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Home My WebLink AboutBLD-19-001379 ip Y 6 Office Use Only • ES" Z Of �� Permit"O °3\"^'"' c-p' \ /' Permit expires 180 days from S BU EXPRESS BUILDING PERMIT A1PLICAT 1.11 C rE i v E a TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 SEP - 6 2018 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 a 9IL a dF''0 ' kr CONSTRUCTION ADDRESS: 69 Captain Shiverick Road ASSESSOR'S INFORMATION: Map: 77 Parcel: 136 OWNER: Mohamed Araba same 508-398-8043 NAME PRESENT ADDRESS TEL It coNTRAcroi:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL.It ■Residential ❑Commercial Est.Cost of Construction S 5000 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lie.# 1C 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: 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 am true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denialr re ation of my license and for prosecution under M.O.L.Ch.268,Section I. Applicant's Signature: Date 9/5/1R Owners Signature(o ehmeaDate: 9 Approved Br Date: 7 — aD /f' uilding Official(or designee) 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 w • - - • The Coininonwealth of Massaehusetts It ,F�fri, -v, Department of Indastrial Accidents • Tel= 1 Congress Street,Suite 100 ` ' ' _DL_e9 • " Boston,MA 02114-2017 • *144.•,,Z0 , • .; .• • ., ;.:.: .www mass gov/dia ' •': ,. .?.. ;, '.. - Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers: • ' •' TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PleaseMai Legibly ' l ,_ :.i Name(Business Organization/[ndivididuaQ:CapeSaveInd Address:7-D Huntington Avenue • City/State/Zip:South Yarmouth,MA 02664 phone#:508-398-0398 • Are you an employer?Check the appropriate box: " 1 - Type of project(required): 1.El I am a employer with 15 'employees(full andiorpart-time).' - - _ r7. Ej New construction - " '• , 2.01 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling • • . ,. any capacity.[No workers'comp.insurance required"] . 3.lam a homeowner doin all work myself.[No workers'co 9: El Demolition g Y rap.insurance required.] 4,plamahomeownerandwillbehiringcontractorstoconductallworkonmyproperty. Lwin - 10 Q Building addition ' r ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. - . . ,, ,. :,r 12.0 Plumbing repairs or additions 4' 5.0 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.: 13.0Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL o. 14.0 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.' ' ' ?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- K. 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 andfob site information, . . . . _ .. . Insurance Company Name: Employers Mutual Casualty Company - • . Policy#or Self-ins.Lic.#:-5D77852 - • - Expiration Date:- 10/16/2018 ' '• ,Job Site Address: 69 Captain Shiverick 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. ._ . _ . . _. l do hereby certify under thpains and penalties of perjury that the information provided above is true and correct Signature: - i�4\�Y Date: 9/5/18 Phone#:888 398-0398 • 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) r' - _= ' 1.Board of Health 2.Building Departm.eat-13.City/Town Clerk 4.Electrical Inspector,5.Plumbing Inspector.1 6.Other • Contact Person: Phone#: ;i'. CAPESAV-01 HWOODS ,4co- CERTIFICATE OF LIABILITY INSURANCE DATE(MM DD YYYYI • �� 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 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 „ CONTACT Rogers&Gray Insurance Agency,Inc PHONE FAX 434 Rte 134CAC,No En): INC,Nob(877)816-2156 South Dennis,MA 02660 . iDa"Aoass:mail@rogersgray.com - - . . . - ^ - - ^. - INSURER(S)AFFORDING COVERAGE NMCN POURER A:Employers Mutual Casualty Company 21415 NSURED - . - -. .. - . . . - INSURER B: - - ._ - - CapeSave,Inc NSURERC: ' 7 D Huntington Ave .. ' . -. INSURER D: - South Yarmouth,MA 02664 '-' - NSURERE: - . NSURERF: COVERAGES - ' CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES 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 • ADDLSUBN POLICY EFF POLICY EXP LTH TYPE OF INSURANCE rn Woo POLICY NUMBER IMM/DDN YYYI IMMIONYYYYl UNITS A X COMMERCIALGENERAL LIABRJTY . • ' ' EACH OCCURRENCE " $ ' 1,000,000 CLAMS-MADE ri OCCUR .