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HomeMy WebLinkAboutBLD-19-3293 r Office Use Only • oF.y9R- sAr lk:. ,7 0 Permitt �. > G 27.1 _AmouAmount .J � �: n t"""3 t I Permit expires 180 days from .crl4 - i issue date. EXPRESS BUILDING PERMIT APPLICATION 1q—b° 3a9'7 TOWN OF YARMOUTH I RECEIVED ' Yarmouth Building Department I 1146 Route 28 South Yarmouth, MA 02664NOV 2 8 2018 (508)398-2231 Ext. 1261 HY c_ DE -Nl CONSTRUCTION ADDRESS: 1 68 Brid.e Street ASSESSOR'S INFORMATION: Map: 61 Parcel:58 OWNER: Marc DeNardo same 508-776-8842 NAME PRESENT ADDRESS TEL. it CONTRACTOR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL Si ■Residential ❑Commercial Est.Cost of Construction$ 5000 Home Improvement Contractor Lic.# 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: 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 ation of my license and for prosecution under M.G.L Ch.268,Section I. - Applicant'sSignature: � � Date•. 11/20/111 Owners Signature(or attacbmen attached Date: �p Approved By. 0 i esignec) 4r I Date: /�77C! Building 0 i EMAIL AD SS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft of Wetlands: 0 Yes 0 No 13 Yes ❑ No /..0,1 CAPESAV-01 HWOODS ACORO" CERTIFICATE OF LIABILITY INSURANCE D YY) 4....---- 0 09//2019/26/2018 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 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 tens 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 kagACT Rogers b Gray Insurance Agency,Inc. 434 Rte 134 No,Ela): l FAX Nop(877)816-2156 South Dennis,MA 02660 US$;mail@rogersgray.com ' INSURER(S)AFFORDING COVERAGE NLICI INSURER A:Employers Mutual Casualty Company 21416 INSURED - INSURER I:Union Insurance Company of Providence 21423 Cape Save,Inc ISURERC: 7 D Huntington Ave - • INSURER D: - . South Yarmouth,MA 02664 .. INSURERE: 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. ISR TYPE OFINSURANCE ADDL.SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS 1 TRINSD MVOIMMIDOGYVYI IMINDDIYYYYI A X COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE $ 1,000,000 CLAIMS.MADE X OCCUR 6077852 - 10/16/2018 10/16/2019 DAMAGETO RENTED 600,000 PREMISES(Eeommnrel S _ MED EXP(Any o,e person) $ 0'0 100 PERSONAL&ADV INJURY $ 1'000'080 GENL AGGREGATE UNIT APPLIES PER GENERAL AGGREGATE $ 2'000'080 POLICY Fil frin LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER -. " - . - _ EBL AGGREGATE $ 2,000,000 A AUTOMOBILE LIABILITY .. . ICEOMBI�NERDSINGLE LIMIT $ . 1,000,000 •X ANYAUTO _ 6Z77852 10/1612018 10/16/2019 BODILY INJURY(Per person) $ ' OWNED SCHEDULED AUTOS ONLY _ Vatic/ • BODILY INJURYLPer accident) $ kW&ONLY AUTa ic/ [name s l eo�oan�l $ A X BMRRFm,A 11AB IX OCCURFACH OCCURRENCE $ 2,000,000 EXCESS LMB CLAIMS-MADE 5.177852 . ." 10/16/2018 10/16/2019 AGGREGATE S 2,000,000 DEO X RETENTION$ 10,000 - $ B WRKCOME - X STUTE W- AND - AEMPLOYERS'NI 1� ANYPROPRIETORIPARTNER/EXECUTIVE YIN 5/177862 10/16/2018 10/16/2019 E.L.EACH ACCIDENT $ 600'000 OgF�FI$�E WR�ilIt1Eingg�p EXCLUDED?.. , • N N I A (aarmprd°'Y N NH) E.L DISEASE-EA EMPLOYEE$ 500,000 H ea,eeapnhe unser . 500,000DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,nay be attached r mon space H required) Cape Light Compact Joint Powers Entity are Included as Additional Insured for General Liability,Automobile Liability&Excess as required by•signed written contract or agreement with the Named Insured. - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CapeLight Compact Joint Powers EntityTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN fl Pa ACCORDANCE WITH THE POLICY PROVISIONS. 261 White's Path,Unit 4 . South Yarmouth,MA 02664 • AUTHORIZED REPRESENTATIVE - . ;Mssii 7% ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. • The ACORD name and logo are registered marks of ACORD M ' The Commonwealth of Massachasetts _ 'Department of Industrial Accidents , , Crimmirx ' , 1 Congress Street,Suite 100 - . t -Boston,MA 02114-2017 y�41 www massgov/dill 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 Inc ` Address:7-D Huntington Avenue ' - "' ' City/State/Zip:South Yarmouth,MA 02664 Phone#:508-398-0398 Are you an employer?Cheek the appropriate box: - Type of project(required): • I.Q I am a employer with 15 employees(full and/or part-time).'- 7: 0 New construction 20 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required] 9. ❑Demolition 3i:1 am a homeowner doing all work myself.[No workers'comp.insurance required)* _ . 10❑Building addition _ 4.0I am a homeowner and will be hiring contractors to conduct all work on my property.Iwill _ ensure that all contractors either have workers'compensation insurance or arc sole 11.0 Electrical repairs or addition proprietors with no employees. .•, , - 12.❑Plumbing repairs or additions 5-0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.: 13.0 Roof repairs 6. We are aco tion and its officers have exercised their right of 14.❑✓ Other Insulation ❑ corporation gexemptionper MGL c. 152,§1(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. Ifthe 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#or Self-ins.Lic.#: 5D77852 - - Expiration Date:' 10/16/2019 . Job Site Address: 1368 Bridge Street 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 verification. I do hereby certify under thpains and penalties ofperjury that the information provided above is true and correct Signature: \\�\� Date; 11/20/18 Phone#:508-398-0398 Oficial 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 Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector-• 6.Other - -. "-- - • -. ... _ Contact Person: • Phone#: �G-�ie tP' -� z;o/oiacA rye Office of Consumer Affairs and Business Regulation',. One Ashburton.Place- Suite 1301 ; Boston, Massachusetts 02108 Home Improvement Contractor Registration Xt� _ t, Type: Corporation CAPE SAVE INC. } i,,,, Registration: 171380 7-D HUNTINGTON AVENUE ill i -:.:4"-- r ' d } '; Expiration: 03/13/2020_ SOUTH YARMOUTH,MA 02664 ,`,rN x t k"" 34 j �-- xru 1 ,k% - .. SCA 1 6 2014-05/17 Update Address and Return Card. • .oixmonuwa t�r�G���.unc/ruavlls - Office of Consumer Attain A Business Regulation HOME IMPROVEMENT CONTRACTOR Registrationvalid for Individual use only TYPE:Corporation r before the expiration date. H found return to: peaistration -; Expiration Office of Consumer Affairs and Business Regulation 171380 . '.03/13/2020 One Ashburton Place-Suite 1301 CAPE SAVE INC , _ Boston,MA 02108 / WILLIAM MCCLOSKEY ' - --. 7-D HUNTINGTON AVENUE'-' SOUTH YARMOUTH,MA 02664 Not valid w ,.`'S IgnatUre Undersecretary Commonwealth of Massachusetts ItDivision of Professional Licensure • Construction Supervisor Specialty Board of Building Regulations and Standards Restricted to: - CSSL-IC-Insulation Contractor ConstructioDSLIp8Mscr Specialty r CSSL-102776 '1":"1-'1-11 Ekpires 06/28/2019 19 a,.s err .ser ‘,..I # { y i. " 444* '' i . WILLIAM J MCCCUSKEY �- i 37 NAUSET ROAOI 7 $ ` \` 4i WEST YARMOUTHMA 02673 ` ,- tp/tiS:i ��tS 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.GOVJDPS • N1 ,41,(4, Permit Authorization cric mass saver Form Swrgs treougl,*rem efficiency Site ID: 3440029 Customer: Marc DeNardo • I, MIC (C. -- 1904kitC0. iet%U(A b ,ownerofthepropertylocatedat: (Owner's Name,primed) 1368 Bridge Street South Yarmouth, MA 02664 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. i Owner's Signature: � � �� (-- . _ 41):. le Date: p — (-1a FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: C4ec. Y&Ve Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: Foe Office Use Only Rev.102015