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Home My WebLink AboutBld-20-002883 (2) r 0• ut -H1 ';Amount ` 1 CS(vae 'cj/ c Permit expires ISO days from ,i issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: k tidP/ ✓(gyp S Y /2I ASSESSOR'S INFORMATION: Map: Lc Parcel: Q07 OWNER: ,e 77T8 o: 7.u/ ,-. -$W e G/72e2/7I'1'a NAME PRESENT ADDRESS /r TEL. # CONTRACTOR:OPp l J /a/..5/,7% '�/emi /F i fl( �!/2 /J 1 II2 7-4JJ-�2 7J`l 2 NAME MAILING D TEL.# Residential 0 Commercial Est. Cost of Construction$ 7.0 6 0 Home Improvement Contractor Lic.# /,4--"S,.. 7 Construction Supervisor Lic,# ./ S Q r r Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor trI have Worker's Compensation Insurance Insurance Company Name: j9i/41/71C C4,q/t7-b i Worker's Comp.Policy# 41 C/ 0/3 L, 9 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: 7,Q,j"O L .. 'J , 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 revoc 'on of my license an for prosecution under M.G.L.Ch,263,Section 1, ti f Applicant's Signature: .t<'//f Date: ///j_5 7/ ? Owners Signature(or attach _ Date: Approved By: ,--------:::____e„.., Date: \1'1�—)5 64 , ,a6t. Building O tficial(or designee) EMAIL ADDRESS: ll` ai Zoning District: i Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No 37ars • Water Resource Protection District: Within 100 ft. of Wetlands: 0 Yes 0 No 0 Yes 0 No t 'r • • 1011•01111.01.1.49.,Cu. Commonwealth of Massachusetts j • �, ® Division of n Board of BuildingProfessio Regulationsal Licensure and Standards Cons•g1 t1.01 45ir isor Cf. CS-100988 spires: 11/11/2021 HENRY E CA, SIDYt r, f 8 SHED ROW;1 `,-` f ,� , WEST YAR.MOj1TH M �y 3 •' ; e ' ›C ,, C Commissioner L%/l(1 J.. />?%i%(1/?( teal/ � ,• �G;J�JCGr! c!rJP IrJ 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: 163567 18 REARDON CIRCLE Expiration: 12/14/2020 SO,YARMOUTH, MA 02664 • Update Address and Return Card, 20m•o5h; i 7-7 /i•niiiivinvi,/// i/• /IiiJJiiiYui•ii//J .. Otfice of Con;umorAffairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: • Registration gx,Iration Office of Consumer Affairs and Business Regulation 163667 12/14/2020 1000 Waehington Street•Suite 710 CAPE COD INSULATION,INC Boston,MA 02118 HENRY E.CASSIDY 16 REARDON CIRCLE SO.YARMOUTH,MA 02664 Undersecretary • a 1th t sign r f . • I • The Conrnwnweaith of Massachusetts Department of Industrial Accidents Office of Investigations • 600 Washington Street Boston, MA 02111 I t ' www.mass.gov/dla orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name tBusiness/Organlzatiurondividuat): 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: Type of project(required): 1.M 1 am a employer with 48 4. ❑ l am a general contractor and i employees(full and/or part-time).*• have hired the subcontractors 6. ❑ 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 g, ❑ Demolition workingfor me in anycapacity. employees and have workers' p tY insurance.t 9, I: Building addition [No workers' comp.comp, insurance required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers,' comp, right of exemption per MOL 12.❑ Roof repairs insurance required.]t a 152,§1(4),and we have no employees. [No workers' 13. ,{a Other Weatherization comp, insurance required.] '.Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowtcrs who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :C'untructors 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. lithe subcontractors have employees,they must provide their workers'comp.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 Nat.ne: Atlantic Charter Policy ri or Self-ins.Lie, #:.WC10.0:136900 Expiration�ti Date;06/30/2020 Job Site Address:_ �}�" �j��/ ce t�L�S 71 ,�04� 4Iry/State/Zip: J�4 A d 2t-4- Attach a copy of the workers' compensation policy declaratida'page(showing the policy number and expiration date). P� Failure to secure coverage as required under Section.25A of MOL e. 152 can lead to the inipositioti'of criminal penalties of a fine 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 hives it'ations of the DIA for insurance covers ee verification. I do hereby certify under the pains and penalties of perjury that the Information provided above is true and correct Signature: I ' Date: �f 1 / 7bone ut�u�, ��.c2.cL�cl� 111': 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 Autbority.•(circle one): 1. Board,pf Health 2, Building Department 3,City/Town Clerk 4,Electrical inspector 5. Plumbing Inspector- ; 6.Other • Phone#: • • • CAPEECO0.27 _,__—_____JUQftNF.. CERTIFICATE OF LIABILITY INSURANCE GATE(MA11pD/!'/Y'!) — __ 711612U1J _ CATE IS IS UED A9 A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS E DOES NO AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES THIS CERTIFIC TE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED i'f6/�/1 , SENTATIVE OR PR•DUCEER,AND THE CERTIFICATE_HOLDER. XR ANTI If tho certificate holder Is an ADDITIONAL INSURED,the poilcy(los)must have ADDITIONAL INSURED provisions or bo endorsed. I SUB'ROGATION IS WAIJED, subject to the terms and conditions of the policy,certain policies may require en endorsement. A statement on this-certificate dons not co)for rl0llts to the certificate holder In lieu of such endorsement(s), i - Good — loyvrs&Gray Insurance Ardency, Inc, • HONENo -- — �— _i 34 Me 134 rvc EX1t 800) 863.1601 i�c,Nol;(8%7�t3'16 215G ,outh Dennis,MA 026$0 _,mall ogers(lray,conl INSURERL31 AFFORDING COVERAGE NAIc u -- T INSURER AIWOst American Insurance Company �439.3__ _._... 4SURE0 . '` RER8;Arbella Protection Insurance Company,lnc_41360__..,.,__ __, Cape Cod Insula'lon, Inc, .Endurance American Specialty Insurance Company 41718_ __ 18 Reardon Circle IN ae;AtiantIc Charter Insurance Company_._44326. ._ South Yarmouth,MA 02664 INSURER F.I ---- .�_ INSURER F I :OVERAGE;S CEtTIFICATE NUMBER; REVISION NUMBER: THIS IS TO CERTIFY THAT HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NO1WTHSTANCING 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. SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, __ ?Cl- TYPE OF INSURANCE---- AWL SUER PO ICY ELL PO IC X\�P 1 LIMITS '— 1NSD WVO POLICY NUMBER „ a �+ _.T --� A X' COMMERCIAL GENERAL LIABILITY Y1 EACH OCCURRENCE 1,000,000I CLAIMS-MADE OCCUR E3KW53328281 4/1/2019 4/1/2020 EaEMI TookENTED 1UO,000I P_HEMI .(6�Oseurfonce 1_�..__.. "'" Ja.4.EXP(Any one Poraon)___ $ __,__ 1 E>,U00 1 5)�l. d AM?INJURY 17000,UUOI GgN'L AGGREQfTF.'LIMIT r\P_l S PER:A GEMEHAL•AGGft6GAl'�^.1_ . 2,000,000 X POLICY( I!Pi LOC " OTHER — — �^_T PRODtLTS•COPAP/UPAGG 2,000,OOO jT AUTOMOBILE LIABILITY "— — .___..--.—_.__—' — _(ERacctsteOISINGLELIMIT 1,000,UOOI AVTO 1020081008 4/1/2019 4/1/2020 1 OWNED SCHL OULED BODILY INJURY(Por.pers n— tom,_, — AURTfO(S ONLY X AUUpTTNOOpSWN D X AUTOS ONLY X AUl'OS O Y paR00PCYR YI AMAO@ INJURY(Pot accldenlL $ ,T__ _I _(Nor aCrl�enl) .L____�__..--- UMBRELLA LIAB _X OCCUR 1.____ _ _ X EX(ESS I.IAO _ C AIMS•MADF. EX010006635004 4/1/2019 411l2020• EA H QA'r RRENCE _— 2,000,000 0(0 —RETENTIONS AGGREQATE. _ 2,000,000 )-WORKERS COMPENSATION �` y AND EMPLOYERS'LIABILITY �R APIY PROPRIETORIPARTNER:EXECI TIVE (' WCI.00136900Sitj-LUIE 1111 (Km _ .IOFFICERIME Mg ER EXCL UDl p7 Fly NIA 6/30/2019 6/30/2020 1(MandatorylnNH) E.L., CCIOQNT _-- —I,000,OU01 I yOs. oscribounder u E.L.QISEASi •EACFAhL�Y E 1,0000(10 ;DFSCRIPT10N OF OPERATION$bQraw ..�..._._�.�_.._..____. — — Y�.-------_— E,L.DISM,§ l Y LIMIT 1:000,OUOi -- II i SCRIPTION OF OPERATIONS/LOCATIDNS/VEHICLES (ACORO 101,Additional Romarke Soliodulo,may bo aaaohod If more apaee la roqulr�R------^ �'-- • I 1 • Pasti§Ign€fr a:F4i€N41=,AI-4 b- lArr4M 1 FEU29§ 14t- RISE OWNER AUTHORIZATION FORM 1, gotta &Iini (Own®!'§Name) owner of the property located at 64 Cabin Noy@. Rood , (Property Address) south Yarmouth, MA 02064 (Property Addreee) hereby authorize e_a-(a Co 8 :En 5o L° on muiffionfraet00 en authorized subcontractor for RISE Engineering,to ant on my behalf to obtain a building permit end to perform wont on my property!This form is only valid with a signed contract, [0•0104 714' two 11/6/2O1 11:43 6M €§T Date RISE Engineering,a Division of Thielsch Engineering,Inc. 5 Dupont Avenue i South Yarmouth,MA 02664 1508-568-1926 www.RlSEengineering.com