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Home My WebLink AboutB-19-3950 pF'YAR :Office Use Only •:1$�Q Permit#.... o V Amount =N ..,i h �� '"`°" c,' Permit expires 180 days from issue date itYth "053930 . EXPRESS BUILDING PERMIT APPLICATIO rIq TOWN OF YARMOUTH ('r E C E HI E j; I Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 JAN 02 ?P19 t (508)398-2231 Ext. 1261Bu ni I _ CONSTRUCTION ADDRESS: 82 Baker Road ASSESSOR'S INFORMATION: Map: 22 Parcel:326 OWNER: Linda Barce same 508-725-1955 NAME PRESENT ADDRESS TEL # CONTRACTOR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL.# ■Residential ❑Commercial Est Cost of Construction$ 2900 Home Improvement Contractor Lia# 171380 Construction Supervisor Lie.# IC 102776 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor • I have Worker's Compensation Insurance Insurance Company Name: Fmployers 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 denial.ration of my license and for prosecution under M.O.L.Ch.268,Section I. Applicant's Signature: \ 401, Date: 12/28/18 Owners Signature .r attachm jt _le, Date: Approved By: ��/� _ - Date: /'7Y/, Building Official(or d r EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts 1� ez1 / Department ofIndustrial Accidents :ei— ; 1 Congress Street,Suite 100 .11q= Boston,MA 02114-2017 • www.mass.gov/dia _ . . ` Yorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly " • Name(Business/Organizationh1ndividital):Cape Save Inc Address:7-D Huntington Avenue City/State/Zip:South Yarmouth,MA 02664 • Phone#:508-398-0398 • Are you an employer?Cheek the appropriate box: - Type of project(required): I.p I am a employer with - 15 employees(full and/or part-time).' -- 7. 0 New construction 2. I am a sole proprietor or partnership and have no employees working for me in � 8. Q Remodeling any capacity.(No workers'comp. insurance required.]: . 3.01 am a homeowner doing all work myself.[No workers'camp.insurance required]? 9. [7 Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 1()El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions k proprietors with no employees, ,. 12.0 Plumbing repairs or additions 5.❑I 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,§1(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. 1 am an employer that is providing workers'compensation insurance for my employee& Below is the policy andjob site information. • Insurance Company Name: Employers Mutual Casualty Company Policy#or Self-ins.Lic.#: 5D77852- Expiration Date: 10/16/2019 ' Job Site Address: 82 Baker Road 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 Certify under t hpains and penalties of perjury that the information provided above is true and correct , Signature: \\�\�5+ Date: 12/28/18 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#: m. /—..41 CAPESAV-01 HWOODS ..4C0 0� CERTIFICATE OF LIABILITY INSURANCE 09/26/20018) 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(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 such endorsement(s). PRODUCER - • + ILCT Rogers&Gray Insurance Agency,Inc. �PHONE FAX 434 Rte 134 .(A/C,N0,Fats (AIC,No(877)816-2156 South Dennis,MA 02660 Daftmail@rogerspray.c0m INSURERO AFFORDING COVERAGE NAIC It msuRERA:Employers Mutual Casualty Company 21415 INSURED - - INSURER B:Union Insurance Company of Providence 21423 Cape Save,Inc INSURER c: " 7 D Huntington Ave MSURERD: 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. - ' INSRTYPE OF INSURANCE - ADDLSUBR POLICY NUMBER POLICY EFF POUCY EXP LIMITS INSQ•WooIMMDDIYYYYI IMMIOWYYYYI A X COMMERCIAL GENERAL LIABIUTY1,000,000 TACH OCCURRENCE E CLAIMS-MADE X OCCUR 5D7785210116/2016 1011612019 DAMAGE TO RENTED 500,000 PREMISES(Fa occurrence) S MED EXP(Any one person) S 10'000 PERSONAL a ADV INJURY S 1,000,000 GEN.AGGREGATE UNIT APPLIES PER • GENERAL AGGREGATE S ' ' 2,000,000 POUCY rig)ECT LOC - PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: ` . -" - EBL AGGREGATE $ - 2,000,000 A AUTOMOBILE UABIUTY covIe) ANGLE LIMIT ntl S 1,000,000 X ANY AUTO 5277852 10/16/2018 10/16/2019 BODILY INJURY(Per person) S OWNED SCHEDULED • AUTOS�pE� ONLY _ AUTOS .., BODILY INJURY(Per ecaden) S AUTOS ONLY _vane _ OPE P mAGE S l S A X UMBRELLA LIAO X OCCUREACH OCCURRENCE S 2,000,000 EXCESS UAB CLAIMS-MADE 5477852 ' '. 