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Home My WebLink AboutBld-20-000865 V l 10. �Permit# \f J0 D.�1, �� Amount ` nA;,,,c� [SEr„, - �•,p,..„p,'�d „Permit expires 180 days from / S� issue date cB EXPRESS BUILDING PERMIT APPLICATION - TOWN OF YARMOUTH �e ., I arinouth Building Department REC E I V E p1 1146 Route 28 1 1 South Yarmouth, MA 02664 AUG 14 2019 ' i (508)398-2231 Ext. 1261 .:- i i CONSTRUCTION ADDRESS: ASSESSOR'S INFORMATION: Map: Parcel: OWNER: y/le/4/ ,g,I0/// Ri yyJ t® ,il 7797f S f P ivlE P S ADDRESS / TEL. # Z CONTRACTOR: / L �ci G rI//l�/J//�l%fi� Jr' p®/9g% �f., �J� ,,,, ,5GJ77 , ;2 l` — ME MAILING AD RESS y TEL.# /Residential 0 Commercial Est. Cost of Construction$ el tl‘5. Co s p Home Improvement Contractor Lie.# As'',a,.5 4, 7 Construction Supervisor Lie.# /4 7 f JP t Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name:___ i //C Zid �_e__ Worker's Comp.Policy; C`eZil`,.74-P9 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 ,e-v Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debtls will be disposed of at: 7,9,eige4 � /vll 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 rev ion f m 'cen d for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: ffXf`/f Owners Signature(or attachment) Date: f J Approved By: '��-7`•p Date: / Building ici or designee) L ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft. of Wetlands: 0 Yes 0 No 0 Yes 0 No e-T-111111 Commonwealth of Massachusetts Division of Professional Licensure Board of Building,Regulapons and Standards ConstRtyttb,r1 iStIpervlsor CS•1009 88 Erg Ores: 11/1 1/20 19 HENRY E CASSIDy 8 SHED ROW WEST YARMOUTfri'Mk„ 8,73 — '41.1 • *.• Commissioner CA- :77 „ /1?/1/(Yle"(`- (1(71- 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 INSULATION, INC Expiration: 12/14/2020 18 REARDON CIRCLE SO,YARMOUTH, MA 02664 Update Address and Return Card. ;A 20M-05 ti APJ /4 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: Registration agirAtion Office of Consumer Affairs and Business Regulation 1535E7 12/14/2020 1000 Washington Street•Suite 710 CAPE COD INSULATION,INC , Boston,MA 02118 HENRY E.CASSIDY 18 REARDON CIRCLE SO,YARMOUTH,MA 02664 — a ith t sign r undersecretary r 1 A CAPECQD-27 THORNE '' CERTIFICATE OF LIABILITY INSURANCE DATE(Mh1/DDYYYY) 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 en ADDITIONAL INSURED, the pollcy(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 rthis certificate does not confer rights to the certificate holder In lieu of such endorsement(s), PRoeucER — ON — J'AMTACT Good — Rogers &Gray Insuranco Agency, Inc, PHONE _ a34 Rte 134 (A/c,No,Exq;(800) 553-1801 FAX �T South Dennis, MA 02660 gg MM� mail ro ors ra com I(Arc,"°).(877) 816 2156 ADVAS: �_� Y• INSURER(S)AFFORDING COVERAGE — ----- _ NAIC;i INSURED INSURER A I West American Insurance Company 44393 _ INSURERa Arbella Protection Insurance Company, Inc. 41360 _—_ Cape Cod Insulation,Inc. INSURER c:Endurance American Specialty Insurance Company 41718 18 Reardon Circle South Yarmouth;MA 02664INSURER o:Atlantic Charter Insurance Company 44326 INSURERS: _ COVERAGES INSURER F: • — 'I CERTIFICATE NUMBER: REVISION NU THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVEE 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, mSR ADDL SUER POLICY EFF POLICY EXP TYPE OF INSURANCE A -------- INSD WVD POLICY NUMBER fMM/DD/YYYY) (MM/DD/YYW) LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS-MADE � )( OCCUR EACH OCCURRENCE g 1,000,000 BKW 53328281 4/1/2019 4/1/2020 DAMAGE To RENTED FRFMISEn REN u�rencea $ 100,000 MED EXP(Any one person) $ 15,0001 GEN'L AGGREGATE LIMIT APPLES DER: PERSONAL 4 ADV INJURY $ 1,Ooo,000 X POLICY JC LOC GENERALAGGREGATE $ 2,000,000 j _ (___ OTHER: PRODUCTS•COMP/OP AGG $ •. 