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Home My WebLink AboutBLD-19-3552 Use ase i°C S ; 4D Only 9.0) 0 °H' Amount'CC\�a\ '°" c '•Permit expires 180 days from g I, issue date j. EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 7cLEyji7 ' 1146 Route 28 , South Yarmouth,MA 02664 DEC 0 7 2018 i . (508)398-2231 Ext. 1261 uY_BuiLo7 cn oi=Faiinne t CONSTRUCTION ADDRESS: 481 Buck Island Road Unit 2E -- ASSESSOR'S INFORMATION: Map:46 Parcel:23 OWNER: Bruce Caswell same 774-994-7144 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 ofConstruction S 1400 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lie.# IC 102776 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 1 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 answers) will be just cause for denialre ation of my license and for prosecution under M.O.L.Ch.268,Section 1. Applicant's Signature: \ ‘Ir. Date: 12/7/18 Owners Signature(or attachmen attached Date: J Approved By: .✓J ��%% Date: / 2 7 tp`' Buildi i (ord ignee) EM 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: D Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts 1.1114 grt Department of Industrial Accidents , :elg 1 Congress Street,Suite 100 ' • [h=it Boston,MA 02114-2017 www.massgov/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 t phone#:508-398-0398 Are you an employer?Check the appropriate box: r -. `• Type of project(required): -- 1.❑✓ I am a employer with 15 employees(full and/or part-time).* . .. - 7. El New construction • 2.0 I am a sole proprietor or partnership and have no employees working for me in - any capacity.[No workers'comp.insurance required] 8. Remodeling 3.p I am a homeowner doing an work myself.[No workers'comp.insurance required.]t . 9Li Demolition - 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 • Building addition . ensure that all contractors either have workers'compensation insurance or are sole 11 TO Electrical repairs or additions proprietors with no employees. .. - .. .- . . _. 12.❑Plumbing repairs or additions 5.0 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0Roof 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 152,11(4),and we have no employees.No workers'comp.insurance required.] 'Any applicant that checks box 41 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. Ifthe 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 fob site information. .. ... . . .. . . , Insurance Company Name: Employers Mutual Casualty Company Policy#or Self-ins.Lie.#: 5D77852 Expiration Date: 10/16/2019 job Site Address: 481 Buck Island Road Unit 2E 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 I do hereby cert;fy under s/i pains and penalties of perjury that the information provided above is true and correct , Signature: \\19 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):" ' L 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 °"'�'MMVDWYYT) kg./ 09/26/2018 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 policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the tens 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 M/ Rogers&Gray Insurance Agency,Inc. . Nu�k I ,N,r(877)816-2156 434 utth Dennis,MA 02660 i�"DI&5S;matt @r ogeregray.com A' - - .. - - . INSURER(S)AFFORDING COVERAGE NAICC INSURER A:Employers Mutual Casualty Company 21416 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. INSR ADDLSUBR1 POLICYEFF POLICYEXP LTR TYPE OF INSURANCE INSD WVDl POLICY NUMBER IMMIDD/YYYYI IMMIDD/YYYYI LIMITS ' A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 5D77852 10/16/2018 10116/2019 pR4MEEOEMrtence) $ 600,000 MED EXP(Any one person) $ 10,000 _PERSONAL a ADV INJURY $ _ 1,000,000 GENL AGGREGATE pGT UNITp�APPLIES PLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY[-xi JELOC .. PRODUCTS•COMP/OPAGG $ 2,000,000 OTHER ' -. . ' - EBL AGGREGATE $ 2,000,000 A AUTOMOBILE LIABILITY _ ICEOM�BINEDSINGLE UMIT ccident) $ 1,000,000 X ANY AUTO 5Z77852 10/16/2018 10/16/2019 BODILY INJURY(Per person) $ OWNED — SCHEDULED AUTOS�pp�� ONLY _ AUUTNOSSyy}.�Ep . BODILY INJURY(Per eorident) 5 1;417293 ONLY _AUTOS ONLY (Per Pe R YXI MAGE $ _ $ A X UMBRELLA UAB X OCCUR EACH OCCURRENCE _ $ 2,000,000 EXCESS LIAB CLAIMS-MADE 5.177862 . 10/16/2018 10/16/2019 AGGREGATE . e 2,000,000 DED X RETENTION$ 10,000 $ B WORKERS COMPENSATION X STATUTE FORK AND EMPLOYERS'TORLUIBILITY 6H77862 10/16/2018 10/16/2019 600,000 ANY PROPRIETOR/PARTNER/EXECUTIVE �Y�IN� . E.L.EACH ACCIDENT $ QQF�FICCER/MEM9E�qq EXCLUDED? •• NIA 500,000 (AtentlalorY in Nll) E.L.DISEASE•EA EMPLOYEE $ n es,deecION OF OPERATIONS .. 6tiO 0ti0 DESCRIPTION OF Obelow E.L.DISEASE•POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addition&Remarks Schedule,my bo aWtlled itmore spew Is nqulled Cape Light Compact Joint Powers Entity are Included as Additional Insured for General Liability,Automobile Liability&Excess as required by a signed written contact or agreement with the Named Insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Light Compact Joint Powers Entity THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PACCORDANCE WITH THE POLICY PROVISIONS. 261 White's Path,Unit4 - _ .. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE . ACORD 25(2016/03) 01988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD le Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 r Boston, Massachusetts'02108 Home Improvement'Contractor Registration s _ * r ,v !(!, Type: Corporation CAPE SAVE INC. irrt ," , — 1y=,'' Registration: 171380 { ,;,I Expiration: 03/13/2020 7-D HUNTINGTON AVENUE pg 1 i'- j,:; SOUTH YARMOUTH,MA 02664 l z\ t p ' j P x a us scA f A 'zoM-0vn �^ Update Address and Return Card. • e.72scrommottmen/bi eybiraiscrehueM Offke of Consumer Affairs a Business Regulation - - - HOMEIMPROVEMENTCONTRACTOR Registration valid for Individual use only - TYPE:Corporation before the expiration date. If found return to: Registration..-.gxolratioq Office of Consumer Affairs and Business Regulation 171380 - `I-' 03/13/2020 One Ashburton Race-Suite 1301 CAPE SAVE INC Boston,MA 02108 - - WILLIAM MCCLUSKEY i,..:*s` \2,GGPK1--- _ 7-D HUNTINGTON AVENUE- U SOUTH YARMOUTH,MA 02864Undersecretary NOt VBlid w IgnatuTe p Commonwealth of Massachusetts �/ Division of Professional Licensure- Construction Supervisor Specialty Board of Building Regulations and Standards to: Restricted CSSL-IC-IC-Insulation Contractor Construction.5k4sgr Specialty. f CSSL-102776 cy ?'""7'1 Elvires 06126/2019 . i � -.L.-•WILLIAM J MCCLUSKEW`J I 37 NAUSET ROAOf ' ! z C 1 WEST YARMOUTH MA 02673 Ss ,,„., I . ` 17)p ,.j-0 _ Failure to possess a current edition of the Massachusetts a _ State Building Code is cause for revocation of this license. Commissioner r DPS Licensing information visit:WWW.MASS.GOV/DPS RISE ENGINEERING OWNER AUTHORIZATION FORM I, Bruce Caswell (Owner's Name) owner of the property located at: 481 Buck Island Road (Property Address) West Yarmouth, MA 02673 (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. 6W{ ic- Owner's Signature / ///10 Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RISEengineering.com