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Home My WebLink AboutBLD-19-003495 Y Office Use Only O 'ilits � -41 H Amount r � �+.0 a g Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATIONArt TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 I�g r� (508)398-223311 Ext. 1261. / p I , CONSTRUCTION ADDRESS: `'U", "V . (/W'' (tlli" it U1 • 1 ,(,vnt/ tt ASSESSOR'S LNFORMATION: {I r- Map: 07 Parcel: l3& O42_ / OWNER: \--)1)cU/l Ole I s9&3- -77/Y93 L7' NM, PRESSEN DRESS TEL. # C CONTRACTOR �/^Jf"erg 4w5uI /la —l0 ?h v /,gitIc „ ,5j o0 . 7z IDV NA:VtE MAILING ADDRESS TEL.//# esideatial 0 Commercial 7,�/ Est Cost of Construction$ 7J 0 Home Improvement Contractor Lic.# (hc 7✓z] Construction Supervisor Lic.# 106 9 GQ U Worlonan's Compensation Insurance: (check one) ss�� / 0 I am the homeowners¢/ 0 I am the s e proprietor Z'I have Worker's Compensation Insurance Insurance Company Name: '{ kV 24414,171/It Worker's Comp.Policy#A e 0031 90 3 WORK TO BE PERFORMED / ' Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# lig Replacement doorrs: %_16,__ Roofing: #of Squares • ( )Remove existing* (max.2 layers) t p Insulatio /0 R-376cclaSe_imaaofeitakti Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing //� /fin' ft 5 cur 5ealctfl. "The debris will be disposed of at ” "t' "" v`A Location of Facility I declare under penalties of p .Iury that the statem erein contained are tme and correct to the best of my Imowledge and belief. I understand that any false answer(s) will be just cause for denial or. vocation oflicense ant for prosecution under MG.L.Ch.268,Section 1. Vet, tr Applicant's Signature: .tA4 a j of. Date: "O/ Zo i(J Owners Signature(or attachment) arilir a Date: Approved By: rat t Date: /2 701, Building•s.• al • desi:.ee) E • l�do DRESS: • Zoning District: ; :-,,. f.' r^ i %,I F. i! ! Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No ; a- la_ _• _ .07 t. cri Water Resource Protection District: Within 100 ft.of Wetlands: ! "' ❑ Yes ❑ No ❑ Yes 0 No C 1 O 2��8 BUi'..Diii?..Dl_PAIZA-IEtJT. RISE E ENGINEERING' OWNER AUTHORIZATION FORM 1, John T Elliott , (Owner's Name) owner of the property located at: 184 South Sea Avenue , (Property Address) West Yarmouth, MA 02673 (Property Address) hereby authorize ` � CO• r( /1 $V ia. "'� r I /' (t n , (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. 0 / re,....... ±7._ 46_, 20 is Signature //02� ifs )4.-Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations sal Lri 1 Congress Street, Suite 100 Nal kP::\ 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): I.El I am a employer with 48 4. ❑ I 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 8. ❑ Demolition working for me in anycapacity. employees and have workers' P tY• 9. ❑ Building addition [No workers' comp. insurance comp. insurance? required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11. repairs or additions 3.❑ I am a homeowner doing all work Plumbing 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' 13.11 Other comp. insurance required.] _ *Any applicant that checks box Xl 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:6/30/2O1°t Job Site Address: IDI( ' /kiC akt 14/1 Pn— City/State/Zip: ('UCt�r i4/ 04 I/ Attach a copy of the workers' compensation policy declaration page(showing the policy number and 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 provided above is true and correct Henry Cassidy �..v,." "' -� ---w-M---- � 5 ?.0 4 Signature: Date; 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#: • • • c' Commonwealth of Massachusetts Division of Professional Licensure / �- . •Board of Building Regulations and Standards . ' . Constj tfk6rfltISp�rvisor • f. CS-100983 •J I ry.r fkjires: 11/11/2019 • HENRYECA • SSIDY°" ', O 8SHED ROW�� r• 2 4 • WEST YARMOCLT�MlIAl•[[••��oi'slI73 a° /t Commissioner v/^"' �/ AGE 21c2 UJ,i,c29 �Gl1P/GG�i 4 Q� �0, •t)k Office of Consumer Affairs and Business Regulation ` 10 Park Plaza • Suite 5170 Boston, Ma� dbtusetts 02116 Home Improve•"me. V. on ractor Registration • r;lnli;in�! 1 ii'P : •. • Typo: Corporation 1.:,:gf?.,l ./.!..147;1:.11.1 I,. / Registration: 183887 Cape Cod Insulation, Inc 1.; r;;;; �t,,,'l,;,.'r, $; Expiration: 12/14/2018 18 Reardon Circle , `t ril .:i f So, Yarmouth MA 02684 `, q1 t\,. / • ,,1,.,.,.�r�,, Update Addroee and return yard, Mark reason for Cheng,. 1` . ......_._. ._. (}� . .• ............�......__�,,...,._..... 13.,Adrra.n ..C'.R•uae.v;nl_fa?aply/%man6.Lllnat.pr.rr . — j* Wa'NNflal6(Wra/e3 ulo4taurrdirruot(u a\ Mos of Consumer Melts&Business Regvlellon , Registration valid for Individual use only Pak Q�, HOM8IMPROVEMaNTCONTRRCTOR 7.y.p'ol Corporation baton the expiration date. It loun• . urn tot ' / iac;a� Fxnlrntloe 0111*,oIConwmitAffairsend•: al -se Regulation �., +++ yj/s fik10 Parte Plaza• • 5170 !7'il),` �``�\8 E 12114/2018 , Si't� I;' Boston,MA . Cape Cod Ins*l¢11 ;::. o,1; 11 /�' Henry• 8 f ardonlClrc� 14 1.,11I/if/ 2,ccalp,-- 30,Yarmouth,MA3,p G�a1�i' �� //'„� �_ _ :,9 Vndorseoretary •0?CI el • —"hout sN ales'= • • ....--""1 CAPECOD-27 AMAHLEF{ A�0" CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDonwY) 06/05/2018 IIITHIS 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). PRODUCER NANpCT Rogers&Gray Insurance Agency,Inc. PHONE No,Ext): FAX No):(877 816-2156 434 Rte 134 I k ) South Dennis,MA 02660 U0REss•mail@rogersgray.com —i INSURER(S)AFFORDING COVERAGE NAIL P INSURER A;West American Insurance Company •44393 INSURED INSURER a:Safety Indemnity Insurance Company 133618 Cape Cod Insulation,Inc. INSURER 0 Endurance American Specialty Insurance Company 1 41718 18 Reardon Circle I INSURER o:AtlanticCharter Insurance Companv 44326 South Yarmouth,MA 02664 INSURER E; INSURER F: 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. INSR ADDL SUER POLICY EFF POLICY EXP ITR' TYPE DFINSURANCE (NSD MD POLICY NUMBER I 1MMInnM'WI I IMMIDONYI'YI� LIMITS A X COMMERCIAL GENERAL LIABILITY I EACH CC URREN E 5 1,00 D,0001 CLAIMS-MADE E( OCCUR BKW(19)53328281 04/01/2018 04/01/2019 DAMAGE TO RENTED 100,000! M •EXP • •ne•arson 5,000: 1,000,000! _GIN%AGGREGATE LIMIT APPLIES PER: IMMEMPIE2,000,000 X POLICYL JE'QT LCD• I PRODUCTS•COMP/OPAGG $ 2,000,000i X see holder dosed()of operations OTHER: I B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT '§ 1,000,000 Me PctiPen11 § ANY AUTO 6232707 04/01/2018 04101/2019 BODILY INJURY(Per person) § �, I AUTOS ONLY X lA.UTOS LED EEpp p p BODILY INJURY(Per accident) y AUTOS ONLY .X J A6to ON�LYp i r�tOPERTY DAMAGE -§ III er PERT nil C• UMBRELLA LIAR X OCCUR § I EACH OCCURRENCE § 2,OOA000 X EXCESS LIAR CLAIMS-MADE EXC10006635003. 04/01/2018 04/01/2019 AGGREGATE I§ 2,000,000, •• DED RETENTIONS D (WORKERS COMPENSATION — PER OTH• I ' AND EMPLOYERS'LIABILITYni WCE00431903 06/30/2018 06/30/2019 S ATIITP FR I ' I ANY PROPRIETOR/PARTNER/EXECUTIVE ! § 1,000,000: OpFFICERI\l°MBgERE%CLUOEDI NIA E.L.EACH ACCIDENT I(t.tentlatary r, IE.L 01$EA$E•EA EMPI OYEEI s 1,000,000: I.describe under '.I DESCRIPTION OF OPERATIONS below LEL E.L.DISEASE•POLICY LIMIT a 1,000,005I . I/ DESkeCo OF OPERATIONS/LOCAsION§/VEHICLES o rat,Additional Remarks Schedule,may be attached If more space Is 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 Liability is follow form. I CERTIFICATE HOLDER CANOQLLATION I • 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 C L ACORD 25(2016/03) 0 1988-2015 ACORD CORPORATION. All rinhtt ratan/ad