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HomeMy WebLinkAboutBLD-23-005496 (4. • `� ermn—Z3 — 5 / 9 s„b�t 0 0 , #y Amount i .uriA n c 4 <......,u4'7.c? Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 2S South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 1 UVko — u ASSESSOR'S INFORMATION: •J Map: 141 Parcel: 11-6 OWNER: 4teucargiA, ( (o l?- -b 5 - '1 y i NAME PRESENT ADDRESS TEL. # CONTRACTOR 11 u,i.5 isty lit�A C, we t . -)av Netikk AP -1-1 - Ali Y LAME MAILING ADDRESS TEL.:: Residential 0 Commercial Est.Cost of Construction 5 w/ re-0 ' Home Improvement Contractor Lic.# 1 F7�t?1 Construction Supervisor Lic.# 10 61 et Workman's Compensation Insurance: (check one) �,/ ❑ I am the homeowner 0 I am the sole proprietor i I have Worker's Compensation Insurance 'nsurance Company Name: MittiC(..4141(taiimt vw ' Worker's Comp.Policy# (P(1 106 12)& 07) WORK TO BE PERFORMED Tent E. Duration (Fire Retardant Certificate attached?) Wood Stove !__._J Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (❑)Remove existing* (max.2 layers) Insulation RI I I Old Kings Highway/Historic Dist. Replacing like for like Pool fencing [1 ii( 14(fit tet, Ditikp *The debris will be disposed of at: 41( 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) vitl be just cause for denial or evocation o license d for prosecution under M.G.L.Ch.268,Section 1. Li(1)1 kpplicant's Signature: �""" Date: t77 )wners Signature(or attachment) j, 6,' ", ~ �I Date: kpproved By: `/L () Date: 7 P 3 Building Official(or desi ) . EMAIL ADDRESS. RECEIVED Zoning District: ' Historical District: Yes .-.1No Flood Plain Zone: Yes No s /AX 11 4 023 Water Resource Protection District: Within 100 ft.of Wetlands: — � Yes No a Yes No BUILDING DEPA� ENT E3 y — losr„ Permit Authorization mass save Form Site ID: 4782301 Customer: Katharyn Delaney I, Katharyn Delaney , owner of the property located at: (Owner's Name,printed) 81 Lookout Rd Yarmouth, MA 02675 (Property Street Address) (City) 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. nD/ Owner's Signature: Ka Mania De 2 4eq Date: 2023-03-27 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: c14 r� rw - ,d 7-d3 Participating Contractor Date Name: RISE Engineering Phone: 508-568-1926 Email: Page 1 of 1 For Office Use Only Document Ref:X8MEF-HQVSS-5YUPD-7J7MU Page 1 of 1 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 7/5/2022 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(ies)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 lieu of such endorsement(s). PRODUCER CONTACTNAME: RogersGray, Inc.-Kingston Branch gHCNNo. )_508 746 3311 I FAX Nol:877-816-2156 63 Smith Lane E-MAIL Kingston MA 02364 ADDRESS: mail@rogersgray_Com INSURER(S)AFFORDINGCOVERAGE • NAIC# INSURER A:Selective Insurance Company of New York 13730 - INSURED CAPECOD-27 INSURER a:Selective Insurance Company of America ; 12572 Cape Cod Insulation Inc INSURER c:Selective Insurance Company of South Carolina 19259 18 Reardon Circle South Yarmouth MA 02664 INSURER D:Atlantic Charter Insurance Company 44326 INSURER E: INSURER F: ' COVERAGES CERTIFICATE NUMBER:1082274092 REVISION NUMBER: THIS 1S 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. ADDL SUER 1 POLICY EFF POLICY EXP ILSR TYPE OF INSURANCE INgD I wsD POLICY NUMBER I(MMIDD/YYYY) (MMIDD/YYYY)t LIMITS A X I COMMERCIAL GENERAL LIABILITY 1 Y I Y 7 S 2513647 4/112022 6130/2023 i EACH OCCURRENCE I$1,000,000 ` i DAMAGE TO RENTED i I 1 I I I PREMISES(Ea occurrence) !$500,000 I CLAIMS-MADE 1 OCCUR r II MED EXP(Any one person) ;$15,000 I I } 1 PERSONAL&ADV INJURY I$1,000,000 GEN'L AGGREGATE UMIT APPUES PER: ! GENERAL AGGREGATE S 2,000,000 PROCT- LOC 1 I PRODUCTS-COMP/OP AGG I X j POLICY 1 i JE S 2,000,000 L—_ ; I I I OTHER: l , I I S BI B AUTOMOBILE LIABILITY { Y � Y A 9109191 4 4/112022 613012023 (EaCOM accNEDident)SINGLE LIMIT I 51,000,000 j ANY AUTO I i BODILY INJURY(Per person) I S i OWNED I7 SCHEDULED I I j i BODILY INJURY(Per accident)I$ AUTOS ONLY I,AUTOS ! I PROPERTY DAMAGE iS X t HIRED I NON-OWNEDT ( i )( j �(Per accident) $ AUTOS ONLY _1 AUTOS ONLY i i C i UMBRELLAUAB I X j OCCUR Y j N S 2513647 s 4/1/2022 6/30/2023 I EACHOCCURRENCE ;$2,000,000 X EXCESSUAB i I CLAIMS-MADE iI Iff ' ,I AGGREGATE 1 52,000,000 DED I 1 RETENTIONS 1 t I$ p WORKERS COMPENSATION Y (WC100136903 I 6/30/2022 613012023 IX I � I PER 1 I ER AND EMPLOYERS'LIABILITY (( IANYPROPRIETOR/PARTNER/EXECUTIVE Y/N I I I ,E.L.EACH ACCIDENT ,S1,060,000 I OFFICER/MEMBER EXCLUDED? N N/Ai(Mandatory In NH) I E.L.DISEASE-EAEMPLOYEEj$1,000,000 I If yes,describe under i i DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY UMIT 1 S 1,000,00D 1 i I I I t I . 