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Home My WebLink AboutBLD-19-2536 pE Y9k Office Use Only '} '. ! �iO. 1 Permilig - t:.; Rye C _ t p F 0 , -3 @ Amoun 'CC Tr in k V.+a 4`+.,.)s;?. Permit expires 180 days from ii Aissuedate 13(1-19-obas3 6 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTIONADDRESS: 33 Boxberry Lane ASSESSOR'S INFORMATION: Map: 39 Parcel: 154 OWNER: Melissa Barone same 508-815-7524 NAME PRESENT ADDRESS TEL # CONTRAcfoR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL# ■Residential ❑Commercial Est.Cost of Construction S 5000 Home Improvement Contractor Lic.# 171380 Construction Supervisor Lie.# IC 102776 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 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 am 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.O.L.Ch.268,Section I. Applicant's Signature: - Data 10/24/1R Owners Signature(or attachmen ttached Date: / ---.2e--7-e- 7 f' 2/ Approved By: ` Date: /c • Buil (or dEMA i DRESS: Zoning District: i L I C I V E Li Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: OCT 25 2016 J ❑ Yes ❑ No ❑ Yes 0 No 1 bU-!LONG DEPARTMENT By: • /1 CAPESAV-01 HWOODS ACORD' CERTIFICATE OF.LIABILITY INSURANCE DAre(MMIDDIWYY) 4....----- CERTIFICATE 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 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 , • ICT Rogers 8,,Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 - - .. _. SNC,Nat - (NC,No):(877)816-2156 South Dennis,MA 02660 j &ss,mail@rogersgray.com -. . - , '-' - INSURER(SI AFFORDING COVERAGE NAIC I n1PRERA:Employers Mutual Casualty Company 21416 INSURED - ' - INSURER s:Union Insurance Company of Providence 21423 Cape Save,Inc 14SURERC: - 7 D Huntington Ave INSURERD: ._ South Yarmouth,MA 02664 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEO 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 - AWL SUBR POLICY EFF POLICY EXP LIR TYPE OF INSURANCE INSD WVD • POLICY NUMBER • IMMIDO/YYYYI IMMIDD/YYTYI LIMITS A X COMMERCIAL GENERAL LIABILITY .. EACH OCCURRENCE S 1,000,000 CLAIMS-MADE X OCCUR 6077852 10/16112018 10116/2019 DMGOEa EONcaTEprDencel $ 500,000 10,000 MED EXP(Any aapereon) $ PERSONAL&ADV INJURY $ 1,000,000 GENLAGGREGATEUMIT APPLIES PER - - GENERAL AGGREGATE S 2'000'000 1POUCY X .1 LOC ' PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER: - - . - . - EBL AGGREGATE $ .2,000,000 A AUTOMOBILE LABUITY ICEOMBINERDISINGIF LIMIT S 1,000,000 X ANY AUTO • 6277852 10/16/2018 10/16/2019 BODILY INJURY(Per person) $ _ OWNED SCHEDULED • . AUTOS ONLY, _AUTOS . . BODILY INJURY(Pee accident/ I AUTOS ONLY _.MVP ' PER WMAGE $ $ A X UMBRELLA LIAR X OCCUR . EACH OCCURRENCE $ 2,000,000 EXCESS UAB_ CLAIMS-MADE 5J77852 .. 10/16/2016 10/16/2019 AGGREGATE _ _ $ 2,000,000 DEC X RETENTIONS 10,000 . S B WORKERS CO/SENSATION' . . . AND EMPLOYERS'LIABLLJT/ T,/N X STATUTE I I ani- ER _ AApNN�Y��PERERROPREIIETOR/PARTNER/EXECUTIVE SHnas2 10/16/2o1a 10H 612019 E.L.EACH ACCIDENT 3 600,000 Rifili alpryln EXCLUDED?,:, Pl NIA _ �', , 1 E.L.DISEASE-EAEMPLOYEES 500,000 Ryes describe ulcer •. 500,000 DESCRIPTIQN OF OPERATIONS below EL DISEASE•POLICY LIMIT S • DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORO 101,Additional Remake Schedule,may be attached(more space Is required) Cape Light Compact Joint Powers Entity are Included as Additional Insured for General Liability,Automobile Liability 8,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 Ce Light Compact Joint Powers EntityTHE EXPIRATION DATE THEREOF, NOTICE WILL'BE DELIVERED IN Cape 9 P ACCORDANCE WITH THE POLICY PROVISIONS. , 261 White's Path,Unit : • .. . . . South