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Home My WebLink AboutBLD-19-2700 i office use Only 0FY9R� lk 41 s43Sur0 Permit# p "I Amount d 41 F '; g Permit expires I80 days from j ._: .;i: issue date 80)—' el -DM-700 EXPRESS BUILDING PERMIT MAPPLICATICNE C E I V. E D TOWN OF YARMOUTH -RECEIVED Yarmouth Building Department 1146 Route 28 I NOV 05 2018 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 BU plPMW BY: IL CONSTRUCTION ADDRESS: 45 Joshua Baker Road ASSESSOR'S INFORMATION: Map:40 Parcel:26 OWNER: Patricia ymark snmc 508-775-6448 NAME PRESENT ADDRESS TEL # CONTRACTOR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL# I Residential 0 Commercial Est.Cost of Construction$ 5000 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lic.# IC 102776 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 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 , it ation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: 4 Date 11/1/1R Owners Signatu (or attachmen q , he. Date: / /7 ! r Approved By: / `� , Date: /5 �U Buildin: s mi:.-ofd ignee) . E ADDRESS: Zoning District: `` E I V E D Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 N I1 E E '_'''"�i Water Resource Protection District: Within 100 ft.of Wetlands: NOV0 2 2018 1 q Yes ❑ No ❑ Yes ❑ No Y BUILDING DEPARTMENT BY: The Common,Dealih of Massachusetts' ' Department•ofindustrial Accidenfs eB[l= I Congress Street,Suite 100 . IF V111—= , __ Boston,MA 01114-2017.. Z.�. r , , • '•www.mass,gov/din ;°. . ,; • r t- • •• Workers'Compensation Insurance Affidavit:Builders/Contractors/Electticians/Plambers.•. r• n "' '•' TO BE FILED WITH THE PERMITTING AUTHORITY. .... g Applicant Information Please Print Legibly Name(Business/Organization/Indtvtdualj:Cape Save Inc Address:7-D Huntington Avenue ‘.•r• s•-^+ City/State/Zip:South Yarmouth. MA 02664 - Phone it:508-398-0398 Are you an employer?Check the appropriate box: Type of protect(required): '. -- 1. ✓ 1 am a employer with- 15 employees and/or part-time).* -- -' ❑ (fullv�-' )- __ !7: ❑New construction- - 201 am s sole proprietor or partnership and have no employees working for me in 8• ❑Remodeling any capacity.No workers'comp.insurance required] , 3 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition 4.01 am a homeowner end will be hiring contractors to condutt all work on my property.I will 10 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. , .:r +,• °• :za 12,Q Plumbing repairs or additions 1'.` 5.0 I am a general contractor and 1 have hued the subcontractor listed on the attached sheet. These sub-contractors have employees and have workers'comp,insurance.t 13.❑Roof repairs 6.13 we ere a corporation and its officers have exercised their right of exemption per MGL c. 14.90ther Insulation i r -,g 152,§t(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 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 I information.Insurance Company Company Name: Employers Mutual Casualty Company Policy#or Self-ins,Lic,#: 5D77852 - "- - - Expiration Date: 10/16/2019 Job Site Address: 45 Joshua Baker Road 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 MOL 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 1 do hereby certify under tth pains and penalties of perjury that the information provided above is true and correct ' Siznature: \,\11 Date: 11/1/18 • 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/1'own Clerk 4.Electrical Inspector 5.Plumbing Inspector • 6.Other Contact Person: Phone it: _..........-ThCAPESAV-01 HWOODS ACO/4O CERTIFICATE OF LIABILITY INSURANCE DATE 1D0"n"' k......----- - 09/26 09/26/2018 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 pollcy(ies)must have ADDITIONAL INSURED provIslons 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 hair CT Rogers 8 Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 INC,eo):(877)816-2156 South Dennis,MA 02660 mess:mail@rogersgray.com . . •_ . .. - ... .. INSURERLS)AFFORDING COVERAGE __ _ _ NAICIt INSURER A:Employers Mutual Casualty Company 21415 MURED . - - INSURER a:Union Insurance Company of Providence 21423_ _ _ Cape Save,Inc . • WSURER c: 7 D Huntington Ave - - NwRER D: " - ' - - - 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 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 ADDL SUBRPOLICY EFF OLIC PY EXP ITR TYPE OF INSURANCE luso vim POUC/NUMBER IMMIDDIYYYY1 IMWDWYTYY) UMITS ' A X COMMERCIAL GENERAL LIABILITY - 1,000,000 - _EACH OCCURRENCE $ _ CLAIM$-MADE X OCCUR 5077852 10/16/2018 10/16/2019 oAMAGE TO RENTED 500,000 PREMISES(Ea warrens?) S . . ' .. on ' MED person) $ 10,000 PERSONAL SADV INJURY _3. 1,000,000 • GEM.AGGREGATE UNIT APPLIES PER . GENERAL AGGREGATE $ ' 2,000.000 PCUCY Fig Ta LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: ' " - . _ _ ESL AGGREGATE- $ • 2,000,000 A AUTOMOBILE LIABILITY , COQ aIN�EnDIsmcLE LIMIT S. 1,000,000 X ANY AUTO . - 5Z77852 10116/2018 10/1612019 BODILY INJURY(Pet person) 1 OWNED — SCHEDULED - — AUTOS ONLY _ O&M . . . . .. . • BODILY INJURY per accident) S • - AUTOSONLY _ AULOS ONLY ' -. .; ., FROPERTYDAMAGE ((�Peerr WWrrxxlleettGGll S .. A X UMBRELLA LAS X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESSLIAS -- CLAIMS-MADE 6.07852 - ,/. - - 10/16/2018 10/16/2019 AGGREGATE " . $ 2,000,000 DED X RETENTIONS 10,000 B WORKERS COMPENSATION '- X I PER I IOTH- AND EMPLOYERS'LIABILITY YIN I STATUTE ER _ ANY PROPRIETOR/PARTNER/EXECUTIVE 5/177952 10/16/2019 10/16/2018 E.L.EACH ACCIDENT $ 600,000 �A:oa�EI Bg)EXCLUDED? ' ' i N I NIA _ .. _ . . . 500,000 N yes describe under - • - - E.L.DISEASE.EA EMPLAYEES DESCRIPTION OF OPERATIONS belay E.L.DISEASE-POLICY LIMIT $ 500,000 • DESCRIPTION OF OPERATIONS ILOCATIONS I VEHICLES(ACORD 101,AddNune Remarks Schedule,may be attadad It,non tepees le required) Cape Light Compact Joint Powers Entity are included as Additional Insured for General Lability,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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 261 White's Path, ctJnit4 _ ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTIORQFD REPRESENTA77VE. • ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 w Boston, Massachusetts02108 Home Improvement Contractor Registration e„-..„ -- : - X t r /f' Type: Corporation 1 . t' u Registration: 171380 CAPE SAVE INC. .Y ... =r i'1 Expiration: 03/13/2020 7-D HUNTINGTON AVENUE �1/ + ' z _ • SOUTH YARMOUTH,MA 02664 I,.. . it$` \ +t s li S tag :P 0' -7 Ti JK t .\` L r. 4� /� .till . .'"'"- Update Address and Return Card. SCAT 8 20M05117 C" ..�ieoonrrnanurn/1A.O f(aaacAetwm - - — -- mice of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corooration `: before the expiration date. If found return to: Registration ---; gxoiraton Office of Consumer Affairs and Business Regulation •171380 r s ' 13 03/13/2020 One Ashburton Mace•Suite 1301 CAPE SAVE INC.:''.. , 4,:.;,'„i' Boston,MA 02108 WILLIAM MCCLUSKEY 7-D HUNTINGTON AVENUE` U \\/ SOUTH YARMOUTH,MA 02664 Not valid w ' .1 -ignature Undersecretary ' c. ` Commonwealth of Massachusetts r�!` Division of Professional Licensure Construction Supervisor Specialty Restricted to: Board of Building Regulations and Standards CSSL-IC-Insulation Contractor ConstructiocgdFM ltsprSpecialty r CSSL-102776 '-"^.'""`i E-jpires 06/28/2019 • V w: 1a 2 ' i WILLIAM J MCCLTISKEY4. .. . \� 'P 37 NAUSET ROAD, C 4 r .3 •• I WESTYARMOUTHMA 02673 . .;� . .t'nitA-. S` Failure to possess a current edition of the Massachusetts State Building Code Is cause for revocation of this license. Commissioner DPS Licensing information visit:W W W.MASS.GOV/DPS RISE ENGINEERING' OWNER AUTHORIZATION FORM I, Patricia Nymark (Owner's Name) owner of the property located at: 45 Joshua Baker Road (Property Address) West Yarmouth, MA 02673 (Property Address) hereby authorize C& P C Say( (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 41 Date..... RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RISEengineering.com