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Home My WebLink AboutBLD-19-003248 -Ir r.. ,` Office Use Only Y-s,,, : ! ` r + Permit* • .."'r "tr 1 Amount• _ <<'yo-`',F..• Permit expires 180 days from ?=:A'' issue date EXPRESS BUILDING PERMIT APPLICA ZR___ � E-- D TOWN OF YARMOUTH NOV 27 2O1B Yarmouth Building Department 1146 Route 28 ----- South Yarmouth,MA 02664 a: — L Oltri (508)• � "�398-2231 Ext. 1261 qanum /J /CONSTRUCTION ADDRESS: 17 Z I V��(�' U' vYt"�=� JO l�7"ASSESSOR'S INFORMATION: 11 / Map: Parcel: ' WI 1vv1(, , �z OWNER: � IL�TO�� 7741-q49/- 5642- NAME PRESENT ADDRESS TEL. # CONTRACTOR: Henry Cassidy Cape Cod Insulation IS Reardon Circle South Yarmouth 508-775-1214 ' NAME MAILING ADDRESS TEL.# , R Residential ❑Commercial Est Cost of Construction$ �J 1500 home Improvement Contractor Lie.4 153567 Construction Supervisor Lie.4100988 Workman's Compensation Insurance: (check one) I am the homeowner C I am the sole proprietor X I have Worker's Compensation Insurance InsuranceCompanyName: Atlantic Charter Insurance worker's Comp.Policy#WCEQ043190 , WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: 4 of Squares Replacement windows: # Replacement doors: /L 6,719 R-I�l kit frcuC �OCL tr[G Roofing: 4 of Squares ( )Remove existing*(max.2 layers) a Insulation 2 rl/�� bet ,t 38G Y'fret vef srrcz Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing �,t .,/� �y/� 1714-30�� faced if l� h'�r fa 27z't Met "The debris will be disposed of at: �YIAJ W4& (�t�v L r Una �dll// 3 /U tir' 4« zill 7 Location of Fact ity 1 I declare under penalties of perjury that the statements Ikre' contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will he just cause for denial or revocation of my license and for prosecution under M.O.L.Ch.268,Section 1. Applicant's Signature: Henry Cassidy SN. - l':. r '- -. Z( , Zp G�ml.v,..,.,,, .. Date: Owners Signature(or attachment) / Date: Approved By: f1 Date: /7---2‘--- Build' , (or esignce) AIL ADDRESS: Zoning District: Historical District: i:. Yes i No Flood Plain Zone: Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: ` Yes :: No Yes C No • it lJ \ a r Commonwealth or Massachusetts I Division of Professional Licensure . •Board or Building Regulations and Standards ConsQ4 tk rtl$G'pprvisor CS•100988 5 J , 11 gjcpires: 11/11/2019 • • , n� t*l.,• n • HENRY E CAtSIDY.�•,��t1� B SHED ROW- ) , , WEST YARMOGTpJ MA. 0 675 e?c ' /tGA'S'7.Ilnn�, ...tt• .,r, • ' CACommissioner // ct,-4iri, Office of Consumer Affairs and Business Regulation ci 10 Park Plaza • Suite 5170 Boston, Mappr 1 usetts 02116 -• Home Improvemetnn:V? •o.ntractor Registration ,inn.:,,t'snrz.,:,,,, 1 r. r h,4d::: ,4}•ift ,, Typo; Corporation Cape Cod Insulation, Inc 0. ;:; ,,,,lt ,,• •.,,nDcC i; Registration: 123687 18 Reardon Circle tG';1s"' Explrallonl 12/tar2018 4, ,.11..:1: So: Yarmouth, MA 02664 '� "'''11it`''` ;'••":i!' 'f, __ •11"a; rr % moon'�••'•�� Update Address end return oard: Mark for chango ICA, a 20A106111 . f 11•uae.lrra;.f 1.°n plaYmon6.111est.^rrr cnoYp'otw,ao+eruvrrlUvt2,Roaarar/rroottu Oilier,el Vonevmer Moire & helms;Regulation r '0I HOMB IMPRCVBMCNT CONTRACTOR Ro9letraticn vend ler indlvidual:Vere only l.ypoi Corporation 4vlory the expiration date, II I¢ n• 6 urn tot N�' ,jtly;lr exnlrnllo0 Clllao of Consumer Attain and'= al 'ea Regulation °'' ' • ",•''�'L�S�;I:. „� V,7E 12(14/2018 10 Perk PIM. • 0 817, Cape Cod InaOl�li''�� rJoJr¢`1�' r\• ?wry CassldY'V.,,, ,911q({rl !/ tBRearden Clro§ { l7 7 \¢ c�.�,� •, So,Yarmouth,MAI•4)0,$;QI41'• C u fa /'_ Vndorseoretary t BI • ' �� haul Si Btu ..