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HomeMy WebLinkAboutBld-20-001278 (2) • �' � .._ ()moo tJso Only 1, ,v �� i ' ii�t � ,I I N r I 1 ` MY 6 �kA.niotlnt �,,, ,A > k_k` �r ., Parmll axpiras 180 drys ._c Y L---4- -�jrt> IV J 111laallo MO 12 EXPRESS BUILDING PERWII,,r ' APPLICATION TOWN OF YARMOUTH ' Yarmouth Building Department bcp ,2/.3 __,Qoia7V 1140 Route 28 South Yarmouth, MA 02664 (508) 398.2231 Bxt, 1261 CONSTRUCTION ADbP ;' ,? .'Ai 0'A-.di 8/`y Z�l �111111111,I,$I,I,IY„I ASSESSOR'S tNFORMATIONI IMap; Paroelt OWNER'Pea-rrI ei 'c�iii e/4/ i a 0,9 G 2 PX8$8NT ACTOR TEL, CONTRACTOR' Henry VmIdy Cepo Cod!Mutation 10 Rsardon Circle South Yarmouth 508.775. 1214 0 T si TEL 0 Commerolal Est,Cost of Construotlon$ ,,Z 3 l v A c, Homo Improvement Contraoto„ LIoI k-153567 100988 �> Cvush'uvtlon SuperYlsor Idle, b Workmn'a Cumpanatlon jnturemot ('oheok ono) 0 I am Iho homcownv"r , Ci I am the solo proprlotor 0 1 hevo Workol'Is Compensation insuranov lnsuranocCompanyNamo; Atlantic Charter Insurance' I WCE004319 , Workers Comp, polloyN WORK TO BE PERFORMED ''Tent Duration (Fire Retardant Certificate attached?) . Wood Stova 0,, � Sldingt H otSquaros 1,;,Roplavement windows! H�______. Replacement doors! W Roo(ingt #of Squares ( ) Remove existing* (MAX. 2 layers). Insulation Old Kings HlghwayfHlstorlo Dist, ( ).Replaoing Ilko for Ilko Pool fencing r ilie dobrli tivill'bQ dleposed of on U 1. Location of Fro Ity I&Atm)under peiial0er of parJut hat IIIa eta meat oroin °IMMO to.irue and oorreo►to iho bawl of my knowladgo tvld ballot I undcrstnnd that any false onswol(s will ba Just owl for denial 0 OR I to and for proaQs�ooutIon;mar MIO,LI Oh,20,Sootlon I. vl�!5���111�iryry}}t ltf�Il/11M11„ �I4WIIIIA��/ Applloanl'b Slgnahlrel IS / a IMIIIIIA 1 ill!HIMthV�1114AIIA11{11 / 7grIAAAwaI�I UII'llo•a Dat01 _l49 01YII011 SIgnnlura(or altnchmeot) Dntoi _/ „-� Cy�Approvad syl DalolBuilding .-,j/ as ao) DDRITSSI� Zoning DIstrloli Hlstorlonl Dlstrloti CI Yoa f,1 No Flood Plnln Zonal 1J Yes 0 No .. Water Rvsourvo Proteolion Distriotl Within 100 RI of Wetlands: 0 Yos CI No :J Yos C) No > ti Commonwealth of Massacliusetts /• 1 .' Division of Professional Licensors Board of Building•Regulatipns and Standards ConstwCtri Itupgrvlsor CS-100988 1, E;X,pires: 11/11/2019 HENRY E CA,-, l t. siz tv r, ,ry 8 SHED ROW A. V , `^ �tt WEST YARMOUTHH IR440 873 ' rif `.,I,W'.6` ,t _ Commissioner \�"" ..(J ,iJ '(/2?/ %lt�le'l Cllf/ < / /l.:%c.jr!W lc)('/fJ Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation CAPE COD INSIfLATION, INC Registration: 153567 • 18 REARDON CIRCLE Expiration: 12/14/2020 SO,YARMOUTH, MA 02664 Update Address and Return Card, ,„ , 2OM•or,n; //, /,./n/a/'/,/,,,iG% ,/. / ./ni.i//,:4//i//4 Office of ConsurnerAffalre 6 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: Reglsld'3I1411 Fxolratlon Office of Consumer Affairs and Business Regulation 153507 12/14/2020 1000 Washington Street-Suite 710 g CAPE COD INSULATION,INC Boston,MA 02118 , HENRY E.CASSIDY 6Q—CC. _ 18 REARDON CIRCLE SO.YARMOUTH,MA 02664 Undersecretary a 1 Ith t signs r i AC CAPECOD-27 THORNE 4.----- CERTIFICATE OF LIABILITY INSURANCE DATE D/YYYY) 7116/216/2019 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. 