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Home My WebLink AboutBld-20-002660 • '- �� JPermitN - ~ II C � r p -y -,Amount MATTA m .6 Lr ' �c31,”t°11111t0'',° Permit expires l30 days from s • >issue date J (-4-20-2(PO EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: /7/ fihito 67e 44/ ASSESSOR'S INFORMATION: Map: Parcel: OWNER: /7JL14,t�1>A', Z�Pm j4SN /,�m e DT 27G3 6 NAM RESENT ADDRESS /� TEL # CONTRACTOR:re � //�t/5f>/jn?-,Y''/�� A�Pligr A, ( ie (�/�l do71G �1-�27%1 2 NAME MAILING ADD / TEL.# Residential 0 Commercial Est. Cost of Construction$ 345' U U Home Improvement Contractor Lie.# A/S,-T.-. . 7 Construction Supervisor Lie. t / ,9 Q f rs' Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 'I have Worker's Compensation Insurance Insurance Company Name: H-714A/7IC 6.--4,q/4 i Worker's Comp,Policy# Ai C'/�0/3 Z. 9(3 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 ✓ 0 Old Kings Highway/Historic Dist, ( )Replacing like for like Pool fencing *The debris will be disposed of at: 747,0,741c,27 ‘J'J , 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 rev ation of my and for prosecution under M.G.L.Ch,268,Section 1. r/i Applicant's Signature: Date: ///17/1 Owners Signatur (or nttachm t) _ Date: Approved By: Date: Building Official(or lane EMAIL ADD S: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No' Water Resource Protection District: Within 100 ft. of Wetlands: . 0 Yes 0 No 0 Yes 0 No i` v ® Commonwealth of Massachusetts Board DivisionofBuildi of Professionaltions Licensureand ng Regula Standards Const\rutt tA4jarvisor f C.1 CS-100988 spires: 11/11/2021 HENRY E COSIDYa - t , 8 SHED ROM �`� WEST YARMQ}JTH' _1 t' 3 • 1 . Commissioner Aju.41 4. 6: //T/l%(%J(l'eCCC�,/( 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; 153587 18 REARDON CIRCLE Expiration: 12/14/2020 SO,YARMOUTH, MA 02664 CA,;t, zo�,.J,;;,; Update Address and Return Card, /h /rrnrnry.rrvn/// r�, /,rivJrirYirrir//J Office of Consumer Affairs 6 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: }teylstratlon Expiration Office of Consumer Affairs and Business Regulation 153587 12/14/2020 1000 Washington Street•Suite 710 . CAPE COD INSULAT)ON,INC • % Boston,MA 02118 HENRY E.CASSIDY 18 REARDON CIRCLE SO.YARMOUTH,MA 02804 Undersecretary a Ith t sign r • Tire Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations • 600 Washington Street Boston, MA 02111 www,mass.gov/dla or ers' ompensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers Applicant information Please Print Leltibiv Ntune (Business/OrganizatiuMndivlduai); Cape Cod insulation Inc. Addt'oss: 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): I.V1 4, i am a gencrai contractor and 1 am a employer with 48 + 0 have hired the sub-contractors 6, ❑ New construction employees(full ll and/or part•tlme), 2,❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7, ❑ Remodeling ship and have no employees These sub-contractors have 8, ❑ Demolition working for me in any capacity, employees and have workers' 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,§l(4),and we have no empldyees, [No workers' 13. (Other Weatherization comp,instuartce required.] *Any applicant that checks box NI must also till out the section below showing their workers'compensation pot Icy information, 'Homeowners who submit this affidavit Indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. ;C'untrectors 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. 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 she Information. Insurance Company Name: Atlantic Charter Policy ti or Self-ins,Lic.#;,WCI00136900 Expiration Date:06/30/2020 'Job Site Address; /7I Al/v e ��i;/Z / i' j �le9l./ ry-1state/Zip: I n d z G workers' com compensation policy declaration A e(showingthe policynumber and expiration Attach a copy of thepe p y p E P date). Failure to secure coverage as required under Section 25A of MGL c. 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 therviolator. Be advised that a copy of this statement may be forwarded to the Office of Inves i ations ofthe DIA fir in c cov eri ati. , I do hereby cenlfy under the pains and penalties of perjury that the information provided above is true and correct Eenaturg; 14/6 Ly a:a:cGe:C t� Date: //��✓9 _ • Phone 4; 508-775-1214 / - Ofj7cTal use only, Do not write in thY 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.CitylTown Clerk 4,Electrical Inspector 5. Plumbing Inspector' 6.Other • Contact Person: Phone#: CAPEC00.27 _________71--p NE. CERTIFICATE OF LIABILITY INSURANCE OATE(MMIDD/YYYYI I CATE IS IS UED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS E DOES NO AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ///ff' THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED �•. SENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, %d iPORTAN'I•: If the certificate holder Is an ADDITIONAL INSUREED, the policy(los)must have ADDITIONAL INSURED provisions or bo endorsed. SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require en endorsement. A statement on ,( this'Cartl(Ica(e does not co ifer Mete to the certificate holder In Ileu of such endorsement(s),� :_ --- -- PRODUCER C AC'f Good Rogers&Gray Insurance AgEncy,Inc, HONE PAX 034 Rlo 134 A/c No EXt: 800)663.1801 I I. N,NO):(877) 816.2156 South Dennis,MA 02680 iffiliss,mallerogersgray,com _ ` INSURER(.S1 AFFORDING COVERAGE _NAIcjj_.___, �.._._. INSURER AIWest American Insurance Company 44393___.,.._. INSURED RE a,Arbeila Protection Insurpnco Company, Inc, 41360 .., _ Cape Cod Insula ion, Inc, c:Endurance American Specialty Insurance Company 41718 16 Reardon Circle IN ERD:Atlantic Chartor Insurance Company____--aA326.....- . .. South Yarmouth,MA 02664 S R F. ---- ---- INSURER F: COVERAGES CERTIFICATE NUMBER—_ REVISION NUMBER: THIS IS TO CERTIFY THAT HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANCING 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, uNSR TYPE OF INSURANCE ADDL.SUER POLICY EP PO ICY EXP ^' ! INSD WVD POUCYNUMSER „„tray AA 1 IMMIDDNYYYI LIMITS __ ___ • A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE — — 1,000,000 CLAIMS•MADE I J OCCUR E3KW 53328281 4/1/2019 4/112020 DAMAGE 7�RENTEO 1OO,000 PRFfAI EflQGCYrrence _ ____..__•_ ,_ • - - -- jAED EXP(Any one person) $ 1 5,000 — PEt QN.At,4,ADM(INJURY 1,000,0001 GgN'LAGGRE F.'LIROTn?(�U SPER: GEMEFIALAGGREGAT'g +,_,_--2,000_000 X 1 POLICY I JGCT l= LOC " PRODtLTS•COMP/OP AGO 2,000,000j OTHER: H AUTOMOBILE LIABILITY— COMBINED—! -— SINGLE LIMIT 1,000,000 _(Ea..aECEQene _ 1.• • ANY AUTO 1020081008 4/1/2019 4/1/2020 BODILY INJURY(Per.person) __ _ 1. OWNED ONLY X SCHEDULED EDULED'AIM ONLY � .ApWNED BS ODILY N DRY Per accident $ _ _ _I X AVTFO�S ONLY X AUTOS ONIY ' (No�accRd'enl)AMAGE ---_ - 1 C - UMBRELLA DAB X OCCUR _ EA^ 7�)t�RRENCF• i 2,000,U00I 7( EX(ESS I.IAB C.AIMS•MADE EXC10006636004 4/1/2019 4/1/2020 —,_ -0,0 -i nGGREsn'rE 2,000,OOOI _ 0E0__ RETENTIONS __ O •WORKERS COMPENSATION T T PER_ OTH• ~ • AND EMPLOYERS'LIABILITY SE ■ ANY PROPRIETOR/PARTNER!EXECUTIVE Y WC100136900 6/30/2019 6/30/2020 �FFICER/MEMBEREXCLUDED? NIA E.L._En(' A IOENT - I,000,OQO i((Mandatory In NH) —.._1,000,000t I II yyes•describe under B.L.OJSF.ASE•EA EMPLO`fEE,�_ 'DF..SCRIPTIONOFOPERATIONSboon, � E.L.OISEA�E•POI.ICYLIMIT 1,000,000� /I DESCRIPTION OF OPERATIONS I LOCATI)NS I VEHICLES (ACORO 1a1,Addltlonol Romarka Sciwdulo,may be attached If more apace Is roqulrod) - '• • CERT „IFICATE iQJ.DER � CANCELLATION ------__.-- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Information On y THE EXPIRATION DATE THEREOF, NOTICE WILL SE DELIVP_Rrn IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE f�/�//`�',w- RISE ENGINEERING' OWNER AUTHORIZATION FORM 1, Drummond Chapman (Owner's Name) owner of the property located at: 171 Blue Rock Road (Property Address) South Yarmouth, MA 02664 (Property Address) hereby authorize G c 1----NCN. 50\ d'" (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 36 /2 I f' Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com