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HomeMy WebLinkAboutBLD-19-003246 r :_��•� Office Use Only Permit* • . ." }: Amounts ^'11^.x..\GT.` Ct7:::.Tn ' •.. a. e_. <. Permit expires 180 days from issue date lib— I q-a73.1 Ola EXPRESS BUILDING PERMIT APPLIC a 1 r C E I V E D TOWN OF YARMOUTH ' Yarmouth Building Department way 27 2018 1146 Route 28 South Yarmouth, MA 02664 BUILDING DEPARTMENT (508) 398-2231 Ext. 1261 By: — CONSTRUCTION ADDRESS: 7 5 1014 *opt—. • ASSESSOR'S INFORMATION: • Map: Parcel: OWNER: 1(C.'^'— kW& ',Vt4 ':/f-• 737-Q 705 NAME PRESENT ADDRESS TEL. 0 CONTRACTOR: Henry Cassidy Cape CodInsulaao 18 Reardon Circle South Yarmouth 508-775-1214 • NAME MAILING ADDRESS TEL# la Residential 0 Commercial Est.Cost of Construction$ 4 OO' r Home Improvement Contractor Lie.# 153567 Construction Supervisor Lie.# 100988 Workman's Compensation Insurance: (check one) - I am the homeowner I' I am the sole proprietor k I have Worker's Compensation Insurance Insurance Company Name: Atlantic Charter Insurance Worker's Comp.Policy#WCEQ0431902_i WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# G Replacement doors: # Q� Roofing: #ofS nares3in�i QW VW q ( )Remove existing*(max.2layers) a��`r Insulation �' yiz gij j,• xP5 Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing 1t, 'I,, di/4RA to `'/R- 37 caeca& fv ,The debris will be disposed of at: y'ylt (//{t(WLP 10 7a � Location of Facti OWL I declare under penalties of perjury that the statements tkre tained ore 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 under M.G.L Ch.268,Section 1. , X71 ZO Henry Cassidy ~: - Applicant's Signature, :.,,.:..w Date: 1 q Owners Signature(or attachment) Date: Approved By: i Date: //— 2 Buil a - (or d igncc) AIL ADDRESS: e Zoning District: Historical District: C Yes ! No Flood Plain Zone: Yes L No Water Resource Protection District: Within 100 R.of Wetlands: Yes :: No :: Yes .: No M .� . =' Permit Authorization ''Irl 1 mass save Form w" ST rncur fn.r7y tNrreney Site ID: 3560511 Customer: AnnMarie Savery I, R(N-W\c\Ne &ire(k 1 ,owner of the property located at: (Owner's Name,printed) / 73 Swift Brook Rd South Yarmouth, MA 02664 (Property Street Address) (OW) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform Insulation and/or weatherization work on my property. (� Owner's Signature: c>d'jl_ (,ri. Date: /b/LS J / c l� FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Com. Co�Tn, (an /o//4 `Participating Contractoractor Date Name: RISE Engineering Phone: 401-784-3700 Email: For Office Use Orly Rev.102015 It • tt U • \ -- . i LOa' Commonwealth of Massachusetts ) Division of Professional Licensure . .Board of Building Re uiations and Standards ConstrtAtArt'Mlip;,rvi sor • /J CS-100988 S' „ 7l r ii E plres; 11/11/2019 • J� • r �tlj. �u 4,.w HENRY E CAS�JSIDY', .I ' ' E. I, 8SHED ROWi ' '0111 '� •-� WEST YARMOGT,H MA."02673 Vic ' qtr/'>J.CS'[:.ICY1� •arkrlJ,'Sbotit:Zi ' Commissioner • sa..,F kil.)160,1e Voilvrno4uctecri% cv/C/�/�zj/jea / 0, Office of Consumer Affairs and Business Regulation "' 10 Park Pima . Suite 5170 Boston, Ma at usetts 02118 • Home Improvement:?a.otractor Registration ,'. .A ry •41k';:ts .;lIPLT '"" I, !„ !,:I' . ,r',,p�;::,:,: )) Typo: Corporallon 'ti '`.;yrtg/..�I ,r !,?I!§;S` :.1 U Roglslratlon: 183887 Cape Cod insulation, Ino ," /l,�,1.1,,;;,,;,,;, Iy Explrallonr 12/14/2018 • ,.: ,,,r,,. 18 Reardon Circle ,,,r ,,;;;;,.. ' So, Yarmouth, MA 02804 �;�6� ,'„ a.', :.:,+��� ,/, — y, . iiii n r% /N • ,pW 0 4oA OM% ^� Vpdaia Addrose and !alum card. Mark reason lot thong!. ....,....._._..�._�_.�....�...,.,....,.,��.,_�.[./.,.__�.,..,......... . ............_,,.,.,...(�.Adr„naam.,l;�.n.tne.lr;n:_f.�P.m,�l:ymanl..L.l1n:.1.Cr.rr• r W' o Votiona16(CNetlek 02/11 r4Jtr•r4(NoM . Wu 01 Comumor NloIrs h 8uolnoar Ropvlallon ft • HOMEIMPROVBMRNTCONTRACTOR i»,oei ,,,, Won Reoletrallo plraLvoile forInte, It o,q . a 74,po1 Corporation bolor!the rxplrallon dote, II Ioyh• 1; urn tel •� yuylcv P•xnlr/2015011lee ofOonaumarAttair' and'= al ,as Rr ulation ' " ({�'�1t�1'h�,l�)1 12114/2018 10 ParkPlora8 • a 6110 g 't1)1, it.i ,\' 'E • eoalon,MA 0 114 Cape Cod maul Il (� I C t1k I?\ ' HenryCaseldy'r„ .,1 ,"+i(, /.j IB Reardon Clrol u1 •,j,` 1,41:1 2 cCQ So,Yarmouth,MA,,.,p;�,.M C e '.•1"1' Yndoreeoretary "'Ii's • "/• hoot 91 att.!, • I.' pumo • The Commonwealth of Massachusetts _tri Department of Industrial Accidents _lsai'-- I Congress Street,Suite 100 Boston,MA 02114-2017 • ,6 www.mass,gov/dia Workers' Compensation Insurance Affidavit: Builders/ContractorsiElectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Letribiv 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?Clack the appropriate box: Type of project(required): 1.©l am a employer with 48 employees(full and/or part-time),• 7. ❑New construction 2.01 em a sole proprietor or parmership and have no employees working forme In 8. 0 Remodeling any capacity.(No workers'comp.insurance required.) 3.01 em a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition 4.0 I em a homeowner and will be hiring contractors to conduct all work on my property. I will10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 i am t general contractor and 1 have hired the sub•contncton listed on the attached sheet 13.Q Roof repairs These subcontractors have employees and have workers'comp.Insurance. 6.0 We are a corporation and its officers have exercised their right of exemption per MOL c. I4. Other Weatherization 152,11(4),and we have no employees.[No workers'comp.Insurance required.] 'Any applicant that checks box Yl 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 end then hire outside contractors must submit a new affidavit indicating such. tContracton that check this box must attached an additional sheet showing the name of the sub-eontacton and state whether or not those entities have employees. If the subcontractors 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 andJob site information. Insurance Company Name: Atlantic Charter • Policy#or Self-ins.Lie..#: WCE00431902 • Expiration Date. 06/30/2011 Wit) Sob Site Address: ' / 1,4 l PE k City/State/Zip:i and ' "` ti"." Attach a copy of the'workers' compensation policy declaration page(showing the policy numb• and expiration date). Failure to secure coverage as required under MOL c. 152,§25A is a criminal violation punishable by 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.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 tire pains and penalties of perjury that the information provided above is true and correct. Sitnattltet HenryCassldy Date: ij/2-7 //g 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.CitytTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6,Other Contact Person: Phone#: _.---"1 CAPECOD-27 AMAELEA ACORO• CERTIFICATE OF LIABILITY INSURANCE DATE 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(tt . PRODUCER WCT Rogers&Gray Insurance Agency, Inc. PHONE 436 Rte 134 (NC,No,EMI: I FAX Nol:(677) 816-2156 South Dennis,MA 02660 ss,mall@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC a INSURER A:WestAmerican Insurance Company 44393 INSURED .,. INSURERa1Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER a:Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER 0;Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E; INSURER F: COVERAGES CERTIFICATENUMBER) 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. INSR ADOL SUER LTR TYPE OF INSURANCE INRD wVD POLICY NUMBER POLICY EFF POLICY EXPMI/pint=IMMlnnp^py)J DD/yyyY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE § 1,000,000 CLAIMS-MADE a OCCUR BKW(18)53328281 04/01/2018 04/01/2019 DAMAGETO RENTED 100,000 _5.._ ,A.as a, ,rare" 4 MED EXP(Any one Carson) 3 5,000 PERSONAL a ADV INJURY § 1,000,000: SFN'LAGGR ATEJ RMOITAPPLIES_ `OER:R'. 2,000,00 X POLICY P L GENERAL AGGREGATE § X OTHER.see holder de.cdp of operations _ •• 4 - • • ei § 2,000,0001 COMBINEDSINGLE LIMIT § B AUTOMOBILE LIABILITY 1,000,000 fFe ecdtlenn § — ANY AUTO 6232707 04/01/2018 04/01/2019 BODILY INJURY(Per person) § ... OWNED SCHEDULED AUTOS ONLY X AUppTNNOppSWw1N.�EEpp PBPORDILY INJURYT (Per accident) S X 1-Fra ONLY X AIJTOSONLY (PeoaccvTRAMAGE 3 C UMBRELLA LIAR X OCCUR $ EACH OCCURRENCE S 2,000,000 X EXCESSLIAB CLAIMS.MADE EXC10006635003 . 04/01/2018 04/01/2019Anem3 A 2,000,0001 DED RETENTIONS D WORKERS COMPENSATION PER p S AND EMPLOYERS'LIASILITY I I I FR YYY III NNN H• ANY PROPRIETOR/PARTNER/EXECUTIVE w..04,1903 06/30/2018 06/30/2010 STATI RF FR FICERrtAEMBER EXCLUDED? NIA EL EACH ACCIDENT § 1,000,000 anoatory in NM) „ If yea,OWN;under EL DISEASR•EA EMPLOYEE 1,000,000 •• D $dRIPTICN OF OPERATyNSSslow iLL,DISEASE•POLICY LIMIT $ 1,000,0004 / • ii •r DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remark*Schedule.may be attached If more pace le 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 Llablllty is follow form. _CERTJFICATE_IOLDER 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(2016/03) ©19B8.201R At`nan rnoono•r,..., a„.,_,..______._..