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HomeMy WebLinkAboutBLD-19-2714 v Ot, YAR Office Use Only k 'rr�_ Permit# i S' Nc o n., Amount 3S- Y' * •,.., . •Permit expires 180 days from issue date 3uJ— q -0da71 v EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 NOV 05 2018 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 B U I kal :f, T N Bv: ' T CONSTRUCTION ADDRESS: 53 Putting Green Circle ASSESSOR'S INFORMATION: Map: 100 Parcel:95 OWNER: Richard Harrod same 508-308-4022 NAME PRESENT ADDRESS TEL. # coNTRACTOR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL# ■Residential ❑Commercial Est.Cost of Construction S 1800 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lie.# TC 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 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 re etion of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: \ Data 11/1/18 Owners Signature(or attaehmen attached // Date: � � Approved By: _ / Ag. Date: // -(V ''71C Building Official(or d�.• c EMAIL ADDRE Zoning District: C � ' E D Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes El No NOV 02 2018 Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes ❑ No Out EP " The CommonwealthofMassachusetts • I ik- / • Department oflndustrialAce:d'ents `' ; • eel • 1 Congress Street,Suite 100 a = Boston,MA 02114 2017 • . • �- , :� wwximassgov/dta; - . , • „', r r Workers'Compensation Insurance Affidavit:Sunders/Contractors/Electriclank/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/lndividual):Cape Save'Inc` - - -- 'Address:7-D Huntington Avenue 'ii ' City/State/Zip:South Yarmouth, MA 02664 Phone#:508-398-0398 ' Are you an employer?Check the appropriate box: Type of project(required): i. -. _1.❑✓ 1 em a employer with 15 employees(fuli and/or part-iime).a - -. .. 7. 0 New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $, a Remodeling • .. . any capacity.[No workers'comp.insurance required.] ., • , Asa I am a homeowner doing all work myself.[No workers'comp.insurance required.]*'. ..• 9. ❑Demolition 4.❑I am a homeowner and will be hiringcontractors to conduct all work on 10❑Building addition my prvycrty:Iwill r. ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees: .,•. :.,.„ „. , 12.❑Plumbing relfairs or additions -- - 5.1:I I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repttirs • t These subcontractors have employees and have workers'comp.insurance.: ' 6.0We are a corporation and its officers have exercised their right of exemption 14.❑✓ Other Insulation • orpore gh p” per MGL e . 152,§1(4),and we have no employees.[No workers'comp.insurance required] *Any applicant that checks box tt I 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 and job site . _ information. .. .. ... . .. .. _ . . . .. . Insurance Company Name: Employers Mutual Casualty Company • Policy#of Self-ins.Lic.#: 5D77852 Expiration Date:' '10/16/2019 , Job Site Address: 51 Putting Green Circle 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 verificafion _ . . /rid hereby certify under tth pains and penalties of perjury that the information provided above is true and correct. Signature: \,\ Date: 11/1/18 Phone#:509-398-0398 \\ 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 Depaitment 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector'; 6.Other Contact Person: Phone#: �.....% CAPESAV-01 . NWOODS ,I►coizo CERTIFICATE OF LIABILITY INSURANCE DITEIM6401 Y17 `.