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Home My WebLink AboutBLD-19-4040 .)Office Use Only OFY'9R SA; `Pemthfligd Amount J .�"rd$ 'Permit expires 180 days from • or t Issue date - gCap—Iqe _RECEIVED EXPRESS BUILDING PERMIT APPLICATIO I TOWN OF YARMOUTH JAN 08 2019 1 Yarmouth Building Department 11 l 1146 Route 28 BUi��t T South Yarmouth, MA 02664 By: /9 fJ(/y (508))33998-22231 Ext. 11261 ({�, CONSTRUCTION ADDRESS: Pill ll O-`' '-- a1L.�.__liwnyt'��t/s "'� ASSESSOR'S INFORMATION: 01-7 auk Map: • Parcel: � OWNER: 1 p'39. 296: 1/ 6 NAME PRESENT ADDRESS TEL. 0 Henry Cassidy Cape Cod Insulation 18 Reardon Circle South Yarmouth 508-775-1 214 CONTRACTOR: . NAME MAILING ADDRESS TEL.R g Residential 0 Commercial Est.Cost of Construction$ 176' -" Ilome Improvement Contractor Lie.N 153567 Construction Supervisor Lie.N 100988 Workman's Compensation Insurance: (check one) 0 I am the homeowner - 0 I am the sole proprietor N I have Worker's Compensation Insurance Insurance Company Name: Atlantic Charter Insurance W0rker's Comp.Policy!!WCE00431902 WORK TO BE PERFORMED . Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: N of Squares Replacement windows: N Replacement doors: Na Roofing: N of Squares ( )Remove existing*(max,2 layers) ZI . 41rnsutatiogf X Ar' � VVa S�tLf GLS; �5 It Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing "The debris will be disposed of at: e ✓'V kW " '_ V 2-7i ✓66144_ Location of Facility I �% I declare under penalties of perjury that the statements here fined are true and correct to the best of my knowledge and be lef. I understand that any false answer(s) will be just cause for denial nr revocation of my license and for prosecution under MAL.Ch.268,Section I. HenryCassidy '07:1:.=11="1"'"'"aI7":T=..,_°" I 'Z lq Applicant's Signature: Date: Owner Signature(or attachment) 7.2 Date: p l 1 -8-i et Approved By: J �C. Date;Building Off tial(or deltrieEMAIL ADDRESS: Zoning District: Historical District: 0 Yes CI No Flood Plain Zone: 7 Yes G No Water Resource Protection District: Within 100 ft. of Wetlands: ' 0 Yes 0 No 1 Yes Cl No RISE t ENGINEERING' OWNER AUTHORIZATION FORM 1, Richard A White (Owner's Name) owner of the property located at: 194 Berry Avenue (Property Address) West Yarmouth, MA 02673 (Property Address) hereby authorize C.. 0, r Q C o I 1 = n S "i a f 'o i (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 : .ture 10- 3 )-1p Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com l`Wi Division of Protessional Licensure l Board of Building Regulations and Standards • Cons`4ttt4itl$[f rvisor , CS-100988 Tres: 11/11/2019 + � Y ' 15 HENRY E CASSIDYt „ .� • 101 1_ " • 8SHED ROW% `� t ` ' 0 WEST YARMOGTpiNq,0 873 S •� mO,.c�;LIOA\ ., " • - C0 Commissioner • w ) ✓/moi Se::/nm neoeaJI0�S/ / / - 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 {, - j Registration: 153567 18 REARDON CIRCLE Expiration: 12/14/2020 SO.YARMOUTH, MA 02664 � i • :fir 1 .�;� • Update Address and Return Card. CA 1 0 20M.05/17 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: Repistratlo'n Expiration Office of Consumer Affairs and Business Regulation • r,i 153567 .i,� 12/14/2020 1000 Washington Street•Suite 710 CAPE COD INSULATION.,INC';" Boston,MA 02118 a HENRY E.CASSIDY 77, ear -- �� - 18 REARDON CIRCLE- U SO.YARMOUTH,MA 02664 Undersecretary �� a i• 'ith t sign/ r • /' • • • Pa • . The Commonwealth of Massachusetts t —a—'r Department of IndustrialAccidents S— QaI=° P " ` 1_ r I Congress Street, Suite .100 �e EiiBoston,MA 02114-2017 eY •.0; ,;,`,,+ www.mass.gov/dla \Yorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. • ,4aplicant Information Please Print Leeibly 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.VI am a employer iyith 48 4. 