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HomeMy WebLinkAboutBLD-19-002765 OF.Y4RA_ �O eUse Only 0 . • :Amount �.N ?e,_nAriA n"VV.," ~YMYO <� 'Permit expires 180 days from s issue date EXPRESS BUILDING PERMIT APPLICA ~e C E I V E D TOWN OF YARMOUTH NOV 0 6 2018 Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 a ' a ..: . -ice r•re //�1II,,. (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 7 l ,U.1/U.Q. all- _.._...___ 5e l reYb(,Olt Y-e.! ASSESSOR'S INFORMATION: 4Map; /I�_ / / Parcel: 40 OWNER: 0GIA.vt)'/ 4 / Dij--IIO- 1330 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Henry Cassidy ape Cod Insulation IS Reardon Circle South Yarmouth 508-775-1214 NAME MAILING ADDRESS TEL.# 0 la y Residential 0 Commercial Est.Cost of Construction$ 2100'0 Home Improvement Contractor Lic.# 153567 Construction Supervisor Lie.# 100988 Workman's Compensation Insurance: (check one) 0 I am the homeowner a 0 I am the sole proprietor N I have Worker's Compcnsation 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: #X �Jlr S /f Roofing: #of Squares ( )Remove existing*(max.2 layers) ��ti hill Ikti I k d Old Kings Highway/Historic Dist. ( )Replacing like for like f P of fencitf g`�� �( 5� *The debris will be disposed of at: �Vu'l,dtit'�'�L () `i � ay`X f J Location of Facility I declare under penalties of perjury that the statements her con ' ed 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 tender M.O.L.Ch.268,Section I. m�x•.+wa..Yn..y .enry Caste y ;. r. .�.,s-.,.... �. Z Zd l� Applicant's ':nature: `"'"a"u'nnC'W"'"-'"' Date: Owners.Ignature l _a Date; //� /� s �� Date: 7/ ` (�//� f w/ Approve : . Building•oar+.' rl!ncc) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes CI No Flood Plain Zone: D Yes 13 No Water Resource Protection District: Within 100 ft.of Wetlands: C1 Yes 0 No :1 Yes 0 No PIS The Commonwealth of Massachusetts '6 ;�t�It= t Department of Industrial Accidents yr 0 1 Congress Street, Suite 100 Boston, MA 02114.2017 www.mass,gov/dia Workers' Compensation Insurance Affidavits Builders/Contractors/Electricians/Plumbers. TO BE FILED WITHTHE PERMITTING AUTHORITY, Applicant Information Please Print Legibly Name (Business/Organizatton/lndivfduao: Cape Cod Insulation Address: 18 Reardon Circle City/State/Zip: South Yarmouth,MA 02664 Phone #: 508.775-1214 Are you an employer?Check the appropriate boat I em a employer wish 4e Type of project (required): I, © employees(full and/or part-time),' 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employee,working forme In any capacity,(No workers'romp, insurance required.) g• ❑ Remodeling 3.0 1 em a homeowner doing all work myself. [No workers'camp.Insurance required,)t 9. E) Demolition , . • 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property, i will 10 0 Building addition ensure that UI contractors either have workers'compensation Insurance or are sole proprietors with no employees. 11,0 Hlectr(cal repairs or additions 5,0lame general oonertotor and i have hired the sub•contrsctore!bird on the attached sheat 12'❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance,.t 13,❑Roof repairs 6.0 We are t corporation and Its officers have exercised their right of exemption per MOL a 14, ✓�Other Weatherizatlon 152,f l(4),and we have no employees, (No workers'romp,Insurance required.) 'Any applicantthatchecks box Ii must also fill out the section below showing their workers'compensation policy Information I Homeowners who submit this affidavit indicating they ere doing all work and then hire outside contractors must eubmia a new affidavit Indicating such. 1conoteters that cheek this box must attached an additional sheet showing the name of the sub•oontraotors and stats whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp,policy number, 1 am an employer thrills providing workers'Compensation insurance for my employees. Below is the policy and Job sire Information. Insurance Company Name: Atlantic Charter • Polioy a or Selt ins.Lie. : WCE00431902 Expiration Date' 06/30/201'1 ^^"A Job Site Address: 1 (_&lti/i. 1141( irk City/State/Zip: V '(`a 141 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 c. 1521 §25A is a criminal vlolation'punishabie 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.:ORDBR and a fine of up to$250.00 a day against the violator,A copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification, 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct ;iknature: Henry Cassidy Phone/it508.775.1214 Data; �f 7.6 ie Official use only. Do not write In this area, to be completed by city or town official, City or Town: Permit/License 1 Issuing Authority(circle one): 1. Board ofllealth 2. Building Department 3.City/Town Clerk 4. Electrical Inspector Ss Plumbing Inspector 6,Other Contact Persons Phone #: • I • I \ c. Commonwealth of Massachusetts gPRroefestsaitolonanls LaicnednSstuarned ards J •BoardDoivfiBinldoinf • ConsktyjH %$prvisor >J . CS-160988 S ��/,� Wires: 11/11/2019 • Jry +r • HENRY E CA?gJDY.';•Vii ' 8 SHED ROW% ;1�IfV,'i F i V • " WEST YARMOGT$MA;WO 671 ?