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HomeMy WebLinkAboutBLD-19-2522 ' 04, YqR tgOffice Use Only 4 4. 400 .Permit# O $; A Amount 3s MTt w �%wens�P1' 'Permit expires 180 days from i . -.: . :::... issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 33 Aunt Janes Road ASSESSOR'S INFORMATION: Map: 51 Parcel:9 OWNER: Amy Holmes same 508-797-7255 NAME PRESENT ADDRESS TEL. # CONTRAcron: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 1500 Home Improvement Contractor Lie.ti 171380 Construction Supervisor Lie.# TC 102776 Workman's Compensation Insurance: (check one) El 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 *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.pr reCation of my license and for prosecution under M.O.L.Ch.268,Section L Applicant's Signature: 1 \�� Date: 10/25/18 Owners Signature(or attachmen a c �d /J Date: Approved By: <2+ Date: / " C vw re Buil ' g O ial( r designee) (/EMAIL ADDRESS: ` C Zoning District: 5� E C E P Yr E 0-1 Historical District: ❑ Yes ❑ No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District Within 100 ft.of Wetlands: OCT 25 2r3"-. 0 8 ❑ Yes ❑ No ❑ Yes ❑ No BUI�DING DEPARTMENT 9Y . CAPESAV-01 HWOODS A�R�' CERTIFICATE OF,LIABILITY INSURANCE us/26/2 18 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: It the certificate holder Is an ADDITIONAL INSURED,the policy(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). - - PRODUCER Rogers&Gray Insurance Agency,Inc.: ... 434 Rte 134 .. .. sac,No,Eat): I FAX No):(877)816-2156 ' South Dennis,MA 02660 ' ys:matl©rogersgray.com • -- - .. . - - - INSURERS)AFFORDING COVERAGE NAIC I wsuRERAB:Employers Mutual Casualty Company 21416 INSURED - . . . . - - - - MSURER B:Union Insurance Company of Providence 21423 Cape Save,Inc INSURER C: 7 D Huntington Ave .. INSURERO: . . '. South Yarmouth,MA 02664 INSURER E: , . .. INSURERF: . 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. .. INSR IDOL SUER POLICY EFF POLICY EXP LIR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMMIDDIYYYYI IMMIDDIYYYYI LIMITS A X COMMERCIAL GENERAL LUIBIUTY - EACH OrGURRENCE $ 1,000,000 DAMAGE TO RENTED 500,000 cwMSMADE X OCCUR 6077862 10/16/2019 10/16/2019 PREMISES)Faoru.leMej 1 .. - - - MED EXP(Any on.person) S 10,000 .. _ PERSONAL&ADV INJURY S 1,000,000 GENT.AGGREGATE UNIT APPLIES PER - GENERAL AGGREGATE S 2'000'000 POUCY X JECT I LOC - ' ' PRODUCTS-COMP/PAGG S 2,000,000 OTHER, . . -- . . ' EBL AGGREGATE $ - 2,000,000 . COMBINEDu ANGLE LIMIT . S1,000,000 A AUTOMOBILE WLBILITY X ANY/aro 6277852 10/16/2018 10/16/2019 BODILY INJURY(Per Matson) S OWNED SCHEDULED ' ' AUTOS ONLY _ AUTOS BODILY pBODILY INJURY(Per accident/ S An ONLY. _ AUTOSONLY _ PR(]PER E . S I A X UMBREl1A UAB X OCCUREACH OCCURRENCE S 2,000,000 EXCESS LIAR - CLAIMS-MADE 6,177852 I .1 10/16/2018 10/16/2019 AGGREGATE �, 2,000,000 DED X RETENTION$ 10,000 S B WORKERS COMPENSATION '- . . X I STAME I I ETH- AND FA1n.orERs•LuewTY 6H77852 10/16/2018 10/16/2019 5007000 ANY PROPRIErOR/PARTNER/EXECUTIVE �Y�IN� E.L EACH ACCIDENT S gpi�eFlaGER�AI Mg PEXCLUDED? . .. . . •- NIA •-. . ..'. 500,000 (wn.n.ry NI NN) E.L DIcnASE-EA EMPLOYEE S _ O s,desthbe under . . . 500,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Rondo Schedule,may be attached I mon space Is required) ' Cape Light Compact Joint Powers Entity are Included as Additional Insured for General Liability,Automobile Liability&Excesses required by a signed written contract or agreement with the Named Insured CERTIFICATE HOLDER CANCELLATION - - - - - - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Light Compact Joint Powers Entity THE EXPIRATIONAE TTHHE POLTE ICY PROVISIONS.NOTICE WILL BE DELIVERED IN 261 White's Path,Unit 4 .., South Yarmouth,MA 02664 AUTHORIZED /T�REPPR�ESSEEENTA7IV�E'�//�f/j�� •- ACORD 25(2016/03) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD , The Commonwealth of Massachusetts 11 ft ' Department of InthisicialAciiiinti , • emi ' ' " 1 Congress Street,Suite 100 `�� - Boston,MA 02114-2017 • .- . r.- r` Yw ,V , ,e�'ri. .. :www mass govidta r ! r . a Workers'Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers.` ' _. _. - - TO BE FILED WITH THE PERMITTING AUTHORITY. '•` ("Applicant Information Please Print Leeibiv' Name(Business/Organization/Individual):Cape Save Inc ',A'ddress:7-D Huntington Avenue City/State/Zip:South Yarmouth, MA 02664 Phone#:508-398-0398 Are you an employer?Cheek the appropriate box: : Type of project(required): . —1.❑✓ I em a employer with IS employees(full and/orpert-time)• .. .. ..__ ... . .._ .,; . 4.7. ❑New construction _ 2.1:1 lam a sole proprietor or partnership and have no employees working for me in g, ❑Remodeling - .: any capacity.[No workers'comp.insurance required.] - I _ '3.0 I am a homeowner doing all work myself.[No workers'comp.Insurance required.]+ 9, ❑Demolition 4.0 lam a homeowner and will be hiring contractors to conduct all work on my property, t 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 repairs oradditions 5.(:1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. eP 13.�Roof repairs These sub-contractors have employees and have workers'comp.insurance.) 6.0 We aa corporation and its officers have exercised their right of exemption per MGL a 14.0Other Insulation are 152,411(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 subcontractor,have employees,they must provide their workers'comp.policy number. !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.#:-5D77852 Expiration Date - 10/16/2019 Job Site Address: 13 Avnt Janes Road 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. • .. .. -. :. .:.:. , !do hereby certify under tth"pains and penalties of perjury that the information provided above is true and correct. • Signature: \\ Date", 10/25/18 - Phone#:508-398 0398 \\\ Oficial use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# c Issuing''Authority(circle one): 1.Board of Health 2.Building Department 3.City/nein Clerk 4.Electrical Inspector 5.Plumbing Inspector Contact Person: Phone#: • ..'IA:, a �,. - .. CU , z Office of Consumer Affairs and Business Regulation One AshburtonPlace- Suite 1301 4 Boston, Massachusetts 02108 Home Improvement Contractor Registration j„ i .,::-.4,-.E.--,:-.:,,/3Y, :°;4 i + RegistrationCorporation 171380 CAPE SAVE INC. -:. -,'. % -.--• l Expiration: 03/13/2020 7-D HUNTINGTON AVENUE 0 I ‘--:-: - SOUTH YARMOUTH,MA 02664 y ,>�i -1 ' _...J : r ”- �. {r y .' Update Atldrosa end Return Card. SCAt 6 YOM-0Sn1 C92, 4'o,nmonwea/fi r/0 f(aaux/u�ae/A -' -- -- _. _ . . _.�._. ___— Office of Consumer Nlat 8 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corooratim before the expiration date.6 found return to: peaistration==. Expiration - Office of Consumer Affairs and Business Regutadon 171380 - --a.03/132020 One Ashburton Race-Suite 1301 CAPE SAVE INC i; ° Boston,MA 02108 - WILLIAM MCCLUSKEY \P r �--- `/ 7-0 HUNTINGTON AVENUE"' U SOUTH YARMOUTH,MA 02664 Not valid w ,,,,• 'I .Ignature Undersecretary ' zCommonwealth of Massachusetts ir Division of Professional Licensure .. Construction Supervisor Specialty Board of Building Regulations and Standards Restricted In: CSSL-IC-Insulation Contractor Constructio,.'SUp4 visorSpecialty 'f CSSL-102776 (rWe.r." Spires 06128/2019 K r y AI vro o•M Vi 4 r WILLIAM J MCCLUSKEY!: i w i•.:, 4 37 NAUSET ROADi ,'t.1 d �� , \�A I WEST YARMOUTH MA 02673 . ,y, LOISV., ..?? ... Failure to possess a current edition of the Massachusetts CIA"' State Building Code is cause for revocation of this license. Commissioner �w DPS Licensing Information visit:WWW.MASS.GOV/DPS µ. RISE ENGINEERING OWNER AUTHORIZATION FORM I, Amy Holmes • (Owner's Name) owner of the property located at: 33 Aunt Janes Road (Property 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. _y! 64a° 0 ?r's Signet, /o Date RISE Engineering,a Division of Thfeisch Engineering,Inc. 5 Dupont Avenue I South Yarmouth,MA 02664 I 508-568-1926 www.RISEengineering.com