• 51377852 10116/2017 10116/2018 PPRM sEESJEeENTED oca runs I 600,000 - • _• - • MED EXP(MY one person) $ 10,000 • PERSONAL&ADV INJURY $ +,000'000 GE 'L AGGREGATE pURMaR APPLIES PER: . . . GENERAL AGGREGATE S 2,000,000 ' POUCY X Jg5 u LOC " . . PRODUCTS-COMP/OP AGG S 2,000,000 OTHER " - ' " - • - '" . . - ' EBL AGGREGATE' - + . - - 2,000,000 A AUTOMOBaE MOIETY „ .. . CEOMBIINEDSINGLE UMIT . S 1,000,000 X ANY AUTO • ' 5277852 , 10/16/2017 10/16/2018 BODILY INJURY(Per penal) S OWNED SCHEDULED • _ AUTOS ONLY• ♦AUBODILY INJURY jeer accident) $ - �ANSONLY - . N0.W0p . BeakpgE S _ S A X UMBREWLIAB X OCCUR • . EACH OCCURRENCE 1 2,000,000 EXCESS LIAR- CLAIMS-MADE 5,177852 •' •• .'.-, 10/16/2017 10/16/2018 AGGREGATE S 2,000,000 DED X RETENTIONS • 10,000 . . . ' - S . A WORKERS COMPENSATION ' ' - - ANDEMPLOYERS'umuurY X STATUTE FORµ ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 5H77852 10116@017 10/16/2018 EL EACH ACCIDENT 1 600,000 pFFICEyMin%EXCWDED?-.. _ . N NIA _ , 1M es dee Y,NX) . , • EL DISEASE-EA EMPLOYEES 500,000 If)es,sesame ober 500,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,AddItlmW Remarks Schedule,nay be attached a mac space Is npded) - • CERTIFICATE HOLDER CANCELLATION • "" "' SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE CapeLight Compact Joint Powers Entity TME EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 pa sty ACCORDANCE WITH THE POUCY PROVISIONS. • Housing Assistance Corporation 'i . . ' . ' . . . -• ' 460 W.Main St • Hyannis,MA 02601 AUTHORS=REPRESENTATIVE' . . - -, ACORD 25(2016/03) 01988.2015 ACORD CORPORATION. All rights reserved. ' The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 1 Boston, Massachusetts 02108 Home Improvement Contractor Registration 7,r_-. :.-.= , .7 ,,.. .-._4;71. ,1 - TypeCorporation E"_t ':-I,-=Ys; ra ,., --:::::::,-75_ Tpr Registration: 171380 CAPE SAVE INC. : S: ,i V-1-7---"la Expiration: 03/13/2020 7-D HUNTINGTON AVENUE / '45:727.' _ t. ,__- SOUTH YARMOUTH,MA 02664 EL ,� t:_:�s �i ta,t-.- / • C--- -4-: r_ 1F H scat O 20nw5/17 Update Address and Return Card. _ r�t i ammonwea/!/10(jaairdui lO - —_—_ _ _. _,_�._._____ ._.,.___.�__ ()Ringo}Consumer Affairs&Business Regulation • HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corooreucn , before the expiration date. if found return to: Aealstration =- Exoiratlon Office of Consumer Affairs and Business Regulation 171380 : ' -103/132020 One Ashburton Place-Suite 1301 CAPE SAVE INC. -41, Boston,MA 02108 7 l',1 WILLIAM MCCLUSKEY: %.: 'C .�er-e-e--• 7-O HUNTINGTON AVENUE` \s,/ SOUTH YARMOUTH,MA 02664 Undersecretary - Not valid w .�. c1 'Ignature • s Commonwealth of Massachusetts VIDivision of Professional Licensure - Construction Supervisor Specialty Board of Building Regulations and Standards CSSL-ICRestricted In: SSL-IC-Insulation Contractor ConstructiooS\}jMwispr Specialty j CSSL-102776 .11”.”vi 7 Ekpires: 06/2812019 WILLIAM J MCCLUSKEW j ,,i •' ��''^^ 37 NAUSET ROAD4 •. J i C s WEST YARMOUTH-MA 02673�� \ .-i 't7>/1\i301 Failure to possess a current edition of the Massachusetts I State Building Code is cause for revocation of this license. Commissioner DPS Licensing Information visit:WWW.MASS.GOV/DPS NOME OWNER WEATHERIZATION WORK PERMIT; PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER. I 17117041k,t,1 ird a hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation on the property located at: I ey` 8 _ You fletOdhe, The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures: Weather stripping; air sealing;attic&basement Insulation; exterior wall Insulation; ventilation measures In consideration of the weatherization work to be done at my home I agree to the following: 1. I give permission to Housing Assistance Corporation to access the property with such equipment and materials as may be necessary to perform weatherization. 2. The Housing Assistance Corporation reserves the right to Inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five (5)years after the weatherization work is completed. I have read the provisions of this agre met d giv my ns nt. Q Home Owner(spnamre) Home Owner email: Date: Agent:(spnature) Date:C Agency Approved Weatherization Company P . Ja[ ,? All Cape Energy Alternative W atherizatio Cape Cod Insulation ape Save Cazeault Frontier Energy Solutions Lohr Home Improvement Agency Signature: o Date: O ,2g,. S Sir For Natural Gas Customers: I have received the National Grid Discount Rate Application form from my auditor. Customer Initials