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Home My WebLink AboutBLD-19-2706 , sit.Y4R Office Use Only ` G Permitil 1 1!!!0P1 Amount' 1a Persuemitdate expires 180 days from : i is4 13LD-is-O -1 o4c, EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 5 2018 South Yarmouth,MA 02664 NOV, J (508)398-2231 Ext. 1261 C•14 .' �y 7 BUILDING DEPARTMENT By: CONSTRUCTION ADDRESS: 37 Cherry Lane ASSESSOR'S INFORMATION: - , Map: 86 Parcel:254 OWNER: Nancy Pereira same 508-737-7023 NAME PRESENT ADDRESS TEL # coNTRAcroR:William McCluskey/Cape Save 7-D Huntington Ave, S. Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL# ■Residential 0 Commercial Est.Cost of Construction$ 4300 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lie.0 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: Fmployers 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 *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 denial r cation of my license and for prosecution under M.O.L Ch.268,Section 1. Applicant's Signature: �nh�\\3?�, Date: 11/1/18 Owners Signature(or attachmen at//($$$C/�h//ryyaa`� J Date: Approved By: 0J� �fF Date: �� Building Offi designee) EMAIL SS: -I c. CL-IVED Zoning District: ~�-- I Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 R.of Wetlands: t NOVNO 0 2 2018 I ❑ Yes ❑ No ❑ Yes ❑ No Pi:SLDING DEPARTMENT r,. 'The Commonwealth of Massachusetts i -- —(1, ,' . Department of Industrtal Accidents eek § 1 Congress Street,Suite 100 ;�fe Boston,MA 02114-2017 , �= , wwwmass.gov/dia . Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Nurnberg. .5 . - i TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le&tbly ' Name(Business/Organization/Individual):Cape Save Inc t " Address:7-D Huntington'Averiue' City/State/Zip:South Yarmouth, MA 02664 Phone#:508-398-0398 Are you an employer?Cheek the appropriate box: - + Type of project(required): I.El I am a employer with 15- - employees(full and/orpart-time)•r -.. - . - .. - .. 7.•❑New construction 2. I am a sole proprietor or partnership and have no employees working for in , - 2.01 am s. ❑Remodeling .. any capacity.[No workers'comp,insurance required.] 3.a 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 '10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions .. [ proprietors with no employees. 1 ,,.,_. 12.❑Plumbing repairs or additions .t 5.1:11 am a general contractor and I have hired the subcontractors listed on the attached sheet 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance? ❑ P 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q✓ Other Insulation 152,111(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'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andJob site information. Insurance Company Name: Employers Mutual Casualty Company • Policy#or Self-ins.Lic.#: 5D77852 - Expiration Date:" 10/16/2019 Job Site Address: 17 Cherry I ane 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 Ido hereby certify under t h pains and penalties ofperjury 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: Permit/License# •f n 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• sacoRO CERTIFICATE OF LIABILITY INSURANCE °"�'"wD°""YY' 16.........---- 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 OW ALTER THE COVERAGE AFFORDED BY THE POUCIES 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 polley(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 sucheenndorsement(s). PRODUCER NAME:CT _ Rogers 8,Gray Insurance Agency,Inc.: PHONE FAX -_ 434 Rte 134 . .. . .. _ .. jNCOM,Ext): . . INC,Nok(877)816-2156 South Dennis,MA 02660AySf.mail�rogersgray.com . . .. _ ... . _ . . _..._.. - _ _ . INSURERS)AFFORDING COVERAGE NAIC e ' INSURER A:Employers Mutual Casualty Company 21415 INSURED . , ---. .