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HomeMy WebLinkAboutBld-20-00951 S -•.�> 1 �w.' ., 0 ::.Permit# �P,� 1, 1,t/� a O -' 11' r . y '-.Amount 3�"'' � .. InGn�.S F,J� ""F' ,:Permit expires 180 days from I.{issue date i3c,iS-• 2O---cq EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH __ _Y"armouth building Department j 1146 Route 28 _ t South Yarmouth, MA 02664 AUG 21 2019 (508) 398-2231 Ext. 1261 BU1 6y • __ IN CONSTRUCTION ADDRESS: T.2 /%fie 7 �i,f// F ASSESSOR'S INFORivLATION: Map; Parcel: OWNER: "9U/eICIO/l iel x*,eos' -idm C 7 ,2 L 8' F/ �� NAME PRESENT ADDRESS TEL. # f CONTRACTOR/ley/Sy VJ'/��/ `F! 9eh�.t/ .6 id� %fgi- ey77) l'iv' NAME / MAILING ADDRESS TEL.# ZAesidential 0 Commercial Est. Cost of Construction$ 6 �/G Z. r d b Home Improvement Contractor Lie.# iJ.- 5 2, 7 Construction Supervisor Lic.# jo, e / J7 f Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor have Worker's Compensation Insurance Insurance Company Name: it/rl,44/77c �..//z7�i- Worker's Comp.Policy# telC7O/,-I ,Y G 7670 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: G�4/2 � l/ �//y� • / 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 ans',ver(sl will be just cause for denial or revoc on of my license ane for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: � ' , / Date: $b�/// Owners Signat or attachment " Date: Approved By: -(,., Date: % - 0., 15 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ 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:2D5E6534-DE94-44DF-9BDO-CD9A43EA3672 Permit Authorization mass Save Form 3er,•r st raugn energy aM civ:mY Site ID: 3778246 Customer: Mauricio Medeiros Mau ri ci o Medei ros ,owner of the property located at: (Owner's Name,printed) 42 Captain Small Road South Yarmouth, MA 02664 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. DocullIgned by: Owner's Signature: BC36269A633E4F6... Date: 8/12/2019 19:05 PM PDT FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Cam- ��.�f15J Lcb�t S-7a- 19 Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: Page 1 of 1 For Office Use Only Rev,102015 A'Sl, Commonwealth of Massachusetts r Division of Professional L.icensure - Board of Building Regulations and Standards ConetrtCtt':1 iSitpervlsor CS-100988 5 z{ E'Xpires: 11/11/2019 HENRY E CASSIDY1f j ✓ 4 8 SHED ROW % WEST YARMOG 1 moYy,73 i ~ !Ws'' Commissioner • 6 /2?/J%(I/I e7 r()0'(// it t„ � /(/^))(/( //).( fi 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 Update Address and Return Card. Office of Consumer Maths&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration data, If found return to: RoDlstratlon Expiration Office of Consumer Affairs and Business Regulation 153567 12/14/2020 1000 Washington Street•Suite 710 CAPE COD INSULATION,INC Boston,MA 02118 / I HENRY E.CASSIDY a ' .--- 1 8 REARDON CIRCLE SO.YARMOUTH,MA 02664 Undersecretary a i Ith t sign r A C®. CAPECOD-27 THORNE. CERTIFICATE OF LIABILITY INSURANCE DATE'" "°°"YYY' 7/16/2 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.19 THIS 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 REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. i IMPORTANT: If tho certificate holder Is an ADDITIONAL INSURED,the policy(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 1 this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), PRODUCER C NTACT Good Rogers&Gray Insurance Agency, Inc. `PPHONE 434 Rte 134 (Arc,No,Ext):(800) 553.1801 I FAX South Dennis, MA 02660 MAI (aC,No):(877) 816-2156 bpRss;mail@rogersgray,com INSURER(S)AFFORDING COVERAGE NAIL n INSURER A:West American Insurance Company 44393__ __ IINSURED INSURER Protection Insurance Company, Inc. 41360 Cape Cod Insulation, Inc. INsuRER c;Endurance American Specialty Insurance Company 41718 18 Reardon Circle 44326 South Yarmouth, MA 02664 INsuRERD:Atlantic Charter Insurance Company p INSURER S: INSURER F; j --------- ' COVERAGES CERTIFICATE NUMBER: REVISIQN 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 WITH 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. L7R TYPE OF INSURR ANCE — ADOL SUBRI POLICY EFT POLICY EXP ----� A INSD MD POLICY NUMBER (MA2DD/YYYY) 1 4f1//D r� r` LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,0M 1 !CIAIMS.MADE ' X OCCUR BKW 53328281 4/1/2019 4/1/2020 DAMAGE TO RENTED 100,000? I PSEtdlsEs(E�ccyusnce $ -- - MED EXP(Any one person) $ 15,000i J• PER$ONAL�ADVIN'JURY 5 1,000,000 I I,GEN'L AGGREGATE LIMIT APPLI S PER: X POLICY IJECT LOC GENERAL AGGREGATE $ 2,000,000. PRODUCTS.COMP/OP AGG- $ 2,000,000 L.. OTHER: AUTOMOBILE LIABILITY ANY AUTO I COMBINED� SINGLE LIMIT 10200810081,000,0 0' It OWNED I 4/1/2019 4/1/2020 BODILY INJURY(Per person) $ SCHEDULED • j�AUTOS ONLY X IAUTOS X HIREED �A NON-pW�.�c BODILY INJURY(Per accident) $ (__-._ AUTOS ONLY I AUTOS O ICY ` PROPERTY DAMAGE (Par accident ' $ _ 2,000,000 UMBRELLA LIAR I X OCCUR $ X 1 EXCESS LIAB CLAIMS.MADE EXC10006635004 4/1/2019 4/1/2020 GGREGCURRENCE $ 2,000,000 AGGREGATE I_ • 1 OED I RETENTIONS _ 4 D WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY SPERTATUTE EORH Y!N WC100136900 6/30/2019 6/30/2020 ANY PROPRIETOR/PARTNER/EXECUTIVE 1,000,OOOj OFFICER/MEMBER EXCLUDED? I I N!AE.L.EACH ACCIDENT $ (Mandatory In NH) _ ITe5,describe under E.L.DISEASE-EA EMPLOYEE 5i 1,000,000! CRIPTIONOFOPERATIONSbelow 1,000,OOOj'E.L.DISEASE•POLICY LIMIT $ I DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) 1 CERTIFICATE HOG.DER-_T 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 ( ,,,,-, 7,a-,-,._____ ACORD 25(2010/03) ©1988-2015 ACORD CORPORATION. All rights reserved.__, The ACORD - (k pit 1T The Commonwealth of Massachusetts Department of Industrial Accidents ''r'`d % r'ra�� " Office of Investigations 600 Washington Street f 4 Boston, MA 02111 t r, + {•a www,mass.gov/dla Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant lnforma_tion Please Print Legibly Name (Businessiorganizatiunflndividual): Cape Cod Insulation Inc. Address: 18 Reardon Circle City/State/Zip: South Yarmouth, MA 02664 Phone #: 508-775-1214 Are you an employer?Check the appropriate box: general contractor and I I am aType of project(required): I. VI am a employer with 48 4, ❑ employees(full and/or pan•time), have hired the sub-contractors 6. 0 New construction 2.❑ l 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 10.0 Electrical repairs or additions 3,❑ lam a homeowner doing all work officers have exercised their 11.0 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' 13. Other Weatherization comp. insurance required.] *Any epplicunt that checks box NI must also till 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. • ;C'ontractors that check this box must attached an additional sheet showing the name ot'the sub-contractors and state whether or not those entities have employers, it'the sub-contrac4vrs have employees,they must provide their workers'comp.policy number. I ant an employer that is providing workers'compensation Insurance for my employees. Below is the policy and Job site injorrnuiion. Insurance Company Name: Atlantic Charter Policy if or Self-ins, Lic.#: .WC IQ0.136900 Expiration Date;06/30/2020 Job Site Address:^ DI/7/1p � S >ee% %$/ 1' try/State/Zip:M54 Q a'"4 Attach a copy of the workers' compensation policy declar/tion'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 line 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 Inyszst_i urns of he DlA for insurance covert a verification. I do hereby certify under the paints and penalties of perjury that the information provided aboi,e is true and trrect. Signatur5: 47 ez4444 f Da1e: a/ �Z-Ti /9� Phone ti: 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# Issuing Authority(circle one): I. Board of Health 2. Building Department 3,City/Town Clerk 4, Electrical Inspector 5. Plumbing Inspector' 6.Other • Contact Person: Phone#: .•