� � osn6/2D16 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(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). PRODUCERM€ACT , Rogers&Gray Insurance Agency,Inc. PHO 4 Rte 134 IAC.No,Enp I(A/C,Nop(877)816-2166 SouthouDennis,MA 02660 - - "amiss:mall©rogersgray.com NAICS INSURER A;Employers Mutual Casualty Company 21416 'MIRED . . _ . - • - - - - - - - - . PISURERB:Union Insurance Company of Providence 21423 Cape Save,Inc - ,. INSURER C: 7 D Huntington Ave.. • ... INSURER D: -- ' -' - South Yarmouth,MA 02664 INSURERE: . INSURER P: COVERAGES ' CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ' ITR TYPE OF NSURANCE . . ADDL Nap p POLICY NUMBER POLICY EFF POUCY EXP IMOLIC/YEFF I PCUCY XP A X COMMERCIAL GENERAL LIABILITY ' EACH OCCURRENCE $ 1,000,000 CLAMS-MADE X OCCUR6D77862 1011612018 tOM6/2018 pRDAMTOF AGE RENTEDa wKe) S ' b00,000 F,NISF Idcayr -.. ' . - - MED EXP(Any one person) $ 10,000 ' PERSONAL a ADV INJ RY $ " 1'000'000 GENT AGGREGATE pURNpIT APPLIES PER: • ' ' GENERAL AGGREGATE $ 2'000'000 POLICY X JECf LOC • '. • PRODUCTS-COMP/OP AGG $ 2,000,000 - - . - - EBL AGGREGATE f .-- 2,000,000 (L 'COMBI�NEDDSINGLE OMIT $ 1,000,000 AUTOMOBILE LIABBJTY X ANY AUTO • 5Z77852 10/16/2018 10/16/2019 BODILY INJURY(Per person) $ OWNED —SCHEDULED _ AUTOSgE� ONLY, AUTOSAUyT . I - B• ODILY RWTyJUpRpYM(Per accident) $ AUTOS ONLY _AUTOSD&9 ,. •. .., (Pera�m'dxd) E s _ - f A X UMBRELLA LAB X OCCUR EACH OCCURRENCE -- $ 2000,000 EXCESS LAB CLAIMS-MADE 6J77862 "' ,. , .•.:• 10/1612018 19/16/2019 AGGREGATE " $ , ' 2,000,000 DED X RETENTION f 10,000 ,. --,-• $• B WORKERS COMPENSATION '.. ' . .. . . .. PER DTH- ANDEMPLOYERS LABILITY YIN - X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE 6H77862 10/1812018 1011612019 E.L EACH ACCIDENT 3 600,000 ER21FigM EXCLUDED]., • , 1'N J N/A - .... ._._ - - - 600,000 I a.describe under , E.L.DISEASE-EAEMPLOYEE 5 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 600'000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional ReeaM Schedule,nay be attached r more space Is regrind 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 MY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CapeLight Compact Joint Powers EntityTHE EXPIRATION DATE THEREOF, NOTICE.WILL BE DELIVERED IN 9 W ACCORDANCE WITH THE POLICY PROVISIONS. 261 White's Path,Unit 4 - - South Yarmouth,MA 02664 - - - - - - AUTHORIZEDREPRESENTATIVE _ ' .- "' . • 4.-4(.......--_____ . ACORD 26(2016/03) - - ®1988-2016 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 Boston, Massachusetts 02108 Home Improvement`Contractor Registration 17:\, 17:4),-_-,,, 04 Type: Corporation I1 �' .a Registration: 171380 CAPE SAVE INC. P..1 s r _z.'141-:"‘ figuration: 03/13 /2020 7-D HUNTINGTON AVENUE SOUTH YARMOUTH,MA 02664 i'E `, VA =t f` _ter--s`"v scA t 8 zorn-os/v Update Address and Return Card. �A I('ONfM4rtlMOl��O�e��QdlAf�/I.lP�ll Omce of Consumer Affairs 6 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 1713801 ".031132020 'One Ashburton Place•Suite 1301 CAPE SAVE INC 'rrj i,..\ Boston,MA 02108 Irk WILLIAM MCCLUSKEY 7,:'' Q.G e-- 7•DHUNTINGTONAVENUE' (`\\i SOUTH YARMOUTH,MA 02664 Undersecretary Not valid w '`+i .Ignature ' c. Commonwealth of Massachusetts 1 '' f Division of Professional Licensure • Construction Supervisor Specialty Board of Building Regulations and Standards RestrictCd to: - - CSSL-IC-Insulation Contractor Constructioc.'S11pdkisor Specialty it CSSL-102776 .'.'i'".,' E'Aires 06/28/2019 / ' '«r' r 4 ...1 I i WILLIAM J MCCLIJROAD1 KE. j'1 ^ ...:,..• l 37 NAUSET ROAD 7 \ i 1 INESTYARMOUTHMA 02673 ♦`• ` 1 ,�,j 3 l fItS L1L)t� Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner DPS Licensing information visit:WWW.MASS.GOVIDPS !1uiii RISE5 Dupont Avenue I South Yarmouth,MA 02684 I 508-568-1926 ENGINEERING www.RlSEengineering.com OWNER AUTHORIZATION FORM (Owners Name) owner of the property located at: • ct*Ws Coen CAS ). A \ (Property Address) (Properly Address) hereby authorize Y ( . Subco or) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property.This is is only val • ' • signed contract. • ers '!nature