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Home My WebLink AboutBLD-19-3551 01"Ir Office Use Only I kt Amount C‘1.1/4# '' Permit expires 180 days from 1, •"' A issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH DY Yarmouth Building Department R E C E I �f Ea" • 1146 Route 28 South Yarmouth,MA 02664 DEC 07 2018 (508)398-2231 Ext. 1261 BUILDING DEPAkTME NT CONSTRUCTION ADDRESS: 62 Crowes Purchase Road By: ASSESSOR'S INFORMATION: Map:23 Parcel:221 OWNER: John Cahill same 617-922-8152 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 2100 Home Improvement Contractor Lie.# 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 recation of my license and for prosecution under MILL.Ch.268,Section I. Applicant's Signature: \ �eV Date: 12/7/18 Owners Signature(or attachmen attache / 56" Date: Approved By: ' 0. frD Date: / G —7/c,Building0 cial desi cc) DRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts I 'z (/ Department of Industrial Accidents t IeIB z 1 Congress Street,Suite 100 t « Boston,MA 02114-2017 � .�.., • www massgov/dice Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. - TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibiv Name(Business/Organization/Individual):Cape Save Inc Address:7-D Huntingtoii Avenue City/State/Zip:South Yarmouth, MA 02664 Phone#:508-398-0398 . Are you an employer?Check the appropriate box: Type of project(required): 1.9 I am a employer with 15 -- employees(MI and/orpart-time).' _ -" • 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees working for me 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.]: 9. El Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition, ensure that all 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 5.0 I 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.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.['Other Insulation `r 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. 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 andJob site information. Insurance CompanyName: Employers Mutual Casualty Company Policy#or Self-ins.Lie-#: 5D77852 Expiration Date: 10/16/2019'. Job Site Address: 62 Cremes Purchase 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 under th 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#: �--Th CAPESAV-01 HWOODS ACORO' CERTIFICATE OF LIABILITY INSURANCE DATE WD 4.,..----- 09(N 09126/2001818 ' 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 roarT Rogers&Gray Insurance Agency,Inc. PHONEFAX o,E l 434 Rte 734 _WC,N : I LAIC,es(877)8162156 South Dennis,MA 02660 _ pas;mail@rogersgray.com • - - INSURER(S)AFFORDING COVERAGE NAIC e 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 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. NSRIADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCEINWD WVD POLICY NUMBER IMMIDD/YYYYI IMwDDIYYYYI LIMITS A X COMMERCIAL GENERALLIABIUTY EACH OCCURRENCE E 1,000,000 CLAIMS-MADE X OCCUR 5D7785210116/2018 10/1612019 DammisAAMAGET ERENTED I $ 500,000 MED EXP My one person) S 10,000 PERSONAL IS ADV INJURY S 1,000,000 GEN.AGGREGATE UNIT APPLIES PER GENERAL AGGREGATE S 2,000,000 POLICY rxl.Fin 1 LOC • PRODUCTS_COMPOP AGG E 2,000,000 11 OTHER: EBL AGGREGATE $ 2,000,000 A AUTOMOBILE WIBIUTY COMBINED SINGLE UNIT 1,000,000 -/EaEGGKentl S X ANYAUTO . _ 5277852 10/16/2018 10/16/2019 BODILYmow per mem) E OWNEAT�q�OpS ONLY _ AUTOS BODILY _ BODILY INJURY(Per accident) S _ AUTOSONLY _AUTOS ONLV • PP20PER YDAMAGE S - l S A X UMBRELLA UAa X OCCUR EACH OCCURRENCE S 2,000,000 EXCESS LLIB CLAIMS-MADE 5J77852 • 10/16/2018 10/16/2019 AGGREGATE E 2,000,000 DED X RETENTIONS 10,000 $ B WORKERS COMPENSATION XSTATUTE ETH- AND EMPLOYERS'UAaIUTY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 5H77852 10/1612018 10/16/2019 EACH ACCIDENT -S 500,000 ofFICERALEM9ER Feel UDEDZ N .NIA (Mandatory In NH) E.L DISEASE-EA EMPLOYEE S 600'000 Mdescribe under - • - 600,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 707,Additional Remarks Schedule,may be attached a mon space M required) Cape Ught 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 AUTHORIZED REPRESENTATVE I ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ice ' jae/i . Office of Consumer Affairs and Business Regulation One Ashburton Place'- Suite 1301 $ Boston, Massachusetts 02108 Home Improvement Registration --, i; Type Corporation k 3,-, Registration: - 171380 CAPE SAVE INC. / _ - ---d;h‘ Expiration: 03/13/2020 7-D HUNTINGTON AVENUE ti __ a t' _-- •I,A - SOUTH YARMOUTH,MA 02664 1 t : i \-'!:,‘,...---,K2. !I .T i , /fee YI n\ 7K • - —} Update Address and Return Card. SCA I 0 2011-05Itt7-r - - Office of Consumer Affairs&Business Regulation - HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE Corporation before the expiration date. H found return to: Beolstratioq - PJcviratIon Office of Consumer Affairs and Business Regulation 171380 : - '.03/132020 One Ashburton Place-Suite 1301... CAPE SAVE INC - Boston,MA 02108 WILLIAM MCCLUSKEY '7" \Q-C — 7-D HUNTINGTON AVENUE'' C_) Not VBlid W I r18ture SOUTH YARMOUTH.MA 02664 9 Undersecretary c. Commonwealth of Massachusetts 11) Division of Professional Licensure .. Construction Supervisor Specialty Regulations and Standards Restricted to: Board of Building 9 CSSL-IC-Insulation Contractor Con structio{65U 4 cs2r Specialty' /f CSSL-102776 ` "7'7 Spires 06128/2019 WILLIAM J MCC SKEY$ i e ` • ,+., .i 37 NAUSET ROAN =:, -. \1f. i WEST YARMOUTH-MA 02673 t 1 Failure to possess a current edition of the Massachusetts 0 /�4_ State Building Code is cause for revocation of this license. Commissioner C/2". '/` DPS Licensing information visit:INWW.MASS.GOV/DPS DocuSign Envelope ID:BFD7EF\31-C821-4184-BODF-DC634A5952F9 • MO RISE ENGINEERING OWNER AUTHORIZATION FORM 1, John A Cahill (Owner's Name) owner of the property located at: 62 Crowes Purchase Road (Property Address) West Yarmouth, MA 02673 (Property Address) hereby authorize Cape Save (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 oocoScled br C6, ` Owner's Signature CA39961257534/F... 11/26/2018 I 12:54 PM EST Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RISEengineering.com