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Home My WebLink AboutBLD-19-2531 I Office Use Only 1 O -7oz , , C Permit# ; Amo35—iy r� Permit expires 180 days from ..��-. issue date gib—«— (z 53 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 20 Dartmoor Way ASSESSOR'S INFORMATION: Map: 141 Parcel:42 OWNER: Thomas Treiber same 781-771-3032 NAME PRESENT ADDRESS TEL. # coNlTRAcroR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL.# ■Residential ❑Commercial Est.Cost of Construction$ 4200 Home Improvement Contractor Lia# 171380 Construction Supervisor Lic.# 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 *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 denialation of my license and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: \ N, Date: 10/24/18 Owners Signature(or attach men attached Date: Approved By: M....77,04/771g..— Date: /D%(C re . Buildnee) IL ADDRESS: Zoning District: RECEIVED Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 R of Wetlands: OCT 2 5 '016 ❑ Yes ❑ No ❑ Yes ❑ No G IBUILDING DEPARTMENT I By' /../41 CAPESAV-01 HWOODS .4�� CERTIFICATE OF LIABILITY INSURANCE osizsno�s 1 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 polky(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 art/floats does not confer rights to the certificate holder In lieu of sucChpeennpdorsement(s). PRODUCER • MIME CT I Rogers&Gray Insurance Agency,Inc. (A/C,No,Ext): (ac,NPI:(877)51x•2155 434 Rte 134 South Dennis,MA 02660 - Ess:mailigrogersgray.com - - - - -- - INSURER(S)AFFORDING COVERAGE NAIC I • NSURER A:Employers Mutual Casualty Company 21415 - - -- - - - INSURER B:Union Insurance Company of Providence 21423 • Cape Save,Inc - INSURER e: _ 7 D Huntington Ave - •-. INSURER D: .. • 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 POUCY 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 ' AWL SUER POLICY EFF POLICY EXP _ LTR TYPE OF INSURANCE INSD WW POLICY NUMBER ' IMINDOryyyn IMINDDnYYn UNITS • A X COMMERCIAL GENERAL LIABILITY . . EACH OCCURRENCE7S ' 1,900,009 CLAIMS-MADE X OCCUR , 6D77852 10/16/2018 10/16/2019 aREM sE50fEaENorrraranal $ 600,000 . . MED EXP(MY ane Penal f 10,000 ' - PERSONALE ADV INJURY S 1,000,000 • GEN'L AGGREGATEUNITAPPLIES PER GENERAL AGGREGATE S 2'090.009 • POLICY I X I JECT LOC PRODUCTS-COMP'OP AGG $ 2,000,000 OTHER: - _ - - - - - - EBL AGGREGATE - f - 2,000,000 A AUTOMOBILE unitin •g -COMef�INEEDSINGLE UNITntl $ 1,000,000 X ANY AUTO _ - SZ77852 10/16/2018 10/16/2019 BODILY INJURY(Per Peaon) $ - OWNED SCHEDULED . AUTOS AUTOS - BODILY INJURY(Par accident) $ . ' AUOONLY AAUpO�Eoo pPpP^ Zppq(PE f f. A X UMBRELLA LAB X OCCUR : EACH OCCURRENCE S. 2,000,000 EXCESS LAB CLAIMS-MADE . 5J77852 . . . - - 10/16/2018 10/16/2019 AGGREGATE $ 2,000,000 DED X RETENTIONS . 10,000 S B WOR KERS COMPENSATION - - - . y PER OTH- ANDEMPLOYERS'LABOJTYYIN i STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE 5H77852 10116/2018 10H&2019 E.L.EACH ACCIDENT S 600.990 o�FFFICCEERMLEM66gEqq EXCWDEDT 1 N NIA • _ ', --- `xe^aMarY VI NMI , E.L.DISEASE-EA EMPLOYEES .609.990 K yes deealbe under . - 500 000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additions)Remade Schadulo,nay be eaadwd E Ren SWa la nalula 1 Cape Light Compact Joint Powers Entity are Included as Additional Insured for General Liability,Automobile Liability 8 Excess as required bye 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 EntityTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 W ACCORDANCE WITH THE POLICY PROVISIONS. 261 White's Path,Unit 4 • -. .. H „ . South Yarmouth,MA 02664 • AUTHORIZED REPRESENTATIVE -. . 77 ' . ACORD 25(2016/03) ' . ' . ID 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD - • • ,. t ,.•. tl.,,, s .. The Commonwealth of Massa schusetts.• i� :' !I`' DepartmentofLidusttdalAccidents :' 5ttii_ ;, 1 Congress Street,Suite 100 ', -74%,),7"--:77409 �� 2 • Boston,MA 02114-2017 • aJ=u 09 a ' •wwW.m(tssgov/dta_ Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. _ ... TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information - Plesse Print Leaibly 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?Check the appropriate box: Type Elf New project(required): 1. ✓❑I am a employer with 15 employees(full and/or part-time).*. _.. . ,_. .. construction ' 2.1111 am a sole proprietor'or partnership and have no employees working for me in 8.'❑Remodeling '�- -;, any capacity.[No workers'comp-insurance required.], 9 • .❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]r 9. ❑Dem01]hon . . . 10❑Building addition 4.❑I am ahomeowner and will be hiring contractors to conduct allwork on my property. Iwilt .. ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions • prop onn with no employees. • 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. airs These sub-contractors have employees and have workers'comp.insurance.: ❑ROOF repairs 6.0 We am a corporation and its officers have exercised their right of exemption per MOL c. 14.❑✓ Othef 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 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'camp.policy number. - I am art 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: 20 Dartmoor Way 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. 1 do hereby certify under th pains and penalties of perjury that the information provided above is true and correct , Signature: �� Date: 10/24/18 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'' 6.Other Contact Person: Phone#: r (: z oQ/leaztdacAr,e,d . 1 5 Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 i Boston, Massachusetts 02108 Home Improvement Contractor Registration i r { ( Type: Corporation ° a II� s; .Registration: 171380 CAPE SAVE INC. ) i - ,..1/..-='-_--.7t,.. Expiration: 03/13/2020 7-D HUNTINGTON AVENUE t > _ SOUTH YARMOUTH,MA 02664 ;-\ t -``;-< .4 . �a ( Y Vrti .r n=72r scat o zpe�osn7 Update Address and Return Card. --_C-'�er P6�nonnnnnrzll�.n`d'ft�acwrr4nae/!d _ __ _.- _ e _ _ _ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation ':.. before the expiration date. if found return to: Registration — fxoiratiop Office of Consume Affairs and Business Regulation 171380 • -„;'.03/132020 One Ashburton Place-Suite 1301 CAPE SAVE INC i Boston,MA 02108 ! WILLIAM MCCLUSKEY ,:: �^ 7-D HUNTINGTON AVENUE'' '''' VENUE” SOUTH YARMOUTH,MA 02664 Not valid w ., .1 Ignature Undersecretary . G. c. Commonwealth of Massachusetts Construction Supervisor Specialty Division of Professional Licensure •• Restricted to: ' Board of Building Regulations and Standards CSSL-IC-Insulation Contractor ConstructiooS MvRscr Specialty /f CSSL-102776 -Y a I "M^'^'n,� Expires 06/28/2019 WILLIAM J MCCLUyro ..t SKEY+ gf ^-P4r 37 NAUSET ROAD,.1 ' a l f 1 J ,7 WEST YARMOUTN'MA 026731 , .tn/SS 00-6 Failure to possess a current edition of the Massachusetts ,y B a__ State Building Code Is cause for revocation of this license. Commissioner «w DPS Licensing information visit:VWVW.MASS.GOVIDPS • W40.# Permit Authorization it( i mass save Form s• •t own/e»zt•Ky Site ID: 3346001 Customer: Thomas Treiber I, 71am(/s l ,ownerofthepropertylocatedat: (Owner's Name,printed) 20 Dartmoor Way Yarmouthport, MA 02675 (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. Owner's Signature: \-- W.4 Date: /6/ZR •eete•a OM aatase•Rssa aea ateRteeas•SS52005;ee e a OA R at alt0R ee•4 0010 sae FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: 0-0 r io /2- 11cr Partidr ating Contractor Dat Name: RISE Engineering • Phone: 401-784-3700 Email: For Office Use Only