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HomeMy WebLinkAboutbld-20-001439 O =Permit# v O . _ ' H t'Amoun ? MAT7A ,, GSF l� .,�°""' .0,-5: Permit expires 180 days from sC��-(Lt39 issue date EXPRESS BUILDING PERMIT APPLICATIQN--.— _____^_ TOWN OF YARMOUTH f x P E I E i Y'armout t Buiiaing Department ? r __._." 'w. 1146 Route 28 ` South Yarmouth, MA 02664 ��� 1 ZOly 1 (508)398-2231 Ext. 1261 [ Ci9-4.61:::irith, CONSTRUCTION ADDRESS: /f Siq/7 f j4,$ A 44/ ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Ppiefc /9/Ve/(L V PRESEN ADDREss 97,17 2#G .eft yZ / NAMECONTRACTOR: . ( .51 0 e' 0 5 7,5-12 l 41- NAME T MAILING ADDRESS TEL.# sidential 0 Commercial Est. Cost of Construction$ P...6---0 Home Improvement Contractor Lic.# /5—l ..5Z.,7 Construction Supervisor Lic.# fpO p F71:7 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor B-(have Worker's Compensation Insurance Insurance Company Name: ,Q� ,v7-/(' -"-IA 7z j C`L Worker's Comp.Policy# (,� C /4 ev 3 L 7 O d 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: 40 ..,jo ti .2>ys/' / 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 revocation .f my license and or prosecution under M.G.L.Ch.268,Section I. i s Applicant's Signature: �1�` Date: 9/l z7/ Owners Signature(or attachment)/ Date: Approved By: �G,- Date: _1 -17. -)1 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 • f`• Commonwealth of Massachusetts `i'� Division of Professional Licensure • Board of Building,Regulatlons and Standards Conetryttth3,fi ItuPervlsor CS•100968 • • E,Kpires: 11/11/2019 HENRY f /, l • 8 SHED ROW WEST YARMOG7)i 1p,07,Q73 t l r rl1 .I.I01 ,6,d14 TAT Commissioner // - l/2?K,//e'l'.(( // r' 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 20',1.os Updat©Address and Return Card. Ottice of ConaunrerAffalre d f)uslnase Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual uee only TYPE:CorporatJon boforo Iho expiration date, If found return to: i3AS:St1l1Qn EXolratfon Office of Consumer Affairs and Business RegulatIon E56% 12/14/2020 1000 Waohington SUeot-Sulto 710 • coo INSUI.;TION, INC Boston,MA 0211 rrry r HENRY k.CASSID ' 10 REARDON CIRCI.f:: C) SO. YARMOUiH, 02664 Undersecretary a Ith t sign, r • f �l. The Commonweaitl► of Massachusetts 4v ,h :.� t tks4 Department of industrial Accidents g� N Office of Investigations ,r;at;' i 600 Washington Street ft4 Boston, MA 02111 r. 0°_:+{_, www,mass,gov/dla Workers' Compensation Insurance Affidavit: Builders/Contractors1Electricians/Plumbers Applicant Information Please Print Legibly Nome (auslness/organIzntion/lndivldual): Cape Cod Insulation Inc. Address: 18 Reardon Circle City/Stab/Zip: South Yarmouth, MA 0266.4 Phone #: 508-775-1214 Are you en employer? Check the appropriate box: Type of project(require-!): � �1.V I am a employer with 48 4, ❑ I am a general contractor and l employees(full and/or part-time).* have hired the subcontractors 6, ❑ New construction 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 8. ❑ Demolition working for me in any capacity, employees and have workers' 9, Buildingaddition (No markers' comp, insurance comp. insurance.- required.) 5. ❑ We are a corporation and its I0.❑ Electrical repairs or additions 3.1] I am a homeowner doing all work officers have exercised their I l.❑ Pltunbing repairs or additions myself. No workers' comp• right of exemption per MGL. I2 ❑ Roof repairs insurance required.] t c. 152,§1(4),and we have no 13.cl Other Weatherization employees, [No workers' camp, insurance required.] ___...1 'Any uppliaunt that checks box WI must also fill out the section below stowing their workers'compensation policy inl'comation. 'Homeowners who submit On affidavit indicating they are doing all work and then hire outside contractors must submit a new affiduvit Indicating such Icontructon the!check this box must attached on additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. lt'th;hub-cantractora have employees,they must provide their workers'comp,policy number, i uman employer that is'providing workers'compensation insurance for my employees. Below is the policy and Job silo..... _ information. Insurance Company Name: Atlantic Charter Policy,+or Self-ins, hie. tt;,WC I00 13G900 _ Expiration Date: 06/30/2020 __ lob Site Address; iakse City/State/Zip: ff Oz a 73 Attica a cope of the workers' compensation policy declaration page(showing the policy dumber and expiration date), I allure 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 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 inve.sti�,;alions of the DIA for insurance cover e veritication, /do hereby c rlfY under the pains and penalties al-perjury that the information provided abobris true and irrecl. Signature: _ �ya� e.--4?-a-daG Datel______7722.,z// } Phone It: 508-775,-1214 -,y�r..n.+-r—...w.��..wwv.�-r......Mt.--..-..r„Y.�TnS."•'^'•.•«..�w. ..-.-+•...wyjn vlc{2r-YY'a: i. Offic a/use only. Do not write in this area, to be completed by city or town official. , I� City or Town: PermitlLicease t! : Issuing Authority(circle one): I. Board ofl-feslth 2, Building Department 3, City/Town Clerk 4, Electrical inspector 5. Plumbing Inspector 6. Other__, Phoned; ' , Contact P c r su a:__________-•_ ._ r _ --- I ...... CAPECOD•27 ___----------THOR!;i CERTIFICATE OF LIABILITY INSURANCE °``Tej' ""° '`'' -rE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. i n s DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES /lS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZC, ' ITATIVE OH PRODUCER, AND THE CERTIFICATE. HOLDER, ,ANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must have ADDITIONAL INSURED provisions or be ondorsou UROGATION IS WAIVED, subject to the torms 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 s), JUCIR Q TA AM cpNCT Good 1 P: Jgers& Gray Insurance Agency, Inc, PHONE T_ d34 Rlo 134 (ac,No,Extp FAX(800) 553.1801 FAX r,e):(877) 816-2156 '!South Dennis, MA 02660 1.6.1)1151,mail@rogorsgray,com • INSURERS)AFFORD NO c0VERAGE _--- NAIC n '3 ;INSURER American Insurance Company <4' °3 —— --- - ' D .INS_URERe:Arbella Protection Insurance Comaany, Inc. 141360 Endurance American Specialty Insurance Company 14'1718 Cape Cod ,isolation, Inc. INSURERC: 18 Reardon Circle South Yarmouth, MA 02664 INSURER D:Atlantic Charter Insurance Company 144326 INSURER F.: --------- ___ ---�_-_— INSURER F: COVERAGES CERTIFICATE NUMBER: _ REVISION NUMBER Tills IS TO CERTIFY ,iPT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY r P;R ND CATEO NOTtMT/ STANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT IMTH RESPECT TO V,I IICH 0I!.�; CERTIFICATE MAY BE ,SSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE rsmrar; EXCWSICNS AND CONTiONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ,' Tyner INS PRANCE AO SUBR POLICY EPF• POLICY exP I. MD POLICY NUMBER 161MIQD/YryyJ_.(D LIMITS A X COMMERCIAL GENC'(AL LIABILITY — • )CLAIMS MADE I X OCCUR BKW 53328281 EACH OCCURRENCE 0' -- 4/1/2019 4/1/2020 DAMAGE TO RENTED 0,':C�: PPdI S_S_(EasC.cyc[sn4e)___,---__-- ---- r--• ---------- -..-- MED EXP(Any ono person) c 1 S,DOU. — __.--_— PERSON/ALA.g(2yiTJJURY_ 51,000 1,000 002I I I r C,N'L AGGRE ATE LIad1'APPLIES PER) 2,VJ UJJ' X POLICI'j PRO. LOC GENERAL AGGREGATE — PROD CTS•COMP/OPAGG i 2,000,000 OTHER: r t-' V U, 080.f LIABILITY _ —.__,_,.__—�...� .----_. COME31rJED SINGLE LIMITI_$ 0 _(E1tiacCtd0uU. 1020081008 4/1/2019 4/1/2020 BODILY II/JURY(Porperson) b 0V1'nED , SCHEDULED AUTOS ONLY I X AUTOS —- X 1-,m u i X NIONQOWt� D BODILY INJURY(Per occident) t OS ONLY ' A i SS OO YY PROPERTY AMAGC ;, p (Per accident) s _ U'dORELIA LIAS : X OCCUR EAcH OCCURRENCC 1 0 X I EXCESSLIAE �CLAIMs•MAce EXC10006635004 4/1/2019 4/1/2020 Dee R teNl:; r,; n.GGRE--GAT6 G00 --------- U PORKERS C 0 APEr SAT! -- —1r C r EMPLOYERS'LIABI 1 PER 1—FIT-1-I. r PRc RILTOP/PARrNETAEXECUTIVE I � WC100136900 6/30/2019 6/30/2020 i�TAiSZTE - YIN -- riC:RnAE t EREYCLUO:O7 N/A EL EA�Hl�CCIDENT I p I,OG� :, (Mandatory In JH) Iles,describe under ,El_DISEAS •EA EMPLOYEE 1,000 000 S DESCRIPTION OF OPERAS HS below —�_ 1,000 OO U---- �"' E.L.DISEASE•POLICY LIMIT 5 I • - .c'SCRIVTION OF OPERATIONS,LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedulo,may In attached If more spuco Is roqulred) CERTIFICATE HOLDER_... ---.- -•- - •--- __.� cANCEIyLATION___ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE: For InformaIk3n Only THE EXPIRATION DATE. THEREOF, NOTICE WILL BE DEL!VNRFD ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZE°REPRESENTATIVE - 7/e� RISE = ENGINEERING" OWNER AUTHORIZATION FORM 1, Doris Bradley (Owner's Name) owner of the property located at: 11 Salt Marsh Lane (Property Address) West Yarmouth, MA 02673 (Property Address) hereby authorize Cam. £ �n S o'�t cv-V (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. oji. Owner's Signa re 9 - ki- ► , Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com