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HomeMy WebLinkAboutBld-20-001310 (2) JPennit# Tr* Amount 435 HATThCn CSf �1, >IPermit expires 180 days from B ` 2�15�T issue date EXPRESS BUILDING PERMIT APPLICATI Wt V TOWN OF YARMOUTH _„____.,_.__..._ (armoUfn Building.Department ,l JE F 201 1146 Route 28 South Yau south MA 02664 (508)398-2231 Ext. 1261 .. �;.� 11 CONSTRUCTION ADDRESS: la7, /��YC46_l ASSESSOR'S INFORMATION: Map: Parcel: Ghri4 i e' 7 OWNER:g v!f7 (MMMLf ��l//tlAlco/zf jab` ' •G / 9. 77 NAME PRESENT-ADDRESS TEL. CONTRACTOR:I/eV/L1/ rl-�ld� `� 2�`/��C'�'� 61ri� �/y,9r ©!l j�y J��b F S 2 / ' NAME MAILING ADDRESS TEL.# ri sidential 0 Commercial Est. Cost of Construction$ lje:2 l/� Home -Improvement Contractor Lie.# /62 4J✓lv p 7 Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor se"fhave Worker's Compensation Insurance Insurance Company Name: iA1/9G �rj��� Worker's Comp.Policy# Li7(/ / ,3 G 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 r/ • Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: ye i 6 elf/!L Pj11/j rs 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 he just cause for denial or revocation of my licens d for prosecution under M.G.L.Ch.263,Section 1. Applicant's Signature: Date: , 9//9 G Owners Signature(or attachment) Date: Approved By: Date: Building Offic r gnee) EMAIL AD S: Zoning District: Historical District: 0 Yes U No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft. of Wetlands: 0 Yes 0 No 0 Yes ❑ No RISE8 Dupont Avenue I South Yarmouth,MA 02664 1508-568-1926 ENGINEERING" www.RlSEengineering.com OWNER AUTHORIZATION FORM 1, e \'I\ 1`- \el 1 Jrauclot (Owner's Name) owner of the property located at: kBL ee Wra.\ . p) a �3 (Property Address) (Property Address) hereby authorize e Cod Tn( ACb.).'i" v (Subcontra or) 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 close out this permit by contacting their municipality at the completion of this work. OAAA•cceeie:[ Owners Signature — 361- 19 Date 6.2016 E l -•v t Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constrr<tCtirf Ittipervlsor • CS-100988 ' EXpires: 11/11/2019 t ` + HENRY E CASSIDY ;. . 8 SHED ROW- • WEST YARMOGT)f 1J1/� 8,73 ;., 4:• 'r'1«.;Lt��11� w Commissioner L ( _;11/1?/i?(?/I(l'E'(1 • (I- Office IrJ{3I/ 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 .; tii 20M.05:1` Update Address and Return Card. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 153587 12/14/2020 1000 Washington Street-Suite 710 CAPE COD INSULATION,INC Boston,MA 02118 HENRY E.CASSIDY \,Q, , 18 REARDON CIRCLE (� SQ.YARMOUTH,MA 02664 Undersecretary a lth t sign r ,/ t / . . ;.��.""'l • CAPECOD•27 AMAHLE ;C:›Rer CERTIFICATE OF LIABILITY INSURANCE DATEIM1DD/YYYY) 1 ..::►*"..' 06/05/2018 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(los)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 NONIACT 20gors&Gray Insurance Agency,Inc. PHONE FAX 134 Rte 134 (A/C,No,Eel): IA/0,No);(877) 816-2156 "South Dennis,MA 02660 ,813Niss:mall@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC q INSURER A:West AmerICan Insurance Company 44393 INSURED INSURER 8;Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER C Endurance American Specialty Insurance Company 41718 18 Reardon Circle INsuRERD;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. -N-SR TYPE OF INSURANCEgp SAD POLICY EFF POLICY EXP POLICY NUMBER IMMIDD/YYYYI IMM/DONYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000; CLAIMS•MADE l X J OCCUR BKW(19) 63328281 04/01/2018 04/01/2019 DAMAGE TOS.JEasRENT aacol _�$ED 100,0001 PR MLSssur MED EXP(Any one person) $ 5,000''' PERSONAL 8 ADV INJURY $ 1,000,00V GE IL AGGR ATE LIMIT APPLIES PER: „ GENERAL AGGREGATE j$ .2,000,0001 X POLICY 1 1 JECT LOG ^ PRODUCTS.COMP/OP AGO $ 2,000,0001 i x OTHER'.see holder deecrlp of operations $ . B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT1 _(EL.astistsm! $ 1,000,0001 ANY AUTO _ SCHEDULED 6232707 04/01/2018 04/01/2019 I BODILY INJURY(Per person) $ OWNED ONLY X AUTOS DULED ' EE U pWNEp BODILYBpR INJURYp (Per accident) $ _ ' X A�RTOS ONLY X AUTOS ONLY F�oOPE deM)AMAG£ $ C. • UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 X EXCESS LIAR CLAIMS•MADE EXC10006635003 04/01/2018 04/01/2019 AGGREGATE $ 2,000,000 • -a j DED RETENTION$ D WORKERS COMPENSATION . AND EMPLOYERS'LIABILITY WCE00431903PER I EE YI 06/30/2018 0613012019 H. ANY PROPRIETOR/PARTNER/EXECUTIVE $ 1,000,0001 OFFICER/MEMBER EXCLUDED? N I A E.L.EACH ACCIDENT _ (Aandatory n J 1,000,0001 II yes,describe under E.L.DISEASE•EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L,DISEASE•POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may bo attached II more space Is required) —1 Porkers Compensation Includes Officers or Proprietors, 1 additional Insured status Is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. Excess Liability Is follow form, • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED-REPRESENTATIVE /C--..4. I I The Commonwealth of Massachusetts - _ Department of Industrial Accidents - Office of Investigations -- _ 600 Washington Street Boston,MA 02111 www.mass.gov/dia —nor ers' 'ompensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information Please Print Legibly 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: lam a annul contractor and 1 Type of project(required): VI am a employer with 48 4. 0 g employees(full and/or part•time). have hired the sub-contractors 6. 0 New construction 2,❑ I 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. 0 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 employees.(No workers' 13.V Other Weatherization comp.insurance required.] 'Any applicant that checks box#I must also till 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. ;Connectors 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, lithe sub-contractors have employees,they must provide their workers'comp.policy number. l 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#or Self-ins.Lic.#; WCI00136900 Expiration Date:06/30/2020 a Job Site Address:- /�i4�'�egg �/ , iiLJA_ City/State/Zip: siQ t 292_G''3 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 hives i'ations of the DIA for ins : ce covera_e v_eri t ation. l do hereby certify under the pains and penalties of perjury that the information provided aboveis true and correct Signature: 447 •a414 4 Date; r bo/ 9f i( — Phone tr: 508-775-1214 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 Contact Person: Phone#: