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Home My WebLink AboutBLD-19-3641 M t . of'YAR• . . �Ofliice Use Only ': 2� 1 ! rPemait# i O � �H: . Amount 3.S- Permit expires 180 days from 2 issue date i t3(D-n- Cb3(04 t EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 30 R.ymond Avenue ASSESSOR'S INFORMATION: Map: 79 Parcel:36 OWNER: Margaret Cortes same 508-394-5753 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 2000 Home Improvement Contractor Lic.# 171380 Construction Supervisor Lic.# '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: u a s - s. tt a. .. • a so s<t Worker's Comp.Policy# 5D77852 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: It 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 cation of my license and for prosecution under M.O.L.Ch.268,Section I. Applicant's Signature: �� Date: 12/12/18 Owners Signature(or attaehmen attached Date: > /, Approved By: e#a�`gy ��J/�. Date: ^// �IJ Building Off ( signe ) EMAI RESS: Zoning District: R E C E I V ER/ f Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes 0 No 1 1 Water Resource Protection District: Within 100 ft.of Wetlands: 1 DEC 13 2018 1 0Yes ❑ No ' 0Yes 0 No I • • ThCommonwealth onwealof I� zDepartmentf h teal Accidents 1 Congress Street,Suite 100 ' Boston,MA 02114-2017 - c.�,., www massgov/dia . . Workers'Compensation Insurance Affidavit:Bullders/Contractors/Electricians/Plumbers. - TO BE FILED WITH THE PERMITTING AUTHORITY. - Applicant Information Please Print Legibly" Name(Business/Organization/Individual):Cape Save Inc Address:7-0 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): 1.0 lam a employer with 15 employees(full and/or part-time).• 7. 0 New construction 2.0 lam a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] _ 3.❑I am a homeowner doing all work mysel£No workers'comp.insurance required.]t 9. ❑Demolition 4.0 I am a homeowner and will be hiring contractorms to conduct all work on y property. I wilt 10 El Building addition ensure that all contractors either have workers'compensation insurance or me sole 11.0 Electrical repairs or additions proprietors with with no employees. .. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.QRoof repairs These sub-contractors have employees and have workers'comp.insurance.* 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.ID Other Insulation - 152,§I(4),and we have no employees.[No workers'comp.insurance required] *Any applicant that checks box WI 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 Raymond Avenue 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 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: i,\ Date: 12/12/18 Phone#:508 398.0398 \ Oficial 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' CERTIFICATE OF LIABILITY INSURANCE °A 09/26/9/26/2TE D 018 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). RPRROODUCER .gjAME; T 434 Rtte 13G4rey Insurance Agency,Inc. PHONE o,Eat): I PIC,N4(877)816-2156 South Dennis,MA 02660 Man mailigrogersgray.com - INSURER(S)AFFORDING COVERAGE - NAICI_.__ INSURER A:Employers Mutual Casualty Company 21416 INSURED • - INSURER B:Union Insurance Company of Providence 21423 Cape Save,Inc INSURER C: 7 0 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 ADDL BURR POLICY POLICY niyyyP Lm MT OF INSURANCE IryAp p POLICY NUMBER mMIDD/YYYTI MA1DM/rMYYl LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE - S 1,000,000 CLAIMS-MADE X OCCUR. 5D77852 10/1612018 10/16/2019 DAMAGE TO RENTED 500,000 PREMISES(Ee acclrrermcel S _ _ MED EXP(Ay one penin) 7 10,000 PERSONAL a ADV INJURY $ 1,000,000 GEN.AGGREGATE JECT UgMaITAPPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY X LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: EBL AGGREGATE $ 2,000,000 A AUTOMOBILE UABI UTY /C AMBale/IDISINGLE LIMIT S 1,000,000 X ANY AUTO _ 5277862 10/16/2018 10/16/2019 BODILY INJURY(Per person) S OWNED SCHEDULED A�U�gqT�� (PM SO��S ONLY _AAUU�T�NOSWWNN��pp BBpgOqDILY INJURY(Per accldent) $ AUTOSONLY _AUTONLY E )pg 'E S . S A X UMBRELLA UAB X OCCUR EACH OCCURRENCE S 2,000,000 EXCESS Luc CLAIMS-MADE 6.177852 • 10/16/2018 10/16/2019 AGGREGATE 5 2,000,000 CEO X RETENTIONS 10,000 S B WORKERS COMPENSATOR' - PER OTH- AND EMPLOYERS'LIABILITY X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 5/177862 10/16/2079 70/1612019 E.L.EACH ACCIDENT y 500'000 �FFlC.ERIMEM EXCLUDED? N NM -' IMiatlstory lmm�iPf�) , - 500,000 E.L.DISEASE-EA EMPLOYEE $ If yes.describe under 50%000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ • DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Ramada Schedule,may be attached I TOM space 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 Cape Light Compact Joint Powers EntityTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P ACCORDANCE WITH THE POLICY PROVISIONS. 261 White's Path,Unit South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE . f / " ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration I � a ,Th i ( Type: Corporation �ip(r - -...-,:_.;,:„i.,--- Registration: 171380. CAPE SAVE INC. I . t ` ` -=-----; Expiration: 03/13/2020 7-D HUNTINGTON AVENUE _ SOUTH YARMOUTH,MA 02664 t \ ' j.-r •te �t - r scA f 6 20Mos n Update Atldresa end Retum Card. f�t rfnxrnnnxarall/e n�d��auar/well3 Offke of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Comaration before the expiration date. If found return to: Registration - Fxniratiort Office of Consumer Affairs and Business Regulation 171380 s >.- -.'.03/132020 One Ashburton Place-Suite 1301 CAPE SAVE INC , Boston,MA 02108 WILLIAM MCCLOSKEY ..(` 2,.GCQ� 7-D HUNTINGTON AVENUE� SOUTH YARMOUTH,MA 02664 n Not valid w Ignature Undersecretary r .. Commonwealth of Massachusetts Division of Professional Licensure .. Construction Supervisor Specialty Restricte - - Board of Building Regulations and Standards CSSL-IC-In: SSL-ICInsulation Contractor ConstructioiS'Up4 isprSpecialty I CSSL-102776 "°`""""6 Expires 06/28/2019 nn Sys ,'i ,,. WILLIAM J MCCLUSKEY?, / v ..- r.,:^`r 37 NAUSET ROAD, .,.' ' . \ It WEST YARMOUTH MA 02673 S' :'1 thrsNe 1011 a. Failure to possess a current edition of the Massachusetts S_ State Building Code is cause for revocation of this license. Commissioner DPS Licensing information visit:WWW.MASS.GOVIDPS DocuSge Envelope ID:E58BC05446054274-8668-00BF0F551892 Ott RISE ENGINEERING OWNER AUTHORIZATION FORM I, Margaret P Cortes (Owner's Name) owner of the property located at: 30 Raymond Avenue (Property Address) South Yarmouth, MA 02664 (Property Address) Cape Save hereby authorize , (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 Lowntrie DocuSigned by: C, Atallr Cie Y3tthature 12/3/2018 I 2:27 PM EST Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com