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Home My WebLink AboutBLD-19-4139 Ot Y -- Office Use Only Il 14 C 'Pernit1 c O y Amount J5 '%' so S•i d' Permit expires 180 days from G issue date... r e )— q colt 139 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 47 Coveview Drive ASSESSOR'S INFORMATION: Map: 91 Parcel:202 OWNER: Velda Hines came 508-394-6082 NAME PRESENT ADDRESS TEL k CONTRAcrOR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL d •Residential 0 Commercial Est.Cost of Construction S 5000 Home Improvement Contractor Lic.It 171380 Construction Supervisor Lit ti 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: Employers Mutual Casualty Company Worker's Comp.Policyl 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 denialre cation of my license and for prosecution under M.O.L.Ch.268,Section 1. Applicant's Signature: \ \ Date: 1/11/19 Owners Signature(or attachrotn art c , Date: Approved By: �f. Date: 212‹.-- / r ry�� B ' mg :tial or designee) MAILAADDRESS: E 1d RECEIV _ Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No JAN 112019 Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No BUILDING DEPARTMENT The Commonwealth of Massachusetts Department of Industrial Accidents 7._-7.101= 1! l Congress Street,Suite 100 a ;:�{_ 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?Check the appropriate box: - - Type of project(required): 1.61 am a employer with 15 employees(full and/or part-time).* 7. 0 New construction , 2.01 am a sole proprietor or partnership and have no employees working forme in S. D Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]' 9. ❑Demolition • 4.01 am a homeowner and will be hiringcontractors to conduct all work on m ]0❑Building addition y property. [war '1.. ensure that all contractors either have workers'compensation insurance or am 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.['Other Insulation 152,§1(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 sub-contractors and state whether or not those entities have employees. If the subcontractors 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: 47 Coveview 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 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. Ida hereby certify underfit pains and penalties of perjury that the information provided above is true and correct .. Signature: \\\P \ Date: 1/11/19 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#: -----"''"IsCAPESAV-01 HWOODS J -----"''"Is A`� CERTIFICATE OF LIABILITY INSURANCE 09/26/2018LY DATE MY1 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 WANED, 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 suchendorsement(s). PRODUCER . . UMAACT Rogers&Gray Insurance Agency,Inc. FAX 434 Rte 134 (AIC,No,EMI: I((NA NA]:(877)816-2156 South Dennis,MA 02660p Miss;malllrogersgray.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 D Huntington Ave • INSURER O: South Yarmouth,MA 02664 INSURER!: 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 TYPE OF INSURANCE N D WVVD POUCY NUMBER m POLICYEFFPOIMIIWLDICYOYYRYfI LIMITS A X COMMERCIAL GENERAL LIABILITY - 1,000,000 EACH OCCURRENCE E CLAIMS-MADE X OCCUR 5D778$210/1812018 10/1612019 DAMAGE TO RENTED 500,000 PREMISES(Eaocwrenco E MED EXP(Any oneperson) $ 1!,009 ' PERSONAL a ADV INJURY $ 1,000,000 GE 'L AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X 2a I I LOC PRODUCTS-COMP/OP AGO S 2,000,000 OTHER: - - - - � •� EBL AGGREGATE $ 2,000,000 A AUTOMOBILE LIABILITY ICO acBIc leeD SINGLE LIMIT ntl $ 1,000,000 X ANY AUTO _ 5277852 10/16/2018 10/16/2019 BODILY INJURY(Pm person) $ _ OWNED SCHEDULED AUTOS��pp�� ONLY _AUTOS�lyWWNNEEpD BODILY INJUpRgYLet accident) $ AUTOS ONLY _ AUTOS ONLY. W &e t) MAGE E A X UMBRELLA UAB X OCCUR2,000,000 EACH OCCURRENCE E EXCESS LAB CLAIMS-MADE 5J77852 10/16/2018 10/1612018 AGGREGATE E 2,000,000 CEO X RETENTION$ 10,000 . S B WORKERS ND EMPLOYERSLIABIILIIN YINX STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE 5H77852 10/16/2018 1011612019 E.L.EACH ACCIDENT 3 500,000 OEFI EWMEMBER EXCLUDED?. - N NIA WO,DOD (M ai In NH) E.L DISEASE-EA EMPLOYEE E _ M yes,descnM under . 600,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may M attached If more apace la 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 Light Joint Powers Entity THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Cape Light e's Compactath,Unit 4 ACCORDANCE WITH THE POLICY PROVISIONS. 26South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE I 7,�a'aT" ACORD 25(2016!03) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Q/ �Q Q i i e&se64 Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 4 Boston, Massachusetts 02108 Home Improvement Contractor Registration i SSE a frit, Type Corporation J' 4 Registration: 171380 CAPE SAVE INC- l ! t z , •,'...:-7.L142.2 p _ \.1 Expiration: 03/13/2020 7-D HUNTINGTON AVENUE , -� ;,i _ SOUTH YARMOUTH,MA 02664 I„�' - y *r �-; 7 - y ef.. .� 7 scat t3 eon+-osnr �� Update Address and Return Card. • e U'ammamereah%IC ii�amadetteit5 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Caracration before the expiration date. tf found return to: peaistration::,.-:, Exoiratton Office of Consumer Affairs and Business Regulation 171380 - .' 03/132020 One Ashburton Place=Suite 1301 CAPE SAVE INC , r-. „ Boston,MA 02108 WILLIAM MCCLUSKEY '.. 2xco,f 7-D HUNTINGTON AVENUE' /� SOUTH YARMOUTH,MA 02664 C� Not valid w :`A -Ignature Undersecretary t ®t Commonwealth of Massachusetts Construction Supervisor Specialty Divisionvision of Professional Licensure Restricted to: Board of Building Regulations and Standards CSSL-IC-Insulation Contractor Construction.511Rvtapr Specialty !r CSSL-102776 . '°' "'. E•pires 06/28/2019 i '4' G ' "�`�,,, WILLIAM J MCCLLISKEY! .4 \� ., ]� -. 37NAUSET ROAD] , -/ I ` `• i "1' WEST YARMOUTH'MA 02673 ' �, In/t 'T_10 MY 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.GOV/DPS Permit Authorization mass save Form swims trials imam eresosincv Site ID: 3583095 Customer: Veida Hines L Veit 61c,_ N� vtcs ,owner ofthe property located at: (Owner's Name,printed) 47 Coveview Drive South Yarmouth, MA 02664 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. �( Owner's Signature: / \, ep I vl I� r , ) Date: s--11 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Cape Save Inc. Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: Page 1 of 1 For Office Use Only Rev.102015