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Home My WebLink AboutBLD-19-2708 Og YaR, . . Office Use Only te 2O otaglg ti. Amount J 1\ce , \" ."i "Cd. Permit expires 180 days from `....:.. .:..:: issue date. . . 13Lb-19 -vt 7bS.- EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 • South Yarmouth,MA 02664 NOV 0 5 2018 (508) 398-2231 Ext. 1261 8Ul a piny, , jn_T CONSTRUCTION ADDRESS: 7 Drake Street By: '� Pi ASSESSOR'S INFORMATION: . Map: 137 Parcel: 27 OWNER: Margaret Cerhone same 914-456-7934 NAME PRESENT ADDRESS TEL # CONTRAcroR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL# I Residential ❑Commercial Est.Cost of Construction S 2100 Home Improvement Contractor Lie.# 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: Pimp] yers 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 denialr re ation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: 11/1/18 Owners Signature(or attach men a ac ed f Date: Approved By: // •L / Date: /7-70C-7/6 Building a`IC. . or designee) E L ADDRESS: ' ' V E D Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No NOV2 201E Water Resource Protection District: Within 100 ft.of Wetlands: ft �t ❑ Yes ❑ No ❑ Yes ❑ No BUILDING DEPARTMENT BY' M • wu , Ir The Commonwebltk'ofMassdchusetts 17....=-7t=._C!lil '. Department of Industrial Accidents '" ' ' 'sf= * 1 Congress Street,Suite 100 t ;1 ! Boston,MA 02114-2017 www mass govidia ; , _. Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers:“. . TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information -. . Please Print Le2ibly Name Business/Organization/Individual):Cape Save Inc - - Address:7-D Huntington Avenue' • City/State/Zip:South Yarmouth,MA 02664phone#:508-398-0398 -' Are you au employer?Check the appropriate box: u e Type of project(required): 1.0 I am a employer with 15 employees(full and/or part-time).* ' • - 7. 0 New construction 2.0 1 am a sole proprietor or partnership and have no employees working forme in - any capacity.[No workers'w insurance 8•: ❑Remodeling rep- required.] • _ • 3 I am a homeowner doing all work myself.No worker'comp;insumnce required.]: • 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 .• 1 ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. :.. ,. .. .. 12.❑Plumbing repairs or additions 51:11 am a general contractor and I have hived the sub-contractors listed on the attached sheet 13.❑Roof airs • These sub-contractorsr have employees and have workers*comp.insurance.: rep 6.0 We are a corporation and its officers have exercised their right of exemption per MGL e. 14.ElOther Insulation 152,§I(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 contractor 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 insurancefor my employees. Below is the policy andjob site information. . .,,Insurance Company Name: ` Employers Mutual Casualty Company • Policy#or Self-ins.Lie #: 5D77852 • - - -- • - Expiration Date: 10/16/2019 - lob Site Address: 7 Drake Street 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:free 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 free 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 fhpains and penalties of perjury that the information provided above is true and correct Signature: \\4\� 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.Bailding Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector" 6.Other . . . ... i5 Contact Person: Phone#: N �....11 CAPESAV-01 HWOODS '``ORO CERTIFICATE OF LIABILITY INSURANCE 09/26/22018 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 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).eqT • PRODUCER - 1COM�ACT, . , Rogers&Gray Insurance Agency,Inc. PHONE FAX South Dennis,is,MA 02660 LSs:mail@rogersgray.com two,"01'(877)316-2156 _ _. . . _. .. INSURER(S)AFFORDING COVERAGE NAIC I • MUMS A:Employers Mutual Casualty Company 21415 INSURED - . -•_ . . . - . . . . '- - INSURER B:Union Insurance Company of Providence 21423 Cape Save,Inc INSURERC: ' 7 D Huntington Ave :_ INSURER 0: _ South Yarmouth,MA 02664 . INSURER E: MEURERF: . 