Loading...
HomeMy WebLinkAboutBld-20-003180 • tt1 v L V J V // -9 (O,( I' — ]Amount ATTA Cscc.1 c51,y°°,d,.:w"°6., Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICAT" TOWN OF YARMOUTH KECEIVED Yarmouth Building Department 1146 Route 28 DEC 0 3 201 South Yarmouth, MA 02664 Oa/ (508)398-2231 Ext. 1261 BUILDING DEPART j BY: • CONSTRUCTION ADDRESS: ' to ,�C1 s �ci7/ gyp/ G�, /Zr,�t ASSESSOR'S INFORMATION: Map: /6 �/ Parcel: key 5,9— OWNER:,i,/%D i f D :c'ei/� ✓`/e/Pt e 2-e) 3.�Z 8 �f G NAi PRESENT ADDRESS TEL. # CONTRACTOR:4 P ei7j /4/S!>�/97-7eVAi 7/elere Cw. //P /, 1iJi771.t �J U c'2 12NMEMAILING D TEL.# Residential 0 Commercial Est. Cost of Construction$ 4,2 /i e2a, ®e' Home Improvement Contractor Lic.# /���1. 7 Construction Supervisor Lic.# 1 A Q r d' e 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: )9I /i1,(f7IC C 4/Z7 5 Worker's Comp.Policy# 4)C`/c9 C'/3(y f Q CS 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: l� l ) U Location of Facility a• 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(3) will be just cause for denial or revocation of my license d for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: ! Date: // Z Owners Signature(or attachme - . Date: Approved By: 'dv Date: /2 — 77 Building Off (or ignee EMAIL SS: 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 n of Professlonal Ucensure I • Boa rdDlv of Biouilding Re ula(lons and Standards Gonst`0.8. 1,[gtypp,rvisor • C: CS-160988' Aires 1111112021 HENRY E C'A�`SID icy{ "i t �•`1YtiI, 8 SHED RO ,� \y l r ` WEST YAftMOj1TH 3; rI ;, 3l wS9.t is f.!` • Commissioner 4)44-' 4'� Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement• Contractor Registration ^ ^ Type; Corporation CAPE COD INSULATION,tNC Registration; 7 18 REARDON CIRCLE Expiration; 12/14/2020 SO,YARMOUTH, MA 02884 rr • ,.,,,; rei,4eSi,Y Update Address and Return Ccrd ./i, /ri„riiiyurrn/// h//VdgiYi/ni///J Office of ConwmorAU,&Business RegutaUon HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE!Corporation before the expiration dale, If found return toi RQglatration xplr,atlon Office of Consumer Affairs and Business Ro- ulation 183887 12/14/2020 1000 Waehlnpton Street•Suite 710 , CAPE COO INSULATION,INC Boston,MA 02118 / r HENRY E,CASSIDY 18 REARDON CIRCLE a SO,YARMOUTH,MA 02884 I Inrleroenrnlnn, Ith t Alnna vim/ ' I i• The Contnronwealt/r 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 Aonlicant Information Please Print Leeibly Name tBusiness/Organizatiunflndividual): 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): 1.VI am a employer with 48 4. 0 I am a general contractor and I 6. ❑ 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. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in capacity. employees and have workers' any p tY 9. ❑ Building addition [No workers' comp, insurance comp. insurance.1 required.] S. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers' comp. right of exemption per Mat. l2.❑ Roof repairs insurance required.]t c. 152,§1(4),and we have no • Weatherization employees.[No workers' 13. Other comp. insurance required.] 'Any applicant that checks box NI must also nit 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 convectors must submit a new affidavit indicating such. :C'1,ntratton than check this box must attached an additional sheet showing the name al'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 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 ti or Self-ins.Lie.h:SVC 00136900 {,� Expiration Date:06/30/2020 Job Site Address: I// j7 L�f,35 r,-M///7 i/21) d City/State/Zip: 4 e5 2 /f/4 j Attach a copy of the workers' compensation policy declaration'page(showing the policy number and expiration date). I:ailure 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 Investi,ations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: 7r t' -7 ec244;4 - ._ Date: /// ?// f _ Phone t+: 508-775-1214 -- ---. r 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 �,. �onf Pa►��nt Phone 4: I .. A - CERTIFICATECAPECOD-27 THORNE OF LIABILITY INSURANCE DATE(MM/DD YYYY) 7/16/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 1 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(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 NONkACT Good Rogers&Gray Insurance Agency,Inc, .PHONE 434 Rte 134 (AIC,No,Ext):(800)553-1801 FAX South Dennis,MA 02660 EMq IL (No,No):(877)816-2156 At)DRESS:mail_ rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# ___i 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 INSURER D:Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 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 (MM/DDfYYYY) IMM/DD//YEYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS-MADE X I OCCUR BKWEACH OCCURRENCE $ 1,000,000 53328281 4/1/2019 4/1/2020 PREMISES(?Es occurrence) $ 100,000 MED EXP(Any one person) $ 15,000 PERSONAL ADV INJURY $ 1,000,000 & GEN'L AGGREGATE LIMIT AP LI SPER: 2,000,000 X POLICY f JE� II LOC GENERAL AGGREGATE $ PRODUCTS $ . 2,000,000 OTHER: B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1$ ANY AUTO 000,000 1020081008 (Ea accident) $ OWNS D ONLY X SCHEDULED 4/1/2019 4/1/2020 BODILY INJURY(Per person) $ AUTOS X HIRED NON•oy� D BODILY INJURY(Per accident) $ AUTOS ONLY X AUTOS O Y ' (Per acci PROPERdentTY?AMAGE $ C UMBRELLA LIAR X OCCUR $ X EXCESS LIAB CLAIMS-MADE EXC10006635004 - EACH OCCURRENCE $ 2,000,000 4/1/2019 4/1/2020 AGGREGATE _.$ 2,000,000 r DED I I RETENTIONS D WORKERS COMPENSATION II g AND EMPLOYERS'LIABILITY 1 STATUTE I I EORH• • AOOFNY FICER/MEIMBOEER/EXCLUOED�ECUTIVE Y/N NIA WC100136900 6/30/2019 6/30/2020 1,000,000 (Mandatory In NH) E.L.EACH ACCIDENT $ I yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000 IDESCRIPTION OF OPERATIONS below 1 000,000 E.L.DISEASE•POLICY LIMIT $ i .. 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 ACORD 25(2016/03) , � ©1988-2015 ACORD CORPORATION. All rights reserved. The DocuSign Envelope ID:CBAOA2C8-056D-4FAD-A932-159BOFE9CD1C • Permit Authorization mass Save@ Form ,,a, e'mruugh a e r v Site ID: 3884480 Customer: Thomas ONeil I� Thomas O'Neil ,owner of the property located at: (Owner's Name,printed) 66 Debs Hill Road Yarmouthport, MA 02675 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. ,—DocuSiyned by: Owner's Signature: o1 ,41,4 Ps? ,1 '-206DCae4E5FE49 0... Date: 11/4/2019 I 2:18 PM EST FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Cam— CcD eL l i // '-Z--12) fJ Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: Page 1 of 1 For Office Use Only Rev.102015