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HomeMy WebLinkAboutBld-20-002662 (2) t �O permit#-- Ou � H ;JJAmountN CSt�ic Permit expires ISO days from 4 r • 1 ` y�()j411(ell =issue date J EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: .9-9 /30'x-vecz fey AA- ASSESSOR'S INFORMATION: Map: Parcel: OWNER: tvpfi7/A//C Y/i'4 J./ e ✓ 41 e 4/7 P 3 OP 7" 7. ' NAME PRESENT ADDRESS TEL. # CONTRACTOR:OPp ;‘,/ /2/.542%97-7(9/(I 7PAver,C,e, �.e ��/ lfl1 rk, �J.�2 7-5 12 NAib1E MAILING TEL.# l'fResidential 0 Commercial Est. Cost of Construction$ t.0-�rfS Home Improvement Contractor Lic.# /,��i.-0.--Z 7 Construction Supervisor Lic.# /1 z9 C2 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: )g-71/9',1/ C 644//7< Worker's Comp.Policy# A.)C'/c.0/3 L' 9 Q WORK TO BE PERFORMED . ''. Tent Duration (Fire Retardant Certificate attached?) Wood Stove "Siding: # of Squares Replacement windows: # Replacement doors: I • 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: 7g,0 d Jt ‘�'J, p 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 revoc tion of my license d for prosecution under M.G.L.Ch.263,Section 1. /i ( Applicant's Signature: ! Date: //1/ ; l y Owners Signature or attachment) /..c....: Date; Approved By: Date: .//` ?.---/ Building Official(or de ' e EMAIL ADDRE 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 fit,: ? C1Ø37 DocuSign Envelope ID:01D63568-77F0-4E9A-6839-189215E5C404 RISE ENGINEERING- OWNER AUTHORIZATION FORM I, Dominic J Vitone (Owner's Name) owner of the property located at: 49 Boxberry Lane (Property Address) West Yarmouth, MA 02673 (Property Address) hereby authorize CA cA/\ (Subcontract ) 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. ooausgned by: �elailniG Watt /flfl INFFGntA4O Owner's Signature 10/11/2019 I 8:36 PM EDT Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com .011SYM®11Mino. 1 .+.�..-.....o._ t _ Commonwealth of Massachusetts .) Division of Professional Licensure Board of Building Regulations and Standards Cons rat% .Ypp.rvisor C: CS-100988 p• spires: 11/11/2021 HENRY E CASIDYt �. VI' t WESTDYARMQJJTH ``k l 3.K 1r 41 ,,;,,dam¢ �� A'� t�(1)FSti I:1LW . Commissioner e.7 (� KI-0/JT/)?(I/u(7c7%'( (t7�r l'(/�J"J•CCr!''/i!rJd/ 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 • ,a I,r, zonn•o:,n Update Address and Return Card, ../4, /'ow,/y,ri•r,r/// i�, /nJdrr.Y�rr r//J Offlce of ConsumorAffalro&Civilness Regulation • HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date, If found return to: Roglstratloi gxg rotiort Office of Consumer Affairs and Business Regulation 153587 12/14/2020 1000 Washington Street•Suite 710 CAPE COD INSULAT)ON,INC Boston,MA 02118 r HENRY E,CASSIDY rz-re t•-- • 18 REARDON CIRCLE (, SO,YARMOUTH,MA 02664 Undersecretary 4ItI9nr The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations / 600 Washington Street Boston, MA 0211! www.mass.gov/tila orkers' ompensation Insurance Affidavit: Builders/ContractorslElectricians/Plumbers Anolicant Information Please Print Legibly Name (Business/Organization/individual): Cape Cod Insulation Inc, Address: 18 Reardon Circle City/State/Zip: South Yarmouth, MA 02684 Phone#: 508-775-1214 Are you an employer? Check the appropriate box: general contractor and 1 Type of project(required): • 1.VI am a employer with4, I am a 48 ❑ 6 employees(full and/or part-time),' have hired the sub-contractors 6. ❑ New construction 2,❑ t am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These subcontractors 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, officers have exercised their❑ I am a homeowner doing all work 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 employees. [No workers' 13,0 Other Weatherization • comp.insurance required.] 'Any applicant that checks boat ill must also fill out the section below showing their workers'compensation policy information, 'Homeowners who submit this sfT davit indicating they are doing all work and then hire outside contractors must submit a new affidavit Indicating such. ;Contractors that cheek this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. tf the sub-c ntracttm 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 she Information. Insurance Company Name: Atlantic Charter Policy it or Self-ins,Lie.