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HomeMy WebLinkAboutBld-20-2746 Y Office Use Only o Ak k s ,1r �O Permit# 0 -\Y- ►.I. Amounts Te ._I � 4' -_Permit expires 180 days from I1. 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: 142 Long Pond Drive ASSESSOR'S INFORMATION: Map: 50 Parcel:65 OWNER: Adam Miller same 774-214-0856 NAME PRESENT ADDRESS 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 S 5000 Home Improvement Contractor Lic.# 171380 Construction Supervisor Lic.# IC 102776 Workman's Compensation Insurance: (check one) I am the homeowner C I am the sole proprietor I 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 Iayers) 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 ation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: 1 l/8/19 Owners Signature(or attachmen attached Date: ` Approved By: `a, (2 Date: //�/Z -i Building Official(o i EMAIL ADD S: Zoning District: Vi ' ' Historical District: C Yes '.1 No Flood Plain Zone: a Yes C No . F Water Resource Protection District: Within 100 ft.of Wetlands: { Yes C! No ❑ Yes 0 No `j The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 1E:'{=_ Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lesibly 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): 1.0 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;0 I am a homeowner doing all work myself.[No workers'comp.insurance 1 9. El Demolition required. t 10❑Building addition 4.17:1 I 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.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors 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.DOther 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: 10/16/2020 Job Site Address: 142 Long Pond Drive City/State/Zip:Bass River 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 pedury that the information provided above is true and correct. Signature: Date: 11/8/19 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#: CAPESAV-01 HWOODS A�RD CERTIFICATE OF LIABILITY INSURANCE DATE MM20D19 I 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 CONTACT RogersGra ,Inc. PHONE 434 Rte 13 (NC,No,Ext):(800)553-1801 I rn c,Noi:(877)816-2156 South Dennis,MA 02660 1'I06s:mail@rogersgray.com INSURERS)AFFORDING COVERAGE NAIC# INSURER A:Employers Mutual Casualty Company 21415 INSURED INSURER a:Union Insurance Company of Providence 21423 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 WTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MISR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INS° INVD flaWDONYYY1 (MM/DDNYYYI A X COMMERCIAL GENERAL UABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 5D7785220 10/16/2019 10/16/2020 PREM SES Ea Ece EDnt:e1 $ 500,000 MED EXP(Any one pereon) $ 10,000 PERSONAL 8 ADV INJURY $ 1,000,000 GENL AGGREGATE UMIT�APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JEpBCT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: EBL AGGREGATE a 2,000,000 A AUTOMOBILE LUIBILITY ( c t)MINGLE LIMIT $ 1,000,000 X ANY AUTO 5Z7785220 10H 6/2019 10/16/2020 BODILY INJURY(Per person) $ VANED SCHEDULED AAURT�O�S ONLY (A�UUT�OSy p PBOODILY INJURY� p (Per accident) $ — AUTOS ONLY ^ AUTOS ONLY (Per accident) E $ , $ A X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS LIAB ^ CLAIMS-MADE 6J7785220 10/16/2019 10/16/2020 AGGREGATE $ 2,000,000 DED X RETENTION$ 10,000 $ B AN EEMPLOYOERS COMPENSATION Y/N X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE 5H7765220 10/16/2019 10/16/2020 E.L.EACH ACCIDENT $ 500,000 OFFICE( Et t EXCLUDED? N N/A 500,000 II�IMM ddaatt MM tN1I111)) E.L.DISEASE-EA EMPLOYEE $ If yes describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ SOO,000 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 CapeLight Com act Joint Powers EntityTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P ACCORDANCE WITH THE POLICY PROVISIONS. 261 White's Path,Unit 4 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE 4: 1,--- I — ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CDi fowvirtowevecila 0/PA • 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: 031i3/2020 SOUTH YARMOUTH,MA 02664 seA i 0 20M-05/17 Update Address and Return Card. Comma„evealtA(/^Iix,acA, Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Carooration 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 7-D HUNTINGTON AVENUE SOUTH YARMOUTH,MA 02664 Undersecretary Not valid = gnature Commonwealth of Massachusetts Construction Supervisor Specialty f Division of Professional Licensure Board of Building Regulations and Standards Restrictedto: CSSL-IC-Insulation Contractor ConstructilooSI /iegr Specialty CSSL-102776 ires:06/28/2021 WILLIAM J MCCLU Y 37 NAUSET ROAD WEST YARMOUTH Moe -s - 'f Failure to possess a current edition of the Massachusetts Commissioner n ..4 x/• ^ "" State Building Code is cause for revocation of this license. DPS Licensing information visit:WWW.MASS.GOVIDPS DocuSign Envelope ID:3E94363D-E531-43ED-AF4C-664F6DF19286 RISE ENGINEERING` OWNER AUTHORIZATION FORM 1, ADAM MILLER (Owner's Name) owner of the property located at: 142 Long Pond Drive (Property Address) Bass River, MA 02664 (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. �-DocuSigned by: atLNR 'MAX �7►�&Ngrature 10/21/2019 I 12:11 PM EDT Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com