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Home My WebLink AboutBld-20-002659 (2) 'v `?0PermitN • C O . - • . H Amount • ct-t�"nrrA n cs[.d� `3",.. �•,00: 5i r//� s Permit expires 130 days from /„ /� =issue date EXPRESS BUILDING PERMIT APPLICATION O�N TOWN OF YARMOUTH �,, ,� � `�� Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext, 1261 CONSTRUCTION ADDRESS: ?6--- V tJ 1-/J 4' 7de Cja e/e ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 7 A A/ V 4-r1 Z o's vN e 7 /2 3 3. '' f ir NAME PRESENT ADDRESS TEL. # CONTRACTOR:aPte' 67r/,/4/.S/>19,7'/e7AI AP'2� �"." C/e 4 /4iUU A, ✓�.S27 J 2/ NAMEMAILING D / TEL.# )itResidential 0 Commercial Est. Cost of Construction$ 7D d a Home Improvement Contractor Lie.# /4_61S,..1- 7 Construction Supervisor Lie. # / 6 Q r r 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: igilgdric- c4/a/7 f Worker's Comp.Policy# GJ C740 C 1/3 L f Q 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: )CJ , 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 ' nse d for prosecution under M.G.L.Ch.268,Section 1. - Applicant's Signature: �&.i i G Date: �/e` -`ir Owners Signatu • (or attachm t //7 Date: Approved By: ""‘ Date: //'` , ��, Building Official(or sia EMAIL SS: 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 NO; RISE ENGINEERING OWNER AUTHORIZATION FORM I, JOHN DUROS (Owner's Name) owner of the property located at: 95 Driving Tee Circle (Property Address) South Yarmouth, MA 02664 (Property Address) hereby authorize Couce Ca c •Tr sv t , (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 Signatu Date RISE Engineering,a Division of Thielsch Engineering,Inc. 5 Dupont Avenue l South Yarmouth,MA 02664 508-568-1926 www.RlSEengineering.com Commonwealth of Massachusetts i1 IP Division of Professional Licensure L Board of Building Regulations and Standards Cons t,i! t/hiil isor C.' CS-100988= �� L µ aE, pires: 11/11/2021 HENRY E CA SIDY4 r e�� . 8 SHED RO 144 ,ti ^ WEST YARMCgITH M \ 'k C 3 • 104 T.10�,` Commissioner / +-0,-4---- • r).—(ww>%('%U(Leal/ (t �,,),) trim.ite//J Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation CAPE COD INSJLATION, INC Registration; 153587 • 18 REARDON CIRCLE Expiration: 12/14/2020 SO,YARMOUTH, MA 02664 A Update Address and Return Card, ,,0 2QM•O;il17 • /! /riniiuyenvri/// , /4/JJ1i6Y/iiii/114 orrice of Consumer Affairs&eusinses Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 163667 12/14/202e 1000 Washington Street•Suite 710 CAPE COD INSULATION,INC ' "" Boston,MA 02118 l � HENRY E,CASSIDY \,Q„C ., 18 REARDON CIRCLE • SO,YARMOUTH,MA 02684 Undersecretary • a ►th t Sign r • , • The 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 Annlicant Information Please Print Legibly Ntune (Business/Organizationflndividuat): 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: g Type of project(required): . I.VI am a employer with 48 4, ❑ I am a general contractor and I + have hired the sub-contractors 6. 0 New construction employees(Rill and/or ptan•tlme)•2•❑ l am a sole proprietor or partner- listed on the attached sheet. 7. ElRemodeling , ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employers and have workers' 9. El Building addition [No workers' comp,insurance comp.insurance.1 required.) 5. 0 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,§1(4),and we have no employees, (No workers' 13. Other Weatherization comp.insurance required,] -'Am applicant that checks box NI must also fill out the section below showing their workers'compensation policy information, j 'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit Indicating such, . t(nntrectors that check this box must attached an addltlortah sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-amtractum have employees,they must provide their workers'comp,policy number, I am an employer that A'providing workers'compensation insurance for my employees, Below is the policy and Job site Information. Insurance Company Name: Atlantic Charter — Policy i/or Self-ins,Llc.ti:'WC 100136900 Expiration Date:06/30/2020 Job Site Address: ?c� 7j2_I'-2, // 1 � /./iP City/State/Zip: /ZJZf� 2J7-t h-1 Attach a copy of the workers' compensation policy declaration'page(showing the polio number and expiration date),4Z 44 Failure to secure coverage as required under Section 25A of MGL e. 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 loves i ations of the elA f.r in c-coy- ern , ion. ,. . ___ __ l do hereby certify under` the pains and penalties of perjury that the information provided above is true and correct Sit nature; d 0 ea44 c am J//�i p Pho G. 508-775-1214-- l/ v -Official use only. Do not write in tI1L area,to be completed by city or town official. City or Town: Permit/License It Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4,Electrical Inspector 5. Plumbing Inspector 6.Other • Phone#: Contact Person. CAPEECOD•27• f_______71 J9.INE- • C�ERTIFICATE OF LIABILITY INSURANCE DATE IMMJDD/YYYY, 711612 .1 ) 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 THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED SENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, ORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(los)must have ADDITIONAL INSURED provisions or be endorsed. I /`f SUBROGATION IS WAIVED, subJect to the terms and conditions of the policy,certain policies may require an endorsement. A statement on r_ this•certifIcate does not Co Tfer rlc,Lhte to the certificate holder In lieu of such endorsement(s),• PRODUCER _ CQNZACr GDOd --- -1 Rogers&Gray Insurance Agency, Inc. . HONE rax n34 Rtv 134 rvc No Ext t 800) 663.1801 _ I tac,No);(877 816.2156 South Dennis,MA 02660 IMAisst _ JNSURER(SI AFFORDING COVERAGE _ _NnIC u_____ INsuaERA'West American Insurance Company 44393______ 1 INSURED . — I RERelArbelia Protection InsurAnco Company,lilt, 41360__ ..._ _ Cape Cod Insole Ion,Inc, R ,Endurance American Specialty Insurance Company 41718 18 Reardon Clrcls IN R D;Atialltic Charter Insurance Company 44326.._.-.. South Yarmouth,MA 02664 _� —..._. I SURER F.; --,— ----- INSURER P: _ _1 - Cr OVERAGES 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 I INDICATED. NOTVVITHSTANC ING 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, SR ApOI SUBR MO ICY EXP ID POLICY Ell 1 I _ TYPE OF INSURANCE INS MD POLICY NUMBER ,,,, a e IA /YYYYI _ LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,OOD,000I CLAIMS•MADE [Xi OCCUR 8KW 53328281 4/1/2019 4/1/2020 DAMAf3E TORENTEO 100,000 • PRFpAIS.ES�Es.QG.Cslrrence .`�_ __ME XP(Any one person) $ _______---1 5 000,I -- PER�9t�ALE.ADVINJURY 1,000,OUO GtN'LAGGREOATE LIMIT APPI PER:n GENERALAGGtZEGAIE^r_.T_-2,000,0001 X 1 OTHER PRO• [ LOCn' --- ---- IJECT PRODILTS•COMP/OP AGO 2,000,OOO _ OTHER_ 8 AUTOMOBILE LIABILITY — COPABINEDSINGLELIMIT 1,000,UOOI (FR accident) ;L_____.—______ ANY AUTO 1020081008 4/1/2019 4/1/2020 BODILY INJURY(Per person) AUTFOI`S ONLY X AUUqTOSSyUyLNEEDD pBOODILY INT pRY Per ccidenl $ , _ X AVT is ONLY AUt C S ONLY • _ea9Fig:RtcreY AMAGE• Tl— — I C . UMBRELLA LIAR �X OCCUR ��, _ 2 QQO,UOOI j. EAQH Q$ ..t1RRENCE $'X EXOESSLIAO C.AIMS•MADE EXC10006635004 4/1/2019 4/1/2020 AQGREQATB 2,000,000; — DEO L RETENTION$ DM WO KERSEMPL CO PENSRS' ETION TT �" S E ■9;H, --. ANY PROPRIETORJPARTNERJEXECI TIVE Y l� WC100136900 6/30/2019 6/30/2020 — �FFICERJMEMBEREXCLUDfD9 II J11 NIA E.L.�AOHACCIDENT I,000,0001 (Mandatory In NH) -- E.L. JSE.ASE•EAEMP •YEE•. 1,000,OOU II yes,descebo under S §___._—.—_.__.___...__.: ^;OF.SCRIPTIONOFOPERAJQISbG w � __ _ __ E.L.DISEASE•POI.IC`rllh?1T 1,000,000 • /I i j DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES (ACORO 101,Additional Remarks Schedule,may be attached It more space Is required) ^� . • CERT)FICATEID DER ATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE'. I THE EXPIRATION DATE THEREOF, NOTICE WILL RE DELIVIEREC) IN • For Information On y ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE I - G