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Home My WebLink AboutBLD-19-3532 'Y 'AJ Use Only r F '� ' 0 : gAmount {. `1' t Permit expires 180 days from t issue date [. EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECE1VF f5 Yarmouth Building Department 1146 Route 28 [—DEC 0 7 2018 South Yarmouth,MA 02664 ` i (508)398-2231 Ext. 1261 BUILDING DEPARTMENT By CONSTRUCTION ADDRESS: 83 West Yarmouth Road ---- ASSESSOR'S INFORMATION: Map: 39 Parcel:207 OWNER: Emily Hibbard same 508-685-4819 NAME PRESENT ADDRESS TEL # coNTRACTOR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL/I ■Residential ❑Commercial Est.Cost of Construction S 2600 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lieif 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.Policyf 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 1 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.L.Ch.268,Section 1. Applicant's Signature: Date: 12/7/18 Owners Signature(or attachhmen:/,�aattttaaccchheed Date: Approved By: �Kif/ )sem/ i Date: /2 Bui g O ml(or designee) E ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within.100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No • The Commonwealth of Massachusetts t p ' Department of Industrial Accidents rail= 1 Congress Street,Suite 100 = . ts =ri•-1�{ Boston,MA 02114-2017 .�., _ . wwwmassgov/dia . Workers'Compensation Insurance Affidavit:Bullders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. - Applicant Information Please Print Leeibly ' Name(Business/organization/Individual):Cape Save Inc - - Address:7-D Huntington Avenue City/State/Zip:South Yarmouth.MA 02664 Phone ft:508-398-0398 . • Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 15 - employees(full andtor part-time).* - -' " 7. New construction 2.0 I am a sole proprietor or partnership and have no employees working forme in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp,insurance required.]t 9. El Demolition 4.p 1 am a homeowner and will be hiring contractors to conduct all work on my property. [will 10 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 5.1:1 1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet 13.0Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.p We are a corporation and its officers have exercised their right of exemption per MGL c. 14.�✓ Other Insulation 152,§I(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. 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: 83 West Yarmouth Road 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 _. . coverage verification. , Ido hereby certify unde`r\th pains and penalties of perjury that the information provided above is true and correct. • Signature: i,\�\�y 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#: /—""ti CAPESAV-01 HWOODS 4C0 v CERTIFICATE OF LIABILITY INSURANCE 09/26/2ATE M�018) 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 Mr' Rogers 8 Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 - ..(AJC,No,Ex): lac, 87877)816-2166 South Dennis,MA 02660 ass;mail@rogersgray.com . • INSURER(S)AFFORDING COVERAGE NAIC a INSURER A:Employers Mutual Casualty Company 21415 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 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 POUCY 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 ADDL SUER POUCY NUMBER POLICY EFF POLICY EXP LIMITS LIR INS) VNID D IMMD(YYYYI IMMDD/YYYYI A X COMMERCIAL GENERAL UABIUTYEACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 5D77852 10/16/2018 10/18/2019 pardics SffeEamu ental $ 500,000 MED EXP(Mone ro person) $ 10,000 PERSONAL a ADV INJURY $ 1,000,000 GENT AGGREGATE UNIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY 1 II fa LOC PRODUCTS-COMPgP AGG S 2,000,000 OTHER: • EBL AGGREGATE $ . 2,000,000 A AUTOMOBILE UABIUTY IEa WNacccideennt SINGLE LIMIT $ 1,000,000 X ANY AUTO _ 5277852 10/16/2018 10/16/2019 BODILY INJURY(Por penal) $ AUTOS ONLY AUTOSU1.�D OWµN��D BODILY INJURIIPeraccident) $ AUTOS ONLY __ AUTOSONLB PROPERTY AMAGE S lPar xu��l s A X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS LAB CLAIMS-MADE 5.177852 .. 10116@018 10116/2019 AGGREGATE $ 2,000,000 DED X RETENTIONS 10,000 $ B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X STATUTE FRS _ ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 5H77852 10/1612019 10/16/2019 E.L.EACH ACCIDENT $ 500'000 FI ERAIryln gExuLUDEDT N N/A _ ' ' 500,000 K ea,describe under E.L DISEASE•EA EMPLOY $ DESCRIPTION OF OPERATIONS below E.L DISEASE•POLICY LIMIT $ 500'000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached V more apace Is requImd) 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 THE Cape Light Compact Joint Powers Entity ACCO DANE WITH ION TDATE POLICY P THEREOF, SIO SCE-WILL BE DELIVERED IN 261 White's Path,Unit 4 South Yarmouth,MA 02664 - AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration I ._.,. / ;. Type: Corporation r i :;-1.-±7,,'"1-' Registration: 171380 CAPE SAVE INC. a+" := ' *,',.._=.7-11,.4 Expiration: 03/13/2020 7-D HUNTINGTON AVENUE >i SOUTH YARMOUTH,MA 02664 1 %.---.: e rr :" q i7 1 � k Update Address and Return Card. SCM A 20M-0S/11 - aZ?e ommomaw,/rk o�ef6 oacAusrrn Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. M found return to: pegistration - Fxn ratlort Office of Consumer Affairs and Business Regulation 171380 - ``. 03/132020 One Ashburton Place•Suite 1301 s CAPE SAVE INC .<- Boston,MA 02108 WILLIAM MCCLUSKEY ,4 Rx ,p--- 7-D HUNTINGTON AVENUE'. SOUTH YARMOUTH,MA 02664 Not valid w <`+S ignature Undersecretary °. Commonwealth of Massachusetts li1 Division of Professional Licensure Construction Supervisor Specialty Restricted to: . Board of Building Regulations and Standards CSSL-IC-Insulation Contractor Construction.4fvispr Specialty / CSSL-102776 - '!'""":":---1 E'Dires 06128/2019 / ��,,.. 4' 11 2 SPT" i, WILLIAM J MCCL,`VSKEY., i i . 37 NAUSET ROADS 1 ,� i WEST YARMOUTH MA 02673`'& " " VOISw'1-O _. Failure to possess a current edition of the Massachusetts State Building Code Is cause for revocation of this license. Commissioner CaLe DPS Licensing information visit:WWW.MASS.GOV/DPS 04 Nt,`- le Permit Authorization qtr( I mass save Form Site ID: 3589799 Customer: Emily Hibbard I, -74-elin f /iw 7 / b .h n'rri ,owner of the property located at: ner's Nam ,printed) 83 West Yarmoutd West Yarmouth, MA 02673 (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. Owner's Signature: rte_0 A. eAbk- • / i' D Date: 41; FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: 0c fc $ C^ v'�. 7_, A< I Participating Contractor Date. Name: RISE Engineering Phone: 401-784-3700 Email: Page 1 of I For Office Use Only Rau in7nic