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Home My WebLink AboutBLD-19-3533 : s 04„Yq. Office Use Only - i ��Cco i "/9 (TD .5 6H Amount N2' Permit expires 180 days from v <issue date t EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department R 1146 Route 28 C ` V b 0 South Yarmouth,MA 02664 DEC0 7 (508)398-2231 Ext. 1261 2018 coNsTRUCTIONADDRESS:- 74 Old Main Street Du'i-o'"��Ep.�r1r`M,�.,n ASSESSOR'S INFORMATION: Map: 50 Parcel: 122 OWNER: Paul Conlon same 508-364-3549 NAME PRESENT ADDRESS TEL. Al CONTRACTOR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL.a ■Residential ❑Commercial Est Cost of Construction S 5000 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lie.# TC 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:# 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 conect to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denialation of my license and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: Date: 12/7/18 Owners Signature(or attachmen//�attachhedd Date: Approved By: l' MAIL Date: /2 -7-7e D meal(or designee) MAIL ADDRESS: 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 0 Yes 0 No e • The Commonwealth of Massachusetts za l Department ofIndustrial Accidents , • C ele]'— 1 Congress Street,Suite 100 • MILL= : Boston,MA 0211 4-2 01 7 %.1x:. .+ www niass.gov/dia . . Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lecibly Save Inc a Name(Business/Organization/Individual):Cape Address:7-D Huntington Avenue City/State/Zip:South Yarmouth,MA 02664 Phone#:508-398-0398 Are you an employer?fleck 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 :- 2.01 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] El - 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]r 9. Demolition 10 D Building addition 4.❑I am a homeowner and will be hiring contrectots to conduct all work w my proverty. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑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 These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other Insulation 152,§1(4),and we have no employees.[No workers'comp.insurance required.] Any applicant that checks box(U 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#or Self-ins.Lic.#: 5D77852 Expiration Date: 10/16/2019 Job Site Address: 74 Old Main 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 fore 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 fore 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 ofperjury that the information provided above is true and correct Signature: \ Date: 12/7/18 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: . Phone#: ...---^1, CAPESAV-01 !WOODS AC0R0' CERTIFICATE OF LIABILITY INSURANCE D /MINDD/YYYY, 1/4,------ 09os/2s/zo16 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(Ies)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 suc�hpe��npdorsement(s). MOO'CT Rogers&Gray Insurance Agency,Inc. No Ertl. I jam,Nol;(877)616.2156 434 Rte 134 South Dennis,MA 02660 lA% .mall@rooemgray.com INSURER(S)AFFORDING COVERAGE NAIC s INSURER A:Employers Mutual Casualty Company 21416 INSURED . INSURER a:Union Insurance Company of Providence 21423 Cape Save,Inc INSURER C: 7 D Huntington Ave INSURER 0: ' ' South Yarmouth,MA 02664 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 TYPE OF INSURANCE - ADM SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LIRNW MOIMMIDDWYTYI IMWDI DYYYYI A X COMMERCIAL GENERAL LIABII Tr EACH OCCURRENCE $ 1,000'000 pqMAGETORENTED 500,000 CLAIMS-MADE X OCCUR 6077852 10116/2018 10/1612018 PREMISF51FaawXrelwet $ . . MED EXP(Any one penon) $ 10,000 fRSGNALSADV INJURY _f 1'000'000 GENT.AGGREGATE LIqMpIT.APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY X i JECT LOC - PRODUCTS_COMPIOPAGG $ 2,000,000 OTHER: - EBL AGGREGATE s 2,000,000 A AUTOMOBILE LABIIJTY /WMFa aBc COMBINEDSINGLELIMIT $ 1,000,000 X ANYAUTO _ 5Z77352 - 10/16/2018 10/16/2019 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS�p�� ONLY AUTOS _PBOOpDI_LEYIIINNYJUOR_gYL(PPGer accident) $ AUTOS ONLY AUTIaONLY IPor P^`""�•] E $ _ $ A X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS UAB CLAIMS-MADE 5J77852 . 10/16/2018 10/16/2019 AGGREGATE S 2,000,000 DED X RETENTIONS 10,000 S B WORKERS • D EMRPLOCOMPENSATION ERSU IlLITY X STATUTE ERµ _ ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 5H77852 10/16/2018 10/16/2018 E.L EACH ACCIDENT S 500,000 OFFICEFyMBER FXCI COED? N NIA _ IMAM alit EL DISEASE-EA EMPLOYEE $ 500'000 H es,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remelts Schedule,may be attached I more ape.b rpWnd) Cape Light Compact Joint Powers Entity are included as Additional Insured for General Liability,Automobile Liability E.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 THE EXPTION DATE THEREOF, Cape Light Compact Joint Powers Entity ACCORDANCE WITH THE POLICY PROVISIONS.NOTICE WILL BE DELIVERED IN 261 White's Path,Unit 4 . South Yarmouth,MA 02664 AUTHORED REPRESENTATIVET7 ... 17,44.4*---.----- ---- ACORD 25(2016/03) . ®1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD c9LWW Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration ti ,. / ,' Type Corporation 1 t ` i Registration: 171380 CAPE SAVE INC. it i ° ' t =_,.y It t Expiration: 03/13/2020 7-DHUNTINGTONAVENUE inl 4 SOUTH YARMOUTH,MA 02664 t-. ` i a � • scat 8 2oM-05/rr Update Address and Return Card. Cj/Aa%ommnnnvaf(A r/0 I(erundnwlll 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 Exolrstion - Office of Consumer Affairs and Business Regulation 171380 _ 03/13/2020 One Ashburton Place•Suite 1301 CAPE SAVE INC Boston,MA 02108 • WILLIAM MCCLUSKEY +4:7 E_CCQtt-- 7-0 HUNTINGTON AVENUE` .. SOUTH YARMOUTH,MA 02664 7 UndersecretaryNot valid w 1`- -Ignature cCommonwealth of Massachusetts Ai; Division of Professional Licensure Construction Supervisor Specialty Board of Building Regulations and Standards Restricted t0: CSSL-IC-Insulation Contractor Con struction.'SUpqMsgr Specialty CSSL-102776 - % E oires 06128/2019 aw. u w �, 1.4 , C. pb,;....,� WILLIAM J MCCL'USKEY, I , • 37 NAUSET ROADS �� s C' \i 14 WEST YARMOUTH MA 02673 ♦ ,� + ' I t 0 c's•1 O Failure to possess a current edition of the Massachusetts Q State Building Code is cause for revocation of this license. Commissioner CeL DPS Licensing information visit:WWW.MASS.GOV/DPS Docusign Envelope ID:25E13A6C-836C-4E9D-826C-FF653B8143BA ._• RISE5 Dupont Avenue I South Yarmouth,MA 02664 i 508-568-1926 ENGINEERING' www.RlSEenglneering.com Efficiency Ener7i1n OWNER AUTHORIZATION FORM Paul Conlon (Owner's Name) owner of the property located at: 74 Old Main Street. South Yarmouth (Property Address) (Property Address) hereby authorize Cape Save Inc. (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. D.cuSipmd b'y:• Owner s RNA" 11/9/2018 I 10:57 AM EST Date