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HomeMy WebLinkAboutBld-20-002881 t : ��o t ao-a 2 1 i C Ou � -,,3 ;Amount` It if( �' _°°" ��� • `Permit expires 1 SO days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Y arrnouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: G 9 ..."Cc' ,1%y5 17J F ASSESSOR'S INFORMATION: Map: 37 Parcel: /33 OWNER: i///AN 04/rj2 eAy 1� �vlri Zd 3�77D2 D NAME PRESENT DRESS TEL. # CONTRACTOR:4 l Aii.S/> r/eV/(I /e ivdr:4,r, C ./le / Iø1Jf.271,t J. 275 1 2 NAMME MA LING D TEL,# ii.Residential 0 Commercial Est. Cost of Construction S I.Z, n e • Home Improvement Contractor Lie. # l`J '_5-Z 7' Construction Supervisor Lie.# / S Q e Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor ,ftrI have Worker's Compensation Insurance Insurance Company Name: J4-'l1A tic- rf 4/7T f Worker's Comp.Policy# ka C'/c.0/3 L. f 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: 74,02,')/d ✓j1, Z 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 licensese and for prosecution under M.G.L.Ch.268,Section 1. r0 /,, ea'6. Applicant's Signature: `%� Qi Date: //�/3//9 Owners Signature(or attachment) . Date: Approved By: �/ �„ Date: 1\ 1%—' ICA Building Official(or designee EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft. of Wetlands: 1.--37a- ,.. 0 Yes 0 No 0 Yes 0 No ! f); FS?, CommonwoaIlh of Massachusclls Division of Prolossional Liconsure • Board of Building•Regulallons and Standards Conctr•>,tCthb,ti ltup?rvlsor CS-100988 'xpirus: 11/11/2019 - HENRY 8 CAy'31DY S f `, l ts ( • 8SHLDRON/ 11 �1 • WEST YARMOOT • �1v Commissioner Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation COD INSt�LATION, INC Registration: 153567 CAEExpiration: 12/14/2020 8 C,F:ARDON CIRCLE P SC !ARMOUTH, MA 02664 Updato Addruaa and Return C'a,u. Olricu of Cons,:marAffalra G UuclnW$ Rupulallon ItOt,IE IMPROVEMENT CONTRACTOR Ropistratlon valid for Individual uca only f YP8:CorooraUon boforo the expiration data, If found return to: fte 1t_a110I1 i;.XDJralfor) Offlcs of Con$urnur Affalra and Buclnoaaa RovulalIon 53567 12J14/2020 '1000 Waohington Slruot•Sulfa 710. CAPE COD INSU':A'i ION, INC t3oston,MA 02118 !r l 1JY CASSIA`" RDON Y,L'ZPrtGU1N,n< 02.G34 Undersecretary e I Ith gl�n� r —� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street _ Boston,liT,i 02111 www.mass.gov/dla or ers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Businesx/Organlzatiun/Individuat): Cape Cod Insulation Inc. Address: 18 Reardon Circle • City/State/Zip: South Yarmouth, MA 02664 Phone #: 508-775-1214 Arc you an employer?Check the appropriate box: Type of project(required): 1.VI am a employer with 48 4. ❑ 1 am a general contractor and I 6. New construction employees(full and/or part time).• have hired the subcontractors 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 workingfor me in anycapacity. employees and have workers' P t)' 9, ❑ Building addition [No workers' comp, insurance comp. insurance.: required) 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11. Plumbing repairs or additions 3.❑ 1 am a homeowner doing all work myself.[No workers'comp, right of exemption per MGL l2.❑ Roof repairs t c. 152,§i(4),and we have no x insurance required.) 13.{!Z Other Weatherization employees.[No workers' • comp. insurance required.) 'Any applicant that checks box#t must also fill 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. :Contractors 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 sub-contractors have employees,they must provide their workers'comp.policy number. am an employer that Is providing workers'compensation insurance for my employees. Below Is the policy and job she information. - Insurancc Company Name: Atlantic Charter • Policy ii or Self ins.Lie.#:�WC I0,0/136900 Expiration Date:06/30/2020 Job Site Address:6 e 5 e lz1 1f t2 hi UV Y ity/State/Zip: '4 © Z Attach a copy of'the workers' compensation policy deelaration'page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MCL c. 152 can lead to the impositiott bf 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Invest�ations of the DIA far insurance coverag$verification. • _____ _ _4. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Ca44s�r Date: //17 3//Y _ Si'nan re: ��� iLtione u: 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 • Phone#: • CERTIFICATE'''p'' CAPECOD-27 _ _ ThjORN F. CERTIFICA 1 E or LIABILITY INSURANCE• DAT/16/20YYY'!I 711612U1t1• 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 PRDDUCER,AND THE CERTIFICATE HOLDER. xi ORTANT; If the certificate holder Is an ADDITIONAL INSURED,the pollcy(los)must have ADDITIONAL INSURED provisions or bo endorsed. . SUBROGATION IS WAIJED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on % this•cel'tiflcate does not co Tfer rl jts to the certificate holder In lieu of such endorsements , __ __ PRODUCER CQ1IIACT Good . !Rogers&Gray Insurance Agency, Inc, .PHHoNNE 215G j I jac,No):(877) 8'16 ';434 Rle 134 Arc No EXt: 800 553.1801 iSouth Dennis, MA 02660 •oliss,mall G©roggerSiray.0om —__ INSVRERLSIAFFORDING COVERAGE _ttrL»__—_�', _ INSURER A;West American Insurance Company 443J3______ INSURED . " IN RERa;Arbeila Protection Insurance Company,Inc, 41360___..,____I Cape Cod Insula•lon,Inc, INSURER C Endurance American Specialty Insurance Company 41716_,_____. 18 Reardon Circle INS ER0:Atlantic Charter Insurance Company 14326___.__ South Yarmouth, MA 02664 p Y I SURER F.: l INSURER F: --•-- --- I--- J COVERAGES 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 PERIOD INDICATED. NOTWITHSTANCING 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. IN-SR I ADOL SUeR POLICY EPF PO ICY EXP TYPE OF INSURANCE INSD WVD POLICY NUMBER ` LIMITS ____ _ SLt__ u u !a a u) ( MIDDIYY W I — ---- I A X COMMERCIAL GENERAL LIABILITY 1,000,000J EACH OCCURRENCE $ `,CLAIMS•MADE r X1 OCCUR BKW 53328281 4/1/2019 4/1/2020 DAMAGE TO RENTED 100,0001 i. PRErd15.ES1Ea oret nonce ,� _._ MED EXP(Any one person $ —__ 15,000 _J _ PERSONA • 0 IN RY s _ 17000,0001 2,000,000! GEN'L AGGREGATE LIMIT APPLE PER: GENERAL AGGREGATE A___ PRo• 2,000,000 X POLICY I JCCT t—_, LOC PRODUCTS•COMP/OP AGG OTHER_ COMBINED SINGLE LIMIT 1,000,0001 _AUTOMOBILE LIABILITY _ (E n accident) _ ' ANY AUTO 1020081008 4/1/2019 4/1/2020 BODILY INJURY(Per person $ _ 1 OWNED SCH1 DOLED AUTOSF ONLY X AUTQSWNEp pBOODILY INJURYp Per accident X AUTOS ONLY X AUUIgS ONLY • (Per?CCRDenl)AMAGE $ r— i C UMBRELLA LIAR 'X 07CUR EACHQQ_QQRRENCE 5 2,000,U001 — 7( EXCESS LIAR 0.AIMS•MADE EXC10006635004 4/1/2019 4/1/2020 2,000,000 ^ DES) —RETENTIONS S __ ; ID WORKERS COMPENSATION —^ PER OTH• AND EMPLOYERS'LIABILITY STATUTE _ S —____ AA:Y PROPRIETOR/PARTNER'EXECUTIVE YIN WCI00136900 6/30/2019 6/30/2020 1,000,000! gg E.L. ACCIDENT __ _ _ .'OFFICE'OandatoryFFIn CER/MEMBER EXCLUDED? NIA 1,000,000I E.L.DISEASE•EA EMPLOYEE$_____—_—_.___ e under DESCRIPTIONO ^— 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $ I I // I • --- --- — DESCRIPTION OF OPERATIONSI LOCATI9NS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) „CERTIFICATEID DER E ATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE. 1 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For Information On y ACCORDANCE WITH THE POLICY PROVISIONS, AAUTHORD1-IZED REPRESENTATIVE �I • • ACORD 25(2016103) 1 ©1988.2015 ACORD CORPORATION. All rights reserved. DocuSign Envelope ID:87E62233-OEDA-4266-9B48-4D5121C19F51 Permit Authorization mass sae Form Sa;mga riue.ugt+tnergy t"ciencv Site ID; 3901300 Customer: William Murray William Murray ,owner of the property located at; lower'§kplui,13,144 69 Ice House Road South Yarmouth, MA 02664 (Prep@rty rOt Addrti (City) hereby authorize the Mass gave Home Energy ierviges Program assigned Participating Contractor listed below W act on my behalf and obtain a building permit to perform insulation and/or weatheri;:ation work on my property: DefioNn# Ayi Owner's 1 natu►fs 11/3/2019 1 11:38 AM EST Data: FOR OFFICE UU ONLY We have assigned the following Maas Save Home Energy Services Participating Contractor to the above referenced project; ( 1- -3 - I Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: Page 1 of 1 For Ica Use Only Rev. 102015