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Home My WebLink AboutBld-20-000863 v 4 0 dPermit# '. �. . ''9 Amount G MATTACM CSE °°°011L°"�crd Permit expires 180 days from eV` (2— issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH _- RECEIVES^ arinouiix Building Departmentr �' 1146 Route 28 South Ya.wnouth, MA 02664 AUG 14 2019 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: -14 /D/2 r-� �r �� By: ASSESSOR'S INFORMATION: Map: Parcel: .OWNER: lei/ %4 �E N � P S ADDRESS TE . # CONTRACTOR:/� 2►P � /4r/o �� / � ��1>l�/� l/�i4 �U f�7�o Ji/ 5- NAME / MAILING D SS TEL.# ff(esidential 0 Commercial Est.Cost of Construction$ L et) d Home Improvement Contractor Lie.# /5'7,...5''G 7 Construction Supervisor Lie.# /O ,e9 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor E1—I have Worker's Compensation Insurance Insurance Company Name: 77 V_ ,C,—17 Worker's Comp.Policy# a C7 p 01 /, 6- f 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) Insulation • Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: //12/10,0P7 �d ylf 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 revoca n of my license d for prosecution under M.G.L.Ch.268,Section I. f Applicant's Signature: Date: !" f f/ f r Owners Signature(or attachme Date: Approved By: Date: ( �Y� Building Offi or nee) EMAIL AD S: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft. of Wetlands: 0 Yes 0 No 0 Yes ❑ No `Nt • •. t ,••• Commonwealth of Massachusetts Division of Professional Licensure • • Board of Builciing•Regula,tions and Standards Const,ruttt6,ri IttP,rvisor CS-100988 ires: 11/11/2019 WV HENRY E CA;'S I DY 8 SHED ROW;:•'?, WEST YARMOLMi frW071 Commissioner L77. /(:) .../(1/1?/i/(1/2((tr<2(7 / r(e'l.,!' (7r).6? • (t) Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home improvement Contractor Registration Type: Corporation Registration: 153567 • CAPE COD INS01..ATION, INC Expiration; 12/14/2020 18 REARDON CIRCLE SO,YARMOUTH, MA 02664 Up-date Addruaa and Return Card, 2 Mi t; office of Consumer Attains A DusIness Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: Registration Zxotration Office of Consumer Affairs and Business Regulation 153587 12/14/2020 1000 Washington Street•Suite 710 CAPE COD INSULATION,INC Boston,MA 02110 HENRY E.CASSIDY 18 REARDON CIRCLE SO.YARMOUTH,MA 02664 a Ith t 819ti r Undersecretary a AC.7C)REd'° CAPECOD-27 THORNE .---" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDYYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE H LD7/16/2 • E 01 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, II IMPORTANT; If the certificate holder Is an ADDITIONAL INSURED, the policy(Ies)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 Ileu of such endorsement(s), PRODUCER ~�� T•. G TACTOOd PHON Rogers 8,Gray Insurance Agency, Inc, .PHON 434 Rte 134 E _.__._. .-, South Dennis, MA 02660 (ac,No,ext);(800) 553.1801 I N,Ne):(877) 816-2156 A n ' ,mail@rogersgray,com t INSURERS)AFFORDING COVERAGE NAIC II INSURED INSURER A;West American Insurance Company 44393 T INSURER B;Arbella Protection Insurance Company, Inc, 41360 ___Cape Cod Insulation, Inc, INSURER o Endurance American Specialty Insurance Company 41718 18 Reardon Circle South Yarmouth,MA 02664 NSURERp;Atlantic Charter Insurance Company 44326 INSURER E; _ 4 4---- --- INSURER F __—.