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Home My WebLink AboutBLD-19-2873 s Office Use Only °t.YgR r *44 �r0 Permitil' O Its Amoum ✓t/.Oi `' MTT.in , *"•" 1-d' Permit expires 180 days from %issue date - - j B(11) -1,-r gT3 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 66 Webbers Path ASSESSOR'S INFORMATION: Map: 86 Parcel:140 OWNER: Katia Miyuki same 508-694-5969 NAME PRESENT ADDRESS TEL. # CONTRACFOR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL.# ■Residential 0 Commercial Est.Cost of Construction S 3800 Home Improvement Contractor Lic.# 171380 Construction Supervisor Lie.# IC 102776 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor it 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 '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 re cation of my license and for prosecution under M.G.4 Ch.268,Section 1. Applicant's Signature: � �� Date: 11/6/1R Owners Signature(or attaebmen attached / Date: �,/� Approved Bree) -t/- Date: �/ D �� Bu: irce-57:41 (ordesignee) L ADDRESS: `P 7�5. e . G l Zoning District: ,-"_'-`Y Historical District: ❑ Yes ❑ No Flood Plain Zone: 0 Yes 0 No s,1 O$ ,Z018 Water Resource Protection District: Within 100 ft.of Wetlands: l ❑ Yes ❑ No ❑ Yes ❑ No ; �,,`- MENT B Iii ---- The Commonwealth' i : lth of Massachusetts . - • i (i/ Department ofIndustrial Aces 6 z P -ft , • .Eiei 1.Congress Street;Suite 100 Boston,MA 021142017 "�� • wwwmassgov/dra _ Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.' TO BE FILED WITH THE PERMITTING AUTHORITY. .. .:.r r Applicant Information •. Please Print Leeibly • Name(Business/Organization/Individual)C Cape Save Inc. Address:7-D Huntington Avenue South Yarmouth, MA 02664 . 508-398-0398 City/State/Zip: ' Phone#: Are you an employer?Check the appropriate box: Type of project(required): I. ✓ Iam aero to with- 15 _ - p yer employees(full and/or ' ❑NeW construction 2.0 I am a sole proprietor or partnership and have no employees working for me in , 8. ❑Remodeling _ any capacity.[No workers'comp.insurance required.] i. . . .. .. ' 3. I am a homeowner doing all work myself.[No workerscomp,insurance term ned]t 9. ❑Demolition 4.01 em a homeowner and will be hiring contractors to conduct all work on sty property. I will 10 El Building addition 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 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. Roof repairs 1 These sub-contractors have employees and have workers'comp.insurance.: ❑ eP i.-6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14.❑✓ Other Insulation ' 152,§1(4),and we have no employees.[No workers'comp,insurance required.] *Any applicant that checks box#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 isproviding 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.#: 5D77852 - Expiration Date: 10/16/2019 " ` Job Site Address: 66 Wehhers Path City/State/Zip:West Yarmouth Attach a copyof 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 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. I do hereby certify under th pains and penalties of perjury that the information provided above is true and correct. t Signature: \\�\� Date: 11/6/18 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) m •.1 •1.Board of Health'2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other o Contact Person: Phone#: ��-...,11 CAPESAV-01 HWOODS .4CORv CERTIFICATE OF.LIABILITY.INSURANCE DATE � 188 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: It the certificate holder is an ADDITIONAL INSURED,the policy(ies)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 sucheendorsement(s). PRODUCER ...- N%ME; T . Rogers&Gray Insurance Agency,Inc.. PHONE PAz 816-2156 434 Rte 134 _ IAIc,no.Ext): LAIO,Nuk(877) South Dennis,MA 02660 mss,mail@rogeregray.com . .. _... . .. _ . - -_. - . INSURER(S)AFFORDING COVERAGE MAIC S INSURER A:Employers Mutual Casualty Company 21416 INSURED .. . - INSURER B:Union Insurance Company of Providence 21423 Cape Save,Inc INSURER . _ 7D Huntington Ave • - _ r wsuRERo: - SouthYarmouth,MA02664 - - 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. _ - . - INSR . ADOL SUER POLICY EFF POLICY EXP ' LTR TYPE OF INSURANCE INSO viva POLICY NUMBER IMMNDIYYYYI IMMDD/YYYY1 LIMITS A X COMMERCIAL GENERAL LIABILITY • EACH OCCURRENCE ; 1,000,000 CLAIMS-MADE X OCCUR . 6D77852 10116/2018 10/16/2019 PMMISAGEORENmDenmS 500,000 •• 10,000 .. - MED EXP(Any ono person! ; - � • PERSONAL S ADV INJURY ; 1.090'000 GENE AGGREGATE LIMIT APPLIES PER • - - - GENERAL AGGREGATE 5 2,000,000 POLICY ujta LOCPRODUCTS-COMP/OP AGG S 2,000,000 OTHER: - . .. , • - EBL AGGREGATE ; • 2,000,000 A AUTOMOBILEIM3 W ICOMBFa adentlINGLELIMIT .. S - 1,000,000 X ANY AUTO ' - 6277862 - +0/16/2019 +0/16/29+9 BODILY INJURY(Per parson) S OWNED SCHEDULED . AUTOS ONLY rAAUTTOp tJFp - - • BODILY ITY DAMAerevJdenti S , AUTOS ONLY _AUTOS ONLY - (Per PE DAMAGE _ ; A X UMBRELLAUAS X OCCUR EACH OCCURRENCE S 2,000,000 EXCESS LMS . CLAIMS-MADE 5.177862. ' '. .10/1612018 10/16/2019 AGGREGATE ; •2,000,000 CED X RETENTIONS - . 10,000 . . - ; . B WORKERS COMPENSATION - :. '. .. X I STATUTE I FORS __ AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 6H77852 10/16/2018 10116!20+9 E.L.EACH ACCIDENT S 500'000 OFm E PMMBER EXCLUDED?. . _ N NIA • ., . (IMMSA NNS I - E.L.DISEASE-EA EMPLOYE 5 '�0'D09 If yea describe under 600,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT S • DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD let,Additions]Remarks Schedule,may 5e attached If mon spew N requeed 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 Cape Light Compact Joint Powers EntityTHE EXPIRATION DATE THEREOF, NOTICE WILL'BE DELIVERED IN Light e's ath, J 4 .ACCORDANCE WITH THE POLICY PROVISIONS- 261. South Yarmouth,MA 02664 AUTHORED REPRESENTATIVE ' ' - . �pyxf/ L - ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Q1 WOI)Mix)/ibttieci/a Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 ' Boston, Massachusetts 02108 Home Improvement Contractor Registration TypeCorporation l ,I Registration: 17 380 CAPE SAVE INC. 1'7 r ' ;i-\ Expiration: 03/13/2020 7-0 HUNTINGTON AVENUE rn f- - ,1 : 1 •, SOUTH YARMOUTH,MA 02664 I i t---.:_t,.1. ; -Ms-^ J �. �r`r111 Y' Update Address and Return Card. scAt 6 20M-05n1 ce rGnnrmonwea/d 1°(launeA4em 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: Registration •" gxolratioq Office of Consumer Affairs and Business Regulation 171380 ; > 03/132020 One Ashburton Place-Suite 1301 CAPE SAVE INC - - Boston,MA 02108 L ri WILLIAM MCCLOSKEY -' :'f 2„[cQ�—. 7-D HUNTINGTON AVENUE' SOUTH YARMOUTH,MA 02664 -� Not valid w '..,1 -ignature Undersecretary ' C. c Commonwealth of Massachusetts `7f Division of Professional Licensure - Construction Supervisor Specialty RestricteBoard of Building Regulations and Standards CSSL-IC tn: InsulationCSSL-IC- Contractor Constructioc ''SU}p`ivisprSpecialty I • CSSL-102776 c= +""m""""^5 Eoires 06128/2019 .T.-, s - 3w ,.� ..ttn r 4 t' - i r a"" WILLIAM J MCCLUSKEY4./ f - ',:,s 37 NAUSET ROAD ';f J \t WEST YARMOUA THM026735 e'er .;t Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner CZ DPS Licensing information visit:WWW.MASS.GOV/DPS i HOME OWNER WEATHERIZATION WORK PERMIT: 6)4 PPLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER. I t A (TV'd Li hereby consent to and agree that weatherization work may be done by the WeAtherization Program of Housing Assistance Corporation on the property located at: (;6 frle:41e6 c.A ( Pit L The weatherization work done will be based on programmatic priorities and availability of funding and it may Include all or some of the following measures: Weather stripping; air sealing; attic& basement Insulation; exterior wall Insulation; ventilation measures In consideration of the weatherization work to be done at my home I agree to the following: 1. I give permission to Housing Assistance Corporation to access the property with such equipment and materials as may be necessary to perform weatherization. 2. The Housing Assistance Corporation reserves the right to Inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five (5) years after the weatherization work is completed. I have read the provisions of this agreement and give my consent. Home Owner(signature)X.) • Home Owner email:`cti c- AN Nce stikccil D e: Otl3. 11 g Agent:(signature) Date: Agency Approved Weatherization Company Cape Save Inc. All Cape Energy Alternative Weatherization Cape Cod Insulation Cape Save Cazeault Frontier Energy Solutions Lohr Home Improvement -� - Agency Signature: VDU* Date:. e), 13fie For Natural Gas Customers: I have received the National Grid Discount Rate Application form from my auditor. Customer Initials