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Home My WebLink AboutBLD-19-004041 • ?OffceU Use Only 'Permitil Amount `nrintiA tc (gin , ;Permit expires 180 days from • BUJ .'sg--00(-Io yf - RECEIVED DECEIVED EXPRESS BUILDING PERMIT APPLICATI JAN 08 2019 • TOWN OF YARMOUTH • Yarmouth Building Department GUI .l, 1146 Route 28 By: , _S South Yarmouth, MA 02664 an4• (508) 39///$$$)))-2231 Ext. 1261 CONSTRUCTION ADDRESS: I utw(/, t./ !V, '_— %Vbtu-(4,ft • ASSESSOR'S INFORMATION: t !/ � / IMap; /� Parcel: OWNER: LtOVV'lw. V 1114rV 7,51- 775 68717 NAME I PRESENT ADDRESS TEL. # CONTRACTOR: Henry Cassidy Cape Cod Insulation 18 Reardon Circle South Yarmouth 508-775-1214 NAME MAILING ADDRESS TEL.# RResidential ❑Commercial Est.Cost of Construction$ -D _pp home Improvement Contractor Lic.# 153567 Construction Supervisor Lie.# 100988 Workman's Compensation Insurance: (check one) D I am the homeowner - 0 1 am the sole proprietor N 1 have Worker's Compensation Insurance Insurance Company Name: Atlantic Charter Insurance Worker's Comp.Policy,/WCEOO431902 WORK TO BE PERFORMED . Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulatio I X ii . g. . tuv i j 96 h 200 Old Kings Highway/Historic Dist. ( ) Replacing like for like Pool fencing II�� ./�, ,.{Q�� tui& d ut,tc o'c-3jd----41 ell/sloe- /hs *The debris will be disposed of at: 4n'✓# �lr`^�I vt g'1_Ili dif G�-'�a j/ --4 RI C/ Location of F cillty Cie ci/� I I declare under penalties of perjury that the stafgents 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.O.L.Ch.268,Section 1. 1 / f Henry_ 3�id °= w. W'{�: Applicant's Signature: y -„1.w";";.":.<.m Date: 1 Owners Signatureattnchmeat) Date: p Approved By: 'tea Date: P --/y Building 0()Mini(or distance) EMAIL ADDRESS: Zoning District: • Historical District: CI Yes fl No Flood Plain Zone: 0 Yes G No Water Resource Protection District: Within 100 ft.of Wetlands: • C] Yes 0 No 0 Yes 0 No no • as%_ The Commonwealth of Massachusetts --'—r'/ DepartmentIndustrial Accidents o.;l�l=; of e. -`rf= .1 Congress Street,Suite 100 _...I_ 7" _•:1 Boston, MA 02114-2017 .k.-c1=- ta;,=,5+y www mass.gov/dia e. \Yorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. • Applicant Information Please Print Le¢ibly 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 with 48 4. 0 lam 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. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working an g for me in capacity. employees and have workers' Y P b• 9. ❑ 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,§I(4),and we have no Weatherization employees. [No workers' 13. 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 ant 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 ii or Self-ins.Lie.#:W 00//44^ 1903 //�� Expiration Date: 06/30/2019 /,I� Job Site Address: ( VG auk 4'r: City/State/Zip: rfil. I !tet' ' Oji// Attach a copy of the workers' compensati n policy declaration'page(showing the policy number and expi tion date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal enalties of a tine up to 51,500.00 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 un�der the pains and penalties of perjury that the information provided above rs true and correct SSignature. 1 re: Date. 9 ! /`7 _ // I 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#: . l�1Division of Professional Licensure Board of Building Regulations and Standards • Cons rttteSbpsrvisor (p CS-100988 J r. 