HomeMy WebLinkAboutBLD-19-002343 •
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EXPRESS BUILDING PERMIT APPLICATIO E C E I V E D
TOWN OF YARMOUTH OCT 19 2018
Yarmouth Building Department
1146 Route 28 i ��
• South Yarmouth,MA 02664 er I 1 MA
(508)
8-2231 Ext1 261
CONSTRUCTION ADDRESS: 115 est - --A,641 '.1e4-
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ASSESSOR'S INFORMATION:
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Map: I Parcel:
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OWNER: '�Olerbl�h �e$ -3be,-7 4)
NAME I PRESENT ADDRESS TEL #
CONTRACTOR:
Henry Cassidy Cape Cod Insulation 18 Reardon Circle South Yarmouth 508-775-1214
NAME MAILING ADDRESS TEL.# 1
R Residential 0 Commercial Est.Cost of Construction S O'0D • 0-0
Home Improvement Contractor Lie.# 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#WCEOO431902
WORK TO BE PERFORMED
Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# Replacement doors: #1.
Roofing: #of Squares ( )Remove existing*(max.2 layers) mit
3j3 ?ve i99 X� 5 i ,
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing f(,Y
era IR,,,* 3cella lagL it) TZZLIteracae 'c7'
*The debris will be disposed of at: JefGtU✓ its vL�4U U4) `7 yin v5 air 1�`/� I
sll� Location f Facility
I declare under penalties of perjury that tatemenn 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.G.Ch.268,Section 1.
Henry Cassidy ...."� °-�-- �U
Applicant's Simian: =""fl;. '""" Date: ilt 5
Owners Signator . Date: n
Approved By: Date: /0
--1(7 it .
Building V c jA
. esignee) EMAIL :sRESs:
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: 7 Yes 0 No
Water Resource Protection District Within 100 R.of Wetlands:
0 Yes 0 No 3 Yes 0 No
RISE
ENGINEERING
OWNER AUTHORIZATION FORM
i Community Systems Inc (Tenant) Carolyn Banks (Landlord/owner)
(Owner's Name)
owner of the property located at:
75 Captain Stanley Road
(Property Address)
South Yarmouth, MA 02664
(Property Address) 1 ,
hereby authorize C '.92 Gp ck TV\S\ 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.
K .4, / £
Owner's Signet f
otA,R
Date
RISE Engineering,a Division of Thielsch Engineering,Inc.
5 Dupont Avenue I South Yarmouth,MA 02664 1508-568-1926
www.RISEengineering.com
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The Commonwealth of Massachusetts
I;=nlegt=�'•
Department of Industrial Accidents
Congress Street, Suite 100
Boston, MA 02114-2017 •
www.mass,gov/dia
Workers' Compensation Insurance Affidavit;Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY,
AoDllcant Infcrm:Hen 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
An you an employer?Meek the appropriate boat
I. I am$employer with 49 employees(full endlorpart•time),e Type of Newconstruction
o project(required):
d):
2.0 I am a sole proprietor or partnership and have no employees working forme In 7. 0 Remodeling:'actlon
any capacity,(No workers'comp, Insurance required,) g, Q
3,01 em a homeowner doing all work myself,(No workers'comp.Insurance required.)t 9. ❑ Demolition
4.01 em a homeowner and will be hiring contractors to conduct all work on my property. !will 10 Q Building addition
ensure that all contractors either have workers'compensation Instinnce or are sole 11.0 Electrical repairs or additions
proprietors with no tnployees.
LC 1 ant a general oontractor and!have hired the sub•contnctors listed on the attached sheet. 12,9 Plumbing repairs or additions
These subcontractors have employees and have workers'comp.Insuranoe,t 13.0 Roof repairs
6.0 We area corporation and Its officers have exercised their right of exemption per MOL o, 14. Other Weatherization
152,{1(4),and we have no employees,[No workers'comp.Insurance required.)
'Any applicant thatcheeW box 41 must also fill out the section below showing their workers'oompensadon policy Information.
t Homeowners who submit this affidavit Indicating they are doing all work and then hire outside eontraotors must submit a new affidavit Indloedng such.
1Contraetors that check this box must attached an additional sheet showing the name of the sub•oontraotors and state whether or not those entities have
employees. If the subcontractors 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.Lie.#://W??C--''E00431902 Expiration Date 06/30/2011 tel
�e,ry
Job Site Address: 1S (.;Lilt r/17/,u City/State/Zip: l"(_�1r7
Attach a copy of the workers//compensation lacy declaration page(showing the policy numb r and expiration date).
Failure to secure coverage as required under MOL c, 152, §25A is a criminal vlolatlonpunishable by a fine up to $1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WOltj '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,
I do hereby certify under the pains and penalties of perjury that the information provided abb9ve isput and correct
Signature: Henry Cassidy �: `;�- ----W-- ^--_,M Date: ID/ 17 J0
Phone fir 508-775-1214 r
Official use only, Do not write in this area,to be completed by city or town official,
City or Town; Permit/License ft
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#:
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--•---1 CAPECOD-27 AMAHLER
ACC) CERTIFICATE OF LIABILITY INSURANCE
DATE(MM(DD/YY1'Y)
06/05/2016
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 suchpp endorsement(s).
NAM€A
PRODUCER CT
Rogers&Gray Insurance Agency,Inc. PHONE FAX No):(877)816.2156
434 Rte 134 (A(0,No,Exq:
South Dennis,MA 02660 mist mall@rogeregray,com
INSURER(S)AFFORDING,COVERAOE NAM P
INSURER AMast American Insurance Company 44393
INSURED '' INSURER B:Safety Indemnity Insurance Company 33618
Cape Cod Insulation,Inc. INSURERC:Endurance American Specialty Insurance Company 41718
18 Reardon Circle INSURER0:Atlantic Charter Insurance Company 44326
South Yarmouth,MA 02664
INSURER E:
INSURER F t
COVERAG $ 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. 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.
INSR ADDL SUER
ITR TYPE OF INSURANCE INAO WVD POLICY NUMBER (MMrO I IMMnnY EXP
l LIMITS
A X COMMERCIAL GENERALLIABILI7Y EACH OCCURRENCE $ 1,000,000
CLAIMS•MADE Ell OCCUR BKW(19)53328281 04/01/2018 04/0112019 DAMAGE TORENTED 100,000
PREMISES Fa pcsurreneel S
MED EXP(Any one parson) $ 5,000
PERSONAL a ACV INJURY $ 1,000,000
SUFL AGGR ELIMIT APP APER: GENERA' AGGREGATE $ 2,000,000
X POLICY g Loci 2,000,006
X •THER:res holder dare p of operations
PRODUCTS•COMP/OP A00 $ _
B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Fe arclneno $ 1,000,000
ANYAoAUTO maw 6232707 04/01/2018 04/01/2019 BODILY INJURY(Per person) I
OWINS ONLY X AUTOSULED
X AU ONLY X A&og`° ? BODILYPOaINJURYTi (Per e«Idene $
(POs BO IOentQAMAGE i
C. UMBRELLA LIAB X OCCUR EACH OCCURRENCE E 2,000,000
X EXCESS LIAO CLAIMS-MADE EXC10006636003 04/01/2018 04/01/2019 AGGREGATE 2,000,000
•• DED RETENTION$ $
D WORKERS COMPENSATION 1
AND EMPLOYERS'LIABILITY STATI)TF FRH.
• ANY PROPRIETORIPARTNER(EXECUTIVE ff WCE00431903 06/30/2018 06/30/2019 1,000,000
FFICERAIry�nM j
EXCLUDED9 NIA E.L.EACH ACCIDENT $
andrto �
, Fyndescribe under E,I,DISEASE•EAEMPLOYEE, $ 1,000,000
DESCRIPTION OF OPERATIONS below �.L.DISEASE•POLICY LIMIT $ 1,000,000
•
//,
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,my be attached If Inert apses 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,
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 25(2016/03) OD 1988.2016 ACORn nnppnparInPJ. All vlo he. .n....,...1