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Home My WebLink AboutBLD-19-00367 .C: YRR Of ,use Only y 2 �!sp .Permit# o .. .� y � `�\,, I4 'Amount ci ai • csk..F41O''sc `'Permit expires 180 days from :) �4#4';^-' {issue date 81.1)—ISI—(,1)307 RECEIVED . EXPRESS BUILDING PERMIT APPLICAT:ON TOWN OF YARMOUTH LDEC 17 2018 Yarmouth Building Department 1146 Route 28 Bui _ i r r South Yarmouth, MA 02664 By ((5f08)) 398-2231 Ext. 1261 (/ CONSTRUCTION ADDRESS: -21 " V Vv r ASSESSOR'S INFORMATION: i �y f Map: Parcel: �1 ,I OWNER: te7 MI�LVIUL 59' 360- 30fl N Q PRESENT ADDRESS TEL. # CONTRACTOR: CfM I tend/Attu ` i P�14ztl C . 5 ! ILV L'ut PF6e r/4 iv/ MAILING ADDRESS TEL.# Residential 0 Commercial Est Cost of Construction$ egoo• Home Improvement Contractor Lie.# (fJ 3 S17 Construction Supervisor Lie.# 100 7�p, Q Workman's Compensation Insurance: (check one) / 0 I am the homeown G I am th •le proprietor 71 have Worker's Compensation Insurance 'Insurance Company Name: AI. l (u Dt Worker's Comp.Policy# t0(�/1�_0 ot2l 1 1 07) WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement�^ doors: # Roofing: #of Squares Remove existing* 4tl �o 1 ei - b q L �7 t o q ( ) e (max.2 layers) I Insulation / Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at /vW Yk,O l/t 4 w diktun �J 50 ie L" Vii1i IA Location of Facility 1 I declare under penalties•f perjury that the statemen ein 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 den: or revoca.' if my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature 1I,„ , -r Date: l: IP1 u iS Owners Signature(or attachment Date: Approved By: .� rfir Date: / 1 77— 4 Odin* Komi ciai or designee) 4,10. , I ADDRESS: // Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts �_� Department of Industrial Accidents 1 g- h t Office of Investigations =��1= 1 Congress Street, Suite 100 • "7-1I_!= Boston,MA 02114-2017 ��4fl' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly 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. ❑ l am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 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 10.0 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.#:WCE00431902 '' QQ.. Expiration Date:6/30120N Job Site Address: Z y � -Fa� City/State/Zip:r • /IV / (v( 409 • Attach a copy of the workers' compensation policy declaration page(showing the policy number d expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of 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 Bove is true and correct. Signature: Henry Cassidy -- ...,.••-. - '"� Date: 2,0" 15 I00 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): t. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: ' 11/28/2018 12:83 5087602699 90. YARMOUTH LIBRARY PAGE 01/01 • RISE ENGINEERING" OWNER AUTHORIZATION FORM I, Joseph J Boland (Owner's Name) owner of the property located at: 29 Maushops Path (Property Address) West Yarmouth, MA 02673 (Property perAddress) / • hereby authorize oar., ad a-hid+A-?!0 n (Subcontractor) en 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 Owners Signature Date RISE Engineering,a Division of Thielseh Engineering,Inc. 5 Dupont Avenue I South Yarmouth,MA 02664 I 508-5684926 www.RlSEengineering.com 71 '3 ?j Faye ,rcs,ore to 3s4, Cenier \Vi Division of Professional Licensure . \ Board of Building Regulations and Standards • - cons`yttttc{rtl%Bp,rvisor f. CS-100988 a k"' 1r 1 Wires: 11/11/2019 Va! �+ v 1• r O , HENRY E CASSIDY \ z s,"��ay'�syt�t ) ' , WEST YARMOUTH Mq`0 87� 8 r 11/6/woo-NS ,„WS, 'fi • Commissioner at 1 • Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 ' Home Improvement Contractor Registration Type: Corporation 1 I" Registration: 153567 CAPE COD INSULATION, INC ft l , Expiration: 12/14/2020 18 REARDON CIRCLE SO.YARMOUTH,MA 02664 1 J Update Address and Return Card. CA i O 20M•05A7 . n grvirnr[vueva lfty4 ¢1JaeZeJtvgl Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:,Corooration before the expiration date. If found return to: Reoistratloit, Expiration Office of Consumer Affairs and Business Regulation • 153567 'u1,, 12/14/2020 1000 Washington Street•Suite 710 CAPE COD INSULATION.-INC Boston,MA 02118 / HENRY S RY 18 REARDON CIRCLE /if_ � SO.YARMOUTH,MA 02664 fa Undersecretary • ith t sign/%r= `; -----1 CAPECOD-27 AMAHLER %C0 oe CERTIFICATE OF LIABILITY INSURANCE DATE(MM1DDr1V1'Y) 0610512018 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(). 1 tODUCER Far )gDrbAa� era&Gray insurance Agency,Inc.ins, PHONE No,Eaq: FAX Nel,(877) 816.2156 4 Rte 134 s y,Com lush Dennis,MA 02880s:mall@rogersgra INSURERS)AFFORDING COVERAGE NAIC a INSURERA-WestAmerlcan Insurance Company 44393 SURE° INSURER a:Safety Indemnity Insurance Company 33618 Cape Cod insulation,Inc. INSURER C;Endurance American Specialty Insurance Company 41718 18 Reardon Circle INsupERolAtlantic Charter Insurance Company 44326 South Yarmouth,MA 02684 INSURER E; INSURER F I OVERAGES 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. SR TYPE OF INSURANCE INSD servo POLICY NUMBER IMM(DDY�) IMMIDDmYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE § 1,000,000 CLAIMS•MADE 1:1 OCCUR BKW(19)53328281 04/01/2018 04/01/2019 DAMAGETORENTED 100,000 PRFMIS=S Fa occurrence) a — MED EXP(Any one person) $ 5,000 PERSONAL 4ADV INJURY $ 1,000,000 — GEM.AGGREGATE LIMIT AP I SPER: GENERAL AGGREGATE $X 2,000,005, XI OOLLIICY ER•.area noltl1r tleaCAp OlaLpa Clone PRODUCTS•COMP/OP AGO $ 2,000,000 3 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000) (Ea e.cidenn $ ANY AUTO 6232707 04/01/2018 04/01/2019 BODILY INJURY(Per person) $ — OWNED X CHEDULED - AUTOS ONLY AUTOS pBOODILY INJURY(Peraccident) $ X AUTOS ONLY X A9 e/NNNU trorr Sccl enIQAMAGE .$ $ V EACH OCCURRENCE § _ UMBRELLA LIAR X OCCUR 2,000,000 X EXCESS LIAR CLAIMS-MADE EXC10008835003 04/01/2018 04/01/2019 AGGREGATE $ 2,000,000 • CED RETENTIONS $ D WORKERS COMPENSATION PER 0TH• AND EMPLOYERS'LIABILITY STATUTE FR ANY pPROPRIETgOERIPARTNERIE%ECUTIVE WCE00431903 06/30/2018 06/30/2019 1,000,0001 OFFndawrySMBER EXCLUDED? NIA E.L.EACH ACCIDENT S II+� EL.DISEASE-EA EMPLOY E. $ 1,000,000! II es describe under 1,000,000 DESytRIPT10N OF OPERAXI NS below EL.DISEASE•POLICY LIMIT f I'I. ESCRIPTION OF OPERATIONS(LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It mon space le required) 'orkers Compensation Includes Officers or Proprietors. ddltional Insured status Is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder, :%cess Liability Is follow form. ;ERTIFLCATE.liQ ER 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 w.,sa.a,ww. /A,IMOD On4e AM/.On •r,nu •n.,-u- .�-_-,..a