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Home My WebLink AboutBLD-19-3944 Ot;•Y Office Use Only A 4' r0 Pcrmit# or 4 c o o SYN 4H: Amount ,ALJ " • ,. ' c' Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPL (8?T-� 0 TOWN OF YARMOUTH ':Ly = I Yarmouth Building Department 1146 Route 28 JAN 02 2[11., i South Yarmouth,MA 02664 _ (508)398-2231 Ext. 1261 tlNT coNsTRUCTTONADDRESS: 638 Route 28 Unit 14 ASSESSOR'S INFORMATION: Map: 32 Parcel:85 • OWNER: Joan Curran same 774-722-0839 NAME PRESENT ADDRESS TEL # CONTRAcroR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL# Residential ❑Commercial Est.Cost of Construction S 2500 Home Improvement Contractor Lie.# 171380 Construction Supervisor Lie.N 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: 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 .r re .cation of my license and for prosecution under M.O.L.Ch.268,Section 1. Applicant's Signature. , \, Date: 12/28/18 Owners Signa e(or■ .amen a ols Date: Approved By: -� � `- Date: /'7//I Building filch :,y igne EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 R.of Wetlands: 0 Yes 0 No 0 Yes 0 No • /1 CAPESAV-01 HWOODS ACORO' CERTIFICATE OF LIABILITY INSURANCE DATE/ 4........---- CERTIFICATE 8 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 suchpendorsement(s). PRODUCER gAi€ACT Rogers&Gray Insurance Agency,Inc. PHONNo,Ext): FAX No):(877)816-2155 South De4 Rte nnis ,MA 02660 mailrogersgre @ .com •• y INSURER(S)AFFORDING COVERAGE NAIC a INSURER A:Emplovers Mutual Casualty Company 21415 INSURED INSURER El:Union Insurance Company of Providence 21423 Cape Save,inc • . WSURERC: 7 D Huntington Ave - INSURER 0: '' ' 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 AWL SUER POLICY EFF POLICYEXP LTR TYPE OF INSURANCE INs, WVD POLICY NUMBER IMMIDD/YYYYI IMMIDDNYYYI UNITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE X OCCUR 5D77852 10/16/2018 10/16/2019 a`MAGETORENTEO 500,000 •PREMISES IEa aunance) 1 10,000 _ MED EXP(Any one venal) $ PERSONAL&ADV INJURY S 1,000,000 GENL AGGREGATE List APPLIES PER GENERAL AGGREGATE S 2,000,000 POLICY XLJECT n LOC PRODUCTS•COMP/OPAGG S 2,000,000 OTHER: EBL AGGREGATE 1 2,000,000 A AUTOMOBILE LIABILITY ICAMBident) LE LIMIT S • 1,000,000 X ANY AUTO 5Z77852 • 10/16/2018 10/16/2019 uoDILYINJURY(PerPetwel t fTO�S ONLY AAmIUUpNITT�OEDyU�TLIEEEDpp BODILY INJURY Ter accident) S AUTOS ONLY AUT ONLY E PROPeMAGE $ Po $ A X uMBREaLA WB X OCCUR EACH OCCURRENCE S 2,000,000 ' EXCESS LMB CLMMS-MADE 5.177852 . . 10/16/2018 10/16/2019 AGGREGATE S 2,000,000 DED X RETENTION$ 10,000 . - S B WORKERS COMPENSATION - X STATUTE ETH• AND EMPLOYERS'LIABILITY ANY PERROPPRIIEET6ORR/PARTNER/EXECUTIVE YIN 6H77852 10/16/2018 10/16/2019 EL EACH ACCIDENT $ 500,000 OFFlCERnA in NH)czrl UDED7 N N/A _ • ( and E.L.DISEASE-EA EMPLOYEE S 500'000 If yet describe under 500,000 DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ • DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD let,Additional Remarks Schedule,Any be attached amore same 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 Compact Joint Powers EntityTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 W ACCORDANCE WITH THE POLICY PROVISIONS. 261 White's Path,Unit 4 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE • I • 7/ v+�ee'n"'`—�— ACORD 25(2016/03) - _. 01)1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD , The Commonwealth of Massachusetts Department ofIndustrial Accidents , _5elH 1 Congress Street,Suite 100 e1'l_ Boston,MA 02114-2017 +.�.+ www,mass govidia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/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?Cheek the appropriate box: Type of project(required): 112 I am a employer with 15 ' employees(Ml and/or part-time).