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Home My WebLink AboutBLD-19-003636 . - Office Use se Only Y�OfYAR S .elm^r ' `'0, PerniGY ' . te Qs— p \ I y Amount " ' Kwruw""SsCd.' Permit expires 180 days from -i' issue date IVED EXPRESS BUILDING PERMIT APPLIC • 1n E� TOWN OF YARMOUTH DEC 17 2018 Yarmouth Building Department 1146 Route 28 BUI .- i South Yarmouth,MA 02664 ey — �.itr J� W (508) 398-2231 Ext 1261 CONSTRUCTION ADDRESS: • "✓L' Z1LL 0' 8friMrttia) ASSESSOR'S LNPORMATION: /� 1�{ Map: Parcel: her -77444 I / -( OWNERP4 �G1.0i, tC / 5n. 7 ! 4rii f��E pp //�' Q 1 f��PRESENT D�RES,.S/) /� TEL # 1 CONTRACTOR:��W0.5'- `I° k b W ll,lli t(J Ii/ 11/aVOLOLI I!Ir 5"�V(I SD" 175. Ii( NAME MAILING ADDRESS I TEL# / 4 Residential 0 Commercial Est.Cost of Construction$ 9 bOl) nHome Improvement Contractor Lic.# 15 61. - Construction Supervisor Lic.# L D 01 U fb Workman's Compensation Insurance: (check one) `/ 0 I am the homeowner��,Aye/❑ II am the s/o�lew op�ri�e�tor Ai I have Worker's Compensation Insurance r- �j 1t Insurance Company Name: /Jt{6 G�t/4✓(/ _` u kv (///�--' Worker's Comp.Policy# v l eoo �t I V WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # [� LV Roofing: #of Squares ( )Remove existing* (max.2 layers) -[ a &I sulatio �'iesi Gerd v�1-z 86 Old Kings Highway/Historic Dist. ( )Replacing like for like 1 fencing ''II'',, ,, �VAt � w Spac� r�z► Fof� r *The debris will be disposed of at / i , , atw ,� I Location of Facility I declare under penalties of perjury that the statements ' co.•.L • e 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 revocy a' o �:•e.. d ton under M.G.L.Ch.268,Section 1. • Applicant's Sign troy Date: i Owners Signa a(p ac ik# nt Date: , Approved By: f Ott-, Date: e t7 f 7. 121 1, ding 0 ficial(or designee)i EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 9 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 R of Wetlands: • 0 Yes 0 No 0 Yes 0 No • RISE ENGINEERING' OWNER AUTHORIZATION FORM I, Patricia Koss (Owner's Name) owner of the property located at: 36 Washington Avenue (Property Address) West Yarmouth, MA 02673 (Properly Address) 0 hereby authorizec.nec (16 -or) 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. I erd • • 07PC14J Owner's Signature a..—Ik 15 Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RISEengineering.com lvY/ Division of Protessional Licensure • l Board of Building Regulations and Standards Con s ttittttitrt i§{S'p�ry i so r • CS-100988 rel -. ea Wires: 11/11/2019 • HENRY E,CASSIDY 1; 4 ., y 't°. • 8 SHED ROW, \tt� 3 `� t •i" • WEST YARMOUTJAA1,02879,3C r•'• Commissioner 1 • Office of Consumer Affairs and Business Regulation • 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 • Home Improvement Contractor Registration ;• i l Type: Corporation ' • , Registration: 153567 CAPE COD INSULATION, INC {I Expiration: 12/14/2020 18 REARDON CIRCLE 11 SO.YARMOUTH,MA 02664 / i Update Address and Return Card. CA 1 O 20M-05/1? . r Kynninneerae(i n/.,44adaezeAdeM .... Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:.Corporation before the expiration date. If found return to: Realstratlon Expiration Office of Consumer Affairs and Business Regulation • r,. 153567 '1,„ 12/14/2020 1000 Washington Street•Suite 710 CAPE COD INSULATION INC; Boston,MA 02118 • r HENRY E.CASSI* / \2uQep._—� //I // - /% 18 REARDON CIRCLE SO.YARMOUTH,MA 02664 Undersecretary • �a • •ith t sign/'�r t - -' The Commonwealth of Massachusetts Department of Industrial Accidents I tOffice of Investigations • ��e��.�l 1 Congress Street,Suite 100 IS Boston,MA 02114-2017 ,.�*1 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.❑� I am a employer with 48 4. Cl I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. 0 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. 0 Demolition workingfor me in anycapacity. employees and have workers' P tY• 9. ❑ Building addition [No workers' comp.insurance comp.insurance.: required.] 5. 0 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.] i c. 152,§1(4),and we have no Weatherization employees. [No workers' 13.0 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.#:fWCE00431902 hie. Expiration Date:6/30/2O11 VUS.&/ d / K, Job Site Address: City/State/Zip: Al, %L�1 Attach a copy of the workers' compens4tion policy declaration page(showing the policy numb• d expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition . • iminal 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. Signature: Henry CaSSldy -.-. -.«- '� Date: f�eo, i ' 'loll 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#: • •......—". CAPECOD-27 AMAHLER %�Oe CERTIFICATE OF LIABILITY INSURANCE DATE 08105ODr1YYY) 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 pollcy(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). tODUCER E2MPCT 'ors&Gray Insurance Agency,Inc. O (AIC,No,Eat): Iac,No):(871)816.2156 4Rte 134 Kith Dennis,MA 02660 t'�oliiRe•mall(G)rogersgray.com INSURERIS)AFFORDING COVERAGE NAIC I INSURER/VT WEST American Insurance Company 44393 SURBO INSURER B:Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER c:Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER0:Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E: INSURERFI I OVERAGES CERIlEICATE 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. NOTVYITHSTANDING 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, SR TYPE OPINSURANCE ANsp SUER POLICY NUMBER IMMNO EFFPOLICY IMM/DDmYY) LIMITS 5. X COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE S 1,000,000 CLAIMS.MADE ElOCCUR BKW19 53328281 04/01/2018 04/01/2019 DAMAGE TO RENTED 100,000 BKW(19) PRFMISESAES nrrirtrence) E _ MED EXP(Any one person) $ 5,000 PERSONAL&ACV INJURY $ 1,000,000 GEN%AGGR AT LIMIT APP IFFS PER: :. GENERAL AGGREGAT° E 2,000,000 XXI POLICY Pj?,a' ILAJI LOP PRODUCTS•COMP/OP AGO E 2,000,000 see bolder den Dof operations OTHER: E 3 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000) fF a err/denn E ANY AUTO 6232707 04/01/2018 04/01/2019 BODILY INJURY(Per person) E — OWNED K SCHEDULED • AUTOSI ¢EppONLY AUUTOSSwNEp BBODILY INJUpRY(Per ecddene $ X MURT05 ONLY X AUTOSONLY (PorOattFEenl)AMAGE $ . E UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 2,000,0001 V X EXCESS LIAB CLAIMS.MADE EXC10006635003 04/01/2018 04/01/2019 AGGREGATE S 2,000,000 • DED RETENTIONS E D WORKERS COMPENSATION PER ER •AND EMPLOYERS'PRIETOR/PARTILITY YIN WCE00431903 06/30/2018 06/30/2019 1,000,000 ANYPRR,1IEMOR/EACLUDED%ECUTIVE f E L.EACH ACCIDENT S pF�endatoh1EM RE%CLUDEOT lJ NIA (mandatory In�`Hi1,000,000: II yes describe under E.L.DISEASE•ER EMPLOYEE E _,DESCRIPTION CF OPERATION'S below E.L.DISEASE•POLICY LIMIT S 1,000,000 I.I. DESCRIPTION OF OPERATIONS I LOCATIONS(VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached ll more space le requited) rockers Compensation Includes Officers or Proprietors. ddltlonal 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. ERTIFICATE 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 � 7 . ,. .•,.ma. en 4n00 of Ae a A nrinn nnnnnne-rte... an.A.L/- .........J