HomeMy WebLinkAboutBld-20-001438 Permit#
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` MATTA ., [s`J� '3Pennit expires 180 days from
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EXPRESS BUILDING PERMIT APPLICATLON--.___-.__ .__.._..__._
TOWN OF YARMOUTH E C E ` `
x armoutn Budding Department
1146 Route 28 I ; SEP 1.2 2019
South Yauuuouth, MA 02664
(508)398-2231 Ext. 1261
CONSTRUCTION ADDRESS: /6 4 `lp T ,t/ /' /al
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: fo-yce 71'I /'4gfigx/a rS LfJ li L3-73 Z�
'NAME PRESENT ADDRESS TEL. if
CONTRACTOR'/ /12y/ �tgssfJ/ /52��� D,I9 6W1,4,2/a61-7 — $ 7 7 .5 12 ( t�
NA ME / MAILING ADDRESS TEL.#
jd'Residential 0 Commercial
Est. Cost of Construction$ „� C
Home Improvement Contractor Lic.# l' ) Jt��i 7 Construction Supervisor Lic.# /Qa q P 1
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor ,[2-1 have Worker's Compensation Insurance
Insurance Company Name: 419,77"9'77G C4,4(2 I /€ Worker's Comp.Policy# lr�C/p ui 3 C. / a
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:___//9/2 OZ.)
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 revo on of my lice e an or prosecution under M.G.L.Ch.268,Section I
i
Applicant's Signature: Date: / / 2_/9 l
Owners Signature(or attachment) / Date:
Approved By: ✓ Date:
Building Official(or designee) EMAIL 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
Commonwealth of Massachusetts
M icW) Division of Professional Licensure
Board of Build ing•Reclulafions and Standards
Conctrytoth6.111tdj rvlsor
CS-100988 ��� Expires: 11/11/2019 .-
HENRY k OAS8IDY {i(, ^r , 4,
8 SHED ROW `
: )�:6 l
• WEST YARMOG7711 �'0•' 73 � {
Commissioner
C_ //
(-r/2?/2?K'/Ic'/`(7/
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: Corporation
CAFE COD INSULATION, INC Registration; 153567
18 R :ARDON CIRCLE Expiration: 12/14/2020
SO, YARMOUTH, MA 02664
Update Address and Return Card —'
office of ConeumorAtlalra G L)uYlnu-si Ru ui tion
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual uca only
TYPE:Corporation boforo the expiration data, If found return to:
aQQ 51rituQn EXDlrallou Office of Consumer Affairs and Buslnoss Regulation
1 3567 12/14/2020 1000 Washington Strout•Suite 710
CAPE COD INSULATION, INC Boston,MA 02118
ly
,
HENRY E. CASSIDY C � •
18 REARDON CIRCLE C)
so. YARmOUTH,r:,a, 02004 Undersecretary e I Ith t signr r ��
,f
;
r
rF{ ; {,; The Commonwealth of Massachusetts
0'';:S,t Fk . Department of Industrial Accidents
awn ��i�,�
�t�,,5. Office of Investigations
i,,.;+ 3�'t in "''' 600 Washington Street
,' � n 1 Boston, MA 02111
, 1 3
;s,;_, www•mass.gov/dta
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (nu`iness/Organlzation/lndivldual): Cape Cod Insulation Inc.
Address: 18 Reardon Circle
City/State/zip: South Yarmouth, MA 02664 Phone #: 508-775-1214
^w•e you an employer? Check the appropriate box; ....._.1
, generalType of project(required):
1 �'1 am a employer with ,48 4 ❑ lam a contractor and ►
employees(full and/or part-time),
• have hired the subcontractors 6. E New construction
2.❑ I am a sole proprietor ur partner- listed on the attached sheet, 7, ❑ Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers'
comp. insurance) 9, [] Building addition
(No workers' comp, insurance
required.) 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 3 ❑ I am a homeowner doing all work I l.❑ Plumbing repairs or additions
myself. workers' right of exemption per MG1.
Y' (No comp. 12.0 Roof repairs
insurance required.) t a 152, §1(4), and we have no
• employees, (No workers' 13.{ 'Other Weatherization
comp. insurance required.] _1
Any upplietot ti,at checks box N I must also till out the suction below stowing their workers'compensation policy inftumation.
' I IOnkwwners who submit this'anldavIi indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such •
C'nnuructors tha!check this box must attached an additional sheet showing the name ot'the sub-contractors and state whether or not those entities have
employees. I1'the sub-contractor have employees,they must provide their workers'comp,policy number,
I um,an employer Mal Ls providing workers'compensation insurance for my employees, Below isthe policy and Job sire_
information,
Insurance Company Name: Atlantic Charter __ ____ _�
Polio is or Selt ins. laic. N; 1NC100136900 Expiration Date; 06/30/2020 __
lob Site Add esi; // ,� f _XI S ate�ip��
Attuctr a copy of the workers' compo4sation policy declar4ation'page(showing the policy number and expiration date).
i eilura to sec.ue coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisorunent,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
_ Iiy54i atio111ufthe.DIA for insurance covers ,e verification,__ _ _
i do hereby ceitlfy under the pains and penalties of perjury Mal the information provided ab/fo/'t is true and 'rrecL
SIg alure; _._ ?'^/�',- ,- ate; `��r J
Phone ir; 50_2.5-1214
x—......�.Qn. �_+-..r,•,- a,•----,. .,.-...,,ter,.,...,.-..�..».. '4 tch L.fl
71;al use only. Do nol write in this area, to be completed by city or town o1ficial.
City or'I own: Perrnit/License tl _ _.-_
Issuing Authority(circle one):
I. hoard of Health 2. Building Department 3, City/Town Clerk 4, Electrical Inspector 5. Plumbing Inspector-
6. Other ..
Contact l'ersua:_��____,• Phone 4: _ I
f
`,
/
/
CAPECOD-27 THORN E
CERTIFICATE OF LIABILITY INSURANCE °A
,FE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
,DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ES CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED,ITATIVE O12 PRODUCER,AND THE CERTIFICATE HOLDER,
,ANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorser..
,sROGATION IS WAIVED, subject to the forms 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 Nondorsemvnt s),
JUCER
c2 rA9EACT Good
,Jgers & Gray Insurance Agency, InC, .PHONE
434 Rte '134 (A/c,No,Ext)t (800) 553.1801 I FAX(NC No);(877) 816-2156
!South Dennis, MA 02660 nias:m a 1 I 0 rogersc3 ray,com
I INSURER(S)AFFORDING COVERAGE MAID e
— — -- INsuaE y RA:West American Insurance Company 44393
s I`E0 INSURER B:Arbeila Protection Insurance Com an , Inc, 141.360
Cape Cod Insulation, Inc. INsuRERc:Endurance American Specialty Insurance Company 141718
to Reardon Circle INSURERD;Atlantic Charter Insurance Company '44326 South Yarmouth, MA 02664
INSURER F.:
- — - INSURER F t
COVERAGES CERTIFICATE NUMBER:
_ REVISION NUMBER: _
THIS IS TO CERTIFY ..LAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLIO''(NL ,
!INDICATED NO rV/ h JTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO IiV1HIICi-1 a CERTIFICATE MAY BE. ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERi:1S
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,,r S t ----- -.— ADQL SUBR .
l _ TYPE OF IN IrtANCE INS1Z WV POLICY NUMBER POLICY EFF' POLICY L'XP
' X I COMMERCIAL Gr r AL LIABILITY - jMMIQ YYY.I_J�Pr �► LIMITS
EACH OCCURRENCE 1,n00 I00
+s r u= X OCCUR BKW 53328281 DArnACE TO RErn eo 4/1/2019 4/1/2020 -EREt.I S_(E<2scuccanc ) 100,000,
_.-___---._---- -- -- ----- r�EDEXP(Lay one p crson 1 JT�.
) —
--_.—_--- PERSONA Aov IFJJUNY_ 1 000
&
I mI AOGREG__LE I INiii APPLIES PER: ' OJr
X_ POI ICY[ JCGT r 1 LOC G[NERA�AGGREGATE. —_y
PROD CTS•COMP/OP AGO
_=-----2,000 CJG
OTHER:
-t� I A UTOHOEILE LIABILITY _~~- -..�• — COMBINED SINGLE LIMIT , '1,000 OI:O
I ANY AUTO 1020081008 —(mac-cisleut)_ .;_
0A' EOSCHEDULED 4/1/2019 4/1/2020 BODILY INJURY(Por person) $
AUTOS ONLY I v AUTOS
X )Z,If os°tan - X NONr. Si
p BODILY INJURY(Por uccidenl) t
` AUTOS bn Y (Per accident)
PROPERTY pAMAG[
f _(Per accident)
UrdURcllu\l.lAB L.X OCCUR --.^_.^. ---�- -- 5
1 EACH OCCURRENCE 2,000 OLIO X I EXCESS uae---- ICLnISS•rnDE EXC10006635004 4/1/2019 4/1/2020 2,00 0,000nccREcnTc r 17D — R '
— TEN 5 •
'Li I ORAERS COMPENSATI^ --�-�• — ��. •� �_"-- ..� PER
,P EMPLOYERS'LIAEI '—' OTH .._-
A vPROPRIETOR/PAR NE rEXECUTIVe YIN WC100136900 6/30/2019 6/30/2020 �IAIUSE FR
OFFICeah:+.C� NH)BER bXCLUC_D7 I N/AE.L_EACH ACCIDENT $
1,000,000,
i(F1 urdalory hi NM LJ I —
Iles,describe undo( El.DISEASE•EA EMPLOYEE 1 000,000'
OcSCRIPTION OF OPERATIONS oelow - .-___-_.__-_
-- E L.DISEASE-POLICY LIId1T 5
j
D"SCRIPTION OF OPERATIONS .00ATIONS I VEHICLES (ACORQ 101,AUdillonel Remarks Schodulo,may bo attachod If more specs Is required) -----
C�_I�:[IF_IC�TI�H0.4_DER __% ^..--.--__�_ _-_----
— _.� QANCELIATION-_ — ..-----_..-
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
•
For Information Only THE EXPIRATION DATE THEREOF,
ACCORDANCE WITH THE POLICY PROVISIONS.ICD WILL BE DELIVERED IN
AUTHORIZED REPRESENTATIVE
— ---- - `----------- -
r•n n n n r ',I/Ann/no, —'---- '-t.�j4VW 7,--elMi`�.1_ '
DocuSign Envelope ID:C89233E1-015C-4400-89B9-2030A7513AA0
RISE
ENGINEERING'
OWNER AUTHORIZATION FORM
1, Joyce Mcfarland
(Owner's Name)
owner of the property located at:
106 Capt York Road
(Property Address)
South Yarmouth, MA 02664
(Property Address)
hereby authorize C Cszt.‘k SnSo\Oa L cAA
(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.
dr-
Owners S`rlgnefure'""
9/8/2019 I 10:12 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
-emci.L 9/13
6v. .01 .. TOWN OF YARMOUTH Building Department BUILDING
• ,. (508) 398-2231 ext.1261
C PERMIT
PERMIT NO BLD-20 001438
natr " s ISSUE DATE 09/13/2019
JOB WEATHER CARD
:tea: APPLICANT ,HENRY CASSIDY PERMIT TO : New
AT(LOCATION) 106 CAPT YORK RD,SOUTH YARMOUTH,MA 0 ZONING DISTRICT 'R 40 1 Bldg.Type: (Residential
SUBDIVISION MAP BLOCK LOT 078.77 BUILDING IS TO BE: CONST TYPE 1;V B USE GROUP R 3
l Noµ —
CONTRACTOR
$ REMARKS Repair-Install Insulation(508-775-1214)
! LICENSE 153567
;Home Improvement
:CAPE COD INSULATION, INC }
1 1 HENRY CASSIDY l
E
18 REARDON CIRCLE
AREA(SQ FT) 1 588,234,240.1 EST COST($) 3000 00 PERMIT FEE($) 35.00L_____LI ISO.YARMOUTH, MA 02664
OWNER 1CARVER ROBERT J ( BUILDING DEPT BY
ADDRESS !CARVER PAUL J 39 DUDLEY ST k
;MARLBOROUGH MA 01752 1816 ,i PHONE
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWA K 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
REQUIRED,SUCH BUILDING SHALL NOT BE MECHANICAL INSTALLATIONS.
COVERING)3)FINAL INSPECTION BEFORE
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.