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Home My WebLink AboutBLD-19-1837 Office Use Only A2o Permit, FLt,$: - Amount )Permit expires 180 days from /' issue date 5 -iq_cot R-37 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department R E C E I V E D 1 1146 Route 28 South Yarmouth, MA 026La .wu'� CONSTRUCTION ADDRESS: 50 Joshua Baker Road B U I LD I N G DE PART M I N T ASSESSOR'S INFORMATION: Map:40 Parcel:34 OWNER: Lucchana Phipps same 207-332-0859 NAME PRESENT ADDRESS TEL , CONTRAcfoR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL 0 ■Residential 0 Commercial Est.Cost of Construction S 3700 Home Improvement Contractor Lie.0 171380 Construction Supervisor Lie.# IC 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: Employers Mutual Casualty Company Worker's Comp.Policy# 5D77852 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: 0 of Squares Replacement windows:# Replacement doors: if 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 denialatioonn of my license and for prosecution under M.G.L.Ch.268,Section 1. • Applicant's Signature: \ �u Date: 9/25/1 R Owners Signature(or attachmen attached Date: p Approved By: / G� Date: / - 6 - i 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 /'", CAPESAV-01 HWOODS ACORO CERTIFICATE OF LIABILITY INSURANCE ATE/19/2017 `-� to/1a/2on 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 pollcy(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). PRODUCERT M ' 3 Gray Insurance Agency,Inc L 434 Rte ,E,rq: Fitt,No):(877)816-2156 4S3of{uth Dennis,MA 02660 Was s;mail@rogersgray.com -' - - NSURER(S)AFFORDING COVERAGE NAICF NSURERA:Employers Mutual Casualty Company 21415 INSURED . . INSURER B: •. -- - Cape Save,Inc - INSURER C: 7 D Huntington Ave _ _ ' . MSURER 0: - ' ' •South Yarmouth,MA 02664 ' ' NSURERE: ' 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - ' CY EFF POUCY EXP INm TYPE OF INSURANCE NSD Y�j�Bp POLICY NUMBER IM l/NODIYYYYI IMWDDIYYlYI UMITS A X COMMERCIAL GENERAL UABIUTY - EACH OCCURRENCE ' $ 1,000,000 CLAIMS-MADE X OCCUR 5D77852 10/16/2017 10/16/2018 DAMAGETORENTED 500,000 PRFYl4F4fFaomRancs) . ' - MED EXP(Any one person) 10,000' 10,000 ' PERSONAL&ADV INJURY S 1'0'000 GERL AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE j 2'000'000 POLICY ri j LOC _ PRODUCTS-COMP_APAGG S 2,000,000 OTHER; ' . - . . - EBL AGGREGATE $ • 2,000,000 A AUTOMOBILE LIABILITY . - rCOMBBII tlEEDDISINGLE LIMIT i 1,000,000 X ANY AUTO • 5Z77852 ' 10/16/2017 10/16/2018 BODILY INJURY(Per person) S — OWNED SCHEDULED AUTOSIryrygq�� ONLY _AUTOSAryUpNVW,NNEEpp • . - - pBOODILY INJURY(Peraccident) S _ _ NJTOS ONLY _ AUT ONLY . ( e,i) ) E S _ E S A X UMBRELLA LAB Ix OCCUR EACH OCCURRENCE S 2,000,000 • EXCESS LIAB CLAIMS-MADE 5177852 - : 10/16/2017 10/18/2018 'AGGREGATE2,000,000 DED X RETENTIONS 10,000 - $ A WORKERS COMPENSATION XES ANMLORLIABILITY STATUTE R YIN ANY PROPRIETORNARTNER,EXECUTIVE 5H77852 10/16/2017 10/16/2018 500,000 FIOF CE LMBE' CLU EXDEEM N NIA EL EACH ACCIDENT S 600,000 (U yeaOXOesrnhelrlder w _ E.L DISEASE-EA EMPLOYEE 1 _ 60 DESCRIPTION OF OPERATIONS below E-L.DISEASE-POLICY LIMIT S 0'000 DESCRIPTION OF OPERATIONS/LOCATN)NS/VEHICLES(ACORD 101,AddMeW Remarks Schedule,may he alleched r mon apace Is m(uksd) . . CERTIFICATE HOLDER CANCELLATION - . -' SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE CapeLight Compact Joint Powers EntityTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 W ACCORDANCE WITH THE POLICY PROVISIONS. Housing Assistance Corporation , ' 460 W.Main St Hyannis,MA 02601 AUTROR¢ED REPRESENTATIVE ' - - I L/ " ' ACORD 25(2016/03) ®1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • • - The Commonwealth of MassOchusetts- .:: _ • • - t =Tea' ':Department oflndustrialAccidents : - ,' , ' i` _-lls s I Congress Street,Suite 100 t "'- ' 'j{=g •Boston,MA 02114-2017 • H, w�„+� a.: .www mass.gov/dire Workers'Compensation Insurance Affidavit Bullders/Contractors/Electrlclans/Plnmbers.. TO HE FILED WITH THE PERMITTING AUTHORITY. •Applicant Information Please Print LeCibly 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?Check the appropriate box: employees Type of project(required): - -tea I am a employer with 15 (fhu en�or p -t me}• 7. New construction ' - ':772.0 I am a sole proprietor or partnership and have no employees working forme in - -•. : g: ❑Remodeling ' any capacity.[No workers'comp.insurance required].. . - • . 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required]r 9. O Demolition 4.01 am a homeowner end will be hiring contractors to conduct all work on my property, will J l U El Building 8ddI•: -. ensure that an contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees.,' ;I , ,, r 12.❑Plumbing repairs or additions 51:I I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑[tOOf repairs These sub-contractors have employees and have workers'comp,insurance.t . 6.0 We are a corporation and its officers have exercised their right of exemption per MCL c. 14.ED Other Insulation . . ' . 152,*1(4),and we have no employees.[No workers'comp.insurance required.) *Any applicant that checks box p I 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. Jam an employer that Is providing workers'compensation insurance for my employees. Below is the policy and job site information. __ . . _ .. .... . _ _. . .Insurance Company Nagle: Employers Mutual Casualty Company • - Policy#or Self-ins.Lic.#: 5D77852 Expiration Date: -10/16/2018 '• 'Job Site Address: 50 Joshua Baker Road .,l 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 is 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.' - .. . _ .. _ _ _ , _ 1 do hereby certify under nthpains and penalties of perjury that the information provided above is true and correct Signature: \\�\� Date; 9/25/18 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# Issuing Authority(circle onej: • 1.Board of Health 2.Building Depai tment'3.City/Town Clerk 4.Electrical Inspector,5.Plumbing Inspector •' - 6.Other — •- - . . h - •: A „ t, Contact Person: Phone#: Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration -._:_-- W fr, Type Corporation Registration: 171380 CAPE SAVE INC. !' . ,� Expiration: 03/13/2020 7-D HUNTINGTON AVENUE 1:31 rr_--+, •"66 SOUTH YARMOUTH,MA 02664 S s r / • lid trit4 '-7+ !+./ Update Address and Return Card. SCM O 20nw5m1 cF32e%oa,a.onu ff1.jef� ��4. r, Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. H found return to: Beoistration -- Expiration Office of Consumer Attain and Business Regulation 171380 1 103/13/2020 One Ashburton Race-Suite 1301 CAPE SAVE INC. =c j= ` Boston,MA 02108 WILLIAM MCCLUSKEY: 2t—Que 7•D HUNTINGTON AVENUE' SOUTH YARMOUTH,MA 02664 Undersecretary Not valid w Ignature Commonwealth of Massachusetts ®j • Division of Professional Licensure Construction Supervisor Specialty - Board of Building Regulations and Standards Restrictedto: CSSL-IC-Insulation Contractor Construction. Mspr Specialty fr CSSL-102776 ti""""""""""1,^ E" ires:06/28/2019 rV ' 1 WILLIAM J MCCLuSKEYl � �u-.'� 37 NAUSET ROAD] j .� WEST YARMOUTH-MA 02673� ,, in/ti\'150-D 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 DocuSgn Envelope ID:C96BFA3C-8393427F-937C-317415FC1837 11/// RISE ENGINEERING OWNER AUTHORIZATION FORM Lutchana Phipps (Owner's Name) owner of the property located at: 50 Joshua Baker Road (Property Address) West Yarmouth, MA 02673 (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 CDoc,aSWrsa by: M PL+pys AM1CDIRS Gi Owner's Signature 9/4/2018 I 1:39 PM EDT Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com