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HomeMy WebLinkAboutBLD-19-002389 o ot'YgR )Office Use Only S..4 "O j PemsitH �7 �,�, S O 'I C ..Amount Nnr; n ,r�3 q�+»er%F 1 Permit expires ISO days from issue dote EXPRESS BUILDING PERMIT APPLICATI 1 N E C E I ?It;D TOWN OF YARMOUTH • Yarmouth Building Department OCT 22 21118 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT .1i,q I,, .1i, _ v — — CONSTRUCTION ADDRESS: J �V/ �� I(Dl I 1'i UIt�(�Lfw ASSESSOR'S INFORMATION: I Map: Parcel: OWNER: ' —77Y 0 7"D/91/S �ME [[�J ,,, PRESENT ADDRESS TEL. VI CONTRACTOR: Henry Cassidy Cape Cod Insulation 18 Reardon Circle South Yarmouth 508-775-1214 NAME MAILING ADDRESS TEL.II R Residential ❑Commercial Est.Cost of Construction$ 6%00 -0-D Home Improvement Contractor Lic.14153567 Construction Supervisor Lic.# 100988 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor g I have Worker's Compensation Insurance Insurance Company Name: Atlantic Charter Insurance Worker's Comp.PolicylI WCE0043190 , WORK TO BE PERFORMED ' Tent .. Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares , Replacement windows:# Replacement doors: #" • p 're kfribtailiii Roofing: #of Squares ( )Remove existing"(max.2 layers) fp 4/-.?8 k 1 Ins latldn Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing*woe.P R-17 � 4/ /cI/w 70% t . *The debris will be disposed of et: AV 144 014,0(1 a(u1.q l0 Mao air f/ Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Henry Cassidy grzavv'S2055.2"i~c"„--- l0 `10/1 Applicant's Signature: t Date: Owners Signature r attacbme ) Date: Approved By: V/!f/D Date: /G— 2 2 -VG' Buildi fiic' or de tgnee) E ADDRESS: Zoning District: Historical District: 0 Yes a No Flood Plain Zone: J Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No P FIBIS �_. The Commonwealth ofMassachusetts Department oflndustrialAccidents =iera� 1 Congress Street, Suite 100 1.4-- " Boston, MA 02114-2017 ` r ' www.mass,gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriclans/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY, n Applicant InffrmatioPlease Print Legibly Name (Bus!Hess/Organization/indlvidual): Cape Cod Insulation Address: 18 Reardon Circle • City/State/Zip; South Yarmouth,MA 02664 Phone#: 508-775-1214 Are you an employer?Check the appropriate boat 1. lamaemployerwlth 4e Type of project(required): © employees(full end/orpart•time),' 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working forme In any capacity.(No workers'comp.Insurance required.) g• ❑ Remodeling 5.0 lama homeowner doing all work myself,(No workers'comp.Insurance required.)t 9. ID Demolition , . 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that W contractors either have workers'compensation Insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. additions S.01 am a general contractor and I have hired the sub•contrecton listed on the attached sheet. 12.0 Plumbing repairs or additions Thesesubcontractors have employees and hive workers'comp.insurances 13.C7 Roof repairs 6.0 We area oorporadon and Its officers have exercised their right of exemption per MOL c, 14. Other W eatherization 152,110),and we have no employees,(No workers'comp.Insurance required.) 'Any applicant that chocks box WI 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 con-more must submit a new affidavit indloeting such. ;Contractors that cheok this box must attached en additional sheet showing the name of the sub.00ntrentors and state whether or not those entities have employees. If the rib-eontrecton 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 she information. Insurance Company Name: Atlantic Charter • '' Policy#or self-Ins.Lie, #: WCE00431902 t t1 ' �q Expiration Date. 06/30/2011 Job Site Address: let NO04 Main n City/State/Zip:S' awd1.COZltf _ Attach a copy of the workers' compensation policy declaration page(showing the policy num er and expiration date). Failure to secure coverage as required under MOL c, 1521 §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 WOR4c,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 Itivestigations of the DIA for insurance coverage verification, 1 do hereby certify under the pains and penalties of perjury that the Information prbvided a ve is truertand correct $itznature: Henry Cassidy E:^^ .,» �D z / phony#: 508-775-1214 Date; r/ Official use only, Do not write In this area, to be completed by city or town official. City or Town; Permlt/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#: A ..-------1 CAPECOD-27 AMAHLE R A`�R� CERTIFICATE OF LIABILITY INSURANCE DATE 06/0512018 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*. PRODUCER NQME•CT Roars&Gray insurance Agency,Inc. PHONE FAX Noh(877)816-2156 434 Rte 134 (NC,No,Est): South Dennis,MA 02660 miss,mall@rogersgray.com , • INSURERISI AFFORDING COVERAGE NAIC N INSURER A'West American Insurance Company 44393 INSURED INSURER B;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 I South Yarmouth,MA 02664 INSURER E: INSURER F: I COVERAGES CERTJFICATE 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. NOTVv1THSTANDING 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. I NTR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP INSD WVD POLICY NUMBER IMMIDDM•YYI (MMIDDIYWVI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE § 1,000,000 CLAIMS-MADE QX OCCUR BKW(19)53328281 04/01/2018 04/01/2019 OAMAGETORENTEO 100,0001 id Moa.__An. L.a r 5,000 ...an, o-xa:1.•1 Ry 1,000,000 faEN'L AGGREGATE LIMIT AijEiJ LOPEa GENFRAL AGGREGATE E 2,000,000 X POLICY upEEGCTT X OTHER',•ee holder dsacdp of operations ."•• • • $ 2,000,000 $ I B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Fa accident) $ 04/0112018 04/01/2019 BODILY INJURY Y(Pereerson) $ AUTO 6232707 AOS CHEDULLED UTONLY X BODILY INJURY(Per accident/ $• t X AU ONLY X AoryOOFppOPC DAMAGE _ C UMBRELLA LIAR 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 EE $ ANO EMPLOYERS'LIABILITY I S ATIITF I I FFRH ANY PROPRIETORIPARTNERIEXECUTIVE WGE00431903 06/30/2018 06130!2018 1,000,000 FFICER/MEMgpq EXCLUDED? NIA EL.EACH ACCIDENT $ andatory In NH) 11 9ea,describe under E DISEASE•EA EMPLOYEE, S 1,000,000 DESCRIPTION OFOpERAT:ON52dlow E.L.DISEASE•POLICY LIMIT $ 1,000,000 / • 1/ 'I DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,AddlIlonal Remark,Schedule,may be ttached If more space Is equired) 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. I 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 26(2016/03) 01988.2015 Annpn ./ • il V Commonwealth of Massachusetts Division of Professional Licensure . .Board of Building Regulations and Standards Conskr..OttliViaB'pprvisor 1. , CS-100988 S' r - 1Fj•t pires: 11/11/2019 • A� t.ta, ` lfO HENRY ECSSIDY'1,At '8 SHED ROWil) r I r, , r WEST YARMODTk1MA, 05 ta / ' N • p Commissioner i • eIE a . Office of Consumer Affairs and Business Regulation 10 Park Pima . Suite 5170 Boston,sMaggh usetts 021818 - Home Im roveme.:. MoNractor Registration 2•IF r:nt:r.NM1i,? •!% A v. f��'.IY/1'(.tLi j.J.�a:i'SG .(01:;:..: rl,.�;::•:;a., Typo, Corporation .,!9 i'':::�7: ".mans ) • C ll ?;..r.i: l''r�,'1 :' !r'ts t;• ; 0' Registration: 183887 Cape Cod Insulation, Inc „r ;;,.,:.. / 1 Expiration:i. lva �'�: i' ; P alOnl 12/14/2018 18 Reardon Circie . ; ':":�;.•� ,;,,,,; • So, Yarmouth, MA 02664 \II ''" t,,¢t;,' £, ',w;y..{a. Jl t • r • , .)t ‘11 ?firr; �� 1�4i..a Ij )lid •••) Vpdele Addroae end return card, Mark reason lot change. . ICA,I 0 tOM•0011 .. ..,...._._.._.._�� (�...�.,,.......,..��.,_..../�...__�,..,.,......... . ............_,.., n,Adr„I�.a•nm..(�.ilsne.:rrn:_f;lP_rr:pl0�/.monL.L7.1.nat.Cnr�! r CVO Ofinwi roq, l4Y c/Q' rr4 odude aN Office of Consumer Allelre IOuting.*Regulation k1 ' v ;l HOME IMPROVEMONTCONTRACTOR Ragletrolionvalid lorIndividual,Lseonly `.a t • 7lpol Corporation belore the expiration dater 1f loun• II urn 10l Qi y,}yy,p,.•,�' Exolrallo^ 011101 of 0oneumerAffairs and'; el -as Regulation 1�r„1tyl(�. d. d7 12/14/2018 10 Pork Pine•• 9 6170 • •'1 A t�1�',yt,�r`rE B01lon,MA •! Cape Cod Instil P C \i tCl to ReardonClro. Henry Cassidy �' \ ;?�� tr' cC9 • / 90.Yarmouth,MA-,0 p$ a� C �A /' :1' Vndorsecrelary /•t aJ ” '+ .// hoot sly Olin. • .,‘ .7 • RISE it ENGINEERING' OWNER AUTHORIZATION FORM I, Alex Braga (Owner's Name) owner of the property located at: 392 North Main Street (Property Address) South Yarmouth, MA 02664 (Property Address) yn�..� hereby authorize `/tPJ a. Src\c,S " 'Cx (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 jstn alid with a signed contract. Owner's Sig',bre ICI Ai/1 Date RISE Engineering,a Division of Thielsch Engineering,Inc. 5 Dupont Avenue I South Yarmouth,MA 02664 1508-568-1926 www.RISEengineering.com