HomeMy WebLinkAboutBLD-19-003006 .:.� -., Office Use Only
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`'�ti:;,�,aila-, issue date
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k-1' BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
/�'�,//�/(5088))r398-2231 Ext. 1261 �y� �q��7 IQ•
CONSTRUCTION ADDRESS: Illi 1t4 21 I uiweY t�vs� OD, ctvri t' atl •
ASSESSOR'S INFORMATION: •
�f��I� /,�, /'l Map: Parcel: '
Qj9
OWNER: lt-' f k• Egos• -47-7e,
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: Henry Cassidy Cape Cod Insulation I8 Reardon Circle SouthYarmouth 508-775-1214 •
NAME • MAILING ADDRESS TEL.# ,
RI Residential 0 Commercial Est.Cost of Construction 5 1 SOD - irb •
Nome Improvement Contractor Lie.# 153567 Construction Supervisor Lic.# 100988
Workman's Compensation Insurance: (check one) -
T I am the homeowner r I am the sole proprietor k I have Worker's Compcnsation Insurance
Insurance Company Name: Atlantic Charter Insurance Worker's Comp.Policy#WCEQ0431905—'
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) Insulation N
(two Aur"Mai(Al
Old Kings Highway/Historic Dist. ( )Replacing� likey� for like Pool fencing
*The debris will be disposed of at: ttYL{,p W'C`s
// Location of Pao iI ry 1
l declare under penalties of perjury that the statements here tained an true and correct to the best at my lalowledge and belief. I understand that any false answer(s)
will be just cause for denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section I.
Henry Cassidy
a......rry 1418
Applicant's Signature: ,.....„,�,••. Date: /
m
Owners Signature(or attachment) Date: �j
Approved By: ,�.. Date: ///�Vg
Building Offi '. (or ignce) EMAIL ADDJeafS:
Zoning District:
Historical District: C Yes ! No Flood Plain Zone: ' Yes t: No
Water Resource Protection District: Within 100 ft.of Wetlands:
Yes :.: No 7. Yes C No
•
-------"I CAPECOD-27 AMAHLER
ACORO• CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
kir-- 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 such endorsement(s).�p
PRODUCER CNW��ACT
topers&Gray Insurance Agency,Inc. RHONE
AMX
(uo ,No):(877)616.2156
134 Rte 134 (NCr0
South Dennis,MA 02660 li ss:mall @ 9er8 ra CO
9 y m
INSURER IS)AFFORDING COVERAGE NAICR
INSURERA:West American Insurance Company 44393
INSURED INSURER a Safety Indemnity Insurance Company 33618
Cape Cod Insulation,Inc. INSURERC 1 Endurance American Specialty Insurance Company 41718
18 Reardon Circle INSURERD:Atlantl0 Charter Insurance Company 44326
South Yarmouth,MA 02664
INSURER E:
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,
INSLTR TYPE OP INSURANCE ADDL
Seo POLICY NUMBER POLICY EFF POLICY
IMOLICIY (POLICYYEXP LIMITS _
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE m OCCUR BKW(19)53328281 04/01/2018 04/01/2019 DAMAGE 70RREENTEDnre1 1 100,000
_ MED EXP(Any one Demon) S 5,000
PERSONAL aAOV INJURY $ 1'000,000
—
SiN'L AGGR LIMIT APP S PER: . GENERAL AGGREGATE S 2,000,000
X POLICYLj & Li LOO. 2,000,000
X see holder doc pof operations
PRODUCTS•COMP/OP AGO 1
OTHER: S
B AUTOMOBILE LIABILITY CO(Fe eBIN DI SINGLE LIMIT S 1,000,000
ANYAAUTO gg p 6232707 04/01/2018 04/0112019 BOOILY INJURY(Per person) S
,� AUTU BOOS ONLY X AUpTNOpSyUyLLEEDp pBpOORDILY INJURY(Per(ccIdent) $ _
' X AUTOS ONLY X ORM? (Perr ecc'dnIQAMAGE .S
'(i• UMBRELLA LIAB X OCCUR 2,000,000
EACH OCCURRENCE $
X EXCESS LIAB CLAIMS-MADE EXC10006635003 04/01/2018 04/01/2019 AGGREGATE $ 2,000,000
•• DED I RETENTIONS $
0 WORKERS COMPENSATION PER OTH•
AND EMPLOYERS'LIABILITY YIN STATUTE FR
ANvpaoPRlEroaronRTNERrsxscutive WCE00431903 06(30/2018 06/30/2019 1,000,000
ApFFIOERP eM PROPRIETOR/PARTNER/EXECUTIVE L NIA E.L.EACH ACCIDENT $
(mandelory Ind j 1,000,000
Il99a describe unser E.L.DISEASE•EA EMPLOYEE $
• DESdRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT S 1,000,000
/'
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additions!Remarks Schedule,may be attached If more apace Ie required)
Norkers Compensation Includes Officers or Proprietors.
4dditional Insured status Is provided under the General Liability and Auto LlabIllty when required by written contract or agreement with the Certificate Holder.
Excess Liability Is follow form. ,
•
CERTIFICATEATE HOA E DDER 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
•
CDIT
I `
--•-. -•ww,aad n,,.a% T 411000„4 f A 1•f11,19 A•ren\, •,,.,..,.•. -----••-J
The Commonwealth of Massachusetts
Department of Industrial Accidents
.
rThr l Office of Investigations
=r_ q_ 1 Congress Street,Suite 100
• Boston,MA 02114-2017
Ns'. www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/organization/individual): 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 box: Type of project(required):
1.0 1 am a employer with 48 4. ❑ I am a general contractor and I 6. ❑New construction
employees (full and/or part-time).' have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
workingfor me in anycapacity. employees and have workers'
P �• 9. 0 Building addition
[No workers' comp. insurance comp.insurance..
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no Weathedzation
employees. [No workers' 13.0 Other
comp. insurance required.]
"Any applicant that checks 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 contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-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 job site
information.
Insurance Company Name:Atlantic Charter
Policy#or Self-ins. Lic.#:WCE00431902 n' ,, Expiration Date:6/30/201t1
Job Site Address: Ila (( 4 'Ttt't' ct City/State/Zip: J• (J�ltLr -o0-, 01-1l
Attach a copy of the workers' c pensation policy declaration page(showing the policy number nd expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 providedaboveis true and correct.
Signature: Henry Cassidy - A•v,...«< "�"" Date: 1 111/• I I it)ft
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#:
\hili
RISE
ENGINEERING
OWNER AUTHORIZATION FORM
I, Beth Fanara
(Owner's Name)
owner of the property located at:
116 Mayflower Terrace
(Property Address)
South Yarmouth, MA 02664
(Property Address)
hereby authorize rQg e Co A SrSC) ct. cA4
(Subcontra or)
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.
Owner's Signature
I t
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926
www.RISEengineering.com
•
•
•
C,
gr' j Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Re9ulations and Standards
Const $Ctt$rt%SbYppp;rvisor
•
/J.
•
•
CS-100988 S
1-
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ires: 11/1112019 •
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• ' ),:;141151.1 . f
HENRY ECA63IDY4 ,1f
B SHED ROw� . y , CWEST YARMOGTfMA0679 �
' Commissioner l/^^'
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•
Q-7 the C9C4/14/11041461e0/4 157CP/, Cil/e,e4e0.
klit rIIOffice of Consumer Affairs and Business Regulation
10 Park PlaAa • Suite 6170
Boston, Magabusetts 02116
-- Home Improveme.fi:�j4+C.o tractor Registration
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!,•1�1 ''Wiln ,,' :i�u;: )� Typo: Corporation
,`,t;; ii)1'r'' , ' •.a;;•;}r 1/' Reglstratlon 163987
Cape Cod Insulation, Ino ;a ,,:cih:. 1 1•�;,i,,;: ,i Expirallonl 12/14/2018 •
. • le Reardon Circle
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1.•,��+vim Update Adding and return card, Marty reason lot change.
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p,,�;, '• HOME IMPROVEMENT CONTRACTOR Reelslrollon valid for lndivldual;uaa only
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