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Home My WebLink AboutBLD-19-3640 .og,Y' Office Use Only r 2 r .,Permit# o n. c O moi, 4:.. .Amount s ` , a• .. 1 Permit expires 180 days from 'r .�. i issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 6 Nightingale Drive at i A- tD39D ASSESSOR'S INFORMATION: • Map: 88 Parcel: 177 OWNER: Nickel Betty same 508-375-5642 NAME PRESENT ADDRESS TEL # coNTRAcroI:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL# ■Residential ❑Commercial Est Cost of Construction S 3900 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 have Worker's Compensation Insurance Insurance Company Name: F.mployers 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 denialr ation of my license and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: \ N. Date: 12/12/18 Owners Signature(or attachmen attach Date: ' Approved By: ‘ i Date: OAWaI/ ►ii � r` Buil ' 0 ial( r designee) EMAIL ADDRESS: I :i__. %sr C ] V_ Zoning District: I ' DEC 1 3 2018 i Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No I Water Resource Protection District: Within 100 ft.of Wetlands: ' :C t T M N T 0 Yes 0 No ❑ Yes 0 No "_I---- The Commonwealth of Massachusetts % y '/. , Department of IndustrialAccidenis ' E-Ifire—ra 1 Congress Street,Suite 100 Boston,MA 0211 4-2 01 7 www massgov/dia .. Workers'Compensation Insurance Affidavit:Builders/Contractors/Electrlclans/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 an employer?Check the appropriate box: - ' Type of project(required): 1.el 1 am a employer with 15 employees(full and/or part-time).' - Z New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8, O Remodeling any capacity.[No workers'comp.insurance required.] - 9. Demolition 301 am a homeowner doing all work myself.No workers'comp.insurance required.]' , 10 0 Building addition 4.02 am a homeowner 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 I am a general contractor and I have hired the subcontractors listed on the attached sheet 13.❑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. 14.0✓ Othe[ Insulation 152,§I(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 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: 6 Nightingale Drive 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 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: 0398 Official Date: 12/12/18 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#: CAPESAV-01 HWOODS ACORO' TE(IMUDDITYYY) CERTIFICATE OF LIABILITY INSURANCE °A 9/26/2 18 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 teens 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 suchpendorsement(s). PRODUCER • C[BNTACT Rogers&Gray Insurance Agency,Inc. MPHH�OONEFAX 434 Rte 134 -plc,No,Eat): I(A/C,No):(877)816-2156 South Dennis,MA 02660Miss;mail@rogersgray.com • INSURERS)AFFORDING COVERAGE NAIC INSURER A:Employers Mutual Casualty Company 21415 INSURED • INSURER e:Union Insurance Company of Providence 21423 Cape Save,Inc INSURER C: 7 D Huntington Ave INSURERD: 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 POUCY 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. NSR ADDLSUBI1 POLICY EFF POUCY EXP LIR TYPE OF INSURANCE AN$O YIVD POLICY NUMBER IMMIDDIYYYYl IMMNDWYYYI - UNITS A X COMMERCIAL GENERALLIABIUTY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE X OCCUR 5D77852 10/16/2018 10/16/2019 DAMAGETORENTED 500,006 PREMISES(Ea pccurra0cel $ _ MED EXP(Any one person) S 10,000 PERSONAL&ADV INJURY S 1,000'000 GENL AGGREGATE pURNpIT.APPLIES PER GENERAL AGGREGATE _ S 2'000'000 POLICY X JECT LOC PRODUCTS-COMP/OP AGO S 2,000,000 OTHER: EBL AGGREGATE 1 2,000,000 A AUTOMOBILE LIABILITYMB�INEentSINGIE OMIT S .1,000,000 X ANY AUTO _ 5Z77852 10/16/2018 10/16/2019 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS�pp�� ONLY _AUTOS BODILY INJURY(Per accident) S AUTOS ONLY _AUTaONLY gPERTV DAMAGE S ea Derv) S A X UMBREL AUAa X OCCUR EACH OCCURRENCE S 2,000,000 EXCESS LIAB CLAIMS-MADE 5.177862 . . 10/16/2018 10/16/2019 AGGREGATE s 2,000,000 DED X RETENTIONS 10,000 S B WOR KERS COMPENSATION AND EMPLOYERS'LIABILITYX STATUTE ERS , ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 5/177862 10/1612018 10/16/2019 E.L.EACH ACCIDENT S 600'000 FFA �rygMUgEREXCLUDED? . • N NIA NN E.L.DISEASE-EA EMPLOYEE $ 500'000 If yes,describe under • 500,000 DESCRIPTION OF OPERATIONS below E.L,DISEASE-POLICY LIMIT S • DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,AddltIorul Remarks Schedule,may be attached I more apace le seubed Cape Light Compact Joint Powers Entity are included as Additional Insured for General Liability,Automobile Liability S.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 oint Powers Entity THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN J hite's Path,Unito ACCORDANCE WITH THE POUCY PROVISIONS. 26South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD dZL3 Q�• • -it 00�� Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 i Boston, Massachusetts 02108 Home Improvement Contractor Registration = 1 < Type: Corporation i_; Registration: 171380 CAPE SAVE INC. r =j ii4't Expiration: - 03/13/2020 7-D HUNTINGTON AVENUE i y! i ' t -, SOUTH YARMOUTH,MA 02664 t .\\_V 'k 'a . 1 ,,i — ,Update Address and Return Card. SCA1 4 20M-05/1/ dZ? ornmonweaflA IQilimoaritear 3 � __ _. __ _ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Comoration 6 before the expiration date. If found return to: Peoistration- Exoiratloq Office of Consumer Affairs and Business Regulation 171380 --` 03/13/2020 One Ashburton Place•Suite 1301 CAPE SAVE INC .. Boston,MA 02108 WILLIAM MCCLUSKEY d..1.2 R.CGQ1 7-0 HUNTINGTON AVENUE'' SOUTH YARMOUTH,MA 02664 U Not valid w .\n Ignature Undersecretary c Commonwealth of Massachusetts Construction Supervisor Specialty k�>' Division of Professional licensure Restricted to: - - Board of Building Regulations and Standards CSSL-IC-Insulation Contractor Con structioe:Su brisorSpecialty 'r CSSL-102776 r r"l E�ires 06/28/2019 WILLIAM J MCCLUSKEY4-f 4 ,� j; 37 NAUSET ROAR � 1 d - h i WEST YARMOUTH MA 02673 s- ' �' I Failure to possess a current edition of the Massachusetts /2 _ State Building Code is cause for revocation of this license. Commissioner ��✓ DPS Licensing information visit:WWW.MASS.GOV/DPS DogeSigh Envelope ID:B1 E97FF4-785Bd09E-AE63-22DA93F0217F RISE ENGINEERING OWNER AUTHORIZATION FORM I, Nickel Betty (Owner's Name) owner of the property located at: 6 Nightingale Drive (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 e—Doeusipn0 by: `9wwlwrrsFStgnature 12/6/2018 I 10:04 AM EST Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth,MA 02664 1508-568-1926 www.RISEengineering.com