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Home My WebLink AboutBLD-19-003975 • O f,�.qR Office Use Only Z • A :' ' 0 :Permit* )O col H +Amount Yfife,n d Q15):-"orsoarra I<t ((�� II\ (7 l'-' 'Permit expires 180 days front OtJ✓4q-zg7s eissuedate CGEVEt-' 1 EXPRESS BUILDING PERMIT APPLICATI ,N __ _ TOWN OF YARMOUTH _JAN 0 ? - + Yarmouth Building Department __ _,.-._..__ ._.. t 1146 Route 28 Butte r` rrNT f South Yarmouth,MA 02664 3y 1`/' —e 1 ( (508)8q398-2231 Ext. 12617 _ Art- 14 CONSTRUCTION ADDRESS: 7t I Old `fowct, "^u AQ` ASSESSOR'S INFORMATION: . /�I� J Map: Parcel: owNERiIUAtat the \/U.IjGh�VIG 27z{ iJ.Va sotR-P& /'�wq'v f' g$ -77t qay NAME �/ PRESENT ADDRESS I TEL. # CONTRACTOR: Henry Cassidy Cape Cod Insulation 18 Reardon Circle South Yarmouth 508-775-1 214 NAME MAILING ADDRESS TEL.#q R Residential 0 Commercial Est.Cost of Construction$ ,rfZ d• n Home Improvement Contractor Lic.# 153567 Construction Supervisor Lic.# 100988 Workman's Compensation Insurance: (check one) 0 I am the homeowner a 0 I am the sole proprietor X I have Worker's Compensation Insurance Insurance Company Name: Atlantic Charter Insurance Worker's Comp.Policy#WCE00431902 WORK TO BE PERFORMED 'Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: #X Roofing: #of Squares ( )Remove existing*(max.2 layers) _ism ,6 S ,juulat' n X 0 OO 7 ec llc005e—v Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing A,r�� /� �/1 mutt Sit(/�r z-, ` lair,• "The debris will be disposed of at: I) tL' V to N,r ` _ ` .uttr p b kjjtr �(/' /ejtt'i, Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. 1 understand that any false answer(s) will be just cause for denial or revocation of my license and for prosecution under M.O.L.Ch.268,Section I. Henry Cassidy ten p = l Applicant's Signature: o,.m..m„.„...-m Date' t Owners Signature(o ttachme:t) Date: ' Approved By: a ae Date: / r'71' Building Official(or. ,nee EMAIL ADDRESS: Zoning District: Historical District: 0 Ycs 0 No Flood Plain Zone: 3 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No J Yes 0 No P' gi' .71 480 West Main Street • Housing /' c Hyannis, MA 02601-3698 Assistance ,i Tel: (508)771-5400 Fax(508)790-2425 Corporation TTY on all lines Cape cud Free Weatherization ! Your tenant has requested and is eligible for weatherization of your rental home through the Weatherization program at Housing Assistance Corporation. An average weatherization job is worth $4,500 and these services are provided at no cost to you. The following weatherization measures are applied to the typical job: air sealing in the attic and basement, insulation in the attic, basement and walls, weather-stripping doors. Bath fans may be installed if necessary. We will test the efficiency of the refrigerator. All work is professionally done by licensed and experienced contractors. HAC will conduct a final inspection to make sure that all work is completed in compliance with quality work standards. Prior to the work being done you will receive a letter from HAC showing the actual measures that will be installed and the total dollar value to the work. To confirm your ownership of the property, we will pull the appropriate town assessor's report. If necessary, we may ask for a copy of your tax bill or deed to prove ownership. The work on your rental property will begin when we receive the signed copy of the attached Agreement. If we do not receive the Agreement, HAC will conduct an energy audit but no weatherization work can be done without the signed Agreement. During the energy audit we will install energy efficient light bulbs and will test the efficiency of the refrigerator. If you have any questions please contact Suzanne Smith at 508-771-5400, ext. 123 or ssmith@haconcapecod.org LANDLORD: 1 0I/ 'I TENANT: ra2bt_4 . l ��" t _� Y�.�QcQUi C Yi - 011 latf � .2o .• y ore u-f'- 74L email: JACkeeLM0�' coWc#V�d • IV email: PHONE:(home) ' b 1 -1)b- q S. PHONE:(home) -- C,�4fl-- V`L� t(t 1J Q(-9 ? f 1 (cell) 14. The Parties acknowledge that this Agreement Is under seal. It Is Intended by the Parties that the Tenant or any successor Tenant is the intended beneficiary of the Agreement and shall have a right of enforcement. PropertgSignature: / S Ieel, Date /AA 6//8 Phone: .,13 9 7?A L//31'1 Address: gra-11C/ /-///ani/✓/ s net, 0.26o 1 AIL Tenant Signature. Aw:.�i 14rnate Agency Approved Weatherization Company - Adam T. Incorporated / All Cape Energy % Alternative Weatherization Cape Cod Insulation / Cape Save / Cazeault • Frontier Energy Solutions / Lohr Home Improvement / Tupper Construction Agency Signaturec?i,Q. iL Date 'a `01-b . 18 'St+,,, +a,,r The Commonwealth of Massachusetts � $ t Department of Industrial Accidents ; i: ;(1Office of Investigations 600 Washington Street ��' — Boston, MA 02111 il�teei:Iu, ,•^`t^, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ' . Applicant Information /nn'''II^^ //�,�'I �,II. � / Please Print Legibly ' Name(Business/Organization/Individual): aft l hL Iw7N,Let r"' Address: b !