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HomeMy WebLinkAboutBld-20-003179 V' S v p • II'�g . ,H Amount ATTACH LS[ *' ......co 9 E d Permit expires 130 days from issue date EXPRESS BUILDING PERMIT APPLICAT C E I V E D TOWN OF YARMOUTH r"arruouth Building Department DEC 03 2Q19 1146 Route 28 - BUII'ING DEPARTMENT South Yarmouth, MA 02664 By (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS:/Jo ,9T / 'v—A/4ts P /ed ASSESSOR'S INFORMATION: Map: 1 Parcel: /625- OWNER: 2.9is,/x., Czb d_a f6 Ij �d NAME PRESENT ADDRESS TE . CONTRACTOR:4:7P C;(-1 At/S/>/r-ievAl AP'� �A.0 C/,e � 14)- L1t'T. �l U S'27J`% 2 NAME MAILING D / TEL.# Residential 0 Commercial Est. Cost of Construction S (5-0Z ) O Home Improvement Contractor Lic.# / .j��_� 7 Construction Supervisor Lic.# 1 ,9 Q 2 ' 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: M-114A/ C � /a/z7/� Worker's Comp.Policy# 0/3 L ! Q 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:_ yg j/yfd jj? 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 re cation of lice se and for prosecution under M.G.L.Ch.268,Section 1. I/ Applicant's Signature: ,./i/ Date: /l/ Z'// Owners Signature(or attac,. ent) Date: Approved By: Date: Building 0 (or signe EMAIL ADDRES • 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 • • Commonwealth of Massachusetts Division of Professional Licensure i1k^171 Board of Building Regulations and Standards Consv llti§t5'p 5visor /I, C; CS•100988• pires 11/11/2021 HENRY E C'AOSIDYt ��'. 8 SHED ROM `,t t ' 'tff' WEST YARMOj1THAf 3; ls'`t '1_ Commissioner 4,/u V�` 1 • • • • • Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor RegIstratlon Type; Corporation CAPE COO INSULATION,tNC Registration; 16.3687 18 REARDON CIRCLE Expiration; 12/14/2020 S0,YARMOUTH, MA 02884 !! Update Address and Return Card. �� err /rirriirivatv/////i V, //,(maivaivi//J Oftico of ConiumorAtfaln d Business Regutauon HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration.date, If found return tot Reglatratloq gxplratlon ONtoa of Consumer Affairs and Business Regulation 163667 12114/2p2e 1000 Waehlnpton Street•Sufte 710 , , CAPE COO INSULATION,INC °^ Boston,MA 02118 / r HENRY E.CASSIDY \Q �� ., 18 REARDON CIRCLE SO.YARMOUTH MA 02684 Ilnr{orocnr�,�.r s Ith t alMna / r • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dla ' Wor ers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Letibly 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: Type of project(required): I.VI am a employer with 48 4. [] I am a general contractor and I 6. El New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ l am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling . ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in capacity. employees and have workers' any p h 9, ❑ Building addition [No workers' comp. insurance comp. insurance.1 required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 1❑ 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 MG1. l2.❑ Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13. Other Weatherization comp.insurance required.] 'Any applicant that checks box ill must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all wort:and then hire outside contractors must submit a new affidavit indicating such. ;C'untrucuxs that check this box must attached an additional sheet showing the name ol'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. A I am an employer that Is providing workers'compensation Insurance for my employees, Below Is the policy and Job site inforirwtion. • Insurance Company Name: Atlantic Charter Policy 0or Self-ins.Lie.#:;WC 100136900 Expiration Date:06/30/2020 Job Site Address:/ 7, 1, 1ID71ZoP /Z611 City/State/Zip y 4 ar4. _Ofd ©Zo ' Attach a copy of the workers' compensation policy declaration'page(showing the policy number 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 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 lnvesti gations of the D1A for insurance coverage verification. t do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Date: /�y�t; Vil I — Si Ana c: 4�� -..-'. Phone u: 508-775-1214 „_Y— _r Official use only. Do not write in this area,to be completed by city or town ofyi'cial. City or Town: Permit/License ti Issuing Authority(circle one): 1. Board of Health 2. Building Department 3,City/Town Clerk 4,Electrical Inspector 5. Plumbing Inspector 6.Other . Phone 4: f•....r.Int Porcnnt AC - CAPECOD-27 THORNE �. c CERTIFICATE OF LIABILITY INSURANCE DATE(MMI°DYYYY) 7/16/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.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. I IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)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 papal. Good Rogers&Gray Insurance Agency,Inc. PHONE 434 Rte 134 .(NC,No,Ext):(800)553-1801 I FAX South Dennis,MA 0266E M mail (ac,Na):(877)816 2156 �oD ss: @rogersgray.com INSURER(S1 AFFORDING COVERAGE NAIC#_ INSURER A:West American Insurance Company 44393 INSURED INSURER B;Attalla Protection Insurance Company, Inc. 4136E Cape Cod Insulation,Inc. 18 Reardon Circle INSURER C;Endurance American Specialty Insurance Company 41718 South Yarmouth,MA 02664 INSURER D:Atlantic Charter Insurance Company 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. WSR ADDLSUBR lTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP L,IIOD ) ( MD 0 LIMITS A X I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,EE0,E00 CLAIMS-MADE I X I OCCUR BKW 53328281 4/1/2019 4/1/2020 DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 15,000 rir PERSONAL&ADV INJURY $ 1,000,00E 1 GEN'L AGGRE A E LIMIT APP.I S PER: 2,000,00E I X POLICY Tee II LOC GENERAL AGGREGATE $ B PRODUCTS-COMP/OP AGG $ . 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO 1020081008 (Ea accident) $ OW ANYX 1 SCHEDULEDAuTOS 4/1/2019 4/1/2020 BODILY INJURY(Per person) $ X HIRED X NON O n BODILY INJURY(Per accident) $ AUTOS ONLY f AUTOS ONJt PROPERTY DAMAGE I I I (Per accident $ C I UMBRELLA LIAR iX OCCUR $ EXCESS LIAB I CLAIMS-MADE EXC10006635004 4/1/2019 4/1/2020 EACH OCCURRENCE $ 2,000,000 DED (_RETENTION$ �' AGGREGATE $ 2,000,000 D WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY 1 PER 1 1OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE6/30/2020 I STATUTE FR Y/N WC100136900 6/30/2019 1,000,000 OFFICER/MEMBER EXCLUDED? N/AE.L.EACH ACCIDENT $(Mandatory In NH) f yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000 IDESCRIPTION OF OPERATIONS below 1,000,00E E.L.DISEASE-POLICY LIMIT $ / DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is requlred) 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 • '' -=,-".4.,...e2 Zel---------____ ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORr . RISE gz--- ENGINEERING' OWNER AUTHORIZATION FORM I, Frank Carder (Owner's Name) owner of the property located at: 106 Captain Lothrop Road (Property Address) South Yarmouth, MA 02664 (Property Address) hereby authorize C -e \ Icd c VJ (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. 4,17i Owner's Signature _�J (" Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com