HomeMy WebLinkAboutBLD-19-1125 ...of 'Of ice Use Only
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t i ',Permit expires 180 days from
issue date
EXPRESS BUILDING PERMIT APPLICAT_(' QOLV E D
TOWN OF YARMOUTH S�
Yarmouth Building Department
1146 Route 28 AUG 23 2018
South Yarmouth, MA 02664 DING DEPART vv
(508)398-2231 Ext. 1261e
CONSTRUCTION ADDRESS: 50 Wood 2.cad ✓
ASSESSOR'S INFORMATION:
(2_
t,,,, /� Map: 5IQ�� Parcel: IC.'
OWNER: Qob&i'* auin(1 `11(./ SU(�hldt\�a1'• Mart biro jrV1 >ba -34S-01ta%
NAME PRESENT ADDRESS TEL,it
CONTRACTOIZ /be re 1C wain' LI I Fe0. r be.d Ln V\1 .' arnn OLAktr1 5o% -13"�-` Loa 1
CLAS CrCL( Cd I tUYY1Qs LING ADDRESS TEL.# 7
// rom "`foo i'_1• ict P)a 3 Uni\ 3a 5o�-ltug-IL-1 a
I5ltesidential ❑Commercial Est.Cost of Construction$ ;g 001)CD
Rome Improvement Contractor Lic.# us °I S 5 a Construction Supervisor Lic.# C S -- IC-a 31 S
Workman's Compensation Insurance: (check one)
0 I am the homeowners 0 I am the sole proprietor Erihave Worker's Compensation Insurance
Insurance Company Name: a OCe .tS 2- Qi 1-TAy Worker's Comp.Policy# 1 P J O Qp-1 H 01 I SU 4 - a-1 l
U WORK TO BE PERFORMED
-
Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove fit,
Siding: #of Squares Replacement windows:# Replacement doors: # cry
Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation
Old Kings Highway/Historic Dist. (t )Replacing like for(like Pool fencing
/Hw t
*The debris will be disposed of ac toIR o \I
Mgr n
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)
win be just cause for denial or revocation of my licens , d for prosecution u Ch.268,Section I.
' Applicant's Signatur / a �,"L" Date: % La3 I I ca
Owners Signs 're or ttachm t) �' / (MR I1Q'
8 t /Pr - ,i. Date:
7i
Approved By: y. �� �ea Date: ii-
Building 0 rcial(. r EMAIL ADDRESS: /25 ./
r��
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
' 0 Yes 0 No 0 Yes 0 No
The Commonwealth of Massachusetts
ph==•= t Department of Industrial Accidents
Vi=
Office of Investigations
•
n 600 Washington Street
Boston,MA 02111 •
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers •
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):r(9 c•Nan 1 etAketk 14.-n is
Address:C1Cfl4-e. I ?�y Suite_•
City/State/Zips . �?ATltS� Phone#S(>3-62/9 .76o7
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with i 5 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, 0 Demolition •
working for me in any capacity. employees and have workers'
t 9. 0 Building addition
[No workers'comp.insurance comp.insurance.:
10.0Electrical repairsor additions
required.] 5. 0 We are a corporation and its
• 3.❑ I am a homeowner doing all work officers haveaexercised their 11.0 Plumbing repairs or additions
myself.[No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees.[No workers' 13.0 Other
comp.insurance required.] 1
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowner who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractor that check this box must attached an additional sheet showing the name of the subcontractors 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. �r�,t I ,
Insurance Company Name:—11 t :rix VC U. s Ins. c 0 -
Policy#or Self ins.Lie.#:1 P J u - 1 H 9 S' -3-11 Expiration Date: a Its Li I i g
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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 pabu wad penalties of perjury that the information provided above is true and correct
Signature: / Date:
Phone#:
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"1
•
A`✓v CERTIFICATE OF LIABILITY INSURANCE DATE(MIUDDIYYYY)
04/26/2018
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 po8cy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms end 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
ROGERS &GRAY INSURANCE AGENCY INC NAME: Rogers and Gray Processing
PHONE
EMI: (508)398-7600 FAX
Mt/C,Nob
434 ROUTE 134
ADDRESS: mail@rogersgray,com
INSUREMs)AFFoRDNecoyERASE NAM*
SOUTH DENNIS MA 02660 INSURER A: TRAVELERS PROPERTY CM CO OF AM 25674
INSURED
INSURER B:
•
HCCC INC DBA CUSTOM CRAFTED HOMES INSURER C:
NSURER D:
900 ROUTE 134 BLDG 3 SURE 30 INSURER E:
SOUTH DENNIS MA 02660 INSURER F:
COVERAGES CERTIFICATE NUMBER: 261674 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.
MLTR e TYPE OF INSURANCEADDD`LISSUB POLICY EFF POLICY EXP
POLICY NUMBER IAIN,DON9'YY1 IMMIDDM/YM LI/.YTS
COMMERCIAL GENERAL LIABLTTY
EACH OCCURRENCE $
1 CLAMSMADE ❑OCCUR DAMAGE'10 REN IED —
PREMISES(Eaoo:urenoe) $
—
MED EXP(Any one person) $
—
N/A PERSONAL Lk ADV INJURY $ -
---CENL AGGREGATE LMR APPLIES PER GENERAL AGGREGATE $
POLICY❑, C LOC
---IIIPRODUCTS•COMP/OP AGO_ $
OTHER: $
AUTOMOBILE OABLrtY COMaNEOSNGLE UMW $
(Ea sadden°
— ANY AUTO—
•
BODILY PJURY(Pre person) $
'AUDSEDLD
TOS N/A
BODILY INJURY(Pm evident: $
PROPERTY DMIAGE SHIRED AUTOS AUTOS (Per soldgdl
S
UMBRELLA LME OCCUR EACH OCCURRENCE _ $
EXCESS LIAM CLAMS•MADE N/A AGGREGATE $
OED RETENTION$ $
WORKERS COMPENSATION v
AND EMPLOYERS NB
LLDY YIN ^I tiTATUTE I I EK
A OFF RM.ERRAEMSEREXCLUOm CUTNE MI WA NIA EL.EACH ACCIDENT $ 100,000
(Mandatory M NH) 7PJU87H81544318 02024/2018 0224/2018
Ny�,deecnbe W,dr EL.DISEAAF•EA EMPLOYEES 100,000
DEaCRIPTIONOFOPERATIONSbelow - EL.DISEASE-POLICYLMIT S 600,000
N/A
DEECRIPfION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 1N,AddlUanalRemuW SoIeduls maybe atlaelmd Smote specs N required)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization Is given to pay
claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy In force on the date that this certificate was Issued(unless the expiration date on the above policy precedes the
Issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage•Coverage Verification
Search tool at www.mass-gov/IwdAvorkemcompensatiDMnvestigations/.
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.
HCCC Inc dba Custom Crafted Homes
900 Route 134 Bldg 3 Suite 30
•
AUTNOrs=REPRESENTATIVE
h 4
South Dennis MA 02660 M.Cro(x
I Daniel M.CroWJey,CPCU,Vice President—Residual Market—WCRIBMA
C 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
l '/L Wcwea12ai12Ze1eClla
algii,a(soac�ur/el6
> Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvementtontractor Registration
Ea:,
E te`= 7 Supplement Card
F r� =v /r/ l Type:
4 ;, —"'� �— - .t Registration: 169552 •
JEFF BARON]
�� {{f'
T= }� .k`?� - Expiration: 07/04/2019
D/B/A CUSTOM CRAFTED HOMES I �, =-'. ill
900 ROUTE 134 SURE 3-30 rI _ r '� '
S,DENNIS,MA 02660 '\,Ytt: 1=
Update Address and return card. Mark reason for change.
SCA 1 0 20M-05/11
_ __. ._. - D Address Q Renewal D Employment D Lost Card
-
C ` wiunaie</rrillA r/r'r'/i.unrietietJ
''� Offiee of Consumer Affairs a Business Regulation
ate HOME IMPROVEMENT CONTRACTOR
. � Registration valid for Individual use only
A�y, :TYPE:Supplement Card before the expiration date. if found return to:
Registration pxnimtioq Office of Consumer Affairs and Business Regulation
f5 .-.169552. 07/04/2019 10 Park Plaza-Suite 5170
JEFF BARONI . :: - Boston,MA 02116
D/B/A CUSTOM CRAFTED HOMES
-',', 1t
DEREK EVANS ' ' ` 62–C-C12?—
900 ROUTE 134 SUITE 3-30• ' "�
S.DENNIS,MA 02660 ' undersecretary Not valid without signature •
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F'# � , Massachusetts ' „-x .. ;a , 7.. ::
Board Department of Public Safet
'�°r , of Building Regulations and Standards
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License: CS-102315
Construction Supervisor
I .
-a DEREK R EVANS . 4 zi
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11 FEATHERBED"LANE" , .
'T y WEST YARMOUTH
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` ARM TH MA
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Commissioner
Expiration: .T
'. 09/01/2018
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