HomeMy WebLinkAboutBLD-20-001326 c +R 77
a`..'r ..! O `i Permit#
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O4. `'_1 `., Amount
ATTACH CSCd k""°""°"Qc', _!Permit expires 180 days from
-/3 2./ i issue date
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EXPRESS BUILDING PERMIT APPLICATI( p; µ;
ED
TOWN OF YARMOUTH
Yarmouth Building Department 1
1146 Route 28 SEP 1(1 2019
South Yarmouth, MA 02664
y �(508) 398-2231 Ext. 1261 Ce
CONSTRUCTION ADDRESS: #/ Aro iy c9 / A A/
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: ) / ..h 4 k G ( A/A/CfZ..i __ 14.2 e' Z1 7 e y` 7 5'7 8
NAME PRESENT ADDRESS / TEL. #
CONTRACTOR: f e� c/ /-i/S!1J/774 A/ /P/�/,1/Zd 6,U' c 744912d e977 --- V7 7 41 2 i/
NAME MAILING ADDRESS TEL.#
E' esidential 0 Commercial Est. Cost of Construction$ 3h('(7:), Q
Home Improvement Contractor Lie.# /9 .3 SG ' Construction Supervisor Lie.# /lj O P ir
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor &have Worker's Compensation Insurance
Insurance Company Name: f9r74?/71 - C'A/q72_j�Brg2- Worker's Comp.Policytt kJ G / Q 4.1/ 7 G 7 en
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: y�/Zlil d'GT�e /V ,7
6 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 answ.ver(s)
will be just cause for denial or revocation of'my license d for prosecution under M.G.L.Ch.268,Section 1.
f, ;.--
Applicant's Signature: Date: 0. //'
/
Owners Signature(or attachment) Date:
Approved By: 4,....."_.e.; Date: \ ' _ICC
Building Official(or designee) EM IL 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
DocuSign Envelope ID:89978142-EC3D-428E-89C4-5434CE63F4B2
\'Wt-
RISE
ENGINEERING"
OWNER AUTHORIZATION FORM
1, Michael F Connors ,
(Owner's Name)
owner of the property located at:
41 Nobby Lane
(Property Address)
West Yarmouth, MA 02673
(Property Address)
hereby authorize C CC) :r S t CV\
(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.
DoeuSip,ad by:
rucnry
8fature
9/9/2019 1 1:17 PM EDT
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926
www.RlSEengineering.com
•
i•
1,4)
axt� Commonwealth of Massachusetts
DiVlsion of Prolesslonal t.lcansure
�' ' Board of Building•Regulatlons and Standards
Conctr.�tcthoif ISupervlsor
•
CS-100988 ,A` 6'npires: 11/11/2019
j
HENRY E CAS SIDY # . M1` : .Ti-.,,
8 SHED ROW '),I, 52t
WEST YARMOC177i M p0,70 ''
� -
Commissioner
CZ—
/r/ r_ir'1/>I/J%KY?(l r.�r'/(%� ( ,_. 7'' r.,),1). 6((/r). ? ,/,,I)
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Typo: Corporation
CAPSCOD INSULATION, INC Registration: 153567
18 R :ARDON CIRCLE Expiration: 12/14/2020
SO,YARMOUTH, MA 02664
Update Addruaa and Return Card.
/ ,i,miv,n „,/,% 7. /7.,.., i�i//'
Oltice of Consumer Affairs 6 1)ualnues Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:CorporaUon before the expiration data. If found return to:
Ba4JStaUon Fxolration Office of Coneurnur Affairs and Business Regulation
1 a567 12J14/2020 1000 WaohInriton Strout-Suite 710
CAPE COD INSULA.ION, INC Boston,MA 02110
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r
?U REARDON CIRCLE C)
SO YARMOUTH,`.,.A Undersecretary �� V
Ith t slgnr r
d"" /
�r;'', +t`t•
The Commonwealth of Massachusetts
< i ;'+(((j�?tryf� Department of Industrial Accidents
drh-1 '@I,itvl
•.,,4t��,� :UN ,;;� Office of Investigations
}3t� �,t, ;i31 i,r �,.. 600 Washington Street
7•,. 5Iii_. Boston, MA 02111
z,r , '}'__ ►vww.mass.gov/dla
Workers' Compensation Insurance Affidavit: Builders/ContractorsfElectricians/Plumbers
A plicantInformation Please Print Legibly
Name (su,inesx/organIzctiort/Individunl): Cape Cod Insulation Inc.
Address: 18 Reardon Circle
City/Stag/Zip; South Yarmouth, MA 0266.4 Phone #: 508-775-1214
7 Are you un employer? Check the appropriate box: �_—
�—�yType of project (required):
i M I am a employer with 48 4, ❑ I am 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. ❑ Demolition
working for me in any capacity, employees and have workers'
[No workers' comp, insurance comp. insurance) 9. ❑ Building addition
required.] 5. ❑ We are a corporation and its I0.❑ Electrical repairs or additions
3 ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MOL, 12 ❑ Roof repairs
insurnnce required.)t e. 152,§1(4), and we have no 13. Other VVeatherization
employees, (No workers' �u
camp, insurance required.] _________ _,
',1,11> upplieunt u.ut checks box NI must also nil out the section below showing their workers'compensation policy info oration.
' hion cowners\aho submit this afildavlt indicating they are doing all work and then hire outside contractors must submit a new affidavit Indicating such.
