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Home My WebLink AboutBLD-17-003708Cape Save Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 508-398-0399 2/27/17 Town of Yarmouth Regulatory Services Building Division 1146 Route 28 South Yarmouth, MA 02664 RC: Building Permit 17-003708 TO: Building Inspector(s), This affidavit is to certify that all work completed for 200 Blue Rock Road has been inspected by a third party Certified Building Performance Institute (BPI) Inspector. Ceiling: R-17 cellulose in attic flats All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey 1 0 J Z017 ou� p�FA�rn.,FNr EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 200 Blue Rock Road ASSESSOR'S INFORMATION: Map: 101 Parcel: 164 ffice Use Only .mount ermit expires 180 days from sue date owNER: Mark Uppendahl same 508-367-1569 NAME PRESENT ADDRESS TEL. # CONTRACTOR:William McCluskeY 1 Cape Save 7-D Huntington Ave, S. Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL. # ■ Residential ❑ Commercial Est. Cost of Construction $ 3400 Home Improvement Contractor Lie. # 171380 Construction Supervisor Lie, # IC 102776 Workman's Compensation Insurance: (check one) ❑ 1 am the homeowner ❑ I am the sole proprietor ■ 1 have Worker's Compensation Insurance Insurance Company Name: _Star Insurance Co. Worker's Comp. Policy# WC 085540700 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Siding: # of Squares Replacement windows: # Roofing: # of Squares ( ) Remove existing* (max. 2 layers) Old Kings Highway/Historic Dist. ( ) Replacing like for like *The debris will be disposed of at: Yarmouth Location of Facility Wood Stove Replacement doors: # Pool fencing Insulation x 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,er r0focation of my license and for prosecution under M.G.L. Ch. 268, Section 1. Applicant's Signature: Owners Signature (or Date: 1/18/17 Approved By: Date: Building Official (or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ Water Resource Protection District: Within 100 ft. of Wetlands: Ll Yes ❑ No ❑ Yes ❑ No 1 g `J, ,o ey RISE ENGINEERING owner of the property located at: 3ov hereby authorize I /Up- leOC16 (Property Address) Irrff "A, 01:�14 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 Signature Date RISE Engineering 5 Dupont Avenue South Yarmouth, MA 02664 The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114 2017 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Cape Save Inc Address: 7-D Huntington Avenue South Yarmouth, MA 02664 Are you an employer? Check the appropriate box: Phone #: 508 - 398 - 0398 1.M I am a employer with 15 _employees (full and/or part-time).* 2,Q I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.[] I am a homeowner doing all work myself. [No workers' comp. insurance required.] t" 4.01 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 proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.1 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required) 7. [] New construction 8. Remodeling 9. ❑ Demolition 10 Q Building addition 11.❑ Electrical repairs or additions 12.0 Plumbing repairs or additions 13.[] Roof repairs 14.E]Other Insulation *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 isproviding workers' compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name: Star Insurance Co. Policy # or Self -ins. Lic. #: WC085540700 Expiration Date: 4/9/2017 Job Site Address: 200 Blue Rock Road City/State/Zip; South Yarmouth Attach a copy of the workers' compensation policy declaration page (showing the policy number 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. I do hereby certify under thkpains and penalties of perjury that the information 508 - 398 - 0398 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # true and correct 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#: E ACCORP CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 10/24/2016 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 pollcy(ies) must 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 endorsements . PRODUCER Risk Strategies Company 15 Pacella Park Drive Suite 240 Randolph MA 02368 NAME: Colleen Crowley PHO No E : (781) 986-4400 FAC No: (781)963-4420 EADAILSS:ccrowley@risk-strategies.com INSURER(S) AFFORDING COVERAGE NAIC� IINSURERA.Liberty Mutual Insurance Cc INSURED Cape Save, Inc 7 D Huntington Ave South Yarmouth MA 02664 INSURERS Allmerica Financial Alliance Ins Cc 10212 iNsuRERc:Ohio Casualty/Peerless Insurance 24074 INsuRERD:Star Insurance CO INSURER E : INSURERF: COVERAGES CERTIFICATE NUMBER:CL16101422377 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. L TR TYPE OF INSURANCE POLICY NUMBER MM1� EFF POLICY1 EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx] OCCUR SLS1767246490 10/16/2016 10/16/2017 EACH OCCURRENCE $ 1,000,000 AGE To RENTED PMISES REE $ 100,000 MED EXP (Any one person) $ 15,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PERC7 LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO SCHEDULED AUTOS ALLO8MED Ix X HIRED AUTOS NON-OMED AUTOS JLWNA46796600 11/6/2016 11/6/2017 COMBINED SINGLE Ee accident LIMIT $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ P r Eadent AMAGE $ C X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE US057246490 10/16/2016 10/16/2017 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 DED I X I RETENTION$ 10,000 $ D WORKERS COMPENSATION AND EMPLOYER$' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN OFFICERIMEMBER EXCLUDED? (Mandatory In NH) If yes. describe under DESCRIPTION OF OPERATIONS below N/A Officers included !or Coverage SPC0855407 4/9/2016 4/9/2017 X OTH- STATUTE ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE- EA EMPLOYEE $ 500,000 E.L. DISEASE- POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS $ LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Evidence of Insurance / Insulation Specialists Housing Assistance Corporation Barnstable County Cape Light Compact 460 Min Street Hyannis, 14A 02061 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Christian/CLC @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) INS025 (201401) The ACORD name and logo are registered marks of ACORD CAPE SAVE INC. WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE SOUTWYARMOUTH, MA 02664 SCA 1 dx 2OM-D5111 ��/Ie COO�7?7Jlft?ILCJCfGfI�L C�C;✓��CCSJCC!'fZG:LEt Office of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR '51 Registration 171380 Type: Expiration Corporation um CAPE SAVE INC. WILLIAM MCCLUSKEY „ 7-D HUNTINGTON AVENUE . ti,�• 1, SOUTH YARMOUTH, MA o2664 Undersecretary Massachusetts Department of Public Safety Board of Building Regulations and Standards 4i.1}}111:! llli/t'}!I .JLti}C%V 1\lD7 .$iJCItB}L V' -.� 96' License: C SSL 102776 tvl-1 WILLIAM 3MC CtU � . 37 NAUSET ROAD 1 West Yarmouth NIA ✓.,,�,..,..,tJ-,.�'. Expiration Commissioner 06128/2017 i X(Il 11 nti n1a' Tr# 419291 Update Address and return card. Mark reason for change. Address C Renewal ❑ Employment Lj host Card License or registration valid for individiul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid vi signature Construction Supervisor Specialty Restricted to: CSSL-IC - Insulation Contractor Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. DPS Licensing information visit: WWW.MASS.GOV/DPS