OWNER AUTHORIZATION FORM
1, Diego Desouza
(Owner's Name)
owner of the property located at:
21 Jefferson Avenue
(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.
-�� C CLo E r fc
Owner's Signature
7- ice / a
Date
RISE Engineering,a Division of Thielsch Engineering, Inc.
5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926
www.RISEengineering.com
ta
The Commonwealth of Massachusetts
10,E=1=-49 t At Department of Industrial Accidents
A I Congress Street,Suite 100
k=
=' h Boston,MA 02114-2017
.0 www mass,gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information
Please Print Lez(bly
Name (Business/Organization/Individual): Cape Cod Insulation
Address: 18 Reardon Circle
City/State/Zip: South Yarmouth,MA 02664 Phone#: 508-775-1214
Me you an employer?Cbeck the appropriate boxy
Type of project(required):t. t am a employer with 45 employees(full
and/orpart•time).* 7. 0 New construction
2.01 em a sole proprietoror partnership and have no employees working forme in 8. ❑ Remodeling
any capacity.(No workers'comp.insurance required,)
3431 ens a homeowner doing all work myself.(No workers'comp.insurance required.)t 9. ❑Demolition
4,0lame homeowner and will be hiring contactors to conduct ell work on my property. I 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.
5.0 lam t general contractor and I have hired the sub-contactors listed on the attached sheet 12.0 Plumbing repairs or additions
These subcontractorshave employees and have workers'comp.insurance.* 13.0 Roof repairs
6.0 vie area eorporation and its officers have exercised their right of exemplon per MOL c. 14.9 other Weatherization
152,11(4),and we have no employees.(No workers'comp.insurance required.)
*Any applicant that cheeks box ill must also fill out the section below showing their workers'oompensadon policy Information.
t Homeowners who submit this affidavit indicating they ere doing all work and then hire outside conveotors must submit a new affidavit Indicating such.
;Contractors that cheek this box must attached an additional sheet showing the name of the subcontractors and state whether or not those endties have
employees, If the sub•eontrectors have employe„ ®a,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.#: WCE00431902 Expiration Date 06/30/2011 _
Job Site Address: Zj 060A) ' City/State/Zip:L • Lj�t,n
i
Attach a copy of the workers' compensation policy declaration page(showing the policy number nd 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 WORIC;'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 it(vestigations of the DIA for insurance
coverage verification.
I do hereby cert(fy under the pains and penalties of perjury that the information provided above s true and correct.
$ignature: Henry Cassidy /
Date: e 27 1
Phone#: 508-775-1214 {{{!!
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 S.Numbing Inspector
6.Other
Contact Person: Phone#:
1
.
• s• Commonwealth of Mnssachusatla
`�� Division of Professional Licensure
•Bonrd of Building Regulations and Standards
Cons tt6 ri'%irpp;ry l s o r
'1
• CS•100988 ,; ' '4.0
''�,�+Aq Epires: 11(11/2012 .
• HENRY E CAO)SIDY.;y,.1.i.pt;Pl%,r . O ( }rf
8 SHED ROW�• • ''' `1• •
`' �QI',
r
WEST YARMOd,T, MA,.0'970 ?C
a
Commissioner "t. 's"V /
4
.•
.ps e Way, 2owwweco4% ot Z
ise,3 , I
-11T-
f 1 Office of Consumer Affairs and Business Regulation
10 Park Plaza • Suite 5170
Boston, Ma .Ob usetts 02118
Home Improveme c! o 'traotor Registration
r. :'.aql-::.:: rtigr..• Tr: Type: Corporation
`P I ?i:?:CM,:lik•r :;'r x:•: 3,i r/• Registration, 163587
Cape Cod Insulation, Inc ft,4/1 t:E.;.`;;' ,y Expiration 12/14/2018
18 Reardon Circle ,,,\ !'';• , .':�r ;;, •r
•' So, Yarmouth, MA 02684 1l `;''°
`\ V`
111', ... •C�'-
�•••••�' Update Address and return card, Mark reason for chango.
/. \ ,CA4 0 eaM•06n1
�...._.1............1,_ ....1__,..,.11...1..... . .....,.11..._11.1.1...t7..Ad nays,..(1.Rsnn.it;n!_rlPxplo/mon11.L11cat.Cr.rN,
r �o Cro twromvurda Oviereaora/rrvolfu
N_. •_, Office of Consumer Metre&eul lnsas Regulation
1 ')%04.,; HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
4.
T•j�pol Corporation before the expiration dale, If foun• • urn lol
'"" 011101 of Consumer Affairs and'; al :5 Regulation
l�tYicv .
,•1 �s k Exolrnllon 10 Park Plass• • e 0170
1 rr•4�Trd�e�{
12/14/2015
Cape Cod Ine01111'' .1l o :1 `i• Hen Cassid \; IN `•18 Reardon Olro(9, j4 ' R1•cC.
Sol Yarmouth,MA,, 1:134.4' �� 1 f4• ///�
.. Undorseoretaryt 9i • °'
hout sla atu
•
•
/"' CAPECOD•27 AMAHLER
A�o/=o• CERTIFICATE OF LIABILITY INSURANCE D06/05IDDIYYYYI
06/0512016
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 suchp�endorsement(s).qrpNAME•
PRODUCER CT
Rogers&Gray Insurance Agency,Inc. PHONE FAx
d34 Rte 134 (AIC,No,Ext): I lac,N0(877)816-2156
South Dennis,MA 02660 IgAss,mail@rogersgray.com
INSURER'S)AFFORDING COVERAGE NAIC s
INSURER A:West American Insurance Company 44393
INSURED INaURERS:Safety indemnity Insurance Company 33618
Cape Cod Insulation,Inc. INSURER c;Endurance American Specialty Insurance Company 41718
18 Reardon Circle INSURER 0:Atlantic Charter Insurance Company 44326
South Yarmouth,MA 02664
INSURER E t
INSURER F 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 WTH 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 TYPE OFINSURANCa ADDL SUBR POLICY EFF POLICY EXP
LTR 'Nal/Jana POLICY NUMBER IMMIDDIYYYYI IMMIDDNYYYI LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE ElOCCUR BKW(19)63328281 04/01/2018 04/01/2019 FREMISFstpEeoi nceJ_) 100,000
MED EXP(Any one person) $ 5,000
— PERSONAL&ADV INJURY $ 1,000,000
SEM LIMIITAPPLIES`OERR•: GENFRAL AGGREGATE j 2,000,000
X POLICY PELT I I PRODUCTS•COMP/OP AGO $ 2,000,000
XOTHER;me holder dncrip of operations
$
B AUTOMOBILE LIABILITY (Ea acclaeOSINGLE LIMIT $ 1,000,000
—
ANY AUTO _ po 6232707 04/01/2018 04/01/2019 BODILY INJURY(Per person) $
AUTOS OWNED X AUTOSULED
BODILY INJURY(Per accident) $
—
X An%ONLY x21467"60WOp PotgenpMAGE $
—
s
C•_ UMBRELLA LIAB X OCCUR • EACH OCCURRENCE $ 2,000,000
X EXCESSLIAB CLAIMS-MADE EXC10006635003 04/01/2018 04/01/2019 AGGREGATE j 2,000,000
•• OED RETENTIONS
D WORKERS COMPENSATION $
AND EMPLOYERS'LIABILITY PERTIITF FR
• AANNYPROPRIIETORIPARTNERIEXECUTIVE WCE00431903 06/30/2018 06130/2019 1,000,000
(FFICERN RI NIA E.I.EACH ACCIDENT $
It9yn desctlba under EL DISEASE•EA EMPLOYEE 5
1,000,000
•• DESCRIPTION OF OPERATIONS below EL DISEASE•POLICY LIMIT $ 1,000,000
. /
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES WORD 101,Addltlonel Remarks Schedule,may be.Reched If mon open 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
ACORD 25(2016/03) 6)1988.2015 ACORD CORPORATION. All rlahts reserved.