HomeMy WebLinkAboutBld-20-002663 (2) : 0PermitN
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ji issue date J
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508)398-2231 Ext. 1261 J
CONSTRUCTION ADDRESS: 1-9G f f/,c/.f ���t 'e�/ /�Y✓
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER:<K4 fr i47>'hJ4,12.4 -S, 1/// - 4-41-,f 2 D`7-- '
NAME PRESENT ADDRESS TEL, #
CONTRACTOR:f. j i" 4..;71/4/.S/-4,7 'iU41 Agerigr�,e, Cie f//�1 Uv ��c'2 7 2
NAME MAILING TEL.#
,Residential 0 Commercial Est. Cost of Construction$ �®Q, b
Home Improvement Contractor Lie. # /`.3� /,i 7 Construction Supervisor Lic, # /I ,9 e.2 r � r
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor edI have Worker's Compensation Insurance
Insurance Company Name: 1,9-77 'A/ e 61y�/yJ/� Worker's Comp,Policy# 4 G—`/D 0/3 L. 9 Q
WORK TO BE PERFORMED .
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
' iding: # 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: )0141,0161 °J Jar ,
Location of Facility
di-
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 m license and for prosecution under M.G.L.Ch.263,Section 1. it i
Applicant's Signature: / / //G,�
Date: //�/
Owners Signature or nttachme ) . . Date: �,�+
Approved By: "� Date: /,' 7' 7 /
Building Oftii ' or gnee) EMAIL AD S:
Zoning District:
i 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 `'d'
1
tt
Irk Permit Authorization
mass saw Form
rn43 through energy ethnency
Site ID: 3914469 Customer: Tika Khatiwada
`n / A—
,owner of the property located at:
(Owner's Name,printed)
496 Higgins Crowell Road West Yarmouth, MA 02673
(Property Street Address) ( Y)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain a building permit to perform insulation and/or weatherization
work on my property.
Owner's Signature:
Date: l o / 3 a/2,o/'l
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Gek Lo CO 7
Participating Contractor Date
Name: RISE Engineering
Phone: 401-784-3700
Email:
Page 1 of 1 For Office Use Only
Rev.102015
Commonwealth of Massachusetts
1 • 1� Division of Professional Licensure
Board of Building Regulations and Standards
ConstFut'tt bOrvisor
<C CS-100988 �r spires: 11/11/2021.
HENRY E CAOSIDY � 1
8 SHED RO „,1 111,,
WEST YARM03,JTHm i 3~ •
•
Commissioner
•
(1 �..i(ViT%l"%".(1//ll tG2c7
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
- " Type: Corporation
CAPE COD INSl3LATION, INC Registration: 153587
18 REARDON CIRCLE Expiration: 12/14/2020
, • SO,YARMOUTH, MA 02664
A ,��; zoM•os>+; Update Address and Return Card,
Office of ConsumorAffalre&Business Regulation
• HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:Corporation before the expiration date. If found return to:
Registration g,xplutloq Office of Consumer Affairs and Business Regulation
153667 12/14/2020 1000 Washington Street•Sutte 710 .
CAPE COD INSULATION,INC Boston,MA 02118
HENRY E.CASSIDY \QG ,
•
18 REARDON CIRCLE
SO.YARMOUTH,MA 02684 Undersecretary a Ith t sign r
The Commonwealth of Massachusetts
Department of Industrial Accidents
{ Office of Investigations
/ - 600 Washington Street
Boston, MA 02111
www,mass.gov/dia
or ers' ompensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers
Analicant Information Please Print Legibly
Name (9usiness/OrganizatioWtndividual); 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:
. I am a general contractor and 1 Type of project(required): .
I.VI am a employer w4
with 48 0 b
employees(full and/or part-time),* have hired the sub-contractors 6. Q New construction
2.❑ l am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity, employees and have workers'
9, ❑ Building addition
(No workers' comp, insurance comp. insurance.; 10.0Electrical repairs required.) 5. 0 We are a corporation and its p irs 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 MGI.. 12.0 Roof repairs
insurance required.]t c. 152,§l(4),and we have no
employees. (No workers' 13. Other Weatherization
comp.insurance required.]
•Any applicant that checks box WI must also fill out the section below showing their workers'compensation policy tnl'ornustion,
i 'Homeowners 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 of the sub-contractors and state whether or not those entities have
employees. It'the pub-wntracwrs have employees,they must provide their workers'comp.policy number.
/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 . —
Policy:tor Self-ins,Lic,tit'WC 100136900 2/ Expiration Dace;06/30/2020 _„
�'
Job Site Address: � r/� � � �l�
�� � , to/� City/State/Zip; _� ��6`s/--
Attach a copy of the workers' compensation policy declaration'page(showing the policy dumber and expiration date).
Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a
litre 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 therviolator. Be advised that a copy of this statement may be forwarded to the Office of
loves i ations of the 1IA fir in _ c covern_e veri t ation.
I do hereby certify underu the pains and penalties of perjury that the information provided abovti is true and correct
s_1gugLum 1 r Dater I ✓/ if Phone 4:4; 508-775.1214 _ ,
'' Official use only, Do not write in this area,to be completed by city or town official
City or Town: Permit/License t'i
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.CitylTown Clerk 4.Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person; Phone It:
vensormililialiliNtiMMULas.4.
r
CAPECOD•27 __�____JL14RN .
CERTIFICATE OF LIABILITY INSURANCE DATE(Mh9f00/YYY'/)
• � 7/16/2019 _
CATS IS IS UED A9 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 PR DUCER,AND THE CERTIFICATE HOLDER,
7'd iPORTAN'R If the certificate holder Is an ADDITIONAL INSURED,the pollcy(los)must have ADDITIONAL INSURED provisions or ho endorsed.
SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
,( this•cetliflcate does not co ifer rldlits to the certificate holder In lieu of such endorsement(s). —^, I
PRODUCER CTACT Good —
ON
iRogers&Gray Insurance Agency,Inc. . HONE
I°AX ---
n34 Rico 134 A/c No Exl; 800)563.1801 I(A/c,Ne),(877.)y6.2156
South Dennis,MA 02660 Miss;mailt�rogers,lray.com _
INSURRRLS)AFFORDING COVERAGE _._NAi_c u____',
�..—._.. INsuRERA;West American Insurance Company 44303____
I INSURED . " 1 aeae;Arbella Protection Insurance Company,Inc, 41360___-.___�
Cape Cod Insole Ion,Inc, R C.Endurance American Specialty Insurance Company A1718 _,__.___
18 Roardon CIrc13 IN RD;Atlantic Chartor Insurance Company 4 4326.
South Yarmouth,MA 02664
INSURER F. --•-- ^---
INSURER F; i
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
I 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.
uvSR ApOI SUER POLICY EPF POLICY EXP !
TYPE OF INSURANCE INSD WVO POLICY NUMBER ,,,, r Ia as I IMM/DOIYYWI LIMITS _____
i 'A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE T 1'000'0001
CLAIMS•MADE I OCCUR BKW 53328281 4/1/2019 4/1/2020 DAMAGE TO RENTED 100,0001 •
PRFpAI .(E�O.�C5lrrenc0 Si_
— --- Jt ED EXP(Any one person) $ ______ 1 1i,000
— ! s9ah1&ADV INJURY 1,000,OOOI
G€N'LAGGREGAT LIMIT AP, LJ$PER:" GENERALAGGa5GATg x—.T E2,000,OOO1
X POLICY I I j� LOC PRODQCTS•COMP/OP AGO fib OTH[R_ F —
LIMIT1, 0,UOO
(FR aCCItha i) ;t_
. ANY AUTO 1020081008 4/1/2019 4/1/2020 BODILY INJURY(Per(preen)
OWNEDSCHEDULED
_ AUTOSF( ONLY v AUTOS BODILY pBODILY IN pRY Per ccidenl $
�-X AUTOS ONLY X AVl'C S ONIY ' l(PorOac R�enl)AFAAGE --1
C • UMBRELLA LIAR X OCCUR — {
^ • EACH p URRENCE S 2,000,0001
7( EXLESSLIAO j CAIMS•MADE EXC10005635004 4/1/2019 4/1/2020 2,000,0001
• ;-- AGGREQATE __ _____ __ _
DeD RETENTIONS
,-'DWORKD ERSG COMPENSATION
P NIAFTI•IN Y S�E ■_•TH $
-- _....___
ANYPROPRIETOR/PARTNER/EXECITIVE WC100136900 6/30/2019 6/30/2020 T'I,000,000
' . OFFICER/MEMBER EXCLUDED? NIA E.L.PELCH ACCIDENT
I(Mandatory IS H) -1,000,000.
II yyes,describe under E.L.(DISEASE•EA EMPLOYEE.1
^;OF.SCRIPTIONoroPERATIONSbeoty � E.L.DISEASE•PQLICYlIAl1'r _____ 1,000,OUO'
•
/•
/I i
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Romsrka Schedule,may bo eHachod If mote apace Ic required) ^� —
•
C,ERTIM ET . 1 o,gCANCELLATION —.--.—.__—_.-
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
•For Information On y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESENTATIVE �I
---- -t_- •- 7 .-._..._._..