Yarmouth,MA 02664 • AUTHOR2ED REPRESENTATIVE • ACORD 25(2016/03) . - ®1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD e The Commonwealth of Masittehusetts • t ! :'y ,Department oflndustrialAccidents , eel_ ,. : 1 Congress Street;•Suite 100 ' a{{ Boston,MA 02114-2017 ' ' wwwmassgov/dia Workers'Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers. - ' ' ' - ' TO BE FILED WITH THE PERMITTING AUTHORITY. - Applicant Information Please Print Legibly Name(Business Orgattization/tndividual):Cape Save Inc Address:7-0 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.Q I am a employer with.. 15 _. employees(full and/orpart-time).' .. .. 7. 0 New construction ;,; 2.0 I am a sole proprietor or partnership and have no employees working for me in - 8. ❑Remodeling - ..- any capacity.[No workers'.comp.insurance required.] v; r: t. 3.Q I am a homeowner doing all work myself.[No workers'comp,insurance required.]t 9. ❑Demolition . 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will - 1• 0❑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.Q Plumbing repairs or additions ' 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 MGL c. 14.❑✓ Dther Insulation 152,51(4),and we have no employees.[No workers'comp.insurance required.] ' 'Any applicant that checks box el 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 ornot 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 jor my employees, Below Is the policy and job site information - ._ . Insurance Company Name: Employers Mutual Casualty Company Policy#or Self-ins.Lic.#: 5077852 Expiration Date: 10/16/2019 Job Site Address: 11 Rnxherry Lane 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.. ' I do hereby certify under th pains and penalties of perjury that the information provided above is true and correct , Signature: \ f�\ 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//'own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other , Contact Person: Phone#: ' • • d7Z3 'p tatMetat wade( Office of Consumer Affairs and Business Regulation One Ashburton.Place- Suite 1301 Boston, Massachusetts02108 Home Improvement Contractor Registration � a 4 A ;f/ Type: Corporation I Registration: 171380 CAPE SAVE INC. r i 7-D HUNTINGTON AVENUE `f l Expiration: 03/13/2020 SOUTH YARMOUTH,MA 02664 ,ke\;77.1, 3 `^ SCA t 4 20M-05/17 Update Address and Return Card. lie%mn nnauald c/d ffawarhoe/4 Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Cancragon - before the expiration date. If found return to: peaistration_ gxoiratioq Office of Consumer Affairs and Business Regulation 171380 -' 03/13/2020 One Ashburton Place-Suite 1301 CAPE SAVE INC Boston,MA 02108 WILLIAMMCCLUSKEY-. \R_C(�.,a-- 7•D HUNTINGTON AVENUE' U SOUTH YARMOUTH,MA 02664 Undersecretary Not valid w Ignature e Commonwealth of Massachusetts Division of Professional Licensure Construction Supervisor Specialty Restricte1 Board of Building Regulations and Standards CSSL-IC-to: • - SSL-IC- Insulation Contractor Constructioi51}pdfvispr Specialty I CSSL-102776 im•v """"¢.M EApires 06/28/2019 e 14 y WILLIAM J MCCL,I1SKEY+� ) ,4 _,:2; '4;:2 r 37 NAUSET ROAD, ` ' WEST YARMOUTH MA 02673 *' •` " m.� Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner CL DPS Licensing information visit:W W W.MASS.GOVIDPS \uit RISE ENGINEERING OWNER AUTHORIZATION FORM 1, Melissa Barone (Owner's Name) owner of the property located at: 33 Boxberry Lane (Property Address) West Yarmouth, MA 02673 (Property Address) hereby authorize C u r t S ow \ (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. ‘I Owner's 1', ature lo ' . I Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com