2,000,000 B AUTOMOBILE LIABILITY '___�'---""' _ $ COMBINED a ;INGLE LIMIT S —_ 1,000,000 ___ ANY AUTO 1020081008 O• WNS ONLY D X SCHEDULED 4/1/2019 4/1/2020 BODILY INJURY(Per person) $1 AUTOS , X AUTOS ONLY X NO p " � `- BODILY INJURY(Per accident) $ PROPERTY DAMAGE (Per accident) $ G UMBRELLA LIAR f X OCCUR g If X EXCESS LIAR I O AIMS•MADE EXC10006635004EACH OCCURRENCE $ 2,000,000 P. — 4/1/2019 4/1/2020 AGGREGATE 2,000,000� DED- RETENTION$ D rWORKERS COMPENSATIONPER $ AND EMPLOYERS'LIABILITY - _ G ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WCI00136900 I oTH• —I OFFICER/MEEMBgER EXCLUDED? ( l N/A 6/30/2019 6/39/2.020 STALAC I FR ___ (Mandatoryin NH) E L.EACH ACCIDENT $ 1,000,000 I yes,describe under E.L.DISEASE•EA EMPLOYEE 1,000,000 DESCRIPTION 9F OPERATIONS below •• E.L.DISEASE-POLICY LIMIT $ 1,000,000 i 1/ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more.space Is required) __ CERTIFICATE HOI..DE ,. CANCELLATION !—^ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For InfOrmatI Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, 6 AUTHORIZED REPRESENTATIVE I ' —i n-:ACORD 25(2016/03) "------•-- 01988-2015 ACORD CORPORATION. All rights reserved, ,..t. �:...d The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dla or ers' ompensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organirationuindividual): 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): 1, I am a employer wIth 48 4, ❑ 1 ern a general contractor and 1 °�° employees(full and/or part-time).* have hired the sub-contractors 6. ❑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, (a Demolition working for me in any capacity. employees and have workers' g. Q Building addition [No workers'comp, insurance comp.insurance.: required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I 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.❑ Roof repairs insurance required.]t c. 152,§1(4),and we have no Weatherization employees.[No workers' 13.A Other., comp.insurance required.] *Any applicant that checks box 111 must also till 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. :Contractors that check this box must attached en additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-corn actors 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 site information. insurance Company Name: Atlantic Charter Policy+€or Self-ins.Lie.#: W CI00136900 Expiration Dates 06/30/2020 Job Site Address:,/, cy'/ - g. ity/State/Zip:f � - 7 J Attach a copy of the workers' compensation policy declarati n'page(showing the policy dumber and 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 line 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 Inver i ations of the DI for ins c covers a verification. I do hereby certify under the pains and penalties of that the information provided abboovee is true and .)tree& Signature: D e/ /i r, .— Z��J ��.cZr1:c� Phone ii: 506-775..1214 — Official use only. Do not write in this area,to be completed by clay 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 Inspecfor 6,Other Contact Person: Phone#: RISE ENGINEERING" OWNER AUTHORIZATION FORM 1, DIRLEI J BELLI , (Owner's Name) owner of the property located at: 151 Webbers Path (Property Address) West Yarmouth, MA 02673 (Property Address) hereby authorize (mac e. Cm.4" --c \01d (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. iliv,.. , 6 , Ali( Owner's Signature L- ia- I ) Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com