Loading...
HomeMy WebLinkAboutBld-20-002201 "'' 0 iPermit# +. Y C • Amount C ATTnCn CSC 'Permit expires 130 days from bi issue date zo a'o I EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Y armoutn Building Department 1146 Route 28 South Yaumouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: // / ,� 9 L3 ASSESSOR'S INFORMATION: / Map: Parcel: o WNER: d4 e/4 Al X4/f �� � 7 3 / p NAME PRESENT ADDRESS� TEL. # CONTRACTOR:,L'ij{IZ f dafc/fr j� 14'/G2 liep � ,bul b j� `J� 6'77) —NAMEMAILING ADDRESS TEL.# Aesidential 0 Commercial Est. Cost of Construction$ fj f e 0 Home Improvement Contractor Lie.# AePQ 7ryv Construction Supervisor Lic.# dco p Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor 4 I have Worker's Compensation Insurance Insurance Company Name: d_r .9iy`irG C�_gjee Worker's Comp.Policy# Q Q 14-3 /p©3 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: 0Pg, G/' //Z/ r • 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 of my license and for prosecution under I.G.L.Ch.268,Section 1. / Applicant's Signature: Date: / L �p Owners Signatur or attachme Date: a� 6� Approved By: /G Date: 6 `( -r/ Building 0 (o ignee) EMAIL ADD . Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: t"ll' 0 Yes 0 No 0 Yes 0 No • + Commonwealth of Massachusetts ) Division of Professional Licensure Board of Building•Regulatlons and Standards Constr&Cttb•ri S pgrvisor • • • • CS-100988 ricpires: 11/11/2019 HENRY E CABSIDY- = 8 SHED ROW'- Y;;i' • WEST YARMOG3;H M4,03Q75 \ • Commissioner � � �.J(v2?/ . ,?!l Le(G7/X l' .•('�(l Jc%CGC lc�E' J 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: 123562 18 REARDON CIRCLE ExpExpiration: 12/14/2020 SO.YARMOUTH,MA 02664 Update Address and Return Card, 1,4; 20M•05,17 Office of Consumer Affairs&Business Regulation • HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date, If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 153587 12/14/2020 1000 Washington Street•Sults 710 CAPE COD INSULATION,INC Boston,MA 02118 HENRY E.CASSIDY C\ 18 REARDON CIRCLE SO.YARMOUTH,MA 02664 Undersecretary a Ith t sign r The Commonwealth of Massachusetts - - - _ Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dla or ers' ompensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/lndividual): Cape Cod Insulation Inc. • Address:µ18 Reardon Circle City/State/Zip: South Yarmouth, MA 02664 Phone#: 508-775-1214 Are you an employer?Check the appropriate box: 1.VI am a employer with 48 4. 0 1 am a general contractor and I Type of project(required): employees(full and/tar part-time).* have hired the sub-contractors 6. 0 New construction 2.0 I 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 working for me in any capacity. employees and have workers' [No workers'comp, insurance comp.insttrance.t 9. ❑ Building addition 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 i insurance required.]t c. 152,§1(4),and we have noWeatherization employees.[No workers' 13. (Other comp.insurance required.] •Any applicant that checks host N t must also nil out the section below showing their workers'compensation policy information. 'Homeowners who submit thii affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such- . 1 ;Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'tamp,policy number. I am an employer that Is providing workers'compensation insurance for my employees. Below is the policy and Job site information. Insurance Company Name: Atlantic Charter Policy it or Self-ins,Lie.#;�WC 100136900 Expiration Date:06/30/2020 _ lob Site Address:// Jfiiv�.1 retry ki9/ 17/1-��d City/State/Zip: , '7 e G y Attach a copy of the workers' compensation policy dec aration'page(showing the policy number 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 tine 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 inves i ations of DIA for in trance covera_e veri t ation. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Sitcnature: ` e414 Dater /!7/!7//lP _ Phone 4: 508-775-1214 gyp/ '- r"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#: CAPECOD•27 _f_MAhtLIr3, ' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/UD/YYYY) 06/06/2018 -TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS FICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES OW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED -EPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder Is en ADDITIONAL INSURED,the pollcy(les)must havo 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 this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER NRj AOT 1 20 ors&Gray insurance Agency,Inc, pA/CNE (AJC,No).(877) 816.2156' _ j 134 Me 134 No,Ext south Dennis,MA 02660 ae.S_S mallerogersgray,com INS.VRER(S)AFFOROINO COVERAGE NAIC a _ INSURER American Insurance Company 44393 — INSUREO INSURER S;Safety Indemnity Insurance Company 33618 Cape Cod Insulation, Inc. INSURER C;Endurance American Specialty Insurance Company 41718 16 Reardon Circle INsuRERotAtlantIC Charter Insurance Company ' 44326 I South Yarmouth,MA 02664 INSURERS: INSURER F: 1 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 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, NSR TYPE OF INSURANCE ADOL SUBR POLICY NUMBER POLICY EFF POLICY EXP —' I TR INSO WVD IMMIDDIYYYY)_tp•IM/OD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000; CLAIMS•MAOE 1 X I OCCUR BKW(19) 63328281 04/01/2018 04/01/2019 DAMA SEETO RENTEueatiol $ 100,0001 Moo EXP(Any one person) $ 5,0001 PERSONAL aAOVINJURY $ 1,000,000 GEN'Lil 1 AGGR A E LIMIT APPLIES PER: GENERAL AGGREGATE $ . .2,000,000! X I POLICY j�T LJ L00• n ,PRODUCTS•COMP/OPAOG $ 2,000,000 X J} see holder Posen')of operations ----i OTHER: $ 8 AUTOMOBILE LIABILITY 'COMBINED SINGLE LIMIT 1,000,000 4E.e ascistaru) _$ _--._ - . ANY AUTO _gg p 6232707 04/01/2018 04/01/2019 BODILY INJURY(Per person) J •r' AUTOSO ONLY X AUTOSQULEO _i IIRREEDD 0t,OWNED 09pDILY INJURYp (Per accident) $ ' X AVTOSONLY X MID ONLY (Perreccldenl)AMAGE $ •C+'( '• UMBRELLA LIAB X OCCUR $ EACH OCCURRENCE $ 2,000,0001 X EXCESS LIAB CLAIMS•MAOE EXC10006635003 04/01/2018 04/01/2019 AGGREGATE 2,000,000 •• OED RETENTION$ $ D WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y PER ER H• $ ANY PROPRIETOR/PARTNER/EXECUTIVE WCE00431903 06130/2018 06130/2019 1,000,000 �FFICERIMEM EXCLUDED? N I A E.L.EACH ACCIDENT $ (MandatoryIn� j 1,000,000 II yes,describe under E.L.DISEASE•EA EMPLOYEE $ _ ___ • OESCRIPTIONOF OPERATIONS below 4.. 1,000,OCG ., E.L.DISEASE•POLICY LIMIT $ //.. •. /i. DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (ACORD 101,Additional Remake Schedule,may be attached II more apace Is required) Norkors Compensation Includes Officers or Proprietors, additional Insured status Is provided under the General Liability and Auto Liability when required by written contract or agreement with tho Cortl(Icate Holder. Excess Liability Is follow form. • CERTIFICATE HOLDER_ CANCELLATIO• SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN • ACCORDANCE WITH THE POLICY PROVISIONS, • . AUTHORIZED REPRESENTATIVE EVIGIVIEEbSIVIG.. 13I2Ej OWNER AUTHORIZATION FORM I, Sheila Kane __--_ —, (Owner's Name) owner of the property located at: 11 Kingsbury Way (Property Address) Yarmouthport, MA 02675 _ (Property Address) hereby authorize_—_ C-c rtd ___. -nS O st=t- \C3\l-, , (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. Owner's S • . ure 0/9 I Cl DateRISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com