HomeMy WebLinkAboutBld-20-00282 „ 1111
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{issue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yaiuiouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 3d ,//4�G1//9 Z4/
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: , i4/C ")7/4/laZ€/`r /44.e'
NAME PRESENT A.DDRESS TEL. #
CONTRACTOR::,4 Vq L 7i. " '/ /NAME l LwIL�'�I�ADDRESS(1/P y�� �U TEL. D�77`i/7
esidential 0 Commercial Est. Cost of Construction$ dal Q
Home Improvement Contractor Lie.# , 41 Construction Supervisor Lie.#
Workman's Compensation Insurance: (check one)
0 I am the homeowner C I am the sole proprietor , I have Worker's Compensation Insurance
Insurance Company Name: )9T/j,t/�G /%/f j 1 /e. Worker's Comp.Policy# .x. 'C'/f ef I c' ®'jL
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: �- ,t‘/f7,4/U
Location of Facility
I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge aid belief. I understand that any false answer(s)
will be just cause for denial or re ocation of my license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: 'r�„/ T Date: ` Z/
Owners Signature(or attac era) Date:
Approved By: / � Date: _`^ i c
Building Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: ❑ Yes 0 No Flood Plain Zone: 0 Yes ❑ No
Water Resource Protection District: Within 100 ft. of Wetlands:
0 Yes 0 No 0 Yes 0 No
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OEM EINNIMMII,
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•.."-7/ Commonwealth of Massachusetts
N Division of Professional Licensure
Board of Building Regulation& and Standards
Constr f lli1 0),s,visor
C: CS-100988 � pires: 11/11/2021
HENRY E CA SIDY"/ 1 1 iROM8 SHED ROM ` :' r�t�
WEST YARMOUTH M•'` ,y 3`. ? ;
i 4 a 7
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Commissioner 4 /
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Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Typo: Corporation •
CAPE COD INS LATION, INC Registration: 16.3567
18 REARDON CIRCLE Expiration: 12/14/2020
SO,YARMOUTH, MA 02864
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,� ; 1pnn•pGit7 Update Address and Return Card,
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22, /r.,/,,w,nvu/// iyr, /7./iJJ//evi//•ii//J
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 EXplratlon Office of Consumer Affairs and Business Regulation
163667 12/14/2020 1000 Washington Street•Sufte 710 .
CAPE COD INSULATION,INC • Boston,MA 02118
l �
HENRY E.CASSIDY \�.
18 REARDON CIRCLE
SO.YARMOUTH,MA 02884 Undersecretary • a Ith t sign r
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The Commonwealth of Massachusetts
' Department of Industrial Accidents
Office of Investigations
i `s 600 Washington Street
Boston, MA 02111
www.mass.gov/dla
orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
' Annlicant Information Please Print Letibly
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Name (Business►Organtzatiun/Individual): Cape Cod Insulation Inc.
Address: 18 Reardon Circle _ -
City/State/Zip: South Yarmouth, MA 02664 Phone #: 508-775-1214
Are you un employer?Check the appropriate box: Type of project(required):
I.�— 'I am a employer with 48 4, ❑ I am a general contractor and I
"�' +r have hired the subcontractors 6. ❑ New construction
employees(full and/or part-time).
3.❑ 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 tY 9, ❑ Building addition
(No workers' comp, insurance comp, insurance,
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.0 i 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,❑ Roof repairs
insurance required.]t c, 152,§I(4),and we have no Weatherization
employees, [No workers' 13. Other
comp. insurance required.)
'Any upplicnnt that checks box NI must also nu out the section below showing their workers'compensation policy int nnatinn,
1 Flomeowners 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 un additional sheet showing the name of the sub-contractors and state whether or not those entities havo
employees. lithe sub-contractors have employees,they must provide their workers'comp.policy number.
., 1 am an employer that is providing workers'compensation Insurance for my employees, Below is the policy and Job site
information.
, Insurance Company Ntune; Atlantic Charter
Policy tl or Self-ins,Lic.#:,WC100136900 Expiration Date;06/30/2020
Job Site Address: 'JJ t/4i2t"//J/ LA/ ( l ,e if (2j�t City/State/Zip: Ap 6/--1 7
Attach a copy of the workers' compensation po icy deciaration'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 S 1,500,00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
ut'up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
,Inves,tiyations of*DIA fir insurance coverage verification. _ _, __, _ _ ,
. /do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Sign n 5: ri767eack- Date /Z/f/if
bone Li, 508-775-1214
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Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority.(circle one):
1. Board,pf Health 2, Building Department 3,City/Town Clerk 4,Electrical Inspector 5. Plumbing Inspector-
6. Other
I Phone#:
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CAPEECOD•27 ____—____T±IQ NF.
CERTIFICATE OF LIABILITY INSURANCE DA TE(NI WOW?Y Y Y)
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CATE IS IS'UED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS I
E DOES NO AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES I
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
//, SENTATIVEE OR PRODUCER,AND THE CERTIFICATE HOLDER.�/ORTANT; If the certificate holder Is an ADDITIONAL INSURED, the policy(Ios)must have ADDITIONAL INSURED provisions or ho endorsed. j
j(f SUB'ROGATION IS WAIVED, subject to the terms end conditions of the policy,certain policies may require en endorsement. A statement on
this•certl(Icate does not co Tfor rieta to the certificate holder In lieu of such endorsement(s),—
',locum
Miff Good --- ^-- —
,owrs& Gray Insurance Agency, Inc, HONE ______,-'-'-i
34 Rtv 134 A/C No Ezt; 800) t)63.1801 I Iac,No);(8%7L'i6.216G
•ouch Dennis,MA 02610 Ss;malleroderscciray,com _
IN$VRERL$)AFEOROINO COVERAGE _, Nit!c.t-„ _-
_.__ •� INSURER AIWest Alrierlcen Insurance Company 44393___.__.
vsunED . . RE a1Arbell.Protoction Insurpnco Company, lilt, 413G0_______
Cape Cod insula Ion, Inc, •Endurance American Specialty Insurance Company 41718
18 Reardon Circle IN •A Char Insurance Company 14326,
South Yarmouth,MA 02664 p Y
INSURER E I
_-__ - INSURER P I
;OVERAGE;S CrriTIFICATE NUMBER.: REVISION NUMBER: __
THIS IS 1'0 CERTIFY THAT `HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NO1WI'1HSTANGING 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 NAVE BEEN REDUCED BY PAID CLAIMS.
SR TYPE OF INSURANCE AWL S,l)eR PO ICY EP- PO ICY EXP --�
TP -- .I OD VD POLICY NUMBER
u„►►h Atr, �[yW1 LIMITS ALGENERAI.LIABILITY
EACH OCctiRRENOE - --
A X' COMMr:RCI 1,0_01)__00, 0
_
cu.,. j.FE OCCUR E3KW 53328261 41112019 4/1/2020 DAMAO_�TORENTEO - 1UU,000I
PRFFAI E�oscuuoU .._�_.._ 1-_—.. ..
_C0 4-€XP(Any one poraonl__. $ ____ 1 t),Uoo
-- P19(Jflb nay INJURY a 1,000,0UOI
_fNY AGGREGATE LIMIT AP? IIJ S PER: r 2,000,000
X POUCY Li yei It LOC RRO• GENEF(AL•AGGftFGAl� _r._.- -.---.---._,
"
PROOk TS•COMP/Op AGO 2,000,0O0I
_ OTHERS
_^�-- - --- - -
3^ AUTOMOBILE LIABILITY COFABINEDSINGLE LIMIT1,000,UOOI
1020061008 (ka�st2enl) --
OWNED p 4/1/2019 4/112U20
AUTOt`S ONLY X AUUoTTNOOpSWULNEEpo 80pILY INJURY(Per•peraon)- cam.,— ^„
X AUTOS ONu' X AUl'OS ONLY ' aRRRopgr IYODILY UUAMAGERY(Per nccldenl $ ,— -I
- — -Nor aC};Idenll .�,___.._
' '- uMORELLA LIAO X OCCUR ��- —' I --•---•.----...____ i
'X ExcESsl.lAo C.AIMS•MADF EXG1000G636004 4/1/2019 4/1/2020• EA VRRENCr; 2,000,U00
DEO_ _RETENTIONS AOGRggyvra 2,UOU,000
)�WORKERS COMPENSATION - - - — _— •AND EMPLOYERS'LIABILITY •Srk••_ IIIQTH•
ANY PR TN OPRIETOR/PARER.'E•XECIITIVE Y WCf00136900 6/30/2019 6/30/2020 6 _ ----_---
OFFICER/MEMBER EXCLUDED? N/A
I(MandaloryInNH) k.L.Pi(` A (DENT I,000,0001
yyas.duscribo under u El.pISF.ASE•SA GMI rrEC 1,000,UOO
OF.SCRIPTION OF OPERATIONS bozo', ¢- --..._.._ ...__:
--;'"— E.L.ols�A�E•POLICY LIMIT < 1,000,OUO'
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SCRIPTION OF OPERATIONS/LOOATIONs/VEHICLES (ACORO 1o1,Additional Romarke Sohodulo,may by ottaohod If mono apace it roqulrod) _ -'-• - -I
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RISEN
ENGINEERING
OWNER AUTHORIZATION FORM
1, Anne Mingolelli
(Owner's Name)
owner of the property located at:
31 Harding Lane
(Property Address)
West Yarmouth, MA 02673
(Property Address)
hereby authorize CC_ Co c -5,CNS oOc-VA
(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.
Owner's Signature
/1 /1/ i9
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926
www.RlSEengineering.com