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Home My WebLink AboutBLD-19-003002 -<:-: -.., RECEIVED Office Use Only ,r j r 7Z, Permit* '� .I,...;;• is a \�. l�, I .,.:c4 I,r � NOV 14 2018 ,3s- -, y,::%, ,,,. Amount `.'.'` iI lL � ;" By I lJ1 " Permit expires 180 days from EXTIC issue date B EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 �j GJJ-� (508)3x998-2231 1Ex�t.. 11�261� '11 ��,/�'�/ CONSTRUCTION ADDRESS: " `"�V'� ""�E_ lN�-"✓__ W. �l -` • ASSESSOR'S INFORMATION: //''''^^ Map: Parcel: OWNER:CIU.t'Ulet 1 I tev, z;NAME PRESENT ADDRESS TEL. II 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$ .217°0_ Dv Home Improvement Contractor Lie.# 153567 Construction Supervisor Lie.# 100988 • Workman's Compensation Insurance: (check one) - C I am the homeowner f' I am the sole proprietor Z I have Worker's Compensation Insurance Insurance Company Name: Atlantic Charter Insurance Worker's Comp.Policy#WCEQ0431902.. WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # `A Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation ,! Old Kings Highway/Historic Dist. ( )Replacing like for like PoolF04114)ORMED T �rt� AIy/� //��nplI��///�� Un��v�f', ear 1e!(,(f`-11 /' ,t *The debris will be disposed of at: V.V1 `& th tu. &rata /L�a (J tR Kiv•Wrd tit(1/.•' iLocation of Facility 1( � 0 ID t I declare under penalties of perjury that the statements tkre contained are true and correct to the best of my Imowledge and belief. 1 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 1. Applicant's Signature: Henry Cassidy a ;M- "= Date: Owners Signature 0 Date: Approved By: �•d rrlis• Date: /A—/�—Ye Buildin: ' 1 '.'or de tgnee) E ;y!IWADDRESS: Zoning District: • Historical District: C. Yes ! No Flood Plain Zone: ' Yes L No Water Resource Protection District: Within 100 ft.of Wetlands: Yes :: No 7. Yes C No RI S E s Dupont Avenue I South Yarmouth,MA 026841 508-558-1926 ENGINEERING www.RJSEengineering.com OWNER AUTHORIZATION FORM 1, ,JaitA-ke y cs _, (Owner's Name) owner of the property located at 95 S;l Pal Lac (Property Address) We-51- 7ovrrn t, t __A nT 0 6 v 3 (Property Address) hereby authorize (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 municipals at the completion of this work. Owner's •-ture e (( Date 9.2019 The Commonwealth of Massachusetts Department of Industrial Accidents • l _ 1 ' Office of Investigations 1 Congress Street,Suite 100 ya Boston,MA 02114-2017 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. 0 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 g. ❑ Demolition working for me in any capacity. employees and have workers' 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.❑ q ] officers have exercised their 11.0Plumbingrepairs or additions I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152,§1(4),and we have no Weatherization employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box NI must also fill out the section below showing their workers'compensation policy information. f 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 Expiration Date:6/30/2019 • Job Site Address: '2h �V Q v' '"r CAA& City/State/Zip: Lu' aV i Attach a copy of the workers' compensation 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 aminal 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 providea above is true and correct Henry Cassidy -n,.w„••-m Date: IAV• I2 / iZOt t 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#: • I li l • \ c' Commonwealth of Massachusetts I. Division of Professional Licensure . •Board of Building Regulations and Standards • , ConsQwO'thbrf% ,;rvisor /1 CS-100988 S' '• �l r!IY Ejtolres: 11/11/2019 • • Y „ III �(y,,. n , • HENRY E CA€91DY' I lif O SSHED ROW� •��f�I < "' " WEST YARMOGS�d MA:'02879 ?+C Vt.-.4, Commissioner e • Z..\ 52p9c2ziwyno4veoecrig 12A/,e cza,aci lir Office of Consumer Affairs and Business Regulation 10 Park Playa • Suite 6170 Boston, Ma t '4 usetts 02116 Home improveme:.:VConn tactor Registration ,1•o0.n.:tvt••unrar,�:l�rr-r, „pl : �;J �„�,,,, ,;.,,;;. J Typo: Corporation Cape Cod Insulation, InC j1it'ii'',r;'�t ,r .,,,” ,. " Registration: 183587 ;i, /t„4/ �i,,,,•; y Expiration: 12/14/2018 18 Reardon Circle iv "•,, 4: ;,;,;,,, ,t • So, Yarmouth, MA 02664 \ '''' i"j1F _ • a, {\n, I;y� ....) Update Addrose and return oard. Mark reason for chsngo 1CA4 0 4oA4a6111 . \` _._..,�._.�(}�..._ ,.,......•....•_ ...•.__ •....•.._•.... . ............._•..••....('/..Ad l:ase,.,tn.11•rne.Ir;nl.f'lPF p1o/m:an6.C11cwt.ce.r� Ono 1pOMMOMVUrtie itYleadurer/rroot(D ,or Office el Conwmer Malts& evilness Regulollon kit. • HOME IMPROVEMENT OONTRACTOR il before a vend for lnIGI t o;Ulv only:• Si�.p o1 corporation holora the explralton dpto. II to h• ..,� 3 urn 101 jrg,lvs exnlrnllop 011loo ol0onaumvrAffair; and el as Regulation '''�"�d • i• 'Prti;Ux.' � e,7, 12/14/2018 10Pork Plant, • 08170 V , t\' '0" 8oalon MA • It; • Cape Cod insoi�l \,''PI�J10 `I`�' I'.t Henry Csssldy'gl `,yi�}tl1pp(4i // 18 Reardon Ciro' , ji�t,. „ R,c ,_., / _ So.Yarmouth,WOO o C� . Is ':'5 ' Vndoreevretary al haul al tu•(,.t 1:1 • ,-e�✓ CAPECOD•27 AMAHLER ACORO' CERTIFICATE OF LIABILITY INSURANCE DATE 4/.....------ 0610506/05120116 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 provIslons 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 A2t;lAACT 20 ers&Gray Insurance Agency,Inc. jHONr o,Eat): FAX No(677)616.2166 034 Rte 134 3outh Dennis,MA 02660rad'69i�ss•mail@rogeragray,com INSURERISI AFFORDING COVERAGE NAICI INSURER A:West American Insurance Company 44393 INSURED INSURERa:Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER c;Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER o;Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER EI INSURER FI 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. NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TOWHICH 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, ILTR TYPE OF INSURANCE IINSO$NNO POLICY NUMBER POLICYM'DDEFF POLICY EXP IMYEFF IPOLIC YRYYI LIMITS A X COMMERCIAL GENERAL LIABILITYEACH OCC7pURRENCE f 1,000,000 CLAIMS•MADE ❑X OCCUR BKW(19)53328281 0410112016 04/01/2019 PREM REESLEIoccurr0encel $ 100,000 — MFO EXP(Any one Demon) $ 5,000 _ PERSONALS ACVINJURY 1 1,000,000 Sin AGGRME LIMIT APP S PER: GENERAL AGGREGATE s 2,000,000 X POLICY 5R&' LOP . PRODUCTS•COMP/OP AGO S 2,000,000 Xsee holder descrip of operations OTHER: i B AUTOMOBILE LIABILITY lFOMBINED SINGLE LIMIT i 1,000,000 — ANY AUTO 6232707 04/01/2018 04/01/2019 BODILY INJURY(Per person) 1 y OWNED ONLY X 6oTNTjpgwULNEED • p BBPOODILY INJURY(Per accldenn $ _ .X AUTO$ONLY X AAVTOOSSONLV (Perr actldenI,IAMAGE I $ 4 C'_ UMBRELLA LIAR X OCCUR EACH OCCURRENCE s 2,000,000 X EXCESS LIAB CLAIM$•MADE EXC10006835003 04/01/2016 04/0112019 AGGREGATE $ 2,000,000 • DEO RETENTIONS KM. i D WORKERS COMPENSATION PERTI ITF AND EMPLOYERS'PRIETOR)PARTILITYNERI �V',l(�N,I WCE00431903 0613012018 0613012019 1,000,000 A�NFFIpPERRAEIMTgORlEXCLUDED7 ECUTIVE U RIA E.L EACH ACCIDENT $ (mentld Dry lnN u 1,000,000 Il vyet describe under E DISEASE•EA EMPLOY'S • DESCRIPTION OF9PERATIgN$¢plew E.L,QISEA$E•POLICY LIMI $ 1,000,000 /1, DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Addltlonel Remarks Schedule,may be attached If more specs 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 REPRESENTATIVE �,u I Zeia " .__......n.LM•0/MM\ /A.4,100 *Ma A rnnn A...nag •n d.u_._......A