BLD-23-005730 BLD-23-005730 - 18 ARROWHEAD DRIVE YPORT
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File Date: 04/13/2023
Application Status:
Description of Work: RETROFIT
Application Detail: Detail
Application Type: Residential Express Permit
Address: t$:' G#1 Y
Owner Name: SAMUEL&LILY HAMMOND
Owner Address: 18 ARROWHEAD DR,YARMOUTH PORT,MA 02675-2401
Application Name: 18 ARROWHEAD DRIVE YPORT
Parcel No: 115.110
Contact Info: Name Organization Name Contact Type Relationship Address Contact Primary
WILLIAM J MCCLUSKEY WILLIAM J MCCLU... Applicant 7-D HUNTINGTON...
Licensed Professionals Info: Primary License Number License Type Name Business Name Business License#
Yes 171380 Home Improvomen... WILLIAM J MCCLU., CAPE SAVE INC
Job Value: 51,476,00
Total Fee Assessed: $35.00
Total Fee Invoiced: $35.00
Balance: 60.00
Custom Fields: ADDITIONAL INFORMATION
Total Job Cost Type
3476
USE GROUP AND CONSTRUCTION TYP
Construction Type Use Classification
WORKERS COMPENSATION INSURANCE
Workers Compensation Insurance Insurance Company Name Workers Comp
I have Workers Comp Insurance EMPLOYERS MUTUAL CASUALTY COMPANY 5D77852
TENT
Tent
No
WOODSTOVE
Wood Stove
No
CHIMNEY REPAIR
Chimney Repair Detailed description of work
No
SHED
Shed
No
*12,3,
SIDING
Re-Side
No
WINDOWS AND DOORS
Replace Windows and/or Doors
No
FENCE
Fence
Fence for Pool Enclosure Fence over 6 F[
No
Linear Feet Fence Height
ROOF
Re-Roof
No
INSULATION
Installing Insulation
Yes
SOLAR SYSTEM INFORMATION
Solar Service ID
Meter ID
•
Type of Use Job Cost Total Inverter P+
Number of PV Modules Number of Inverters Total Roof Area
Roof Coverage Type of Roof Roof Material
Roof Layers
DEMO
Demolition Detailed description of work
No
OTHER
Other Detailed description of work
GENERAL DETAILS
Construction Debris will be taken to(Name of Disposal Facility) Electrical Drop within Area of Work?
YARMOUTH TOWN DUMP No
Gas Meter or Regulator within Area of Work?
No
ZONING INFORMATION
Zoning District Historic District Historic District
Historic Building Endangered Species
Zone Description Supplier
Wetland Description Total Land Area
INSPECTION RESULTS
Inspection ID Inspection Type Inspection Result Inspection Date Result Comment Inspector Record ID Record Type
Workflow Status: Task Assigned To Status Status Date Action By
Application Acceptance. ....... Linda Cipro
Initial Review Linda Cipro
Building Review Tim Sears
Issuance Linda Cipro
Inspection Tim Sears
Close Out Linda Cipro
Condition Status: Name Short Comments Status Apply Date Severity Action By
Application Comments: View ID Comment Date
Initiated by Product: ACA
Scheduled/Pending Inspections: Inspection Type Scheduled Date Inspector Status Comments
Resulted Inspections: Inspection Type Inspection Date Inspector Status Comments
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
=Er
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):
1.0 t 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. Ei 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 Building addition
4.0 lam 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 I 1.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.E3 I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
I 1E:Roof repairs
These sub-contractors have employees and have workers comp.insurance.;
14.00tber Insulation
6.0 We are a corporation and its officers have exercised their right of exemption per MG1_c.
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.
/am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Employers Mutual Casualty Company
Insurance Company Name:
Policy if or Self-ins. Lie.#: 5D77852 Expiration Date:10/16/2023
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under N46Le?f51,'§25A is a criminal violation punishable by a tine up to S1,500.00
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 certift under th pains and penalties of perjury that the information provided above is true and correct.
Signature: \ / Date: 3/28/2023
Phone#:598-398-0398
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):
I.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Ac o® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDrtYYY)
�- 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 PH
PHONE
63 Smith Lane (A/C.No.Ext1:508-746-3311 FAX
,No):877-816-2156
Kingston MA 02364 E-MAIL
ADDRESS: mail@rogersgray.com
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A:Employers Mutual Casualty Co 21415
INSURED CAPESAV-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 ADDL SUBR
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDY/YYYYY) (MM/DD/YYY XYY) 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:
POLICY X PRO- GENERAL AGGREGATE $2,000,000
JECT 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
X ANY AUTO (Ea accident)
BODILY INJURY(Per person) $
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY(Per accident) $
X HIRED WNE
AUTOS ONLY X AUTOS ON-O ONLDD PROPERTY DAMAGE
(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$1 n,nn $
B WORKERS COMPENSATION Y 5H77852 10/16/2022 10/16/2023 X MUTE EMPLOYERS'LIABILITY Y/N STATUTE ER
ANYPROPRI ETOR/PARTNER/EXECUTI VE
OFFICER/MEMBEREXCLUDED? N N/A E.L.EACH ACCIDENT $500,000
(Mandatory in NH)
If yes,describe under E.L.DISEASE-EA EMPLOYEE $500,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000
C Pollution Y Y PPK2527254 3/10/2023 3/10/2024 Per Incident 1,000,000
Aggregate 1,000,000
Deductible 5,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
When Required by Written Contract the following Applies:
General Liability—Additional Insured Ongoing(CG 71743 10/13),Additional Insured Completed(CG 71743 10/13)Primary and Non-Contributory Basis(CG
7578 02/19),Waiver of Subrogation(CG 7578 02/19)
Automobile—Additional Insured(CA 7450 11/17),Waiver of Subrogation(CA 7450 11/17)
Excess/Umbrella
Additional Insured follows form over underlying General Liability and Automobile Liability,Waiver of Subrogation(CU7460 12/15)
Pollution-Additional Insured,Primary and Non-Contributory Basis&Waiver of Subrogation(PIC-EVCP-001 7/22)
Workers Compensation-Waiver of Subrogation(WC 00 03/13 04/84)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Evidence of Insurance
AU D REPRESENTATIVE
jormiwi 7
ACORD 25(2016/03) The ACORD name and logo are registered ma s8of ACORD
CORPORATION. All rights reserved.
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs and Business Regulation
1000 Washingtonreet-Suite 710
Boston Massachusetts 02118
Home Improvement Contractor Registration
• _ ,Type: Corporation
CAPE SAVE INC. Registration: 171380
7-D HUNTINGTON AVENUE • EriFation: 03H312024
SOUTH YARMOUTH,MA 02664 � • '
Update Address and Return Card.
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs,&Business Regulation Registration valid for individual use only before the
HOME IMPROVEM CONTRACTOR expiration date. If found return to:
TYPE:e'oFporation Office of Consume►Affairs and Business Regulation
Recarattig a": Exphati°^ 1000 Washington Street•Suite 710
111$B0 ",93t1312024 Boston,MA 02118
CAPE SAVE INC.
WILLIAM MCCLUSKEY':'
7-D HUNTINGTON AVENUE`"��: "�
SOUTH YARMOUTH,MA 02864
Undersecretary Not valid with ' i ure
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Commissioner,
Permit Authorization
mass .ve Form
Site ID: 4790135 Customer: Sam Hammond
I, Sam Hammond ,owner of the property located at:
(Owner's Name,printed)
18 Arrowhead Dr Yarmouth, MA 02675
(Property Street Address) (City)
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.
Owner's Signature: C d
Date: 2023-03-31
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Participating Contractor Date
Name: RISE Engineering
Phone: 508-568-1926
Email:
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Document Ref NXYP3 97L3K SCSID-2MKPJ i r r Office Use Only
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Sam Hammond
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Email:shammond151@gmail.com
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IP address:96.81.76.137 ' • , '
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rEmail verified 31 Mar 2023 08:22:17 UTC Location:Hyannis,United States , 1
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MASTER DISCLOSURE &
RISE
PREPARATIONS
ENGINEERING' REQUIREMENTS
RISE Engineering
765 Attucks Lane,
Hyannis,MA,02601 Customer Name:Sam Hammond
Email:Shamrnond151@gmail.corn
Phone:774-722-3861
Premise Address:18 Arrowhead Dr,Yarmouth,MA 02675
Project ID:4790135
At your Home Energy Assessment your Energy Specialist has reviewed and identified applicable cost-effective opportunities,potential
health and safety concerns as well as any customer required actions to facilitate improvements in your home.
The following conditions were noted at the time of the Home Energy Assessment:
CUSTOMER PREPARATION REQUIREMENTS
E Storage Removal ❑Flooring Removal ❑CO Detector Other
❑ El Platform Buildup
Customers are responsible to complete any noted required actions in order to be eligible for program weatherization
work at their home.The participating Contractor will be confirming the completion of these required actions prior to
scheduling an installation date.
Hosneowneris rostionsilfilio71,tfteremovalof n items,steeredr�r 4 a edzatio=measure Il
workork trs%will need the „ " e e The
,ce/wil r ~ :e feared Safely l rtni their t to aril aiatert s rninAh t irl: �tf a trr ve ty -;
specific urns,pleease'bri them tt theattention attat-16,40,your subcontractor"when t
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Initial here
This notice does not constitute an endorsement or warranty regarding the presence or absence of other real or potential health and
safety hazards that may exist at this address or premises. If you have questions regarding this information,or to schedule a follow-up
inspection after the noted conditions have been corrected, please call our Customer Service at 508-568-1926.
Customer Signature:
Satu ifacutuotcd Date:
03-31-2023
Energy specialist: Robert Brancato
Phone:508-568-1926 Email:
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Document Ref NXYP3-9713K.5GSID-ZMKPJ
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