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HomeMy WebLinkAboutBLD-19-2403 OiY'lR 'Office Use Only �+: . `t0 1Permit# s O �atf ! H ]Amount S 35 1'(n1 t• ,uri n a 4 - 35)a`".»n." rr0 t Permit expires 180 days from a issue date eth-1'cr — QOc) /O 3 EXPRESS BUILDING PERMIT APPLICATII[O - C E I V E U TOWN OF YARMOUTH • Yarmouth Building Department OCT 22 2018 1146 Route 28 South Yarmouth,MA 02664 BUILDING DEPARTMENT �/�j �L(508)) 398-22311Ext.i1261 'n' ,a�Y, �--- CONSTRUCTIONADDRESS: !/!(A1 Y 'tatiiYI�.., u(.vl- W ' 1(4Vilt'LL `41 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: SSA" N1�1P� 1V en- 6D4 .79i9 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Henry Cassidy Cape Cod Insulation IS Reardon Circle South Yarmouth 508-775-1214 NAME MAILING ADDRESS TEL.# R Residential 0 Commercial Est.Cost of Construction$ I f OOD ' D"D Home Improvement Contractoy Lie.N 153567 Construction Supervisor Lir.Of 100988 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I ant the sole proprietor $1 I have Worker's Compensation Insurance InsuranceCornpanyName: Atlantic Charter Insurance Worker's Comp.Policy#WCE00431902-. WORK TO BE PERFORMED ' Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares .. Replacement windows:# Replacement oars: # !t a fie?2, Vas; h —7 40,121n4 II Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing —to //// VxI /,/1A, IIT (OH X-ZZ ZZh dfUttl lG . 'The debris will be disposed of at: AV YVl�(t ye?, d1MM.n T Location of Facility I- 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.O.L.Ch.268,Section I. Hen Cassidy =rat, p 2 �18 Applicant's Signature: : Date: Owners Slgnatu (or attachment / Date: / G /� Approved By: 6>-li C ... Date: /0 t J —/ Buil ' 0 i (or designee) EDDRESS: Zoning District: Historical District: 0 Yes ;.7 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: t. 0 Yes Ci No 3 Yes 0 No RISE ENGINEERING' OWNER AUTHORIZATION FORM 1, Susan Kinnear (Owner's Name) owner of the property located at: 45 Salt Marsh Lane (Property Address) West Yarmouth, MA 02673 (Property Address) i hereby authorize Cl p. Cjj J 1/) st.I c4 ti U , \ (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. Ow r's Signature ial Jo /020781 Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com I (2 k•• c. • Commonwealth of Massachusetts ��l Division ofProlesslon'alLIcensure .Board of Building Re ulatlons and Standards Cons`�;ett> ri%brip.rvisor y/ • • CS•100988 „S' a Tres: 11(11/2019 ...MP: `r 8 SHED ROW IDY. :::,Pf �!j% f . s' i f WEST MA, >55' \ , • • 41Clis ih1011 . »:rn5ta • Commissioner 'f• C4?—"-- C. • e 5225204noQuoecdS of Z ;:arif �aa r Office of Consumer Affairs and Business Regulation 10 Park Plaza • Suite 5170 Boston, Mag asbiusetts 02118 Home Improveme.:tt .oNractor Registration :'•'�{'y'l,'j:fid 1;":.�.•.�..�.�. R;1:,:.:: 11:- Type: Corporation J:',;, ' .'•r:ter::: ��'•r; `}.....g`tJ �;.:;.. •); 0 Registration: 153587 9 Cape Cod Insulation, Inc �.� ::,.;; ;:1..)t•,I•�.•::::•; ,y Expiration: 12/14/2018 18 Reardon Circle ,? "; {. `" • So, Yarmouth, MA 02664 • ;) ;�, / eq-,..5.•;4 .... l • • • '�••.•'�" Update Addrosa and return card, Mark reason for change. ;' \ ICA5 Cr COM 05/11 _p_-n� (�...�.... ,.....__ ,_.._..._._...... . .... ........_:......_M..AcidecIC. 1•.R•thou;a:_fap pbylleont•r11as1.Card. Il//so tpontrlswarwfFlek o,/Q readrt 4u4eM C:\ Office of Conrumer Ntelre&eudnese Regulation r,1�3„'Stti ,m • HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only ° L; . 1•91:001 Corporation before the expiration date, It loun• • urn tot ' ;,-,��<;p6iilstraton I Office of Consumer Altair,and = el ;as Regulation 1 r '1'ktii ketol' 12/14/2018 • 10 BPark oston, aza• e 61T0 r . ', ,,it;V,••,'r;l. Boston,MA Cake Cod InVIatt W�1Olt !;\• /// HenryC8581d t:• , .Y 18 Reardon Clrct9' %iii; " �.tc-C. •— • 1Js__ So.Yarmouth,MA;,Q'`b j'../e: �i( "'t' Undersecretary (yt 91 • hout sl•/Afar. tk • e CAPECOD-27 AMAHLEfi A`CORLY„� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIOO YW) 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(1). PRODUCER JarACT Rogers&Gray Insurance Agency, Inc. PHONE 434 Rte 134 (NC,No,EMI: X (A/C ,NP):(877) 816.2156 South Dennis,MA 02680 Min INSURER'S)AFFORDING COVERAGE NAIC e INSURER A;West American Insurance Company 44393 INSURED INSURERS 1Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER c;Endurance American Specialty Insurance Company 4171$ 18 Reardon Circle INSURER13:Atlantic Charter Insurance Company 44326 i South Yarmouth,MA 02664 INSURER E 1 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 CONTRACTOR 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 CF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MTP TYPE OFINSURANCE ADDL SUER POLICY EFF POLICY EXP INSD MN POLICY NUMBER IMM)DDIYYYY JMM/DD/YYYy) LIMITS A X COMMERCIAL GENERAL LIABILITY 1,000,0DO X OCCUR ACH OCCURR N E CLAIMS.MADE BKW(19)53328281 04/01/2018 04/01/2019 DAMAGETO RENTED 100,000, 14 x�An.ra3 .rem 5,000 P R •NA VIN RV 1,000,000 SOIL AGGREGATE IIMITAP 9PER: .Y-- �1 2,000,000 X POLICY j ST 2,000,000 X sill balder tlaeoperations of opmtlona -- eTHER: $- B AUTOMOBILELIAe1LRY COMBINED1,000,000 ANYAAUTO E 6232707 04/01/2018 04/01/2019raliMIM A TU OS ONLY X $CpH DUULNEEDD .., X AU OS ONLY 2—` AUTOS ONLY BOqOP RDILY ITNY'AMAGE J RV Per accident SrPecce ant C UMBRELLA LIAR X OCCUR $ 2,000,000 X EXCESS LIAR CLAIMS-MADE EXC10006635003 , 04/01/2018 04/01/2019 ran 2,000,000 +• DED RETENTIONS D WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY i PER I i pTRH. ANY PROPRIETOR/PARTNER/EXECUTIVE Y/ WCE00431803 06/30!2018 06/30/2019 RTATIRF FF 1,000,000 FFICERrtAEMO¢p EXCLUDED? NIA E.L.EACH ACCIDENT $ andatory In NH) lives,describe under E.L.DISEASE•EA EMPLOYEES 1,000,0001 DESCRIPTION OF OPERATIONS below ,DISEASE•POLICY LIMIT $ 1,000,OOOI -r 1 .. 1/ '1 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached li more spice Is required) Workers Compensation Includes Officers or Proprietors. Additional Insured status Is provided under the General Liability and Auto Llabillty when required by written con/ract or agreement with the Certificate Holder. Excess Llablllty 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 I Cf ACORD 25(2016/03) 601988.2016 Aman The Commonwealth of Massachusetts Department of Industrial Accidents r 1= ' Congress Street,Suite 100 0' Boston,MA 02114-2017 • www mass,gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/0rganizationfndividual): Cape Cod Insulation Address: 18 Reardon Circle City/State/Zip: South Yarmouth,MA 02664 Phone#: 508-775-1214 Are you so employer?Check the appropriate box: Type of project(required): 1.©I am a employer with 48 employees(full and/or parttime).* 7, 0 New construction 2.01 am a sole proprietor or partnership and have no employees working forme In 8. ❑ Remodeling any capacity.(No workers'pomp,insurance required.) 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.)* 9. ❑ Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.Q Roof repairs These subcontractors have employees and have workers'comp.insurance.* 6.0 We are a corporation and its officen have exercised their right of exemption per Mot c. I4.2 Other Weatherization 152,i 1(4),and we have no employees.[No workers'comp.Insurance required.) *Any applicant that cheeks boxes 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 end then hire outside contractors must submit a new affidavit Indicating such. *Contractors that cheek this box must attached an additional sheet showing the name of the tub-contractors and state whether or not those entities have employees. If the sub-contactors have employees,they must provide their workers'comp.policy number. lam 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.Lic.#; WCE00431902 • Expiration Dale. 06/30/2011 �Q_'n Job Site Address: tie, C%Ir v t'uL k- City/State/Zip: OP ("/aV F' "V Attach a copy of the workers' compensation policy declaration page(showing the policy number land 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 WORK'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 Ix{vestigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above isrue and correct w� 0f(3 Signature; Henry Cassidy r. �. .. ^-^'"'" ""�"" " Date: I 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 5,Plumbing Inspector 6.Other Contact Person: Phone#: 0