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Home My WebLink AboutBLD-19-2523 ~~ Office Use Only Y`I Og. R 1Q ! 4 - 6 Permits 0 '�ta � - Amount -�� Permit expires 180 days from 1 ^issue.J_ �/ I Pik - EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2 a 2231 Ext. 1261 1 CONSTRUCTION ADDRESS: Claude Armeen 0 Tot 11 Pi isle s bit ( ASSESSOR'S INFORMATION: Map: 117 Parcel: 19 OWNER: Claude Armeen same 508-760-5171 NAME PRESENT ADDRESS TEL # coNTRAcroR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL# ■Residential ❑Commercial Est.Cost of Construction S 1900 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lic.# IC 102776 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor I 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 . tion of my license and for prosecution under M.O.L Ch.268,Section I. Applicant's Signature: w Date: 10/25/1R Owners Signature(or attachmen. . t .. r - s Date: Approved By. - Date: //072Z-740 .. /I,: eff1 al(or designee) " EMAIL ADDRESS: ^ C Zoning District: R E C E I v E D Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: OCT 2 5 2018 ❑ Yes ❑ No ❑ Yes ❑ No BUILDING DEPARTMENT BY �1CAPESAV-01 HWOODS A R n* CERTIFICATE OF LIABILITY INSURANCE 09/2612018 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 WAIVED, subject to the tens 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 succhppeNn�pdorsement(s). PRODUCER MAME;CT ". Rogers&Gray Insurance Agency,Inc.-, - PHONEFAX No):(877)816-2156 434 Rte 134 �.M South Dennis,MA 02660 ADOREp�� ss:mall@rogersgray.com - - . - -- -.. - - INSURERS)AFFORDING COVERAGE NAIC 0 INSURER A:Employers Mutual Casualty Company 21416 INSURED - - - INSURER B:Union Insurance Company of Providence 21423 Cape Save,Inc ' _ INSURER C: _ 7 D Huntington Ave " .: . ' - • _.- !- INSURER o:. South Yarmouth,MA 02664 : .. INSURER E: 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. NSR - ADOL SUBR POLICY EFF POLICY EXP 1 LTR TYPE OF INSURANCE INN) WVD POLICY NUMBER IMMIDDNYYYI mMIDOIYYYYI LIMITS , A X COMMERCIAL GENERAL LIABILITY . ' - - EACH OCCURRENCE § 1,000.000 CLAIMS-MADE X1 OCCUR• , 6077852 10/16/2018 10/16/2019 RA`MAGETORENTED " 500,000 PREMISF4lFe opaarencel $ MED EXP(MvM Danon) s O 10,000 PERSONAL ADV INJURY $ - 1.0(0'080 GENT.AGGREGATE LIMIT APPLIES PER . . . GENERAL AGGREGATE $ • 2,000,000 1.POLICY X j LOC + ' " PRODUCTS•COMP/OPAGG S 2,000,000 OTHER: - EBL AGGREGATE 1 2,000,000 A A1fi0M0&lE warn.warn �MBINEDISINGLE UMIT S 1,000,000 •X ANY AUTO -- _ 5277852 - - 10/16/2018 10/16/2019 BODILY INJURY(Per person) ' $ AUTOS ONLY _AANUvp�rosWLNE�Opp _ • • BODILY INJURY E'?racddeM) $ AUTOS ONLY _AUTOS ONLY (Veto 1O0N) AGE S S • - A X UMBRELLA LIAB X OCCUR - EACH OCCURRENCE $ 2'000'000 EXCESS Luc CLAIMS-MADE 5J77862 - t! ,.. 1 ', . 10/16/2018 10/16/2019 AGGREGATE ' t -- 2,000,000 DED X RETENTIONS " .10.000 E - B WORKERS COMPENSATION . X S ATUTE ETR H- D1 AND EMPLOYERS'LIABILITY 6H77862 - 10/16/2018 10/16/2019 600,000 ANY PROPRIETOR/PARTNERIEXECUTIVE Y/N 1 _E,L EACH ACCIDENT- E QpF�FQ@ERMEMWpEXCLUDED?. . N N/A i'�- -. _ (A1aa0SIOIY IR NH) - ... - .. - _. _ E.L DISEASE-EA EMPLOYEE S 600,000 I yes.doswlbe w+oar , ' . '. 500,000 DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached Sawn space M rpulntl) Cape Light Com pact Joint Powers Entity are Included as Additional Insured for General Liability,Automobile Liability&Excess as 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 - ACCORDANE CE WITH THION E POLICY PROVISIONS.NOTICE WILL BE•DELIVERED IN 261 White's Path,Unit - South Yarmouth,MA 02664 — AUTHORIZED REPRESENTATIVE ""/ ._ .. •I ACORD 25(2016/03) - 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD -e- ' .. ' The Co»tmonwealthof MasSachuietts '. _ t '_ / .; Department ofIndtistria!Accidents •C lmf '+ +, , ,' 1 Congress Street,Suite 100 $ +• . - ;�{— Boston,MA 02114-2017 = . • , wwwmassgov/dsa _ Workers'Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers " TO BE FILED WITH THE PERMITTING AUTHORITY. . r u ;Applicant Information Please Print teeibly' 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?Cheek the appropriate box: .. Type of project(required): I. I em a employer 15 - employees(full and/or .- - 'J,:❑New construction - I. lama to with ,.- amp Ye!' . , ❑ proprietororpartnershipandhavenoemployeesworkingformeto - , 8: Remodeling 9. ❑Demolihon . 3.0 I am a homeowner'doing all work myself.[No workers'comp,insurance required.]' , - . 4.0rams homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition `.? ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions : .,r:; proprietorswith no employees. _ , 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet. 13.❑Roof repairs These subcontractors have employees and have workers'comp.insurance.* 6.0 We are a corporation and its officers have exercised their right of exemption per MOL c. 14.❑✓ Other Insulation 152,11(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 :Contactors 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 '- information. . Insurance Company Name: Employers Mutual Casualty Company Policy#or Self-ins.Lic.#: 5D77852 Expiration Date: 10/16/2019 . Job Site Address: 20 Tall Pines Drive City/State/Zip:Yarmouth Port ' 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. . . ... .. .., .,. .:. .., , .,.. .. . . . ..;- Ido 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 \ 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 one). 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Contact Person: - Phone#: te Woignito4teoefa � o Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Matsachusetts'02108 Home Improvement Contractor Registration Type: Corporation CAPE SAVE INC. fy'. #. .I '� Registration: 171380 7-D HUNTINGTON AVENUE ._ . «Ns - 101 Expiration: 03/13/2020 • I I i sl ;S SOUTH YARMOUTH,MA 02664 5,�"- : 3.--1-n"5,7177-'1J///C k scn 1 6 zonwsrn "'S Update Address and Return Card. it- Office of Consumer Affairs a Business Regulation HOME IMPROVEMENT CONTRACTOR Registrationvalid for Individual use only TYPE:Carnoral i - before the expiration date.If found return to: negistratior — Fxniratiort Office of Consumer Affairs and Business Regulation 171380 --' 03/13/2020 - - One Ashburton Place•Suite 1301 CAPE SAVE INC 4 ;i�� :Boston,MA 02109 WILLIAM MCCLUSKEY ` }� ' 7-0 HUNTINGTON AVENUE` U\\\ SOUTH YARMOUTH,MA 02669Unde rntary -Not valid w . 'i 'ignature Commonwealth of Massachusetts 7 r Construction Supervisor Specialty Division of Professional Licensure Restricted to: • - Board of Building Regulations and Standards CSSL-IC-Insulation Contractor Con structioelltITMWtsorSpecialty • f CSSL-102776 c- r"'"'":"'" E Dires 06/28/2019 WILLIAM J MCCL, SKEY5 �., 37 NAUSET ROA42 ,' ,3 \3 WEST YARMOUTH MA 02673 lc` «.„ -.,� 1iltiti T_5L1�S Failure to possess a current edition of the Massachusetts r!f {e State Building Code is cause for revocation of this license. Commissioner v,"'- DPS Licensing information visit:WWW.MASS.GOV/DPS RISE ENGINEERING OWNER AUTHORIZATION FORM 1, Claude Armeen (Owners Name) -`" owner of theroPriY e located at: P 20 Tall Pines Drive (Property Address) Yarmouthport, MA 02675 (Property Address) S hereby authorize /r l 4p(... Jnv<- (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. Owner's Signature taDate RISE Engineering,a Division of Thielsch Engineering,Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RISEengineering.com