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HomeMy WebLinkAboutBld-20-000954 -•+R il `'O Permit# u. H Amount ATTA C%,g Z: r�,6•.0'p c� Permit expires 180 days from issue date $&D-2 is EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED i ar uou n Building Department _ 1146 Route 28 South Yarmouth, MA 02664 AUG 91 ?019 (508) 398-2231 Ext. 1261 eul _ 11 CONSTRUCTION ADDRESS: 1=#- isle c/QA// C 'ye ii2cJ r ASSESSOR'S INFORMATION: Map: Parcel: OWNER: /fr✓gh-jefr gOSI' ie ‘.1:A'/,1 e )1.--i 5'3 ! -I-- 7.) NAME c PRESENT ADDRESS TEL. # CONTRACTOR: ,UIZ,/ C45fi/p `0 iZ '#2.1,G 9 �/,e,Y/No gJ'i JJIJ 7,.5/Z NAME i, 1ILING ADDRESS TEL.# Q esidential 0 Commercial Est. Cost of Construction S ,i'G U/ O Home Improvement Contractor Lie.# 1., -----3...3-17 Construction Supervisor Lic.# /GO 4 l , O Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor FL:ave Worker's Compensation Insurance Insurance Company Name:,4r//9/VfG af9 jy�,4' Worker's Comp.Policy# l4 6/c Q/ 3 1 en 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: 76:1 )- J6iird '[lth 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 answers; will be just cause for denial or revocation-my license and for prosecution under M.G.L.Ch.268,Section 1. I / Applicant's Signature ii e ! / Date: Z f/l Owners Signature(r a ichment Date: CCCC Approved By: ,.....Ly Date: % —a\'' ICI Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft. of Wetlands: 0 Yes 0 No 0 Yes 0 No Commonwealth of Massachusetts Division of Professional Llcensure Board of Building•Regulatlons and Standards Constructt*{lt4pervlsor CS•100988 5..vires: 11/11/2019 S tittHENRY E CAS$IDY r {, F✓ ' } 8 SHED ROW \ll •` : }•4, WEST YARMOGT)-1 1,1A 0:1�673 Commissioner l • L. (� C(.)7t/)?/%%7'//c'l cC/(// l/._, � CG.:Jc%Clr!4/c%E'7/i 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 ConsumerAtfalri&Buslnaas Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: Roalstratlon FxDJrAtlon 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 Q ( . 1 9 18 REARDON CIRCLE SC.YARMOUTH,MA 02664 Undersecretary a I Ith t sign r i CAPECOD-27 THORNE.. L...•--- CERTIFICATE OF LIABILITY INSURANCE DATE(M1,f,,rDDYYYY) I—THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES I 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. I If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require en endorsement. A statement on this certificate does not confer rights to the certificate holder In Ileu of such endorsement(s), PRODUCER CONTACT Good I Rogers 5,Gray Insurance Agency, Inc. .PHONE 434 RRte ogers 134 (A/c,No,Ext):(800)553.1801 FAX ---_-- South Dennis, MA 02660 I(A/O,No):(877) 816-2156 p^� .mail@rogorsgray•com INSURERISI AFFORDING COVERAGE NAIC n ' - — INSURER A:West American Insurance Company 44393 INSURED _ INSURER a:Arbella Protection Insurance Company, Inc. 41360 Cape Cod Insulation, Inc. INSURER C:Endurance American Specialty Insurance Company 41718 18 Reardon Circle --__ South Yarmouth, MA 02664 NSURERo_AtlanticCharter Insurance Company 44326__ INSURER F..: - — -' INSURER F: 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 CONTRACTOR 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, INSR— ADDL SUBR POLICY EFF POLICY EXP T TYPE OF INSURANCE INSD WVD POLICY NUMBER --j (MMlDD A X COMMERCIAL GENERAL LIABILITY /YYYY),( IDD �)0LIMITS EACH OCCURRENCE $ 1,000,0001, CLAIMS-MADE I X I OCCUR BKW 53328281 4/1/2019 4/1/2020 DAMAGETORENTEp 100,000I PREMISES jEa ocEd[rontie) $ MED EXP(Any one person) $ 15,000 r PERSONAL 4•ADV INJURY 5 1,000,000I GFN•c AGGREGATE LIMIT PLIES PER' _GENERAL AGGREGATE a 2,000,000' , X POLICY I I JEGOT : I LOC PRODUCTS•COMP/OPAGG $ ; )OTHER; 2,000,000,, _B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT -IEaaccident) $ 1,000,OOO __ ANY AUTO 1020081008 4/1/2019 4/1/2020• OWNED 1 SCHEDULED -----X AUTOS ONLY _X �AUTOS BODILY INJURY(Per person) $ X HIRED X_ I NON-oWNoD _ BODILY INJURY(Per accident)!$• „r- AUTOS ONLY __ AUTOS OrJLY `- PROPERTY DAMAGE -------- _(Per accidenll 5 _ -'. I I C f- UMBRELLA LIAR X�I OCCUR I --�$ EACH OCCURRENCE $ 2,000,OUOj X EXCESS LIAB I CLAIMS•MADE EXC10006635004 4/1/2019 4/1/2020 �� AGGREGATE $ 2,000,000I DED RETENTION$ ._ I D WORKERS COMPENSATION S AND EMPLOYERS'LIABILITY OTH- �1 Y!N STATUTE I IER!ANY PROPRIETOR/PARTNER/EXECUTIVE W 1,000,000I CI00136900 6/30/2019 6/30/2020 _ OFFICER/MEMBER EXCLUDED? I I N/A E.L.EACH ACCIDENT $ _• (Mandatory In NH) 1,000,000 E.L.DISEASE•EA EMPLOYE EA_tBlPTIONFPRATICNs s,describe under ERATIONS below 1,000,000I E.L.DISEASE-POLICY LIMIT 5 • ii DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space 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 IN ACCORDANCE WITH THE POLICY PROVISIONS. • AUTHORIZED REPRESENTATIVE ici—,--,,„4.7 7 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION, All rights reserved• The ACCRr1 name and L.......... ...«,..a....-.._._...._ _. . ....__— — -- -_ t. f ,tr ;�s)°t.,1.. The Commonwealth of Massachusetts � z ' ' �' ' Department of Industrial Accidents r ,.,,,' �d "��Y- Office of Investigations '�,,' "` 600 Washington Street t -'Piz Boston, MA 02111 si: „ .x[ www.mass.gov/dla Workers' ompensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name (Business/Organization/Individual); 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: , 1ama general contractor and 1 Type of project(required): I.v 1 am a employer w4 with 48 0 employees(full and/or pan•tirne). + have hired the sub-contractors 6. ❑ New construction 2.❑ t am a sole proprietor or partner- listed on the attached sheet, 7. 0 Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P tY 9. [] Building addition [No workers' comp. insurance comp. insurance.t required,] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3,❑ 1 am a homeowner doing all work officers have exercised their 11.❑ 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 applicant that checks box it I must also fill out the section below showing their workers'compensation policy information. 'Honxwwners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. . ;C oniracun that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the iutrcvntrauors 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 fob she inforntation. Insurance Company Name: Atlantic Charter Policy++or Self•ins. Lic.#; WC(00136900 Expiration Date:06/30/2020 i • Job Site Address:,¢#79164f/ciN1 fryg ea genmc/i/City/State/Zip:y4ye a z-G 73 Attach a copy of th7workers' compensation policy decl tion'page(showing the policy dumber and expiration date). I•ailure 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 imprisonment,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 invest, ic�, 'atiion of the DIA for insurance covens ,e verification. --__.___, , I do hereby certify under the pains and penalties of perjury Mai the information provided aboir is true and _lrrect. / f / Si�t r5: 44vtc���c2c�ewcc Date: — Phone$4: 508-775-1214 V ,u JJ �Offcial use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3.City/Town Clerk 4, Electrical Inspector 5. Plumbing Inspector' 6.Other Contact Person: Phone#: — • i k • Permit Authorization mass save Form Site ID: 3667799 Customer: Walter Rostek I, 11)f1 G-7 e D.ST EK ,owner of the property located at: (Owner's Name,printed) 44 Pheasant Cove Circle Yarmouth Port, MA 02675 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature: („.X C -4( Date: J� i c/ FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: ao`-(3e- Cod Tr►S O rcx4 Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: Page 1 of 1 For Office Use Only Rev.102015 eiMaAAS) 00),i het _ __ .1-Y.iitt TOWN OF YARMOUTH Building Department BUILDING ,,,e, % (508) 398-2231 ext.1261 0 PERMIT ,6".,, ,�' Al. PERMIT NO BLD-20-000954 000954 "* " � ISSUE DATE 08/21/2019 JOB WEATHER CARD APPLICANT HENRY CASSIDY PERMIT TO : New AT(LOCATION) /44 PHEASANT COVE CIR YARMOUTH MA 0267 ZONING DISTRICT 1R-40 J Bldg.Type: }Residential SUBDIVISION MAP BLOCK LOT 149.37 . BUILDING IS TO BE: 1CONST TYPE 1 V B 1 USE GROUP ER-3 ...REMARKS ,...,�.M��._.�.,......�.a .. .,�� ..,...,.._ .,.w_ . ,�_.,.. . ..,A.� _.__,..,.__..�. CONTRACTOR Repair-Install Insulation (508-775-1214) I _ _ I 1 LICENSE 1153567— — x d Home Improvement z CAPE COD INSULATION,vINC `HENRY CASSIDY AREA(SQ FT) 683,107 920. ¢EST COST($) ,2500 00 PERMIT FEE $) ;35 00 I z 18 REARDON CIRCLE ( ( . d ISO.YARMOUTH, MA 02664 OWNER 1ROSTEK WALTER J JR 1 ..w. _ _ BUILDING DEPT BY ADDRESS ROSTEK BARBARA,64 PHEASANTS CROSS 1 . tn_ M }yµ* y m We L [WEST SPRINGFIELD MA 01089 HONE 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 BEEN MAD 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.