Loading...
HomeMy WebLinkAboutBLD-19-003253 • .9 . "";:=,,. Office Use Only %:4'tee.: n\-•• '• z;ori,,,•; , 33--- t...,i"; ;:i i Amount :. IPTl'KercWe`r `"'" �%' Permit expires 180 days from • :..22..a.:317e#s issue date IVED EXPRESS BUILDING PERMIT APPLICA .` C E TOWN OF YARMOUTH ----- Yarmouth Building Department ����� �Q 1146 Route 28 ��0��2 /' South Yarmouth, MA 02664 Y��`"- BUILDING DEPARTMENT /(/� (508)�t8)398-223198' 0) Ext. I1,2'61 By _ _ CONSTRUCTION ADDRESS: "CJD /`�rti rte`""' W ` Vafrokint / ASSESSOR'S INFORMATION: Map: 17 Parcel: /5 3 OWNER: /%�C k 1(4d��//� [y/�cz3 122-1 N PRESENT ADDRESS .. TEL. # CONTRACTOR: Henry Cassidy Cape Cod Insulation 18 Reardon Circle South Yarmouth 508-7 75-1 214 • NAME MAILING ADDRESS TEL.p R Residential ❑Commercial Est.Cost of Construction$ IP" Home Improvement Contractor Lie.# 153567 Construction Supervisor Lie.# 100988 Workman's Compensation Insurance: (check one) • '_ 1 am the homeowner C I am the sole proprietor 5G I have Worker's Compensation Insurance InsuranceCompanyName: Atlantic Charter Insurance Worker's Comp.Policy#WCEQ0431901..+ WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacemenk doors: : ' Roofing: #of Squares et-�0 id*GGU y I" 2 4, q ( )Remove existing*(max.2layers) " ��s la on ��LO1tl/5 arty -�1�9,�/ Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing Grasfg: jC-2IG(n-,4 ed 10 736 �,`„ p �.b�i1v�6f w( r�eErwYr *The debris will be disposed of at: rylt 'tom ((""�""t �I( Q,(�,L� Location of Fact iry ipav "Y'p0� J -"vnr-' I declare under penalties of perjury that the statements ' contained are 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. Applicant's Signature: Henry Cassidy M R` : Date: r 2-6/ Z010 Owners Signature(or attachment) Date: �7� Approved By: /�- Date: /7 �. / Z B in lei ( design; EMAIL ADDRESS: Zoning District: Historical District: C. Yes I No Flood Plain Zone: Yes C. No Water Resource Protection District: Within 100 ft.of Wetlands: Yes :: No Yes C No • The Commonwealth of Massachusetts tee= 4 Department of Industrial Accidents _s ,=; OfceofInvestigations _ 1 Congress Street, Suite 100 '= = Boston,MA 02114-2017 sw -03 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: I Type of project(required): 1.0 I am a employer with 48 4. 0 1 am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. 0 Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition No workers' comp. insurance comp. insurance? required.] 5. 0 We are a corporation and its 10.❑ Electrical repairs or additions q ] officers have exercised their 11.0Plumbingrepairs or additions 3.❑ I am a homeowner doing all work P myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] f 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. #:WCE004'31199�02 Expiration Date':'6/30/201tj Job Site Address:�50 w City/State/Zip: W' �d��f r t11 ('" 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 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certifi,under the pains and penalties of perjury that the information provided above is true and correct Signature: Henry Cassidy .-...,,,,,,.... .,-* Date: 1QQ�"'J' le i 41/S Phone#: 508-775-1214 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: • • C • \ • l0C. r Commonwealth of Massachusetts / Division of Professional Licensure • .Board of Building Re ulations and Standards Const, tt4rtl%b'ppvisor ii CS•1d0988 S' Ek pikes: 11/11/2019 • HENRY ECASJSIDY':r;(I{,,tI...,' fi fl �Yj�t 0212WESTYARMOTJMA.1O2¢78 ' • Commissioner v'" / i • • &a.. U/-LPiep9o470/22o4vociec/fi A of Wg(vio LU'/�/ P/Z it ; \\,I . Office of Consumer Affairs and Business Regulation 10 Park Plaza . Suite 6170 Boston, Masta'btiusetts 02116 .. Home Improveme:. + .o�iyy'traotor Registration vrm.