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HomeMy WebLinkAboutBld-20-000933 J• ap Permit# O . . H Amount ATTACP CS[ "°°°'•'""Q 'd Permit expires 180 days from {issue date >-ZDR33 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH x armoutii building epartment 1146 Route 28 South Yarmouth, MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: / 0,0JC/A/l DR" Q1 ,i ASSESSOR'S INFORMATION: l Map: Parcel: OWNER:P IJ 4 /X) 4///14 J 7 f 0,ee .�/� S� NAME PRRESENT ADDRESS TEL. # CONTRACTOR:�C�/fl� e7e55. �y Apia 21 G-/� �✓!'f10 .�2' 77 NAME / MAILING ADDRESS TEL.# residential ❑Commercial Est. Cost of Construction$ ,300 Home Improvement Contractor Lic.# /� �.y 7 Construction Supervisor Lic. t /)Q L� p' (57 Workman's Compensation Insurance: (check one) I am the homeowner ❑ I am the sole proprietor , .I have Worker's Compensation Insurancer / Insurance Company Name: ,,��ji k ( 4/2Ye/e Worker's Comp.Policy# !� C/d%:9 f 0 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: l� f� QJ) 7 1- 'm e / 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 revoc tion of my license d for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: • Date: evif Owners Signature(or attachme Date: Approved By: �� Date: Building Offici ee) EMAIL ADD Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes ❑ No REcEivEn Water Resource Protection District: Within 100 ft. of Wetlands: ❑ Yes ❑ No 0 Yes 2019 ❑ No BtiIt.DING �EpARTM NT ( Commonwealth of Massachusetts r/ Division of Professional t.icensure ' Board of Builcfing•Regulatlons and Standards Cone trkiett i ittIpervlsor CS-100988 • r t{ Expires: 11/11/2019 4 tic HENRY ECASSIDY 1 „ t ;a 8 SHED ROW:; \4t -tf' .,.. WEST YARMOGT)i O'><•6,73 !fi • c • 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 Registration: 153567 • 18 REARDON CIRCLE Expiration: 12/14/2020 SO.YARMOUTH, MA 02664 Update Address and Return Card. otncu of Consumer Affairs 8,Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: Registration Fxplratlon Office of Consumer Affairs and Business Regulation 153567 12/14/2020 1000 Waahington Street•Suite 710 CAPE COD INSULATION,INC Boston,MA 02118 HENRY E.CASSIDY 18 REARDON CIRCLE SO.YARMOUTH,MA 02604 Undersecretary a Ith t sign r A,� CAPECOD-27 __ THORNE; CERTIFICATE OF LIABILITY INSURANCE °ATE'MMI°°YYYY) 16/29 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLD R01 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 roquiro an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement s). PRODUCER C NTACT Good Rogers&Gray Insurance Agency, Inc. PHONE 434 Rte '134 (A/c,No,Ext):(800)553.1801 (A/c,No):(877) 816-2156 South Dennis, MA 02660 p^AF Ss,mail@rogorsgray,com INSURER(S)AFFORDING COVERAGE NAICq INSURER A:West American Insurance Company 44393 INSURED INSURERe:Arbella Protection Insurance Company, Inc, 41360 -- I Cape Cod Insulation, Inc, INSURER C;Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER D;Atlantic Charter Insurance Company44326 South Yarmouth, MA 02664 INSURER F.; --- INSURER F; 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. 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, j EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1NSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP -- _1 INSD WVD POLICY NUMBER (MMIpDTY]TY) IMM/NI " r1 LIMITS A X COMMERCIAL GENERAL LIABILITY 1 EACH OCCURRENCE $ 1,000,000• CLAIMS MADE ! X I OCCUR BKW 53328281 4/1/2019 4/1/2020 DAMAGE TO RENTED 1 00,000 PREMISES(Eamcs1l4nReJ MED EXP(Any one person) 5 15,000, t • ---- - ---� PERSOIJAL ADV INJURY- g____1,000 000.' GENL' AGGREG�r TE LIMH APPLIE,s PER: 2,000 000 X ilPOLICY1 IJECT — LOC GENERAL AGGREGATE $ PRODUCTS-CQMP/OP AGO $ 2,000,000 OTHER: I __ BTAUTOMOBILE LIABILITY $ r- COMBINED aI1 /SINGLE LIMIT 1,000,000� ANY AUTO 1020081008 4/1/2019 4/1/2020 OWNED SCHEDULED BODILY INJURY(Por person) I AUTOS ONLY X AUTOS — BODILY INJURY(Per accident) g E pWN p -' • ,_,I X AU70S ONLY X.I A�OS ONLY PROPERTY DAMAGE (Per accident) $ ----�- C UMDRELIA LIAB I�X OCCUR I - I • EACH OCCURRENCE S 2,000,000! X EXCESS LIAB I CLA!MS•MADE EXC10006635004 4/1/2019 4/1/2020 AGGREGATE 2,000,000 _ DED I RETENTION$ —_ D !WORKERS COMPENSATION S AND EMPLOYERS'LIABILITY Y/N SPE TATUTE 1 ERH i ANYPROPRIETOR/PARTNER/EXECUTIVE WC100136900 6/30/2019 6/30/2020 1,000,000'. OFFICER/MEMBER tn NH EXCLUDED? NIA E.L.EACH ACCIDENT $ It yes,describe under• E.L.DISEASE•EA EMPLOYEE.5i 1,000,0001 • DESCRIPTION OF OPERATIONS below 1,000,000 E.L.DISEASE•POLICY LIMIT S --- -- -- I f DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schodulo,may be attached If more space Is required) _ CERTIFICATE HOLDER _ CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE For Information Only ACCORDAEXPIRATION DATE NCE WITH THE POLICY PROVIS ONgCE WILL BE DELIVERED IN AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. Ail rights reserved J , The ACORr) namo onr! I........... .....,.,a-_-., _._-,.. , . l' r r`+t.=,A i, ,� "•4,,i,, The Commonwealth of Massachusetts 'h,'•l tr af4, Department of Industrial Accidents i i 14:t. r+r t li :rt If, t't ;,, t,. Y.tV', Office of Investigations '" i�'i 600 Washington Street I t,� "� ' ',w, ' Boston, MA 02111 t i ,-i tt rt,v t i tit „ n. li a ', :�„r; :4 ;“i� www.mass.gov/dla Workers' ompensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Let!-ibly Name (Business/Organization/Individual): Cape Cod Insulation Inc. Address: 18 Reardon Circle City/State/Zip: South Yarmouth, MA 02664 Phone #: 508-775-1214 Are yuu an employer? Check the appropriate box: Type of project(required): I.VI am a employer with 48 4. ❑ 1 am a general contractor and 1 6. ❑ New construction employees(full and/or part time).' have hired the subcontractors 2 ❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P tY 9, ❑ Building addition (No workers' comp, insurance comp, insurance.t required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3 ❑ l 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 WI must also nil out the section below showing their workers'compensation policy int'ornration. 'Homeowners who submit ttfii affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. • ;C'untracion that check this box must attached on additional sheet showing the name of the sub-contractors and state whether or not those entities have employers. If the sub-contractors have employees,they must provide their workers'comp.policy number. I sun 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 If or Self-ins.Lie.#: WC100136900 Expiration Date;06/30/2020 __ ' Job Site Address:, /9Afi(/A '� /7r/>,,e ,/Z _._ City/State/Zip , Attach a copy of the workers''corni sation policy declaration'page(showing the policy dumber and expiration date). l'ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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$250.00 a day against the,violator. Be advised that a copy of this statement may be forwarded to the Office of Ind ti�a�„tions of the DIA for insurance covetsge verification. - _-__ ..._., - 1 do hereby certify under the pains and penalties of perjury that the information provided aboi,e is true and -lrrect i,,a z Yr Date: riti-/f!, — Phone u: 508-775-1214 �. _ ..__ ., Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# issuing Authority(circle one): I. Board of Health 2. Building Department 3.Cityrf own Clerk 4. Electrical Inspector 5. Plumbing Inspector' • 6.Other Contact Person: Phone#: i - tt._.. - asY RISE ENGINEERING" OWNER AUTHORIZATION FORM 1, Paula F Williams (Owner's Name) owner of the property located at: 1 Dancing Brook Road (Property Address) South Yarmouth, MA 02664 (Property Address) hereby authorize Coa-:'C\SV\c`I (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. Owner's Signatu s/7 Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com t ewrAA-0-6/ 4 4/ 61*Y4 TOWN OF YARMOUTH Building Department BUILDING (508) 398-2231 ext.1261 or, " c. PERMIT NO BLD 20 000933 PERMIT c' ;t Ems '' JOB WEATHER CARD `"0.01'" rd ISSUE DATE 08/20/2019 APPLICANT HENRY CASSIDY PERMIT TO New AT(LOCATION) 11 DANCING BROOK RD,SOUTH YARMOUTH M ! ZONING DISTRICT R 40 x Bldg.Type: Residential SUBDIVISION MAP BLOCK LOT §058 177 i BUILDING IS TO BE: ICONST TYPE €'V B s USE GROUP iR 3 r , I CONTRACTOR REMARKS Repair: Install Insulation(508-775-1214) q I �.. ! LICENSE i153567 ;Home Improvement ' „CAPE COD INSULATION, INC HENRY CASSIDY 1 18 REARDON CIRCLE AREA(SQ FT) 455 376 240.i EST COST($) 3000 00 i PERMIT FEE($) 35 00 i SO.YARMOUTH, MA 02664 OWNER IABRUNZO GAIL ANN ��� BUILDING DEPT BY ADDRESS 1 DANCING BROOK RD ieV SOUTH YARMOUTH 1MA 102664 I_. NE 1 THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWAL AOR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE APPROVED BY THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM INSPECTIONS REQUIRED FOR ALL APPROVED PLANS MUST BE RETAINED ON WHERE APPLICABLE CONSTRUCTION WORK: 1)FOUNDATIONS OR JOB AND THIS CARD KEPT POSTED UNTIL SEPARATE PERMITS ARE FOOTINGS.2)PRIOR TO COVERING STRUCTURAL FINAL INSPECTION HAS BEEN MADE. REQUIRED FOR ELECTRICAL MEMBERS(READY FOR LATH OR FINISH WHERE A CERTIFICATE OF OCCUPANCY IS PLUMBING/GAS AND COVERING)3)FINAL INSPECTION BEFORE REQUIRED,SUCH BUILDING SHALL NOT BE MECHANICAL INSTALLATIONS. OCCUPIED UNTIL FINAL INSPECTION HAS OCCUPANCY 4)REFER TO DETAILED INSPECTION BEEN MADE. SCHEDULE POST THIS CARD SO IT IS VISIBLE FROM STREET BUILDING INSPECTIONS APPROVALS OTHER: I WORK SHALL NOT PROCEED PERMIT WILL BECOME NULL AND VOID IF INPSECTIONS INDICATED ON THIS CARD UNTIL THE INSPECTOR HAS CONSTRUCTION WORK IS NOT STARTED WITHIN CAN BE ARRANGED FOR BY TELEPHONE APPROVED THE VARIOUS SIX MONTHS OF DATE THE PERMIT IS ISSUED AS OR WRITTEN NOTIFICATION. STAGES OF CONSTRUCTION NOTED ABOVE.