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HomeMy WebLinkAboutbld-20-001275 (2) rvl � ..._._..____...�,.____ ._._._�_. _ � A �0 RECEIVED ! 4Of11oe Uso Only C IParmRIN t I, �`06:Mop' �, ' SEP — 6 2019 3 1�a.nsount ( S ��kµ 'A { 9 t I1..._.... .._m .__ I NO e cplras 180 days from eui _ nlssuodate EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department a-� 1146 Route 28 ZD South Yarmouth, MA 02664a (508) 398.2231 Ext, 1261 CONSTPVCT1ON ADDRF551' o/D/(/� /r1i>c/ id c� per , / ? ,I,,,�,IIM IIIII ., ASS! SO1t'S INFORMATION' IMap; I Parooll owNSRt / � o/ 0.c 2/4— .3 ? s".�ng , RB At SS LI if CONTRACTOR' Henry Cassidy Cape Cod Insulation II Rrardon Clrcte 3ovth Yermovih 508.775. 1214 O T TEL Rasldanlial 0 Commerolal eat. Coal of Construotion$ .o 4.9 m v Home improvement Contracto, blo,H 153567 100988 ,o Consiruollon Supervisor Llo, if Workmen's Cumpensalloninsuranoei (oheok one) 0 I am Iho hornaowrdr% t1 1 am the solo proprietor 0 1 havo Workor's CompansatIon turn lnsuranoaCompanyNamo' Atlantic Charter Insurance' , WCE004319 Worker s Cvmpl PoIIoyN �i .., WORT{TO BE PERFORMMu '''Tent Duration Duration (Fire Retardant Certificate attached?) . Wood Stovv ,'"SldIngt a ofSquaros S,;,Rvplaoomant windows' # Re placement doors' H Roofing' ii of Squares ( ) Remove existIn 13 (max, 2 layers). Insulation Old Kings Highway/Historic Dist, ( )'Replaaing llko for like Pool fencing ►Tile dobrh wlll'bQ dltposad of olt 1, Location of Foci Ity 1 Jwulary undorparialUes of porJut 1 till st n s haroln ontotnad aro true tutJ oorroo1 to Iho hot of my knowlcdgo and belief, I understand that any false Answor(s will bo Just QIWI for dental or r s o and for prosoovtlon nodal*M C LI Oh,2681 5aotton I, ' pMIV^M,IIAq`I'I1III��11'1 �ew111MA�y� ApplloAnl s 5lgnahrrot SS 6III;Deli iiiii 1�w'"AIPAII,,, li DAtel fs L' Owners Signature(or Allathmeo1) —'"�"' ---- ,Dntorr Approved 9yi /� 9ullding:.•A a. y s gnao TG� 1 DAM ' -7-''� .. nvww NW I, Zoning DIslriolr Hlstorlot,l Dlstriotl CI YcA t',) No Flood Plain Zono► 7 Yes to 'No .. • Walol'Rosouroe Protcolion CIstrloll Within 100 ft, of Wettandsl % 1. 11) Yes CI No J Yos Cl No ,, RISE ENGINEERING" OWNER AUTHORIZATION FORM 1, Elizabeth Holmes (Owner's Name) owner of the property located at: 107 Witchwood Road (Property Address) South Yarmouth, MA 02664 (Property Address) r�T 1,44smiktu-, hereby authorize fPQ W S✓ (Su cbritractor) 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. Vsitila/6-#A na D ' Vat 00 ( C5-T)RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com 4G Commonwealth of Massachusetts Division of Professional Licensure Board of Building•RegulatIons and Standards Constructtd,r1'Supervisor CS-100988 t`i E:Ajoires: 11/11/2019 • (,yti }„a�ty+ •• HENRY E CASSIDY' 1te s • 8 SHED ROW ; ri WEST YARMOGi M�' 0�,•8,70J,If1 • • Commissioner C/^"" l2 r J /2 t1(1 ( /( Office 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 Update Address and Return Card• zoM.os;, //7, ,/ /ic/ /4 Office of Consumer Mein&Business ReVUlaUon HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date, If found return to: Rogit J,12/3 Expiration Office of Consumer Affairs and Business Regulation 153567 12/14/2020 1000 Washington Street•Sulte 710 CAPE COD INSULATION,INC Boston,MA 02118 r / HENRY E.CASSIDY R GG �_� • 18 REARDON CIRCLE C� SO.YARMOUTH,MA 02664 Undersecretary a I Ith t signs r i ACORO' CAPECOD-27 THORNE `.._ CERTIFICATE OF LIABILITY INSURANCE DATE 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. 