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Home My WebLink AboutBLD-23-005996 ina% )6,9(— 4 .-/ /Z> Permit# 0-4 135 3-e O •.e.1., " 'j Amount 3 c.lea 0 �,63 �`A" ~ Permit expires 180 days from ',%issue date El L4)-.23 -6C05 1q, EXPRESS BUILDING PERMIT APPLICAT C E I V E D TOWN OF YARMOUTH -"- Yarmouth Building Department APR 2 7 2023 1146 Route 25 South Yarmouth, MA 02664 BUILDING DEPARTMENT (508) 398-2231 Ext. 1261 By _ CONSTRUCTION ADDRESS: 21 �! `(, r1 iL I • qli N1 A at- ASSESSOR'S INFORMATION: .J Map: Parcel: OWNER: Nd va- 1 iA 1 t, Vt. 3100- ?fig% NAME ,( y,� �� PRESENT ADDRESS j ,��yy TEL. # f, CONTRACTOR: j� 47r7 lt� `V t DLC4V4 5. ()au lri� -i7i - 1114 NAME MAILING ADDRESS TEL.r '-OResidential El Commercial Est.Cost of Construction 2�0O . Home Improvement Contractor Lic.# I F/i I Construction Supervisor Lic.# 1061 B Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance nsurance Company Name: 14`ra., k 1145tiveute. Worker's Comp.Policy# (PV iOO 12)( 0 7.) WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation 171 I I Old Kings Highway/Historic Dist. CD Replacing like for like Pool fencing (j( , ikkp *The debris will be disposed of at: "`'i 14 / 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) vili be just cause for denial or revocation o license d for prosecution under M.G.L.Ch.268,Section 1. Litkpplicant's Signature: ,... ill Date: 2i i. . 3wners Signature(or attachment) i 11,Qi a'h ~ Date: - kpproved By: Date: ✓ r 23 Building Official(or d ' ee EMAIL ADDRE Zoning District: Historical District: 12 Yes No Flood Plain Zone: = Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes _ No Permit Authorization 411011111rk, mass save Form :aarav+g.tTaa.sel entrytp Site ID: 4730764 Customer: Sandra Blajda Sandra Blajda I, , owner of the property located at: (Owner's Name,printed) 29 Elton Road West Yarmouth, MA 02673 (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. &it ora BCa/da Owner's Signature: Date: 04-2o-2023 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Name: RISE Engineering Phone: 508-568-1926 Email: Page 1 of 1 For Office Use Only Document Ref:SW5PR-5HCMV-UUAMB-JJHJZ Page 1 of 1 THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affa "an Business Regulation 1000 Washing r t- Suite 710 Bosto i=Massaciausetts2118 Home Impro e - ®- fractegistration sr emomoslime ..a. I(' .....s�..... ,. .F. i�{Type: Corporation jmii = = ';a i5tration: 153567 CAPE COD INSULATION, INC i..4 E pitation: 12/14/2024 18 REARDON CIRCLE ;,, = SO.YARMOUTH, MA 02664 .- Update Address and Return Card. '?' THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation i Registration valid for individual use only before the i HOME IMPROVEMENT4:CONTRACTOR i expiration date. If found return to: TYPE `ii ration Office of Consumer Affairs and Business Regulation ; Reyistratio IC iration 1000 Washington Street -Suite 710 I 5356 L 8024 i Boston,MA 02118 APE COD INSULATION - - I,. > e ) HENRY E. CASSIDY J a ,: - 8 REARDON CIRCLE r _`_ ..•., � n`�fCG�`�"�` -,. 30.YARMOUTH,MA 026fi4,l s.-. Undersecretary /�ry y{d t ou i ature Commonwealth of Massachusetts ar Division of Professional Licensure Board of Building Regulations and Standards C o nstruAiiiervisor CS-100988 -/ Expires:11/11/2023 HENRY E CASSIDY / , 8 SHED ROW` - WEST YARMQJITH MA`.02873 /t l Commissioner dcr< 14f ^t�� c AW E D. CERTIFICATE OF LIABILITY INSURANCE DAT (MMIDD2 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 riot confer rights to the certificate holder in lieu of such endorsement-fa). PRODUCER CT NAME RogersGray, Inc.-Kingston Branch PHONE lac.No,Est):508-746-3311 FAX i/C,No):877-816-2156 63 Smith Lane E-MAIL Kingston MA 02364 ADDRESS: mail@rOgersgray_Com INSURER(S)AFFORDING COVERAGE • i 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 f 19259 18 Reardon Circle 44326 South Yarmouth MA 02664 INSURER D:Atlantic Charter Insurance Company INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:1082274092 REVISION NUMBER: THIS IS TO ERTIFY THAT THE ND CATED.GNO iTHSTANDING ANY 1REQUIREMENT,TERM OR CDNDmON OF ANY CONTRACT OR OTHER DOCUMENT WIED TO THE INSURED NMED DTH RESPECT TOVE FOR THE WHICH PERIODICY WHICHTH S 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. ILf t AODL SUER] 1 POLICY EFF POLICY EXP I LIMITSTYPE OF INSURANCE IN i WVDI POLICY NUMBER I(MM100IVYVYI (MMIDDIYYYYI; A X I COMMERCIAL GENERALLUABILrrY Y 1 Y S 2513647 411/2022 6/30/2023 1 EACH OCCURRENCE 1 S 1,000,000 i ( DAMAGE TO RENTED !S 500,000 I PREMISES(Ea occurrence) • I i CLAIMS-MADE i A {I OCCUR 1 } i i 1 I } I MED EXP(Any one person) I S 15,000 I I PERSONAL&AOI VINJURY $1,000,000 ' i GEML AGGREGATE WIT APPUESPER:I I GENERALAGGREGATE I S2,000,000 X {POLICY i JECT I PRO- �LOCO I1 1 PRODUCTS-COMP/OP AGG j 52,000,000 I � I 1 g OTHER: 1 1 COMBINED SINGLE LIMIT Y Y i41112022 6/30/2023 [$i,000,000 B AUTOMOSILELIAB1LrrY � A9109191 (Ea BODILY INJURY(Per person) I S 1 ANY AUTO i f !OWNED SCHEDULED i BODILY INJURY(Per accident)j$ AUTOS ONLY I XAUTOS i I i PROPERTY DAMAGE }S HIRED I X 1 NON-OWNED i 1 i (Per accident) X I AUTOS ONLY r AUTOS ONLY IS C i UMBRELLALlAB i X j OCCUR Y j N G S 2513647 4/1/2022 i 6130/2023 EACH OCCURRENCE i$2,00D,0c0 X i EXCESS LIAR i 1 CLAIMS-MADE ,AGGREGATE i$2,000,000 i ` I i5 I DED I i RETENTIONS I I i• D WORKERS COMPENSATION Y WC100136903 6/30/2022 6/30/2023 X 1 PER 1 I ER AND EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT S 1,000,000 IOFFiCEO XCR/M MBERE UD D7ECUTiVE N ENiA1 l i I )(Mandatory In NH) ' i ( i I E.L.DISEASE-EA EMPLOYEE{51,000,000 IF yes,describe underii E.L DISEASE-POLICY LIMIT 1 S 1,000,000 (DESCRIPTION OF OPERATIONS below i } I ; f I I i E I t I I I i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) When Required by Written Contract the Following Applies: General Liability—Additional Insured Ongoing(CG 7300 01/19)and Completed Operation(CG 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. A EDREPRESENTATIVE Wi 7 ,roal ,A.A.,............. ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents • 1 t =p1 1 Congress Street,Suite 100 _i,i _9 Boston,MA 02114-2017 " ._ www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ,} + Please Print Legibly Name (Business/Organization/Individ?ual): l)6�il7Ul (Vi '[/4( how Address: 10 ` dot''(- ,vvk- City/State/Zip: IOL & V I V1M,U1Afet, 1 Yi4A Phone#: I?Dr)-17 ' i lig Are you an employer?Check the appropriate box: Type of project(required): ='i l.X I am p� a employer with (31 employees(full and/or part-time).• 7. ❑New construction 2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp,insurance required.]' 9. 0 Demolition 10 Ej Building addition 4.0 ram a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation irsurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet ❑ 13.0 Roof repairs .. These sub-contractors have employees and have workers'comp.insurance.t fheir 6.0 We are a corporation and its officers have exercised their right c f exemption per MGL c. 14. Other vVIZ"t'{014, 152,§i(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 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. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employee& Below is the policy and job site information. �� Insurance Company Name: pZU j��'ludic, �—v' vi-ev c V WW Policy#or Self-ins.Lic.#: Expiration Date: _ 2O'S Job Site Address: 11 Li (/I RA.- City/State/Zip: IN ' et VVv&O'u ma Attach a copy of the workers'compensation policy declaration page(showing the policy number d 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. 7 I do hereby certify under the pains and pe tt of per' 1 t the information provided ab ye is true and correct Signature: Date: 27 2 Phone#: r l(N'i- 17'?'Ili Official use only. Do not write in this area,to be complete y 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#: