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Home My WebLink AboutBLD-19-1848 a 0A. Ot„y _ office Use Only st O :Permit# N $ Amount 3C—' Pernit expires 180 days from E3LC) - fG -OD( . d EXPRESS BUILDING PERMIT APPLICATIO E C E T i E D TOWN OF YARMOUTH Yarmouth Building Department SEP 2 6 2018 1146 Route 28 South Yarmouth,MA 02664 BUIL (508)398-2231 Ext. 1261 13,.- l'lle- T CONSTRUCTION ADDRESS: 29 Lakewood Road ASSESSOR'S INFORMATION: Map: 60 Parcel:37 OWNER: Thomas Cardone same 860-597-0867 NAME PRESENT ADDRESS TEL # CONTRACTOR:William McCluskey/Cape Save 7-D Huntington Ave, S. Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL# •Residential 0 Commercial Est.Cost of Construction$ 5000 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lie.# IC 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: 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 *me 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 bejust cause for denial r recatioon of my licenseenand for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: \ �1Date: 9/25/12 Owners Signature(or attachmen attached Date: Approved Br 1.6V g By: J-.I.. . i Date: 7 Building Official(or designee) EMAIL ADDRESS: Zoning District: , Historical District: ❑ Yes 0 No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 R.of Wetlands: 0 Yes 0 No 0 Yes 0 No ....----"1 CAPESAV-01 HWOODS ACORO' CERTIFICATE OF LIABILITY INSURANCE � TE(MMATO/YYTY) `-� 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(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 lights to the certificate holder In lieu of such endorsement(s). PRODUCER ' ]C(INTACT ' , Rogers&Gray Insurance Agency,Inc- PHONE FAX 434 Rte 134 - _. . . INC,ENLo,Est): I WV,No}:(877)816-2156 South Dennis,MA 02660 IIppR'ESs:mail�rogersgray.com -' INSURER(S}AFFORDING COVERAGE NAICS INSURER A;Employers Mutual Casualty Company 21415 INSURED ' INSURER B: Cape Save,Inc ' . - NSURER C: . 7 D Huntington Ave - - - . . -- INSURER o:- South Yarmouth,MA 02664 INSURER . MSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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 TYPE OF INSURANCE - ADDLISUBR POLICY NUMBER POLICY EFF POLICY UP ITR NSO WVO IMMIDOO•YYYI IMMIDGIYYYYI LIMITS A X COMMERCIAL GENERAL LLLBILJTY • EACH OCCURRENCE $ 1,000,000 ' CLAIMS-MADE X OCCUR 5D77852 10/16/2017 10/16/2018 DAMAGETORENTED 500,000 PRFMISES(Fe occlmencei $ MED EXP(Any one person} ' $ 10,000 PERSONAL A ADV INJURY S +,000,000 GEN.AGGREGATE pGi URMpIT APPLIES PER: ' GENERAL AGGREGATE j 2,000,000 POUCY JE X LOC PRODUCTS•COMP/OPAGG $ 2,000,000 OTHER - EBL AGGREGATE 1 2,000,000 A AUTOMOBILEUABWTY . • (Fesondem SINGLE LIMIT $ +,000'000 X ANY AUTO 5Z77852 10/16/2017 10/16/2018 Booty mums(Pereamon) $ OWNED SCHEDULED — - _ AUTOS��qE� ONLY AUTOSNpNNWN pp - - pBpOORDIL�Y INJURY7yppEt amtlont) S _ la ONLY AUTaONLY . - Wx PaaseeMl AGE, S S A AI UMBRELLA(JAB X OCCUR . • EACH OCCURRENCE S 2,000,000 EXCESS LJAB CLAIMS-MADE 5J77852 - 10/16/207 10 /16 /2018 AGGREGATE S 2,000,000 DED X RETENTIONS ' 10,000 . . $ A WORKERAND LOYERYNSATION Y/NX STATUTE FORS ANYpNFPROPRIETOEERRR/PARTNER/EXECUTNE 5H77852 10/16/20+7 10/16/2018 600,000 grarry9n�H)cset UDED7 H N/A E.L EACH ACCIDENT S 500,000 Y � � EL.DISEASE-EA EMPLOYEES _ DESCRIPTION OFOPERATIONSDWIow EL DISEASE-POLICY LIMIT S 506.000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES IACORO 101,Additional Remarks Schedule,may be attached I more woe le required) , • • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Light Compact Joint Powers EntityTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 ,ACCORDANCE WITH THE POLICY PROVISIONS., Housing Assistance Corporation - - 460 W.Main St - Hyannis,MA 02601 AUTHORED REPRESEENTATIVEE, ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 0/P. .. .. . . . . _ TheCommoniwealth-ofMassachusetts' -_ _ . - .-."- ". it e*-- 'l' '" " ' , ' ' 'Department ofIndustrial Accidents ''' _'3-lir, i . ; . . .1 1 Congress Street,Suite 100' .. .-:i i - Boston,MA 02114-2017 '„ = ' -' .�, `www mass gov%dict ,. . • .. Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.' ' ' " TO BE FILED WITH THE PERMITTING AUTHORITY. . ' Applicant Information Please Print Legibly • ' Name(Business/Organizationandiviausl):Cape Save Inc:11 = • Address:7-D Huntington Avenue'`? t ; . ' CIty//State Ip:South Yarmouth,MA 02664._ _____4 Phone#:508-398-0396 Are you as employer?Check the appropriate box: Type of project(required): 1. ✓❑I am a employer with -15 employees(full and/or part-thne).'t' " - 7. 0 New construction "' 2.01 am a sole proprietor or partnership and have no employees working forme in . ; 8. 0 Remodeling •. • , . . any capacity.(No workers'comp.insurance requited.], '•` .. . ;• .. ., 3"01 am a hon s eowner doing all work myelf:[No workers'comp.insurance required.]t ' 9. Demolition , 4.0 i am a homeowner and will be hiring contractors to ionduct all work on my property. 1 will . 10 Q 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.❑Plumbing repairs or additions 50 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.; 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q✓ Gdlet Insulation 152,§I(4),and we have no employees.[No workers'comp.insurance required.] ''"' applicant that checks box#1 must also fill out the section below showingtheir workers'compensation*Any pp' 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.Lie.#: 5D77852 . . Expiration Date: '10/16/2018 - Job Site Address: 29 Lakewood Rifad ' ' ' 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 .- ._ . _ . ._ . . " . - _ _.. . . 1 do hereby certify under thpains and penalties of perjury that the information provided above is true and correct Signature: Date: 9/25/18 Phone#:508-398-0398 \ • Oficial use only. Do not write in this area,to be completed by city or town official. City or Tm: - PermitILIcense# Issuing Authority(circle one):1- : 1.Board of Health'2.Building Depariment'3:City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector,, 6.Other - . . . . - . . - •_ Contact Person: _- "' Phone#: . 44 • Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 r Boston, Massachusetts 02108 ' Home ImprovementContractor Registration . ' . -, 1 , ; _ s:-,. : rt Type: Corporation • `1 a-= =. --'v.' . 1s I -' Registration: 171380 CAPE SAVE INC. j,711,-,7--.7.4:3.4 .77,777:---77-..-..772:7:17'.1 7-D HUNTINGTON AVENUE a = s1--" r _ 114 1, . Expiration: 03/13/2020 SOUTH YARMOUTH,MA 02664I;,+ - .x,- 'rr; - i ,r4a scAf 0 20M-05/17Update Address and Return Card. Ccile pammonremaij lof6aia msetta Office of Consumer Attain&Business Regulation HOME IMPROVEMENT CONTRACTOR - Registration valid for Individual use only . . TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 171380 • --' 03/13/2020 One Ashburton Place-Suite 1301 CAPE SAVE INC. I,- . Boston,MA 02108 i WILLIAM MCCLUSKEY-,t;i: e-cco 7-D HUNTINGTON AVENUE' C`� --- SOUTH YARMOUTH,MA 02664Undersecretary .Not valid w Ignature Commonwealth of Massachusetts ®` Construction Supervisor Specialty ! Division of Professional Licensure Restricted to: Board of Building Regulations and Standards CSSL-IC-Insulation Contractor ConstructioeS\} MsgrSpecialty /J . CSSL-102776 :S. E'iyires:06128/2019 . iV 1 ;;4Th ;. ir."‘; WILLIAM J MCCCUSKEY! ,4a es - T 37 NAUSET ROARi : , i 411 WEST YARMOU MA 02673 sir ` • -- I .'1 n14,-,I IOtJ Failure to possess a current edition of the Massachusetts 4'„- State Building Code Is cause for revocation of this license. Commissioner CL DPS Licensing information visit:W W W.MASS.GOV/DPS r DocuSign Envelope ID:6B2AEAB5-6851-4FA1-96E9-8CA7D286DDA4 *x'11:. Permit Authorization vy� mass save Form S+wYgs e'r'oW1 endr4y e�bBcy Site ID: 3392672 Customer. Thomas Cardone Thomas Cardone I, ,owner of the property located at: (Owners Name,printed) 29 Lakewood 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. auduSlgn.d b,: Owner's Signature: [17.. d.,c,� EC1M3B5F03542C... Date: 8/28/2018 I 11:51 AM EDT 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