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Home My WebLink AboutBLD-19-000982 Cape Save Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 508-398-0399 10/23/18 Town of Yarmouth Regulatory Services Building Division RECEIVED 1146 Route 28 South Yarmouth,MA 02664 OCT 25 2018 BUILDING DEPARTMENT RE: Building Permit 19-000982 BY -- TO: Building Inspector(s), This affidavit is to certify that all work completed for 22 Braddock Street has been inspected by a third party Certified Building Performance Institute(BPI)Inspector. Foundation Walls: 2" rigid board All work performed meets or exceeds Federal and State Requirements. Sincerely, \\\NV William McCluskey r • Of Y ;Office Use Only 1 ili :r: G Pernit# OH. i Amount 36 a(g Permit expires 180 days from t 1 issue date 3Lb— IQ-0R5G8L1 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department -------- 1146 Route 28 AUG2 0 2018 South Yarmouth,MA 02664 G (508)398-2231 Ext. 1261 __ . .._. _ J LurLJIt.G UEFAR1 tdENT CONSTRUCTION ADDRESS: 22 Braddock Street ASSESSOR'S INFORMATION: Map:34 Parcel: 192 OWNER: Martin Roach same 508-694-5542 NAME PRESENT ADDRESS TEL # CONTRAcroR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL# ',Residential ❑Commercial Est.Cost of Construction S 3200 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lic.# TC' 102776 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor ■ I have Worker's Compensation Insurance Insurance Company Name: u . a - IN u s. , , t 110010 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 correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial r re ation of my license and for prosecution under M.O.L Ch.268,Section 1. Applicant's Signature: � � Date: R/17/12 Owners Signature(or attachmen attached Date: Q Approved By: Date: It '4.) s. )S Building Official(or designee) EMAIL ADDRESS: _ Tuning District:: i ! 1.1 i Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 o i Water Resource Protection District: Within 100 ft.of Wetlands: AUG 17 2018 1 ❑ Yes ❑ No ❑ Yes ❑ No 1 , 4_8D%. i - - Th'e Commonwealth of Massachusetts .- " - ' ' it rsar.kfl ' . . Department of Industrial Accidents• , , . ' C-=_i te_ 99 - ' ' ' 1 Congress Street,Suite 100 ' 3_il - -- Boston,MA 02114 2. 017 - _� ., . .. " ivwncmass.gov%dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. '. TO BE FILED WITH THE PERMITTING AUTHORITY. ' Applican't Information . • Please Print Deathly' ' Name(Business/Organization/Individual):Cape Srave Inc ' • Address:7-D Huntington Avenue ` ''' ' City/State/Zip:South Yarmouth, MA 02664 ' ' phone#:508-398-0398 . Are you an employer?Check the appropriate box: Type of project(required): 1.D✓ I am a employer with 15 employees(MI and/or part-time).* -- - - - - - 7. 0 New construction . .2.0 I am a sole proprietor et partnership and have no employees working forme in 8. 0 Remodeling , • - - any capacity.[No workers'comp.insuiance required]• - . - - : „ , 3.0 tam a homeowner doing all work myself.[No workers'comp.insurance reequired] 9. ❑Demolition 4.01 am a homeowner and will be hiring donbactors to conduct all watt on my property- I will- 1 O 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 . ' •1 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors 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.Q✓ Other Insulation - ' 152,§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 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.' - "6' ' :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 employees Below is the policy and job site. information. .- - _ -- - . . - - - _ . .. . ' Insurance Company Name: Employers Mutual Casualty Company . Policy#or Self-ins.Lie.#: 5D77852 - Expiration Date: 10/16/2018 ' • • Job Site Address: 22 Braddock Street . City/State/Zip:Bass River Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). , I 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 cern;fy under t h pains and penalties of perjury that the information provided above is true and correct Signature: \�\\\ Date: 8/17/18 Phone#: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# 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#: i..'"01111 CAPESAV-01 HWOODS 'l`� CERTIFICATE OF LIABILITY INSURANCE °10/19 "' /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 policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the teens 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 sucCChppendorsement(s). - - PRODUCER .NRM?CT Rogers&Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 . . . . . ANC,No,Ed): • INC,No):(877)816-2166 South Dennis,MA 02660 litaktk.mail@rogersgray.com • — - -INSURER(!)AFFORDING COVERAGE NAICF INSURER A:Employers Mutual Casualty Company 21415 INSURED - INSURER B: —CapeSave,Inc INSURER C: . 7 D Huntington Ave ' NSURER o:• - South Yarmouth,MA 02664 INSURER!: 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. jt in TYPE OF INSURANCE NW POLICY NUMBER BSUBR IMTONYYYY1 IMMOLICY EFF JDDI YYXWI LIMITS A X COMMERCIAL GENERAL umlaut( EACH OCCURRENCE S 1,000,000 CLAIMS-MADE X1 OCCUR 5D77862 10/16/2017 10/16/2018 WaGSETORENTooTE° ) $ 600,000 MED EXP(MY operson) $ 10.000Ode ^ PERSONAL 8 ADV INJURY $ 1'000'000 GENL AGGREGATE UMIT APPLIES PER. i - GENERAL AGGREGATE _ $ 2'000'000 POLICY I X 1 ria II LOC ' PRODUCTS-COMP/OP AGG $ 2,000,000 OTHERI. - - . ' - - - ' EEL AGGREGATE $ 2,000,000 A AUTOMOBa.E Lamm! ICOMBMBIINNEEDD SINGLE UNIT ral1 1,000,000 X ANY AUTO 5277852 10/16/2017 10/16/2018 BODILY INJURY(Per person)I S _ OWNED —SCHEDULED _ AUTOS ONLY AUTOSBODILY IINJURlPer accident) $ POS ONLY _ AIXV OPERTnpMAGE $ _ S A X UMBRELLA UAB X OCCUR EACH OCCURRENCE S 2,000,000 EXCESSLIAB CLAMS-MADE 5J77852 10/16/2017 /0116/2018 AGGREGATE 3 2,000,000 DED X RETENTIONS , 10,000 ^ $ - A AND WORKERS EARS WRIT YIN - - X STATUTE ERN- ANY ��PEREnOnPMMREIIET9OERIPARTNER,EXECUTIVE SH77552 1N16/2017 10/16/2018 EL EACH ACCIDENT $ 600'000 1Marna[oryln NH)FYCIUDED7 , ^ H N 1 A • . . 500,000 EL DISEASE-EA EMPLOYEE,$ Vyen describe user ._ 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached V more spas M required) .: - - CERTIFICATE HOLDER CANCELLATION -.. . SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION THEREOF. Cape Light Compact Joint Powers Entity ACCORDANCE WITH T TE THE POLICY PROVISIO SCE WILL BE DELIVERED IN Housing Assistance Corporation - - - 460 W.Main St. Hyannis,MA 02601 AHORRUTEDD)REPRESENTA7IVE I - • ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • �� o/QSo� • Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 I Boston, Massachusetts 02108 Home Improvement Contractor Registration .,.-. j ,, t.}_^r= .,•t,-.7,....7.-...%,„-_ „a. Type Corporation , 2. r,:-_ Registration: 171380 CAPE SAVE INC. _, {;"= �,,.; ,1 Expiration: 03/13/2020 Iii 1&.:-.4 s:1 l=: ;- 1Y. E:� 7-D HUNTINGTON AVENUE t - l- r-.S:. I'M SOUTH YARMOUTH,MA 02664 r_ z o h - -.777 -'7...,k4;,/ scat 4 201.1-05/17 - Update Address and Return Card. (929-Wm-mo;;;;eand VG- trauarAudell3 -____ -.______.__—.^.-- Office of Consumer Affairs&Business Regulation , ' HOME IMPROVEMENT CONTRACTOR - Registration valid for Individual use only TYPE:Coroora6on before the expiration date. If found return to: Tieoistration--- Expiration Office of Consumer Affairs and Business Regulation 171380 :- -.) 03/13/2020 One Ashburton Place-Suite 1301 CAPE SAVE INC_ '!<.'L; ; ;,=, Boston,MA 02108 ~ WILLIAM MCCLUSKEY-- %.m -'' , 6R --^ ' 7-D HUNTINGTON AVENUE' SOUTH YARMOUTH.MA 02664 Undersecretary Not valid w ,x4 Ignature • t. Commonwealth of Massachusetts 171 Division of Professional Licensure .. Construction Supervisor Specialty Board of Building Regulations and Standards Restricted tn: CSSL-IC-Insulation Contractor Con structioosWW:vi or Specialty CSSL-102776 71"'71,1, E/ipires: 06128/2019 �, .' . , G '„'„'RR ' WILLIAM J MCCLUSKEYt a ,- � (r 37 NAUSET ROADS i-+f J ,' ' S to Y " WEST YARMOUTH-MA 02673`$-- . . ?' -+ rrl ' ., l�t/si=1�LSt Failure to possess a current edition of the Massachusetts A ✓L State Building Code Is cause for revocation of this license. Commissioner /Cet /�L�� DPS Licensing information visit:WWW.MASS.GOV/DPS RISE ENGINEERING OWNER AUTHORIZATION FORM I, Martin D Roach (Owner's Name) owner of the property located at: • 22 Braddock Street (Property Address) Bass River, MA 02664 (Property Address) hereby authorize Cape Save Inc. (Subcontractor) 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. 1114 Owner's Signature Date (/ 11/ RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com