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Home My WebLink AboutBLD-19-3535 O ice Use Only F o" YARD .„ --lc?'OD 3'. t, � O 4 0 �H AmountY\z 4 �• ,Permit expires 180 days from i, .i issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH R E C I tJ E i ,11 Yarmouth Building Department 1146 Route 28 DEC 07 2018J I South Yarmouth, MA 02664 (508)398-2231 Ext. 1261 BUILDING DEPART .1c h!T ,,r _, CONSTRUCTION ADDRESS: 60 Captain Lothrop Road ASSESSOR'S INFORMATION: Map: 78 Parcel:6 - OWNER: Virginia Pereira same 774-994-0330 NAME PRESENT ADDRESS TEL. # CONTRAcroR:William McCluskey/Cape Save 7-D Huntington Ave, S. Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL# ■Residential ❑Commercial Est.Cost of Construction$ 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 correct to the best of my knowledge and belief I understand that any false answer(s) will be just cause for denial r recation of my license and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: \ �N. Date: 12/7/18 Owners Signature(or attach men attached,/ Date: �7 Q Approved By: d/`" Date: /2— / /C/ Buil � g 0 tel(or designee)" E 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 ❑ Yes 0 No • __ • The Commonwealth of Massachusetts ` i ft Department oflndustrialAccidents G sitIBI 1 Congress Street,Suite 100 n't ;�� Boston,MA 02114-2017, _ 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 as employer?Check the appropriate box: Type of project(required): I.❑✓ i am a employer with 15 - employees(full and/or part-time).• 7, O New construction 2.1:1 1 am a sole proprietor or partnership and have no employees working forme in 8. O Remodeling any capacity.[No workers'comp.insurance required.] . 30I am a homeowner doing all work myself.[No workers'comp,insurance required.]t 9. El Demolition 10❑Building addition 4.0l am ahomeowncr and will be hiring contractors to conduct all work on my property. Iwill - - ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions • proprietors with no employees. ._: 12.0 Plumbing repairs or additions 5.0 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof rep airs 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 o. 14.ElOther Insulation .. 152,§1(4),and we have no employees.[No workers'comp.insurance required.) *Any applicant that checks box al 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 additionalsheet showing the name of the subcontractors 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 • Policy#or Self-ins.Lie.#:- 5D77852 Expiration Date: 10/16/2019 Job Site Address: 60 Captain Lothrop Road 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. Ida hereby eerhfy under tth pains and penalties of perjury 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#: /'"N CAPESAV-01 HWOODS ACORO CERTIFICATE OF LIABILITY INSURANCE D UDD/YYYY) 1/4.----- 0 09129/26/2018 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 poilcy(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 - map Rogers&Gray Insurance Agency,Inc.. --mom . FAX 434 Rte 134 nuc,No,EatI INC,Nor(877)816-2156 South Dennis,MA 02660 - vast o, mail@rogersgray.00m . INSURER(S)AFFORDING COVERAGE NAIC N ' INSURER A:Employers Mutual Casualty Company 121415 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 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. NSRADMSUBR POLICY EFF POUCYEXP LIR TYPE OF INSURANCE MED WI/D POLICY NUMBER IMMIDDWYYYL IMMIDBIYYYYI WAITS A X COMMERCIAL GENERALLIABIUTY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE C OCCUR 6D7786210/1612018 10/16/2019 DAMAGE TO RENTED 500,000 ED 1 : .._ -,� u •- $ 10,000 MED EXP(Any one person) S _ PERSONAL&ADV INJURY $ 1,000,000 GENL AGGREGATE UMIT APPLIES PER GENERAL AGGREGATE S 2,000,000 POLICY X j ef LOC PRODUCTS•COMPQPAGG $ 2,000,000 OTHER EBL AGGREGATE $ 2,000,000 A AUTOMOBILE LIABILITY COMB INEEDDISINGLE UMIT $ 1,000,000 X ANY AUTO 5277852 10/16/2018 10/16/2019 soon,INJURY(Perperson) S OWNED SCHEDULED AUTOS�gE� ONLY _AUTOSANUp� WµTN.��Dp '- ppBOOR�DILY ITNJJUpRpYLer accident) $ AUTOS ONLY AUTO ONLP (Per dela) 'E $ • $ A X UMBRELLA LUIS X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESSLIAB CLAIMS-MADE 5J77852 10/16/2018 10/16/2019 AGGREGATE $ 2,000,000 DED X RETENTIONS 10,000 1 B WORKERS COMPENSATION ' AND EMPLOYERS'UABIUTY X STATUTE ERH _ ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 5H77852 10H6/2018 10/16/2019 E.L EACH ACCIDENT $ 500,000 OFF! E EXCLUDED? . N N/A 500,000 (IaM1 MN)EMBER E.L DISEASE•EA EMPLOYEES _ H yes,despite under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD 101,Additional Remain Schedule,may be attached I more apace Is 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 THE ION 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 AUTHORIZED REPRESEEREPRESENTATIVEI �RAn-12 7f / ACORD 25(2016/03) C 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD °19 tetZeila, Office of Consumer Affairs and Business Regulation One Ashburton Place-Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration TT 4 m r f i,' Type: Corporation L'.11i _ a �`w RegIstration: 171380 CAPE SAVE INC. f ' ; 1 Expiration: 03/13/2020 7-D HUNTINGTON AVENUE i) _ SOUTH YARMOUTH,MA 02664 s `� ` !i 14- `I }�„.. 1Ff �r ya --"r Update Address and Return Card. SCAM a 20M-05/17 e PommonweaffA o�e ffaiioekwni8 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Ccrooraticn before the expiration date. It found return to: fteoistratioq:-- Fxoiratioq Office of Consumer Affairs and Business Regulation 171380 '-'z.03/13/2020 One Ashburton Place.•Suite 1301 '.. CAPE SAVE INC : , Boston,MA 02109 WILLIAM MCCLUSKEY ', RGG13-e- 7-D HUNTINGTON AVENUE' f.__3 \ • SOUTH YARMOUTH,MA 02664 Not valid w 'J 1 ignature Undersecretary Commonwealth of Massachusetts Construction Supervisor Specialty •%.®S Division of Professional Licensure Restricted to: - - Board of Building Regulations and Standards CSSL-IC-Insulation Contractor Con structiooSUp itor Specialty • 'Pt CSSL-102776 - """" """!.� Epires 06/28/2019 ji. .ice.:_ 0 � �,� '4 WILLIAM J MCCLUSKEY'` / 4 37NAUSET ROAD; ' :'yr `� WEST YARMOUTH MA 02673 r v Failure to possess a current edition of the Massachusetts ✓1 State Building Code is cause for revocation of this license. Commissioner ��L✓ DPS Licensing information visit:WWW.MASS.GOV/DPS DocuSIgn Envelope ID:0900FBB7-59D7-49BA-BBC8.140EB5E1AE95 4W/ RISE ENGINEERING OWNER AUTHORIZATION FORM 1, Virginia Pereira (Owner's Name) owner of the property located at: 60 Captain Lothrop Road (Property Address) South Yarmouth, MA 02664 (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. Docusfsne0 by: ViY/�tNia Pt tint 11 tune o� Owner's igriatur 10/9/2018 I 12:54 PM EDT Date RISE Engineering,a Division of Thielsch Engineering,Inc. 5 Dupont Avenue I South Yarmouth,MA 02664 1508-568-1926 www.RISEengineering.com