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HomeMy WebLinkAboutBLD-19-2704 ,„ (ice Use Only Og"Y`L4 1$ 1110- PermitA 2� u O 1 Amount W '""'i"••a Permit expires 180 days from 1 ±issue date (, EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 NOV 05 2018 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 55 Captain Dore Road e ulLptiit& ASSESSOR'S INFORMATION: Map: 67 Parcel: 167 OWNER: Marcos Ribeiro same 508-815-9082 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 4200 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lic.# 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.Polity# 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 Me 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 denialration of my license and for prosecution under M.G.L.Ch.268:Section I. Applicant's Signature: Date: 11/1/18 Owners Signature(or attachmen a c ed Date: Approved By: A` — Date: / --,..5---767 Building rci r designee) E ADDRESS: .—l; E C E i I E D Zoning District: N ^r+ Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No NOV 02 2018 Water Resource Protection District Within 100 ft.of Wetlands: 0 Yes 0 No ❑ Yes 0 No BLILDING DEPARTMENT By _ The Commonwealth of Massachusetts -_ II=LSt =e' ' Department ofIndustria'lAccidents ' _ei - • 1 Congress Street,Suite 100 t.1 I Boston,MA 02114-2017 '�a� , , . : www.massgov/dia Workers'Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers; " .. TO BE FILED WITH THE PERMITTING AUTHORITY. i' :'Applicant Information - - - Please Print Legibly 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 of project(required ): 1.El I am a employer with 15 employees(full and/orpad-time).'.. -' •7. ❑New constriction ,- , ..2. 1 am a sole proprietor or partnership and have no employees working for me in • , any capacity.[No workers'comp.insurance required.] • .. ❑Remodeling 9. ❑Demolition 3.❑1 am a homeowner doing all work myself.[No workers'comp.insurance regmred.)t 4.0 I 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 are sole I I Electrical repairs or additions . proprietors with no employees 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hived the subcontractors listed on the attached sheet Q P 13. Roof repairs i i 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 o. 14.❑✓ Other Insulation 152,41(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. - -- I 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-contractora have employees,they must provide their worker'comp.policy number. a I am an 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.Lie.#: 51)77852- - - — Expiration Date: 10/16/2019 Job Site Address: 45 Captain Dore Road 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 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 tth pains and penalties of perjury that the information provided above is true and correct , Signature: \,\ 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; Perinit/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#: • �1 CAPESAV-01 HWOODS A`ORO* CERTIFICATE OF LIABILITY INSURANCE • os(MMAXI T ) 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 WANED, 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 .. - ACT Rogers 6 Gray Insurance Agency,Inc.. PHONE FAX ' 434 Rte 134 bac.No,Eat): • (AsoNo tan 816.2156 South Dennis,MA 02660 wet Dam mail@rogersgray.com '. - -' - - - '- ' -INSURER(SI AFFORDING COVERAGE NAICS INSURER A:Employers Mutual Casualty Company21416 • INSURED - - - ---• INSURER a: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. • YE R TYPE OF INSURANCE ,j, soon POPOUCY NUMBER MJDDITYYCY POLICY EXP LIMITS LIR IVSD WVD IMWDD/YWTI IMWOWWYYI ' A X COMMERCIAL GENERAL LULBIUTY : 1,000,000 EACH OCCURRENCE $ CLAIMS-MADE X OCCUR , ' - 5D77852 10116/2018 10/16/2019 gaGaS(EBENTo TE ance1 $ 500,000 . - MED EXP(My epeon) S 10,000 nn PERSONAL IS ADV INJURY S 1'000'000 GENL AGGREGATE UNIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY n z n LOC ' . PRODUCTS-COMP/OP AGG S 2,000,000 OTHER, ' . . . - •' EBL AGGREGATE- S- 2,000,000 A AUTOMOBILELMINUTY (Ea COMBINED SINGLE LIMIT 3 . 1,000,000 X ANY AUTO 5277852 • . - 10/16/2018 10/16/2019 BODILY INJURY(Per person) S - AUTOSONLY _ AAWNED ANUTp�OOSµµULNNEEEDpp,. - - - BODILY INJURY(Per accident) S AUTOS ONLY _ AUTl2ONLY. .. , <Pw PEaiRoan) MAGE $ A X UMBRELLA UAB X OCCUR . EACH OCCURRENCE S 2,000,000 EXCESS UAB . CAMAS-MADE 6J77852 .. . .: .. ' 10/1612018 10/16/2019 AGGREGATE S '' 2,000,000 ' DED X RETENTIONS • 10,000 s B WORKERS COMPENSATION - ' . . X AND PER ME I ERµ • EMPIGYEAS LMBa.IfY 6H77862 10/16/2018 10/16/2019 600,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N NIA ,.,) E.L EACH ACCIDENT S • __, O ancasoq m r.n)EXCLUDED?i,'. ' H .. .. atory in NH) - - .. _ E.L.DISEASE-EA EMPLOYEES 600,000 If vet deecnbe Mlaer 500,000 DESCRIPTION OF OPERATIONS below Et DISEASE•POLICY LIMIT S DESCRIPTION OFOPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks achedN.may im attached E mon apace le 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 CapeLight Compact Joint Powers EntityTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 Da ACCORDANCE WITH THE POLICY PROVISIONS. 261 Whhe's Path,Unit 4 - 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 �G-�e - Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Massachusetts 02108 Home Improvement„Contractor Registration ` T Type: Corporation CAPE SAVE INC. �i i0isi” Registration: 171380 7-D HUNTINGTON AVENUE I7f x r }. a l l Expiration* 03/13/2020 SOUTH YARMOUTH.MA 02664A�. - ` 1 + .' � .. Y Update Address and Return Card. SCM 0 som-os17 Office of Consumer Attain&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Carooraticn before the expiration data. If found return to: Registration,- Exoiretlon Office of Consumer Affairs and Business Regulation 171380 • ".03(132020 One Ashburton Place-Suite 1301 CAPE SAVE INC 'ill +_i ti. Boston,MA 02108 WILLIAM MCCLUSKEY ;. / LGQ� 7-D HUNTINGTON AVENUE' C\Q _. SOUTH YARMOUTH,MA 02664 Unde re Not valid w ;`'i -Ig nature Commonwealth of Massachusetts Itc Construction Supervisor Specialty Division of Professional Licensure �� Restricted to: • - Board of Building Regulations and Standards CSSL-IC-Insulation Contractor ConstructiooStpdwtsorSpecialty it CSSL-102776 ""3;,- !. E"Aires 06/28/2019 WILLIAM J MCCL'USKEY!/ O 6 37 NAUSET ROADI '. p C R .. I ` WEST YARMOUTH MA 02673 i.. • �1 Failure to possess a current edition of the Massachusetts ^ 0 a.- State Building Code is cause for revocation of this license. Commissioner CI- DPS Licensing information visit:WWW.MASS.GOVIDPS RISE ENGINEERING OWNER AUTHORIZATION FORM 1, Marcos Rogerio Ribeiro , (Owner's Name) owner of the property located at: 55 Captain Dore Road (Property Address) South Yarmouth, MA 02664 (Pro erty Address) hereby authorize Cr _S: Q _ G i (Subcont r) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. Thisform is only valid with a signed contract. G 2--) / ) al Owner's Signature /C-7 (7...7 Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com