The URL can be used to link to this page

Home My WebLink AboutBLD-19-3982 AL 1 O 10f11ce Use Only 'Permit#1Amount .S!Permit expires 180 days from BC.D-lG_Cb 3Rg-a- 41ssuedateR E C E 8 r EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH JAN 0 D. nig .i Yarmouth Building Department BI � l.;-r' ' r'r 1146 Route 28 n C SI-440- f South Yarmouth, MA 02664 n-41 'I''.(5508) 398-223 Ext. 1261 ��f i CONSTRUCTION ADDRESS: ` 1 �Lvwt) 'AK t14G� 01 . ettra49-L J •ASSESSOR'S INFORMATION: r Acta(nI ' 1,Map: Parcel: OWNER: 1 "Left �YwW` I -70g-ZBD- 7i/ NAME PRESENT ADDRESS TEL. p CONTRACTOR: Henry Cassidy Cape Cod Insulation IS Reardon Circle South Yarmouth 508-775-1214 NAME MAILING ADDRESS TEL.# ro c R Residential 0 Commercial Est.Cost of Construction$ 10V ' Home Improvement Contractor Lie." 153567 _ Construction Supervisor Lic.# 100988 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor PI I have Worker's Compcnsation Insurance Insurance Company Name: Atlantic Charter Insurance Worker's Comp.Policy#WCE0043190.3 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)t jZyn ca `DI s}({at on uU� Old Kings Highway/Historic Dist. ( )Replacing like for like M� 5L`7 Pool fencing ry g� {'II//II �� y.� n 7 Ofirnit',C4 26 /,arc, 'The debris will be disposed of at: aV pay lI I "�day �Q b R-'57 c�/W(,l e 4 bb j�ew-- 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. I understand that any false answer(s) will be just cause for denial or revocation of my license and for prosecution under M.Q.L.Ch.268,Section 1. Henry Cassidy •.,,.. i:..,.4. Applicant's Signature: a.=a�.=.�•�=.•;.a.m Date: iiii, Owners Signature(. attach .eat) Date: /j Approved By: 7- � or Date: / ' /T Building 0'icia .r . rill e) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 7 No Flood Plain Zone: Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No _J Yes 0 No \R,7) Division of Processional Licensure Board of Building Regulations and Standards • Consty(Cttt�rtf${1p�rviso r . rJ. CS-100988 y7 {fN Ejfpires: 11/11/2019 HENRY E CASSIDY� � �r a p ,' , 8SHED ROW�n I:Nw a '< •* -3 } • WEST YARMOUTiMAJ 870 s>." rt'Ofc mst • Commissioner lam 1 • Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration 1 ' ) Type: Corporation tt" Registration: 153567 CAPE COD INSULATION,INCi Expiration: 12/14/2020 18 REARDON CIRCLE ' 1 1 SO.YARMOUTH, MA 02664 rr Update Address and Return Card. CA 1 O 20M-05/17 .We aimvneweeeakfe /balsa se/V.1 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: fteaistratloqExpiration Office of Consumer Affairs and Business Regulation • • 153567 1,, 12/14/2020 1000 Washington Street-Suite 710 CAPE COD INSULATION,.IN6 Boston,MA 02118 • HENRY E.CASSIbh ' \2_fGQrf-- /..ale 18 REARDON CIRCLE U SO.YARMOUTH,MA 02664Undersecretary �� fa I' -ith t sign/%r. • j ' • • • • • • .-----Th CAPECOD•27 AMAHLER %CORO- CERTIFICATE OF LIABILITY INSURANCE DATE(MM/ •Y) 06/06/2018 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 I ''this certificate does not confer rights to the certificate holder In lieu of such endorsement(s), ; I0DUCER N%kRACT :oars&Gray Insurance Agency,Inc. lett°,"Np,Eat): FAX No);(877) 816.2156 4 Rte 134 ars ra mMiss,Dennis,MA 02660 mall ro 9 9 ytom INSURER(S)AFFORDING COVERAGE NAICl/ INSURER A•WestAmerlcan Insurance Company 44393 SURED -. INSURER B;Safety Indemnity Insurance Company 33618 Cape Cod insulation,Inc. INSURER c;Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURERD:Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E: INSURER Fl I OVERAGES CERUFICATE UMBER: 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 TOWHICH 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 AWL SUER POLICY NUMBER POLICY EFF POLICY EXP 'R (MMIDDY/YYYI IMMIDD/YYYYI LIMITS X COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE } 1,000,000 CLAIMS-MADE X OCCUR BKW 18 53328251 04/0112018 04/01/2019 DAMAGE Tp RENTED 100,000 • ( ) R=MISE ,FS occurrence) E 5,000 — MED EXP(Any one person) E — PERSONAL SADV INJURY } 1,000,000 _afll'L AGGRER4s LIMIT AP, IES PER: GENERAL AGGREGATE E 2,000,000 X POLICY I I IILOO' a PRODUCTS•COMP/OP AGO $ 2,000,000 Xsee holder descrip or operations • OTHER: p f 3 AUTOMOBILE LIABILITY (FOaBBINEDI SINGLE LIMIT E 1,000,000 ANY AUTO 6232707 04/01/2018 04/01/2019 BOotY INJURY(Per person) E — OWNED SCHEDULED • AUTOS¢EppONLY X AUUTTOSSy�.�Ep pBODILY INJURY(Per sodden° } 'X A�RTOS ONLY X AUTOS ONLY risRe Rtlenl)AMAGE .$ , E _ UMBRELLA LIAB X OCCUR __ EACH OCCURRENCE } 2,000,000 J X EXCESS LIAB CLAIMS-MADE EXC10006635003 04/01/2018 04/01/2019 AGGREGATE $ 2,000,000 _. • DED RETENTIONS $ II- D WORKERS COMPENSATION PER FR •AND EMPLOYERS'LIABILITY YIN WCE00431903 06/30/2018 06/30/2019 1,000,000 PROPRIETOR/PARTNER/EXECUTIVEAApN�YIPEPXRNEI I NIA E.I.EACH ACCIDENT $ Imantlalory In� I I—J E L.DISEASE•EA EMPLOYEE 5 1,000,000' II yes,describe under 1,000,000 • DESCRIPTION OF OPERATIONS below E L.DISEASE•POLICY LIMIT $ I'I. 'ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,AddItIonal Remarks Schedule,may be attached If more space Is required) corkers Compensation Includes Officers or Proprietors. dditlonal Insured status Is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. ixcess Liability is follow form. • 1 ;ERTIFIQATE HOLDER CANCELLATIQN 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 Ii./ G ..•.._.. n. ,ww.mm„, /A 41100 once A noon non nnnA"-pew A n.,su_ u..—...J b fli#1$....at`'CtiThe Commonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigations 600 Washington Street + 6 _ - Boston,MA 02111 „.0.21„."rebrpiwiww1 .4`F�'` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ' Applicant Information / 'n. / r� Please Print Legibly ' Name(Business/Organization/Individual): Ogre GO Pt,1blyti ml��ld7ti Address: F` eakh-,,,, (av, � /' City/State/Zip: `� 1441441•44., 01 W Phone#: �Jd$- 774 •) Z`7 Are you an employer?Chthe appropriate box: Type of project(required): I.k7I am a employer with 48 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 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 workingfor me in anycapacity. employees and have workers' P tY• t 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.❑ 1 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#t 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•contracturs have employees,they must provide their workers'comp.policy number. 4 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.#:WCE00431 903 Expiration Date: 06/30/2019 Job Site Address: 2f ¶Q f it fad ?Art-- City/State/Zip: tv Cl4k U / tt niA 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 tip 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 Investig tions of the DIA for insurance coverage verification. I do hereby certify under1the pains and penalties of perjury that the Information provided a ove t true and correct Signature: 71447 e O Date: 1� 1 /9 — (/ 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#: RISE ENGINEERING' OWNER AUTHORIZATION FORM I, Michael Pimental (Owner's Name) owner of the property located at: 24 Templeton Place (Property Address) West Yarmouth, MA 02673 (Property Address) hereby authorize CO (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. tOwner's Signature �z yc-/1 %Date - RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RISEengineering.com