Loading...
HomeMy WebLinkAboutBLD-19-002882 V Permit# 1 Permit expires 180 days from tissuedate 15 Co—' (C1� -DO, ; . , EXPRESS BUILDING PERMIT APPLICATIO R E C E I V E D TOWN OF YARMOUTH Yarmouth Building Detiartment NOV 09/ 2o178 1146 Route 28 South Yarmouth,MA 02664 Bui �f� (508) 398-2231 B1. 1261. f ey - #' - CONSTRUCTION ADDRESS: `� 'S :1`Vt *Pi V ASSESSOR'S INFORMATION: if a Map: Parcel: OWNER: f �IigiL N1• -Ph IID • J5O%- 7iY' 7317 FRESDRESS TEL. # mail Address: CONTRACTOR: pe�46 Iuit{ nA>i 'OC�GIVG u cIY �jbg-775'• 17- NAME MAILING ADDRESS TEL.# EmailAddres: Residential )( Commercial Est.Cost of Construction$ Cf160 -C� Home Improvement Contractor Lie.# 1 57011 Construction Supervisor Lit.#- 1061Z• 061 qU U Workman's Compensation Insurance: (check one) I am the homeowner {{,,IlIam the s ropriettorr// I �,I have Worker's Compensation Insurance Insurance Company Name: NM, �ft' 1W) $ Worker's Comp.Policy# (vC2 Deg 3l1°7--- WORK TO BE PERFORMED • ' Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares ' Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove + existing (max.2 layers) n� f�In�sulation Old Kings Highway/Historic Dist. ( )Replacing like for liker Achift 6' ' I f" �a 441u/if fa. 5I'Cc eat/ collie twit , !The debris will be disposed of an ',�"(1 Location of Facility 9 I declare under penalties of.erjury that the statements contained are true and correct to the best of my imowledge and bellef. I understand that any false answer(s) will be just cause for denial.r vocation• '.y license and for prosecution under M.G.L Ch.268,Section 1. Applicant's Signature: Sli.. . A 4l.L.is/ Date: 141 /11 111 Owners Signature(or attachment) ��� s ate: .,/ Approved By: / A�I — Date: //7'/ f Buil,on i,1(or.esignee) • Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No Pin - The Commonwealth of Massachusetts hosltit=fir Department of XndustrialAccidents EE+ds= 1 Congress Street,Suite .100 Boston, MA 02114-2017 www,mass,gov/dla Workers' Compensation Insurance Affidavit:Builders/Contractors/Electr{clans/Plumbers, TO BE FILED WITH THE PERMITTING AUTHORITY, Applicant Information Please Print Leeibly Name (Business/Organizttion/Indlvtdual): Cape Cod Insulation Address: 18 Reardon Circle City/State/Zip; South Yarmouth,MA 02664 Phone#: 508-775-1214 An you an employer?Cheek the appropriate box: - L©lamaemployer with 48 employees(full end/orpart•time),' Type of project(required): 2.01 am a sole proprietor or partnership and have no employees working for me In 7. 0 New Remodelingnt'nedon any capacity,(No workers'comp,Insurance required,) S. ❑ 3,01 em a homeowner doing all work myself,[No workers'comp.insurance required,)s 9. 0 Demolition , . CO I am a homeowner and will be hiring oontractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees, 11.0 Electrical repairs or additions 5,0I am a general contactor and I have hired the subcontractors listed on the attached sheet, 12.0 Plumbing repairs or additions These subcontractors have employees and have workers'comp,Insurance: 13,0 Roof repairs 6.0 We are 'corporation and its ofticen have exercised their right of exemption per MOL o. 14. Other Weatherization 152,11(4),and we have no employees,[No workers'comp,Insurance requind.) 'Any appiieentthat checks box ill must also fill out the section below showing their workers'compensation policy Information. Homeowners who submit this at9devlt Indicating they ere doing all work end then hire outside contractors must submit a new affidavit Indicating such tContnetors that check this box must attached en additional sheet showing the name of the sub•oontraotors and state whether or not those entities have employees, If the rib•contractors have employees,they must provide their workers'comp,policy number. I am an employer that Is providing workers'compensation Insurance for my employees. Below Is the policy and lob site Information. Insurance Company Name: Atlantic Charter '' Policy#or Self ins,Lie,#: WCE00431902 Expiration Date 06/30/201'11Ipp Job Site Address: 2-C1 Rite 411- City/State/Zip: ♦QV � M/Ott(`/ Attach a copy of the workers' compensation policy declaration page(showing the policy n m•er and expiry •n date). Failure to secure coverage as required under MOL o. 152, §25A is a criminal violation'punishab e by a fine up to $1,500.00 and/or one•yeas imprisonment, as well as civil penalties in the form of a STOP WORfc'pRDBR 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(nivestigations of the DIA for insurance coverage verification, Ido hereby cert(fy under the pains and penallles of perjury that the itt/'ormation provided above is true and correct $ienature: HenryCassldy phone#: 508-775-1214 Date: �(ov.1� 2-2) 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/Town Clerk 4. Electrical Inspector Si Plumbing Inspector 6,Other Contact Persons Phone#s • -...---1 CAPECOD-27 AMAHLER A`ORO' CERTIFICATE OF LIABILITY INSURANCE DATE I 06105/2018 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 such endorsement(s). 'RODUCER N(1ryTACT togera&Gray Insurance Agency,Inc. PHHOONNEA 34 Rte 134 A/C,Ne,lath FAX Ne):(877)816-2156 Muth Dennis,MA 02660 Wiss:mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# ,.INSURER A:West American Insurance Company 44393 NSURED INSURER a:Safety Indemnity insurance Company 33618 Cape Cod Insulation,Inc. INSURERc:EnduranceAmericanSpecialtyInsuranceCompany 41718 18 Reardon Circle INSURER o?Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E: INSURER F: ;OVERAGES 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. ISR TYPE OF INSURANCE ADDL SWYO POLICY NUMBER POLICY EFF POLICY UP 1MMIDDA•YYYI IMMIDD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE { 1,000,000 CLAIMS.MADE O OCCUR BKW(19)63328281 04/01/2018 04/01/2019 DAFA$TO RENTED 100,000 Etta occunormel J _ MED EXP(Any one orlon) S 5,000 PERSONAL&ADV INJURY S 1,000,000 SENT.AGGREGATELIMIT AP.fU.SLPER GFNERAI AGGREGATE S 2,000,000 X POLICY II�_JJII PEEGLOTT I �� OPRODUCTS COMP/OP AGO S 2,000,000 OTHER; X sea holder dncdp of operations COMBINED SINGLE LIMIT S B AUTOMOBILE LIABILITY ldenn S 1,000,000 (Ea acc— ANY AUTO g pV 6232707 04/0112018 04/01/2019 BODILY INJURY(Per person) S OWNEDUIRpTHgUpONLY X AUOTI VLLEEDD X. AUTOS ONLY X AUTO$ONLY prpDOPEgTYDILY VAMAGE RY(Per occident) S 1�er ecc,denl� { S C UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,000,000 X EXCESS LIAR CLAIMS-MADE EXC10008636003 04/01/2018 04/01/2019 AGGREGATE $ 2,000,000 •• DED RETENTIONS D WORKERS COMPENSATION p & AND EMPLOYERS LIABILITY STATIITF pRTH• ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WCE00431903 06/3012018 06/30/2019 1,000,000 QFFICERft4 M9IAi EXCLUDED? L NIA FL EACH ACCIDENT $ 1 endo cryFln ) 1,000,000 Il yesdescribe under E.L DISEASE•EA EMPLOYEE S • DESCRIPT!QN OF9PERATION$below _E I.,DISEASE•POLICY LIMIT $ 1,000,000 i/ • ESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES (ACORD 101,AddIIlonsl Remarks Schedule,msy be attached II mon spice Is required) 'orkers Compensation includes Officers or Proprietors. . . dditionel insured status Is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. noes Liability Is follow form. • :ERTIFICATE 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 Li ,CORD 25(2018/03) ©1988.201E A r.npn nnoonoArinA, • • • I U 1 • C.• Commonwealth of Massachusetts 1 j Division of Professional Licensure •Board of Building Re� ggulations and Standards Constr�t:CStlirtl$G'p�rvisor 4 CS-100988 .. ,r. 7,J r,l , EXpires: 11/11/2019 • HENRY E CA)SIDY:ct'1ijr C.+.' + p toil* WEST YARMOdT�MA12§78 '> ' • Commissioner l/I- • R ' ` Office of Consumer Affairs and Business Regulation b 10 Park Playa • Suite 6170 Boston, Mag$ 'bt usetts 02118 a - Home improveme.::.4+ .o. jractor Registration .!1...,6tl. YVI..II'J�41 ic!,!, !'tiv��'6�iI'tt4,�rval�ar;�,�r;�r � ;,I;;rnl.,;;:: I :tk'r � ,pl :�:•:•:,; ,as,•gs:k;:,,,i Typo: Corporallon Cape Cod Insulation Ino 14 '^fi ''�/"'! / "' ''f''1 it' //' Registration: 163567 ii,!',i i / , I , • 18 Reardon' Circle 1,+•I'livid Expiration: 12/14/2018 • So, Yarmouth, MA 02664 ,, '' :':`''! } " :S,I,,i . _ \' xm • ., aid• vJilt • "0"/.:.61.:4./.5,1 V. '\...-1- ' •.1 . one.Vpdale Addroea and return one. Mark reason for chon0o \ ICM 61 41M.06/I1 . ., aam.,CI Ittnn.v;n:_r.PF.n plOymonLal,ri..t.Crrie • �o�o7ryr6weruvro��u�Cd2�(rtatlrec�6atl4<(v 'A• oNleo of Con,vmer Allaire & Byline's Rogvletion \t� ROM! IMPROV!MaNT 00NTRACTOR Rogletratlonvalid forindlvldual.Vee only „ pet Corporation before the expiration date, ��•, P If lou • 4 urn tel e• jnjainv Exnlr^IIo" 0111/4 ofOonsumerAffairs end�'= • Cape Light D Compact e„ 5 Dupont Avenue South Yarmouth, MA 02664 '4 n` i. M3 OWNER AUTHORIZATION FORM I, MARILYN N DILILLO (Owner's Name) owner of the property located at: 255 Pine Street • (Street) YarmouthPort, MA 02675 (Town, State, Zip) hereby authorize (' r,,, jj d, -1-Ncc')1I Tv (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. -Custom i ature -Sign Date 05/02/2018