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Home My WebLink AboutBLD-19-001359 . O? Y�R Office Use Only p�2 �O Permit$ f� Jr,c Amount v `� +• i Permit expires 180 days from .�.. . issue date ab- [g4U°1397 RECEIVED EXPRESS BUILDING PERMIT APPLICATI 1 TOWN OF YARMOUTH SEP 05 2018 Yarmouth Building Department 1146Route 28 BUIL' Fair 3, South Yarmouth,MA 02664 By (508)398-2231 Ext 1261 • CONSTRUCTION ADDRESS: /9 /eia -P_/ ff'VP 67ZCV3 ASSESSOR'S INFORMATION: Map: // Parcel: • ��s. A/ lfe y OWNER: i (O /i r 7.r.G i .44 tit-e" / / (/457-7 -- NAME PRESL _/DDDR,,E,SSS / }TEE-L e Q /� CONTRACTOR: `r . ' OF j f(S ce ✓ r J v,J /c/ 05 9 NAME MAILING ADDRESS TEL 8 ao4 ],Residential 0 Commercial �jC Est.Cost of Construction S o-72‘., ("0"1:27 ap /Home Improvement Contractor Lia k /�7L /J Construction Supervisor tic.# (3 !/7.3T/er Workman's Compensation Insurance: (check one) U I am the homeowner r I am the sole proprietor I have Worker's Compensation Insurance / [� Insurance Company Name: e .y • A Workers Comp.Policy# 77 W 752/Z 3 / WORK TORE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # V Roofing: #of Squares 23 ( �)Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic jjt Dist. ( )Replacing like for like Pool fencing °The debris will be disposed of at: /. A / (n. /_cee" Location of Facility 1 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 fake answers) will be just cause for denial or revocation of my license an._;,,,�,,,;' -'... M O L Cl..268,Section I. D l5 • Applicant's Signature: _. Date' T' .57 4 Oween Signature(or an. t) ttrii /,h%/w'/ Dale Dq 'Q ' 2616 / Approved By. ti en Date: 2 -) /441' Bu g Official(a designee) LMAII.ADDRESS: 1 Zoning Dist Historical District: Yes No Flood Plain Zone: Yes C No Water Resource Protection District: Within 100 P.of Wetlands: 1- Yes i, No +': Yes i I No 4 ____ . The Commonwealth of Massachusetts .-1'7./i-_=,yli�_ '/ Department of Industrial Accidents 4 =- _ 4 .1 Congress Street,Suite 100 =':SEM 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 Lezibly Name (Business/organization/Individual): 4/rA 4.4., Afeeeeseittaitrafril Address: / /D,//�� et-+sir, s7rr�e uk City/State/Zip: /7A- Se 9 Phone #: afO7O4 -J Are you an employer?Cheek the appropriate box: Type of project(required): 1.❑I am a employer with 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 • any capacity.[No workers'comp.insurance required.] $• ❑Remodeling 3.0 I am a homeowner doing all workmyself t 9. ❑Demolition [No workers'comp,insurance required] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole dor,i11.❑Electrical repairs or additions proprietors with no employees. (�*��' C�,�o r 12.❑Plumbing repairs or additions I am a general contractor and I have hired the sub-contractors listed on the ed sheet A17'Z These sub-contractors have employees and have workers'comp.insurance.* 13.0'Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL e. 14.❑'Otber 152,§1(4),and we have no employees. [No workers'comp.insurance required] *Any applicant that checla 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. 1 am ars employer thefts providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:��j / , e 45. ( .B Policy#or Self-ins.Lk.#: Z g' 9 &� Expiration Date: (p l? '7/7 Job Site Address: /7 &'znt-e City/State/Zip: /(7.4 O''Z Attach a copy of the workers' compensation policy declaration page(showing the policy numberexpiration 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.enalties of perjury that the information provided above is true and correct Signature: ----- —� Date: 97. 67 /O Phone#: 3459 MY e -39 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#: • 'ACORD CERTIFICATE OF LIABILITY INSURANCE DA'E'MW°°"""' 06/15/2016 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 en ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require en endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CNAME:ONTACT Linda Sullivan DOWLING&O'NEIL INSURANCE AGENCY PHONE a,, (508)775 4620 ;,w°,N,,: E-MAIL ADDRESS: Isullivan@doins.com • 973 IYANNOUGH RD PISI3RER(S)AFFORDING COVERAGE NAILS HYANNIS MA 02601 INSURER A: AMGUARD INSURANCE CO 42390 INSURED • INSURER B: CAPE COD HOME IMPROVEMENT INC INSURER C: INSURER D: 27 MILL POND ROAD INSURER E: WEST YARMOUTH MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 281511 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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. NSR ADDL SUER POUCY EFF POLICY UP LTR TYPE OF INSURANCE NSD WWI POLICY NUMBER (MMNM'YYN IMMOD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED S CLAIMS-MADE n OCCUR PREMISES(Es otteurnmee) $ MED EXP(Any one penon) S N/A PERSONAL&ADV INJURY S GENT.AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE S -1 POLICY u JECT n LOC PRODUCTS-COMP/OP AGO $ OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Es accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULEDAUTN/A BODILY INJURY(Per. Idem) 5 HIREDNON-OWNAUOS _ AUTOS AUTOS ED (Pt aEc DAMAGE S UMBRELLA LAB OCCUR EACH OCCURRENCE S EXCESS LMB CLAIMS-MADE N/A AGGREGATE S DED RETENTION$ $ WORKERS COMPENSATION X PERRTUTE ETH- AND EMPLOYERS'LABILITY A OFFIC R/MEME BEREXCLU�ECUTIVE '/l ED? WA WA R2WC940123 06/03/2018 06/03/2019 ELFACNAccroENT $ 1,000,000 (Mandatory, Mand,atory In NH) EL DISEASE EA EMPLOYEE $ 1,000,000 If y» under DESCRIPTION OF OPERATIONS bebw E.L DISEASE-POLICY LNm $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached N mon spate Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 8,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/Avd/workers-compensation/iinvestigations/. CERTIFICATE HOLDER CANCELLATION -- -- ----- - — / SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED Ih ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1 S Daniel M.Cdinlei M.CrolMey,CPCU,VicePresident—ResidualMarket—WCRIBMA ®1988-2014 ACORD CORPORATION. All rights reserw ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD .E Commonwealth of Massachusetts !,®I Division of Professional Licensure Board of Building Regulations and Standards C o n st rrlctb n$0 A?ry i s o r CS-093798E3�ires:07107/2019 d i i .1 Y' "7. ALEKSANDROV B KONSTANTIN ;,- _ I,�,i P.O.BOX 842:',.. ':., : r , _ WEST YARMOUTH MA 02673 \ ',;'i> • Commissioner C "� Office of Consumergrya rs Eac alell� HOME IMPROVEME 6 Boal"esa Regulation TYPE:Indivldupa�, IRACTOR 149245 = ., t2/1 . D/B ASM&K CONSTR CD OM ;r KONSTANTIN B ACEK5.4Npgpy 77 BMOUTH & `,mat YARMOUTH,Mq 02673—" U `�'tT— Undersecretary