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 Ileu of such endorsement(s). PRODUCER CONTACT Good Rogers&Gray Insurance Agency,Inc. PHONE 434 Rte 134 (A/c,�N`o,Ext):(800)553-1801 1 iaC,No):(877)816-2156 South Dennis,MA 02660 ADDRESS: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 ADDL SUBR LTR TYPE OF INSURANCE INSD WVD POUCY NUMBER POLICY EFF POUCY EXP POLICY IMMIDD/YYYY) LIMITS A X COMMERCIAL GENERAL UABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR BKW 53328281 4/1/2019 4M/2020 DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 15,000 - PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGRE E LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY II J 1c LOC 2,000,000 PRODUCTS-COMP/OP AGG $ OTHER: B $ AUTOMOBILE LIABILITY Es aaBIINdED SINGLE LIMIT ent) $ 1,000,000 ANY AUTO 1020081008 4/1/2019 4/1/2020 BODILY INJURY(Per person) $ OWNED ONLY X SCHEDULEDpyyNE X AUTOS ONLY X AUOTOS ONLY BODILY INJURY(Per accident) $ PROPERTY 4AMAGE {Per accident $ $ C UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,000,000 X EXCESS LIAR CLAIMS-MADE EXC10006635004 4/1/2019 4/1/2020 AGGREGATE $ 2,000,000 DED RETENTION$ $ D WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STATUTE OTH- ER O Y/N WCI00136900 6/30/2019 6/30/2020 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 FFICEEEMBER EXCLUDED? N/A 1,000,000 (Mandatory In E.L.DISEASE-EA EMPLOYEE $ 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 REPREENTATIVE I 2_i 7/Y ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All lights reserved. The ACORD name and logo are registered marks of ACORD v I. Y �f>t� � }, The Commonwealth of Massachusetts r t Department of Industrial Accidents 4' Office of Investigations F - , a F.., yr ,,sY ,- ', /,=t 600 Washington Street ' t'- ads :. Boston, MA 02111 t 4! ' � �h tor. r•Y i :-.1 a„±-,r 'y,,, y t t=s� t';i'; www.mass.gov/dla Workers' ompensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information Please Print Legibly Ntune (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): 1.VI am a employer with 48 4. ❑ I am a general contractor and t 6. ❑ New construction employees(full and/or pan-time),' have hired the sub-contractors 2.❑ I ant 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.❑ Electrical repairs or additions officers have exercised their I I. Plumbing repairs or additions ;.❑ 1 am a homeowner doing all workP myself. [No workers' comp. right of exemption per MGL 12.❑ 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 W I must also fill out the section below showing their workers'compensation policy information. 'Hamxxawners 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 an additional sheet showing the name oldie sub-contractors and state whether ur not those entities have cmptoyces, 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 M_ Policy It or Self•ins. Lic.#; WCI00136900 Expiration Date;06/30/2020 .Job Site Address;/0? Id/7-#VQ®d /✓)1�, tty/state/Zip: 0/ z? 1i L Attach a copyof the workers' compensation policy da:frration'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 lint up to$1,500.00 and/or one-year imprisorunent,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 of the.DIA for insurance covens a verification. — /do hereby certify under the pains and penalties of perjury that the information provided abdvt%is true and correct. $it;naturl; 1 r e441- Date: ?it,7/ 9 — Phonc tt; 508-775-1214 _ .7n ,, ,.®,.. �� Official use only. Do not write in this area,to be completed by city or town ofclat 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#: