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HomeMy WebLinkAboutBLD-19-003706 R Lam.. \a E'� / V E D 0 e Usc Only ` -=� � ap-g-et 3906 r ,,' ;,; �A- t DEC 19 2018 P .e> ZS`6T) I, '^i�,t ti, ti ' Amount ^,y-; ..:. <`, 3��-'_t 4fg4 Permit expires ISO days from ✓JJ-✓- u issue dote EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 �/J''1 'n /� fjj�(�5�0�8) 39{[8-22231 Ext. 1261/ ! r���� ^ CONSTRUCTION ADDRESS: ILk s"l t%` Mina L `L _ , 11)' efrikg u Wr I / : ASSESSOR'S INFORMATION: 7 I JJJ /� �(�/ /Map: fit q / [h',(', Parcel: 14 y,I /CZ. ) OWNER: I✓e.e.M Aul er'5c w 90 l�Gt�G ani 0- ill, QS571 m/)- 608- ZZ1-dll . NAME PRESENT ADDRESS TEL. # CONTRACTOR: Henry Cassidy Cape Cod Insulation I8 Reardon Circle South Yarmouth 508-775-1214 NAME MAILING ADDRESS TEL.# Residential 0 Commercial Est.Cost of Constructions ileo .n • Home Improvement Contractor Lie.# 153567 Construction Supervisor Lie.14100988 Workman's Compensation Insurance: (check one) - Z I am the homeowner f' I am the sole proprietor X I have Worker's Compensation Insurance Insurance Company Name: Atlantic Charter Insurance Worker's Comp.Policyft WCEQ0431902- WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares �al i (rltl4L 3&3 41 q ( )Remove existing*(max.2layers) &ec 3b31$suglation q Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fedcing `// `�a I *The debris will be disposed of at: *W14,1,1414 Location of Fact ity 1 I declare under penalties of perjury that the statements Neni tained 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 or revocation of my license and for prosecution under M.01.Ch.268,Section I. Applicant's Signature: - .. Henry Cassidy ;..„..-"` Date: Dal/ 10 Owners Signature(or attachment) Date: tt ,['� Approved By: �i Date: A- —i i Building Ofti ' I esignee) EMAIL ADDRESS: Zoning District: Historical District: i.: Yes ! No Flood Plain Zone: Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: Yes :: No :: Yes C No RISE ENGINEERING' OWNER AUTHORIZATION FORM 1, Deena Anderson (Owner's Name) owner of the property located at: 9 Windemere Road (Property Address) West Yarmouth, MA 02673 (Property Address) • hereby authorize Gip aJ /Aas u l4/ I bN (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. Owner's Signature / 2 . ii ' / t Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com • The Commonwealth of Massachusetts Department of Industrial Accidents z Office of Investigations — 1 Congress Street,Suite 100 _ ^ 1 Boston,MA 02119-2017 — - 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.El I am a employer with 48 4. 0 I am a general contractor and 1 6. El 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. ❑Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9. 0 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#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.#::Vv WCE00431902' Expiration Date: �6�/30/2019 (� Job Site Address: l�v`tPheg'- w'City/State/Zip: qaat "`r Attach a copy of the workers' compensation policy declaration page(showing the policy number and 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 provided above is true and correct. Signature: Henry Cassidy '� Date: .C' (R/ tag 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#: • • ..----"1 CAPECOD-27 AMAHLER CORE' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDYY) 1..—../ 0E/05/2018 Its CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS ERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES FLOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED I EPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on Is certificate does not confer rights to the certificate holder In lieu of such endorsement(!). )UCER NAME•CT ars 8 Gray Insurance Agency,Inc. Pja"c00,,"No,Ext): INC,No),(877)816.2156 Rte 134 E�_MAiI� maIl@rogersgray.com Dennis,MA 02660 ESs' �,lrogersgray.com .• INSURER(S)AFFORDING COVERAGE NAIO a _INSURER A:West American Insurance Company 44393 REO — INSURER! Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER C I Endurance American Specialty Insurance Company .41718 18 Reardon Circle INSURER o,AtIarltiC Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E: _ INSURER F: j VERAGES CERTIFICATE NUMBER: REVISION NUMBER: -IIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD IDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS ERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, XCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE AND)SUBRvPOLICY NUMBER iM POLICY I I POLICY I LIMITS X COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE E 1,000,0001 CLAIMS-MADE Q OCCUR BKW(19)53328281 04/01/2018 04/01/2019 DARMAOqO^ENT Garel $ 100,000 MED EXP(Any one person) $ 5,000 ■ PERSONAL a ADV INJURY $ 1,000,000, aN'L AGGREGATE LIMITAPP S PER: GENERAL AGGREGATE 5 2,000,000'; X POLICY U PI+a LOP PRODUCTS•COMPIpP AGO E 2,000,0001 - Xsea holder descdp of operations I OTHER: $ AUTOMOBILE LIABILITY �FOMaBIcDdINGLE LIMIT 1,000,000 $ • ANY AUTO Q 6232707 04/01/2018 04/01/2019 BODILY INJURY(Per person) $ flOWNED ONLY X SCHEDULED I [[pp pp WpM��NNEpp BODILYppRqINJURYp (Per accident) $ © Air&ONLY X IBleta NLY (P or eccRdent)AMAGE .$ 1 j$ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000' X EXCESS LIAB CLAIMS-MADE EXC10006635003 04/01/2018 04/01/2019 0001 AGGREGATE $ 2,000, .j DEO RETENTIONS $ WORKERS COMPENSATION PER nF 0TH" 1 IAND EMPLOYERS'LIABILITY y'q WCE00431903 06/30/2018 06/30/2019 ANY PROPRIETOR/PARTNER:EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 ipi,r,i owir$R EXCLUDED? t_� NfA 1,000,000' Lnlmdatory A Nd) E L.DISEASE-EA E}APLOYEE E VYu,daacdb*under 1,000,000' DESCRIPTION OF OPERATIONS below �� _,E.L.DISEASE•POLICY LIMIT 5 I i I ].. / • . SCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,AddIUonel Remarks Schedule,may be attached If more*pact le required) Irkers Compensation Includes Officers or Proprietors. ditlonal Insured status is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder, 1 :cess Liability Is follow form. - 1 • ;RTIFICATE 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 REPRESENTATIVE I . c Commonwealth of Massachusetts ®) Division of Professional Licensure Board of Building Regulations and Standards Const`alettdrt%it:"rvisor Q CS-100988 u .m eves: 11/11/2019 HENRY E CASSIDY� 8 SHEDROW.• t `c .-..v N C • WEST YARM067H1 MA 02673 X _ e + Commissioner • • Fe/72/)2oneeyeeal,C�/✓//Ua4 Q'CZeol e ��• 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 Registration: 153567 18 REARDON CIRCLE Expiration: 12/14/2020 SO.YARMOUTH,MA 02664 Update Address and Return Card. CA 1 0 20M-05'17 ,T/.r 6.menrnuwJ//r/..//n.Yiiioinr/,O Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corooratlon before the expiration date. If found return to: Realstration Expiration Office of Consumer Affairs and Business Regulation 153567 12/142020 1000 Washington Street-Suite 710 CAPE COD INSULATION,INC Boston,MA 02118 HENRY E.CASSIDY /� / 18 REARDON CIRCLE V I SO.YARMOUTH,MA 02664Undersecretary a I• Ith• t sign's r.