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HomeMy WebLinkAboutBLD-19-001906 • C yOrnoe Vso OnlPermII� 'a "Perndl asplraa 180 daye hon B(})—(q-00P0b 11aauoOtte ' • EXPRESS BUILDING P'ER1YYV�'T APPL C •+�. 9 ' TOWN OF YARMOUTH Yarmouth Building Department OCT 1 - 2U18 1140 Routa 28 South Yarmouth, MA 02664 B u eir --'-r T (S08) 398.2231 Ext, 1261 CONSTRVCTIONADDRE$$i' 7 4V41 1 ' kW ,„„W„,:.„,„ 4V 4-g—> A$$$$$01L'S INFORMATION! i11, r 1 . _I Map' I Parooll I ovamt , Ulell�l V55-e/ • 1 174- 3/7Z.• PM NT AOORBSS Ittri IIarerdon01nh 4ourhY4mouth 608.775. 1214CONTRACTOR! AILING AODRHs TELN R Raldantlal 0 Commorolal Eat Coll of Conotruollon$ . 200-r8 Homo Improvement Conlraoto'oLtorH 153567 ConohuollonSuparYlunr410, A 100988 Wurkmun'4 Cumpenuatlort insurenoel (ohaok ono) o I tm lhehomeowmr'^ Cl 1 em the solo propriotor 0 I heve Workor'u Compcnuellon Insuranoo lnauranosCompanyNamol Atlantic Charter Insurance' WCE004319 Workar'a Comp, polloyNi . WOWC r0 BTS FICRRORMEp "Ton{ ° Duration (Biro Ratardan! Cdrtifioato Allah 8417) . 'WOOd Ston o\11 SIdingt N orSquaros 1,,Roplooamant windowsi ,�_ .. NRoplaoement doors! 11 Roofing! HofSous poi ( ) Ramova axiality* (maz• 2layera). .L ca _a( �°i Old ging;NI hwa (Filalorlo 01411 ( )'RoplaoingliketoDo Pool Inga ,, ' ITI�f4abrhwlll'bpdhpoadofoh • 1 • . . V FL ,,. Q .... 47272 e i0. bio y —�Ct( Locution of Prot Hy I druiuro undar prickle'of parjuly!Nitta ulatomonlu Wain ontolnod as lrt o MO 9orreo1to Iho Von of my knowlad`o rid bailor. I undcrotnnd that my rolso onewop will bo Mt awe for denial or revoontion of my tloanaa and for props'mutton'mar MA ..Oh.264,section I, APVIIaan1731tnolnnl Henry Cas5ldy ttlr;�l¢'1�'�tll"�IrlYrbaORtad q �/ YdV{ihii l6if,ha &clot / 2 t 8 Own on sltoniore(or alinchmaat) Approval Byt � �� &ntol 'll tno • - o : •%Or at t . P, e 1 !Not /Q �/�/�' Historical OMNI!! Cl ZYo ng0larNololi Flood —'ono 0 Yea 0 No X11 Wolof Itomouro, Prolaollon Dlairloh Within 100 ft, of Woltando e • 0 Yea CI No :l You C) No .4, The Commonwealth of Massachusetts _ > t_ mos-. Department of Industrial Accidents o 1 Congress Street,Suite 100 Boston, MA 02114-2017 • 4.4,; �•' www.mass.gov/dla \Yorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/plumbers. • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibiv Name(Business/Organization/Individual): Cape Cod Insulation Address: 18 Reardon Circle City/State/Zip: South Yarmouth,MA 02664 phone#: 508-775-1214 Ars you u employer?Cheek the appropriate but - f.©l am e employer with 48 employees(full and/or part•t me),e Type of project(required): 7. 0 New construction 2.0 lama sole proprietoror parolership and have no employees working forme in 8. ❑Remodeling any capacity.(No workers'pomp.insurance required,) 3.0 I em a homeowner doing all work myself,[No workers'comp.insurance required.)r 9. ❑ Demolition , 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees, 5,01 am a general eonerectorand I have hired the sub•contracton listed on the attached sheet, 12.0 Plumbing repairs or additions These subcontractors have employees end have workers'comp.insurance,/ 13.❑Roof repairs 6.0 We ere a corporation and Its officers have exercised their right ofexemption per MOL o. 14.El Other Weatherization 152,11(4),and we have no employees,{No workers'comp.Insurance required) *Any epplicentthat checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contraotors must submit a new affidavit indloadng such. /Convectors that check this box must attached art additional sheet showing the name of the eub•oontraotors and state whether or not those entitles have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. am an employer that::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: 1Lae, City/State/Zip:IP afitt e Attach a copy of the workers' cors ensation policy declaration page(showing the policy numberand expiration date). Failure to secure coverage as required under MGL 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 WOR,IcCRDER 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, I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct, Sienature: HensyCassidy Dal : /gyp Phone#: 508-775-1214 �- Date: 6l/ (I 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 Person: Phone#: 1 ( 1, • . Commonwealth of Massachusetts `�� Divisional Professionalticensure •Board of Building Regulallona and standards Con s`1,6:Ctivrl istv pe„rvlsor i/ CS.100988 ,,.:,5,' U ,x,11 Cplras: 11111/2019 , • a4 iI10,.. . HENRY E CAS IOy,:yl, ( c O g SHED ROW/, . 