#:;,WC100136900 Expiration Date:06/30/2020 'Job Site Address: 4-9 8oA l?62/Z/ I f City/State/Zip: D tJ 77L ,Lid Attach a copy of the workers' compensation policy declarstloa'page(showing the policy umber 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 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 S250.00 a day against thd'violator. Be advised that a copy of this statement may be forwarded to the Office of hives i ation of the 111A fir in c coy- _e eri anon. I do hereby err*under the pains and penalties of perjury that the Information provided above is true and correct Signature: r r '1444 r- - Dater 1//9//f Phopc ti: 508-775.1214 OfflcTai use only. Do not write in this area,to be completed 6y 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 t: • . • CAPECOD•27• ________71 jOINE.- _ • CERTIFICATE OF LIABILITY INSURANCE DATE IMh1100/YYY'f) 7/16/ZU19 GATE IS IS UED A9 A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS E DOES N0 AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORI2 ED SENTATIVE OR PRDDUCEER,AND THE CERTIFICATE HOLDER. 1PORTAN'I*: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(los)must have ADDITIONAL INSURED provisions or be endorsed. f SUBROGATION IS WAIVED, subject to the terms end conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not co lfer rights to the certificate holder in lieu of such endorsemont(s),M —i PROOUCF.R CQ[tjAC'r Good — — -- Rogers&Gray Insurance AgEncy,Inc. . eHHOONeNE c No EXL; 800)663.1801 tqc,No);(8/7) II—6— 2156 434 Rto 134 _ ;South Dennis,MA 026G0 Miss,mail t©roc)ersdray,com _ _ • . IN _SURERLSI AFFORDING COVERAGE —_ ruyr _c __ INSURER_A iWest American Insurance Company 44393____. INSURED . " RE 8.Arbella Protection Insurance Company, Inc. 41360__.._____I Cape Cod Insula Ion, Inc, c Endurance American Specialty Insurance Company 41718 18 Reardon Clrcis _-- South Yarmouth,MA 02664 IN t;RD y;Atlantic Charter Insurance Company .a�326__..___.. INSURER F; —i[ _ . — Cr OVERAGES CERTIFICATE NUMBER;_ REVISION NUMBER: j THIS IS IFY ND CATER NOTIM THSTANC NG ANY REQUIREMENT,AT THE POLICIES OF TERM NCE LISTED OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RURED NAMED ABOVE ESPECR T TO WHICH POLICY PERIOD j 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, • ADDL SUER --- wSR TYPE OF IN$URANC i POLICY EP 1 IMMIDDY EXP INSD WYD POLICY ,,,,PIIII AA IYYwI _ LIMITS— —^ I A X COMMERCIAL GENERAL.LIABILITY EACH OCCURRENCE 1,000,000 CLAIMS-MADE Xl OCCUR BKW 53328281 4/1/2019 4/1/2020 OAMAO TO RENTED 100,000 • ESEPAI (E�oCcsrrrence _—____-.-__.. ... _ftED EXP(Any one porson)_ S _____ 1:i,000 — .L?SJNAL6AD' INJURY 1,000,OOO GgN'LAGGRE ATF.'UA?IT AP LE PER; GENEFtALAGGLiEGAI'E __—Y , _2,000,000I - j X POLICY( P O LOC n PRODtLCTS•COMP/OP AGO ,000,0001 _ OTHER:_ --- — �—— — --- — — AUTOMOBILELIABILITY COMBINED SINGLE LIMIT 1,00076001 _(Fa accldenl) �_ —_---.- I I.' ANY AUTO 1020081008 4/1/2019 4/1/2020 BODILY INJURY(Per person) 5 I OWNS ONLY X SCE(ULEO —------- pO AUTOS Eo BODILY NJ DRY Per ccldenl $ , ____ _ __ _X AUTOS ONLY X AUl'OS ONLY • �(PoOP ;Rr�enll AMAGE ' i_-- C- • UhteRF.LLALIAB I X OCCUR EACH Q QRRENCE S 2,000,U60 'X EXCESS LIAR J CAIMS•MADE EXC10006636004 4/1/2019 4/1/2020 2,000,000 • _ DEO__RETENTION$ _ 0 WORKERS COMPENSATION T p R •TH• • AND EMPLOYERS'LIABILITY 1 ANY PROPRIETOR/PARTNER/EXECUTIVE Y WCI.00136900 6/30/2019 6/30/2020 s E _ 'I,000,OQ01 • OFFICER/MEMBER EXCLUDED? N/A E.L._EEM A /DENT _ _ _ Olendalo In NNH IIt yes,describe under El,DISEASE•EA EMPLOYEE.A. 1,000,UOUi — DESCRIPTION OF OPERATIONS beow r E.L.DISEASE•POLIC`/LIMIT 1,000,000' a ( II DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORO 101,Additional Remarks Modulo,may bo attached If more space Is required) I • • CERT•I.E•ICATEJ Qj.DER L ATION ^— SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I For I1lformatI01T On y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, ' • AUTHORIZED REPRESENTATIVE