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HomeMy WebLinkAboutBLD-19-2346 Or Y',-i4 Office Use Only 114 a,4 Permis f ")t• l �` $ Amount —� f. i�:• Permit expires 180 days from s BL�I f -�^„"� / , atssue date l EXPRESS BUILDING PERMIT APPLICATI 1 N� E C E I `J E D TOWN OF YARMOUTH OCT 19 2018 Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 By: n d �T F(508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 0 22 t�/ W1G & .� Rt, r, Qi V-07 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 1- 4)31&C• T3eittraVSkI cog. 00- 5327 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Henry Cassidy Cape Cod Insulation 18 Reardon Circle South Yarmouth 508-775-1214 NAME MAILING ADDRESS TEL#D� �j1 g Residential 0 Commercial Est.Cost of Construction S �'U76' s' v Home Improvement Contractor Lic.# 153567 Construction Supervisor Lie.# 100988 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor X 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 doors: #V Roofing: #of Squares ( )Remove existing*(max.2 layers) &nett c,/,-Ia''tsula�ion X Z* „ ,/„- - Kings Highway/Historic Dist. ( )Replacing like for like yt'',. • Pool fencing Wei)' fp-gnat- Old *The debris will be disposed of at: LA,,,„..4. (Mahf.non of Facility 1 declare under penalties of perjury that the statements herein conaltrue and correct to the best of my knowledge and belief. I underst d that any false answers) will be just cause for denial or revocation of my license and for prosecution under M.O.L.Ch.268,Section 1. Henry Cassidy °W""'°"x. _ Gb 'I f� Applicant's Signature: • r`--...�'—m Date: Owners SIgnaiu (or attachment) Date: Approved By: �wpL� SEM Date: 'r7�" i/p Building ctalal r rdesigneeJ) EMA DRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 2 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 2 Yes 0 No • RISE '7E- ENGINEERING' OWNER AUTHORIZATION FORM I, Lisa C Betrovski (Owner's Name) owner of the property located at: 83 Mattachee Road (Property Address) Bass River, MA 02664 (Property Address) hereby authorize C aP.e, GA I j. vtad• on (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. /J DC-1 "-"j C - • oar's S'• • • - 10/3/14� Date RISE Engineering,a Division of Thielsch Engineering,Inc. 5 Dupont Avenue I South Yarmouth,MA 02664 1508-568-1926 www.RISEengineering.com The Commonwealth of Massachusetts =qdi:_ Department of Industrial Accidents =eTatl 1 Congress Street, Suite 100 _ Boston, MA 02114-2017 • • c w.,•G www.mass,gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY, Avelicant Information Please Print Leeibly Name (Business/Organization/Individual): Cape Cod Insulation Address: 18 Reardon Circle City/State/Zip; South Yarmouth,MA-02664 phone#: 508.775-1214 An you an employer?Cbeckthe appropriate bus I, I am a employer with 48 Type of project(required); © employees(Mi end/orpart.time),s 7. 0 New construction 2.0 lama sole proprietor or partnership and have no employees working forme In 8. 0 Remodeling any capacity.(No workers'comp,Insurance required.) 3,01 am a homeovmer doing all work myself.(No workers'comp.insurance required.)t 9, E3 Demolition 4,0 i am a homeowner and will be hiring contractors to conduct ell work on my property, 1 will 10 0 Building addition ensure that UI contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no auployees, 5,C3 1 am a general contractor and I have hired the sub•conbsheetacton listed on the attached 12. Plumbing repairs or additions These sub-contractors have employees and have workers'comp.Insurances 13.[]Roof repairs 6.0Weare acorporadonand Its offloershave exercised their right ofexemption per M.OLa, 14. Other Weatherizatlon 152,11(4),and we have no employees, (No workers'comp,Insurance required.) 'Any spplicantthat cheeks boxWl must dao fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they en doing all work and then hire outside contractors must submit a new affidavit Indicating such. 1Concaotors that check this box must attached an additional sheet showing the name of the sub•oontreotors and state whether or not those enddes have employees, If the sub-connectors have employees,they must provide their workers'comp.policy number. 1 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,Lb, fit r/�W, ,CExpiration Date* 06/30/2011 'A_ Job Site Address: q3 Y" G /'E_00431902 t!/ City/State/Zip: 65 i VUr Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MOL e. 152, §25A Is a criminal violatlon,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,i '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 I4vestigations of the DIA for insurance coverage verification, 1 do hereby certify under the pains and penalties of perjury that the Information provided ab ve I true and correct •5ierature; Henry Cassidy `:7,"o' r., Date, 7DZ �/, d Phone 4: 508-775-1214 (J 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 ot.Health 2. Building Department 3. City/Town Clerk 4, Electrical Inspector Si Plumbing Inspector 6.Other Contact Persons Phone#: -----"Th CAPECOD•27 AMAHLE- A�oRo CERTIFICATE OF LIABILITY INSURANCE DATE 0610512018YI 0610512018 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 pollcy(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 don not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER MPCT Rogers s Gray Insurance Agency,Inc. PHONE 434 Rte 134 (UD,No,an: Iia"c,t40):(877)816-2156 South Dennis,MA 02660 mat.mall@rogersgray.com INSURER(S)AFFORDING COVERAGE NAICa INSURER A,West American Insurance Company 443• INSURED `^ INSURER II Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc, INSURER 0:Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURERD:Atlantl0 Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E: 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 INDICATED. N0TVv1THSTANDING 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. IjNp TYPE OFINSURANCC ADDL SUER POLICY EFF POLICY EXP )NSD wvn POLICY NUMBER _IMMIODn7n1 (MMDD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS•MADE E OCCUR BKW(19)63328281 04/01/2018 04/01/2019 DAMAGE TORENTED 100,000 PRFMISF RENT rrencef $ MED EXP(Any ono person) $ 6,000 PERSONAL a ADV INJURY $ 1,000,000 nFN'L AGGRE,GUE LIMIT APP 1 S PER: GENERA) AGGREGATE $ 2,000,006 X POLICY Li ye,: L LGP PRODUCTS•COMP/OP AGO $ 2,000,000 X OTHER;gee holder dont,of operations B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1 IFe acclaim) $ 1,000,000 ANY AUTO 6232707 04/01/2018 04101/2019 BODILY INJURY(Per person) I AIUgT�O�S ONLY X AvvTN�pgwULNEEDp pBOODILY INJURY(Per accident/ S ". X AUTO$ONLY x AUTOS ONLY LPeOeciltlanlQAMAGE .1 D' UMBRELLA UAB X OCCUR $ EACH OCCURRENCE S 2,000,000 X EXCESS LIAR CLAIMS-MADE EXC10008836003 04/01/2016 04/01/2019 AGGREGATE 2,000,000 •• DED RETENTIONS S D WORKERS COMPENSATION pp H• $ AND EMPLOYERS'LIABILITY PER ER • ANY PROPRIETOR/PARTNER/EXECUTIVE n WCE00431903 08130/2018 08/30/2019 OFFICERMi BER EXCLUDED? NIA EL EACH ACCIDENT $ 1,000,000 (IMMends O NHHd( 1,000,000_ Il yyea desotlbe under E.L.DISEASE EA EMPLOYEE S • DESCRIPTION OF OPERATIONS below ,_E L.DISEASE•POLICY LIMIT I 1,000,000 l/ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more specs le required) Workers Compensation Includes Officers or Proprietors. Additional Insured status Is provided under the General Liablllty and Auto Liability when required by written contract or agreement with the Certificate Holder. Excess Liablllty Is follow form. CERTIFICATEHOLDER CANCELLAIIQN SHOULD ANY OP THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE 17 — ACORD 25(2018/03) 01988.2016 ACORn nn Rpnp ESTI nm. AN.Inld. .sew..,,.A \'1 • • 1-nIS IS inoy. • IS let i.' 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