Loading...
HomeMy WebLinkAboutBLD-19-002770 • • ,O f,�.qR ROfti/cenUse Only 7 ;k 0 q� 0 ' i `✓N. 1Amount W \Y,.,\A..a : $. , *"1Y°"e 6C., t Permit expires 180 days front )issue date EXPRESS BUILDING PERMIT APPLICATItffi-n E C E I V E D TOWN OF YARMOUTH • Yarmouth Building Department NOV 0 6 2018 1146 Route 28 South Yarmouth, MA 02664 BWL4 e s -aTt r IIL(5p0/��8�'��),,//3/�9'�8-/2^2.31 Ext. 1261 By: �ij `.f. CONSTRUCTION ADDRESS: 17 5ry l 14141(41'_ 1-0149 _ ASSESSOR'S INFORMATION: .�/ /^Map: L/� 1 Parcel: f'J442 OWNER: (/,544 {limo V V U vW� 1t r !/"GfYt�('/Yvu�(!li nor &i(,- &go - rift! AME PRESENT A DRESS / TEL. # CONTRACTOR: Henry Cassidy Cape Cod Insulation 18 Reardon Circle South Yarmouth 508-775-1214 NAME MAILING ADDRESS TEL.# R Residential 0 Commercial Est.Cost of Construction S /2/6100 e f Home Improvement Contractor Lir./4153567 Construction Supervisor Lie.# 100988 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor la 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: it of Squares Replacement windows:# �j' Replacement doors: #' Roofing: #of Squares ( )Remove existing*(max.2 layers) I r R- ' ` CeI6 I ak � ,Of(G5y /IbA Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing �/� "The debris will be disposed of at: `1 - t{W %i,7Location of Facility / •I declare under penalties of perjury that the statements here:54V/%6Zt ntained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will bejust cause for denial or revocation of my license and for prosecution under M.O.L.Ch.268,Section I. Henry sidy a.a"wont o.w t7 Applicant's sign, """"m"C"*�:�'f'a mimirtnn1a Date: Owners SI;,�is'ti;1 / %�� Date: Approve. :,, 4.thi� Date: //'6., Building Warr cc) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 2 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes L1 No 2 Yes 0 No pria The Commonwealth of Massachusetts Y acTiMt= t Department of Industrial Accidents _+' I�n 1 Congress Street, Suite 100 t=-. Boston, Ml 02114-2017 • -4. .0 www,mass,ggov/die Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers, TO BE FILED WITH THE PERMITTING AUTHORITY, • Applicant Information Please Print Le;fibly Name (BuslnesstorganiaatioWIndividual); 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.©l am a employer with 48 employees(full endlorpan•ttme),e Type of project (required); 2.01 am a sole proprietor or partnership and have no employees working forme in 8, 0 New construction any capacity,(No workers'comp,insurance required,) 8, ❑ Remodeling 3.0I em a homeowner doing all work myself[No workers'comp.insurance required.)t 9, ❑ Demolition , 4.0 I am a homeowner end will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation Insurance or are sole proprietors with no employees, I1,❑ Electrical repairsor additions 5.0 I sin a general contractor and I have hired the subcontractors listed on the attached sheet, 12,0 Plumbing repairs or additions Thesesub•contractors have employees and have workers'comp,insurance.; 13,[]Roof repairs 6.0 We ere s corporation and its toners have exercised their right of exemption per MOL a 14. Other W eatherizatlon In,11(4),and we have no employees,(No workers'comp.Insurance required.) 'Any applicant that checks box gI 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 contractors must submit a new atAdevlt Indicating such. ;Contractors that check this box must attached an additional sheet showing the name of the sub.00ntraetors and rate whether or not those entities have employees, !f the subcontractors have employees,they must provide their workers'comp.policy number. • 1 am an employer that is providing worked'compensation insurance for my employees, Below is the policy and Job site Information, • Insurance CompanyName: Atlantic Charter Policy#orSelfIns.Lio, #: WICE01�0431902 Expiration Date/�q 06/30/201�i _ Job Site Address: 7 OL!I ►' 1&('u t y City/State/Zip: V°' av — Attach a copy of th 'workers' compensation policy declaration page(showing the policy numbeand expiration date). Failure to secure coverage as required under MOL c. 152, §25A is a criminal vlolation,punishable by a Eno up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORJC'pRDER and a fine of up to S250.00 a day against the violator,A copy of this statement may be forwarded to the Office of Livestigations of the DIA for insurance coverage verification, 1 do hereby certify under the pains and penalties of perjury that the Information provided ab ve is t({'ue and correct, 173 ittnature: Henry Cassidy w; „r. ... . ....,. ., I/1 y�A Phone#: 508-775.1214 Date' V �U Official use only. Do not write in this