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HomeMy WebLinkAboutBLD-19-1849 t / _ Og,�,—. Office Use Only c k •�p Permit i S 3S i �G . , 0 s Amount N\�� ���b\\"" c�' s Permit expires 180 days from .tc8 issue date i EXPRESS BUILDING PERMIT APPLIC • ON--- TOWN OFYARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 SEP 2 6 2018 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 e u i t ea(A in 7 , T BY' SGLV . _ CONSTRUCTION ADDRESS: 21 Sierra Way ASSESSOR'S INFORMATION: Map: 67 Parcel:32 OWNER: Glen Martel came 508-988-5848 NAME PRESENT ADDRESS TEL # coNTRAcrott: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 900 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lie.# 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: Rmployerc Mutual Casualty Company Worker's Comp.Policy# 5077852 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 re ation of my license and for prosecution under M.O.L.Ch.268,Section 1. Applicant's Signature: Date: 9/25/18 Owners Signature(or attachmen attached Date: Approved By. • ✓A c Date: 41-r/C-/7 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 ,..i.....$1, CAPESAV-01 HWOODS AC-ONCE CERTIFICATE OF LIABILITY INSURANCE DATE/ 9/201YYY) 4..---- 77 108/2017 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 policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED, subject to the terms and conditions of the porky,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). PRODUCERCONTACT Rogers&Gray Insurance Agency,Inc. PSN,FAX No):(877)FAX 816.2156 434 Rte 134 - - • South Dennis,MA 02660- oast mall©rogersgray.com - -• • . . . . INSURERS)AFFORDING COVERAGE - NAIC 0 NSURERA:Employers Mutual Casualty Company 21415 MSURED . - - - NSURERB: - - ' Cape Save,Inc INSURER C; 7 D Huntington Ave . � -- , INSURER D: - - . -South Yarmouth,MA 02664 - , - INSURER E INSURER P: 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. ' NSR - ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF MSURANCE MO WVp POLICY NUMBER onamo/YYYYI 1MIAMON YYI LIMITS A X COMMERCIAL GENERAL LABILITY EACH OCCURRENCE ' S 1,000,000 CLAIMS-MADE X OCCUR 5077852 10/16/2017 10/1612018 MMAGETORp¢urrerinl S ENTED 600,000 PREMISFSfFa MED EXP(MY one person) S 10,000 - PERSONAL IL ADV INJURY S 1,000.000 GENL AGGREGATE LIMIT APPLIES PER: - GENERAL AGGREGATE _ S 2,000,000 POLICY X jL Loc PRODUCTS-COMP/OP AGG S ' 2,000,000 OTHER: - - EBL AGGREGATE - $ - 2,000,000 A AUTOMOBIE LABILITY ' CO�BIdNpEEDD SINGLE LIMIT S 1,000,000 X MY AUTO - . 5Z77852 - - 10/1612017 10/16/2018 BODILY INJURY(Per person) S OWNED SCHEDULED - - _ AUTOSAII�pp���� ONLY _ AUTOSs/Up�� VA��NJ��pp _ - - - •- - - BODILY INJURY jeer accident) S _ —MS ONLY Al/iONLVPROPERDAMAGE S llPeear 1) S A X UMBRELLA LUIS X OCCUR , EACH OCCURRENCE S 2,000,000 EXCESSLIAB CLAIMS-MADE 5.177852 " - - . 101112017 10/16/2018 AGGREGATE _} 2,000,000 DED X RESSTAAE7NpTTIINON S . 10,000 - S , A W- AND EEMPLOYERSLLIABWTY XI STATUTEI I FORS ANY�PRROPRIIEETg?c)OR/PARTNER/EXECUTIVEWYIN 6/177862 10/18/2017 10/18/2018 EL EACH ACCIDENT S 500,000 ariFIGRIM In MFI UDEDT N N/A - - . . -- - - G MMS • EL DISEASE-EA EMPLOYEE S 500'000 [fr.describe under 600,000 CRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATWNS/VEHICLES(ACORO tel,AddmaW Remarks ScIndula,may M atbclwd a non spate M required) - . - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE Cape Light Compact Joint Powers EntityTHE EXPIRATION DATE THEREOF,- NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Housing Assistance Corporation - - ' - - 460 W.Main St Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) 01888-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD y - TheCoinmonwealthofMassachusetts — '� I 'r DepartmentoflndastnalAceidents ,', ! t . ' '1.4- • 1'__1411'=1 I x ... t'i• _ 1 Congress Street,Suite 100 r ;?i11j_$ • - --- Boston,MA 02114-2017: • -=o • 11'' ' " . .-. . _ _ .. , . - Workers'Compensation Insurance Affidavit:'Buildeis/Coritractora/Electrldans/Plumbers. `-• _ TO BE FILED WITH THE PERMUTING AUTHORITY. r '' 'Applicant Information • Please Print Legibly • Name(Business/Organization/Individual):Cape Save the•- • • •''Address:7-D Huntington Avenue :' i'•"'' • : • City/State/Zip:South Yarmouth, MA 02664 ' ' Phone#:508-398-0398 : • .. • • Are you so employer?Check the appropriate box: Type of project(required) : ' • -- La am a employer with '15 - employees(full and/or part-time).* .- - . - - - -�-: .; 7.,EI construction - '- . . 2.0 I am a sole proprietor m partnership and have no employees working forme in. . 8. ❑Remodeling any capacity.[No workers'comp,insurance required.] •, - • • , - , 3. I run a homeowner doingFell work in.[self. ..' 9• ❑DenlOhhon' ❑ 'My. (No workers'comp.insurance required.]t ,: ;4.01 am a boneowner and will be hiring contractors to conduct all wink on my property:I will _ . , 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. Plumbing tt:pahs or additions 5 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs s. These sub-contractors have employees and have workers'comp.insmance.t ❑ p ' '-6.0 We are a corporation and its officers have exercised their right of exemption pa MGL e. 14.DOther 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 fob site I information.- . .. Insurance Company Name: Employers Mutual Casualty Company , •• , . .. • - Policy#or Self-ins.Lic.#: 5D77852 . . --Expiration Date:- 10/16/2018 • , Job Site Address: 21 Sierra Way ' 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance - coverage verification. -- - .- .. . , 1 do hereby certify under th pains and penalties of perjury that the information provided above is true and correct . Signature: i\�\� Date: 9/25/18 Phone#:508-398-0398 • Official use only. Do not write in this area,to be completed by city or town officiaL . _ - _ - City or Town; Permit/License# . IssuingAnthority(circle one):': s 1.Board of Health 2.Building Department.3.'City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector,. , 6.Other - - -- - . Contact Person: .. Phone#: 4t-- - . .__._ , .,.$' . - ,. •,, t . . :.r:. , . : „ t', . ,,. I , . -Ix .a PI�ieWit a IP� Ueda Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration 44 :--a- - ;'::-;_'_- 0 , Type: Corporation VI ____(: F. I = . 'i 1, ,“."..-.:7754,,k' Registratlon: 171380 CAPE SAVE INC. j, +i.`':`: Expiration: 03/13/2020 7-DHUNTINGTONAVENUE 'f t:-.,'='"__T° '; 1 SOUTH YARMOUTH,MA 02664 =;,�\, - J i, _- yr;'_::_- \C>,.\-,174 ---. 1( . . . • V '1\'�t`v-. WAV ,. ��__ r stia scat 4 20nt-05r1t --1 Update Address and Return Card. Office of Consumer Attain&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE Corporation , before the expiration date. H found return to: Registration =- Expiration Office of Consumer Affairs and Business Regulation •171380 ,_7 2 03/13/2020 One Ashburton Place-Suite 1301 CAPE SAVE INC._ -. - _. Boston,MA 02108 -- i WILLIAM MCCLUSKEY--;12:•••,=•;f" [� _ °2-C A-- \ 7-D HUNTINGTON AVENUE."' ♦ Al SOUTH YARMOUTH,MA 02664 Undersecretary Not valid w , A -ignature • ' c Commonwealth of Massachusetts ®/ Division of Professional Licensure •- Construction Supervisor Specialty Board of Building Regulations and Standards Restricted n: CSSL-IC-Insulation Contractor ConstructioylSUACagrSpecialty. f CSSL-102776 S' mi, rk ires:06/28/2019 WILLIAM J MCCLUSKEY? >t,4 /. 37 NAUSET ROA ;1:,, t L. \inti, D-, i WEST YARMOUTH MA 02673 x .,j Failure to possess a current edition of the Massachusetts 4^_ State Building Code is cause for revocation of this license. Commissioner Ch DPS Licensing information visit:W W W.MASS.GOVIDPS DocuSigj Envelope ID:C6C979FA-2DAC-427F-84A6-BBO4DCEAE5BE 1�► , ,e ': Permit Authorization • -I 1 mass save Form Site ID: 3459526 Customer Glen Martel I, Glen Martel ,owner of the property located at: (Owner's Name,printed) 21 Sierra Way West Yarmouth, MA 02673 (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. DocuSlenW by: Owner's Signature: [at&. ittlild 2669B2A97DC747D... Date:9/11/2018 I 8:37 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