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HomeMy WebLinkAboutBld-20-001311 (2) �tl7 jj =I Permit# • (Q� y Amount W `� ` MATT;.. n CSC B—`+ ^ �3 J 1 ,.' �,"`°••a• �•"' d G D— t:�Permit expires 180 days from {issue date EXPRESS BUILDING PERMIT APPLICATIQN, F. TOWN OF YARMOUTH c r I ' E D x arinout i Building Department 1146 Route 28 JP ;a019 South Yarmouth, MA 02664 i (508) 398-2231 Ext. 1261 � -- CONSTRUCTION ADDRESS: 7/ ( �1 e' Poe ASSESSOR'S INFORMATION: Map: Parcel: 0WNi ER: _0X ggp/(/ �i9/?�LL 5m e f/3 5Yd SJz l7 Z NAB PRESENTADDRESS TEL. CONTRACTOR: /WIV/./A7TI'A/ /f/ I(-i�bf, yd/ /b../�e,rot_ NAME MAILING ADDRESS / TEL.# ern.esidential ❑Commercial Est. Cost of Construction S 7c2 d' d p e> Home Improvement Contractor Lic.# /.-3„C.-4 7 Construction Supervisor Lic.# / 2 2 9 P if Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor Cthave Worker's Compensation Insurance Insurance Company Name: 4�,q,v7-6 ,4j '7 'e Worker's Comp.Policy# vz/, �4 9 0 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 Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: �,Q/2 o 1J/sL �JJ(Jk/7 t� 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- ion of my lie use.e.d for prosecution under M.G.L.Ch.263,Section I. Applicant's Signature: Date: 57 Owners Signature(or attach nt) Date: Approved By: Date: Building Offi or ,,nee) EMAIL ADDRE : Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft. of Wetlands: 0 Yes 0 No 0 Yes 0 No • DocuSign Envelope ID:5211654D-0C44-46CA-B40D-F25936855728 RISE5 Dupont Avenue I South Yarmouth,MA 02664 1508-568-1926 ENGINEERING www.RlSEengineering.com Efficient,E;si OWNER AUTHORIZATION FORM Kevin Hamel I, (Owner's Name) owner of the property located at: (Property Address) (Property Address) hereby authorize C1i�.� �Sv '127V (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. The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's responsibility to dose out this permit by contacting their municipality at the completion of this work. - by: kwiA. Auld, CwrtfrStiWffire 9/1/2019 I 2:48 PM EDT Date 6.2016 44 c Commonwealth of Massactiusetts Division of Professional Licensure Board of Building•Regulatlons and Standards Constr{tctt d'Supervisor CS•100988 Utz E;X,pires; 11/11/2019 t� Y HENRY E CASSIDY try�t' 8 SHED ROW% \yi f°f�J' • WEST YARMO&1 H MkO 675 aat Commissioner /•�G.�_ Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type; Corporation CAPE COD INS ATION, INC Registration; 153567 18 REARDON CIRCLE Expiration: 12/14/2020 SO.YARMOUTH, MA 02664 Update Addrosa and Return Card, 2OM•J5;1 ..%,'%• /ivnn,iv,m,,i%% Ofticu of ConsumnrAffalre&6uslnes3 Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: Ro91:I4t12/1 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 Q G�0 a_^, • 16 REARDON CIRCLE SO YARMOUTH,MA 02664 undersecretary a i Ith t signs r r i AC�- CAPECOD-27 THORNE 4111.....--"- CERTIFICATE OF LIABILITY INSURANCE DATE(MNUDD/YYYY) 7/16/ 9 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. 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 Good Rogers&Gray Insurance Agency,Inc. PHOECTN E 434 Rte 134 (A/C,No,Ext):(800)553-1801 I FAX No):(877)816-2156 South Dennis,MA 02660 ib"Dilkss: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 INSURER a: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 POUCY NUMBER IMM/DDIYYYY) IMM/DD/YYYY) UMITS 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'LAGGRE�$TEjEERRCCpO IMITAPPLIESLPECR: GENERAL AGGREGATE $ 2,000,000 X POLICY II II PTT �I �I O 2,000,000 PRODUCTS-COMP/OP AGG $ OTHER: $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 _(Ea accident) $ ANY AUTO 1020081008 4/1/2019 4/1/2020 BODILY INJURY(Per person) $ SCHEDULED AUTOS ONLY XAO pN y(�Ep BODILY INJURY(Per accident) $ X AU ONLY X AIR OyNLY PROPERTY pAMAGE (Per accident, $ $ C UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 X EXCESS[JAB CLAIMS-MADE EXC10006635004 4/1/2019 4/1/2020 AGGREGATE y 2,000,000 DED RETENTIONS D WORKERS COMPENSATION $ PER AND EMPLOYERS'LIABILITY S ATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WCI00136900 6/30/2019 6/30/2020 1,000,000 OEFICEILMEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ ( ands o in 1,000,000 If yes,describe under E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more apace 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 I �, ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD t ti?>`�z;" j.h;,•] The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street � `p =< ; 1 lll./1 o� Bo t n 02111 \ S www.mass.gov/dia Workers ompensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Ntune (Businessiorganlzatiun/individual); Cape Cod Insulation Inc. Address: 18 Reardon Circle City/State/Zip: South Yarmouth, MA 02664 Phone #: 508-775-1214 Are you en employer?Check the appropriate box: Type of project(required): 1.VI am a employer with 48 4, ❑ lam a general contractor and t 6. El New construction employees(full and/or part-time)." have hired the sub-contractors 2.❑ t 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 tY 9, ❑ Building addition [No workers' comp. insurance comp. insurance.: 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 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 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 M I must also nil out the section below showing their workers'compensation policy information. Fi cowncrs who submit this affidavit Indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. • 1Contrecton the check this box must attached on additional sheet showing the nurse ot'the sub-contractors and state whether or not those entities have cmployces. If the sub-conuacu m have employees,they must provide their workers'comp.policy number. I• 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 r�or Self-ins.Lic.#:_WC100136900 Expiration Date,06/30/2020 Job Site Address:YC ,,1j d9e" yie0leU City/state/Zip: //in O G73 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 2$A of MOL e. 152 can lead to the imposition of criminal penalties of a line 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 rations of the ,16 for ins�trance c overage do hereby certify under the pains and penalties of perjury that the information provided abavt%is true and correct Signature: 74447 ea4:44 Date: 9/9//1 _ Phone k: 508-775-1214 Official use only. Do not write Tn 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.CityiTown Clerk 4. Electrical Inspector 5. Plumbing Inspector- 6.Other Contact Person: Phone#: