bld-20-001437 •
a' O ,,Permit#
O . H Amount
MAT TA M p3
*Oro 11S CO Permit expires 180 days from
,l issue date
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EXPRESS BUILDING PERMIT APPLICATIC 1 _F` -k
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28 I 1 SEP 11
2019
South Yarmouth, MA 02664
508 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: f5 4/A/7evi,e Pji/ LW
ASSESSOR'S INFORiMATION:
Map: Parcel:
OWNER: nig e.A/v Lice/ (�Y4Y/ G �2 3 PAIL - '
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: y 1/ -V t �.�S/ � /� c1D.CL C, Ah7-1141,4)77f— 27.5 2 / V'NAME / MA1L1NG ADDRESS TEL.#
lfesidential 0 Commercial Est. Cost of Construction$ (YO a, U
Home Improvement Contractor Lic.# ,4'--3 S/y7 Construction Supervisor Lic.# ,/pL.3 / e 6P
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: d ..V77'G l'19c2 rk2 Worker's Comp.Policy# 4/icicle, /3 G < Q Q
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: 7,02o/9c/7k 7 (/ /
Location of Faci ity
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 revocatio f my licen and r prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: Date: f�f
Owners Signature(or attachment Date: OOl
Approved By: ./ -,l' Date:
Building Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: ❑ Yes 0 No Flood Plain Zone: ❑ Yes a No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes 0 No
, ( Commonwealth of Massachusetts
IP/ Division of Prolessionai Licensure
Board of Building•Requlatlons and Standards
conctruCttl5,li ISupervlsor
CS-100988 t . 54pires: 11/11/2019 -.
HENRY E CA$ IQY (,{�!,^r
8SHEDROW i ,:WEST YARMOLI,7i IAAn oy,73 �"
•
Commissioner
L/7/(2 �.i(L/2?/2?Kt/,c'l'�Cll?� < <_- 7/4.,i,..)al% r:i �/7.)
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
8 R :ARDON CIRCLE Expiration: 12/14/2020
SO YARMOUTH, MA 02664
Update Addruca and Return Card.
0fflce of Cona•nmerAllalra G Uualno,Revulauon
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual ure only
TYPE:Corporation before the expiration date, If found return to:
8, ist.IlUon Fxolratlon Offtco of Consumer Affairs and Business Regulation
153567 12/14/2020 1000 Washington Strout•Suite 710
CAPE COD INSUI ATION,INC Boston,MA 02118
HENRY E.CASSIDI'
U REARDON CIRCLE
SO Ynal+auTH,r 02654 Undersecretary _ ° I Ith t �Ign� " r
r.
, , Yt The Commonwealth of Massachusetts
N� °t 4t,�t;)�� Department of Industrial Accidents
,t'�t ��d'" +'' t Office of Investigations
4 .7W, � r' 600 Washington Street
i >>''}' Boston, MA 02111
z�' 4*.:;.J� t, www.mass.gov/dla
Workers' Compensation insurance Affidavit: Builders/Contr•atctorsfElectriciansfPluunbers
Applicant.Information Please Print Legibly
Mime (Business/organization/individual): Cape Cod Insulation Inc.
Address: 18 Reardon Circle
City/Statc!Zip: South Yarmouth, MA 02664 Phone #: 508-775-1214
_
_�
Are you an employer? Check the appropriate box: Type of project(required):
I. I am a employer with 48 4, ❑ lam a general contractor and I
employees(full and/or pan time).+ have hired the sub 6. ❑ New construction
contractors
2.Q I 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' 9, 0 Buildingaddition
(No workers' comp, insurance cornp. insurance)
required.) 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3,❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
G myself. o workers' com right of exemption per MGI..
y t p c. !S 1 4 and12.❑ Roof repairs
insurance required.) 2, § O, we have no
employees. (No workers' I 3. 'Other Weatherization
comp, insurance re•uired,)
'Any applicant that checks box ti I must also nil out the section below showing their workers'compensation policy information,
'flomeowncrs who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit Indicating such •
:C.ontruelocs that check this box must attached an addiliorud sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-conlrncaors have employees,they must provide their workers'comp,policy number,
I urn an employer that is providing workers'compensation insurance for my employees. Below Lv the policy and Job she V
infortnurlon.