0 I am a general contractor and 1 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 working for me in any capacity.acity• employees and have workers' t 9. ❑ Building addition [No workers'comp. insurance comp.insurance. required.] 5. ❑ 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 q 113.{[ Other Weatherization employees.[No workers' --• _ 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 on 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 fob site information. • ' Insurance Company Name: Atlantic Charter Policy #or Self-ins.Lie.#:WCE004]31.903 Expiration Date: 06/30/2019 �QQ Job Site Address: rig l5 City/State/Zip: o I,�NX s4 4 Attach a copy of the workers' cont ensation policy declaration'page(showing the policy number nd expiration date). Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a fine up to SI,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 ab ye/t�Jltrue and correct Signature: Y147V7 ea U/ Date: 1/7/ /9 _ J ( I Phone k: 508-775-1214 _ _ • Official use only. a 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#: --- - ---------- 4 • -----'1 CAPECOD-27 AMAHLE- A`OROe CERTIFICATE OF LIABILITY INSURANCE DATE IMMIOOM/YY) 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(s). PRODUCER MQgliACT Rogers 8 Gray Insurance Agency,Inc. PHONE pAX 434 Rte 134 lac,No,Ext): (ac,No):(877)816.2166 South Dennis,MA 02660 imiss,mail@Arogersgray.com INSURER'S)AFFORDING COVERAGE NAIL N INSURER AMeet American Insurance Company 44393 INSURED INSURER a:Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER c;Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURERo:Atiantic Charter Insurance Company 44326 South Yarmouth,MA 02684 INSURER E: INSURER P I 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. NOTWTHSTANDING 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. INSR TYPE OF INSURANCE INSD SUER POLICY NUMBER IMMIDDY EFF I IMMLDDY/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ❑X OCCUR BKW(19)53328281 04/01(2018 04101/2019 PREM 4FA'OrFAoaur lenrel s 100,000 -- MED EXP(Any one person) $ 5,000 — PERSONAL S ADMINA/RV $ 1,000,000 Sin AGGREE LIMITAPPLIESPER: GENERAL AGGREGATE $ 2,000,000 X POLICY lOderdnLOO• PRODUCTS•COMP/OP AGO a 2,000,000 see holder dedp of operations X OTHER: ; B AUTOMOBILE LIABILITYCOeMecafdeBINED ntl SINGLE LIMIT ; 1,000,000 ( _ — ANY AUTO 6232707 04/0112018 04/01/2019 BODILY INJURY(Per person) $ AUTOS ONLY v SCHEDULED Peng/en? 1 X ApTOS ONLY X IA/M149 pBgOOILYINJUDDRY(Per accident) $ — (Pe�acaRrJant)AMAGE .; $ C _ UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,000,000 X EXCESS MB CLAIMS-MADE EXC10006835003 04/01/2018 04/01/2019AGGREGATE $ 2,000,000 •• DED RETENTIONS EE $ 0 WORKERS COMPENSATION S7ATUTF I FFRH AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE n WCE00431903 06/30/2018 06130/2019 E.L.EACH ACCIDENT $ 1,000,000 OFFICERMI¢M$gpRpEXCLUDED9 NIA (Mandatory In NH) It yesdescribe under E.L.DISEASE•EA FMP $ 1,000,000 • DESCRIPTION OF OPERATIONS below E DISEASE-POLICY $ 1,000,000 • . / DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space 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. CERTIFICATE_ROLDER 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 �, 7� _._ ACORD 25(2016/03) 01988.2015 ACORD CORPORATION. All riahts reserved.