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Home My WebLink AboutBLD-19-979 t t .Ot,,�; Office Use Only �, e.4..ciz 6. Permit# � Amount 3S- '' g Permit expires 180 days from { 'issue date I3Lb-Iq-0oq-7 g EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH >= ^ r-* I V E Yarmouth Building Department t ---M=—'---- 1146 Route 28 South Yarmouth,MA 02664 AUG 20 2018) (508)398-2231 Ext. 1261 ` L.__..- f Pt_dWIiJ�i CCrAIcl ML-NT CONSTRUCTION ADDRESS: 404 Main Street (p4 -- ASSESSOR'S INFORMATION: ' Map: 123 Parcel:46 OWNER: Joel Chaison same 508-375-6424 NAME PRESENT ADDRESS TEL. # coNTRAcroR:William McCluskey/Cape Save 7-D Huntington Ave, S. Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL.# ■Residential 0 Commercial Est Cost of Construction S 5000 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lie.# IC 102776 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: Employers Mutual Casualty Company Worker's Comp.Policy# 5D77852 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 X Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing 'The debris will be disposed of at Yarmouth Location of Facility I declare under penalties of perjury that the statements herein contained are true and coned to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denialr ation of my license and for prosecution under M.O.L.Ch.268,Section I. Applicant's Signature: Date. 8/17/18 . Owners Signature(or attachmen attached Date: r��t1 Approved By: a- Date: (J—17 a 77 Building OfE (or designee EMAIL ADDRESS: Zoning District: ^ - .-— Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No ' R E C M i I - L• Water Resource Protection District Within 100 ft.of Wetlands: I ❑ Yes ❑ No ❑ Yes 0 No (�,r 17 2018 ` By b ';''''i: . °' t: s r Th'e Commonwealth'of Massachusetts-- ! mit_'—y el :' '`'' • Department of In du.stria,Accidents . , ' '' a ',..,',e,-": - . - . r _iFb- S 1 Congress Street,'Suite 100 ?=1114—=t- - Boston,MA 02114-2017 - • ' wwwmassgov/dia . Workers'Compensation Insurance Affidavit:Bullders/Contractors/Electricians/Plumbers.'.'' '': - - TO BE FILED WITH THE PERMITTING AUTHORITY. ,t : -Applicant Information Please Print Legibly ,' Name(BusinesslOrganizationntidividt;ai):Cape Save Inc • . Address:7-D Huntington Avenue .: r ' ,.,. • City/State/Zip:South Yarmouth,MA 02664 ' Phone#:508-398-0398 An you as employer?Check the appropriate box: . ;„ Type of project(required): - 1.f7 I am a employer with 15 employees(full and/orpart-time).• - . .7. ❑New construction " 2. 1 am a sole proprietor or partnership and have no employees working for in,. , - ❑ 8. ❑Remodeling „ any capacity.[No workers'comp.insurance required.] ', -" , - • - CI am a homeowner doing all work myself.(No workers'comp.insurance requiredl t ' . .. 9. ❑Demolition • 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will _ , 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. , . . 12.0 Plumbing repairs or additions • 5.1:1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0ROof repairs These subcontractors have employees and have workers'comp,insurance.: ' 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c, 14.0 Insulation :52,11(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 subcontractors and state whether or not those entities have- . , employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site ' , information. . , .. _ - - -. _ Insurance Company Name: Employers Mutual Casuay Company • •, r . Policy#or Self-ins.Lic.#: 5D77852 -. . Expiration Date: 10/16/2018 ' Job Site Address: 404 Main Street• City/State/Zip: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$250.00 a • day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance 1 • coverage verification. - -- 1 do hereby certify under th pains and penalties of perjury that the information provided above is true and correct Signature: \�\�3� Date: 8/17/18 , phone#:506-398-0398 Official use only. Do not write in this area,to be completed by city or town officiaL . , City or Town: Perinit/License# Issuing Authority(circle one): . 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector ' .. - 6.Other . - • - -- - -. , • Contact Person: - • - _ - , Phone#: _ ^t •r. ,: ----^$ CAPESAV-01 ' HWOODS ACO- CERTIFICATE OF LIABILITY INSURANCE D10/19/2 17 `� 10/18/2017 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(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 lieu of such p endorsement(s).�,A PRODUCER E _MT" _ , Rogers 8 Gray Insurance Agency,Inc. PHONE . FAX _ 434 INC,No,Eat: WO.NO):(S77)816-2156 South Dennis,MA 02660 f ODt'6§s;mall@rogersgray.com INSURERS)AFFORDING COVERAGE NMC S INSURER A:Employers Mutual Casualty Company 21415 INSURED - - . INSURER 8: . - . . - . Cape Save,Inc INSURER O; 7 D Huntington Ave - _ NsuRER D; '- - South Yarmouth,MA 02664 INSURER E: INSURER F: 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. - INSRpm TYPE OF INSURANCE ASDL UBR POLICY NUMBER PODCYEFF POLICY EXP LIMITS ITRNSD YYYD MwOC/YEFF POLICYYYYI A X COMMERCIAL GENERALLABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 6D77852 10/16/2017 10116/2018 DAMRFIy, R IAGETOEa RENTEl $D 600,00' Po unarlce _ ' MED EXP(Any one peNonl $ 10,000 PERSONAL BADV INJURY $ 1,000,000 GENL AGGREGATE ppLIRMCTpIT APPLIES PER: • GENERAL AGGREGATE $ 2'000'O2,000,06)I POLICY X JELOC PRODUCTS•COMP/OPAGG $ 2,000,000 OTHER ' ' ' '• EBL AGGREGATE $ 2,000,000 . A AUTOMOBLELABRITY COMBIINEDSINGLELIMIT $ 1,000,000 X ANY AUTO • _ 5Z77852 10/16/2017 10/16/2018 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOSRREE�� ONLY _ AAaIUUpT��OpSSy�A.��NIEE•pp- -- • - ' - pBRO�DILYIITNyJUpRgYM(Par accident) $ Zia ONLY _AUTO.SONLV (Per PERI) AGE $ $ A X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS LIAR • CLAIMS-MADE 6J77852 10/1612017 10/16/2018 AGGREGATE _3 - 2,000,000 DED X RETENTION$ . 10,000 • . $ A WO EMPLOYERS WBWN .. X STATUTE FORS ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 6H77aS2 10/16/2077 10/16/2018 EL EACH ACCIDENT $ 600,000 $pF-FICEpp��,.�1EEMg9EERR EXCLUDED] _ N N/A (IYrldalary fn Nil) r • EL DISEASE•EA EMPLQYE 500,000 girdYes,deacnoe unser ' ' 600,000 DESdRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT § DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD lot,Additional Remarks SchadlM,may be aaaUN N'E mon apace M required) , • CERTIFICATE HOLDER • CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ' Cape Light Compact Joint Powers Entity ACCORDDA E WITH THE POLICY PRORATION DATE VISIOSCE WILL BE DELIVERED IN Housing Assistance Corporation , - 460 W.Main St Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ®1888-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD P7Am W z Olagleaddattthee4t . Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 ; . ' Boston, Massachusetts 02108 Home Improvement Contractor Registration •c ?f"?, . Type Corporation CAPE SAVE INC. 1 - Registration: 171380 7-DHUNTINGTONAVENUE j*'I t,:= t'"`°'.g-=_'_=1 t"-` Expiration: 03/13/2020 SOUTH YARMOUTH,MA 02664 i`, ` —`"t ` I, jjj''' : t �J " ,y scot Ozoo+-osr» - Update Address and Return Card. • Cara Pammonuren/IA a`'o&aimAweal _ _...__ .._,__.__..,_. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only • TYPE:Caooraticn before the expiration date. K found return to: Registration---_ Expiration Office of Consumer Affairs and Business Regulation 171380 : ---' 03/13/2020 One Ashburton Place-Suite 1301 CAPE SAVE INC.. .. -:. i :. Boston,MA 02109 i.4 WILLIAM MCCLUSKEY-.-;%-,,}i' 2.0 ---- 7-D HUNTINGTON AVENUE' . SOUTH YARMOUTH,MA 02664 Undersecretary Not valid w ;\ci -ignature •r C. Commonwealth of Massachusetts 17` Division of Professional Licensure Construction Supervisor Specialty Board of Building Regulations and Standards Restricted n: I CSSL-IC- nsulation Contractor ConstrucfiooS' Msgr Specialty / CSSL-102776 - "-a- 1-a", Cokes:06/28/2019 . WILLIAM J MCCLUSKEYr J 1 O ;.:�. ., r i 37 NAUSET ROD, , - ; ! C WEST YARMO TH'MA 02673,`rt ,_- '„ . t0/(V HO‘' . Failure to possess a current edition of the Massachusetts S--- State Building Code Is cause for revocation of this license. Commissioner DPS Licensing information visit:WWW.MASS.GOV/DPS \WW4 RISE _ 5 Dupont Avenue South Yarmouth, MA 02664 ENGINEERING OWNER AUTHORIZATION FORM 1, JOEL CHAISON , (Owners Name) owner of the property located at: 404 Main Street (Street) Yarmouth, MA 02675 (Town, State, Zip) hereby authorize 0000 C sr Score- , (Subco tractor) 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. • The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. )11`4A– f's arS" 1— -Customer Signature -- 1 k. ? -Sign Date 03/01/2018