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HomeMy WebLinkAboutBld-20-0980 Office Use Only O1"Y4R, k 4 O Permit 0 4 y Amount35 J "", ,; c� Permit expires 180 days from . , . W 20 O 0 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: 86 Phyllis Drive ASSESSOR'S INFORMATION: Map: 78 Parcel:27 owNER: Deborah Bearse same 508-398-8305 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$ 5000 Home Improvement Contractor Lic.# 171380 Construction Supervisor Lic.# IC 102776 Workman's Compensation Insurance: (check one) 0 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.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 ation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: 8/20/19 Owners Signature(or attachmen attached Date: Approved By: 4/Z-.27 ___ Date: 6 /7 Builder designee) E ADDRESS: Zoning District: R Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: , l tr 0 Yes 0 No ❑ Yes ❑ No ll t ` J' ��....40 CAPESAV-01 HWOODS ACORU® ( D/YYYY) fir......----- CERTIFICATE OF LIABILITY INSURANCE 0 DATE(MMIDMMID018 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(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 ,coif/ACT Rogers&Gray Insurance Agency,Inc. PHONE FAX 877 816-2156 ge 434 Rte 134 WC,No,Ext): (Ac No( ) South Dennis,MA 02660 i s_mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC Si INSURER A:Employers Mutual Casualty Company_ 21415 INSURED INSURER a:Union Insurance_Company of Providence _ 121423 - Cape Save,Inc INSURER C-,---_-_— 7 D Huntington Ave INSURER D: South Yarmouth,MA 02664 — INSURER E;--_.._ ----- ---...---- I INSURER F: I 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. A X COMMERCIAL GENERAL LWBILITY INS wvD — - LTR TYPE OF INSURANCE IMNVD ,yyyv,IIMMIDD/YYYY1 LIMITS hNSR ADDLSUBR POUCY Y NUMBER EACH OCCURRENCE_ $ 1,000,000 0 CLAIMS-MADE iL X J OCCUR 15D77852 10/16/2018 10/16/2019 DAMAGE TO RENTED 500,000 PREMISES(Ea occurrence) $ 10,000 MED EXP Ly onepersgn) a 1,000,000 PERSONAL&ADV INJURY $ GM_ S AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2'000'000 POLICY r X l d LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER EBL AGGREGATE $ 2,000,000 (Ea MBINEnDI SINGLE LIMIT $ 1,000,000 A 1 AUTOMOBILE LIABILITY X ANY AUTO ,5Z77852 10/16/20181 10/16/2019 BODILY INJURY(Per person) $ OWNED ' SCHEDULED AUTOS ONLY 'AUTOS I BODILY INJURY(Per accident) $ III ASTD ON p i OPERB�IAMAGE UTOS ONLY AUUTT N YY '', { ) -.-._.. $ I $ OCCUR EACH OCCURRENCE 2'000'000 A X ' EXCESS LI1B X CLAIMS-MADE I5J77852 10/16/2018 10/16/2019 AGGREGATE $ 2,000,000 I DED I X RETENTION$ 10,000 $ STATUTE ERH- ,AND EMPLOYERS'LBABILJTY 10/16/2019 X 500,000 B I ANYOPE gE�COMPENSATION DEXECUTIVE rN l N I A j 5HT7652 10/16/2018 E L EACH ACCIDENT._ _ $_- -------_ Aar ddaato►y i NH) I E.L.DISEASE-EA EMPLOYEE$ 500'000 E describe under 500,000 DESCRIPTION OF OPERATIONS below t I E.L.DISEASE-POLICY LIMIT $ I I I I 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 POUCIES BE CANCELLED BEFORE Ca LightCompact Joint Powers EntityTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Pe P ACCORDANCE WITH THE POUCY PROVISIONS. 261 White's Path,Unit 4 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE I 41 ::•)r.''...d040,414? 70/€/14641...---------- 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 'e1el= p 1 Congress Street,Suite 100 1, l- 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 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.] 9. El Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.] 10[J Building addition 4.❑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 50 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.❑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 employee& Below is the policy and job site information. Insurance Company Name: Employers Mutual Casualty Comjany Policy#or Self-ins.Lie.#: 5D77852 Expiration Date: 10/16/2019 Job Site Address: 86 Phyllis 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. I do hereby certify under t pains and penalties of perjury that the information provided above is true and correct Signature: Date: 8/20/19 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#: 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 0 20M-05/17 // s/ ._._ JHe'orltm491'rnw iA( n.f a4Jaehael it 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: lkairatalkan Exalualan Office of Consumer Affairs and Business Regulation 171380"' 03/13/2020 One Ashburton Place-Suite 1301 CAPE SAVE INC. Boston,MA 02108 WILLIAM MCCLUSKEY U�1,.C�',�---- `' 7-D HUNTINGTON AVENUE SOUTH YARMOUTH,MA 02664 Undersecretary Not valid .i Ignature Commonwealth of Massachusetts Construction Supervisor Specialty Division of Professional Licensure / Board of Building Regulations and Standards CSSL-IC Restricted tn: Insulation- Contractor Constructipn.S /ispr Specialty CSSL-102776 1 st�pires:06/28/2021 WILLIAM,.1 MGCLU ,,,. ,r_ 37 NAUSET READ WEST YARMOJ.JTH O 3 -y sf �()I44''1,1�}\`� Failure to possess a current edition of the Massachusetts Commissioner itY.A.c)yr State Building Code is cause for revocation of this license. DPS Licensing information visit:WWW.MASS.GOV/DPS . ,A. R) Jrfl17 ED { 0 *Ida '�1 460 West Main Street % Housing JUN 1 9 2019 Hyannis,MA 02601-3698 Assistance Tel:(508)771-5400 Fax(508)790-2425 Corporation HOUSING ASSISTANCE TTY on all lines Cape Cod CORPORATION Free Weatherization ! Your tenant has requested and is eligible for weatherization of your rental home through the Weatherization program at Housing Assistance Corporation. An average weatherization job is worth $4,500 and these services are provided at no cost to you. The following weatherization measures are applied to the typical job:. air sealing in the attic and basement, insulation in the attic, basement and walls, weather-stripping doors. Bath fans may be installed if necessary. We will test the efficiency of the refrigerator. All work is professionally done by licensed and experienced contractors. HAC will conduct a final inspection to make sure that all work is completed in compliance with quality work standards. Prior to the work being done you will receive a letter from HAC showing the actual measures that will be installed and thetotal dollar value to the work. To confirm your ownership of the property, we will pull the appropriate town assessor's report. if necessary, we may ask for a copy of your tax bill or deed to prove ownership. The work on your rental property will begin when we receive the signed copy of the attached Agreement. If we do not receive the Agreement, HAC will conduct an energy audit but no weatherization work can be done without the signed Agreement. During the energy audit we will install energy efficient light bulbs and will test the efficiency of the refrigerator. If you have any questions please contact Suzanne Smith at 508-771-5400, ext. 123 or ssmith@haconcapecod.org LANDLORD: � h Pit: 2S£. TENANT: 1 .3'a F:e...i(s Si (Litt_ )e(� email: a snR$£ C0 1C,!}54-• pia email: (12311 Ahov•cOM PHONE: (home) 50 i-3 4 - 2 3 U 5 PHONE: (home) (\J i (cell) 50 q to r 1 (cellj u' _ ri ice+ 3 i Tenant under WAP program requirements. The Agency may terminate this Agreement, by providing wt, notice to the Property Owner and Tenant, if the Agency determines that the unavailability of funds or ineligibility. the Tenant warrants termination. 14. The Parties acknowledge that this Agreement is under seal. It is intended by the Parties that the Tenant or any successor Tenant is the intended beneficiary of the Agreement and shall have a right of enforcement. Property Owner's Signature: pAirkti„ r .al."-- Date 6 f o?J/9 Phone: 5f '- IIt . 04 7 Address: Et Gja4-l'l L,4 . y41-11t o1A, AI4 D Ja73 Tenant Signature i!� EQa Date (o 1 z. ► ClitAgency Approved Weatherization Company Advanced Windows Inc / All Cape Energy / Alternative Weathenzation Cape Cod Insulation / - / Cazeault / M.T. McMahon&Son Inc. Frontier Energy Solutions I Lohr Home Improvement / MDH Construction, Inc Agency Signature /I Date '( 1.6i( Af�� 10/2/19Cape Save Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 508-398-0399 10/2/19 Town of Yarmouth Regulatory Services Building Division i, , ., 1146 Route 28 � r '' ''��g South Yarmouth,MA 02664 RE: Building Permit#BLD-20-000980 TO: Building Inspector(s), This affidavit is to certify that all work completed for 86 Phyllis Drive has been inspected by a third party Certified Building Performance Institute(BPI)Inspector. Ceiling:Added R-49 cellulose Heating ducts: Installed R-8 duct wrap All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey