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Home My WebLink AboutBLD-19-2526 a 0T,',k'r 1 Office Use Only 2� c- . hPermit/1 ti . mat4I I:is ; !Amount,9S 1 a�' Permit expires 180 days from f Tissue date - 151-t XI eb)57(9 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 111 Chipping Green Circle ASSESSOR'S INFORMATION: Map: 100 Parcel:62 OWNER: Johann Garino came 508-6194920 NAME PRESENT ADDRESS TEL H CONTRACTOR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL a ■Residential 0 Commercial Est Cost of Construction S 4900 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lie.# TC 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 1 declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. 1 understand that any false answer(s) will bejust cause for denialre cation of my license and for prosecution under M.O.L.Clt.268,Section 1. Applicant's signature: Date: 10/25/18 Owners Signature(oranachmen tta he • Dae: Approved By: �j, ... l Date: �0 :2 Buil ' O (or esigneE)' EADDRESS: RECEIVED Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: 0 Yes 0 No OCT 25 2018 Water Resource Protection District: Within 100 R of Wetlands: 0 Yes 0 No 0 Yes 0 No BUILDING DEPARTMENT • ./"It CAPESAV-01 HWOODS ,4CORO CERTIFICATE OF LIABILITY INSURANCE � 9/26/2 TE ' V - os/zs/zols 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(es)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... PHONE FAx 434 Rte 134 .. '- . . .. .. .. - 1 .Nq,ESI): . INC.No):(877)8164156 South Dennis,MA 02660 mist mail@rogersgray.com . - INSURERS)AFFORDING COVERAGE NMC a 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 - -- - " - _ _ • INSURERD: 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. ' INSR ADDLSUBR , POLICY EFF POLICY EXP LIR TYPE OF INSURANCE INSD ONO POLICY NUMBER IMMIDD/YYVYI IMMIDD/YYYYI - LIMITS A X COMMERCIAL GENERAL LIABIUTY. • - . .. . . • EACH OCCURRENCE $ 1,000.000 CLAIMS-MADE X OCCUR 6D77862 10/16/2018 10/16/2019 DAMAGETORENTED ' 600,000 PREMISES fEa ocwrtMPel $ ... MED EXP(Any one Person/ $ 10,000 PE, R MNAL a ADV INJURY s 1,000,000 GENT.AGGREGATE UNIT APPLIES PER - - GENERAL AGGREGATE $ 2,000,000• POLICY X LOC " PRODUCTS_COMP/OP AGG $ - 2,000,000 OTHER: - . ... .` .. . . . - EBL AGGREGATE $ .- 2,000,000 A AUTOMOBILE LIABILITY . - ICEOM9Bl E SINGLE UNIT $occident) ..1,000,000 X ANY AUTO . . . - 6Z77852 10/16/2018 10/16/2019 BODILY INJURY(Pe'person) $ • _ _AAUTTdOO�S ONLY . _ AANpUpT�NO.pSSyyU��}tL..11EEEDop . . .. r. BODILY INJURY(Per accident) $ AUTOS ONLY, _AUIOBONLY P OPEey.ROAMAGE S , • l S A X UMBRELLA IMS X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESSLYIB CLAIMS-MADE 6.177862 .. ' ' ^ P 10/16/2018 10/1612019 AGGREGATE ' _ ; " 2,000,000 DED X RETENTIONS . 10,000 S B WORKERS COMPENSATION '- _ ._ -' _ - " . - X S7AME gr AN°EMPLOYERS' 5H77852 10/16/2018 10/1612019 600,000 ANY PROPRIETOREXCLUDRDXECUTIVE YIN E.L.EACH ACCIDENT $ ' Q(M�anthorylnNH)EXCLUDEDY: N NIA ' (wnesWq In NH) .. - . . . E.L.DISEASE-EA EMPLOYE $ 500,000 NI yes,deealbe under - 600,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD tel.Additional Remarks Schedule,may be attached Inc.,space Is required) . Cape Light Compact 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Cape Light Compact Joint Powers Entity ACCORDANCE WITH THE POLICY PROVISIONS. 261 White's Path,Unit4 - - "' South Yarmouth,MA 02664 • AUTHORIZED REPRESENTATIVE -' ' ...' .- ' _.. • ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD - -r C�^�l - ..ice ,] :�; ,ij e.:.,. ,., 3 1 ".. . < • l{ ',. , ,. The Commonwealth of Massachusetts . ' ` i1 'r ......"16"—• e—' / ,Department oflndustrialAccidents ;` t r -tnt ' "' I Congress Street,Suite 100 - tii I �° Boston,MA 02114-2017 WorkersCom Compensation Builders/Contractors/Electricians/Plumbers.' P tkrldsns/Plombers: TO BE FILED WITH THE PERMITTING AUTHORITY. ,'Applicant Information Please Print Legibly `' ' Name(Business/Organization/Indiwdu'aij:Cape Save Inc Address:7-13 Huntington Avenue ' ' ' City/State/Zip:South Yarmouth, MA 02664 ' ' Phone#:508-398-0398 . Are you an employer?Check the appropriate box: Type of project(required): 1 1.12 i am a employer with - 15 - employees(full and/orpan-time).' ' ._" .. . - _ .. .. 7. New construction 2.0 I am a sole pmprietoror partnership and have no employees working for me in 8. Q Remodeling " -, any cdpacity.[No workers'comp.insurance'tegmmd.] .. ; �: n , ' 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required]r 9. ❑Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property: I will 10 0 Building addition ,,. ensure that all contractors either have workers'compensation insurance or am sole 11.0 Electrical repairs or additions , g proprietors with no employees. . r : r ;r.:. .:,•_ . , 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the subcontractors listed on the attached sheet ,.• - These sub-contnctors have employees and have worker'comp.insurance? 13.❑Roof repairs is.0 We aa corporation and its officers have exercised their right of exemption per MGL e. 14.�✓ Other Insulationm 152,¢1(4),and we have no employees.[No workers'comp.insurance required] 'Any applicant that checks box al 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' :Conhactors 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 i information Insurance Company Name: Employers Mutual Casualty Company . , , - Policy#or Self-ins.Lie,#:. 5D77852 --- - . - Expiration Date: 10/16/2019 Job Site Address: 111 Chipping Green Circle 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 MGLc. 152,§25A is a criminal violation punishable by a free 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under tthpaint and penalties ofperjury that the information provided above is true and correct ." Signature: \\�\�r Date: 10/25/18 Phone#:508-398-0398 Official use only. Do not write in this area,to be completed by city or town ofeiaL -, City or Town; Permit/License# • _ .Issuing Authority(circle one) r 1.Board of Health'2.Building Department 3 City/1'tiwn Clerk 4.Electrical Inspector S.Plumbing Inspector,= 6.Other - - Contact Person: Phone#: a� G ��2re chi � . Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 ; Boston, Massachusetts"02108 Home Improvement`Contractor Registration z [2 Type: Corporation 11..r l.=....,:.---7-`i 11.4., Registration: 171380 CAPE SAVE INC. i ,b _ " } Expiration: 03/13/2020 7-D HUNTINGTON AVENUE _ SOUTH YARMOUTH,MA 02664 „,,\,�._ ''. - • ,L _ -,4,!-=-.3.`pii,, ,---2 r SCA 1 8 20M-05n1 Update Address end Return Card. Office of Consumer Affairs a Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corwratim before the expiration date. If found return to: :..Registration -= g$DlratiOn - Office of Consumer Affairs and Business Regulation 171380 : =' 1.03/132020 One Ashburton Place•Suite 1301 CAPE SAVE INC : ' Boston,MA 02108 WILLIAM MCCLOSKEY 't:% 2LC.Q.1 D 7- HUNTINGTON AVENUE' SOUTH YARMOUTH,MA 02664 Undersecretary Not valid w •q'i Ignature c : c. Commonwealth of Massachusetts Division of Professional Licensure - Construction Supervisor Specialty Board of Building Regulations and Standards Restricted tn: CSSL-IC-Insulation Contractor Construction-,51}p4wisor Specialty T CSSL-102776 c> m, +r Eyires: 06/28/2019 ' i � '. f .. n„,.1 WILLIAM J MCCLi1SKEY' lc-, i. z 37NAUSETROAD '. Id \t -� i WEST YARMOUTH MA 02673 �� ' 1 tn/S<'IdL*J Failure to possess a current edition of the Massachusetts (�`A,_ S— State Building Code Is cause for revocation of this license. Commissioner �/'"� DPS Licensing information visit:WWW.MASS.GOV/DPS RISE ENGINEERING • OWNER AUTHORIZATION FORM 1, Johanne Garino (Owners Name) owner of the property located at 111 Chipping Green Circle (Property Address) South Yarmouth, MA 02664 (Property Address) hereby authorize rlit.nthitte. 'P. • an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit end to perform work on my property.This form is only valid with a signed contrail. • / - A LG. Aft14•0 owns,s S f ', re /WA ig Date 4 � RISE Engineering,a Division of Thielsch Engineering,Inc. 5 Dupont Avenue I South Yarmouth,MA 02664 i 508-568-1926 www.RLSEengineering.com zoos ZHYRSQ vD OZB4eT9902 ZYd ttZ:ZT 9T0Z/9T/OT