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Home My WebLink AboutBLD-19-2871 4 gOffice Use Only Uf YqR F t. 0 Prnnit# . 0I : ppp§Amountg— ,N urr .' .Permit expires 180 days from issue date 1_ Eth 1e I-t�-/y�96�(�-7( EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 9 Cocheset Path ASSESSOR'S INFORMATION: ' Map: 86 Parcel: 140 • OWNER: Kevin&Janice McBride same NAME PRESENT ADDRESS TEL It 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 Est$ Home Improvement Contractor Lie.0 171380 - Construction Supervisor Lie.0 IC 102776 Workman's Compensation Insurance: (check one) 0 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 denialre ation of my license and for prosecution under M.0.L Ch.268,Section I. Applicant's Signature: Date: 11/6/18 Owners Signature(or attach men attached Date: Approved By: /`,;e Date: /A�" 76 Buildin mi deli ce Ess'ss""eefluu%%!![[ DRESS: �� Zoning District: R C______-----\-\\* Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes ❑ No WV o 8 2O\6 Water Resource Protection District: Within 100 R.of Wetlands: 1`t Y ""]x NT ❑ Yes ❑ No ❑ Yes 0 No aur s• -,,,;rji,' (l� — Nr - ,per \ The Commonwealth ofMassachusens P"--==P=er-- : 'Department of Industrial Accidents ' 1 ' qel— 1 Congress Street,Suite 100 1[ 6 Boston,MA 02114-2017 k.,�,� , www. massgov/did • , ,, Workers'Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers. • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information -. Please Print Legibly Name Business/Organization/Individual):Cape Save Ino' • - - - ! 7`Address:7-D Huntington Avenue '•• ' ' " ' City/State/Zip:South Yarmouth,MA 02664 '' Phone 1k 508-398-0398 Are you an employer?Cheek the appropriate box: ,„;-:.,:., Type of project(required): am a employer with15-- employees(full and/orpart-tune). _ ..7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working forme in $; O Remodeling .'. ' any capacity.[No workers'comp.insurance required.] F , F 3.0I em a homeowner:doing all work myself.No workers'comp.insuranceequ rired': 9. ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. t will 10❑Building addition j 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 end I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.: • 6.❑We area corporation end its officers have exercised their right of exemption per MGL c. 14.QOthe[ Insulation . 152,§1(4),and we have no employees.[No workers'comp.insurance required.] , *Any applicant that checks box el 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 . employed. 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 _ - Insurance Company Name: Employers Mutual Casualty Company Policy#or Self-ins.Lic,#: 5D77852 _,_ - _ _ Expiration Dater 10/16/2019' Job Site Address: 9 Cocheset Path 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 I do herebyy cetmi underthsains and penalties ofperjury that the information provided abovestrue and correct. Signature: ”\pDate: 11/6/18 Phone#:508-398-039 Official use only. Do not write in this area,to be completed by city or town official. _ .: 7 ^' City or Town; Permit/License# Issuing Authority(circle one) 1, 1.Board of Health 2.Building Department 3'.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Contact Person: Phone#: ___„.....1 CAPESAV-01 HWOODS• A�R0* CERTIFICATE OF LIABILITY INSURANCE oeiz6o�s 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). - PRODUCER . RME:CT . Rogers&Gray Insurance Agency,Inc. PHONE , FAX 434 Rte 134 - . SNC,No,EI WC,No el: p(877)816-2156 South Dennis,MA 02660 Vass,mall@rogersgray.com '- - '" "' '- -' -- -" INSURER(S)AFFORDING COVERAGE - NAICII ' INSURER A:Employers Mutual Casualty Company 21416 INSURED - INSURER B:Union Insurance Company of Providence 21423 Cape Save,Inc • INSURER C: 7 D Huntington Ave . " „ .. INSURER D: - ' South Yarmouth,MA 02664 INSURER E: . . • INSURER P: ' 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. WSR ' . • ADD'.SUBR POLICY EFR POLICY EXP - LTR TYPE OF INSURANCE INSO LAND POLICY NUMBER IMWDDIYYYYI IMWDDIYYYYI LIMITS A X COMMERCIAL GENERAL WBILDY EACH OCCURRENCE " $ 1,000,000 DAMAGE TO RENTED 500,000 CLAIMS-MADE X OCCUR 5077852 10116/2016 10/16/2019 PuhugSIE I $ . ' • . MED EXP(Any one person) ' $ 10,000 • ' PERSONALA ADV INJURY ' f. ' • 1.000,000 AL GENT AGGREGATE UNIT APPLIES PER: - : GENERAL AGGREGATE _ S 2,000,000 POLICY X JEGT LOC PRODUCTS-CAMP/OP AGG $ 2,000,000 OTHER: . . - - EBL AGGREGATE $ - - 2,000,000 A AUTOMOBILE LIABILITY , ICEOMABI amu ANGLE LIMIT $ 1,000,000 X ANY AUTO _ . 6277862 " • . 