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Home My WebLink AboutBLD-19-001748 ` o4"'ARI Office Use Only kItoI Permit# L. , 55:4...... fi• Permit expires I80 days from • issue date f BC- u- Iq-0D /7 EXPRESS BUILDING PERMIT APPLICATION 1 /' TOWN OF YARMOUTH RECEIVED ( Yarmouth Building Department „_--.i 1146 Route 28 j South Yarmouth,MA 02664 SEP 2 0 2018 I (508) 398-2231 Ext. 1261 BUIr - •. Er-- By :rar. `sem!— — — CONSTRUCTION ADDRESS: 143 Astor Way ASSESSOR'S INFORMATION: Map:99 Parcel: 17 OWNER: Wayne Ernest • same 508-246-6863 ' 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$ 4600 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lie.# IC 102776 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor M.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 denial r cation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: � � Date: 9/11/18 Owners Signature(or attachmen -attttaac-h—ed Date: 1 r Approved By: ,��y,, Date: q - ego -1 6 Building Official(or designee EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes ❑ No - ' - .. The'CommonweaIth of Massachrisetts. - - . ' • 1—.1 (l • r ' ;Department . r`.. ' C ei 9 ' 1 Congress Street,Suite 100 ' llic Boston,MA 02114-2017 i ;'�J– - . ;. . r. .www titass.gov/dia , • , E . • , _ .t . Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. ' •' :• ‘:1. , TO BE FILED WITH THE PERMITTING AUTHORITY. . .. ^ Applicant Information , .' PleasePrint Legibly -' ' ".'" 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 en employer?Check the appropriate box: Type of project(required): - 1.1:1 I am a employer with- 15 employees - - ' . ... (full and/or part-lime ,r, ,,7. El New construction ' :2.0I am a sole proprietor or partnership and have no employees working forme in . 1 . 8. ❑Remodeling r r t - ., , ' any capacity.[No workers'comp.insurance required.] .) , . . 9. ❑Demolition , '].a I am a homeowner doing all work myself[No workquers'comp,insurance reired.]t : is •, 4.01 am a homeowner and will be hiringcontractors to conduct all work on 1 O 0$uilding'addition my Nv1A'ty. I will ,t•" r• 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 , 5.0 lam a general contractor and I have hired die sub-contractors listed on the attached sheet 13.0Roof 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 e. 14.❑✓ Other Insulation 152,11(4),and we have no employees.[No workers'comp.insurance required.] 7< ' _ " *Any applicant that checks box al 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 .. .'r employees, If the subcontractors 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.#: .51377852 - _ - -.--- - Expiration Date?"i0/16/2018 ''•' • ' ' Job Site Address: 143 Astor Way'' 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 fate 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 under th pains and penalties ofperjury that the information provided above is true and correct Signature: \� 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 - ,- .- . . - - , . =,t •:. City or Town; - Permit/License# ' , - Issuing Authority(circle one): I • • ,1 •. ,. 1.Board of Health 2.Building Department 3.City/To"wn Clerk 4.Electrical Inspector,5.Plumbing Inspector - 6.Other - - •- - Contact Person: ' • .. Phone#: /...4, CAPESAV-01 •HWOODS ACORO• CERTIFICATE OF LIABILITY INSURANCE D / k........--- • 1100/119/209/20 YYYI 17 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 pollcypes)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 CONTACT • Rogers 8 Gray Insurance Agency,Inc.. JPHHOONNE FAX Sut Dennis,MA 02660 it van. gersgra .cors 'NOl`�877)816-2156 A mail ro y - INSURER(S)AFFORDING COVERAGE NAICO INSURER A:Employers Mutual Casualty Company 21415 INSURED -- - NSURERS: ' .. - ' Cape Save,Inc INSURER C: ' 713 Huntington Ave - - _ - . , INSURER D: - South Yarmouth,MA 02664 NSURER E/ • MSURER 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. WSR • ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE NSD WVD POLICY NUMBER (MMIDOD'YYYI IMMIDDNYYYl UNITS • A X COMMERCIAL GENERAL LIABILITY ' - - EACH OCCURRENCE S 1,000,000 CLAIMS-MADE n Ort IR 5D77852 10/1812017 10/16/2018 PriEIAA ISEEi(EaEIIToms aKe) $ 600,000 - MED EXP(Mir one operson) $ 10,000 PERSONAL 8 ADV INJURY S 1,000,000 GEN.AGGREGATE pURMpIT.APPLIES PER: - GENERAL AGGREGATE $ 2,000,000 POUCY X JECT LOCPRODUCTS-COMPAJP AGO S 2,000,000 OTHER-- ._ - - - - - EBL AGGREGATE 1 2,000,000 A AUTOMOBSE LIABILITY CO BB MSINGLE UNIT S . 1,000,000 X ANY AUTO _ 5Z77852 10/16/2017 10/16/2018 wove INJURY(Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOSF/p��((�yy��N.�E�pp - - BODILY INJURY(Pm accident) S AUrO.S ONLY N.1T0.50NLY PROPE (SWMAGE _ S • _ V� S ' A X UMBRELLA LUIS X OCCUR - EACH OCCURRENCE S 2,000,000 EXCESS LIAB - CLAIMS-MADE - 5.177852-.. . ` - 1 . " 10/16/2017 10116/2018 'AGGREGATE s 2,000,000 DED X RETENTIONS 10,000 - „ . $ • , A WORKERS COMPENSATION . AND EMPLOYERS'LIABILITYX STATUTE ERS ANYpFpPR�OqPRIETgO�Rq,PARTNEP,EXECUTIVE YIN 5H77852 10/16/2017 10116/2018 E.I.EACH ACCIDENT $ 500'000 OFFIQER FAMBERFYri HUED/ . . . N NIA . . . . . - _ -_ . 500,000 If yes.d U.NN) - . . ,• EL.DISEASE-EA EMPLOYEE S DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500'000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional RanaksSchaduh may be•Wchd it mon space M required) . . . - _-_ • • l ' CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CapeLight Compact Joint Powers EntityTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 Pa ACCORDANCE WITH THE POLICY PROVISIONS. Housing Assistance Corporation ' - - - - ' 460 W.Main St. - Hyannis,MA 02601 - AUTHORIZED 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 1.1 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation CAPE SAVE INC. w a a Registration: 171380 ) . :_`,i ,. _:.�w Expiration: 03/13/2020 7-D HUNTINGTON AVENUE �' ',.-,. !x;� i,l SOUTH YARMOUTH,MA 02664st i;rrr-t, 4-µ'`i �" 4C1 .. ,'Yt - r •7 stmt A 20M-05/1/ Update Address and Return Card. (52fommoxuweafrl tioffown4weJ/f . . _ Office of Consumer Attain&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Ca toratton before the expiration date. If found return to: Realstration Fxnlration Office of Consumer Affairs and Business Regulation 171380 -. -' 03/13/2020 One Ashburton Race-Suite 1301 CAPE SAVE INC.:'. s' Boston,MA 02108 WILLIAM MCCLUSKEYp -,. % - 7-0 HUNTINGTON AVENUE- SOUTH YARMOUTH,MA 02664 Undersecretary Not valid w .\f Ignature • E. Commonwealth of Massachusetts Division of Professional Licensure •• Construction Supervisor Specialty Board of Building Regulations and Standards Restricted In: - CSSL-IC-Insulation Contractor ConstructiorbSlip4fvisgr Specialty x CSSL-102776 >' �""" noires:06128/2019 e ,...m .,. a WILLIAM J MCCL!USKEY! /i' 1 r•`r i 37 NAUSET ROAD, - r--) 6 ' ; i� WEST YARMOUTH-MA 02673 �C r ..»\," " �. Failure to possess a current edition of the Massachusetts CA" JA� 4-_-- State Building Code Is cause for revocation of this license. Commissioner V"" DPS Licensing information visit:WWW.MASS.GOVIDPS RISE ENGINEERING OWNER AUTHORIZATION FORM 1, Wayne L Ernest (Owner's Name) owner of the property located at: 143 Astor Way (Properly Address) South Yarmouth, MA 02664 (Property Address) hereby authorize Cape Save Inc. (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. IP Owner's Signature 1 . 9a- / 4 Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 j 508-568-1926 www.RISEengineering.com