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 (A/C,No,EA):(800)553-1801 I(Fc,No):(877)816-2156 South Dennis,MA 02660 o' ss: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 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 TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER IMM/DDIYYYYI (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR BKW 53328281 4/1/2019 4/1/2020 PREMISES(EaEocccurrrence) $ 100,000 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREQLALE LIMITR APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECT LOG PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY CO eBBINEDSINGLE LIMIT $ 1,000,000 (Ea— ANY AUTO _ 1020081008 4/1/2019 4/1/2020 BODILY INJURY(Per person) $ AUTOS ONLY X SCHEDULED ON gyyHED BODILYO INJURY(Per accident) $ X 'ANDS ONLY X AUTOS ONLY ( er acoiR t1AMAGE $ 1) $ C UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 2,000,000 X EXCESS LIAB CLAIMS-MADE EXC10006635004 4/1/2019 4/1/2020 AGGREGATE `$ 2,000,000 DED RETENTION$ D WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY PERTUTE ERH- ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WCI00136900 8/30/2019 6/30/2020 E L.EACH ACCIDENT $ 1,000,000 QfFICERIMEMBE�EXCLUDED? N/A 1 anda o In 1IVVIHi E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below 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 I Li ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD S . } '� �•' � x;3,f The Commonwealth of Massachusetts Z _ }�� r: ra ff Department of Industrial Accidents Office of Investigations ti 600 Washington Street Boston, MA 02111 •�,`; 1M j,,';;' www.mass.gov/dla Workers' ompensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information _ Please Print Legibly N<une (Business/Organluitionf1ndividuai): Cape Cod Insulation Inc. Address: 18 Reardon Circle City/State/Zip: South Yarmouth, MA 0266'4 Phone #: 508-775-1214 Are yuu 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 employees(full and/or part-time),* have hired the sub-contractors 6, ❑ New construction 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 anycapacity. employees and have workers' p comp, insurance.t 9, ❑ Building addition [No workers' comp, insurance required,) S. ❑ 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.❑ Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL 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 NI must also fill 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 on additional sheet showing the muse ot'the sub-contractors end state whether or not those entities have employees, It'the sub-contractors have employees,they must provide their workers'comp.policy number. um 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 a or Self ins. l.ic, #; WC l00136900 Expiration Date: 06/30/2020 Job Site Address: 2 JK ec ' �uf .�7A J�m vCity7S'tate/Zip: PIM O ?�C� 3 Attach*copy of the workers' compensation policy deelfration'page(showing the policy dumber and expiration date). Failure to secure coverage as required under Section 25A of MGL a 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 Investigations ofthe DIA for insurance coyeroge verification. /do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Si na rg; - _ Date: 9/ //9 - Phone u: 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 S. Plumbing Inspector- 6. Other Contact Person: Phone#: 5 RISEN ENGINEERING' OWNER AUTHORIZATION FORM 1, Peter Osullivan (Owner's Name) owner of the property located at: 22 Sheffield Road (Property Address) West Yarmouth, MA 02673 (Property Address) hereby authorize lX 1 Y\S u (a -(-; in (Subcon ctor) 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. Owner's Signature Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com