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O4 Y9R Office Use Only { �0 }PertnitR t, ON Amount �� 4R f N 4 - C`3�•..t•3e=J. 1Permitexpires 180 efrom 1. . ::.: ..�T:..'. issue date BLit-ta -u) EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth,MA 02664 [ilece)kgoa (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 730 Willow Street BUILDING DEPARTMENT n _ _— ASSESSOR'S INFORMATION: Map:42 Parcel: 112 OWNER: Raymond Roach same 617-696-2392 NAME PRESENT ADDRESS TEL. # coNTRAcroR: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 5000 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lie.# IC 102776 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ 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:it 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 ation of my license and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: a � Date: 11/27/18 Owners Signature(or attach �{�tta✓chheed Date: Approved By: l ' Off' SiDate: ��2� Build' Offi (or do rgnce) y!/G EM�tI.ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No _ The Commonwealth of Massachusetts 1C i !l. Department of Industrial Accidents C 5el 1 Congress Street,Suite 100 -*Ng e9' Boston,MA 02114-2017 ",ti�, - . , -wwwmassgov/dia , . 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?Check the appropriate box: Type of project(required): 1.17 I am a employer with- 15 employees(full and/or part-time).' ,7, O New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling _. any capacity.[No workers'comp.insurance required.] 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]r 9. ❑Demolition 10 Q Building addition 4-❑1 an a homeowner and will be hiring contractors to conduct all work on my property. t will r ensure that an contractors either have workers'compensation insurance or am sole 11.0 Electrical repairs or additions proprietors with no employees.. . 12.0 Plumbing repairs or additions 5.E1l am a general contractor and 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 are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑✓ Ddlet Insulation 152,§I(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 employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. !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 x. Policy#or Self-ins.Lic.#: 5D77852 Expiration Date: 10/16/2019 . Job Site Address: 710 Willow Street City/State/Zip: Bass River 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. !do hereby certify under tthpains and penalties of perjury that the information provided above is true and correct Signature: \\�\� Date: 11/26/18 Phone#:898 398 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 Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: -----"."00CAPESAV-01 IHWOOOS J4 ORO CERTIFICATE OF LIABILITY INSURANCE 09/2/2018 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 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 CLMT/LCT • Rogers&Gray Insurance Agency,Inc. NPHH�OONNE FAX 434 Rte 134 . _Wc,No,EAE [(AIC,No}(877)816-2156 South Dennis,MA 02660 iD 11 s:mallerogersgray.com .- - INSURER(S)AFFORDING COVERAGE NAIC I INSURER A:Employers Mutual Casualty Company 21416 INSURED INSURER e:Un ion Insurance Company of Providence 21423 Cape Save,Inc INSURER C: 713 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. INSR TYPE OF INSURANCE AnDL SUER POLICY NUMBER POLICY EFF POLICY EXP LNAITS I TR INSD VMD IMMIDD/YYYYI (MMm➢IYYYYI • A X COMMERCIAL GENERAL� � �LIABIUTY EACH OCCURRENCE S LJ 1,000,000 CLAIMS-MADE OCCUR 6D77862 10/16/2018 10/16/2019MAGE TO RENTED 500,000 PRF MISES(Fe occurrence) E MED EXP(Any Cos Penn $ 10,000 PERSONAL&ADV INJURY 5 1,000,000 GENT AGGREGATE WAIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY X rIta LOC - - PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: EBL AGGREGATE E 2,000,000 A AUTOMOBILE UABIUTYcaden M ?INGLEUNIT E 1,000,000 X ANYAUTO _ 6Z77852 . • 10116/2018 10/16/2019 BODILY INJURY(Per Penn) $ OWNED SCHEDULED AUTOSA�� ONLY _ AUTOSANUT�� yy��T..II��pp - BODILY INJUpRVAPPeer=ideal) $ AUTOS ONLY _ itggeLLY lPx )AMAG E $ $ A X UMBRELLA LAD X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS LIAB CLAIMS-LADE 6J77852 - 10/1612018 10/1612019 AGGREGATE ' - s 2,000,000 DED X RETENTIONS 10,000 - E B 'N- AND EMRPIOYERRS'LLIAABILLITY YIN SATION X STATUTE ERH- AQNfY��P�ROPREIMETgOER/PARTNER/EXECUTIVE 5H778$2 70/76!2078 10/16/2019 E EACH ACCIDENT $ 500,000 QFFICEMRFMDER EXCLUDED?. N N/A _ _ . . - 500,000 (Mantl In NN • E.L.DISEASE-EA EMPLOYEE$ If yes,deununder der - - 60-0706-0 0 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT E DESCRIPTION OFOPERATIONS/LOCATORS/VEHICLES(ACORD 101,Adettonl Remarks Schedule,may be attached If more apace le required) 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 CapeLight Compact Joint Powers EntityTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 P ACCORDANCE WITH THE POLICY PROVISIONS. 261 White's Path,Unit 4 , South Yarmouth,MA 02664 - - AUTHORIZEDREPRESENTATIVE • ..I Rya!/SEf / ACORD 25(2016/03) ' - (01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD -. VGrk • / 'I o1,r!^ 4�%(,U.Jf'iGl.O Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration r Type: Corporation --T1:-7:1,$'.^:) Registration: 171380 CAPE SAVE INC. �� t ._ 4at Expiration:. 03/13/2020 7-D HUNTINGTON AVENUE _ SOUTH YARMOUTH,MA 02664 ix,„ r : v r - if '.: bra fi • (7"Cl ♦yyy YJ �h( Update Address and Return Card. • SCA1 A 20M-05117 cT/� — — 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: peoistration..- Expiration - Office of Consumer Affairs and Business Regulation 171380 r -1 03/132020 - One Ashburton Place•Suite 1301 CAPE SAVE INC , Boston,MA 02108 WILLIAM MCCLUSKEY '_i• \F rGQ.1p--- `/ 7-0 HUNTINGTON AVENUE` C, • SOUTH YARMOUTH,MA 02664 Not valid w ‘_ti• ti -Ignatur6 Undersecretary r. Commonwealth of Massachusetts Construction Supervisor Specialty r i1 Division of Professional Licensors - Restricted to: . - Board of Building Regulations and Standards CSSL-IC-Insulation Contractor Constructioc••SUp4fvisor Specialty 'r CSSL-102776 r'""7"1''1 Spires 06128/2019 • WILLIAM J MCCL'USKEY! � q •- �{ -, 37 NAUSET ROAD :. a 1 � WEST YARMOUTH-MA 02673 ,w, Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner DPS Licensing information visit:W W W.MASS.GOV/DPS RISE ENGINEERING' OWNER AUTHORIZATION FORM I, Raymond T Roach (Owners Name) owner of the property located at: 730 Willow Street (Property Address) Bass River, MA 02664 (Property Address) hereby authorize O. r€ S 4 V\ (Subcontractor) 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. O e Signature II - 17 - 1 Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com