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HomeMy WebLinkAboutBld-20-000557 Office Use Only 4�� � �0 Permit# Or' H Amount c --' !"'wit, cTd Permit expires 180 days from issue date Ph— 20-551 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 481 Buck Island Road Unit 5D ASSESSOR'S INFORMATION: Map: 46 Parcel:23 OWNER: James Dooley same 508-280-0928 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$ 1700 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: Employers 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 re ation of my license and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: Date: 7/30/19 Owners Signature(or attachmen attached Date: Approved By: ✓at Date: • 10'`1 y Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes 1 No Flood Plain Zone: ❑ Yes No Water Resource Protection District: Within 100 ft.of Wetlands: J i..11_ ,) E Yes 0 No U Yes ❑ No �.� CAPESAV-01 HWOODS ` �/ 1 DATE/26 YY) Ask CERTIFICATE OF LIABILITY INSURANCE 09126/201/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS OR ALTER THE CVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATEFIRMAT OF INSURANCE DOES NOTLY CO STITUTE AAMEND, END CONTRACT ETWEENTHE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(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 T Rogers e14mYinsurance Agency,Inc. PHONE (, ,Ext): 'FAX No (877)8 16-.2.15 6 S4 R 134 Dennis,MA 02660 MMus:mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER n:Emeloyers Mutual Casua-ity_C ompanY 21415 —I- INSURED INSURER B:Union Insurance Company of Providence 21423 - Cape Save,Inc LINSURERC; ---- _ L..___ 7 D Huntington Ave INSURER D:South Yarmouth,MA 02664 INSURER E: -__ t" - — 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 POLICY NUMBER 1 11� EMITS A C X COMMERCIAL GENERAL LIABItm ! 1 YDIYYYYI TYPE OF INSURANCE ADDL U 1 EACH OCCURRENCE 1,000,000 LTR INSO WVD AGE TO RENTED � 1 CLAIMS-MADE 1 X i OCCUR ,5D77852 10/16/2018 D 10/16/2019 PRAMMISEES(Ea occwrencej _$ 500,000 10,000 MEDEXPSAny oneperson)_ .$PERSONAL&ADV INJURY $ 1,000,000 GENt AGGREGATE LIMIT APPLIES PER I GENERAL AGGREGATE $ 2,000,000 POLICY(X1 jiTef , LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER I EBL AGGREGATE $ 2,000,000 A AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT 1,000,000 ANY AUTO 15Z77852 10H6/2018{ (Ea accident) $X !10/16/2019 BODILY INJURY(Per OWNED SCHEDULED person)—$_-_ ---- AU�T�OnS ONLY AAUUTryOSSyy��p I BODILY INJURY(Per accident) $ AUTOS ONLY foam ! _PROPERTY MACE `{ A X ,UMBRELLA LIAB accident) $X{OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS UAB CLAIMS-MADE ,5J77852 10/16/2018 1 10/16/2019 AGGREGATE $ 2,000,000 10 DED X 000 r RETENTION$ $ B I WORKERS COMPENSATION ! X .STATUTE ERA AND EMPLOYERS LIABILITY Y/N ;5H77852 10/16/2018`10/16/2019 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVEXCLUDE E.I.EACH ACCIDENT $ PQ_Fl y�i ER EXCLUDED? N� N/A — -- (f y n NH) I I EL.DISEASE-EA EMPLOYEE $ 500,000 D describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more 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 Entity THE ACCORDANCEX E WITH DTION AT POLICY P OTE , NOTI E WILL BE DELIVERED IN 261 White's Path,Unit 4 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE 1 4 ,---.0041061 7,44"...—"---------- ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD _ The Commonwealth of Massachusetts Department � of Industrial Accidents ®i=w 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia 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 boa: Type of project(required): LO I am a employer with 20 employees(full and/or part-time).* 7. 0 New construction 2.0 I am 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 doingall work myself. 9. ❑Demolition y [No workers'comp.insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.DRoof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0We are a corporation and its officers have exercised their right of exemption 14.❑✓ Other Insulation ap per MGL c. 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. 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: 481 Buck Island Road Unit 5D 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 th pains and penalties ofperjury that the information provided above is true and correct Signature: Date: 7/30/19 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#: PY---1,eWo/in~41,te.)-eAgitA 0/&' //i,(1/Jacteltrizei6 Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation Registration: 171380 CAPE SAVE INC. 7-D HUNTINGTON AVENUE > � 03/13/2020 SOUTH YARMOUTH,MA 02664 SCA 1 0 20M osnr Update Address and Return Card. '/Ac t(7IXMONwea/IA c/ fIattncA Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration rasgindig0 Office of Consumer Affairs and Business Regulation 171380 03/13/2020 One Ashburton Place-Suite 1301 CAPE SAVE INC. Boston,MA 02108 WILLIAM MCCLUSKEY \ 7-D HUNTINGTON AVENUE SOUTH YARMOUTH,MA 02664 Undersecretary Not valid w •i ignature Commonwealth of Massachusetts Construction Supervisor Specialty Division of Professional Licensure Restricted to: Board of Building Regulations and Standards CSSL-IC-Insulation Contractor Constructioo'Si &Rr Specialty CSSL-102776 ccpires:06/28/2021 WILLIAM J PXCLUS�3�� f. 37 NAUSET ROAD 4 WEST YARMQjJTH MA/473 -- /"�' - Failure to possess a current edition of the Massachusetts fJ Commissioner State Building Code is cause for revocation of this license. DPS Licensing information visit:WWW.MASS.GOV/DPS t1 Building Permit Authorization I, James Dooley , as owner hereby give my permission to Cape Save, Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Office: 508-398-0398 to take all necessary steps to obtain a building permit to perform work at my property located at 481 Buck Island Road - 5D W. Yarmouth, MA 02673 Signed Date