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HomeMy WebLinkAboutBld-20-001218 • Permit# Ou _HAmount HA;: C C S[ _,l °4° Permit expires 180 days from 7,, r d issue date i1 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH armuutii Building Department r CE ! VE 1146 Route 28 t South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261if 3 �C� 2[11y COYSTRUCTION ADDRESS: ,CdI/, ASSESSOR'S INFORMATION: Map; Parcel: OWNER: l,/ Pe-4.,A/tdi s !/YI e 9 J� S'O f O NAME PRESENT ADDRESS TEL. # CONTRACTOR: , rJi/ 445'S./1/y `fr irtr'r4/Z�bAo ">1e /4714'Arie,jJ/� J es F�T-sf z (`f' NAME MAILING ADDRESS TEL.# B'fesidential 0 Commercial Est. Cost of Construction$ 0d,5'oU Home Improvement Contractor Lic.# /.5 ,% S G y Construction Supervisor Lic.# / (7 f .f Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor 'I have Worker's Compensation Insurance Insurance Company Name: 111g, /76 (X f'Z �je Worker's Comp.Policy# 4' / /347Qe) 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: y,1Jrne7V 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 revo'ation of my cense and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: 7/7/lie Owners Signature(or attachme Date: C� !� Approved By: —✓ Date: / .7497 Build (or esignee) Eiv ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft. of Wetlands: ❑ Yes 0 No 0 Yes 0 No RISE ENGINEERING OWNER AUTHORIZATION FORM 1, John Peona (Owner's Name) owner of the property located at: 5 Lake Road (Property Address) West Yarmouth. MA 02673 {Property Address) hereby authorize C C_Apc, 3..0S V t (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. -7 e r Owner ignature g 9 /% Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 j 508-568-1926 www.RISEengineering.com • i. c Commonwealth of Massachusetts Division of Professional Licensure Board of Building•Regulatlons and Standards Con atructitSA ISiipervlsor CS•100988 EXpires: 11/11/2019 HENRY E CASSIDy i �fr ;1',440* • 8 SHED ROW \Y1 I \`: `e WEST YARMOG71 M/�.0�6,73 Commissioner l../^"' • t..// - (. f J // .�� �� � /iT/ri(1/?((•�CCI �'� 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: 153567 • 18 REARDON CIRCLE Expiration: 12/14/2020 SO, YARMOUTH, MA 02664 Update Address and Return Card, /%. �ivr.r;,r/,r.,.r%% i/, ��nJ•i//r%//i/✓/• Ofrice of Consumer Affnlra&Buelnesa Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date, If found return to: RogIv.r.ail4!] Expiration Office of Consumer Affairs and Business Regulation 153567 12/14/2020 1000 Washington Street•Suite 710 CAPE COD INSULATION,INC '" Boston,MA 02118 HENRY E.CASSIDY t 8 REARDON CIRCLE SO.YARMOUTH,MA 02664 Undersecretary a I lth t signs ' r , a ACORO' CAPECOD-27 THORNE �.� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HO/LDER.19 THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have 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 CONTACT Good Rogers&Gray Insurance Agency,Inc. PHONE 434 Rte 134 (NC,No,Ext):(800)553-1801 I uvc,N0):(877)816-2156 South Dennis,MA 02660 ADDRESS:mail@rogersgray,com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:West American Insurance Company 44393 INSURED INSURER B:Arbella Protection Insurance Company.Inc. 41360 Cape Cod Insulation,Inc. INSURER C:Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURERD:Atlantic Charter Insurance Company South Yarmouth,MA 02664 P Y 44326 INSURER E: INSURER F: 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. INSR ADDL SUER LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMMIDD/ L IMMIDDIYYY), LIMITS A X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE $ CLAIMS-MADE X OCCUR BKW 53328281 4/1/2019 4/1/2020 DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY jERCOT- I 11 LOC PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER: B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000 00 (Ea accident) $ r 0 ANY AUTO — 1020081008 4/1/2019 4/1/2020 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY X AUUTNOSyy�Ep BODILYO INJURY�yp (Per accident) $ X AUR S ONLY X AL]TOS ONLY (PeOPERrfentl AMAGE $ C' UMBRELLA LIAB X OCCUR $ EACH OCCURRENCE $ 2,000,000 X EXCESS LIAB CLAIMS-MADE EXC10006635004 4/1/2019 4/1/2020 AGGREGATE 2,000,000 DED I I RETENTIONS $ D WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITYI PER I I ERH Y/N WCI00136900 6/30/2019 6/30/2020 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE QFFICER rynn BE l EXCLUDED? N/A E.L.EACH ACCIDENT $ en ERI NH If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below 1,000,000 E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Information Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ( .t---$4./ze-2 Zda""--""------_- ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD r}�d` i'�}44 The Commonwealth of Massachusetts ° Department of Industrial Accidents s ?t =c ^ > Office of Investigations •J. ,} 600 Washington Street rt ni T} Boston, MA 02111 4 A . . + r70 i74` www.mass.gov/dta Workers' ompensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/lndividual) 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): I.V I am a employer with 48 4, 0 1 am a general contractor and 1 6. El New construction employees(full and/or part•time).'' have hired the sub-contractors 2.❑ 1 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 b comp. insurance.: 9. ❑ Building addition [No workers 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.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MG1 12.0 Roof repairs insurance required.)t c. 152,§l(4),and we have no Weatherization employees.(No workers' 13. Other comp,insurance required.] • •Any applicant that checks box tit must also All 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, if the sub-wntracturs 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 Name: Atlantic Charter Policy rt or Self•ins. Lie.h: WC100136900 Expiration Date:06/30/2020 Job Site Address: � ��>✓� y�� /1 v�� City/State/Zip:4i 1' 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 S1,500,00 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 Inver i ations ofthe DIA for insurance covert a verification, I do hereby certify under the paths and pen a/i/es of perjury that the information provided above is true and correct: ,i in l Y7L CQQdG Date; 04, Phone k; 508-775-1214 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/Llcense t Issuing Authority(circle one): I. Board of Health 2. Building Department 3.City/Town Clerk 4, Eleeirical Inspector 5. Plumbing inspector- 6.Other Contact Person: Phone#: