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Home My WebLink AboutBLD-19-1380 • i 4 'Office Use Only 4 to �O !!Permitil i.. 35-....... E oy .yes 'Amount #. cs1,". .; , j q _MI3 D0 ,j Permit expires 180 days from UlJ 1issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth,MA 02664 SEP - 6 2018 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 1 Captain Wright Road By:UI a `s 4 /ENT ASSESSOR'S INFORMATION: Map: 67 Parcel: 121 OWNER:_Lyssa Morin same 603-930-1952 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 2900 Home Improvement Contractor Lia# 171380 Construction Supervisor Lie.# TC 102776 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ 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 correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denialationnoof my license and for prosecution under MAIL Ch.268,Section I. Applicant's Signature: \t,�V Date: 9/5/18 Owners Signature(or chmen Date: Approved By: r - Date: 9 ` L ./F wilding Official(or dcsi nee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: • 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts - - t =Am _, . t 1. t. Department of IndustrialAccidents • , , . ' C = e1= " t ' i 1 Congress Street,Suite 100 • 111— J Boston,MA 02114-2017 • - • `°.,. , . i, , . . -ivwwmassgov/dia- . . . , . . , . _.. Workers'Compensation Insurance Affidavit:Bullders/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 ' City/State/Zip:South Yarmouth,MA 02664 ` Phone ii:508-398-0398 , Are you an employer?Check the appropriate box: Type of project(required): - - I. I am a employer with- 15 employees(fan and/or part-time); - ,7. 0 New construction - 2.9 I am a sole proprietor or partnership and have no employees working for me in . any capacity.[No'workers' insurance 8. El Remodeling comp.' required.] _ 9. 1:3 Demolition • .O - 3 I am a homeowner doing all work myself.[No workers'comp.insurance required.]', ' , _ 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will10❑Building addition i ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. . , , . ,: .., 12.❑Plumbing repairs or additions • . • 5.9 I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet 13. Roof airs These sub-contractors have employees and have workers'comp.insurance.: ❑ repairs '."6.0 We are a corporation and its officers have excrcised their right of exemption per MGI.c. 14.DOther Insulation , 152,§1(4),and we have no employees.[No workers'comp.insurance required] . ' 'Any applicant that checks box p1 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. Ifthe subcontractors have employees,they must provide their workers'comp.policy number. e Iain 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.Lic.#: 5D77852 - - . . - Expiration Date: 10/16/2018 - Job Site Address: 1 Captain Wright 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 co erage 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- - . - , Ido hereby cert Jy under th pains and penalties of perjury that the information provided above is true and correct . Signature: \\�\�S*� Date: 9/5/18 Phone#:508-398-0398 • Official use only. Do not write in this area,to be completed by city or town officiaL ___ . . - _ • , City or Town; PerinitiLicense# Issuing Authority(circle one):.: 1 t. ' • .. 1.Board of Health 2.Building Department 3.City/Pown Clerk 4.Electrical Inspector 5.Plumbing Inspector. 6.Other - , r Contact Person: Phone#: CAPESAV-01 HVVOODS AC RD CERTIFICATE OF LIABILITY INSURANCE �10/19/200TE 17Y1 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. H 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 . T Rogers 8.Gray Insurance Agency,Inc. PHONE FIJI 434 Rte 134 swc,it t : • wc,No):(877)516-2156 South Dennis,MA 02660 Lcu IREss:mailQrogersgray.com - - - - - - - ' ' • INSURERS)AFFORDING COVERAGE •NAICN INSURER A;EMSIOWIrs Mutual Casualty Company 21415 INSURED _ INSURER 8: - '- • - . Cape Save,Inc - INSURER C: 7 D Huntington Ave - "" , '_ " . INSURER 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. NSR • ADDL SUER POLICY SF? POLICY EXP LTR TYPE OF INSURANCE NSD WVD POLICY NUMBER IMMIDOM'YYI IMMIDD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY .- EACH OCCURRENCE S ` 1,000,000 CLAIMS LtADE X OCCUR 5D77852 10/16/2017 10116/2018MAGE TORENTED oOCMIWKe) $ 600,000 PREMISES IFa . - {Ai , MED oneperson) E 10,000 ' '' PERSONAL&ADV INJURY S 1,000,000 GEN%AGGREGATE JEpGT URMpIT.APPLIES PER: - . • GENERAL AGGREGATE ' $ 2,000,000 POUCY X LOC - ' PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER - EBL AGGREGATE 1 - - 2,000,000 A AUTOMOBILE LIABILITY COMBINEEDSINGLE UNIT( accident) S 1,000,000 X ANY AUTO' _ ' 5277852 - • - 10/1612017 10/16/2018 BODILY INJURY(Perpenon) S OWNED SCHEDULED AUTOSp��ONLY _ AAFIUpTFIO.ppSy�R..IEp - - _ _ _ , •" • _pBROpDILY INJURYpp (Per accident) $ AUTOS ONLY ' .T saw ., LPer aPEERJY mAGE $ - S A X UMBRELLA LAB X nrnBT EACH OCCURRENCE j 2,000,000 EXCESS UAB -. CLAIMS-MADE _ . 5J77852 J - , ' . ." , 10/16/2017 10116/2018 AGGREGATE 1 2,000,000 CED X RETENTIONS 10,000 . $ , A WORKERS COMPENSATION " - AND EMPLOYERS'LABILITY X STATUTE FRS 5H77852 10/16/2017 10/16/2018 600,000 ANY CEI I%I MpO EXCLUDED? EXECUTIVE Y/N E.L.EACH ACCIDENT S OF C F,nr.n) ."; N NIA _ - E.L.DISEASE-EA EMPLOYEES 500,000 NYn esRlbe Ulder - DESGIRdIPTION OF OPERATIONS below - EL"DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,AddlsaW Remarks ScheduK nay be mused If mon space Is WHOM/ - . . CERTIFICATE HOLDER CANCELLATION ' '- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE Cape Light Compact Joint Powers Entity ACCORDANCE WITH THE POUCY PROVISIONS. CE WILL BE DELIVERED IN Housing Assistance Corporation , . - - 450 W.Main St Hyannis,MA 02601 AUTNORDED REPRESENTATIVE ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • V4 i ,i L t1f I + r 7n!6clPP ,rl - Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 i Boston, Massachusetts 02108 Home Improvement Contractor Registration ( `_; ? T Corporation t 0.i s':y_:,-.�• : IC.r Registration: 171380 CAPE SAVE INC. f-:--; *.k'r<.,:_ 't w' Expiration: 03/13/2020 7-D HUNTINGTON AVENUE ,I pi.--:::A.,,,- ;`:f-. };1 SOUTH YARMOUTH,MA 02664 l , ..r..->?.,.1-.t;*,: .: '� ._ ,,it\\_- 3.7 Y • -1i""'� Update Address and Return Card. SCA1 O 20M-05/17 C ie,rrommontaratti 16 lfauaeirue/!s - . .. - . .--_........_.--_. ._ -_ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Caoaaticn before the expiration date. If found return to: Reoistration -. EIIRrattffi Office of Consumer Affairs and Business Regulation 171380,, ' 03/13/2020 One Ashburton Place•Suite 1301 CAPE SAVE INC.:''i- ;,'221,,,i '.i�`Y Boston,MA 02106 ' WILLIAM MCCLOSKEY,,-_%,'F 62...C.4521.--- 7-D HUNTINGTON AVENUE' Not valid W I t18tUTC SOUTH YARMOUTH,MA 02664 Undersecretary 8 c Commonwealth of Massachusetts ®1 Division of Professional Licensure Construction Supervisor Specialty Regulations and Standards Restricted In: Board of Building 9 CSSL-IC-Insulation Contractor Con structi\ooSZI MsorSpecialty ,r CSSL-102776 41flie''7 , Lryires:06/28/2019 WILLIAM J MCCLUSKEY0 i Y , 37 NAUSET ROAD; . . . - i WEST YARMOUTH MA02673 tn Failure to possess a current edition of the Massachusetts C ✓1 State Building Code Is cause for revocation of this license. Commissioner (�w /�L•_' DPS Licensing information visit:WWW.MASS.GOV/DPS DocuSign Envelope ID:622183E3-7C05-4E78-912E-929AA90FD51A RISE ENGINEERING' OWNER AUTHORIZATION FORM Lyssa Morin (Owner's Name) owner of the property located at: 1 Capt Wright Road (Property Address) South Yarmouth, MA 02664 (Property Address) CAPE SAVE hereby authorize Cape Save Inc. (Subcontractor) an authorized subcontractor for RISE Engineering,to ad on my behalf to obtain a building permit and to perform work on my property.This form is only valid with a signed contract. D«usgoed by: Merica Owner's S'gna ure - 8/28/2018 I 12:26 PM EDT Date RISE Engineering,a Division of Thielsch Engineering,Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RISEengineering.com