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HomeMy WebLinkAboutBLD-19-3635 /01.. r Office Use Only :: ,_ So, k.,i :Permitil . O i1 '� Pi. r Amount Nx` MB Permit expires 180 days from issue date —�� 3EXPRESS BUIL APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508)( 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 1..31'0 & I/Jie 11— o ASSESSOR'S INFORMATION: • PIM' ' / Map: Parcel: OWNER: ► "I�'svG '- Cu,4tec (s-Hat50-774 -9f/1z //�/I / / /�y,�PRESEQNT+1yB/p�R�ESS �" TEL. # CONTRACTOR:L �- C1 ,— ` bn/c !/ Ki �V �j'I COIF o , 5fr. i6I'77$ l t4 NA.IE MAILING ADDRESS �( • 0 Residential 0 Commercial / Est.Cost of Construction$ i2, ' 17 Home Improvement Contractor Lie.# 11 567 Construction Supervisor Lie.# /eol 0 0�y Workman's Compensation Insurance: (check one) 0 I am the homeowner�l]��e soje-gr�/elto��/q�J 'I have Worker's Compensation Insurance � (� 7� Insurance Company Name: (/ C j t/ f `r Worker's Comp.Policy f)x DQ 3 / /0 / WORK TO BE PERFORMED I Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) bakti/erad jtai t'pn II fief kJ._ Old Kings Highway/Historic Dist. ( )Replacing like for like iti moveyp ( at"The debris will be disposed of c itk� 1g_ d ..p cv 5 •�Z�z*f-17 Location of Facility I declare under penalties of pe'ury that the s tements herei c rained 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 o revocation license and for prosecution under M.G.L.Ch.268,Section I. �( Applicant's Signature: ,{ Date: Pee • i 2. Zen Owners Signature(or a ac meat) j Date: Approved By: !y /t-- c— Date: /2—/?vI' Buil...*;0...4 (or d- ignee) E DRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 R of Wetlands: 0 Yes 3 No 0 Yes 0 No N. if Permit Authorization -Stirrag mass save Form Site ID: 3440029 Customer: Marc DeNardo I, MIC (C, k RA. C a Te NI 4(61 t ,owner of the property located at: (Owner's Name,printed) 1368 Bridge Street South Yarmouth, MA 02664 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. r .kcaRayt Owner's Signature: Date: 0 — �-�� FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Com Cock - Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: For Office Use Only Rev.102015 The Commonwealth of Massachusetts _�.— Department of Industrial Accidents —_� t Office of Investigations "a1= 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): I.: I am a employer with 48 4. 0 I 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 g. 0 Demolition workingfor me in anycapacity. employees and have workers' P tY• 9. D Building addition [No workers' comp. insurance comp. insurance required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ q ] officers have exercised their 11.0Plumbingrepairs or additions I am a homeowner doing all work P 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' 13.0 Other comp. insurance required.] *Any applicant that checks box NI must also fill out the section below showing their workers'compensation policy information. 