-----"1 CAPECOD-27 AMAKE ACORO' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDITYYY) 1 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 BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED I 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 enndorsement(* .. j PRODUCER N%�'EACT i Rogers&Gray Insurance Agency,Inc. PHONE (NC,No,Est): FAX Nol:(877)816.2156 434 Rte 134 South Dennis,MA 02660 fAA6ss,mail@rogersgray.com !I INSURERIS)AFFORDING COVERAGE NAIC a INsuRER9lWestAmerIcan Insurance Company 44393 INSURED ,r INSURER a?Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER C;Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURERD:Attantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E: INSURER le: i COVERAGES CERTIFICATE NUMBERS 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 I INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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. !NSR ADDL SUER ITR TYPE OF INSURANCE !NSD WVD POLICY NUMBER I POLICY Ij OLIC I LIMITS A X COMMERCIAL GENERAL LIABILITY A NeC URREN E 1,000,0001 CLAIMS-MADE a OCCUR BKW(19)53328281 04/0112018 04/01/2019 OAMAGE;TO RENTED 100,000. M • X- An •ne•ere• 5,000 1,000,000 GEN'L AGGREE LIMIT ARMIES PER: ,3:IarGl4.1:/ 2,000,000, 1IPOLICY lei I LOS' PR.DA S. •MPOPA 2,000,0001 see holder docile of operationsX OTHER: $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 ANY AUTO EE 6232707 04/01/2018 04/01/2019 ;.DI IN RY P.her.on AUTOS X AUT5SULED IM? ooNFI ppyW�NE�pp BODILYpITTNJ RY Pe aooldenl X AUTOS ONLY x AIJTOSONLY P-rreE Tenl AMAGE A. C. UMBRELLALIA9 X OCCUR $ 2,000,0001 X EXCESS LIAR CLAIMS.MADE EXC10006635003 04/01/2018 04/0112019 2,000,0001 DED RETENTIONS D WORKERS COMPENSATION E AND EMPLOYERS'LIABILITY I 5 PAR I I�QRTH• ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WCE00431903 06/30/2018 06/30/2019 TI ITF Wm/149MEXCLUOED7 I NIA E.L,EACH ACCIDENT S 1,000,0001 • 11 pea,tlaacribe ansa E.L.DISEASE.EA EMPLOYEE $ 1,000,000 ... C $CRIPTION of OPERATIONS Wow .L.DISEASE.POLICY LIMIT E 1,000,000 /P 'I DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,AddItIonal Remarks Schedule,may be attached If more apace Is equired) Workers Compensation Includes Officers or Proprietors. Additional Insured status Is provided under the General Llablllty and Auto Llablllty when required by written contact or agreement with the Certificate Holder. Excess Liability Is follow form. CERIWICATE_H_OI;DER 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 JREPRESENTATIVE ia vrey ACORD 26(2016/03) 0 1988.201R Annan f`.no DnlaA+Ir,.. •„.,�,.._ -____. • The Commonwealth of Massachusetts Department of Industrial Accidents _ _ 't Office of Investigations Ia ��1= 1 Congress Street, Suite 100 it = 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.El 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.❑ 1 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 ❑ Building addition [No workers' comp. insurance comp. insurance? required.] 5. ❑ 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 Weatherization employees. [No workers' 13.• 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.#: C 00431902 Expiration Date:6/30/2019 1 i Job Site Address: 12 ki City/State/Zir:A Vl L 0)01/1-1- IV` A Attach a copy of the workers' compensation policy declaration page(showing the poli, n mber and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imps Ilion 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 provide dlrbove is true and correct. Henry Cassidy �� ,t�f�/nVt � ^I Signature: _nee- -^'-"'-�"'w 'Date: 24 / Z()fed 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#: \sit RISE ENGINEERING' OWNER AUTHORIZATION FORM I, William Astore (Owner's Name) owner of the property located at: 172 Thacher Shore Road (Property Address) Yarmouthport, MA 02675 (Property Address) hereby authorize C (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. itt Owner's Signa e Il- 6 - I9 Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com