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Home My WebLink AboutBLD-19-001750 Cape Save Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 508-398-0399 10/26/18 Town of Yarmouth Regulatory Services ` Building Division � G ti0�� 1146 Route 28 � 0`� �� South Yarmouth,MA 02664 o\NGa e tal RE: Building Permit 19-001750 TO: Building Inspector(s), This affidavit is to certify that all work completed for 23 Fairwood Road has been inspected by a third party Certified Building Performance Institute(BPI)Inspector. Attic Flats: R-22 cellulose Basement Sills: R-19 fiberglass All work performed meets or exceeds Federal and State Requirements. Sincerely, \S4\ \V William McCluskey Y Office Use Only l 4•Y 1 .O �0 ;Permit" 1 0in, .. Amount ..C4 ` % ey.' Permit expires 180 days from !issue date ' EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 SEP 20 2018 (508)398-2231 Ext. 1261 eBUrIL Tq, E CONSTRUCTION ADDRESS: 23 Fairwood Road ASSESSOR'S INFORMATION: Map: 91 Parcel:5 OWNER: Eugene Blanchette same 508-694-5939 NAME PRESENT ADDRESS TEL. It 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 600 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lit.# TC 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: Fmployers 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 31 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 ationnoof my license and for prosecution under M.G.L Ch.268,Section 1. Applicant's Signature: \ Av Date: 9/1l/IS Owners Signature(or attach men attached Date: �� Approved By: ` /,ti-.,,/ Date: S ' ) 0- /Qr . Building OfTiiccial(or desi EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft of Wetlands: 0 Yes 0 No 0 Yes 0 No i'\ .,1 The Commonwealth itfMassachusetts .- - - - - .. , : 1 .>;1R ft , .. Department oflndustria,Accidents - -. ' . c. '- e =4-ria: ;. ' = • 1 Congress Street,Suite 100,- -. , : __ _{ Boston,MA 02114-2017 l'ear# ; i • ., 'www.massgov/dia _ Workers'Compensation Insurance Affidavit:Builders/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 44 '' s phone#:508-398-0398 : Are you an employer?Check the appropriate box: Type of project(required): 1-Q✓ I am a employer with - 15 employees(full and/orpan-time).• ' - " 7.,❑New construction 2.0I am a sole proprietor or partnership and have no employees working for me in - , 8. O Remodeling' ' - any capacity.[No workers'comp.insurance required.], .- . • - • - , 3.01 am a homeowner doing all work myself.[No workers'comp,insurance required.]t, - . 9..❑Demolition . - 4.1:11 am a homeowner and will be hiring contractors to conduct an work on my property- twill 10 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 5.0 I am a general contractor end I 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.p 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. • '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.Lic.#: 5D77852 . . .- . . . - . Expiration Date: 10/16/2018 . = Job Site Address: 23 Fairwood 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. . _ .. i I do hereby certify under illpains and penalties of perjury that the information provided above is true and correct Signature: \ Date: 9/11/18 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/License# ' „ • Issuing Authority(circle one): - '• - , 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector,5.Phimbing Inspector : --- 6.Other - - Contact Person: Phone#: •s r . .. . , /.e.% CAPESAV-01 " HW00DS A`�R�� CERTIFICATE OF LIABILITY INSURANCE DATE 0/19/2M 0 7YI 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 POUCIES 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(es)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the tonna 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). ,NA PRODUCER MTACT Rogers Bray Insurance Agency,Inc. PHONE FAX 434 _ _ (A/C.NLo,Eaq: Wc,No):(877)816-2156 South Dennis,MA 02660 pppRIES-q,mail@rogersgray.com - 'INSURER(S)AFFORDING COVERAGE WC NSURER A;Employers Mutual Casualty Company 21415 INSURED - • INSURERS:- - 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POLICY EFF POLICY EXP • LTR TYPE OF INSURANCE NSD WVO POLICY NUMBER SAM/DOJYYTY1 IMMIDnryyY1 LIMITS ' A X COMMERCIAL GENERAL LWBIuTY - EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X Om Cr' R 5D77852 10/16/2017 10/16/2018 PDRMAGSEEOEREoNcGTEllDrenco) S 600,000 10,000 MED EXP(My one person) $ PERSONAL SADV INJURY 3 1,000,000 GE I.AGGREGATE UNIT APPLIES PER GENERAL AGGREGATE S 2'000'000 POLICY X ga LOC PRODUCTS-COMP/OP AGO S 2,000,000 OTHER" " ' EBL AGGREGATE $ 2,000,000 A aurosoBILE LABILITY COMBINED SINGLE LIMIT acantl $ 1,000,000 X ANY AUTO _ .. - 5Z77852 10/16/2017 10/16/2018 BODILY INJURY(Per Person) $ ' OWNED SCHEDULED AUTOSg�� ONLY _ AUTOSANp�� WWNNEEpp BODILY ITNyJURfPer accident) j -- AUTOSONLY Odra .. - - - leer denr E $ $ • A X UMBRELLAL AB X OCCUR EACH OCCURRENCE 3 2,000,000 EXCESS LAB CLAIMS-WADE 5J77852 - . 10/16/2017 10/16/2018 AGGREGATE J 2,000,000 1 DED X RETENTIONS 10,000 j A WORKERS COMPENSATION AND EMPLOYERS'LABILITY X STATUTE FR ANYAQNFCCPEREOPREIIETggO�RRqIPARTNER,EXECUTIVE Y/N 5H7755x ta16/2o17 10/1 Wzola E.L.EACH ACCIDENT $ 500,000 (WIC RN leM NNI EXCLUDED? 1 • N NIA - - 500,000 EL DISEASE-EA EMPLOYEE $ If dex'me Oder 600,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATORS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached Yawn pace le required) --- . CERTIFICATE HOLDER CANCELLATION - - - . SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE Light Compact Joint Powers EntityTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Cape l9 pa - ACCORDANCE WITH THE POLICY PROVISIONS. Housing Assistance Corporation . . , ' 460 W.Main St. " Hyannis,MA 02601 AUTIORDED REPRESENTATIVE - ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD el-2e oia�� . - • Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Massachusetts 02108 Home Improvement.Contractor Registration _ ::, Type: Corporation yj Registration: 171380 CAPE SAVE INC. r 4:2`.x?'-.?..,,f;',�_=-j\ Expiration: 03/13/2020 7-D HUNTINGTON AVENUE ( 4=;' ` 4'' SOUTH YARMOUTH,MA 02664 =l Ic-.�£ . E°_ ^- -1 \s-,>„,[,'.::,j, ^ ".9 C t ^4_H--.:7 • r :**:-...Y f:.-ai.-.r Update Address and Return Card. SCA f 0 20M-057 ('moi / JJ// - --__. ., _ ..____...-.._._ ___--'— Office of Consumer Affairs 6 Business Regulation HOME IMPROVEMENT CONTRACTOR Registrationvalid for Individual use ordy TYPE:Caroaa6on • before the expiration date. If found return to: • penistration - - Fjmiratlon Office of Consumer Affairs and Business Regulation 171380 ,___ ° 03/132020 One Ashburton Place-Suite 1301 ' CAPE SAVE INC..f ' ' F- - Boston,MA 02108 —`-.•64.-_--;!`/5 WILLIAM MCCLUSKEY-: _-,-:, Q ." GGQ`f-- 7-D HUNTINGTON AVENUE' 44 SOUTH YARMOUTH,MA 02664 Undersecretary Not valid w •,. 'Ignature • ' r. Commonwealth of Massachusetts Construction Supervisor Specialty VDivision of Professional Licensure Restricted to: - - Board of Building Regulations and Standards CSSL-IC-Insulation Contractor ConstructiorTSi M rSpecialty. i/ CSSL-102776 Prwer 's, spires:06/28/2019 rd., a !r - ...,,.., WILLIAM.3 MCCLUSKEY? i ,a .. - - - 37 NAUSET ROADI + 3 ,:r \t ti • WEST YARMOUTH-MA 02673,' .•-".,�' •1tots\- Ao " Failure to possess a current edition of the Massachusetts D ✓1 State Building Code Is cause for revocation of this license. Commissioner l/./,^_' !��__ DPS Licensing information visit:WWW.MASS.GOV/DPS ,est ':" ' .r, Permit Authorization mass save Form Saw writ Curator eaerOy eeC1enty Site ID:3447348 Customer. Eugene Blanchette I, U4inte. �j/nvtcIuU.c� ,ownerofthepropertylocatedat: Q (owners Name,pined) 23 Fanwood Road South Yarmouth, MA 02664 (Property street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature: ØL/.4ltC_57' /Ga,LIJ — Date: 2-27- ta- 4®e9B8M'SMOait 00004.04Tt lA tet$00S°9444FMMte-01091•41Me 64,4,liltIMOMIS4Qe1:la FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: • Cape Save Inc. Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: For Office Use Only Rev.102015 ,, .. . ..� .. , . .,.,,.. _ ., ... . .