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HomeMy WebLinkAboutBLD-23-005501 vvw►lt¢ #117 ,6t0-Z 3 - 00 5 . r YE Office Use Only A.: gR 1u� �dv �' °Permidl o . :a" APR 0 4 2023 Amount 3s- ,r5.3.... is U I L D I Iv G DEPARTMENT issuePermit expires x Tres 180 days from date By. CMG— 10(45 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: (+a1 Camp c c\. u(11i ‘Oa 1 . I P(>ax ASSESSOR'S INFORMATION: Map: e1 Parcel: ��p �,�L �p -ten �t�p� OWNER: �QCO\NAMEUk,1((W\ Ian T u.i'PRESENT y DD�S (�fYllxl� IIM 0303 (.�t,p) D- nekt TEL. # CONTRACTOR:(doe Sme, Inc, 1O rAIR�'i(Y 1 N�SQ.&\Iacmo�1k-h e MP} Cat:614 (5 ) 8-actp) NAME N4AILING ADDRESS TEL.# 'residential ❑Commercial Est.Cost of Construction$ 7C0 Home Improvement Contractor Lic.# 1113W Construction Supervisor Lic.# CSSL- Ioa-T16 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor WI have Worker's Compensation Insurance Insurance Company Name:tcyy Viers Muk1r1 i (w UO 3 CO Worker's Comp.Policy# 51\T7e Sa WORK TO BE PERFORMED Tent .0 Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (0)Remove existing*(max.2 layers) Insulation gl I l Old Kings Highway/Historic Dist. ®Replacing like for like Pool fencing I I *The debris will be disposed of at:LQ(I1 -4\ I,6(1C) c\1 l 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. Applicant's Signature:l'iW�"A Date: 31-so) O Va3 Owners Signature(or ttachme it./ Date:Approved By: Date: T T)3 Building Official esi EMAIL ADD S . 1eu. I�ax s( CA�Q 1e :Cectrl Zoning District: F� Historical District: `, Yes l No Flood Plain Zone: _ Yes 1. No Water Resource Protection District: Within 100 ft.of Wetlands: Yes _J No S Yes ill 1 CAPE . SAVE 7-D Huntington Ave South Yarmouth,MA 02664 Office:(508)398-0398-Email:info®capesave.com Building Permit Authorization L C Y -"bS yt4111-/UJ i, l , as owner hereby give permission to Cape Save, Inc. 7-D Huntington Ave South Yarmouth, MA 02664 To take all necessary steps to obtain a building permit to perform work at my property located at: Address: k 2 k CaVVn c 1 r , V n k \j s c `;o.rn".o 0 L1 NM. i,2 13 Signed: _ a$ -423 Date: ' br THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston, Massachusetts 02118 Home Impro emer_it,q?ntractor_He9istration j1+F la+f L L 1 : Type: Corporation CAPE SAVE INC. m egistration: 171380 7-DHUNTINGTONAVENUE wi _� Ezpiration: 03/13/2024 .� T7 Jµ SOUTH YARMOUTH,MA 02664 .=::." .U j e('''�, 9 "� . Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs 8 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-D HUNTINGTON AVENUE ... ..ra.7 SOUTH YARMOUTH,MA 02664 Undersecretary Not valid with I ature • Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructi,c i 414kitspr Specialty CSSL-102776 iliccpires: 06/2812023 WILLIAM J CL1 37 NAUSET O A : WEST YARM i Commissioner dl • K. F: ( t The Commonwealth of Massachusetts ti4 1, Department of Industrial Accidents 1 Congress Street, Suite 100 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 Leibly Name (Business/Organization/Individual): cape 5(-1\)Q Address: If) 40n-�i(3 P City/State/Zip: s,yQc t`n0(Akvn, p \ ( (,L( Phone#: (sob)346—03C:t8 Are you an employer?Check the appropriate box: Type of project(required): MI am a employer with aC) employees(full and/or part-time).* 7. New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 401 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.QElectrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.DI am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1 3.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other( (��1l�(i .1 10n 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 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. tContractors 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: ,,e6ekhUSCS ,1JCAA Policy#or Self-ins.Lic.#: S'()-7 7 3S a J Expiration Date: t /IbI 0oZ3 Job Site Address:( \ CNN) S*. va\ City/State/Zip:W. fri(MCL ch, NA ()a673 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 the pains and penalties of perjury that the information provided above is true and correct. Signature: (;1,,).Ai j(0 p Date: 63)3c�/E0D3 Phone#: (SCO g- O3c1 B 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): I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 3/27/2023 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 (A/C.No.Est):508-746-3311 tac,No):877-816-2156 Kingston MA 02364 ADDRESS: mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC 8 _ INSURER A:Employers Mutual Casualty Co 21415 INSURED 7.APESAV-01 INSURER a:Union Insurance Company of Pro 21423 Cape Save, Inc INSURER C:Tokio Marine Specialty Insuran I 23850 7 D Huntington Ave p 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 ADDLISUBR POLICY EFF POLICY EXP LTR INSO WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY 5D77852 10/16/2022 10/16/2023 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED 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 X]jE a LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY Y Y 5Z77852 10/16/2022 10/16/2023 COa axidMBINEDent)SINGLE LIMIT $1,000,000 (E X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS 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 LIAB CLAIMS-MADE AGGREGATE $2,000,000 , DED X , RETENTION$1nf10o $ B WORKERS AND EMPLOYCOMPENSATION Y/N Y 5H77852 10/16/2022 10/16/2023 X STATUTE OTH- ER ANYPROPRIETOR/PARTNER/EXECUTIVE N NIA E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED?(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 I 3/10/2024 Per Incident 1,000,000 Aggregate 1,000,000 5,000 DESCRIPTION OF OPERATIONS/LOCATIONS I 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),Additional 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. Evidence of Insurance AUT ED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD