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HomeMy WebLinkAboutBLD-19-002402 ' I Oftice Use Only Ot'Y`9R .01 Se, I Permit* ! ) 0y 1. - H '!Amount S(O G MArrA M r 10 �waa• aV :Permit expires Igo days from `a issue date 80-19 -eig- bECEIVED EXPRESS BUILDING PERMIT APPLICATIO TOWN OF YARMOUTH I OCT 22 2018 I • Yarmouth Building Department I 1146 Route 28 I BUILDING DEPARTMENT South Yarmouth,MA 02664 (508) 398-2231 Ext./ t (1�261� CONSTRUCTION ADDRESS: Alli I. A .6ALV ; 4 a Ygf &� S. [ v ASSESSOR'S INFORMATION: II'' VppMappA: Parcel: OWNER: w JokIt /tit, ` ti3 • 37y- 5/00 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Henry Cassidy Cape Cod Insulation 18 Reardon Circle South Yarmouth 508-775-1214 NAME MAILING ADDRESS TEL 0 R Residential 0 Commercial Est.Cost of Construction$ 7706 'n Home Improvement Contractor Lic.Of 153567 Construction Supervisor Lic,# 100988 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor N I have Worker's Compensation Insurance InsuranceeompanyName: Atlantic Charter Insurance WorkersComp.Faliey#WCE00431902., WORK TO BE PERFORMED ' Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove • Siding: #of Squares Replacement windows: # Replacement doors: # /3" ie-y5 ID I')5b2 u 1c 5Q. Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation /0 Atli Py al v caustic Old Kings Highway/Historic Dist. ( �)Replacing likeforlike Pool fencing . *The debris will be disposed of at: V4'ad Y i o'lc(�,t /sh,(MQ,I� ULocation of Facility I• I declare under penalties of perJuty 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 end for prosecution under M.O.L.Ch.268,Section 1. Applicant's Signamn; Henry Cassidy w *wrtwia" "I .. ,_m. " Date: (0/ 1y Owners Signature( r attachment)/� / _ Date: Approved By: -�iA� oi ,' Date: /0 —21 'YO Build'.• affi '. orde• gnee) E • :'DRESS: Zoning District: Historical District: 0 Yes ,'I No Flood Plain Zone: 2 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: t. 0 Yes LI No J Yes 0 No RISEit ENGINEERING OWNER AUTHORIZATION FORM 1, John Pedro (Owner's Name) owner of the property located at: 87 Quartermaster Row (Property Address) South Yarmouth, MA 02664 (Property Address) hereby authorize c_ c = (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. Jo - 9- IP Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com PPM The Commonwealth of Massachusetts I ------.1 CAPECOD-27 AMAHLE A`C� CERTIFICATE OF LIABILITY INSURANCE oATeIMMIDomtiY) 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 I 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 Rogers&Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 (AIC,No,Eat): lac,No):(877)816.2156 South Dennis,MA 02680 Ab dbs5,mall@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC a 1NSQ_RERA:West American Insurance Company 44393 INSURED ' ' INSURER a:Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER C:Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER a:Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER!: I 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 I INDICATED. NOTWITHSTANDING 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. jITR TYPE OF INSURANCE ADDL NWYVVDsUB POLICY NUMBER POLICY EFF POLICY EXP IMMIDO/YYYY) IMMIDD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE O OCCUR BKW(19)53328281 04/01/2018 04/01/2019 DAMAGETORENTED 100,000. PREMISFS(Es ocrurrenre) $ MED EXP(Any one person) 5 5,0001 PERSONALS ACV INJURY $ 1,000,000, QFN'LAGGR E LIMIT APP IES PER: GENERAL AGGREGATE $ 2,000,00 X POLICY PELT LOOK X OTH.R sea holder descdp of operations •• • • .� J 2,000,000 $ I B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000j Fa errldenII $ — ANY AUTO p 6232707 04/01/2016 04/01/2019 BODILY INJURY(Per person) $ AUTOS ONLY e• AUUTTOOSWULNEEDp • x AUi05 ONLY x 'ARAM pBgODILY INJURY(Peraccident) j (PSrracopdent7 AMAGE j $ 0`. UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,000,000 X EXCESS LIAR CLAIMS-MACE EXC10006635003 _ 04/01/2018 04/01/2019 AGGREGATE $ 2,000,000 DEO RETENTIONS D WORKERS COMPENSATION $ ANO EMPLOYERS'LIABILITY F I STATUTE I I ORH ANYPROPRIETORIPARTNERIEXECUTIVE WCE00431903 06/3012018 06/30/2018 1,000,000 OFFICErAIEneER EXCLUDED? NIA •E EACH ACCIDENT $ l antla o MH�I Il yyes describe under E DISEASE•EA EMPLOYES $ 1,000,000 • DESCRIPTION OF OPERATIONS below IFIL.DISEASE•POLICY LIMIT $ 1,000,000 • // 1 DESCRIPTION OP OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional 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 cont/ ract 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 L ACORD 25(2016/03) ©1988.2013 Amnion nnoDnDAT,ner A„.r_-.---_-_ . • ' i U • l��1 J• Commonwealth of Massachusetts Division of Professional Licensure •Board of Building Regulations and SlandarUs Cons`�I:Ott>Srt1Mtlpf.rvlsor • y/ •• CS•100g88 ,f,::,' tiF ,1.11, B,pIres: 11/11/2019 HENRY E CAQ$iDY,4t td�' • O 8SHED ROW i. :`4III}�?I ' ,. C'• t WEST YARMOGTfj M✓1,0; 70 N. t'C1/n:r:to��b \ /r • A Commissioner w V'' \ _. ' • • tot, 920 (P c4veoet2i6 aft / as Office of Consumer Affairs and Business Regulation 10 Park Plaza • Suite 5170 Boston, Ma?: tabusetts 02116 Home Improveme.iC.oNractor Registration • he'll • r\+' Type: Corporation I,i ' t';is Ri'n r. .� • ` ;% :Wi ,`: ,r ,;;.:,:: ,., 1' Registration: 183987 Cape Cod insulation, Inc .f,1,,,.M:,x. '. Expiration: 12/14/2018 18 Reardon Circle ,� "i; :,; ,;:";;` ?, So, Yarmouth, MA 02664 • F "' ...\\ 1'11,14.?:•r til 4 `'•`•••••)'' Update Address end return card. Mark reason for change. \ lens p MOMS n..Ad I,sns..l' .LLsnr.rr;a:_flP�rpl:a/manE.Clloat.Cr.rd.. CVOVo�cnawaruvn��u�CJ2'�aaJra�rrdeG(J ���y• Office of Consumer Mike a evilness Regulation 1tll at HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only A tl. • t o: Corporation before the expiration date If loun• urn tel Office of Consumer Affairs end'; el ;is Regulation Aa r.ii nti Exnlrntlon 9 '� " ''Ij��l;k', 8.� 0/ 12/14/2018 10 Park Plaza• • v 8170 , o' �i1� o no„} Boston MA r • u1\.I� �' J . Cape Cod Ins01101 otl.;� . t, / • HenryCessldy'a, 1 .'" �' . / / 18 Reardon Cect§' 0 ` if ey-cCaar—•-- So,Yarmouth,MA;,,,,p,, a /� � ' Undersecretary �t el • -"'rhout sls atu 1\