area,to be completed by city or town official, City or Town: Permit/License# Issuing Authority(circle one): • 1.Board of Health 2.Building Department 3. City/rown Clerk 4. Electrical Inspector Si Plumbing Inspector 6,Other Contact Person: Phone#: • • . • . . . U t 95.a' Commonwealth of Massachusetts Division of Professional Licensure . •Board of Building Regulations and Standards ' Cons ,Ci:Ct rtiStiesrvisor (f. • CS-100988 J I ttli.cor' noires: 11/11/2019 • :t� i" • HENRY E CA5SIDY'+,I{�FS. . ^ ' B SHED ROWt- '' rai\i,f�%;' •• WEST YARMOGT$MA;"OItt(koss,P673•,�C Commissioner “..4 y.o" L/ /2E (�PG'�'4vino126uecr ig 1W i 4. '� /' Cfflce of Consumer Affairs and Business Regulation 10 Park Plaza • Suite 6170 Boston, Masib usetts 02116 - - Home Improveme.,:: +, ,or'craotor Registration .. r �,I 'F :;i:,I ,•;::�(1v.1;. G::1!'; '� Typol Corporation r :?ii,g,iiy,f,: ,l :jr' ia1, t• P Registration: Cape Cod Insulation Inc "1 • 1 ,,ti .••- it 9 iration: 163567 °' J.V.'i:; 4.tll' 4.4:''; 'w Expiration: 12/14/2018 18 Reardon Circle w ,1•. .•:1' • 'd.h'F, ;ir,;;u. So, Yarmouth, MA 02664 '�,e ` �5�•`. i t•tg 't, _ 6:, • ,,,;fix 6q 0611i ••�•••^1• Update Addroea end return card, Mark reason for chango {Me 0 40A1. . .........._. ^...,..•.,.,•.. .•.,.__—,.............. . •.,........_,..,,.,.M.Afidnamen..M.61.uta.wral-CI amplormt.tnetzt.Ca.ref hoTo Cvw onruurr/41 u C4aeurao4rroom C. OHM of Comumor Nlelre I. 8veinese Regulation � ii ril " HOMEIMPROV!M8NT CONTRACTOR , " 1 ? ti 0or orallon Recon the el piratlid foreif o,u • only tt@ ,YP, , P talon the expiration dole, If IOU • is urn tel N jnya'icte;'• •. Exnlrntlen 011letolOonaumerAlf airs and'; al a; Regulation `'� • " 'SCt'ggg'u.� CB•d7{ 14114/2018 10 Pork Plaza• - • 8110 S`r t�)rit""4 Boelon,MA • Cape CodIna0I I '; I'ro vyI t1 HonryCassidy'rt1'f+ ,'1,1' `, // 15 ReardonClfo a ,��1' �•r ae.cc.6,...., 1Is_sf_ +• Vndorseoretary t • ''hoot al atu•= • t\ ----II CAPECOD-27 AMAHLER A�oRo CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDOM'YY) 06/05/2018 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 en endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 12GAOT - Rogers&Gray Insurance Agency,Inc, PHONE 436 Rte 134 ! ESU ©rogeregray,com (N0,No,Eat): FAX _ South Dennis,MA 02680 L mall lac,Nol:(877)816.2156 INSURER/SIAFFORDING COVERAGE NAZCA INSURER A:West American Insurance Company 44393 INSURED .1^ INSURERS:Safety indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INsuRERC:Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER D:AtlaftiC Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER!I INSURER F: COVERAGES CERIJFLQATE NIIMBER; 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. II NTR TYPE OR INSURANCE AODL SUER POLICY EFF POLICY EXP !NSD WVO POLICY NUMBER (MMIOD/VYYYI IFTdIDDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUREACH�OCCpURRENCE 1 X1,000,000 BKW(19)53328281 04/0112018 04/01/2019 PRMMQEs(FeacEOencet $ 100,000 MFD FXP(Any one Dereom $ 6,000 PERSONAL aADVINJURY $ 1,000,000 ,, YL AGGA AT J o APp` ,S PER: GENERAL AGGREGATE i 2,000,000 X POLICY POT LI _ X see holder deecdp of operations PRODUCTS•COMP COMP/OP AGO 3 2,000,000 OTHER: B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO Fe striders!! 1 1,000,000 — OwNED 8232707 04/0112018 04/01/2019 AUTOSUppONLY X �pTq�pgWOLNEpDp BODILY INJURY(perDereanl i n X AII�FOS ONLY X AUiO5S0NlY fPalqq BODILY NYUAMAGEecCldenU i leer ecce e�l4 1 _ 0: UMBRELLA LIAR X OCCUR 1 X EXCESS LIAB CLAIMS.MADE EXC10006836003 04/01/2018 04/01/2019 EACH OCCURRENCE E 2,000,000 .• DEO I IRETENTIONE AGGREGATE 1 2,000,000 D WORKERS COMPENSATION FM 3 ANO EMPLOYERS LIABILITY YIN I nTATIITE I I FpH• ANY ICE�O ARIMBOE R/EXCLUDE�7 ECUTIVE t�' N/A WCE00431903 06/30/2018 08/30/2019 1,000,000 (mettle ory�n ) I� E.L EACH ACCIDENT I Nyesdescnbe under E.L.D16EASE•FA EMPLOYEE $ 1,000,000 ' DESILIPTION OF OPERAT19Nggelow 1,000,000 ., E.L.DISEASE•POLICY LIMIT $ •r DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (ACORD 101,Addltlonal RemarkiSchedule,may be attached If mon space le 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 HOLDErE 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 SE7am I ACORD 25(2018/03) elft 4OCO _ RISE ENGINEERING OWNER AUTHORIZATION FORM 1, Susan Kinnear (Owner's Name) owner of the property located at: 19 Salt Marsh Lane , (Property Address) West Yarmouth, MA 02673 (Property Address) hereby authorize C 'life (Di rt-la 1/ (, y-� , (Suntractor) 1 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. XO er's Signature / 6 > ( pIv) / e x Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com