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HomeMy WebLinkAboutBld-20-001038 • O ,1 Permit# /QE- I Amount 3 MATTA 1� CS[ -,.1 �, `°^^a••°°"' d ,1Permit expires 180 days from issue date -20--I D 3 EXPRESS BUILDING PERMIT APPLICATI TOWN OFYARMOUTH RECEIVED Y arinuuti Building iepartment 1146 Route 28 AUG 2 3 2019 South Yauniouth, MA 02664 (508) 398-2231 Ext. 1261 BU By: CONSTRUCTION ADDRESS: /4 f3,Q4 j G,.Q Sr Z/1/ ASSESSOR'S INFORMATION: Map: Parcel: OWNER: ...7,-rom .1,9p-itor 2 6 3 33/.3'-54 4- r NAME / l PRESENT ADDRESS TEL. # CONTRACTOR: L/,/0r C4f$/ / E 4€41 G//2 ) 1Dlj�L ��$7 7'y4, �IL" NAM MAILING ADDRESS TEL.# /Residential 0 Commercial Est. Cost of Construction S d O� d Home Improvement Contractor Lie.#p m 3,1 li 7 Construction Supervisor Lic.# /OG ter Workman's Compensation Insurance: (check one) I am the homeowner ❑ I am the sole proprietor ivflave Worker's Compensation Insurance Insurance Company Name: deft4- adage Worker's Comp.Policy# GJ C I O e2 j 3 Li 0,0 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: /,/,0/Z10/0 U ! '�u w, P 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 revocat-n of my license d for prosecution under M.G.L.Ch.268,Section i. l Applicant's Signature.__. ,I/; Date: Pi:,j/1/P Owners Signature(or arta- me ) Date: // Approved By: Date: a3 1 uilding Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft. of Wetlands: C Yes 0 No 0 Yes ❑ No 1- ,r Commonwealth of Massachusetts l / Division of Professional Licensure Board of Building•Regulations and Standards Constrytct ri tttpervisor • CS•100988 E.Xpires: 11/11/2019 - c il�T '� E i3r1 4.1 HENRY E CASSIDY "+ S SHED ROW� r'"" WEST YARMOUTH ' 673\` c 0 ��. 1 . Commissioner Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation CAPE COD INSIfLATION, INC Registration: 153567 • 16 REARDON CIRCLE Expiration: 12/14/2020 SO,YARMOUTH, MA 02664 zo,, „ . Update Address and Return Card. Office of ConsumerAffalra&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 153567 12/14/2020 1000 Washington Street-Suite 710 CAPE COD INSULATION,INC Boston,MA 02116 I HENRY E.CASSIDY 18 REARDON CIRCLE �J SO.YARMOUTH,MA 02664 Undersecretary a I Ith t sign r i AC CAPECOD-27 THORNE i_ CERTIFICATE OF LIABILITY INSURANCE °ATE(h „°D YYY' 7/16/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 1 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 i REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an 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 I this certificate does not confer rights to the certificate holder In Ileu of such endorsement(s). PRODUCER CONTACT Good ---- Rogers&Gray Insurance Agency, Inc, PHONE 434 Rte 134 (A/c,No,Ext):(800) 553.1801 FAx — South Dennis, MA 02660 (Ac,No):(877) 816-2156 Miss.mail@rogersgray,com INSURER(S)AFFORDING COVERAGE NAIC d INSURER West American Insurance Company 44393 INSURED INSURER B;Arbella Protection Insurance Company, Inc. 141360 Cape Cod Insulation, Inc. INsuRER c:Endurance American Specialty Insurance Company_1718 18 Reardon Circle INSURER D;Atlantic Charter Insurance Company '44326 South Yarmouth, MA 02664 INSURER E L-_ 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 WTH 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. IL SR i TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP _ INS° WVD POLICY NUMBER (MMIDDIYYYYI (MMIDD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY 1,000,0001 1 ! 1 CLAIMS MADE X OCCUR EACH OCCURRENCE g -- BKW 53328281 4/1/2019 4/1/2020 DAMAGE TO RENTED 100,0001 PREMISES(Ea ocourronEe) $ MED EXP(Any one person) $ 15,000I — PERSONA(&A9VINJURY $ 1,000,000! GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000i X POLICY i I PE [ LOC PRODUCTS•COMP/OP AGO $ •. 2,000,000 OTHER: $ B7 AUTOMOBILE LIABILITY ^C COMBINED SINGLE LIMIT $ 1,000,000 I 1 !ANYAUTO 1020081008 4/1/2019 4/1/2020 BODILY INJURY(Per person) $ i �'(DOMED 1 SCHEDULED AUTOS ONLY X AUTOS BODILY INJURY(Per accident)4 L. HIRED I X I NON.OWNcq I -- _---- X AU OS ONLY _, AUTOS OdLY PROPERTY DAMAGE _(Per accident) $ $ C UMBRELLA LIAR 1 X OCCUR • EACH OCCURRENCE $ 2,000,0001 ',. X EXCESS LIAR I CLAIMS•MADE EXC10006635004 4/1/2019 4/1/2020 2,000,000l AGGREGATE __ __ __I- DED III RETENTION$ ----- D WORKERS COMPENSATION $ ANC/EMPLOYERS'LIABILITYPER OTH• "' Y/N STATUTE FR "__—___ WC100136900 6/30/2019 6/30/2020 1,000,U00'' ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ „I (Mandatorylrt H) 1,000,OOC! II yes,describe under E.L.DISEASE•EA EMPLOYEE 5 I DESCRIPTION OF OPERATIONS below FL.DISEASE-POLICY LIMIT $ 1,000,000! — lI DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) 11 ! CERTIFICJTE 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 ` 1.")---,-..A...-2 7 ACORD 25(2016/03) ©1988.2015 ACORD CORPORATION. All rights reserved. The ACORn narr,a and Inns ;_.-._�__-_,_ • ..___ c Vi. fr 't,.;4*, The Commonwealth of Massachusetts i ''q r'. 't; ' 1. Department of Industrial Accidents t ,-. , )"airs".:tr r ,t±•iil i wit''.!''t Office of Investigations n °•r t t• , j`, 600 Washington Street �,.(" , ' .,g;,r. r; Boston, MA 02111 tjr x .A, ..tea ti ``- r.; 4 y;-,i.. www.mass.gov/dla Workers' ompensation Insurance Affidavit: Builders/ContractorsfElectriciang/Plumbers Annlicant Information Please Print Legibly Name (Business/Organization/individual): Cape Cod Insulation Inc. Address: 18 Reardon Circle City/State/zip: South Yarmouth, MA 02664 Phone #: 508-775-1214 Are you art employer?Check the appropriate box: Type of project(required): 1.VI am a employer with 48 4. ❑ lam a general contractor and I employees(full and/or part-time),* have hired the subcontractors 6. ❑ New construction 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. ❑ Demolition workingfor me in an capacity. employees and have workers' Y P 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.❑ 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 employees.[No workers' l3.{�Other Weatherization comp. insurance required.] 'Any applicant that checks box NI must also fill 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. • tC'untracton that check this box must attached an additional sheet showing the name ol'the sub-contractors and state whether or not those entities have employees. If the sots-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees, Below is the policy and Job she inforrwtlon, Insurance Company Name: Atlantic Charter Policy++or Self•ins.Lic. : WC 100136900 Expiration Date:06/30/2020 . Job Site Address:Ji" /l e& A el c 4 fq_JAI 4 Qvpu A City/State/Zip: 0iif & Z . 7"3 a copyof the workers' compensationpolicydEelaration'page(showing the policy number and expiration date). Attach Pe I'ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ling 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 at up to$250,00 a day against the,violator. Be advised that a copy of this statement may be forwarded to the Office of lnvestitlotions of the DIA for insurance coveru a verification. '+ �tsr'➢161'i1iaC7�TCt�ri—"—sc 1 do hereby certify under the pains and penalties of perjury that the information provided aboi r is true and greet. Signature; 744"27 Dates &'5.7, _- 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 H Issuing Authority(circle one): I. Board of Health 2. Building Department 3.Cityllowa Clerk 4. Electrical Inspector 5. Plumbing Inspector. 6.Other Contact Person: Phone#: RISE ENGINEERING' OWNER AUTHORIZATION FORM J1/) aaI /a. , `w I, JAMES CODY (Owner's Name) owner of the property located at: 14 Broadcast Lane (Property Address) West Yarmouth, MA 02673 (Property Address) hereby authorize C 2sz C� 2t m5k)LC (� (Subcontrac or) 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. a <<r Owner's S gnature /7 7 Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com