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 SUBR POLICY EFF POLICY EXP ' LTR TYPE OF INSURANCE /NSD Wen POLICY NUMBER IMMIDD/YYYYI IMWDDIYYYYI .. . L1IAITS A X COMMERCIAL GENERAL LIABILITY . EACH_OCCURRENCE ' - $ 1,000,000 CLAIMS-MADE I OCCUR. .. 5D77852 10/16/2018 10/16/2019 DAMAcero RENrED -- 500,000 PREMISFS IFa omarerYel S MED EXP(Any ale person) $ 10000 PERSONAL IADV INJURY 1,000.000 GENL AGGREGATE UMIT APPLIES PER _ GENERAL AGGREGATE $ 2,000,000 POLICY X P, r ❑Loc . _ _ PRODUCTS:COMPVPAGG $ 2,000,000 OTHER, - . . . _ EBL AGGREGATE --- $ 2,000,000 A AUTOMOBILE LABILITY . . COMBINED• idern)INGIELIMIT $ . 1,000,000 X ANY AUTO ,ED _ • 5277852 ' 10/1612018 10/1612019 BODILY INJURY(Per Person) $ AII�U�ppT��O��S ONLY AArJUUpTqOOSµµNN��E�pp . . . . pBODILY INJURY(Per accident) $ AM ONLY,', _ AUT ONLY : ' . _ ,,...u, IaOPERTV AMAGE $ . . �1 $ A x UMBRELLA DAB X OCCUR EACH OCCURRENCE 3 2,000,000 Emus DAB CLAIMSMADE 5.177852 c.'': i " :.. ' : 10/16/2018 10/16/2019 AGGREGATE . . .. • $ ..2,000,000 DEC: X RETENTIONS . 10,000 S B WORKERS COMPENSATION ' • - - - "' X STATUTE ET µ AN°ENPLOYENB'DtlJ AB7Y 5H77852 10/16/2018 10/16/2019 9000 ANY PROPRIIETORIPARTNERIEXECUTIVE R YIN 0,0 E.L EACH ACCIDENT $ A _ ED O_ EMBERFYrA UDT � .. N NIA - _.. .. . . 500,000 %maney�in NH) - E.L DISEASE•EA EMPLOY S _ H s,describe under • -• .. 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $ I ., DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,ARemotesdtdonalRemotattachedr mace Remotes Schedule, y be attached more ee re Is q .. Cape Light Com pact 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 THE EXPIRATION DATE THEREOF.,Cape Light CompactJoint Powers Entity ACCORDANCE WITH THE POLICY PROVISIONS.NOTICE WILL BE DELIVERED IN-- , , 261 White's Path,Unit.4 , • South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE .. . C )61(-02401 __ _. 7 I . .._. .. Oma_. - ACORD 25(2016/03) _ 01988-2015 ACORD CORPORATION. All rights reserved. . The ACORD name and logo are registered marks of ACORD w CD ofPAtzuctekaa Office of Consumer Affairs and Business Regulation One Ashburton Place-Suite 1301 ; Boston, Massachusetts 02108 Home Improvement Contractor Registration r (i • Type Corporation CAPE SAVE INC. iU'r._-x ,+ kii "�l`i� Registration: Expiration* 03/13/2020 7-D HUNTINGTON AVENUE `I 4c.f.;, 7 -1 SOUTH YARMOUTH,MA 02664 III t i tom''' � j qtr. c` 6 SCA r O zonwsrf 1 _ _ Update Address and Return Card. C978't< t/o f(aarreleuet4 — .. ` -. —._..-' _ .-_ Na 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: peaistration -— Expiration Office of Consumer Affairs and Business Regulation 171380 ;'.03/132020 . One Ashburton Place-Suite 1301 CAPE SAVE INC .� :'... 1:1 Boston,MA 02108 WILLIAM MCCLUSKEY ' R.ces/e--- 7-D HUNTINGTON AVENUE''/ U� SOUTH YARMOUTH,MA 02664Undersecretary _ Not valid w Ignature • - r ( ®! Commonwealth weaoh of Massachusetts Division of Professional Licensure ConstructionRestrictedto Supervisor Specialty Board of Building Regulations and Standards t0: CSSL-IC-Insulation Contractor Constructioe,Slip4(�iaor Specialty l CSSL-102776 c=` .P Jo E fres 06/28/2019 WILLIAM J MCCLLUSNEYi s i „ I, 37 NAUSET ROADI ",..1 ,i , �C Ak t 1 WEST YARMOUTH MA 02673 .y " .,,i Failure to possess a current edition of the Massachusetts 4s_ State Building Code is cause for revocation of this license. Commissioner DPS Licensing information visit:WWW.MASS.GOV/DPS N iiW RISE itc ENGINEERING OWNER AUTHORIZATION FORM 1, Margaret Cerbone (Owner's Name) owner of the property located at: 7 Drake Street (Property Address) Yarmouthport, MA 02675 (Property Address) Nhereby authorize — `Q' C, • (Subcontra \.r) 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. aggigginsissar OwneYs/Signature CI / Sib Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RISEengineering.com