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Home My WebLink AboutBld-20-002455 V �rO • r Permit# -li O �•/�-'9 'Amount ATTA ,. est . � ',..,,,,,�,0 E;d r Permit expires 130 days from _ 20 issue date EXPRESS BUILDING PERMIT APPLICATION-------,,--------i TOWN OF YARMOUTH - .�- - — € Yarmouth Building Department i 1146 Route 28 a OCT 29 2O19 South Yarmouth, MA 02664 _. (508) 398-2231 Ext. 1261 s � e CONSTRUCTION ADDRESS: ..-`' ecvA W 4 I le £ 4 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 1 24Z 1/N YAW,t j d - riT e 41--fJ/ 7 Pit- 3 7 a b NAME PRESENT ADDRESS �t TEL. # CONTRACTOR:cl� ��t/.SU�jg1-/(J� /te'e� r�,rP C�/e 27_l1 2YTEL# ;11/Residential 0 Commercial Est. Cost of Construction$ 0�f`' e, 0 I L) Home Improvement Contractor Lic.# /J.'S 5 7' Construction Supervisor Lic.# /1 S Q r 8' Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 'I have Worker's Compensation Insurance Insurance Company Name: ,9-ri,l,l7 C C-440,7 J Worker's Comp.Policy# 1)C"/,.. c,/3(„ 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: 7,4„e/4/47 •��J ,. Location of Facility I declare under penalties of perjury that tie 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• • of my license and for rosecution under M.G.L.Ch.263,Section 1. i Applicant's Signature: , ,�� Date: /Q/.� 2 f/ 9 Owners Signature(or attachmen l , . Date: Approved By: �r Date: /at- —/27-- Building Offici r gne EN DRESS: 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 DocuSpn Envelope ID;817CE938-979D 448F-8F32-7A OBDCEA288 RISE 't• ENGINEERING' OWNER AUTHORIZATION FORM Martyn Taubert (Owner's Name) owner of the property located at: 58 Gunwhale Road (Property Address) Yarmouthport, MA 02675 (Property Address) hereby authorize Co-op. rc,cv T -. - ` O z cN \ (Subcont ctor) 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. p Doeuegn.d by; 1Y` t_uikirrlrauunr Owner's Signature 9/4/2019 I 7:45 AM EDT Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue l South Yarmouth, MA 02664 508-568-1926 www.RlSEengineering.com • Commonwealth of Massachusetts ® Division of Professional Licensure 11 Board of Building Regulations and Standards Cons�rtr��iSippvisor C5 CS-100988 `�. fpires: 11/11/2021 HENRY E CASIDYt * ^� „ �y 8SHEDRO !� ' AIL WEST YARMC+,jITH- ')t• 3' Commissioner • • �%/•(� r)-(vimi%l'/?U.d'Cll�� (t ,�l' �1.•,J�JCGt^ tr�EP J Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration - " Type: Corporation • CAPE COD INOLATION, INC Registration: 153587 18 REARDON CIRCLE Expiration: 12/14/2020 SO,YARMOUTH, MA 02664 1.. 2OM•Q;;n; Update Address and Return Card. Office of Consumer Affairs&Business Reautstlon • HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date, If found return to: Registration gxparDtlon Office of Consumer Affairs and Business Regulation 163667 12/14/2620 1000 Washington Street•Butte 710 CAPE COD INSULATION,INC a Boston,MA 02118 HENRY E. Y 18 REARDONON CIRCLE SO.YARMOUTH,MA 02884 Undersecretary a Ith t sign r • I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations , / 600 Washington Street Boston, MA 02111 rvww.mass.gov/dia or ers' ompensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Ijtformation Please Print Legibly 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: 1,�'I am a employer with 48 4. 0 I ant a general contractor and 1 Type of project(required): . employees(fill and/or pan•time), + have hired the sub-contractors 6, ❑ New construction 2.❑ 1 ant a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9, ❑ Building addition (No workers' comp, insurance comp, insurance.1 required.) S. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3,❑ I am a homeowner doing all work officers have exercised their I l.❑ Plumbing repairs or additions myself. [No workers'comp, right of exemption per MGL 12,0 Roof repairs insurance required.]t c. 152,§I(4),and we have no employees.[No workers' 13,0 Other Weatherization comp.insurance required.) •Any applicant that checks boat NI must also All out the section below showing their workers'compensation policy Information. j 'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. . ;C'onma:um 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 sub-contractors 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 , information. Insurance Company Name: Atlantic Charter - Policy//or Self-ins,Lie.M..1=I90136900 Expiration Date:06/30/2020 — Job Site Address:c1 �i�l/�A /� �1 ��/f�d Ctie/Zip' )44� � ZG7� Attach a copy of the workers' compensation policy declaration'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 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 i ation of the DIA fir in-_.: c cove _ veri c ion, _ ___ I do hereby certify underr the pains and penalties of perjury that the information provided above is true and correct Signature: f`7 4 44s- Date: J /a c,//In Phone G: 508-775-1214 'i Official use only. Do not write in this area,to be completed 6y city or town official Ciry or Town: Permit/License# Issuing Authority(circle one): i. Board of Health 2. Building Department 3.Cityrrown Clerk 4,Electrical Inspector S. Plumbing Inspector 6.Other • Contact Person: Phone#: CAPGCOD•27 __�_____TI:Qf_NE CERTIFICATE OF LIABILITY INSURANCE OATEIMMIDD/YYY Y) _ _• 711612Q1f) — CATE IS IS'UED AS 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 CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED SENTATIVE OR PR DDUCER,AND THE CERTIFICATE HOLDER. /iPORTANT; If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must have ADDITIONAL INSURE.°provisions or be endorsed 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 co ifer ricflTts to the certificate holder In lieu of such endorsement(s), i PRODUCER Or GDod .—,_—_•--_---' QNLAC' i Rogers&Gray Insurance Agsncy,Inc• . HONE INN -- 434 Rtv 134 ac No Exl; 800)663.1801 _ 11ac,Na):(877) 816.215G South Dennis,MA 02660 Main;mailer rogersc)ray,com ------------ JNSURERLSI AFFORDING COVERAGE ___._NA)C n_--__', I.--_.- INSURER A'West American Insurance Company 44393__._._.__ I INSURED . - N RER a;ArbellaiProtoctIon InsurpnCo Company Inc, 41360___..-,.___� Cape Cod Insula Lott, Inc, c'Endurance American Specialty Insurance Company 41 718 18 Reardon CIrcie IN RaRp;Atlantic Charter Insurance Company 44326.....____.I South Yarmouth,MA 02664 I S RE F.; ---- ---- I _— —•.,,__,__ INSURER F; ,w1—_• — Cr _ OVERAGES CERTIFICATE 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 PERIODWI I INDICATED. NOTTHSTANCING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTr 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. ___ _ INSR AOOL SUER POLICY EPF POLICY EXP —TYPE OF INSURANCE INS° WVO POLICY NUMBER ,,,,P a a iiai j_jiy1 /D_QPNYYI LIMITS A X COA1Mr:RCIAL GENERAL.LIABILITY EACH OCCURRENCE __--__1,000,0001 CLAIMS•MAOE Xl OCCUR 6KW 53328281 4/1/2019 4/1/2020 D2HAMAImE RiaNDenc0 �-�--_--.10-0,.00.-- 01 • __ME_Q.1 XP(Any one perm)) $ ___ 1:i,000 — -- PE _SDA•AL 6 AOY INJURY 1,000,000I GEN'E AGGREGATE LIMIT AP cg,sPER: ' 2,000,OOO PRO• GENERAL AGGftEGAI'� _—,____-_.__-_, X POLICY l I JECT [ LOCn� PRODLZCTS•COMP/OP AGG 2,000,00Oj _ OTHER: _^— f B AUTOMOBILE LIA8ILITY +-- _(OFAF)IN�•EV SINGLE LIMIT —^ 1,000,U00 ANY AUTO 1020081008 4/1/2019 4/1/2020 BODILY INJURY(Per.person)— • OWNED ONIY X SCHEDULED ----- RRF�-O` UpTN WNED pS BODILY IN PRY Pet celdenl $ ____ X AVTOS ONLY X AUl'C ONLY . ,_tPo?$ccld�enll AMAGE — - ---I C • UMBRELLA LIAR X OCCUR EACHQE QRRENCE g 2,000'000I 'X EXCESS LIAR ^ C.AIMS•MADE EXC10006636004 4/1/2019 4/1/2020 — 2,000,600I • %— AGGREgAT F. _ DEO__ RETENTIONS _ O~'WORKERS COMPENSATION TT — PE ■ OTH. S --• ------~ AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y WCI00136900 6/30/2019 6/30/2020 'I,000,OUO,O�FICERIMEMg ER EXCLUDEp9 N/A E.L.EACH ACCIDENT _ I I(n anda(ory In NH) 1,000,0001 ' !II Y9os,describe under E.L.DISEASE•EA EMP •YEE,-_________ !DF.SCRIPTIONOFOPCR�TIONSborow 1,000,000' "'—'—^— E.L.DISEASE••POLICY LIMIT c 1 // I DESCRIPTION OF OPERATIONS/LOCATI)NS I VEHICLES (ACORD 101,Additional Romarka Sahodulo,may be attached If more space la required) ^ �, ' • CGRT)FICATE„j1QL•DER _ ATION —^-- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Information On y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, • • `AUTHORIZED REPRESENTATIVE �^