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HomeMy WebLinkAboutBld-20-003585 (2) '. t .;•�0 jPermit# • i C O • `'-�H -;AmountN C!(11°"�E�� Permit expires ISO days from s4gir • °issue date b-av--3S,s--s 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/ ,/di/j/7I///.1 /Z ASSESSOR'S INFORMATION: Map: Parcel: �OW OWNER: , -.:TO lff ."--- EI ,dve' im, e F/ 1'7772 NAAE PRES ADDRESS TEL, # CONTRACTOR:r; P l /..t1.SA -ia/(I AP."gel" , C�r�,"c /M11I2/G ✓).S'2 7i l 2 NAME MAILING D TEL.N Pi/Residential 0 Commercial Est. Cost of Construction$ 7 C9 Q C) • Home Improvement Contractor Lic. # /,'SL...§fZ• 7 Construction Supervisor Lic, # / / Q r ,? ,y • 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: /917/9'A1 C C.44/ J /e Worker's Comp.Policy# r/�0/3 L 9 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: 7,4,0 d 2- ., (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 answ,ver(s) will be just cause for denial or rev ation of my license�nd for prosecution under M.G.L.Ch.268,Section 1. i/i Applicant's Signature: /G` • Date: /Z Owners Signature(or attach nm(f t) L Date: Approved By: / �(�,. Date: lot-o; q .-i/ Building Official(or designee) EMAIL ADDRESS: Zoning District: .cj I v E.. / Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 o DEC 2 4 2019 Water Resource Protection District: Within 100 ft. of Wetlands: BU 0 Yes 0 No 0 Yes 0 No ���f By �J e�- • ti• Commonwealth of Massachusetts Division of Professional Licensure l`� IP Board of Building Regulations_and Standards Cons -.uf%11i15'pe5visor • V. CS-100988 :a # ' ltpires 11111/2021 , HENRY ECA�' SID`: 1 ; /, 8 SHED ROVV3 TFi�iVi'� � • 3`� r 'i, � � . WEST YARM }J r Commissioner ! + J / T/2?••(1/?. to (7� � �1;JcJCGr!/lrf '/ Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation CAPE COD INS XATION, INC Registration: 16.3687 18 REARDON CIRCLE Expiration: 12/14/2020 SO.YARMOUTH, MA 02884 • ,,6 2Om•Oai,9 Update Address and Return Card, I/ Office of Consumer Metre&Businsss Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for.Individual use only TYPE:Corooratlon before the expiration date, If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 163667 12/14/2020 1000 Washington Street•Sults 710 CAPE COD INSULATION,INC Boston,MA 02118 l � HENRY E,CASSIDY Lroia . 18 REARDON CIRCLE SO.YARMOUTH,MA 02604 ry • e Ith t sign r The Contnwnwealtlt of Massachusetts Department of Industrial Accidents Office of Investigations 4A 600 Wasltington Street • ,-,i ;. Boston, MA 02111 www,mass.gov/dia oricers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/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: 1,VI am a employer with 48 4, ❑ lam a general contractor and 1 Type of project(required): employees(full and/or part time).* have hired the sub•contractors 6, ❑ 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 8, ❑ Demolition working for me in any capacity. employees and have workers' (No workers' comp, insurance comp, insurance.: 9, ❑ Building addition required,) 5, ❑ We are a corporation and its l0.0 Electrical repairs or additions 3.❑ lam a homeowner doing all work officers have exercised their 11,❑ Plumbing repairs or additions myself,(No workers; comp. right of exemption per MOL • 12.E] Roof repairs insurance required.]t C. 152,§1(4),and we have noWeatherization employees.(No workers' 13,�Other comp. insurance required.) any applicant that checks box WI must also fill out the section below showing their workers'compensation policy inhumation, Homeowners who submit this affidavit indicating they art doing ell work and then hire outside contractors must submit a new affidavit indicating such. :Contractors!her check this box must attached un additional sheet showing the name at the sub-contractors and state whether ur nor those entities have cmploytes. If the sub-contraclurs 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 d or Self ins. hie T'VVC 100136900 Expiration Date:06/30/2020 Job Site Address: 1/State/Zip: Attueb a copy of the workers' compensation policy decla tion'page(showing the policy number and expiration date), Failure to secure coverage as required under Section.25A of MOL a 152 can lead to the imposition bf criminal penalties of rite 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 or up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certih underr� the pails and penalties of perjury thin the informit ion provided above is true and correct Signatyre: 7/47. � a��� Date:: )Z// t-7/ Phone u: 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 b issuing Authority-cell-de one): I. aoardpf Health 2. Building Department 3.City/Town Clerk 4, Electrical inspector 5. Plumbing Inspector- 6,Other ao- Phone#: ��R• CAPECOD-27 THt .. 4.... CERTIFICATE OF LIABILITY INSURANCE DATE-. 7/16/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In Ileu of such endorsement(s). PRODUCER CONTACT Good Rogers&Gray Insurance Agency,Inc. PHONE 434 Rte 134FAx South Dennis,MA 02660 (NC,No,Extp(800)553-1801 �(ac,No):(877)816-2156 ss,mail@rogersgray,com —INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:West American Insurance Company 44393 INSURED juRERa:ArbeIla Protection Insurance Company,Inc. 41360 Cape Cod Insulation,Inc. INSURER c:Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER D:Atlantic Charter Insurance Company South Yarmouth,MA 02664 p y 44326 INSURER E: 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 INDICATED. NOTWITHSTANDING 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. INSR ADOL SUER LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS A i l�Dn �rt,vll n X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE is 1,000,000 CLAIMS-MADE I X OCCUR BKW 53328281 4/1/2019 4/1/2020 DAMAGE TO RENTED 100,000 I PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 15,000 PERSONAL&ADVINJURY $ 1,000,000 i GEN'L AGGRE ATE LIMIT APPLIES PER: 2,000,000 X POLICY II jej I LOC GENERAL AGGREGATE $ I OTHER: PRODUCTS-COMP/OP AGG $ 2,000,000 B L AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT 1,000,000 ANY AUTO (Ea accident) $ 1020081008 4/1/2019 4/1/2020 BODILY INJURY(Per person) $ AOUTCS ONLY y AUTOSDULED HIRP OWN G BODILY INJURY(Per accident) $ X AUTOSO ONLY X I AUUTOS O Y PROPERTY DAMAGE (Per accident) $ C UMBRELLA LIAR I X OCCUR $ 2,000,000 X EXCESS LIAB CLAIMS-MADE EXC10006635004 EACH OCCURRENCE _$ - 4/1/2019 4/1/2�2� AGGREGATE 2.000,000 I- DED I I RETENTIONS S D WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY Y/N I STATUTE I ERH ANY PROPRIETOR/PARTNER/EXECUTIVE WCI00136900 6/30/2019 6/30/2020 1,000,000 OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory In NH) f yes,describe under E.L.DISEASE•EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below 1,000,000 E.L.DISEASE-POLI;Y LIMIT $ 1 i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Information Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1 ACO RD 25(2016/03) ©1988-2015 ACORD CORPORATION, All rights reserved. The ACORr1 namo anr1 Inn,..........r..._--.+-- .---- HOME OWNER WEATHERIZATION WORK PERMIT: PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER. yyz� .� t �k 05 :1-0vcsC 1'vAkhl.ea" 14en14►4 u hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation on the property located at: 1-31 1ht.,/ 9tinA Af S0LA.4-k •.pi\ it,,.vLd1tei cais e)741. Y The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures: Weather stripping; air sealing; attic&basement insulation; exterior wall insulation; ventilation measures In consideration of the weatherization work to be done at my home I agree to the following: 1. I give permission to Housing Assistance Corporation to access the property with such equipment and materials as may be necessary to perform weatherization. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five (5) years after the weatherization work is completed. I have read the provisions of this agreement and give my consent. Home Owner(signature) "./ Y)d7Thvi2,41/ Home Owner email: Date: Agent:(Signature) Date: Agency Approved Weatherization Company All Cape Energy Alternative Weatherization Cape Cod Insulation Cape Save Cazeauft Frontier Energy Solutions Lohr Home Improvement 4(24 Agency Signature: Date: 1X 6 For Natural Gas Customers: I have received the National Grid Discount Rate Application form from my auditor. Customer Initials