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HomeMy WebLinkAboutBLD-19-001907 • CI: A \ • IOffloeWaOnly • N pt O Porrltf,') Amount 3S — ,� i 1Permltexptrae IBOdaye hon gc b-IG -b014a� I,1J711ad�rb • EXPRESS BUILDING PERMIT APPLICA . v -• $ ''' TOWN OF YARMOUTH OCT 1 - 2018 Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 B"c "1v'!��' (308) 398.2231 Bxt, 1261 CONSTRVOTIONADDRL551' �9 P�iV2G[rt/ -/'(IUt'/ � Il ASSB$$OR'$INPORMATIONI Mapl I Parcell OWNBRI T'L& OW y J PAe$BNT AODRBS$ Te off- 8 -z3o z CONTRACTORI Henry CeeeldyCep OHInevietlon leAuction Circle Inch Vermouth 508.776. 1214 • . a, • :.._ R Realdentlal 0 Commercial Bet colt of Contruotlon $ 5 00, n Home Improvement Conlrnotokldlot H 153567 Cohsh'vcticn 5uparylaor Llo, H 10988 Workmanly Cumpenaatlon tnsuranoel (roheok ono) 0 I am the homeowner^^ ^ Cl I am the sole proprietor 0 I havo Workor'a Componaetlon fnauranoe IneuranocCompanyNamel Atlantic Charter Insurance' WC3004319 Worker's Comp, FolloyH did WORK TO mo PICR1 __/, n "Ten! Duration • (Biro Ra{ardan{ Certifloata Attach ed7) . 'Wood Stove N;Sidingl HofSquaros t,,,Roplaoamont wlndowal N„_.� Repiaoemont doom H Root7ngl IIot5quarea__ ( ) Ramon exleAuga (MAXI 2layera),fZ II ulellon h' Old Ringo Highwny(Nlstoplo Dlst, '•fL $ �� 5� Gjt�' �,��- ( )'Replacing ilko for Ilko Pool lancing rT�fdebrlitrlll'bediepeaedofou • U I 92- c /v/z4 9efL I. Locallolf Pro Icy •••• altit /l1 AMP,iffy c(J/L I daclury undir poratlln of perpuly that Ilia etatelnollte heroin •ontolned We true tuW correct to the boil of my knowladeo Ind boltof. I undontnnd that any fats' ontwor, All beJun enu,fort/inlet or revocation of my lloenec and for prwwullon under MALI Ch 26i $eollou I, Applloen'edlenomrel Henry CaSSICIy f!lt,°il !:YiPatyrr : l,rd o�unto man,'I%n z1 t Dalai It Orvuoly Slannture(or allnehmeot) a Approved By' rr Dntol :u • hp •'e!�a r era co i• . ,4,;, , I Dalai O — — .. IW WA .W • Zag Hlatorloal Dlatrlotl CI Yoai',D17NocllFloo plain Zonol 0 Yee 0 No Wator Roaouroo Proteolion Oloiriotl Within I 00 fL of Wetlands; a w • 0 Yes hl No i Vol CI No E., S • The Commonwealth of Massachusetts =y, t_: Department of Industrial Accidents C. =ts+n= 1 Congress Street,Suite 100 e=V= h Boston, MA 02114-2017 • www.mass•gov/dla Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITHTUE PERMITTING AUTHORITY, AM11cent Information Please Print Legibly Name(Business/OrgantzatIon/lndivtduaq: Cape Cod Insulation Address: 18 Reardon Circle • City/State/Zip; South Yarmouth,MA 02664 Phone#: 508-775-1214 Are you Alt employer?Meek the appropriate boxy t.©t am a employer with 48 employees(full and/or part-time).? Type of Newcoproject(required): d): 7. 0 construction 2.01 am a sole proprietor or partnership and have no employees working forme In 8. Remodelin any capacity.(No workers'comp.insurance required.) ❑ g 3.0 l am a homeowner doing all work myself.(No workers'comp.insurance required,)t 9. C3 Demolition , 4.0 t am a homeowner and will ha hiring contractors to conduct all work on my property, !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 I am a general contractor and I have hired the sub•contrecton listed on the attached sheet. 12.0 Plumbing repairs or additions These sub•contreetors have employees end have workers'comp,insurance,: 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MOL o. 14. ✓�Other Weatherization 152,11(4),and we have no employees,(No workers'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 affidavit indicating they are doing all work end then hire outside contractors must submit a new affidavit Minting such. :Contactors that chuck this box must attached an additional sheet showing the name of the sub-contractors end state whether or not those entities have employees, Utile sub-contractors have employees,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. G tic.#: WCE00431902 Expiration Date 06/3300/20111 _ Job Site Address:M -eValr _ City/State/Zip:V/` 1?tv-W1 kit Attach a copy of the'workers' coyitpensatIon policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MOL c. 152, §25A is a criminal violation-punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WOR$:ORDER and a fine of up to$250.00 a day against the violator,A copy of this statement may be forwarded to the Office of huvestigations of the DIA for insurance coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided bove Is true and correct (:mature: Henry Cassidy :wM "r•• •..••• •• .••._,« 2/ Date: 9' 7 1, phone#: 508-775-1214 Official use only, Do not write In this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Realth 2.Building Department 3. Clty/Town Clerk 4. Electrical Inspector 5, Plumbing Inspector 6,Other Contact Person: Phone#: • 1 U t. • nt. Commonwealth ol Massachusetls OIvlslon ol Proleaslonal licensure •Board of Building Rag ulallons and Standards Con s`V;CPt�riIt11'rsrvls or >y • es.100966 ,; ' h� itiril B,pIrest 1111112019 . %LD! t 1 . • HENRY ECAp�SIDY;„'4I�� lt$'' o 8SHED ROW"• : Y ti'i' ,• if t�f . WEST YARMOGTkI MA.'.0+ 0 , C � • Commissioner : V'w • tov: p Office of Consumer Affairs and Business Regulation 10 Park Plaza • Suite 5170 Boston, Mas t•It usetts 02118 Home Improvemet;t•Rao''traotor Registration -^ '1`1•'.•,;1:.>; l TYpel Corporation "tr'. ;';""'.. i / ?;;;.;;;t •Y 1' Re IStrallon; 163687 Cape Cod Insulation, Inc I::'6;' ,. •ft,,,,'(.,.;'':•:� IW ExplratIonl 12/14/2015 18 Reardon Circle .,: , grlic • So, Yarmouth, MA 02664 ''` • ..1 1 � •t I[f •• 1••'••) Update Address end return card, Mark reason or change. 1iCA4 Cr 20M 06,11 \ _._.._._Cfotkrn.,..............,......__ ............... . ..........._..., (7.,Ad ssann.f1sootvmt_I .5 ploymant.C.Jnoat.C.rnd 4U/l4 Ipoore•rliotttuvn/�v/CSL�`'wQ? 4tr44�(4 ONleo of Consumer Moire&evilness Ropteellon 1 ( y•„ •• HOME IMPROVEMENT CONTRACTOR RaglclrsUonvelltllorintllvldueluseonly ° �• T',:p'ei Corporal on balore the expiration dale. it foun• urn' lot " Of floe of Consumer Allaire and': al es Regulation ,`.r attmlrs exolrnlloq • . ,• � � 10 Park Plage• e 01T0 ('Itk'M .�� d4 12/14/2016 Boston MA Cape Cod Instil ii`', l 017�+1'+ r.,1 �� • HenryCassldy'iti ,t • 1'i,lf,::;:, t • 18 Reardon Circl�w ,p$ C�2 cG.G�.P—•- / /So.Yarmouth,MA•oyQuf,,.,SM. i1 ,, _ A�iT. , Undersecretary t aJ shout SI. atu': • • 1,I. • /-"N CAPECOD-27 AMAHLER A`�O- CERTIFICATE OF LIABILITY INSURANCE DATE(MM/OD/YYYY) 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 en ADDITIONAL INSURED,the policy(los)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 Beni Rogers4 134rey Insurance Agency,Inc. PHONE I Sac,No(;(877)816.2156 A/C, Fel(; South Dennis,MA 02680 kg:*sy.mall@rogersgray.com INSURERISI AFFORDING COVERAGE NAM 0 INSURER A;West American Insurance Company 44393 INSURED -` INSURER 9!Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER c;Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURERD:Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER!: INSURER Ft COVERAGES CERTIFIVATE-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 TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP INRo WVD POLICY NUMBER IMMIOD/YYYYI IMM/DD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,006 CLAIMS-MADE Ej OCCUR BKW(19)63328281 04101/2018 04/01/2019 pREMIISES(aoccyrroencel $ 100,000- — MED EXP(Any one Demon) I 5,000 — PERSONAL&ADV INJURY $ 1,000,006 GEN%AGGREGELE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,006 XxPOLICY Li gef I I Loo. PRODUCTS•COMP/OP AGO $ 2,000,005 OTHER:see holder dacrlp of operations s B Es AUTOMOBILE LIABILITY COMaBIEeDUSINGLE LIMIT $ 1,000,000 _ ANY AUTO _ 6232707 04/01/2018 04/01/2019 BODILY INJURY(Pr person) S AUTOS ONLY X ACTprULED — 11 BODILY INJURY(Per occident) jXALS ONLY xAppOoo NEE? pailedTentppAMAGE 5 $ C•_ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 X EXCESSLIAB CLAIMS-MADE EXC10006635003 04/01/2018 04/01/2019 AGGREGATE $ 2,000,000 •• DED RETENTIONS D WORKERS COMPENSATION oo $ AND EMPLOYERS'LIABILITY �yam,Lt{L PER AND -R ANY• ApN� PROPREIIETgO�Rq/PARTNER/EXECUTIVE UWCE00431903 06/30/2018 08/30/2019 E.L.EACH ACCIDENT s 1,000,000 farm=eER EXCLUDED? LJ NIA 1,000,000 If yesdescribe under E.L.DISEASE•EA EMPLOYEE 5 • DESCRIPTION OF OPERATIONS arrow - E.L.DISEA$E•POLICY LIMIT $ 1,000,000 / DESCRIPTION OF OPERATIONSI LOCATIONS(VEHICLES (ACORD 101,Additions)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 LlabIlity 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) ®1988.2016 ACORD CORPORATION, All rlahts reserved. DocuSigci Envelope ID:8D849E5E-670C-44F5•ACOE-9EFBABE50753 RISE14#g ENGINEERING' OWNER AUTHORIZATION FORM I, Diane Perry , (Owner's Name) owner of the property located at: 88 Evergreen Street (Property Address) Bass River, MA 02664 (Property Address) hereby authorizeCo-Q.2 Ca'�� ©J- .2-c\sa1 , (Subcontract rr) 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 Lousip,ra by: VIoe- P owrie ietelgnature 9/19/2018 I 6:58 AM EDT Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com