10/1612018 10/16/2019 AGGREGATE S 2,000,000 DEC X RETENTIONS 10,000 . S B AND EMPLOYERS'COMPENSATION YINX STATUTE ERµ ANY PROPRIETOR/PARTNER/EXECUTIVE, SH778$2 10/16/2018 10/16/2019 E.L EACH ACCIDENT 3 .600,000 FFI EryEMeER EXCLUDED? N NIA 500,000 In NH) E.L DISEASE-EA EMPLOYEES _ If yes.describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,AddtaaW Remarks Schedule,may be attached V more sop M 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 - SHOUW ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CapeLight Compact Joint Powers EntityTHE EXPIRATION DATE THEREOF, NOTICE WILL. BE DELIVERED IN 9 P ACCORDANCE WITH THE POLICY PROVISIONS. 261 White's Path,Unit 4 " South Yarmouth,MA 02664 - - - -- --,--- AUTHORIZED REPRESENTATIVE 7E_/fJ.4 ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD C��fie �P•i • z; Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 i Boston, Massachusetts 02108 Home Improvement Contractor Registration rr Ott Type: Corporation ' ei, Registration: 171380 CAPE SAVE INC. = ," Expiration: 03/13/2 020 7-D HUNTINGTON AVENUE i 'r _ SOUTH YARMOUTH,MA 02664 1'7-4 - " ) � y t Y scn t 8 20rwafr Update Address and Return Card. - Office of Consumer Affairs a Business Regulation `:' HOME IMPROVEMENT CONTRACTOR ' Registration valid for individual use only TYPE:Coro:ration before the expiration date. If found return to: Reoistration Fxniratlor Office of Consumer Affairs and Business Regulation 171360 - -: 1.031132020 One Ashburton Place-Suite 1301 CAPE SAVE INC Boston,MA 02108 WILLIAM MCCLUSKEY 7-D HUNTINGTON AVENUE' SOUTH YARMOUTH,MA 02664 U — ° Not valid w ; 4 .Ignature Undersecretary s, Conmonweahh of Massachusetts • Division of Professional Licensure Construction Supervisor Specialty Regulations and Standards Restricted to: Board of Building Re 9 CSSL-IC-Insulation Contractor Con structioc-SU .465sor Specialty if CSSL-102776 :""""":"".'"""`�:M r Aires 06/28/2019 - C %. 'i = WILLIAM J MCCLUSKEY' a = w 37 NAUSET ROAD2 y' .� \ x WEST YARMOUTH MA 02673 ?" C "P • c=H Failure to possess a current edition of the Massachusetts ✓L State Building Code is cause for revocation of this license. Commissioner /��+/ DPS Licensing information visit:NWW.MASS.GOV/DPS fin.,-_..._ -___• i i • lig d 7 r a El c ' x r � 1 € b * r ■ -. . �{ ?Qtc!Lir `i i4 € a s? i. r � I Z • {V V E a z 4 9 a a Q i /�� Q , a •2y a_.44 I. 0 e F• F i C r c` t F ' ,, Lii y p' • ` q T p k < , tail cs 1 41 gs f `\ 2 . `� - I . S LIfaa £ , S 1tf ,g UHI .O. x Ute . ' 1 -EN I" sit 'epi 9 ..- 11111 A`^ k'''' . � r a = . 0E914 `s i N ', " y , 1 F s . a , Y niu �S c 6 r. c 42iz6-'< " tz e .c -• ,, t 6 ' t !4, tr i; -,t- -- C C 4 V 1' W it ,i V R. Cri j t":. F+ NOME OWNER WEATHERIZATION WORK PERMIT; PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER. CGS hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation on the property located at i-j4k, n 1ts_ The weatherlzation work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures: Weather stripping;air sealing; attic& basement insulation; exterior wall insulation; ventilation measures In consideration of the weatherization work to be done at my home I agree to the following: 1. I give permission to Housing Assistance Corporation to access the property with such equipment and materials as may be necessary to perform weatherlzation. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five(5)years after the weatherization work is completed. I have read the provisions of this agreement and give my consent. Home Owner(signature) 6azae_) Home Owner email: Date: Agent(signature) Date: r Agency Approved Weatherization Company C��e,3 / All Cape Energy Altemativ atheri tion Cape Cod Insulation Cape SavCazeauit Frontier Energy Solutions Lohr Home Improvement Agency Signature: Date: V .\ c'6 ' 1 For Natural Gas Customers-. I have received the National Grid Discount Rate Application form from my auditor. Customer Initials