* _ _7. El New construction 2.p 1 am a sole proprietor or partnership and have no employees working for me in 8.-0 Remodeling any capacity.[No workers'comp.insurance required.] 3.11 am a homeowner doing all wok myself.[No workers'comp.insurance required.]t 9. ['Demolition 10 0 Building addition 4.0I 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 • 5.01 am a general contractor and I have hired the subcontractors 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 o. 14.Q✓ Othe[ Insulation 152,{1(4),and we have no employees.[No workers'comp.insurance required] 'Any applicant that checks box NI 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: 638 Route 28 Unit 14 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. • Ido hereby certify under th pains and penalties of perjury that the information provided above is true and correct. Signature: i\� Date; 12/28/18 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#: Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration ! T Corporation 11`i'� - : s= ' Registration 171380 CAPE SAVE INC. - . 'i e ; _—,k?...,; Expiration 03/13/2020 7-D HUNTINGTON AVENUE i SOUTH YARMOUTH,MA 02664 {, ,i7,..---i. - j bci.1-5-:;;;.+:=.i.:-.7/,P,5 scr,f O som-osnr Update Address and Return Card. c9L ''mmonnvafrA 10 fAu.,Auxlk Office of Consumer(Wain&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only :TYPE:Camaration . '. before the expiration date. If found return to: - Heoistration Expiration Office of Consumer Affairs and Business Regulation 171380 = - ".03/132020 One Ashburton Place-Suite 1301 CAPE SAVE INC., :-. . Boston,MA 02108 WILLIAM MCCLOSKEY " 2=Le124.1*--- 7-0 HUNTINGTON AVENUE' SOUTH YARMOUTH,MA 02664 Not valid w to z1 -Ignature Undersecretary dersecretary - ' r. Commonwealth of Massachusetts V) Division of Professional Licensure .. Construction Supervisor Specialty Board of Building Regulations and Standards RestrictedIn: CSSL-ICto: Contractor Constructiot:Si} FvisorSpecialty CSSL-102776 " ‘"""71 0 Spires 06/28/2019 . .,gip + t 2 ,,, W -.... , ILLIAMJ MCCLOSKEYj. J ,4 � ,..I ,. e' 37 NAUSET ROAD; ,' \3 i WEST YARMOUTH MA 02673`yam i -F. 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.GOVJDPS I. NOME OWNER WEATHERIZATION WORK PERMIT: PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER. 1 CLAcrGn I �J OCt� hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation on the property located(0 S'9 IA6 Uv 3k .I`-1 , \I�MotJM\ l The weatherization 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 weatherization. 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. i \ — I Home Owner(signature) Home Owner email: Date: 171 i LOW Agent:(sbnamre) Date: Agency Approved Weatherization Company �a`M,Semi, All Cape Energy Alternative eatherizattbn Cape Cod Insulation ape ave Cazeault Frontier Energy Solutions Lo r ome Improvement f� Agency Signature: X! fibRAIOa^Date: l ON I c� For Natural Gas Customers: I have received the National Grid Discount Rate Application form from my auditor. Customer Initials 6- t e/ MMCCARTHY CONSTRUCTION CO. MMC Date:PLEM mjmccarthyconst@gnail. corn Building Commissioner Building Department PO Box 52 T°`'�'s o� `(�2,�1�,�-�,l West Dennis,Ma 131-0- t 9' - 00 3?9 5/ 02670 To whom it may concern, This affidavit is to certify that all work completed for Permit Location: 1- R-o rrl 2$ vu 6 Has been inspected by a certified Building Performance Institute(BPI) inspector. All work performed meets or exceed Federal and State requirements. Sincerely yo rs.; // Michael McCarthy RECEIVE D / EP47 2Q19 e UILDt DEPgRT/N�NT