1 DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) When Required by Written Contract the Following Applies: General Liability—Additional Insured Ongoing(CO 7300 01/19)and Completed Operation(CO 7988 01/19)Primary and Non-Contributory Basis(CG 7300 01/19),Waiver of Subrogation(CO 7300 01/19) Automobile—Additional Insured,Primary and Non-Contributory Basis,Waiver of Subrogation(CA 78 09 11/17) Workers Compensation—Waiver of Subrogation(WC 00 03 13 04/84) Excess/Umbrella—Additional insured follows form over underlying General Liability and Automobile Liability, Additional Insured Primary and Non-Contributory Basis(CXL 449 06/17) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Cape Cod Insulation, Inc. At,TxaaizEOREPRESENTATIVE ,#,44% ,___ k .....;/„....._4cur.el 7 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts fit. Department ofJndustrialAccidents • 1111 a A 1 Congress Street,Suite 100 ;idyl; `� Boston,MA 02114-2017 = www.massgov/dio Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly /I Name(Business/Organizaiion/lndividtial): Copt(�'L?!ll N 1��1 v f/'� i Address: 10 ` Ird01.-'41Gt-6' - City/State/Zip: i'0Mgt- {-I tVl' fet,- t `-R Phone#: '5O I7' - 17 Are you an employer?Check the appropriate box: ",- Type of project(required): LW am a employer with til employees{full andlor part-time).* 7. 0 New construction 2.0 ism a sole proprietor or partnership and have no employees working forme ill 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. 0 Demolition 3.0 lam a homeowner doing all work myself.[No workers'comp.insurance required.] 10 Q Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietor with no employees. 12.Q Plumbing repairs or additions 5.D I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs .. The. subcontractors have employees and have workers'comp.insurance? 14.21 Other . �.it�Z 4 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. S 132,§1(4),and we have no employees.[No workers'comp.insurance required.] ~Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowner who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that cheek this box must attached an additional sheet showin gthe name of the sub-contractors and state whether or not those entities have employees. lithe sub-contractor have employees,they must provide their workers'comp.policy mmber. I am an employer that is providing workers'compensation insurance for my employees: Below is the policy and job site information. �(.- �( Insurance Company Name: Al 6lV1hi, `�J l_ Vet-4/ / Policy#or•Self-ins.Lic.#: L,Lf' 1'3Iv103 Expiration Date: e/ /201 Job Site Address: r L I It -- CitylStat&Zip:_ qa,./4 eZ(.7 Attach a copy of the workers'compensation policy declaration page(showing the policy nur fiber and expiration date). Failure to secure coverage as required under MGL c.152,,25A is a criminal violation-punishable by a fine 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 the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. j/ I do hereby certify under the pains and pe U of per' t the information provided ab e is true and correct — I ZSignature:nature: / Date: Phone#: ' ! l Official use only. Do not write in this area,to be completely city or town official: City or Town: _Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer =Business Regulation 1000 Washt, Suite 710 BostonAl 118 Home Imh ement tractor egistration t ' ; 1 to --' i i y 1- ,r-ii ... ", Type: Corporation ..___..__Regssfiation: 153567 CAPE COD INSULATION, INC (tTil -, E piration: 12/14/2024 18 REARDON CIRCLE r l SO.YARMOUTH, MA 02664 �" fic7.1 El fir, ! - i .a"5'i t"f`i d �— '``, Update Address and Return Card. '% THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the i TYREEtporation HOME IMPROVEMENTCONTRACTOR expiration date. If found return to: A Office of Consumer Affairs and Business Regulation i Registratro Xpiration 1000 Washington Street -Suite 710 s 53567- 462024 i Boston,MA 02118 ; APE COD INSULATIO r _ - `:- - isr'i1 r�F- i- 1ENRY E. CASSIDY JR:\ ,,ter �.:; . 8 REARDON CIRCLE !}7: (a� ` • 30.YARMOUTH,MA 026fi4•, ;"_ Undersecretary / yid t ou i ature L. Commonwealth of Massachusetts f Division of Professional Licensure _ Board of Building Regulations and Standards Constru ' AYpeMsor CS-100988 - - Expires:11/11/2023 HENRY E CASSIDY, e z 8 SHED ROW` WEST YARMQITH ` 'i' , / s. n 647 Commissioner �ra� fi.