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Home My WebLink AboutBLD-19-1378 _. r Office Use Only • 10 .y44It tPermit# 9 z i � '5 ' O 1 Amount i ��..�� ab—I 1�nd�/ Permit expires 180 days from „ ll l�—a) issue date EXPRESS BUILDING PERMIT APPLICATI TOWN OF YARMOUTH ` E C E I V E D Yarmouth Building Department 1146 Route 28 SEP - 6 2018 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 BUIL. - ; T By: _ CONSTRUCTION ADDRESS: 142 Captain Small Road ASSESSOR'S INFORMATION: Map: 77 Parcel:37 OWNER: Sharon Degennaro same 508-619-6963 NAME PRESENT ADDRESS TEL. # CONTRAcroR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL It ■Residential ❑Commercial Est.Cost of Construction$ 5000 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lie.# IC 102776 Workman's Compensation Insurance: (check one) 0 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 nue and correct to the best of my knowledge and belief. I understand that any false answers) will be just cause for denialr cation of my license and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: 1\ Date 9/5/18 Owners Signature(ora men attache. Date: q Approved By: dA <Date: ^C -yr Bu' ng Official(or esigne EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No • the Commonivealth ofAfassachusetts • • iso"–='hgri ., Department ofIndtistrwlAccWen-is , ,• �._' '1 Congress Street,Suite 100 .• ";�._�9' Boston,MA 02114-1017 `% — • www mass.gov/dia - Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.' ' ' ` '.' TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leelbly Name(Business/Organization/Individual):Cape Save Inc Address:7-D Huntington Avenue' t • t City/State/Zip:South Yarmouth,MA 02664 Phone#:508 398 0398 Are you en employer?Check the appropriate box: Type of project(required): • - 1.Q l am a employer with 15 employees(foil ancvorpart-time). - • : - 7. ❑New construction • - .,2.❑I am a sole proprietor or partnership and have no employees working for me in - 8•-❑Remodeling any capacity.[No workers'comp.insurance required.] .. , - . _ . •• - - , 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t '9. 0 Demolition • 4O t am a homeowner and will be hiring contractors to conduct all work on my property. twill 10 Building addition ensure that all contractors either have workers'compensation insurance or aro sole 11.0 Electrical repairs or additions proprietors with no employees. . .. . , 12.❑Plumbing repairs or additions • $.Q I am a general contractor and 1 have hired the subcontractors listed on the attached sheet 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.: ' 6.0 We area corporation and its officers have exercised their right of exemption per MGL c. 14.0✓ D01er Insulation 152,{1(4),and we have no employees.[No workers'comp.insurance required.] ` Any applicant that checks box XI 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 isProvlding workers'compensation insurance for my employees Below is the policy and fob site information. _ .. .' Insurance Company Name: Employers Mutual Casualty Company Policy#or Self-ins.Lic.#: 5D77852 _ — . - Expiration Date: 10/16/2018 Job Site Address: 142 Captain Small Road 1 City/State/Zip:South Yarmouth 'Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date): H 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 underr tth pains and penalties of perjury that the information provided above is true and correct Signature: i,\�\�3� Date: 9/5/18 Phone#:5°8-398-0398 \ • Official use only. Do not write in this area,to be completed by city or town official. ,. City or Town; Permit/Llcenae# lssuing 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#: /.Th CAPESAV-01 HWOODS ACORO' CERTIFICATE OF.LIABILITY INSURANCE °10/1912017ATE ' `� 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 pollcy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED, 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 Rogers&Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 - - (=JOT,EN): (NC Nob(877)816.2156 South Dennis,MA 02660 AD'pARiss,mall@rogersgray.com • "' - _ - _.- -INSURERS)AFFORDING COVERAGE NAICF NSURERA:Employers Mutual Casualty Company 21415 INSURED . . - INSURER B: " - - _ ._ . . . . Cape Save,IncNSURER C: ' 7 0 Huntington Ave _ .. -- .. NsuRERD: - ' South Yannouth,MA 02664 . .. •�,� - INSURER E: ' • ' ' ' NSURERF: 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 •'ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE WSD WVD POLICY NUMBER IMMIDOIYYYyi IMIAMNYTyT - LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S ' 1'000'000 CLAIMS-MADE X OCCUR . - 5D77852 10116/2017 10/16/2018 D MAG$ o RENTTEED 1 $ 500,000 ., MED EXP(Any one Person: S 101000 - PERSONALSADV INJURY S 1,000,000 GEN.AGGREGATE LIMIT APPLIES PER: - ' GENERAL AGGREGATE $ 2,000,000 POLICY X JECT LOC PRODUCTS•COMP/CPAGG S 2,000,000 EBL AGGREGATE s — 2,000,000 A AUTOMOBILE LIABILITY . , , , IEOaMBINEDSINGLELIMIT 5 1,000,000 X ANY AUTO 5277852 10/16/2017 10/16/2018 BODILY INJURY(Per Person) S OWNED — SCHEDULED AUTOSpp�� ONLY AAFIUUpTs�IOSyy��1..��pp. - . _, - - pBOODILY INJURY(Peramden0 5 _ L ONLY.• _ eame • - (Paramdard: E s _ $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE 3 2,000,000 EXCESS LIES . . CLAIMS-MADE 5J77852- . . ' ' ' -, 10/16/2017 10/16/2018 'AGGREGATE ,3 2,000,000 DED X RETENTIONS . 10,000 S A ANEMPLOYERS'LIABILITY Bluir Y/NTION . X STATUTE W. ANY PROPRIETOR/PARTNER/EXECUTIVE 5H77852 10/16/2017 10/1612018 600,000 ANN�YPPROPRIEORPARTNEEOT NJ NIA — _ _ EL EACH ACCIDENT S' "•—"V�n ) i E.L DISEASE-EA EMPLOYEE S• X0'000 yes,describe under ' If .. 500,000 DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS:LOCATIONS I VEHICLES(ACORD 101,Additional Remark.Schedule,may be attached Emote specs M required) ., . .• • -, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CapeLight Compact Joint Powell;EntityTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 0 pa ACCORDANCE WITH THE POLICY PROVISIONS. • Housing Assistance Corporation - •• 460 W.Main St Hyannis,MA 02601 AUTHORDED REPRESENTATIVE - - ACORD 25(2016/03) • ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD _. )TOME OWNER WEATHERIZATION WORK PERMIT; PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER. I .tan . ' hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation on the property located at 5. kia.tivkizmAt.d Ma oa &lo4 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 wail 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 agreement and give my consent. Home Owner(signerwo frc.9'Wa+% . il1M.NQr&St Home Owner email: his -)dl(yrec re el Date: $ I Cz Agent(signature) Date: Agency Approved Weatherization CompanyCA P _ MQ� All Cape Energy Alternative Weatherization Cape Cod Insulation 0 Cazeault Frontier Energy Solutions Lohr %ome Improvementlg Agency Signature: (�Date: b 'at Ig For Natural Gas Customers: I have received the National Grid Discount Rate Application form from my auditor, Customer Initials • • _• ��j I '/ b / / ta4et a, Office of Consumer Affairs and Business Regulation . One Ashburton Place- Suite 1301 1 Boston, Massachusetts 02108 Home Improvement Contractor Registration . _fit_.. = ' =9 i T tion 4' C: _a: :alt TYPE,: Corpora }?t4=: :-'i--j.- = ,,•,2 Registration: 171380 CAPE SAVE INC- r,i t_ .,.-..;•; .. .1]..-,f-F---.7.10.-,1_, 7-DHUNTINGTONAVENUE 1.' ` `_--4 twt Expiration: 03/13/2020 _ • SOUTH YARMOUTH,MA 02664 i"� �"((''q)t4-, � :w=may �� ` �< a-OV Update Address and Return Card. SCAT 0 YOM-0Sn7 81 f'ammanuea/PSrt¢1ita reAti /4 Ofnce of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: Reoistratlon -- Exoiratioft Office of Consumer Affairs and Business Regulation 171380. r- .-' 03/13/2020 One Ashburton Flocs-Suite 1301 CAPE SAVE INC.. - ''s r, Boston,MA 02108 r ..�- :l,a ~ WIWAM MCCLUSICEY. % -''1'\?/ 'CB-e'-- \/_ 7-D HUNTINGTON AVENUE' (� SOUTH YARMOUTH,MA 02664 Undersecretary Not valid w .y ;i -Ignature • °. Commonwealth of Massachusetts Division of Professional Licensure ' Construction Supervisor Specialty �1 Restricted Board of Building Regulations and Standards CSSL-ICtn: InsulationSSL-IC- Contractor Constructio*S\}rM rSpecialty ' CSSL-102776 I'""7"7E jlires: 06/28/2019 ��,,, t . > WILLIAM J MCCL'USKEY, i . ' EV 37NAUSET ROAN .:ir \Tc�, ti 1 WEST YARMOUITH'MA 02673 `C - .„ - -1 Failure to possess a current edition of the Massachusetts /2 _ State Building Code Is cause for revocation of this license. Commissioner ��✓ DPS Licensing Information visit:WWW.MASS.GOVIDPS