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Home My WebLink AboutBLD-19-214 4. .1 ,�,n.4 09'Y Oraos the Only • ss'��' ca C � permllN Y'wN:MI, �IAnlount ��t �z. a w a Perndl ax Iras 180 days hon BCD-19C SI RECr. � "r EXPRESS BUILDING P'ERMI'T APPLI, • T��is 2018 • TOWN OF YARMOUTH Yarmouth Building Department noir...,y,,. , , , 1140 Route 28 South Yarmouth, MA 02664 ((308)/39,8.2231 Bxt, 1 1 CONSTRUCTIONAbbRESSI' /8 Arm,. C at &v'1M lett rY offr 1U1y / . , ASSESSOR'S NPORMATIONI IMspl I Paroeil J 51- %0 7/b /oWNEa _ r6y � �� ABSENT ADDRESS 'tenCONTRAOTON Homy_auldyCop Cod lnNbtlon IBMerdonCtrcleSouth Yormoalh 508.775,1214 AILINO ADDRESS TEL,B g Resldenllal 0 Commercial Ssi,Coat of Construotlon $ /�'921. in Home improvement ConIrnotokbto,H 153567 Construction Supervisor Llo, K 100988 Workmen'aCvmpenaetlol>j1nsuranoel (oheok one) 0 I am the homeover r"" CI 1 am the solo proprlelor 0 I havo Workor's Compensation Insuranoo Insarano*CompenyHamel Atlantic Charter Insurance' WCE0043I Worker's Comp PoIIoyNi ., WORK To BTSpirm iivrmn "'rant °' Duration ;__ (Fire Retardant ?Minolta aUachad7) . Wood Stove s1;Sldingl HotSquaros I,,,Roplaoomettt wlndowsl it_____. Replacement doors' M Roonngl k of$quBres__ ( ) Remota existing* (max,2, layere), et* R. 1Q ingu al o�n;,� h' Old Kings Highway(Hlstorlo 01st, ( )'Replacing llko for Ilko I' �� _ r�7y � 6(Jelt Pool fencing • ••'• ,, stilt debrllwliI'bedisporsdofole 4 ►La:. lz €e- . 1. Looallon of Foe Il y " �'"' "• ry, I decluryundo pelialiles of por)uly that the stalomenls heroin�toinod VI Iruo aid correct to Iho V $t or my knowledge and holler. I underslnnd thot any fnbo ens WOO VII bcJwlown fotdmlel or revoontlon of my Menlo end for proseMunonunder M,O,L,CIL 26$,sooilon I, ApplloMl'e Slgnehue Hen _Cassidy �,YI 11 . 1If'hl r�M„r;;$rat i•,nr a el6ii.a Dui lb I ; anon 5lgaalu Approrod eyl / Dntol :u • ne •' oa or a• gn.o :• . Aril ; I Date! — d �f�/, • • ' Hlsloplool Dlslrloti CI ZVo; gotl 0 NoPloo� dp— Holm Zonol 'b Yes 0 'No Wator Rogouroo Proration District: Within 100 ft, orWettandst ,w ' CI Yes CI No J Yos CJ No ‘,, DocuSm Envelope ID:C7835175-7278-4D43-932E-6C8D93744D6A Cape Light At Compact Sit. 5 Dupont Avenue South Yarmouth, MA 02664 U ' . , OWNER AUTHORIZATION FORM I, CAROLYN BANKS (Owner's Name) owner of the property located at: 18 Myrtle Lane (Street) Yarmouthport, MA 02675 (Town, State, Zip) hereby authorize C C6A S.ncJ\ca- c.An (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. The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. DocuS'gnW by: (aralyu Nests - u T'omefSignature 6/8/2018 12:41 PM EDT -Sign Date 05/10/2018 gat • The Commonwealth of Massachusetts rit t Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA.02119-2017 www mass,gov/dla \Yorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. • Applicant Information Please Print Leeibly Name (Business/Organization/Individual): Cape Cod Insulation Address: 18 Reardon Circle City/State/Zip: South Yarmouth,MA 02664 Phone#: 506-775-1214 Are you an employer?Check the appropriate box: Type of project(required): 10I am a employer Alt 48 employees(MI and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me In 8. 0 Remodeling any capacity.(No workers'comp.insurance required.) • 3.01 am a homeowner doing all work myself(No workers'comp.insurance required.)t 9. Demolition 10 0 Building addition 4.01 am a homeowner and will be hiring contactors to conduct ail work on my property. 1 will ensure that all contactors either have workers'compensation insurance or ere sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions s.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs 'nese sub-contractor have employees and have workers'comp.insuranee.r 6.0 We area corporation and its officers have exercised their right of exempdon per MOL e, 14.El Other W eather12at10r1 152,11(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that cheeks box#1 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 and then hire outside contactors must submit a new affidavit Indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-connectors and state whether or not those entities have employees. If the sub-contactors have employees,they must provide their workers'comp.policy number. I amen employer that is providing workers'compensation insurance for my employees. Below is the policy andJob site ' information. Insurance Company Name: Atlantic Charter Policy#or Self•Ins.Lie.#: WCEOO431902 ' Expiration Date tate-- 06/30/2019 , Job Site Address: t'S 'fl ✓r'-�' tem City/State/Zip: Wa�' tl t �l0,t7vI twit Attach a copy of the'workers' ompensation policy declaration page(showing the policy nu bet and expiration date). Failure to secure coverage as required under MGL 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 Investigations of the DIA for insurance coverage verification. Ido hereby certify under the pains and penalties of perjury that the information provided above irs/trye and correct HenryCassidy Wok Date: ff7f�'Y/ Je ,SittnatnTe: / 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#: ...-----1 CAPECOD-27 AMAHLE- A�oe CERTIFICATE OF LIABILITY INSURANCE DATE(MMIYY) 06105/201201 8 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 sucheendorsement(s).NR PRODUCER VCT Rogers &34ray Insurance Agency,Inc. PHHIAJOONr o,Ext): FAQ South Dennis,MA 02660 (A ,No):(877)816.2166 &tb 68.1;mall@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIL N INSURERA(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 o:Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E 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 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. IINTfi TYPE OF INSURANCE ADOL SUER POLICY NUMBER POLICY EFF POLICY EXP JG'SD_IN0(D_ IMMIDD/YYYYI IMMIDDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS•MADE El OCCUR BKW(19)63328281 04101/2018 04/01/2019 DAMA5FTO ggigmcel $ 100,000 — MED EXP(Any one(semen) £ 5,000 -- PERSONAL 4ADV INJURY E 1,000,000 GEN'L AGGft LIMIT APP 1 S PER: GENERAL AGGREGATE E 2,000,000 POLICYLI jeLOT L j LOP - PRODUCTS•COMP/OP AGO 1 2,000,000 XOTHER:sae holder descrlp of operations B , , $ AUTOMOBILE LIABILITY COMBINEDSINGLELIMIT { 1000000 (Fa accident) _ — ANY AUTO 6232707 04/01/2018 04/01/2019 BODILY INJURY(Per person) $ AIUgTIqTO¢O�S ONLY X g55TNgpgWULNEEDp P X AUTOS ONLY X AUTOS ONLY BODILY INJURYmAG accident) { _ Sr( ccci enIQAMAGE { $ D UMBRELLA LIAB X OCCUR EACH OCCURRENCE { 2,000,000 X EXCESS LIAB CLAIMS-MADE EXC10006636003 04/01/2018 04/01/2019AGGREGATE $ 2,000,000 ' DED RETENTIONS D AND EMPLOYERS'LNSAIABIIUTy PER ERH• E WCE00431903 06/30/2018 06/30/2019 sTArvrE ER ANY CPROPPpIETgO�Rq/PARTNERAi%ECUTIVE YIN 1,000,000 (MFpEiloVAANH)EXCLUDED? I I NIA E.L.EACH ACCIDENT $ (IlMyesddescribe under E.L.DISEASE•EA EMPLOYEE $ 1,000,000 • DESCRIPTION OF OPERATIONS�e1OW E.L.DISEASE•POLICY LIMIT E 1,000,000 • • I. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be ttached If more space Is required) Norkers Compensation Includes Officers or Proprietors. OdditIonal 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) ©1988.2015 ACORD CORPORATION. All rlahts reserved, 1 i U v, ( • l�� Commonwealth of Massachusetts Division of Professional Licensure •Board of Building Regulations and Standards Cons :0.t4hM,ri'I%t1 pp,rvl s or ;1 . • CS.10.0966 ,;a' 4t.,igi, eypires; 11111/2019 • . HSHEDRoASSIDY:i'p1it( . . C S 8 SHED ROW%• • 'A:'t , ' WEST YARMOGS�jM ..'A,l76 V' • qtr(.'11•riif•.tC 9 \ ,r ro M?ks • Commissioner "z• C'^' 4..---- • eehe Vaao4zcoeco4h oiWgad/Scr,cA� y � = , Office of Consumer Affairs and Business Regulation e 10 Park Plaza • Suite 5170 Boston, Mato usetts 02116 Home Imsroveme.:.: +,C.oyy' tractor Registration 1. ..Yi.ttpi,rf'::::ai?'7::'. ) Type; Corporation • ('! ` .tig`;;`' :�s':::0`:::: 0' Registration: 153587 Cape Cod insulation, Inc ;I :? , > >' Exit 18 Reardon Circle yt .,r,„. ('°t" . � Expiration: 12/1x/2018 So, Yarmouth, MA 02664 �;, • ? ,,`1. .. . " ' ,,r .. . r v. • t a.•i::r'ry ro o'>,wr ry,e u n r ` ` )'•/ Update Address and return card, Mark reason for change. • i' cn+ o sonlosn' • (J..Ad nasa,.,t .rtsnr.trr .-f 1. n p./moot-r1J as..., r4• . �\• 0 el Consumer Nlel a&Dullness rReg(Regulation OZ.?! a h�. , n Ihri1`r}:N, HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only r.i12 I.�'•M., • 7.ype; Corporation before the expiration date. If foun• • urn to: c r;;ti:Adglatratlon Fxnlrntlon OIIIoe of Consumer Allalrs and.r. at :95 Regulation d • ;. ,.��•�r„" k 10 Park Plaza. • e 5170 .,., .,`Alt..ai�crOr1 12/14/2018 Boston MA • Cape Cod Insalail"'�f'f�lJ1vitas; !:t • HenryCessldy'<2,rip y. 18 Reardon CIrc�'� �, ` 1 „,R-c6. -•^ So,Yarmouth,MA;,,9@�:^.i /,L ��_ � `. Undersecretary �t el • °'hout skiatu., ' t1.