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Home My WebLink AboutBLD-19-003638 / 1 Of .Use Only /04 AYAR. $d. ' O. Permit# C <O •r�Iill. H' Amount e -_�," +"9�:d•' Permit expires 180 days from ::. e-19,CWb3t issue date RECEIVED EXPRESS BUILDING PERMIT APPLICAT OST TOWN OF YARMOUTH 11 DEC 17 2018 i Yarmouth Building Department 1146 Route 28 Bui`rl�t, ENT South Yarmouth, MA 02664 ( CORE-- 3/9/8-M31(444,C) ExxJt.�1�26)1 ��} CONSTRUCTION ADDRESS: ii (/t'`^` "u ie ' `444, 1\141/1414,g' ASSESSOR'S DIFORMATION: • f Map: Parcel: OWNER: 51a, Cai(,frit°mi (067 -00- 7q1 ...+� PRESarESS tI TEL # CONTRACTOR: ' ' CPIS— 111 "w(6n 111) n ,�1 elti< ?L 1Y '5E -fly• (z14 14' t MAILING ADDRESS TEL.# ' // Residential 0 Commercial Est.Cost of Co struction$ 1 2-)1700 - 1-6 Home Improvement Contractor Lic.# 6 ' 7 Construction Supervisor Lic.# / 00 7 gO Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 II'am the sole(1 p ''et�or�� 6 have Worker's Compensation Insurance Insurance Company Name: �% "'�"`^ "'�, `.J'M,r•v-eW l ws • Worker's Comp.Policy# Wet"0°t01' el D WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # i1 9.-- co %I. 1 b kat�icistitti ' Roofing: #of Squares ( )Remove existing* (max.2 layers) I su atio 1� 0 kr x-ti'(edi (o.c sza 6: its Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing /,A In' �, c(�y/� ^�I ' 'i USA) ate)CeL(laliieflalJI` (-e *The debris will be disposed of at: • !(N'rVW7/ U, l 6. c&tu. LL'1 -7tet 1 11 Location of Facility I declare under penalties of perjury that the statements here tained are true and correct to the best of my Imowledse and belief I understand that any false answer(s) will be just cause for denial or revocation of y lice a or pro under M.G.L Ch.263,Section 1. Applicant's Signature: Date: /2 —77—,g' • Owners Signature(tpattac Ali , ,/'/ Date: �� / Approved By: , AlAV,' � Date: ete ' 't /i/fg Yuilding C ficial(or designee) EMAIL.ADDRESS: r v 11 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 • .------"si CAPECOD-27 AMAHLER 0e CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDn-YYY) 0610612018 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 1 ' this certificate does not confer rights to the certificate holder In(leu of such ��ep eq�ndorsement(�, I tODUCER NAME OT agars&Gray Insurance Agency,Inc. PHONE Est): I rm,Nol,(877)816-2166 utht Dennis,MA 02660 1.,t'j(34q9.mall@rogersgray.com INSURER(S)AFFORDING COVERAGE NAT P JNSURER9:We SS AmerIcan Insurance Company 44393 SURER INSURER a'Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER C:Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER oAtlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E: 4 INSURER Fl 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 CR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TOW-ICH 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 ADDL SUER POLICY EFF POLICY EXP PR TYPE OF INSURANCE INSD Wvo POLICY NUMBER IMMDDn'VWI IMMIDor Y?) LIMITS 1, X COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE $ 1,000,000 1 CLAIMS-MADE OX OCCUR BKW(19)53328281 04/01/2018 04101/2019 PPRFMSFZIF:ccrurnnc,L3 100'000 _ MED EXP(Any one Berson) $ 5,000 — PERSONAL SADV INJURY S 1'000'000 _4•AGGREGATE LIMIT APP I S PER: n GENERAL AGGREGATE $ 2,000,000 X POLICY I_ jEp7 LOP PRODUCTS•COMP/OPAGG $ 2,000,000 X .TREK;see holder dna p of operation. $ 3 AUTOMOBILE LIABILITY COeBBINEDI SINGLE LIMIT $ 1,000,000 _ ANY AUTO g E 6232707 04/01/2018 04/01/2019 BODILY INJURY fPerpenon) $ y AUTOSg�pONLY x AUpT�IO.OSyUyINEDp pBOODILY INJURY(Peraccident) $ ' X AUTOS ONLY X MDSONLY (Por ccc' ant,AMAGE t $ _ UMBRELLA LIAB X OCCUR EACH OCCURRENCE a 2,000,000 X EXCESS LIAB CLAIMS-MADE EXC10006635003 04/01/2018 04/01/2019 AGGREGATE $ 2,000,000 DED RETENTIONS a D WORKERS COMPENSATION PER 0TH• AND EMPLOYERS'LIABILITY STATUTE ER _ YIN WCE00431903 06/30/2018 06/30/2019 1,000,000 ANYPROM¢IET9OERI EXCLUDED?ECUTIVE O NIA E.L.EACH ACCIDENT S Fdendalory In NH) LI.DISEASE-EA EMPLOYEE $ 1'000,000' II yea describe under 1,000,000 • DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT I I'I: iESCRIPTION OF OPERATIONS(LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If mon.pace Is required) 'orkers Compensation Includes Officers or Proprietors. dditlonai Insured status Is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder, ixeess Liability is follow form. ;ERTIFICA Th LDER 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 • n.inn.nose. nu Inoo ln.c A rnnn nit."' u,.,-6,_ --''".-.._.1 RISE ENGINEERING' OWNER AUTHORIZATION FORM 1, Susan Kinnear , (Owner's Name) owner of the property located at: 19 Salt Marsh Lane , (Property Address) West Yarmouth, MA 02673 (Property Address) hereby authorize C cite Col 1': n_-/cz 1/ 6 n , (Sutractor) 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. • Iii ^ O er's Signature / 62/ 0 /. .e) / e x Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com co) Division of Protessional Licensure `- Board of Building Regulations and Standards • ConstptttMISSillrvisor J. CS-100988 ' i vtn E'9ires: 11/11!2019 • HENRY E CASSID�' .a s .r 1° ' 8 SHED ROW� '�.i `t1` ; r,- .` f i - • • WEST YARMOCLT$IUTA:O 679, N. Commissioner v 1 • tZFittnn lVS ; - 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 I it ! ,;la Registration: 153567 18 REARDON CIRCLE „ Y J ` Expiration: 12/14/2020 SO.YARMOUTH, MA 02664 'ii '.. itt UI Update Address and Return Card. CA 1 O 200M�M-05/l7 ,,l�AA p e Fevnmewateailif essai 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: ReatstratioR., Expiration Office of Consumer Affairs and Business Regulation • ,-.:.153567 „i,, 12/14/2020 1000 Washington Street Suite 710 CAPE COD INSULATION,INC ' Boston,MA 02118 r /!i , , _,,, , HENRY E.CASS�IbY ,, ° \2„CGQrr--- id 18 - 18 REARDON CIRCLE '1, ' C.� a SO.YARMOUTH,MA 02664 Undersecretary /• la •Ith tsign/%r= j' / ' • i The Commonwealth of Massachusetts Department of Industrial Accidents • Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 41. �. 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. ❑ 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 8. 0 Demolition workingfor me in anycapacity. employees and have workers' p tY• 9. 0 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' 13.11 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:6/30/2011 ion Job Site Address: — /J tf 4 °t' V V - 14a-U City/State/Zip:c. w vp Attach a copy of the workers'compensation policy declaration page(showing the policy numbe a d expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition o c 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 providedaboove is true and correct t Signature: HenryCassidy Date: da6O / (4 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#: