The URL can be used to link to this page

Home My WebLink AboutBld-20-002452 V t • jermit# .w y,/E`. H Amount v-� ATTA M ese �s 4,0.....to"'" .d �,� E� Permit expires 130 days from issue date b Lid.- Z -Zy s-a EXPRESS BUILDING PERMIT APPLICIWCFIVFDI TOWN OF YARMOUTH Yarmouth Building Department D � 2 1(�1' 1146 Route 28 t South Yarmouth, MA 02664 -- -.� r, , 508 398-2231 Ext. 1261 suEt � - 1 CONSTRUCTION ADDRESS: fS--- 262 e*-44.g 72,/ ASSESSOR'S INFORMATION: Map: Parcel: OWNER:ER: , j//.c/ 4�,e/97 ._ 4/7 tP 7P,'e'Z 4 d—c- NAME / PRESENT ADDRESS TEL. # CONTRACTOR:OPP e29-4,/,/,,t/.5z.lgy'/694l zP'JZ� f�,r� Cl/e. � gied0 74 j 2� 1 2 7 2 NAME MAILING ADD / TEL.# litResidential 0 Commercial Est. Cost of Construction$ / '4 L., 67, D Home Improvement Contractor Lie.# 4.4—".",..r.‘ 7 Construction Supervisor Lic.# /z Q f 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: Mi/I1A/ e 6.--44/4 /C Worker's Comp.Policy# Ai CR/‘... 0/3 L 9 d e) 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 J Old Kings Highway/Historic Dist. ( )Replacing like for like Pool,fencing • *The debris will be disposed of at: 74,0/4/G2 ' e:i , Location of Facility C. 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 revo)tion of my lice e an• 'r prosecution under M.G.L.Ch.268,Section 1. / Applicant's Signature: 6 „i Date: /U Z 41// Owners Signature(or attachm' Date: Approved By: Gar Date: /�—V ---/9 Building 0 al esinee) EMAIL 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 t Commonwealth of Massachusetts / 11 ® Division of Professional Licensure 1, Board of Building Regulations and Standards Consrut ��visor C5 CS-100988 i{acpires: 11/11I2021 HENRY E CA SIDY , *l 8 SHED RO � WEST YARMCjJTH^ 'l 3 ' Commissioner Aiu. -- 7...%1/>7/17<'/?(pe(e67/ 9 ,.l/ (l;Jc%CGr! /rie/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: 15358y • 18 REARDON CIRCLE Expiration: 12/14/2020 SO.YARMOUTH, MA 02664 CA 1,0 zon+o:,i+; Update Address and Return Card, Office of Consumer Main&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Re9lsgatlon Expiration Office of Consumer Affairs and Business Regulation 163687 12/14/2020 1000 Washington Street•Suite 710 CAPE COD INSULATION,INC ' % Boston,MA 02118 l � HENRY E. Y 18 REARDON DN CIRCLE SO.YARMOUTH,MA 02884 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/dia or' ers' otnpensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Y.,etrib1v Name(Business/Organization/Individual): Cape Cod Insulation Inc. Address: 18 Reardon Circle City/State/Zip; South Yarmouth, MA 026k Phone#; 508-775-1214 Are you an employer?Check the appropriate box: 1 am a general contractor and 1 Type of project(required): • 4, 1.VI am a employer with 48 ❑ employees(full and/or part•time).' have hired the sub-contractors 6, ❑ New construction 2,❑ 1 am 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' [No workers' comp, insurance comp.insurance.: 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 insurance required.]: a 152,§l(4),and we have no employees,(No workers' 13.�Other Weatherization comp.insurance required.] •Aip applicant that checks box M I must also fill out the section below showing their workers'compensation policy infornua►ton, Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. • ;Convectors that check this box must attached an additional sheet showing the name(lI'the sub-contractors and state whether or not those entities have employees. If the sub-contractors hays employees,they must provide their workers'comp,policy number. /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 t/or Self-Ins,Lic,#:;,WC100136900 Expiration Date:06/30/2020 "Job Site Address:/ 20 2 ,1 /Z.. L City/State/Zip: /924 7 3 Attach a copy of the workers' compensation policy eclaration'page(showing the policy dumber and expiration date), failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a tine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250,00 a day against therviolator. Be advised that a copy of this statement may be forwarded to the Office of hives i ationsofthe *IA for in c cove le veri t i•n, I do hereby certify under the pains and penalties of perjury that the information provided above is true/ and correct 1 Signature: /7��'1444t Date , �j 2 fp Phone#: 508-775-1214 Official use only. Do not write in this area,to be completed by city or town Ocia1 City or Town: Permit/License Issuing Authority(circle one): I. Board of Health 2. Building Department 3.Cityrrowo Clerk 4,Electrical Inspector 5. Plumbing Inspector. 6.Other Contact Person: Phone#: CAPECOD•27 ________TI-IQFINE.. CERTIFICATE OF LIABILITY IN. SURANCE DATE lMMrO 7/1 i,p _) 1 // RTIFIcATE AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS IRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED� CER,AND THE CERTIFICATE HOLDER, /i ORTANT: If the certificate holder Is an ADDITIONAL INSUREi0,the pollcy(Ios)must have ADDITIONAL INSURED provisions or be endorsed. i SUO'ROGATION IS WAIJED, subJect to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this cel'flflcate does not co Ifor rlets to the certificate holder In lieu of such endorsement(s), PRODUCF.R _ TAC'E Good — C Rogers 8,Gray insurance AgEncy,Inc, . HONE "-- "'G 434 Rte 134 A/c No Ext: 800 553.1801 Fax ,South Dennis,MA 02660 bbJ,maII@rogersc)ray,Com (wc,Na);(877La16.215 INSURRRLS1 AFFORDING COVERAGE __NAIC(I____-!, _—._ INsuRERAIWest American Insurance Company 44393____._.. INSURED RE elArbella Protection Insuranco Qompanyjlnc, 41360__ _.-___1 Cape Cod insula'Ion, Inc. .Endurance American Specialty Insurance Company 41718 I 18 Reardon CIrc13 IN gnc;Atiantic Chartor Insurance Company ,14326. South Yarmouth,MA 02664 1 S RE F.: --'-- __-- - INSURER F: _ `1 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: j THIS IS TO CERTIFY THAT -HE 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. u.SR AWL SUBR ._m_ TYPE OF INSURANC f INS° WVO POLICY NUMBER POLICY j Via) PO yyl LIMITS___ __ A X COMMERCIAL GENERAL Lff,eILITY 1 EACH OCCURRENCE 1,000,OOU1 `)CLAIMS•MADE i]OCCUR E3KW 53328281 4/1/2019 4/1/2020 DAMAGE Tp RENTED 100,0001 • PRFMI�ESIE;�QCCSlfrenc0 �`- -._____—.. _. • — -- _MEP EXP(Any one person) $ ____ 1:i,000 —-- PE W AL F.ADY INJURY 1,000,000I G€N'LAGGRE, ATF.'LIMITAPI PER:P GEMEFIALAGGREGAlg—!—_ _2,000,0001 j X 1 POLICY[ I Ter. [ LOC " OTHER; PRODIZCTS•COMP/OR AGO 2,000,0O0 i-T3 AUTOMOBILE LIABILITY _(F COa ea9ld.MBINEO0np �._SINGLELIMIT 1,000,0001 ANY AUTO 1020081008 4/1/2019 4/1/2020 BODILY INJURY{Per.person)— • ^_ OWNED F-``S ONLY X AUOTNOOSWULNEEOp BODILY IN RY Per — - -I. i _X AVTOS ONLY X AUl'C 5 ONLY • pPp_PROPER'Y DAMAGE cordon' $ ,- _--- r(Nor acLi�enl) _L__— C � UMBRELLA LIAa 1 X OUCUR' _ _._.�.-"_— �-- i EAQcg £ QRRENCE 2,000,U00 — —----, 00!1 'X EX4ES51.IAB J CAIMS•MADf. EXC10006636004 4/1/2019 411/2020 2,000,0001 AGGREQATF. —_ _...: ' Du L_ RETENTIONS $0 WORKERS COMPENSATION Ulnae R eTH• •� •AND EMPLOYERS'LIARILI'rY n WCI00136900 6/30/2019 6/30/2020se III PROPRIETORIPARTNER!EXECUTIVE 'I,000,OUO OFFICER/MEMBER EXCLUDED? NIA E.L.EACH ACCIDENT _ (Mandatory In NI • II — 1 00U V_UU! II yfes,doscribo under E.L.DISEASE•EA EMPLe'(EE•_�___-_— DF.SCRIPTIONOF OPERATIONS b<.yv ---• ^� E.L.DISE A�E•POI.IC`lLIh11' < 1,000,000' // DESCRIPTION OF OPERATIONS/LOCATI)NS/VEHICLES (ACORO 101,Additional Romarks Srhodulo,may bo SIaohod If more space Is required) • • 1. .CERTIFICATEIDLOER. L ATION ---____--- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ;• For Information On y THE WITH THE POLICY PROVISIONS, WILL BE DELIvr:Rr:n IN • AUTHORIZED REPRF..5FNTATIVB• —~� -L-- • 7/-erd-,-;- r 41164' Forst i l'. . ,,---71:--,:leff:'_:',':;-,,-.,:L - A �_l�i1. +IrfwM1 w hereby_ err to +�bl sumo' +Ii1MMil ram, _hater Wien IFfiellfa gnitor CrAvasell le--4:161: i gal t p 0, +. i :::,._';.:;:';',„1,- #� a` 1 M ^►�k 4�B mN N#a w f+i fs'1 4M MR JIF t N `# i�p o.."1A �M#FM R �A i tiF M #�i ii lk k -- ems ishoostitegOilloS kkoltimPlillise !�r' 'r� ,',.,,.__5::,,l, 4111'1""''"' 1s ' ' :. w � - -f % ,-am `' � hi-- r