Insurance Company Name: Atlantic Charter _-______._.
Policy ii or Self-ins. Lie. ti: WC100136900 -• Expiration Date; 06//3 __
0/2020_
Job Site Address,./5 6 fii e.�p 12 �__/Kg G'ity�ip:_f(,1 / Oz, !, 4
Attach a copy of the workers' compensation- policy deelaration'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
1 nine up to$1,500,00 and/or ono-year irnprisorunent,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
;vc t anions of ths,D1A for insuranaecoveru ,e verification,
j / do hereby certify under the paths and penalties of perjury Ihpl the information provided abo'be is true and -srrect.
Signature; _ _ 744 ���24ct^! __ _ Da �',z�1 r
Phnnc,l;; 50_�?�5.1214 .. UU�� ___
m. .w
T Offrcir 11 use only, Do not write in tit-Ts-area, to be completed by city or town official. i;
City or'Iowa: _ _ Permit/License t _---
L
Issuing Authority (circle one):
iI. hoard of Health 2. Building Department 3, City/Town Clerk 4, Electrical Inspector 5. Plumbing Inspector.
b, Other_.
' Phone 4:
Contact Person:_ T_ _ __ - •_ ,I
,
' /
r
7
i •
CAPECOD-27 TFIORI_JF.
INSURANCE DATE":
CERTIFICATE OF LIABILITY
--- _.__ _ - -- — — —— _ II
7I1 f 12019
i8 'S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. I,;
UOE, NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
(IS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AU1 HOR ZEL,
iTATIVE 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
,rROGATION IS WAIVED, subject to the forms and conditions of the policy, certain policies may require an endorsement. A statement on certificate does not confer rights to the certificate holder In lieu of such endorsement sj,
,vUCER --- Cppt`TACT Good
�JAMF'
.ogers & Gray Insuranoo Agency, Inc. .PHONE --
13r1 Rto 134 (NC,No,Ext); (800) 553.1801 FAX
�.— (NC,No):(8I7) 816-2156 •
South Dennis, MA 02660 •M ' mail c ro ers ra com
D` s3; 9 Y'
I --__ IM RERISIAFFORDINGCOVERAGE i NhIL
— INSURER A:West American insurance Company I,14393
s D _INSURER e:Arbella Protection Insurance Comaany, inc. 141360
Cape Cod nsulatlon, Inc. INSURERC;Endurance American Specialty Insurance Company 14 1718
18 Reardon Circle INSURER Atlantic Charter Insurance Company i44326
South Yarmouth, MA 02664
INSURER F.:
INSURER E: -- --- ---- ----- _I
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 CR 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'fHE TEr?:,-S
EXCLUSICHS AND COH':_TIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
li IYPC-OF INS JRANCE POLICY FOP POLICY EXP - --- "-------_
6 11TD POLICY NUMBER MM/B.12.1rE_-(LA1iLaWYY YYI_� _ LIMITS
A X i COMMERCIAL CE v.ICAL LIABILITY V - --- -- ------.-.-__.
t• — 1-- I'--. 1,000 00
CI_-11t.1S.AIACE X OCCUR BKW 53328281 EACH OCCURRENCE --
4/1/2019 4/1/2020 DAMAGETORF.NTEO 1C ,GOL
PEEPdLS�$_(Ea occuc[snce)_—_S.
--- ._ - MED EXP(Any one person) 5 r L
PERSONAL F�2 INJURY ;, 1,000
�cVC_N'L AGGREGATE LIE I'��PPLIES RET1' 2'00
X POLICY l JRC i_ LOC GENERAL AGGREGATE Se
I _ OTt-IER:
PRODUCTS•COMP/OP AGOL _ 2,000,00,i.
t3 f UTOCA001LE LIABILITY ._._ COMBINED SINGLE LIMIT « 0__ Or._
ANY AUTO _(Ea acststsnlL.
