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HomeMy WebLinkAboutBLD-23-005503 lot i I-e (41,-I`vi Y RECEIVED ice Use Only I . . .-in: H [ APR 0 4 2023 Amount 3S oe �"""'"�c�a' ------— Permit expires 180 days from BUILDING DEPARTMENT issue date By --- CC —ly.S EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: I6LI I(Oc-bUQ 1 S 6oule11 a f c i Lu. laC("AMA-VIM ASSESSOR'S INFORMATION: Map: Parcel: OWNER: MOn 1 CQ Gee() Ion I(Ouot S 64u• W.`lac oc I-V" MA O361 S en")a5S-9361 NAME <,, PRESENT ADDRESS c TEL..�# CONTRACTOR: C a .XJt J 1 nC. Z O NU(1 111Q fl • J y a[_(K1QLl�c Ivt� Oo l > 6-3 ge NAM MAILING RESS TEL.# yiResidential CI Commercial Est.Cost of Construction$ LI t 300 f Home Improvement Contractor Lic.# I1\3Q Construction Supervisor Lic.# CSSL ' Ida-1-7 Workman's Compensation Insurance: (check one) 0 I am the homeowner O I am the sole proprietor gi I have Worker's Compensation Insurance Insurance Company Name: Emoot6ers ANAA-Jt L, CJS Jpa'4(,1JJ worker's Comp.Policy# S N 11 BS o2 WORK TO BE PERFORMED Tent .D Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation V v l L I Old Kings Highway/Historic Dist. d Replacing like for like Pool fencing I I *The debris will be disposed of at: yQemou-\--h LCi -V►1 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 or revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. �^ ^n n Applicant's Signature: (/1QQ � Date: OS/ 1'pc(�p(3 Owners Signature(o chment Date: Approved By: Date: e������Building Officia or'dd,v72 EMAIL ADa. hra.�QU1. Zoning District: Historical District: Yes -i, No Flood Plain Zone: _ Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes .._1 No ❑ Yes L No Permit Authorization mass save Form Simms through anbrey• Y Site ID: 4298474 Customer: Monica Green CL Cron , owner of the property located at: (Owner's Name,printed)) 104 Iroquois Boulevard West Yarmouth, MA 02673 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obta a building permit to perform in ion and/or weatherization work on my property. Owner's Signature: Date: S-113. a3 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: C,LP.e Sav P OS/ za3 Participating Contractor Date Name: RISE Engineering Phone: 508-568-1926 Email: Page 1 of 1 For Office Use Orly Rev. 1n2n1c THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston, Massachusetts 02118 Home Imp!? en eat,C• tractor Registration '� ----= Type: Corporation CAPE SAVE INC. egistration: 171380 7-D HUNTINGTON AVENUE `"' f Pi tion: 03/13/2024 SOUTH YARMOUTH,MA 02664 .: NV t Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Corporation Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 171380 03/13/2024 Boston,MA 02118 CAPE SAVE INC. WILLIAM MCCLUSKEY 7 �� 7-D HUNTINGTON AVENUE SOUTH YARMOUTH,MA 02664 Undersecretary Not valid with u I ature Commonwealth at Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructioati►` 't Al Specialty /i CSSL-102776 • spires 06/28/2023 WILLIAM J I CLU 37 NAUSET R9AD WEST YARMO ,JTH MA 02673 1-10 Commissioner s � • I'. mLink- The Commonwealth of Massachusetts ► =cam!/, Department of Industrial Accidents 1 Congress Street, Suite 100 �^ —1 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): I.❑✓ 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 any capacity.[No workers'comp.insurance required.] 8. Remodeling 3.1:3insurance am a homeowner doing all work myself.[No workers'comp. required.] t 9. ❑Demolition 10 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.Q Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.1:3 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. 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:10/16/2023 Job Site Address: 104 Iroquois Boulevard 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 undei-M@3UP.451;•§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: 3/30/2023 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 (MM/DDlYYYI� A`�RD® CERTIFICATE OF LIABILITY INSURANCE DATE E/27/2023(MWDD/Y 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 CONTACT RogersGray, Inc.-Kingston Branch PHONE FAX 63 Smith Lane (NC.No.EA):508-746-3311 (A/C,No):877-816-2156 Kingston MA 02364 ADD TRESS: mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# _ INSURER A:Employers Mutual Casualty Co _ 21415 INSURED 7)APESAV-01 INSURER B:Union Insurance Company of Pro 21423 Cape Save, Inc 7 D Huntington Ave INSURER C:Tokio Marine Specialty Insuran 23850 South Yarmouth MA 02664 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:729014574 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 EFF POLICY EXP LTR INSO WVD POLICY i4UMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY 5D77852 10/16/2022 I 10/16/2023 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $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 L X]jEca LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY Y Y 5Z77852 10/16/2022 10/16/2023 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) A X UMBRELLA LIAB X OCCUR Y Y 5J7785222 10/16/2022 10/16/2023 EACH OCCURRENCE $2,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $2,000,000 DED X RETENTION$1n non $ g WORKERS COMPENSATION Y 5H77852 10/16/2022 10/16/2023 X PER ETH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 C Pollution Y Y PPK2527254 3/10/2023 3/10/2024 Per Incident 1,000,000 Agg regate ate 1,000,000 5,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) When Required by Written Contract the following Applies: General Liability—Additional Insured Ongoing(CG 71743 10/13),Additicnal Insured Completed(CG 71743 10/13)Primary and Non-Contributory Basis(CG 7578 02/19),Waiver of Subrogation(CG 7578 02/19) Automobile—Additional Insured(CA 7450 11/17),Waiver of Subrogation(CA 7450 11/17) Excess/Umbrella Additional Insured follows form over underlying General Liability and Automobile Liability,Waiver of Subrogation(CU7460 12/15) Pollution-Additional Insured,Primary and Non-Contributory Basis&Waiver of Subrogation(PIC-EVCP-001 7/22) Workers Compensation-Waiver of Subrogation(WC 00 03/13 04/84) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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