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HomeMy WebLinkAboutBLD-19-2404 04,•',AR'er Office Use Only S$ t, % .;Permit* te-7 i - v! O '1 *H Amount 3S Te $ARA n r ,4 �,'^Mtlt" c& I Permit expires 190 days from issue date / EXPRESS BUILDING PERMIT APPLICATIO • E C E ! `✓ E D TOWN OF YARMOUTH Yarmouth Building DepartmentOCT 22 2018 1146 Route 28 , South Yarmouth,MA 02664 Bt'it ' W ; P31 T (�5�0/8/t's )) 39988-2231 Ext. 1261 __ L / U r ''t'tt• CONSTRUCTION ADDRESS: ' tt /411.t.--- L,• gal{ It ASSESSOR'S INFORMATION: � /n/Maap: Parcel: U,S OWNER: ' uu (, '\itil ar 6/745o-79/Q NAME PRESENT ADDRESS TEL. # 1 CONTRACTOR: Henry Cassidy Cape Cod Insulation 18 Reardon Circle South Yarmouth 508-775-1214 NAME MAILING ADDRESS TEL.# R Residential ❑Commercial Est.Cost of Construction$ '3 ' O Home Improvement Contractor Lic.# 153567 Construction Supervisor Lie.N 100988 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor Z I have Worker's Compensation Insurance Insurance company Name: 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 doe # IV 4,,S 1-1, /h K4.. Roofing: #of Squares ( )Remove existing*(max.2 layers) s alien /49A-il9 k i 1/ a aha y Old Kings Highway/Hlstoric Dist. ( )Replacing like for like Pool fencing / 1^^,, ,x•(1 0 Audi bit/c-22/ �C2/it,tole Ib ZZ ' )/O14 k: Sp . *The debris will be disposed of at: 0 Ad 1'N o try'-& a{au•n 1 VtDtAV 5 aw heL�t it r l Location of Fad ity 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.G.L.Ch.268,Section 1. Henry Cassidy -,..17-:.,:.."=-,..wW /0/Z6 / Applicant's Signature: Date: Owners Signatur or attachment) Date: Approved By: .— Date: /40. —2 %p Buil.' •02 of de tgnee) A EMAIL A ESS: Zoning District: Historical District: 0 Ycs ,'1 No Flood Plain Zone: 7 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: t 0 Yes LI No 3 Yes 0 No 1, V F • • l�� • i °• Commonwealth of Massachusetts Division of Prolessfon'elLicensure • •Board of Building ReQulallons and Standards Cons`U:Ctt6rtlillpprvisor i/ • ' 05.100986 ,;J' a 31 EX Ives; 11/11/2019 • . •.. �h1171'Inq f (t �uc i • HENRY ECAf�SICY.4i,l} +,b� • . ^ I 8SHED ROW:. . '?kI> r `r , I WEST YARMOGSfi Mg,';0,,B70 >� • �trl'�lS;tiiWllti�`� \s�r Commissioner 'R- C•43-L' C 9�/ 26 l(/t�170n04uoeca% of'a �iecr,o4Gi/vem,& kv?..kr• ; I , IOffice of Consumer Affairs and Business Regulation tli 10 Park Plaza • Suite 6170 Boston, Mag tabttusetts 02116 Home Improve_me.: +C.oyy''tractor Registration 7.:7iVI FF1M1W7T Ina,,.• IS;• Type: Corporation n "vi•ile N+ .. !,`�' ':.s::-1,����a ,'��" 'r��' � )• Registration: 153687 Cape Cod insulation, Inc %i:•:' ,?a,,;�:: 'W Expiration: 12/14/2018 18 Reardon Circle Irk , t, • So, Yarmouth, MA 02664 ;',; {1 ,;i, d x : /rte\p, . V) ll"i\.,.f f,V `•••'�'•� Update Addrose and return card, Mark reason for thongs. / \ ;C1J 0 aoM•OaHf • - -- —__.... __.._...__..... C.ndrl:a.a,..t .n.we;n:-rt.Entpl,.,ment..DJ-ost.Cerri 4U/Id Tom N/iOtnryof[e utddeadJaGiltdaV7J C:\ Officio(Consumer Alledril&Business Regvlelton ' i, .; • HOME IMPROVEMENT CONTRACTOR RegistratIon valid for Individual use only ,ew • 7,yp,: Corporation before the expiration date, If foun• , urn to: Office• . .N�9 ';y;<.%;•P�iilstratlep Fxnlrntlon Office of Consumer Affairs end • el =as Regulation ''�t; i!la •,8,71 12/14/2019 • 10 Park Plaza• a 5170 • ,`:\� 1`1kir;10; ;�y,. Boston,MA • Cape Cod Instil' t '1,1 0 .;;,` c I • HenryCassidy'ra, '�i "•J C �, 18 Reardon C14, ff1,�y ft; R.cc.Qt—•--. So.Yarmouth,MA*,QB ^,,t C� 1/S� �_ Undorsecreary if. el • whout $1. atu • • \` RISES ENGINEERING OWNER AUTHORIZATION FORM 1, Susan Kinnear , (Owner's Name) owner of the property located at: 41 Salt Marsh Lane , (Property Address) West Yarmouth, MA 02673 (Property Address) hereby authorize C a �. Co J Tr\ 5 V 1 a -I 1,)^ c) (Subcontrac4r) 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. li ` )(cowner's Signature 10/ 16 /20 / r )(Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com • • ----a', CAPECOD-27 AMAHLEFF A`� CERTIFICATE OF LIABILITY INSURANCE DATE I 06/05/2018 THIS CERTIFICATE 13 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 ISSUINGINSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(ies)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). i PRODUCER N2necT I Rogers 8.Gray Insurance Agency,Inc. PHONE 434 Rte 134 WC,No,Ex(); I rd,Noon) 816.2156 South Dennis,MA 02660 I'DPO ss.mail@rogersgray,com INSURERS)AFFORDING COVERAOE NAIC e wsuRERA WestAmerlcan Insurance Company 44393 INSURED INSURER B:Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER 0 I Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER D;Atlantic Charter Insurance Company 44326 I South Yarmouth,MA 02664 INSURER E; INSURER 11: COVERAGES CERTIFICATE NUMBERS 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. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT IMTH 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 OP INSURANCE ADDL SUER POLICY EFF POLI I TR WED wVD POLICY NUMBER IMWDD/Y1'YYI 1MMIDDCY EXP IYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE I; 1,000,0001 CLAIMS.MADE Ill OCCUR BKW(18)53328281 04/01/2018 04/01/2019 J.a , Si DAMAGETQ RENTED i 100,0001 MED EXP(Any one Person) $ 5,0001 PERSONAL 4ADV INJURY $ 1,000,0001 _.Q.LN'L AGGREGAATipPIMITAP S PER: GENERAL AGGREGATE $ 2,000,0001 X POLICY L- I Jej LOSS' I X •THER:•ae Folder dncdp of operations •. $ 2,000,0001 $ 13 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ; 1,000,000] (Ea _ 04/01/2018 04/01/2019 BODILY INJURY Person) $ANY AUTO 6232707 _ASOXAOULED I AUTOS BOOILY accident) $X AIDS ONLY x & % ORDAMAGE $ C.. UMBRELLA LIAR X OCCUR S EACH OCCURRENCE $ 2,000,000! X EXCESSLIAB CLAIM$.MADE EXC10006635003 , 04/01/2018 04/01/2019 AGGREGATE $ 2,000,0001 DED RETENTIONS D WORKERS COMPENSATION pi ; AND EMPLOYERS'LIABILITY - I STATI ITE I I FRH ANY PROPRIETOR/PARTNER/EXECUTIVE WCE00431903 06/30/2018 06/30/2019 1,000,000 pFFICERrtA�MBER EXCLUDED? NIA 1I NN��andatary n NNNI E.L.EACH ACCIDENT $ Ir qes describe antler E.L DISEASE•EAEMPLOYEE S 1,000,0001 DESCRIPTION OE OPERATIDNS below ,, _E_L,DISEASE•POLICY LIMIT $ 1,000,000 ,. // y DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It 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 Liability Is follow form. OERTIFICATEE LD_ER 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 7 ' — ACORD 25(2016/03) ©1988.2014 Aman rno onoA r,n., •,,.r_,-a_ 1 • POW • 4a\ Inwassim The Commonwealth of Massachusetts _'=v Department of Industrial Accidents _Tog t I Congress Street,Suite 100 _.cif_ n' Boston, Mei 02114-2017 • ‘ 7:÷...*:" ..=,,o www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. • Anolicant Information Please Print Legibly Name(Business/Organization/Individual): Cape Cod Insulation Address: 18 Reardon Circle City/State/Zip: South Yarmouth,MA 02664 Phone#: 508-775-1214 Are you an employer?Chock the appropriate box: Type of project(required): 1©l am a employer with 4 employees(full and%or parttime).* 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.(No workers'comp.insurance required.) 3.0 I em a homeowner doing all work myself.(No workers'comp.insurance required.)r 9. C3 Demolition 10 0 Building addition 4.01 em a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contacton either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions S.0 I am a general contactor and I have hired the subcontractors listed on the attached sheet 13.Q Roof repairs These sub-contracton have employees and have workers'comp.Insurance.? 6.0 We are a corporation and its officers have exercised their right of exemption per Mak e. 14.0 Other WeatherizatiOn 152,{l(4),and we have no employees. [No workers'comp.Insurance required.) •Any applicanttaut checks box II must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they ea doing all work and then hire outside contaotors must submit a new affidavit Indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors end state whether or not those entities have employees. If the sub-contactors 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-las.Lic.#: WCE00431902 • Expiration Date 06/30/20,1ncAt1,1 ,,,,, �1,, Job Site Address: LI ( 'U' 114011k City/State/Zip: to 4r'`'w vl/ "Pi Attach a copy of the workers' compensation policy declaration page(showing the policy number aid expiration date). Failure to secure coverage as required under MGL a, 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 Investigations of the DIA for insurance coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct HenryCassidy '"`"'-""""" `""" Date: (o'er lie iir ,Signature: 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#: