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Home My WebLink AboutBLD-19-3639 Si• YqR @Office Use Only PermiWSO Amount. • Permit expires 180 days from �.. tissue date Bub— iq--0031739 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 27 James Street ASSESSOR'S INFORMATION: Map: 68 Parcel: 116 owNER: Clifford Keirstead same 339-222-1881 NAME PRESENT ADDRESS TEL # CONTRACroR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL# I Residential 0 Commercial Est.Cost of Construction S 2300 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lic.# IC 102776 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 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 I declare under penalties of perjury that the statements herein contained are tine and correct to the best of my knowledge and belief I understand that any false answer(s) will be just cause for denial r reation of my license and for prosecution under M.O.L.Ch.268,Section 1. Applicant's Signature: \ � Date: 12/12/18 Owners Signature(or attachmen attache.41'd Date: ., Approved By: Date: I'2^ i< F= I V `. ; i B ' m inial or designee) EMAIL ADDRESS: Zoning District: DEC 13 2O1a Historical District: ❑ Yes 0 No Flood Plain Zone: El ❑ No - Water Resource Protection District: Within 100 fl.of Wetlands: 0 Yes 0 No 0 Yes 0 No r The Commonwealth of Massachusetts I; *.rk=(I ,Department of Industrial Accidents ,. - qp— l 1 Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia , Workers'Compensation Insurance Affidavit:Builders/Contractors/Electriclans/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.I9 lam a employer with 15 employees(full and/or part-time).* .,_7. 0 New construction - 2.0 I am a sole proprietor m partnership and have no employees working forme in : '8. O Remodeling_, 0 any capacity.[No workers'comp.insurance required.] -- 31am a9• . ❑Demolition m a homeowner doing all work myself.No workers'comp.insurance required.] 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition . •- ensure that all contractors either have workers'compensation insurance or are sole MEI Electrical repairs or additions proprietors with no employees. 9 12.0 Plumbing repairs or additions 5171 1 am a general contractor and 1 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 officershave exercised their right of exemption per MGL c. 14.1:Other Insulation 152,§I(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 additional sheet 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. I am an employer that is providing workers'compensation insurance jor 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: 77 James Street 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 DLA for insurance coverage verification. . . 1 do hereby certify under tthpains and penalties of perjury that the information provided above is true and correct ; Signature: \ Date: 12/12/18 Phone#:5°8 - 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#: el, „.....emI1 CAPESAV-01 HWOODS ACORO' CERTIFICATE OF LIABILITY INSURANCE °09/26/20` 4...-----4...----- -08 9126/2018 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(ies)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 suc��hppeerI�npdorsement(s). PRODUCER IIAME; Rogers 8.Gray Insurance Agency,Inc. PHONEFAX 434 Rte 134 VW.Na Ed): I WC,Nor(S77)816-2156 South Dennis,MA 02660 Main mall@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC a INSURER A:Employers Mutual Casualty Company 21416 INSURED NSURERB: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. WSR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY FEE POLICY EXP LIMITS IIRINSD MD IMMIOwIYYYYI IMWDWYYYYI A X COMMERCIAL GENERAL LMBIUTY - EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 5D7785210/16/2018 10/16/2018 DAMAGE TO RENTED 500000 PREMISES(Ea occurrence) $ _ MED EXP(My one person) S 10,000 • PERSONAL SADV INJURY $ 1,000,000 GENT.AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY X ST& LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: - ... . . EBL AGGREGATE a 2,000,000 A AUTOMOBILE LUUXIUTY COMB iNED dem) NGLE LIMIT $ 1,000,000 X ANY AUTO _ 6Z77852 10/16/2018 10/16/2019 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOSpDONLY NAUUT�O{SµN�p _ • _BODILY II7NJJUpRpYJPer accident) $ FM ONLY _AUTOB ONLY • - PPer�eouGeittlE $ $ A X UMBRELLA LMB X OCCUR EACH OCCURRENCE S 2,000,000 EXCESS LUU3 CLAIMS-MADE 5J77852 10/16/2018 10/16/2019. AGGREGATE ' $ 2,000,000 DED_.,X RETENTIONS 10,000 a B WORKERS COMPENSATION X PER 0TM- AND EMPLOYERS'LIABILITY YINSTATUTE ER AQN�V��PROPREIET9OR/PARTNER/EXECUTIVE 6H77852 10/15/2016 10/16/2019 E.L EACH ACCIDENT S 600,000 (alend.te y IA NHS EXCLUDED? ra I N/A __ E . 600,000 If describe under E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT S 500'000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached I more spec 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 CapeLight COm iCtJOlnt Powers Entity THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g P ty ACCORDANCE WITH THE POLICY PROVISIONS. 261 White's Path,Unit 4 South Yarmouth,MA 02664 - - _- • AUTHORIZED REPRESENTATIVE - 17 - ACORD 25(2016/03) '' ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD r Cite a/ dada eL i Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 ; Boston, Massachusetts 02108 Home Improvement Contractor Registration i r ,.:?/-•,-. ,2 Type: Corporation Registration: 171380 CAPE SAVE INC. !xi' 'r` 7 y', Expiration: 03/13/2020 7-D HUNTINGTON AVENUE - SOUTH YARMOUTH.MA 02664 _ iy i`; r rr �' i ti;. . -( 1 p im G _j . Update Address and Return Card. Sea 1 O 20M-05/17 ��ciA rxrnonwra//h nfc3 f�PdNlfAu.N//t Office of Consumer Attain&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Comoraticn before the expiration date. If found return to: peoistratIon---- Expiration Office of Consumer Affairs and Business Regulation 171380 ,-_- .'.03/132020 One Ashburton Place-Suite 1301 CAPE SAVE INC , t•;' Boston,MA 02108 WILLIAM MCCLUSKEY !% 2.L-(Pxe---- 2-D HUNTINGTON AVENUE`" Not validW I nature SOUTH YARMOUTH,MA 02664g Undersecretary s- Commonwealth of Massachusetts v' Division of Professional Licensure .. Construction Supervisor Specialty Board of BuildingRegulations and Standards Restricted In: 9� CSSL-IC-InsulationCantrador ConstructiocSUp&ivlsor Specialty rr CSSL-102776 -? r i E-kpires 06128/2019 ��,,� `4 1 WILLIAM J MCCLUSKEYa'_ . .ra \� ,�r. d 37 NAUSET ROAD, , f d �` N, 1,.""i J. I WEST YARMOUTH MA 02673 „ ' lo,kC i.t0-1S Failure to possess a current edition of the Massachusetts State Building Code Is cause for revocation of this license. Commissioner DPS Licensing Information visit:WWW.MASS.GOVIDPS Building Permit Authorization 1, Clifford Keirstead , as owner hereby give my permission to Cape Save, Inc. 7-13 Huntington Avenue South Yarmouth,MA 02664 Office:508-398-0398 to take all necessary steps to obtain a building permit to perform work at my property located at 27 James Street S. Yarmouth, MA 02664 Signed rjtart4t0 Date la-a- 1$