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:6/30/220111 (/� Job Site Address: 2)b ?0� v/jV Idgp • City/State/Zip: l//l y &V6 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 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 providbbovve is true and correct. signature: Henry CassidyDate: �jffifi it/ ZQ "ia 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: CAPECOD-27 AMAHLF. ALGORo CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDlYYYY) 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 endorsement( . PRODUCER • CTACT Rogers&Gray Insurance Agency,Inc. PONHONE FAX 434 Rte 134 (A1C,No,Ext): I tac,No1:(877) 816-2156 South Dennis,MA 02660 WD'As mail@rogersgray.com ADSR: INSURER/SI AFFORDING COVERAGE NAIC F INSURER A:West American Insurance Company '44393 INSURED INSURER B;Safety Indemnity Insurance Company 133618 Cape Cod Insulation,Inc. INSURER c:Endurance American Specialty Insurance Company 141718 _ 18 Reardon Circle INSURERD:Atiantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E: Il 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 WTH 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. . INSR1 TYPE OF INSURANCE ADDL SUBR' I POLICY EFF POLICY EXP LTR I!NSD WVDI POLICY NUMBER .�yDDMCCEII IayQDreyyl l LIMITS A ! X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 I CLAIMS-MADE FT OCCUR I BKW(19) 53328281 04/01/2018 04/01/2019 DAMAGE TO RENTED 100,0001 REMISF.4(Fe o�wrencel $ 5,0001 MED EXP(Am One person) $ f—� ! I PERSONAL a ADV INJURY § 1,000,000! GEML AGGREGATE LiAPPLIES APPLIES PER: I I I G°NERAL AGGREGATE I$ 2,000,0001 ` POLICY J JECT 1 I LOO- 1 iOTHER see holder descdp of operations I PRODUCTS•COMPOPFGG $ 2'000,000' • 1 ! $ • B j AUTOMOBILE LIABILITY ! i 1(CO BIINEDPe 1SINGLE LIMIT i§ 1,000,0001 ANY AUTO 6232707 04/01/201804/01/2019 I BODILY INJURY;Per persons $ 1 OWNED SCHEDULED I I ..TI-�AUTOS ONLY X AUTGpSW1� p I BODILY INJURY(Per accident! $ C AUTOS ONLY ED X I NON-OWNED CNLY 1 PROPERTY QAMAGE --�I ' I I I (Per accident) I$ C I UMBRELLA LIAR X OCCUR • Is • I ! !EACH OCCURRENCE I$ 2,000,000! X I EXCESS LIAR CLAIMS MADE I EXC10006635003 04/01/20181 04/01/2019 AGGREGATE $ ,2,000,000 I •.1 DED RETENTION$ I I $ -— —DiWORKERS COMPENSATION P_ ARD EMPLOYERS LIABILITY Y I I STATUTe ER. I ' ANYPROPRIETOR/PARTNERIEXECUTIVE II111 WCE00431903 06/3012018 06130120191 ��F ICERMeMO REXCLUDED? uN!A E.L.EACH ACCIDENT $ 1,000,000. lr,:andaloryln N 1) , , .1 D�SCRIPT ON CF OPERATIONS below `1 , 1 EL.DISEASE•EA EMPLOYE&S 1,000:0001 .L I . E.L.DISEASE•POLICY LIMIT $ 1,000,000; j I_ 1r ( DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more apace 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. • r CERTIFICATE HOLDER CANCELLATION I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE i THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATI VE !/�J/�, I L / "�"'`M"� . ACORD 25(2016/03) ©1988.2015 ACORD CORPORATION. All rinhtc rcen.,,u.e Division of Protessional Licensure `-- Board of Budding Regulations and Standards Constrt tt>Srtl%iiprvisor f. CS-100988 ' in noires: 11/11/2019 • HENRY E CASSIDY‘ ` ij d `' • 8 SHED ROW n l +3 ro r ;7' WEST YARMOLIT$! ,,0 673 • Commissioner ) • .T� FsonefieadIo/A' , - 4 Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration , Type: Corporation CAPE COD INSULATION, INC �1 Registration: 153567 18 REARDON CIRCLE Expiration: 12/14/2020 SO.YARMOUTH,MA 02664 ' 'i 1 • Update Address and Return Card. CA 1 0 2r0MM-05//17 17Vis' d IcJP.IIJ J/eP revs oneera /L 0lat2JJaM,' 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: Registration, Fxniration Office of Consumer Affairs and Business Regulation • 12/14/2020 1000 Washington Street•Suite 710 CAPE COD INSULATION;IN& Boston,MA 02118 1 I1 HENRY E.CAS51Y-:.; •;-' \ 18 REARDON CIRCLE-•' U /, SO.YARMOUTH,MA 02664Undersecretary • a I• •ith• t sign/s r: \ .