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Home My WebLink AboutBLD-19-3553 1,1•_ ai Ice Use Only O ,. al Amount :u f' Permit expires 180 days from 1 issue date 1; EXPRESS BUILDING PERMIT APPLICA IG TOWN OF YARMOUTH i< _ Yarmouth Building Department 1146 Route 28 DEC 0:712:1:- ir South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 By BUILDING oeNa—WTh t r CONSTRUCTION ADDRESS: 30 Salt Marsh Lane 00 ASSESSOR'S INFORMATION: . Map: 17 Parcel: 113 OWNER: Richard Kane same 646-286-3373 NAME PRESENT ADDRESS TEL. X cONTRAcTOR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL X ■Residential ❑Commercial Est.Cost of Construction S 2400 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lie.# IC 102776 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor I 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 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 ation of my license and for prosecution under MAIL Ch.268,Section 1. Applicant's Signature: Av Date: 12/7/111 Owners Signature(or att�men , a ached Date: Approved Br ^5�c�) L A Date: �! �� /C/ Buildin ffic' or de � nee LADDRESSr Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft of Wetlands: 0Yes 0No 0Yes 0 No The Commonwealth of Massachusetts Department of Industrial Accidents 'el 1 Congress Street,Suite 100 Boston,MA 02114-2017 �.., -. www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.. .. TO BE FILED WITH THE PERMUTING AUTHORITY. Applicant Information Please Print Legibly Name(sus nesslOrganizatiodlndividual):Cape Save Inc Address:7-D Huntington Avenue City/State/Zip:South Yarmouth, MA 02664 Phone#:508-398-0398 Are you■a employer?Check the appropriate box: - - Type of project(required): I.p I am a employer with 15 - employees(N11 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.] . ' 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition ]0 Q Building addition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will ." 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 51:11 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 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 61 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: 10 Salt Marsh Lane 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-e. 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 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#: .-----"1 CAPESAV-01 HWOODS ,4CORO' CERTIFICATE OF LIABILITY INSURANCE D IDDIYYYYI 4...----- 09/26/2018 09/29/26612018 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 pollcy(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).Tp PRODUCER ERECT Rogers&Gray Insurance Agency,Inc. �A,cONE Ext) FAX 434 816-2156 434 Rte 134 Q�IAq��South Dennis,MA 02660 laths.mall�rogeragray.eom INSURERS)AFFORDING COVERAGE NAIC N INSURER A:Employers Mutual Casualty Company 21416 INSURED .. _ - INSURER B:Union Insurance Company of Providence 21423 Cape Save,Inc INSURER C: _ 713 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 REDUCEDBY PAID CLAIMS. INSR ADDL SUER PMIDDY EFF POLICY ESP LIR TYPE OF INSURANCE WSD pryp POLICY NUMBER (Mwpplyyyp (MLVDDIyYyp OMITS A X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000 CWMSJMDE X OCCUR 5D77852 10/16/2018 10/16/2019 PRRMESll6ES rirro Emrrerhcel $ 500,000 _ MED EXP(Any one person) $ 10'000 PERSONAL 6ADV INJURY $ 1,000,000 GE 'L AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY n JE& Li LOC PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER: _ .._ EBL AGGREGATE - $ 2,000,000 A AUTOMOBIlELU1BWTY (EEaaMBident)INED LIMIT $ 1,000,000 X ANY AUTO _ 6277852 10/16/2018 10/16/2019 BODILY INJURY(Per pmson) $ OWNED SCHEDULED AA TOSS ONLY _ AUTOSAUV�Ep - - pBOOpDILY INJURYTypp (Per accident) $ AUTOS ONLY _ ORM . . (Per eaa,aeM) E $ • A X UMBRELLA UAB X OCCUR EACH OCCURRENCE _4 2,000,000 EXCESS IJAB CWMSIAADE 5J77852 _ , . 10/16/2018 10/16/2019 • AGGREGATE $ 2,000/000 DED X RETENTIONS 10/000 $ B WORKERS COMPENSATION • - X I STATURE I 10TH- AND ET ANY EMPLOYERS'PARTNE Y 5H77862 10/16/2018 10/16/2019 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE YIN Et EACH ACCIDENT $ _ OPFICEtogInNER EXCLUDED? N NIA - - llte�un0 cry NNN�) 500'000 E.L.DISEASE-EA EMPLOYE $ If yes.desalbe under 600,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD lel,Additional Remarks Schedule,may be attached a more space le required Cape Light Com pact 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 Pa ACCORDANCE WITH THE POLICY PROVISIONS. 261 White's Path,Unit 4 . • - ' South Yarmouth,MA 02664 AUTHORQED REPRESENTATIVE ._ ACORD 26(2016/03) - 101988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD z � � vaas Office of Consumer Affairs and Business Regulation One Ashburton Place Suite 1301 ' Boston, Massachusetts 02108 Home Improvement Contractor Registration i; { }t rw Type: Corporation ' " s�, Registration: 171380 CAPE SAVE INC. II": / i' t f Int Etgilration: 03/13/2020 7-D HUNTINGTON AVENUESOUTH YARMOUTH,MA 02664 , V`,__-",*t" _4 rk. scai. 0 20M-05/17 Update Address and Return Card. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corocration before the expiration date. If found return to: Realstration Expiration Office of Consumer Affairs and Business Regulation 171380 t -' 03/132020 One Ashburton Place-Suite 1301 CAPE SAVE INC , „l. f Boston,MA 02108 WILLIAM MCCLUSKEY R_CG01-- 7-0 HUNTINGTON AVENUE' . SOUTH YARMOUTH,MA 02664 Not valid w ,, <i lgnature Undersecretary Commonwealth of Massachusetts ®1 Division of Professional Licensure .. Construction Supervisor Specialty Board of Building Regulations and Standards Restricted In: • - CSSL-IC-Insulation Contractor Constructiort.SUFJis?r Specialty �f CSSL-102776 :' k 4,4,-""'''"`",, E Aires 06/28/2019 V -,,y, r o} i { °4r WILLIAM J MCCL'USKEY* I r = \� "fir 37 NAUSET ROADI , .d s c, k i WEST YARMOUTH MA 02673 K _y •tp/c,4);OnS M.+ Failure to possess a current edition of the Massachusetts a_, State Building Code is cause for revocation of this license. Commissioner DPS Licensing information visit:W W W.MASS.GOV/DPS RISE ENGINEERING OWNER AUTHORIZATION FORM 1, Richard Kane (Owner's Name) owner of the property located at: 30ait Marsh Lane (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. Owner's S gnature Dat/1 -/C! y e RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue 1 South Yarmouth, MA 02664 1 508-568-1926 www.RISEengineering.com