-- - - INSURER B:Union Insurance Company of Providence 21423 Cape Save,Inc . INSURER C: - ' 7 D Huntington Ave . - INSURER D: -" South Yarmouth,MA 02664- , NSURER 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - • NSR AODLSUBR POLICY NUMBER POLICYEFF POLICY EXP LINTS LTR TYPE OF INSURANCE IVSD WYD IMMIDDNYYYI NMIDONYYYI A X COMMERCIAL GENERAL LIABIUTY ^ EACH OCCURRENCE $_ 1.000,000 1?AMAGET OREMED 500,000 CLAIMS-MADE X rrrxN 6D77852 1011612018 10/16/2019 pREMISFS LEe.4r6lnence) $ . r • MED EXP(Any one person) — $ 10,000 • ' PERSONAL SADV'WRY ' $ 1,000,000 GENL AGGREGATE UNIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POUCY X To H we - - ' -. PRODUGTs-COMP/OPAGG $ 2,000,000 OTHER: ..•". -. . - - - EBL AGGREGATE • $ - 2,000,000 COMBINED SINGLE LIMIT 1,000,000 A AUTOMOBILE LUBIUTY IE amJoent) S X ANY AUTO - 6277$62 _. 10/16/2018 10/16/2019 BODILY INJURY(Per person) $ OWNED SCHEDULED ' - AUgT�O�SONLY _ AANUpT�O{{S�WWNN�Epp. . - :. . BODILYO� INJURY(Per accident) $ - ' AUTOS ONLY _AUTOSONLY _ . PParP ) E f - - A X UMBRELLA UAB X OCCUR EACH OCCURRENCE S 2,000,000 EXCESS LABCLANS-CLANS-MADEcMsE 5J17852 - ' . 10116/201$ 10/16/2019 AGGREGATE 3 2,000,000 DED X RETENTION$ • 10.000 .— f B WORKERS COWENSAT1ON '- .. -.- - AND EMPLOYERS'LABILITY X I STATUTE I 1 ERS AoNpY PR¢Oq/PMRIETOR/PARTNER/EXECUTIVE YIN 5H77852 10/18/201$ 10118/2019 E.L.EACH ACCIDENT $ 500,000 OFF10ER/ME • EL DISEASE-EA EMPLOYEE 5 500,000 desalt Wye,.DESCRIPTION OF 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES ACORD 101,Addifoeal Remarks Schedule,may be attached I more space Is requl.W . 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 MY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE • Cape Light Compact Joint Powers Entity ACCORDANCE WITH TION DATE E PO THEREOF, PROVISIONS CE ALL BE DELIVERED IN 261 White's Path,Unit 4 . . . South Yarmouth,MA 02664 _ . . AUTHORIZED REPRESENTATIVE '- - ACORD 25(2016/03) . . '- ®1888.2015 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 e Boston, Massachusetts02108 Home Improvement Contractor Registration I'll` ', k=�, ' ; / ' • Type: Corporation ' trt s-5 RegistratIon: 171380 CAPE SAVE INC. +i S : ) r j� t E�piratlon: 03/13/2020 7-D HUNTINGTON AVENUE int c r _ SOUTH YARMOUTH,MA 02664 ti-:;71,1-4b, >} ''ri v,, i , 3 tt ..7 it' \K' ty 7 j1p; , '\ ' scxt 8 2oa�-oafT -.....4 , - Update Address and Return Card. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR :Registration valid for Individual use only TYPE:Corporation before the expiration date.if found return too Registration--;pamlratloq Office of Consumer Affairs and Business Regulation -171380 • -' 03/13/2020 One Ashburton Place-Suite 1301 CAPE SAVE INC '<- - Boston,MA 02108 4- ;�I WILLIAM MCCLUSKEY '' R --, 7-D HUNTINGTON AVENUE' c .C(i.� ' SOUTH YARMOUTH,MA 02664 Unde��rn�ry . Not valid w ,;`'i -ignature ' r.' Commonwealth of Massachusetts 17) Division of Professional Licensure Construction Supervisor Specialty Restricted to: Board of Building Regulations and Standards CSSL-IC-Insulation Contractor Con structioceSU r Specialty I CSSL-102776 J ^^ '" "'""7. Ipires:06/28/2019 r) WILLIAM J MCCLUSKEY4` d i 37 NAUSET ROAOI . ':- 71 � ' 1 1 WESTYARMOU ` THMA 02673 - .. Failure to possess a current edition of the Massachusetts a`_ State Building Code is cause for revocation of this license. Commissioner DPS Licensing Information visit:WWW.MASS.GOVfDPS Cape Light ASR Compact !� 5 Dupont Avenue South Yarmouth, MA 02664 in I OWNER AUTHORIZATION FORM i, NANCY PEREIRA (Owner's Name) owner of the property located at: 37 Cherry Lane (Street) West Yarmouth, MA 02673 (Town, State, Zip) hereby authorize Cape Save Inc. (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. The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. ?'4q ,r &LJ-Customer Siture to -Sign Date 3/30/2018