4t f,/,' S t • } WESTYARMOdTieMA.'A,�75 h. \ fr Commissioner . V's'.' \ . • s` eThe r/' 4ye,aJvcoef�i g kt)-3 Office of Consumer Affairs and Business Regulation 10 Park Plaza • Suite 5170 Boston, Maspietysetts 02116 Home Improveme.:lr• .o'dractor Registration S'P AJA 11'J!n I:::q V:`1 M. -. I 1I' , , r Type; Corporallon . ;%1 `./2;;;1(0,,1:"' I 'c ij /' ReglSlrallom 1835E7 Cape Cod Insulation, Inc �I,,,,hr..a. Expiration. 12/14/2018 18 Reardon Circle • ;"t ''•: '£, • So. Yarmouth, MA 02864 'I• `,I `. Ilia?. „;1, /(fit\ ,�•`v4 y N/n • n../ Update Addroas end return card, Mark reason for change, '\ ICA4 0 e0M.06/0 .. ._._.. ,_�./_) (y��..._s,N,............ .,4mm/a u/C.Y( r,./..eaJrl•C�rr4oet)..__ .._..,......... . ..........._•,...,...(�.Ad ramm..f .nsna.lr;4!_f1P�rplar/mnl.tllaal.^r.rd . — t ?/ Ipo •�• °Ales Oceanian Metre I evelneue Regulation PI 11.• ••• HOME IMPROVEMENT CONTRACTOR Reglslrslion valid for Individual use only T,ypol Corporallon before the expiration date, If foun• • urn tot • erew Office of Consumer Aflalrs and'4 al •se Regulation � ,}• ;r°,;v , Pxnlrntlon .�}\if((rl 5�ryo ay4 12(14!2018 Beaten,MA10 Park B. • x8170 ,, Cape Cod ins tl : 1, °•t t�'`; !s, ” • Henry Cassidy+;l,�,.,ieh� I4I �^ 18 Reardon Clrcq' e hws,,' , R.cc.., So.Yarmouth,MAy,4 5B �� , //'� Atte; ,9 Undersecretary At al •—shout al. atu : • • 4\ • • ,/", CAPECOD-27 AMAHLER ACORD" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNY1'Y) 06106/2018 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: It 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 NaM�ACT Rogers&Gray Insurance Agency,Inc. PHONE FAX 436 Rte 134 INC,No,Est): (pa,No):(877)816.2156 South Dennis,MA 02680 Miss,mall@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC N INSURER A:West American Insurance Company 44393 INSURED INSURER a:Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER C;Endure nee American Specialty insurance Company 41718 18 Reardon Circle 1NSURERO,Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E I 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. 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. INS0. TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP I TRINSD WVO_ POLICY NUMBER ,(MMIDD/YWYI IMMIDD/YYWI LIMIT! A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE a OCCUR BKW(19)63328281 04/01/2018 04/01/2019 CAMAG ETORe NTEDencel $ 100,000_ — MED EXP(Any one person) $ 5,000 — PERSONALSADV INJURY $ 14000'000 _QUA AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY U Ija ILII LOG' PRODUCTS AGO $ 2,000,000 X us holder{tondo of operatIons - OTMER; $ B AUTOMOBILE LIABILITY CROMBCNEacidEDISINGLE LIMIT $ 1,000,000 ANY AUTO - 6232707 04/0112018 04/01/2019 BODILYINJURY(Perperson) $AOS _ AUTOS XUODBODILY INJURY(Per accident) $X AIIVO$ONLY ppNNOppWpp BRORnMAGE $ C UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2000,000 X EXCESSLIAB CLAIMS.MADE EXC10006635003 04101/2018 04/01/2019 AGGREGATE $ 2,000,006 •• DED RETENTIONS D WORKERS COMPENSATIONNH. $ AND EMPLOYERS'LIABILITY YIN PERAUTE ANY PROPRIETOR/PARTNER/EXECUTIVE WCE00431903 06/30/2018 06/3012018 E.L.EACH ACCIDENT S 1,000,000 g FICERfEnBER EXCLUDED? U NIA 1,000,000 ( ends e I NNNN�( E.L.DISEASE•EA EMPLOYEE 5 If yes,describe under • DESCRIPTION OFOPERATIONS below EL DISEASE•POLICY LIMIT $ 14000'000 • . / DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES (ACORD 101,Additions/Remarks Schedule,may be aached If mon 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. 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 ACORD 25(2016103) ®1986.2015 ACORD CORPORATION. All rlahts reserved. DocuSigrt Envelope ID:1EF9CB5A-29A6-4C46-974A-885491 F53E55 • � Permit Authorization fr mass save Form S 'wigt rbougn MOrtvy.4t c*ncy Site ID: 3326395 Customer: Matthew Lacrosse I, Matthew Lacrosse ,owner of the property located at: (Owner's Name,primed) 7 Harding Lane West Yarmouth, MA 02673 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. DocuSIo..d by; Owner's SignatureAa(&t.w tAtreSSt. 88D708A9357c439... Date: 8/11/2018 17:30 AM EDT FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: C. ace_ Cad.- SNSLAcd(cJY1 r9— Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: For Office Use Only Rev.102015