102006100E1 4/1/2019 4/1/2020 BODILY person)
I$OYCLED � SCHEDULED
._ A,ITOS ONLY '
AUTOS
X j h,RFD X NOp OpVISI BODILY INJURY(Per accident)_13
-.__I AU10S ONLY . AUTOS OP PROPERTY DAMAGE
(Per accident) $
L•I UMBRELLA I.IHeIX OCCUR — -- -_i-
EACH OCCURRENCE S 1,000 000�!
--- -__
!-X EXCESS Use CLAIMS•MADE EXC10006635004 4/1/2019 4/1/2020 ----- -
' 2,AGGREGATE __
i._ DOD I 1 RFTENI:p,NI$ _ - - J1
-3._
O ;WORKERS C:Oh1PENEATIO! �`— - — I S
r 0 EMPLOYERS'LIA61 '� Y/N ,__S.TATUTE J ER- I--- -_
•
PROPmETOR/PAar L+IEXECUTIVE WCI00136900 6/30/2019 6/30/2020 rt --
Orf ICf_KiNCS1BHR EYCLL _D9 NIA E.L.EACH_ACCIDENT I S :J0 C,- '
C(mandatory In NH) --.
II es descr�So under E.L.DISEASE.,•EA EPdPLOYEEI,_;. 1,000 000'
DESCRIPTION OF OPERATIONS below -
T— — _ E.L.DISEASE•POLICY LIMIT S 1,SOU,-WC:
i
I
"'.':,onion o,OrOPERATIONS. .Ocn CATIONS I VBfiI —___'--- --.----
-
CLES (ACORC:101,Additional Remarks Schedule,may bo attached II morn spoon Is required)
CERTIFICATE HOLDER _ , CANCELLATION__
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
For Information Only THE EXPIRATION DATE. THEREOF, NOTICE WILL BE DELIVERED
ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESENTATIVE
�
-_._------- ------ _ r.// �/ `��
r`non nC In ne n An n, '---. —.
RISE
ENGINEERING"
OWNER AUTHORIZATION FORM
1, ART CARLUCCI
(Owner's Name)
owner of the property located at:
15 Ginger Plum Lane
(Property Address)
South Yarmouth, MA 02664
(Property Address)
hereby authorize__ _ __ 4 �rSv� CND —__—
(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.
Cativtf;•
Owner's Signature
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926
www.RlSEengineering.com
w cl,
. 6*. 4,4 TOWN OF YARMOUTH Building Department BUILDING
`tee (508) 398-2231 ext.1261
_ PERMIT
fl PERMIT NO BLD-20-001437
001437
JOB WEATHER CARD
N"4/004.0o'"Wo ISSUE DATE 09/13/2019
APPLICANT HENRY CASSIDY PERMIT TO New
AT(LOCATION) I15 GINGER PLUM LN,SOUTH YARMOUTH, MA !ZONING DISTRICT IR 40 I Bldg.Type: Residential I
SUBDIVISION MAP BLOCK LOT 059.227 BUILDING IS TO BE: /CONST TYPE `IV B € USE GROUP R 3
REMARKS Repair-install Insulation(508-775-1214) CONTRACTOR
LICENSE 1153567 S
/Home Improvement
/CAPE COD INSULATION, INC
_ /HENRY CASSIDY
AREA(SQ FT) F 2 049 280 2 EST COST($) '4800 00 PERMIT FEE($) 135.00 18 SO.YARMOUTH,ARDON CIRCLE
__
w,-_ MA 02664
OWNER [KNIGHT SEAN W BUILDING DEPT BY
ADDRESS 15 GINGER PLUM LN l
SOUTH YARMOUTH IMA 02664 -72fiaectiidg/4 PHONE d
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR 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.
OCCUPANCY 4)REFER TO DETAILED INSPECTION OCCUPIED UNTIL FINAL INSPECTION HAS
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.