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HomeMy WebLinkAboutBld-20-3710 og'YAR Office Use Only �� Permit# .a4["* C 2 c- 0 414 Amount JJ ". ,.,, ey. cam Permit expires 180 days from issue date l.D-20 3-7 i 0, EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 55 Sullivan Road ASSESSOR'S INFORMATION: Map: 47 Parcel:51 OWNER: Chris Meimaris same 508-944-8660 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) ❑ I am the homeowner D 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: 12/26/19 Owners Signature(or attachmen attached Date: Approved By: „„� gnee) / Date: -2� Build' i ' or de d� E ADDRESS: Zoning District: Historical District: 13 Yes 7 No Flood Plain Zone: 7 Yes 11 No Water Resource Protection District: Within 100 ft.of Wetlands: Yes Li No [' Yes rl No _ The Commonwealth of Massachusetts ,` Department of Industrial Accidents 1 Congress Street,Suite 100 °�,'•�=_ 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 IrIC 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): i.❑✓ I am a employer with 20 employees(full and/or part-time).* 7. El New construction 2. I am a sole proprietor or partnership and have no employees working for me in ❑ 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]* 9. Demolition 10❑Building addition 4.0i 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.❑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: 10/16/2020 Job Site Address: 55 Sullivan 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: 12/26/19 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#: _�_.....1 CAPESAV-01 HWOOD_ ACOREr CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIVYYY) �� 10/2/2019 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((es)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 CtltACT RogersGray,Inc. PHONE 434 Rte 134 (Alc,No,Ed):(800)553-1801 I jam,No):(877)816-2156 South Dennis,MA 02660 mass,ss:mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC S INSURER A:Employers Mutual Casualty Company 21415 INSURED INSURER B: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 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 ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LTR INSO WVO (MM/DD/YYYY) IMM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 5D7785220 10/16/2019 10/16/2020 pREM13ES EaEox ExrDence) $ 500,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY X yE LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER EBL AGGREGATE $ 2,000,000 A AUTOMOBILE UABIUTY (Ea BI(JED_SINGLE LIMIT $ 1,000,000 X ANY AUTO 6Z7785220 10/16/2019 10/16/2020 BODILY INJURYent (Per person) $ OWNED - SCHEDULED _ AURTEO�S ONLY _ AUTOS BODILY BODILY INJURY(Per accident) $ _ AUTOS ONLY AIMS (Per PERDAMAGE $ $ A X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS LAB CLAIMS-MADE 6J7785220 10/16/2019 10/16/2020 AGGREGATE $ 2,000,000 DEO X RETENTION$ 10,000 $ B WORKERS ND EMPLOY RPS'UAABILITNY Y/NX STATUTE ER ANY PRROPMRIIETBORR/PARTNER/EXECUTIVE 5H7785220 10/16/2019 10/16/2020 EL EACH ACCIDENT $ 500,000 antory inMNH)EXCLUDED? N N/A 500,000 E.L DISEASE-EA EMPLOYEE $ l(yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 261 White's Path,Unit 4 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE 17/44 ACORD 26(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD fOzriV,12042WeCtia 0-igATZo-Cidttoa41, 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 Expirati 7-D HUNTINGTON AVENUES 03J13/2020 SOUTH YARMOUTH,MA 02664 Update Address and Return Card. SCA 1 Ce 20M--005/11�77 / ,f r^;ll[v °mo/t,wea/ (/'F c,4,vJefd 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 MCCLOSKEY f�?.C.CQ 7-D HUNTINGTON AVENUE SOUTH YARMOUTH,MA 02664 Not valid w -lgnature Undersecretary Commonwealth of Massachusetts Li Construction Supervisor Specialty Division of Professional censure Restricted to: Board of Building Regulations and Standards CSSL-IC-Insulation Contractor Gonstructiit3?}1r Specialty CSSL-102776 < spires:06/28/2021 WILLIAM J MCCLUSt 37 NAUSET ROAD .. Y WEST YARMOUTH MAt ' 3 .- °i15ti 11/4.�� 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.GOV/DPS Permit Authorization f SS Vie` Form Sorrow through*homy erhobericg Site ID: 3808470 Customer: Chris Meimaris Chris Meimaris I, ,owner of the property located at: (Owner's Name,printed) 55 Sullivan Road West Yarmouth, MA 02673 (Property Street Address) (CRY) 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. Docusigned by: Owner's Signature: CaViS M.t,iltut iS 67483190E0AB48D... 12/9/2019 1 4:37 PM EST Date: 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