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HomeMy WebLinkAboutBLD-19-002883 OY7k $" `r0 lit i Permit# . Ci Amount 3 b J cecATTAI„^Yu1 •{Faed • (� Permit expires 1800days from I�u)JI VI', I, '1�* �' 'CnEaI V 1= D 1 EXPRESS BUILDING PERMIT APPLIC • TOWN OF YARMOUTH NOV 09 2018 Yarmouth Building Department 1146 Route 28 B a .iY.r South Yarmouth,MA 02664 :Skit (508) 398-2231 Ext. 1261 ....1CONSTRUCTION ADDRESS: 65 W-i(/c,( n/ iKis---/ (Pe 4(tVW1ftt' ASSESSOR'S INFORMATION: `` II Map:" Parcel: Q /� OWNER:J. 1U CC(,Jl� kt 70 I- ze -u9, N r,( PRES ADDRESS I TEL # NAME jitenA-gg la�� it {- 1 [(6 Ental Address: CONTRACTOR: �ttUdDU�V� dt I6 Y7DU 77� 1��!_ x nuwB. aADDRESS TEL# EmailAddres: Residential / ` CommercialrEst.Cost of Construction$ It 200 Home Improvement Contractor Lie.# G c 3 ,/67 Construction Supervisor Lie.# 106 10 0 Workman's Compensation Insurance: (check one) I am the homeowner r i 1 I am Bile proprietor �i have Worker's Compensation Insurance 2 Insurance Company Name: IQ(jt C�JIM/Cf,(.t-� Worker's Comp.Policy# WCWO4,2)110.z- WORK ' )11 u WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares ' Replacement windows:# Replacement doors: # Rooting: #of Squares ( )Remove existing*(max.2layers) - Insulation r 11 tZ"6-3' l 55if daufc • Old Kings Highway/Historic Dist. ( )Replacing like for like �i p R_ v1o �t /0t7-e `6 1// 2'"„'�'_�/ C 7I�-', fv,7J/s &6vfGfa ' '7"GLK7G !p!Thedebris will be disposed of at Ablamtet t� //s dal 'SZCrtrneQ Y Location of Facility �J I declare under penalties of prjury that the statements herehreottained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for de o revocatiod]my linens and for prosecution under Kat.Ch.268,Section 1. 5q Applicant's Signature: t ,1.0 Date: ilium Owners Signature(or attachment Date: �j' Approved By: ,� Date: //1776 Building O ial esti./ • Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No DocuSign Envelope ID:A97913660-2C23.4FBA-BCB2-214CDD9E4BOE RISE ENGINEERING' OWNER AUTHORIZATION FORM I, Joseph M Calahan (Owner's Name) owner of the property located at: 75 Webster Road (Property Address) West Yarmouth, MA 02673 (Property Address) a hereby authorize C�2. CO tns kai-ka ) (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 [0.36st:riLeooeuSlyntd by: trs'stgnatu e 10/28/2018 I 10:01 AM EDT 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 —`:e'— =: = r Department oflndustria lAccidents 1 Congress Street, Suite 100 r"; 4.4 "' Boston, MA 02114-2017 • ` �;.,'N www.mass.gov/dla Workers' Compensation Insurance Affidavit:Builders/Contractors/Electrlcians/Piumbers. TO BE FILED WITH THE PERMITTING AUTHORITY, Applicant Information Please Print Le'pibly Name(13ustness/organfzatiortindividuaq; Cape Cod Insulation Address: 18 Reardon Circle • City/State/Zip; South Yermouth,MA 02664 Phone P. 508.775-1214 Are you an employer?Cheek the appropriate box, I. tamaemployerwfth as Type of project (required): © employees(fall endiorpart•time),e 7. 0 New construction 2.0 1 em a sole proprietor or partnership and have no employees working forme in any capacity,(No workers'comp,insurance required.) 8. El Remodeling 3.0 1 em a homeowner doing ailwork myself.[No workers'comp.Insurance required.)t 9, E) Demolition , . 4,0 t am a homeowner end will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that ill contractors either have workers'compensation Insurance or are sole proprietors with no employees, 11,0 Electrical repairs or additions s.❑lam a general contractor and I have hired the sub•contrecton listed on the attached sheet 12.0 Plumbing repairs or additions Thee sub-contractors have employees and have workers'comp.Insurance.: 13,❑Roof repairs 6.0We ere a corporation and i ofllcers have exercised their right of cxemp*ii per MO!.o, 14. ✓®Other Weatherizatlon 152,I1(4),and we have no employees,[No workers'comp,Insurance required.) *Any applicant that cheeks box el must also fill out the section below showing their workers'compensation policy Information. t Homeowner:who submit this affidavit indicating they are doing ell work and then hire outside contractors must submit a new of Idavlt Indicating such. 1Contractors that cheek this box must attached an additional sheet showing the name of the sub•oontraotors end state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. lam 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-les.Lie.#; WWeir-11W Expiration Date 06/30/201q _ Job Site Address: 1 iD W etr t RA/C./ City/State/Zip:w• av)A�,tft-- Attach a copy of the workers' compensation policy declaration page(showing the policy numbs and expiration date). Failure to secure coverage as required under MOL c. 152, §25A is a criminal violatiompunishable by a fine up to $1,500.00 and/or one•year imprisonment, as well as civil penalties in the form of a STOP WORN'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 ab ve is true and correct Signature: Henry Cassidy " 'fit., .., . ,, ., is ?bona#: 508-775-1214 Date: Official use only, Do not write In this area,to be completed by city or town o1liciat City or Town: Permit/Llcense# Issuing Authority(circle one): I.Board of Health 1 Building Department 3. City/Town Clerk 4. Electrical Inspector Si Plumbing Inspector 6,Other Contact Person: Phone#t i U Commonwealth of Massachusetts `�) Division of Professional Licensure .Board of Building Regulations and Standards Cons`O:dVlti 1311ps.rvlsor 'J . 05.100988 .J' t,,j;i, Cjs Tres; 11111/2019 ' :�y4�1�V1''Fc4,.• �. li :Ay', ..,r .1.' • HENRY E CAS�SIOY.; �,�j, • t f 8 SHED ROW c• '�)o '/ r ,t , WEST YARMOU,T,H Mk b)7.0 ?+C' .,• s :lea.. • Commissioner w CL A'N. 6 5(/c 4uoece/(/g OfPW,Kazi/Ja JeZ . "`• '1 Ari Office of Consumer Affairs and Business Regulation ti 10 Park Plaza • Suite 5170 Boston, Math usetts 02118 Home Improveme: + .O ractor Registration r:) (il • .. Il , ,., \),,. r) Type; Corporation ( is (( :'i1'JI'J ,..4.+I., 1;; " Registration: 153587 Cape Cod Insulation, Inc ,:, ::;.,;4 ,,o,,•'( ,� Expiration: 12/14/2018 18 Reardon Circle ,� , Sol Yarmouth, MA 02664 .)k. ''; ),I1; /,y, 4,1.1 :b.... ,,,,,,, -L.).— Update Address and return card. Mark reason for change. tC+as er 20M•06/11 . --•—_-n_(y�...._...........•,...,.....__�,._....._...... . . LJ••Adr„a .nr,...CI-I1sna.urn:-0 !Int ploymant..01oat.Card — r1 0 rpof,wroeseouna olberraan.irwele0 CN Office of Consumer Alfeirs&evilness Regulation N31)`y ROME IMPROVEMENT CONTRACTOR Registration valid for Individual use only &y:po; Corporation before the expiration dale. if faun. ti urn to; cutw2' 6gislretton Ex Ira etlon OIIIce of Consumer Affairs and s at -es Regulation :, ` J `�"" 12/14/2016 10 Pork Plaza• a 6170 �'* ' ';1 r'uJ'ir .•S'c.p..i'67Elston MA ' Cake Cod Insul'0ll'f1'j-1l..nt4 i,•.,”' , • HenryCassldY1,iN :j.T1•' 18 Reardon Clrcc`- l ': I'; R..cCQ.f-.•-. So.Yarmouth.MA ,QiGl? /I•' ' Al AL. �— — :3 "' Undersecretary IA t al • "hout sl, atu • • 1\ • ----""1 CAPECOD-27 AMAHLE A� CERTIFICATE OF LIABILITY INSURANCE DATE IMMYY) 06/0512018 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 j 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 such endorsement(s). PRODUCER AAM€ACT Rogers&Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 (AIC,No,Ext): lac,No):(877)816.2156 South Dennis,MA 02660 I'Doalss•mali@rogersgray.com INSURER'S)AFFORDING COVERAGE NAIC S INSURER A•West American Insurance Company 44393 _ INSURED INSURER e;Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER c:Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER D:Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E: • INSURER F: 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 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. INSR TYPE OF INSURANCE SNSOL SVJVo POLICY NUMBER J POLICY EFF I POLICY E%P (MMID AX' (MMIDNVYYy) LIMITS • A XICOMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,0001 CLAIMS•MADE n OCCUR BKW(19)53328281 04/01/2018 04/01/2019 PREM SFS iFe o rurrencal $ 100,0001 MED EXP(Any one Doreen) E 5,0011 PERSONAL$ADV INJURY $ 1,000,0001 GEN'L AGGREGATE LIMIT-APPLIES PER: GENERAL AGGREGATE $ 2,000x008-I POLICY IJEL'T LOP PRODUCTS•COMP/OP 3 2,000,0001 X Bea holder duchy of operations -----11111 OTHER: $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,0001 (Fe acctdentl $ ANY AUTO _ 6232707 04/01/2018 04/01/2019 BODILY INJURY(Per person) E AUTpOpS ONLY X SCHEDULED pR ij X AUTOS ONLY X AUTOS ONLY BODILY ggynRAM G accident) $ i (Por acci erItQAMAGE • E $ C'_ UMBRELLA LIAB X OCCUREACH OCCURRENCE j 2,080,008j X EXCESS LIAB CLAIMS•MADE EXC10006635003 04101/2018 04/01/2019 AGGREGATE $ 2,000,000 DED RETENTIONS D WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY PER ERH ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WCE00431903 06/30/2018 06/30/2019 1,000,0001 QFFICER/MEMBER EXCLUDED? NIA E.L.EACH ACCIDENT ,rJFICERA Iln NN) $ If yea.describe under E.L.DISEASE•EA EMPLOYEE $ 1,000,000 • DESCRIPTION OF OPERATIONS below _ E.L.DISEASE•POLICY LIMIT $ 1,800,008 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may beattached Ir more space la 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 I ACORD 25(2016103) ®1988.201 S ACORD CORPORATION. All rlahts reserved.