;Cuitrueton the:check this box must attached an additional sheet stowing the name ot'the sub-contractors and state whether or net those entities have
smpioyees. If the sub-contractors have employees,they must provide their workers'comp.policy number,
— ----_--,-----J--- --•---- ...=: :_
I and an employer that Ls providing workers'compensation Insurance for my employees. Below Isthe policy and Job site_
infornrurlon,
Insurance Company Name: Atlantic Charter _____
Polk.),ni or Srlfins. Lic, th; 1NC 100136900 Expiration Date; 06/30/2020 __
Job Site Address: ,.9r//UD/l/3 y L.e/ �f` j'2YL1 6,4.„,• —City/State/Zip: "( e z G 75
Attach a copy of the workers' compensation policy declaration'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 ola
Ilse 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 line
of up to S250,00 a day against the,violator, 'Be advised that a copy of this statement may be forwarded to the Office of
^Inyesnpationu o,ftlic,DIA for insurance cpy,s,cuse verification, ,_, ___ R =M
/do hereby(Tally under the pains and penalties of perjury that the information provided abobr is true an' rrrect
SLyO atur; __ /..� `.1' � Date: y /,, 7,/
_ 5 ,5j2 _non,u; 7 14 —
Official use only. Do not write in this area, to be completed by city or town official.
•
City or'Iowa: ,— Permit/LIcense#•
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3, City/Town Clerk 4, Electrical inspector 5. Plumbing inspector I
I:
b Other__, it
t
,l
Contact Person:_ ___,—_ Phone 4: __ -�
CAPECOD-27 THOi21;t_
CERTIFICATE OF LIABILITY INSURANCE DATE= "''�`'
,rE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
COES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
,IS CEP UFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE!;(TATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
,ANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed
.ROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require en endorsement. A statement on
certificate does not confer rights to the certificate holder In lieu of such ondorsemont s),
wceR c TACT Good -'
ac ers & Cray InsuralTco Agency, Inc. ��7E. —
J Y J Y PHONE
t34 Rto '134 I FAx
(n�c,No,Exl);(800) 553 1801 WO,No):(877) 8'16.2156
!South Dennis, MA 02660 MAI mall C r0 erst ra ,COm
IfrfURER(S)APYORDINGCOVERAGE I p; Ir,;,,
— INURERA:West American Insurance Company —_ I14 3 3_�
_INSURER e:Arbella Protection Insurance ComLany, inc. I41360
Cape Cod asulation, Inc. IesURER G,Endurance American Specialty Insurance ComPa m/ 4 1 71 u
18 Roardo0 Clrclo --
South Yasr.Touth, MA 02664 INSURER D:Atlantic Charter Insurance Company 144326
INSURER E.; _
INSURER F_
COVERAGES CE _TIFICATE NUMBER: REVISION NUMBER: __^ _
THIS IS TO CERTIFY I HAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE.POLICY PI_!ir I)
INDICATED NOTOMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VkIlr,: 0 ;
I CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE T505 F
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
!jai— T TYPE OF Ir c 'RANGE POLICY EH.' POLICY EXP
--T Y1ND POLICY NUMBER IfAMIQpJxyyY)__CGft' LIMITS
A X I COMMERCIAL GE .aAL LIABILITY 1,000 0'i�:
j CI��II,tS n,ADE )( OCCUR EACH OCCURRENCE _
i BKW 53328281 4/112019 4/1/2020 DARAGETORENTED 100,000'
r PRFPQLS_(F4L9�C.v1L4nGe)_ S__
— — MED EXP Any one porsonZ 1 0
T _ {L 000 PERSONAL DVINJURY 4 S
! GEN'L ACOREC TE LIMIT vPPLA_s PE'R: --- - -
X i POLICY F'RO' GENERALAGGREGATE___ 2,0UL,n-G.
Ills I Tef L O C
PRODUCTS•COMP/OP • 2,000,OOOi
--- I OTHER: ..
H AUTornoolLe LIABILITY
— —'
COMBINED SINGLE LIMIT ;,00 0001
n,v Aura .IE: scL iv)__ I L
102.0081008
V 0 1 > sCHEouLED 4/1/2019 4/1i207.0 R001!Y Irl uaY For Orson
X `,,,R A GI1, ��r'JF(� I 1 BODILY INJUR` Mx'ucc Berl i
"' PROPERTY AMAGE
n,
d^!Lv
_Tor accident S
, :vtoDRELIA L.IAB . X OCCUR � '_ —__—.. 4
X Excess DAB EACH OCCURRENCE 2,000,o001
cLAIMS•MADE EXC10006635004 4/1/2019 4/1/2020
`---I nccaEcnTe — - 2,000,000';
Dt D r 1 RETE.NTor,s 3--
U WORKERS oOhtPL'NSAT1Cr -------- --..
AND EMPLOYERS'LIALILI_,r PER -
---
Y/N �.TATUTE_ Q .•
ANY PROPRIETOR/PARrNcroFXECUTIV[ WC100136900 6/30/2019 6/30/2020
(MandOFFICatory In 11 N/A EL._EACHn (DENT �_$________ 1,rJOG,CUG..
(rtandalory In NH)
LJ
!I es,describe under - F:.L DISEASE•EA. EMPLOYEE 5
DESCRIPTION
1,000,00Y
'7" _ OFoF'ERAT!ONSbelow ----
--- — —�--'—•�—' --- _- E.L.DISEASE-POLICY LIMIT —.>—_-----
���--.-
IZWT!Qrl or OPERATICrIS'.00ATIONS/VEHICLES (ACORD 101,AddlIIonol Remarks Schedule,may be attached II more space Is required) ��
OC_IRTIFIC-ATE H01_DER_ _-_.
CANCELLATIOrJ.___
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
For InformatinIT Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE. DELIVERED IN '
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
-- -- -