+C Commissioner ,fid U /2Pr 2990/ ='�/Y12�/!?/6(1G'CGt/!//'G Q� • 4 i Cl /,f, ' wriso �I `I Office of Consumer Affairs and Business Regulation 10 Park Plaza • Suite 6170 Boston, dMua,:.grbusre:t ts 02116 - - Home Improveme ? eliSraotor Registration tration : irlt:. V4; .;;,;.! Typo; Corporation(,rl 'v :;•1r. 'i :•.B • 1 Reglelrallonl 180887 Caps Cod Insulation, Inc (a ,,;; :•',ikit'r,I,+• • Explratlonl 12/14/2018 ' 18 Reardon Circle • ?;+;,: ' So. Yarmouth, MA 02664 d '`+":`' ' 1" 'i, ++ '!`- w.';:1,y;Y +y � A. •••••/ (monUpdate Addrooa and return pard, Mork ron for change. iCA4 0 40A1.06r11 _._.._ �j...._.,,..,....,..1/_ ./....__ ' •,..,,........ . ............_,..,,,,-CLAdd nmm..0,rt•snr+.v;n!_r.ZR.mplor/munt,.C11.rtal.ca.re +✓' 110 ,Do9lNnwttvuRlVY v�wv4frdJr6C/irWae(J ilit � OHlee of ConevmetPJlelre 8 Bvelneee Regulation HOME IMPROVEMENT CONTRACTOR Rogletrotlon valid for Individual.144 only T, poi Corporation before the tsplrallon date, II fcu • L un tol {' ?t, Exnlrnlion 01111o01OonavmarAffair; and•= el ,i o Regulation ci.i: 18 7 12/14/2018 IO ParkPlaae• - 80170 VicTA • ! iIIP \ t:1� ��i te /�r �� A /'Vndoraecrelary 41 6I� ''hout ale alu = 41 •.----"1 CAPECOD•27 AMAHLER Acc,RO• CERTIFICATE OF LIABILITY INSURANCE DATE(MM/ (Y) 1�./ 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 an endorsement, A statement on ' this certificate does not confer rights to the certificate holder In lieu of suchooeeIJT�nppdorsement(s), PRODUCER NAME'CT 20 ars&Gray insurance Agency,Inc. PHH"c°,No,Eat): I FAX No):(877)816.2156 t34 Rte 134 mall r0 Bre ra CO $ouch Dennis,MA 02660 %' s: 9 9 y• m INSURERI$)AFFORDING COVERAGE NAIC If IN$uRERA West.Amerlcari)nsurance Company 44393 INSURED '. INSURER B:WON Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. iristiltsH cI Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER 0:Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E: INSURER F t COVERAGE$ 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. NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH 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. INSRLTYPE OF INSURANCE ANSA SUBR POLICY NUMBER IMMIDWYYYLJMMlDDMYYVI LIMITS A X COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE E 1,000,000 CLAIMS.MADEEj OCCUR BKW(19) 63328281 04101/2018 04/01/2019 ats DPAMAGEalycl unDenrel $ 100,000 _ MED EXP(Any one person) $ 5,000 PERSONAL 3ADV INJURY $ 1,000,000 — San AGGR LIMITpp'APP S PER: . GENERAL AGGREGATE $ 2,000,000 L X POLICY .J ILOP . PRODUCTS•COMP/OP AGO S 2,000,000 Xaea holder ducdp of operations OTHER: E B AUTOMOBILE LIABILITY CBOMBMNEDISINGLE LIMIT S 1,000,000 — ANYAAUTO 6232707 04/01/2018 04/01/2019 BODILY INJURY(Per person) S , AUpT�O�S ONLY X �pp}HNNMppgULEEEDpp BODILYBpqINJURY(Per accident) $ • _ I X ALTOS ONLY X AVTOSTNLY (Per eccideniAMAGE $ S 'C' UMBRELLA LIAR r OCCUR2,000,000 EACH OCCURRENCE E X EXCESSLIAB CLAIMS-MADE EXC10006836003 04/01/2018 04/01/2019 AGGREGATE E 2,000,000 DED RETENTION SEE S D WORKERS COMPENSATION 5)gTIITE OTETH• AND EMPLOYERS'LIABILITY WCE00431903 06/30/2018 06/30/2019 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE LI E.L.EACH ACCIDENT E (Mend11017 Eit EXCLUDED? NIA (mandatory In NH) E.L.DISEASE•EA EMPLOYEE $ 1,000,000 • 11 yes deecrlbe under DESCRIPTION OF OPERATONS below E L.DISEASE•POLICY LIMIT $ 1,000,000 • DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If mon spew Is required) Norkers 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 REPRESENTAway TIVE I C� •/•/•111\...........,ant no Aton AAAA A rr'rert A r1 el •11•I�Le— •���•.•�J Docusign Envelope ID:84F92750-3616-4981-84C8-6C842535AA7D RISE ENGINEERING' OWNER AUTHORIZATION FORM 1, Thomas F Hague (Owner's Name) owner of the property located at: 7 Curve Hill Road (Property Address) South Yarmouth, MA 02664 (Property Address) hereby authorize Cape Cod Insulation (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. C"�DeeusbnW w: e%,at hr. Owner's Signature 2C7A22780AD142A.. 10/23/2018 I 4:04 PM EDT Date RISE Engineering,a Division of Thielsch Engineering,Inc. S Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RISEengineering.com