10/16/2018 10/16/2019 BODILY INJURY(PI Iran) S OWNED SCHEDULED - . - AUTOS ONLY AAUUTgOSSµN�. , pB�OpDIILEY II7NJJU�RY(Pe[erlSent) $ _ AUTOS ONLY„ _AUTOS ONL� ._ lPela�aML1AMAGE • $ — . $ A X UMBRELLA UAB X OCCUR . EACH OCCURRENCE f 2,000,000 l7(CFSSIIAB CLAIMS-MADE _ 5.177852 r.l'r-:.. .' ' 70/1612018 10116/2018 AGGREGATE - f , 2,000,000 DED X RETENTIONS 10,000 " f B WORKERS COMPENSATION ' AND EMPLOYERS'LIABILITY X STATUTE ERS _ ANY PROPRIETO/UPARTNER/EXECUTIVE Y/N 6H77852 10/16/2018 70/16/2019 E.L.EACH ACCIDENT $ 500,000 F ERIAFin RcR EXCLUDED?,. N N/A . • _ _ . .. - 600,000 ayyees deevibe • E.L DISEASE-EA EMPLOYEE f DESCRIPTION OF OPERATIONS below . E.L.DISEASE-POLICY LIMIT $ 500,000 • DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD ICneInc..L Additional Redv Schedule,may be attached Imaareb nM a qul ) . 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 ACCORDANCE WITH THE POLICY PROVISIONS. ' .. 261 White's Path,UnIt 4 - - . . South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE .. . . ACORD 25(2016103) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD grk ? o Q Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 ; Boston,Massachusetts°02108 Home Improvement Contractor Registration F L '� : r. . Type: Corporation , ti „I '� Z - Registration: 171380 CAPE SAVE INC. )r=1 t : ry ° ,r s —t Expiration: 03/13/2020 7-D HUNTINGTON AVENUE i _ SOUTH YARMOUTH,MA 02664 k7: ,.•,---;..:7,-,1.4--n.!---.1:-.7.1` ; �j { YI .i \ , /r s ---t— SCA 1 8 2eM-05/17 Update Address and Return Card. C ie Pnnwmanawala ny9e riaeaackunr!tl Office of Consumer Affairs&Business Regulation - HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use oniy TYPE:Corporation ”before the expiration date. N found return to: Registration -- Fxnlratlor Office of Consumer Affairs and Business Regulation 171380 _'.03/132020 One Ashburton Place-Suite 1301_ CAPE SAVE INC L Boston,MA 02108 4 WILLIAM MCCLUSKEY ' .' `�� 7-D HUNTINGTON AVENUE SOUTH YARMOUTH,MA 02664 U se ° Not valid w 4. a ignature Undersecretary • °. Commonwealth of Massachusetts ‘rli Division of Professional Licensure Construction Supervisor Specialty ' Board of BuildingRegulations and Standards Restricted to: 9 CSSL-IC-Insulation Contractor Con structioo.5\ip4F%isprSpecialty 7 CSSL-102776 > rr "^."' A{ E-kpires 06/28/2019 WILLIAM J MCCLUSKEY i s .-»s 37 NAUSET ROADI .. r • \`�� i . WEST YARMOUTH MA 02673 'C ,ate I 1015\IdLisJ Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner Cele DPS Licensing information visit:WWW.MASS.GOVIDPS lfi , O a 03 480 West Main Street Jh. W4gJ1 a ^""yam � 'Tr, Housing I'k\a s+ Hyannis,MA 02801-3698 n t? Assistance Tel:(508)771-5400 Fax(508)790-242310Z wiu a , Corporation TTY on an lines 4 �;1, Cape fed a:'s y- 'CV Free Weatherization ! ' ```A=_6_eic i Your tenant has requested and is eligible for weatherization of your rental home through the Weatherization program at Housing Assistance Corporation. An average weatherization job is worth $4,500 and these services are provided at no cost to you. The following weatherization measures are applied to the typical job: air sealing in the attic and basement, insulation in the attic, basement and walls, weather-stripping doors. Bath fans may be installed if necessary. We will test the efficiency of the refrigerator. All work is professionally done by licensed and experienced contractors. HAC will conduct a final inspection to make sure that all work is completed in compliance with quality work standards. • Prior to the work being done you will receive a letter from HAC showing the actual measures that will be installed and the total dollar value to the work. To confirm your ownership of the property, we will pull the appropriate town assessor's report. If necessary, we may ask for a copy of your tax bill or deed to prove ownership. The work on your rental property will begin when we receive the signed copy of the attached Agreement. if we do not receive the Agreement, HAC will conduct an energy audit but no weatherization work can be done without the signed Agreement. During the energy audit we will install energy efficient light bulbs and will test the efficiency of the refrigerator. If you have any questions please contact Suzanne Smith at 508-771-5400, ext. 123 or ssmith@haconcapecod.org f n LANDLORD: ,' V 'a� tJ..[ - ttno. TENANT: 0,01.1 , (2'77 a ( • J . s 9 Co rseW/ smell: K AA 11 ' J s .a CCe + email: iiiii t I PamN bei/(0.-/O . LOP) PHONE:(home) PHONE:(home) (cell) (ta)) 3 Ca-?7)A (cell) 8 X364- /e9/ -7 . ' �l .'Y_ , 14. The Parties acknowledge that this Agreement Is under seal. It Is Intended by the Parties that the Tenant or any successor Tenant Is the Intended beneficiary of the Agreement and shall have a right of enforcement. Property Owner's Signature: S Date 6/aq./ r'F Q Phone: t20 if4-'.27.11 / Address: X11 COcl vt.;v. Qc t .-si h (A), 4r-rnn. AI 'n4 Or71,7a Tenant Signature9 1I7 /0/i/is rnI Date 6 Z 0//ampoc" Jj Agency Approved Weatherization Company Cape Save Inc. • Adam T.Incorporated / All Cape Energy / Alternative Weatherization Cape Cod Insulation / Cape Save- / Cazeault Frontier Energy Solutions / Lohr Home Improvement / Tupper Construction Agency Signature <MLA) Date 9 112 I t1 . y s:5 E 7�o\,, 0. _ 1 JUN m14 \ taei;A 'Q i `(hw t