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HomeMy WebLinkAboutBld-20-002151 . 1'', Office Use Onlyjj 4 0 �,e0 G ' h,idl?/-do �/ / y O - b'S H Amount _ ' Permit expires 180 days from �:.; issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 19 Independence Road ASSESSOR'S INFORMATION: Map: 86 Parcel: 106 OWNER: Matthew Hughes 4 e44 5t 5-l4v_iidCY.. 508-237-9600 NAME PRESENT ADDRESS Kil3 TEL. # CONTRACTOR:William McCluskey/Cape Save 7-D Huntington Ave, S.Yarmouth 508-398-0398 NAME MAILING ADDRESS TEL.# ■Residential 0 Commercial Est.Cost of Construction$ 4200 Home Improvement Contractor Lic.# 171380 Construction Supervisor Lie.# 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 r re cation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: 1 D/$/19 Owners Signature(or attachmen attached �+ Date: / Approved By: Date: ,# '''��7 - Buil ' (or esignee) E DRESS: R r V E. 0 Zoning District: E _ --'1 Historical District: ❑ Yes No Flood Plain Zone: ❑❑ Yes No 4 15 Zn 9 Water Resource Protection District: Within 100 ft.of Wetlands: OCT - Li ❑ No E.] Yes No gU1LDIt3G E�ARTMENT BY - — _—" CAPESAV-01 HWOODS ACORO" DATE(MMIDD/YYYY) 4...---- CERTIFICATE OF LIABILITY INSURANCE 09/26/2018 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). PRODUCER €ACT Rogers&GrayInsurance Agency,Inc. ). Fez 434Rte 134 ( (A�Noy(877)816-2156 South Dennis,MA 02660 Itlaw mail a(rogersgray.com ___ INSURERSS)AFFORDING COVERAGE T NAIC 1 INSU A:Em ploxers Mutual Casualty Company 2.1415 INSURED 1,INSURER 8:Union Insurance Company of Providence 121423 Cape Save,Inc INSURER C: 7 D 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 i ADDLISUBR POLICY EFF POLICY EXP LTR i TYPE OF INSURANCE INSD MC_ POLICY NUMBER ( pDnYYY1,j,,,,(MIIIDD/YYYn LMNTS A X !COMMERCIAL GENERAL UABILnY EACH OCCURRENCE $ 1,000,000 1 .. _--- - -__-- CLAIMS-MADE X OCCUR DAMAGE TO RENTED 500,000 '5077852 10/16/2018 10/16/2019 PREMISES(Ee NTErence) $ MED EXP(_Any one 10,000 person" 3 PERSONAL&ADV INJURY $ 1'000'000 GEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY Xl LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: EEL AGGREGATE $ 2,000,000 A AUTOMOBILE LIABILITY ((EaaMBINED cciden1SINGLE LIMIT $ 1,000,000 X ANY AUTO 5Z77852 10/16/2018 10/16/2019 BODILY INJURY(Per persons_ $ OWNED SCHEDULED AUTOS��n ONLY i AUTOS BODILY INJURY(Per accident) $ AUTOS ONLY I NpN�yyN OPE trMAGE $__ AUTOS ONLY 1 L + OCCUR EACH OCCURRENCE $_ 2,000,000 A X UMBRELLA LAB I X I EXCESS LIAB ; i CLAIMS-MADE i EACH 10/16/2018 10/16/2019 AGGREGATE $ 2,000,000 DED X RETENTIONS 10,000 $ B l'WORKERS COMPENSATION ' X STATUTE I I ER AND EMPLOYERS'LIA&CITY ANY IPROOPPRIE PROPRIETOR/PARTNER/EXECUTIVE rN N/A 5H77852 10/16/2018 10/16/2019 E.L.EACH ACCIDENT------. $ --_-- 500,000 Y/N Qp �CE E gER 500,000 andawry In ) E.L.DISEASE-EA EMPLOYEE $ i If yes describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I 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 POUCIES BE CANCELLED BEFORE THE EXPIRATION ,Cape Light Compact Joint Powers Entity ACCORDANCE WITH T THETE POUCY PR�OVISIIO�NSCE WILL BE DELIVERED IN 261 White's Path,Unit 4 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVEATTIIV I i ,? s 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 1�!I. Department of Industrial Accidents " _ 1 Congress Street,Suite 100 �j- Boston,MA 02114-2017 `= w` ww massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electriclans/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.❑✓ I am a employer with 20 employees(full and/or part-time).* 7. ❑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.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 1 1.[]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. 13.0Roof 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. 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: 19 Independence 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 th pains and penalties of perjury that the information provided above is true and correct Signature: Date: 10/8/19 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#: . P__/,‘,e (69 o./ //,,c-t-doctoitte/Jeih, Office of Consumer Affairs and Business Regulation One Ashburton Place-Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation CAPE SAVE INC. Registration: 171380 7-D HUNTINGTON AVENUE Expiration: 03/13/2020 SOUTH YARMOUTH,MA 02664 Update Address and Return Card. SCA 1 42/ zonws/n (''iAe*eminenuwif:4 e/ fiakitwAte.1414 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 Expiration Office of Consumer Affairs and Business Regulation 171380 03/13/2020 One Ashburton Place-Suite 1301 CAPE SAVE INC. Boston,MA 02108 WILLIAM MCCLUSKEY �R C� \ / 7-D HUNTINGTON AVENUE Not valid w �`•t _ gnature SOUTH YARMOUTH,MA 02664 Undersecretary , Commonwealth of Massachusetts Construction Supervisor Specialty Division of Professional Licensure ;` ' Restricted to: Board of Building Regulations and Standards CSSL-IC-Insulation Contractor Constructip634141Vispr Specialty CSSL-102776 spires:06/28/2021 WILLIAM J MCCLU i& 37 NAUSET ROAD WESTYARMOJITH 3 i t 4)fd1 {01 Failure to possess a current edition of the Massachusetts Commissioner State Building Code is cause for revocation of this license. DPS Licensing information visit:WWW.MASS,GOVIDPS DocuSign Envelope ID:C58E8597-068C-44C6-9002-14978E156A96 RISE ENGINEERING' OWNER AUTHORIZATION FORM I, Matthew Hughes (Owner's Name) owner of the property located at: 19 Independence Road (Property Address) West Yarmouth, MA 02673 (Property Address) hereby authorize Cape Save Inc. (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. ,--oocusronea� ll.iI l '-Ot 4siei nature 9/23/2019 I 8:17 AM EDT Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com