---- COVERAGES CERTIFICATE NUMBER: REVISION — — THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOnVE 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. INNSR ADDL SUER T TYPE OF INSURANCE NSD WVD POLICY NUMBER POLICY EFF POLICY EXP A X COMMERCIAL GENERAL LIABILITY IMMIOplYYYYI IMM(DP(YYYYI LIMITS CLAIMS MADE X OCCUR EACH OCCURRENCE $ 1,000,000 BKW 5332$2$1 4/1/2019 4/1/2020 pRFMISESCE m RENTED $ 100,000 MEDEXP(Any one person) $ 15,000 PERSONAL$,ADVINJURY $ 1 000,000; — N'L AGGREGATE LIMIT APPLIES PER' X POLICY I GENERAL AGGREGATE g 2,000,000 _GE JGe I_i LOC PRODUCTS•COMP/OP AGG $ 2,000,000 OTHER: - [AUTOMOBILE LIABILITY , $ COMBINED SINGLE LIMIT 1,000,0 0 ANY _ _(EEILC.c Bali) $ ANY AUTO 1020081008 4/1/2019 4/1/2020 AUTOS ONLY X SCHEDULEDBODILY INJURY(Per person) $ E __ AUTOS _OW X AUTOS ONLY X NON.OWN p BODILY INJURY(Per accident) $ AUTOS OY "s' PROPERTY DAMAGE —+ _(Per accident) $ C ■ UMBRELLA LIAS X OCCUR $ ® EXCESS LIAR I EACH OCCURRENCE $ 2,000,000, CLAIMS,MADE EXCI0006635004 4/1l2019 4/1/2020 AGGREGATE s 2,000,0001 _ DEp- RETENTIONS ______ ID WORKERS COMPENSATION AND EMPLOYERS'LIABILITY PER OTH• •� ---I ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WC100136900. 6/30/2019 6/30/20201,000,000 . STATUTE ER _ OFFICER/MEMBER EXCLUDED? I N IA (MEL.EACH ACCIDENT $ (Mandatory Inn NH)NH) os,describe under E.L.DISEASE•EA EMPLOYEES 1,000,000 DESCRIPTION OF OPERATIONS below ., E.L.DISEASE•POLICY LIMIT $ 1,000,000 // DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) I i CERTIFICATE HOLDER_ CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Information Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ""^--- 1988-2015 ACORD CORPORATION, All rights reserved. The ACORn name and Inn.,• •,,«,..w..__., ___ ... r . __ tViAljy tr.: The Commonwealth of Massachusetts > ff s _� Department of Industrial Accidents *Aft jP „ , Office of Investigations fttioit d 4*, _: 600 Washington Street .. !'. 5, Boston, MA 02111 41t4x�fa www.masS.gov/dia orkers' otnpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ,. Please Print Legibly Ntune (Business/Organizstiunflndividuai): Cape Cod Insulation Inc. 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 am a employer with 48 4, 0 1 am a general contractor and 1 employees(full and/or part-time), + have hired the sub-contractors 6. ❑ New construction 2,0 l 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 for me in any capacity. employees and have workers' [No workers' comp, insurance comp. insurance.: 9, Q Building addition required.] 5. ED 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 MOL 12,0 Roof repairs insurance required.)t c. 152,§1(4),and we have no 13. Other 1/Vatherization employees.[No workers' _ comp.insurance required.] 'Any applicant that checks box WI must also tlil out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. • ;Contractor that check this box muss attached an additional sheet showing the name ot'the sub-contractors and state whether or not those entities have employees, it'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 she inforn utlon, Insurance Company Name: Atlantic Charter Policy if or Self-ins. #:'WC100,136900 Expiration Date:06/30/2020 eksvi —Job Site Address-;j f p/ZTIt, Y�l /?) � Gity/Stafe(Zip:_ () 2. Attach a copy of the workers' compensation policy declaration` age(showing the policy'number and expiration date). failure to secue coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of e tine 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$2$0,00 a day against the,violator,'Be advised that a copy of this statement may be forwarded to the Office of Inyesli, ttonns of the DIA for insurance covevi e verification. I do hereby certibi under� the paints and penalties of perjury that the information provided aboi4 is true and -irrecl. Signature: Y r Date: e/,-/if Phone a: 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): 1. Board of Health 2, Building Department 3,City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector. 6.Other Contact Person: Phone#: I R 4‘,,.,,o, ;1,1 ENGINEERING' OWNER AUTHORIZATION FORM 1, Linda R Schnarr (Owner's Name) owner of the property located at: 369 North Dennis Road (Property Address) Yarmouth, MA 02675 (Property Address) hereby authorize Cc .e Co A. ,�� e ,c (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. Ck ./1--ir \() i—krIsivvv Owner' Signature Date tI/ a- � / 9 RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com