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HomeMy WebLinkAboutBLD-19-3494 i O Use Only /1 °FR I 'tT' -'9-5O3Y' o I,- ^i Amount `_C' n«: . ,_0,p):4,,„„,„0 p,. Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 i �11 G (508) 398-2231' Ext. 1261 CONSTRUCTION ADDRESS: 1 "U�_7 GQUI (�QGftZ W • Ilafroaw1'L✓ ASSESSOR'S INFORMATION: � � J,��Ma��p�: le Parcel: 2,01,,,OWNER: OF{ef41 6�! ,,ryry--I deli hf-%/— 0 e6�I Nr.�'IIAp11� ,! ��L,1 I 1YI XIP PRES T>A�DDRESS /1�� TEL # CONTRACTORI (2A I e 4 DQ4t 1�" [°o ati IA. rked / 6 7-15- vid NAME MAILING ADDRESS TEL# ' esidential 0 Commercial Est.Cost of Construction$ 4i 6 0. 15 # ��,/q Home Improvement Contractor Lie. i �7 Construction Supervisor Lic.# 1 e al 00 Workman's Compensation Insurance: (check one) �G 0 I am the homeowne( /}�.�o 0 I am the sQ,e proprietor L !' I have Worker's Compensation Insurance Insurance Company Name: ll, �Gl jt.�u'Ll{/ lvv a V Worker's Comp.Policy °OL& 9b WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Repla eme t doors;,# tri K-7/6f tMll u _ q Slit, ei A.a Roofing: #of Squares ( )Remove existing* (max.2 layers) top itg/ coat%n lati `NAL 16 ejy Old Kings Highway Historic Dist. ( )Replacing like for like Pool fencing �/ j/0104114. � � 4 IMIwy Ctai- �I�"The debris will be disposed of aC Location of Facility I declare under penalties of p rlury that the statements herein 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 deni ocation y license and for prosecution under M.G.L.Ch.268,Section I. �Qq Applicant's Signature: Date: '�'�" ( � I " Owners Signature(or attachment v Date: /� ( Approved By: sigi e) Date: /Z��C1 B dine ificial or designee EMAIL ADDRESS: . r r C ! 'I E L Zoning District: ' °'" " Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No "' W1 Water Resource Protection District: Within 100 ft.of Wetlands: DEC l0 2018 1 1 ❑ Yes ❑ No ❑ Yes 0 No 'diiuD:NG DEPARTMENT DocuSign Envelope ID:8BF9AC28-6982.4F74-B862-287D696D9DF6 RISE ENGINEERING OWNER AUTHORIZATION FORM I, Sidney C Sheaffer , (Owner's Name) owner of the property located at: 11 Muscovy Lane (Property Address) West Yarmouth, MA 02673 (Property Address) p hereby authorize Com^ C� S-cros.&g'tCPC , (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. LIl( DDuSIOd by: —Owrve'« M r-- I SIgl a use 11/19/2018 I 10:37 AM EST Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RISEengineering.com • The Commonwealth of Massachusetts Department of Industrial Accidents 1=‘,-,v=9 Office of Investigations lt1=a 1 Congress Street, Suite 100 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.E] I am a employer with 48 4. 9 I am a general contractor and I 6. ❑New construction employees (Ml and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 9 Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P LY• 9. 9 Building addition [No workers' comp. insurance comp. insurance.: required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11.0 repairs or additions 3.❑ I am a homeowner doing all workPlumbing 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.#:WCE00431902 Expiration Date:6/30/201(°/:, t, ,I y1 Job Site Address: I l (Au C/ • L . City/State/Zip: - IAv r'✓V, W I V`It Attach a copy of the workers' compensationipolicy declaration page(showing the policy number a d expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of cr minal 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 certift under the pains and penalties of perjury that the information provide ove is true andno correct Sianature: Henry Cassidy Date:Cid �...,,. -- ---�----- !ki r 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 U c • ' i t' Commonwealth of Massachusetts \®1 Division of Professional Licensure / • , Board of Building Regulations and Standards ' • Const S&t%il'mvisor , Cs-100988 . y '••••74,11 : Wires: 11/1112019 • HENRY E CASSIDY Cel i O Nr„ rA ' 8 SHED ROW! `' > 1 • WEST YARMOdT}}MAA`0` 673 >C r Commissioner l • e-44 52,041/411.04/400Cd4 IW 00 4 1 a"OS lit.0 IT • { ,r Office of Consumer Affairs and Business Regulation e 10 Park Plaza • Suite 6170 Boston, Masi',gb�iusetts 02116 Home Improveme.:: {C,00ryl�tractor Registration iSpm.•��fl'dgl�:R'I:'Sb'l:I ;li :; Typo: Corporation e r ;nre,':/ `•r :1V,Vc-s? V Registration: 183587 Cape Cod Insulation, Inc ,a 'r; ii4•,r,-' ,r. + Expiration; 12/14/2018 18 ReardonClrole it, r.t.,.. tt ?,:;' So, Yarmouth, MA 02684 0 `:,,; ..c:( � 1 I� ITI i� `d, Fal' sir, . .``�1.�^a/,V� • Vpdele Addroaa and return card, Mark reason for change. cp .oa�n . .,.......-....... .----• ..-•-.....•.........--,• ._..,,__•-••,,...,....•... . ........_._,,.•....M.•Ad17; anmZ.F1•snnvr:_r: °mplayman6.C1.nat.rnrr CM,Crotnmenrotuvala 010(0044(rd0/7) ft• Office of Consumer Ar leis&evsinoss Population • �;�rry, 1:«;t)ial '• HOM8IMPROVBMaNTCONTRACTOR Registration valid lot individuM use only Vast Corporation before the expiration dale, It Ioun• • ern tot ` •t1;�l;;;•�'y g�pD ex trn n11e^ 011loe or Consumer Attain; and': al =as Regulation ' ,...1\410,5,` t6��874 12/14/2010 • 10 Park sloe,Plaza• e 4170 r �'>1� ti•t�",'LIQ Boston,MA • . Cake Codlns.tidi '.g I • 1. I? • Henry Cassidy'<; ii :tit ;,, ie Reardon Clrc�, 1 1(f `��+ �\2.cC(> �— So.Yarmouth,MA;>,.Q, p• ;�,',,I p'/ ' 1/Alt /Cs ' ' Undersecretary t al • "hout sl, atu • ..----..."1 CAPECOD-27 AMAHLER A� CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDDWYYY) 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 ppe��nppdorsement(!). PRODUCER hAME•CT Rogers&Gray Insurance Agency,Inc, PHONE FAX 434Rte134 (NC,No,Ext): I IA/g Noe(877) 816-2158 South Dennis,MA 02660 VDAAss.mail@rogersgray.com _1 INSURER(S)AFFORDING COVERAGE MAIC F INSURER A:West American Insurance Company '44393 INSURED - INSURER B;Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER C:Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER D;Atlantic Charter Insurance Company 144326 South Yarmouth,MA 02664 INSURER E: INSURER F: COVERAGES CE-TIFICATE 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. PIER ADDLTYPE OF INSURANCE (NSD SUBR POLICY EFF 1 (pMOD EXP 4 LIMITS ITR NSD MD POLICY NUMBER i A I X COMMERCIAL GENERAL LIABILITY I IEA HOC URRENCE IE 1,000,0001 CLAIMS-MADE X OCCUR BKW(19)53328281 04/01/2018 04/01/2019 DAMAGE TO RENTED 100,000i M D P • •ne ninon 5,000 EIMMERMI 1,000,0001 S+EN'L AGGREGATE LIMIT APTP�LIeS PER: - ee- 2,000,0001 X POLICY L.J PRO. 1 JE PRODUCTS•COMP/OP AGG S 2,000,0001 X I OTHER:see polder demi', open or operations I$ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1 1,000,0001 (En arriCann E __ ANY AUTO 6232707104/01/2018 04/01/2019 BODILY INJURY(Peroerson) E OWNED SCHEDULED • AUTOS ONLY X AUTOS I BODILY INJURY(Pereccldenn $ • 7 HIRES X NStior EL? i PROPERTY AMAGE AUTCS ONLY _ AUTOS GNLV (Per eccdent) I'§ 1 C• UMBRELLALIAB X OCCUR § EACH OCCURRENCE 1E 2,000,0001 X EXCESSLIAB CLAIMS-MADE IEXC10006635003. 04/01/2018104/01/2019 AGGREGATE $ 2,000,000. I '• DED RETENTION S I D WORKERS COMPENSATION Hp�TT $ I AND EMPLOYERS'LIABILITY A TATIITE ERH I I 1 ANYAQPROPRIETOR/PARTNER/EXECUTIVE WCE00431903 06/30/2018 06/30/2019 EL.EACH ACCIDENT 1$ 1,000,0001• Ir OFFICER/MEMBER to NH)EEXCLUDED? J NIA EL DISEASE1,000,000' III es,describe under I { EAEMPLOYEE,s , • DESCRIPTION OF OPERATIONS brow E.L.DISEASE•POLICY LIMIT § 1,000,000 • • I I I/. DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD lot,Additional Remarks Schedule,may be attached It more space Is required) Workers Compensation Includes Officers or Proprietors. (Additional Insured status is provided under the General Liability and Auto Llabllity when required by written contract or agreement with the Certificate Holder. Excess Liability is follow form. • CERTIFICATE HOLDER CANOELLA]'ION • 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) ©1988-2015 ACORD CORPORATION. All tin Me rnccn,ea