'T'0 Wires: HENRY ECASSIDY, a , 8 SHED ROW'[i '��, 3 O t E • WEST YARMOUTS MA,0 673 • `1,101 ,00'10 • Commissioner • 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 1 1, IifI' Registration: 153567 18 REARDON CIRCLE Expiration: 12/14/2020 SO.YARMOUTH, MA 02664 / j1 /, Update Address and Return Card. CA 1 O 20M-OS/17 Office of Consumer Affairs 6 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: fteoistration,:, Expiration Office of Consumer Affairs and Business Regulation • ,;153567 11,., 12/14/2020 1000 Washington Street-Suite 710 CAPE COD INSULATION IND•' Boston,MA 02118 7,rl l� 1 r HENRY E CASSIbY r /�^°^Ce2 --- 18 REARDON CIRCLE•= u /�� Ifh fS� [ SO.YARMOUTH,MA 02664 Undersecretary gn/ rF . , Permit Authorization eyi mass save Form Site ID: 3577412 Customer: Lori Lynch (a t (/"Q- J �� ( ,owner of the property located at: (Owner's Name,printed) 14 Country Club Drive South Yarmouth, MA 02664 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature: 4CAM1tAA& ), pVjU i1-1 Date: I k;•\\lFS FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: Page 1 of 1 For Office Use Only Rev.102015 �� • -�.'11 CAPECOD•27 AMAHLER 4CORC CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDOIYYYY) 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). 'RODUCER gRjwCT . lagers&Gray Insurance Agency,Inc. PHONE FAX 36 Rte 134 - INC, o,Eat . (ac,Nol:(877)816.2156 south Dennis,MA 02880 t'r5kss:mail1rogeragray.com INSURERISI AFFORDING COVERAGE NAIL F iNSURERA;West American Insurance Company 44393 NSURED INSURER o Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER c;Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURERo)Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E) INSURER F 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, NOTVYITHSTANDING 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. ISR ADOL SUER TR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP 1MMmDmvY) IMMlDOIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS•MADElij OCCUR BKW(19)63328281 04/01/2018 04/01/2019 OAFACE ?FnccarDeare) S 100,000 MED EXP(AnY One person) 3 5'000 PERSONAL 3ADV INJURY $ 1,000,000 GE 'L AGGR A ELIMIT AP 1 BPER: GENERALAGGREGATE $ 2'000,000 X POLICY J I9f LOCI. PRODUCTS•COMP/OP AGO S 2,000,000 •THER; X see holder deer pror operations $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 $ (Ea accIdenn — ANY AUTO 8232707 04/01/2018 04/01/2019 BODILY INJURY person) $ AUTOS ONLY ONLY X aUpTNINS?wUyLNNEEEDpp P X AUTOS ONLY X AUTOSONLY BODILY GOPERNYU MAGE GGItlenU $ (�er sec' ens '3 _ $ C' UMBRELLA LIAR X OCCUR EACH OCCURRENCE 3 2,000,000 X EXCESS LIAB CLAIMS•MADE EXC10008835003 04/01/2018 04/01/2019 AGGREGATE $ 2,000,000 OED RETENTIONS D WORKERS COMPENSATION EE $ AND EMPLOYERS'LIABILITY WCE00431903 SiATUTF FR ANYQPROPRIETOR/PARTNER/EXECUTIVE08/30/2018 00/30/2019 1,000 000 gust os lnm EXCLUDED] NM E.L EACH ACCIDENT $ If pee describe antler E.L.DISEASE•EA EMPLOYEES 1,000,000 DE 54�RIPTION OEOPERATIONS below1,000,000 _.L.DISEASE•POLICY LIMIT $ , // ESCRIPTION OF OPERATIONS!LOCATIONS:VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) 'orkers Compensation Includes Officers or Proprietors, ddltIonal Insured status Is provided under the General Llabillty and Auto Liability when required by written contract or agreement with the Certificate Holder. xcess Liability Is follow form. IERTIFI.CATE 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 ,CORD25(2016/03) CD 1988.2015ACORnCnapnraa'lnkl AN.1.ke. .n.,..,,,..,