�avtun :mv^.,rt1,^ri '''s ^a fyiti''I`r hti4i1%;I{,,^'�I"r.'' ti\ ';;;Orli In111 ' '�� ��t' Typo: Corporallon Cape Cod Insulation Inc C I " rli�" ' } ' V Rogislratlon; 183587 18 Reardon Circle " ;? (' ' Expiration, 12/14/2018 .a.„•,,. So. Yarmouth, MA 02684 y\0M iivi \`?'t"' .' '+ 'f, i. / • <i•ita: t4,% • \ \•••• •/ Vpdelo Addrose and (alum and. Mark reason lot thong° ICM 45 4051,04/II \` ,.,....,__.--------------------..—.....•••• • •.......--........nAdr„+aam,.c .R.u1r;. ag_cia m,cia/mont..C.11nr.t.!;rrr. et,%twmororuvedep v/c7'l(rraare.r/aooM C. OHM of Comvmor Moira & ayslness Population �I HOM2IMPR0V!MENT CONTRACTOR j Registration gelid or Indlvldual:Ufa only 1•,y".p'ol Corporation on the ex trollop data, II Io,yn• II vtot 11 p itilitYPAIPWy}c;,it$ E /I4/2 16011loool0oneumerAllolr.1and': sl ,n Regulation' - •. 12/14/2018 10 Park Plata. eat7oCa eOodlnsulftl le.../,' 1`I rt � i • Boelon,MA • 11; Henry CassldY'iEM,\ :1) '`, ', �/ 18 Reardon Clrov,� 11�,. tt Q cC,g .., 30,Yarmouth,MA� ar ,Q IQ$, �o' C� ' O/.r. /, Vndorsecrstary t el • how sl atu-: • •.t • •------1 CAPECOD•27 AMAHLER ACORD' CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDDYYYYI `,� 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 poilcy(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 ppeE: endorsement(s). NAM PRODUCER CT 20 era&Gray insurance Agency,inc. (NC,NNo,Eat): FAX Nol:(877)816.2156 134 Rte 134 South Dennis,MA 02660 k'tnisa:mall@rogeragray.com INSURERS)AFFORDING COVERAGE NAIC N INSURER A:West American Insurance Company 44393 INSURED INSURER a:Safety Indemnity Insurance Company 33618 Cape Cod insulation,Inc. INSURER c,Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER 0 1 AtientIC Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE_4UM@ER: 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. NOTIMTHSTANDING 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. INTRR TYPE OF INSURANCE AINS IL YAM POLICY NUMBER IMMIIDDDIYY Ern1 I DDmYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE § 1,000,000 :■ CLAIMS-MADE a OCCUR BKW(18)63326261 04/01/2018 04/01/2019 PRFMISFS((FtecIT tu Snce) $ 100,000 MED EXP(Any one person) S 5,000 Ill PERSONAL 4ADV INJURY S 1,000,000 NI.AGGREE LIMIT AP�yP�1 LI PER: GENERAL AGGREGATE S 2,000,000 © POLICY j& IJ LOO• . PRODUCTS•COMPrOPAGG S 2,000,000 X is.holder ducrlp of operallons OTHER: S B AUTOMOBILE LIABILITY COMBI aEDI SINGLE LIMIT $ 1,000,000 IIIA ANY AUTO 99 pp 6232707 04/01/2018 04/01/2019 BODILY INJURY(Per person) 5 _ • III♦ AUTOS ONLY © AUTOgILEo BODILY INJURY(Per accident) 3 • AIMS B21157 Ep p OPERTiY AMAGE © AUTOS ONLY AUTOS ONLY (Iger accldenitj $ S C• UMBRELLA LIAR X OCCUR EACH OCCURRENCE S 2,000,000 © EXCESS LIAB . CLAIMS•MADE EXC10006835003 04/01/2018 04/01(2019AGGREGATE § 2,000,000 •• DED RETENTIONS S D WORKERS COMPENSATION PER 0TI4 AND EMPLOYERS'LIABILITY STATUTE FR ANY PROPRIETORIPARTNERIEXECUTIVE ff WCE00431903 06/30/2018 06/30/2019 1,000,000 RFFICERAI FiMBER EXCLUDED? NIA E.L.EACH ACCIDENT $ sndato n 1,000,000 E 11 yea,dasalDs antler .L.DISEASE•EA EMPLOYES S .. DESCRIPTIONOEDPERATI.ONSgglow E.L.OISEA$E•POLICY LIMIT S 1,000,000 • i/. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Ramarka Schedule,may be attached If more space 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 ', • I j�Wcf/ 7/a ._ •............. ...41100 venae' A/2/2/2/2 •T,ne, All d.b.....m.J • 4/ RISE E ENGINEERING' OWNER AUTHORIZATION FORM 1, Angela Haddad (Owner's Name) owner of the property located at: 258 South Sea Avenue (Property Address) West Yarmouth, MA 02673 (Property Address) cal l hereby authorize C ��' Ce c\ :�sv\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. Ow 's Sig ture / / 9 //r Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue l South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com