BLD-19-1749 OF �,� Office Use Only n
�O �`Permit)/
O ��y: Amount s
L MtT 1 [,y/
: "��%'-� Permit expires 180 days from s
•:. issue date
.QC)-Pi --ooi7y9
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH RECEIVED
Yarmouth Building Department
1146 Route 28
South Yarmouth,MA 02664 SEP 2 0 2018
(508)398-2231 Ext. 1261 f_� ___ T tI
CONSTRUCTION ADDRESS: 18 Town Brook Road
iiitel c �=LtT
ASSESSOR'S INFORMATION:
Map: 37 Parcel:89
OWNER: Mariya Holbrook same 774-327-1527
NAME PRESENT ADDRESS TEL #
CONTRAc'roR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398
NAME MAILING ADDRESS TEL#
■Residential ❑Commercial Est Cost of Construction$ 5000
Home Improvement Contractor Lic.# 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: 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 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 denialr re ation of my license and for prosecution under M.O.L.Ch.268,Section 1.
Applicant's Signature: \ �� Date: 9/11/18
Owners Signature(or athchmen attached Date: q
Approved By: ......4-1.: ./ Date: - ko -115
Building Official(or designee 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 0 No
_. .. -'The Commmonwealth of Massachusetts .
��et ' ' ' . Department of Industrial Accidents
c .. '• r =tint= ;. -"' - . , ., , : 1 Congress Street,Suite100 .-'
- _'l f . . Boston,MA 02114-2017
. r;��4 . . .F www.massgov/dia ,:
- Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. : ' ` . -
• TO BE FILED WITH TBE PERMITTING AUTHORITY. '
• :I . ''ApplicantInformation Please Print Legibly'''" ` '•i'.;
Name Business/Organization/Individual):Cape Save Inc '
Address:7-D Huntington Avenue-' ,= ' ,' , "•
City/State/Zip:South Yarmouth, MA 02664 - Phone#:508-398-0398 ,
Are you an employer?Cheek the appropriate box:
Type oCproject( required):
1.91 am a employer twith 15 - employees(full and/or part-time),* ' - -7. ❑Newconstruction - ..
- - . 2.0 I am a sole proprietor or partnership and have no employees working forme in ., 8. O Remodeling ,
, . .any capacity.[No workers'comp.insurance required.] ; ' ". . . • . • _
' -3.p I am a homeowner doing all work myself(No worm
ken"comp. smance required.]r '9. Demolition
AOIamahomeowner and winbehiringcentractnr'stoconductall work onmyproperty. [will ,
10 El Building addition
ensure that all contractors either have workers'compensation insurance or am sole 11.[]Electrical repairs or additions i
proprietors with no employees: . - 3. , 12.❑Plumbing repairs or additions
5.❑I am a general contractor and 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
•
6.0 We are a corporation and its officers have exercised their right of exemption per MCL c. 14. ✓ 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. - '
l am an employer that is providing 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: 18 Town Brook Road city/State/Zip:West 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. - - . . .- ._ -.
/do hereby certify under tth pains and penalties of perjury that the information provided above is true and correct
Signature: '>s., Date: 9/11/18
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#
i .,', Issuing'Authority(circle one): • t ,
1.Board of Health 2:Building Department 3.City/Town Clerk 4.Electrical Inspector &.Plumbing Inspector i•
6.Other . - - .- _
Contact Person: • Phone#:
•1• .
/-"Th CAPESAV-01 HWOODS
4CORO. CERTIFICATE OF LIABILITY INSURANCE t onn
9M n
017
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(Ies)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 CONT CT - .
Rogers&Gray Insurance Agency,Inc. PHONE FAx
434 Rte 134 _ _INC,NL,sE1 : ;tic,No(877)818.2156
South Dennis,MA 02660 U1 IMFS3;mail@rogersgray.com
• "- - INSURER(SI AFFORDING COVERAGE NAIC I
%%BRERR::Employers Mutual Casualty Company' 21415
INSURED - . . - NSURERB:
Cape Save,Inc _ NSURER C:
7 D Huntington Ave _ _ INSURER o: -
South Yarmouth,MA 02664
INSURER E:
INSURER F:
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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NSR ADDL SUER POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE NSD INT/1) POLICY NUMBER ryAIDONYYYI IMMIDDIYYYYI UNITS
A X COMMERCIAL GENERALLNNUTYEACH OCCURRENCE $ 1,000,000
CLAIMS-MADE X OCCUR 5D77852 10/16/2017 10/16/2018 RAMEMLSESfEe oAGETORENTEaulreDrKel E 600,000
RA
MED EXP(NN one Pelson) $ 10,000
PERSONAL SADV INJURY $ 1,000,000
GENL AGGREGATE UMpIT.APPLIES PER. GENERAL AGGREGATE $ 2'000'000
POUCY X jNECT l LOC PRODUCTS:COMP/OPAGG $ 2,000,000
OTHER' EBL AGGREGATE $ 2,000,000
A AUTOMOeta WNIJTY - • IlEaacciNdentSINGLE UNIT , $ 1,000,000
X ANY AUTO ' 5Z77852 10/16/2017 10/16/2018 BODILY INJURY(Per person) $ _
OWNED SCHEDULED
AAHIUIppT��O��S ONLY _ AUTOS - • - _BODILY INJURYpp (Per accident) $ _
AUTOS ONLY _ AUTOS ONLY • (I&SWR Y) MAGE $
_ $
•
A X UMBRELLA WB X OCCUREACH OCCURRENCE S 2,000,000
EXCESS LIAB CWMS4,IADE 77852 10/16/2017 10/16/2018 AGGREGATE S 2,000,000
DED X RETENTIONS 10,000 a
A WORKERS COMPENSATION - X I STATUTE I I FORH_
AND EMPLOYERS'LIABILITY
ANY PROPRIETOPoPARTNER,EXECUNVE YIN 5H77852 10116/2017 10/16/2078 E.L.EACH ACCIDENT $ - 600,000
q�FICEryIM TM EXCLUDED? N NIA
(Ma11datofy m NN) - - - 600,000
.
Nyea describe)rider EL DISEASE-EA EMPLOYEES
DESCRIPnON OF OPERATIONS below E DISEASE-POLICY LIMIT $ 60%000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IACORD tet,AddlUo.W Remarks Schedule,may be attached It non apace Is required):
•
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Cape Light Compact Joint Powers En THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
' Housing Assistance Corporation ACCORDANCE WITH THE POLICY PROVISIONS.
460 W.Main St - - - - - -
Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE
ACORD 25(2016/03) ®1988.2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
•
•
g92 ' z o/oSuaettl
•
Office of Consumer Affairs and Business Regulation
One Ashburton Place- Suite 1301 1
Boston, Massachusetts 02108
Home Improvement Contractor Registration
tti
rDr,,tr Type: Corporation
e( (i = �(� Registration: 171380 •
CAPE SAVE INC. 3 ` 1 Expiration: 03/13/2020
7-D HUNTINGTON AVENUE C i ���'r
SOUTH YARMOUTH,MA 02664
•- �`ry .g •
4u�y`
Update Address and Return Card.
SCAT 8 2014-05/17 -
c5aeroyarmonarafi4e 10&aa ada
Orrice of Consumer Affairs✓k Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:Corporation before the expiration date. B found return to:
fteolstration--- fainfrellon Office of Consumer Affairs and Business Regulation
171380 _- ' 03/13/2020 One Ashburton Place-Suite 1301
CAPE SAVE INC., +, ; i t Boston,MA 02108
`i'i
WILLIAM MCCLUSKEY-i j '-""" 't
7-D HUNTINGTON AVENUE
SOUTH YARMOUTH,MA 02664undersecretary Not valid w •i Ignature
•
•
Conxnonweaith of Massachusetts
®� Division of Professional Licensure „ Construction Supervisor Specialty
•
' Board of Building Regulations and Standards Restricted In:
CSSL-IC-Insulation Contractor
Construction,SUjWM,pr Specialty
f
CSSL-102776 ' r' " '' 9,� Ej5pires:06/28/2019
1♦
.,� i 4
•
WILLIAM J MCCLUSKEY! .,
37 NAUSET ROAD; :. > 1 _
WEST YARMOU7N�MA 02873 s":". F
Failure to possess a current edition of the Massachusetts
State Building Code Is cause for revocation of this license.
Commissioner DPS Licensing information visit:W W W.MASS.GOV/DPS
•
RISE
ENGINEERING
OWNER AUTHORIZATION FORM
Mariya Holbrook
(Owner's Name)
owner of the property located at:
18 Town Brook Road
(Property Address)
West Yarmouth, MA 02673
(Property Address)
hereby authorize C a P e S a u l
(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.
Owner's Signature
Date
RISE Engineering,a Division of Thielsch Engineering, Inc.
5 Dupont Avenue i South Yarmouth,MA 02664 i 508-568-1926
www.RlSEengineering.com