/ v,�(/r�de'n /�ffffff City/State/Ziplbr avwritl:G r (V+']4 Phone#: '5D2` Z2S• W c/ Are you an employer?Ch ck the appropriate box: Type of project(required): . I.'I am a employer with 48 4. 0 1 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. 0 Remodeling ship and have no employees These sub-contractors have g, 0 Demolition workingfor me in anycapacity. employees and have workers' P ty• comp.insurance= 9. ❑ Building addition (No workers'comp. insurance p• 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.m seo workers'comp. right of exemption per MGL Y (N P 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have noWeatherization employees.(No workers' 13.W 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. 1 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. Liie.#::WCE00431903� I Expiration Date: 06/30/2019 ,,q t Job Site Address:-241 O { IDivi Ovwx„ f` L_ City/State/Zip: Lb- (J4 u,4i j'' Attach a copy of the workers'compensation policy declaration'page(showing the policy number a 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 Investi'ationsoftheDIAforinsurancecovera-everification. I do hereby certi.ty under the pains and penaltiesof perjury that the information provided rbow / true and correct Signature: YP3447eaa .y Date: 1/ 0/ /7 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#: • -�—n CAPECOD-27 AMAHLER %`o cr CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYrn 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 end conditions of the policy,certain policies may require an endorsement. A statement on i ' this certificate does not confer rights to the certificate holder in lieu of such endorsement(!). 1 IODUCER NAM A T )gars&Gray Insurance Agency,Inc. PHO (AIC, EMI: Fac,No1:(877)816.2156 4 Rte 34 sass,mall@rogersgray.com 4 Dennis,MA 02660 INSURERIS)AFFORDING COVERAGE NAIC S Il uRER AI West American Insurance Company 44393 SURED - — INSURER B 1 Safety Indemnity Insurance company 33618 Cape Cod Insulation,Inc. INSURER C:Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER D:Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E INSURERFI 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 ACOL SUER POLICY NUMBER POLICYEFF POLICY EXP R INSO WVD IMMIDD 1 (MMIDD/YYYYI LIMITS k X COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE $ 1,000,000 CWMS•MADE Ell OCCUR BKW(19)53328281 0410112018 04101/2019 DAMAGE TO RENTED 100,000 ( ) PRFMIPE51EA nrrurrrncel_3 MED EXP(Any one canon) $ 5,000 — PERSONAL SADV INJURY $ 1,000,000 GRN'L AGGRECTE LIMIT APP S PER: GFNFRAL AGGREGATE $ 2,000,000 X I POLICY j& LOD• A PRODUCTS•COMP/OP AGO $ 2,000,0001 Xsee holder descrip of operetlons OTHER: S 3 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 _ (Fs accident) E — ANY AUTO _5 E 6232707 04/01/2018 04/01/2019 BODILY INJURY(Per person) S AUTOS ONLY ONLY X AUpTNppSWULNEEOp BOODILY INJURY(Per accident) $ X A OS ONLY X AUTO!ONLY I Off lcd eMAGE $ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 V X EXCESSLIAB CLAIMS-MADE EXC10006635003 • 04/01/2018 04/01/2019AGGREGATE $ 2,000,000 • DED RETENTIONS $ D WORKERS COMPENSATION PERLER OTH• STATUTE AND EMPLOYERS'LIABILITY N WCE00431903 06/30/2018 06/30/2019 1,000,000 ANYAp� PROPRIETOR/PARTNERIEXECUTIVEg (h1,ndatory In NH)EXCLUDED/ NIA E.L.EACH ACCIDENT $ EL DISEASE•EA EMPLOYIL S 1,000,000! If sT dIPTION FO 1,000,0001 �.DYSCRIPTION OF OPERATIONS below _E L.410€ASE•POLICY LIMIT $ . I DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If mon space le resulted) 'orkers Compensation Includes Officers or Proprietors. ddltlonai 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. ;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 • • .-..-..s..,.A.,.m.. M,4 nae eras C A mnnn ttJ) Division of Protessional Licensure , Board of Building Regulations and Standards Constr ttt itiSilpgrvisor Q. CS-100988 a' �. nil 71Es ires: 11/11/2019 HENRY E CASSIDYk w,�•gyp 0 d , 8SHED ROW Ji ,Yl' 3� C it r 1 ' WEST YARMOUTH MA;0 673 % Commissioner v/ se C o„,,, 7wnetteaII /9J ' / / - 4, Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 • Home Improvement Contractor Registration j{ • t$ Type: Corporation CAPE COD INSULATION,INC f1 t " Registration: 123567 18 REARDON CIRCLE 1' t ,� Expiration: 12/14/2020 SO.YARMOUTH, MA 02664 Update Address and Return Card. CA 1 0 200�M--05/17+ �6 ,�• p ✓/1R (i vmnt4fawagI ty€1.2Jaao4JR/X1 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: Reaistratlon,., expiration Office of Consumer Affairs and Business Regulation • ,..„--153587----ia;„ 12/14/2020 1000 Washington Street-Suite 710 • CAPE COD INSULATION INb?'% Boston,MA 02118 i i ,[i iri HENRY E CAssloy i •� it - 4 18REARDON CIRCLE iv' SO.YARMOUTH,MA 02684 Undersecretary /a 'ith tsign/%r: ' - '—"