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HomeMy WebLinkAboutBLD-19-1716 2:13.1 OQQ n L 3 ._ . C a4 Amount t7D— tyPermit expires 180_days from . F issue date . EXPRESS BUILDING PERMIT APPLICAT • E C E I V E D TOWN OF YARMOUTH Yarmouth Building Department SEP 21 2018 I 1146 Route 28 BY BUIL F. t�(-�J l �ya{ South Yarmouth, MA 02664 (508) 398-2231 Ext. 1122611r �� f CONSTRUCTION ADDRESS: 71- C7-T C(la OLP— yeil2mn!)( /77-i ASSESSOR'S INFORMATION: , • Map: 2 Parcel: CZ OWNER:b FrJNI IS f.‘h 0raPF (]L—f NAME PRESENT ADDRESSSCost TEL # CONAaroR: ,. \S ({ V"/G ---.)tot_ ( t I ietn/t 1€� � / J I S NAME MAILING ADDF§ „�/ ? to (e Lig # )'Residential 0 Commercial , Est.CoostoofConstruction S 2000 y- IT� Home Improvement Contractor Lie.m j('� C� '\ 5 09-*D9 D V P 1 J (6V a Construction Supervisor Lic. Workman's Compensation Insurance: (check one) ` / 0 I am the homeowner 0 I am the soleo/proprietor I have Worker's Compensation Insurance �-/ / ��7� Insurance Company Name: MA' 1S A y !!! ��` Worker's Comp.Policy#b �'UT U' .3-31 S r " 3 / WORK TO BE PERFORMED CDavk 0 5 Tent _ Duration (Fire Retardant Certificate attached?) �J�} Y`Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove eristing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing Yii4A4a ^y Newly' &AtS7"/ �6 •The debris will be disposed of at 1/T, n4vh-1 "') D k (S S 1 1 CLocation of Facility �j(f No T-4-1 ni 01,4-iA/AT L- 2_p2 I declare under penalties of. iury th. •- statements herein contained re true and correct to the best of my knowledge d belief understand any�a arn`swers will be just cause for d..'. or . ...n.f nay license and for prosecution under M.G.L.Ch.268,Section 1. Q .� /7 ( Applicant's Signature: Date: 9(� ( ( �+ ore__ _�,7 Owners Sig,namre(or attachment) Date: Approved By: , 77' Date: Ilkkithr Building Official(or designee) EMAIL ADDRESS: Zoning District Historical District 0 Yes 0 No Flood Pit Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts • 11 h ___, _ Department of Industrial Accidents = I= . 1 Congress Street,Suite 100 t.. e. • Boston, MA 02114-2017 fir www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibiv Name (Business/Organization/Individual): ln/1 S Address: 1 ( ( )4-1292) (L4( R ( / City/State/Zip: 1-4—/A-Al / 14 ! S Phone #: S—OS Are you an employer?Check the appropriate box: Type of project(required): am a employer with /5'employees(full and/or part-time).' 7. ❑New construction .0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ emodeling • any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. em0litioII 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 1 ❑ Building addition ensure that all contactors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contactor and I have hired the sub-contractors listed on the attached sheet These sub-contactors have employees and have workers'comp.insurance? 13.El Roof repair 6.0 We are a corporation and its officers have exercised their right of exemption per MOL c. 14.0 Other 152,i 1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box ail must also ell 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'corripensation insurance for my employees Below is the policy and jab site information. Insurance Company Name:�(t p.�/ as I' Tif l Policy#or Self-ins.Lic.# ��—0_44Zg I C 1 is Expiration Date: / t 0 / ( CI � �- � ' ^ / lilt 11 .� Job Site Addres / a(�Z c-c City/State/Zip: V I/ . yt't-(141// -4 41 Attach a copy of the workers' compensation policy declaration page(showing the policy number nd expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against u.-violator. A copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage v= 'fi on. I do hereby cerci i under e p 'ns and penalties of perjury that the information provided a ove is rue andancorrect Signature: I Date: 9 Z l I I Phone#: ' b 3(N Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone 4: CS/re Wom,manearld oilbfraa Office of Consumer Affairs&Business RegWail'tI ifF HOME IMPROVEMENT CONTRACTOR "...N TYPE:Corporation _LogE-_=pea'istratlon EXPIration • y`tonoroi0'G 03/28/2019 LEWIS&W ELtio1415STtal,ONI CABINETRY,LLC. . CLARENCE HA R _ ;a • § 111 AimortRd ' =E` - 1" Hyannis,MA 02601 Undersecretary c Commonwealth of Massachusetts ��� n Division of Professional Licensure Board of Building Regulations and Standards Const d%iSpprvisor C5-097094 J' N pires:07/16/2020 n i ^ i . 1 CLARENCE WART` q{` i Z tt PERCNAL'$JJtt111/E\]flr�.. E Qtif WEST BARNSff,[.E.,MAAQ,04'61�f) .vORS330-, Commissioner l l 1 • I LEWIS &WELDON CUSTOM BUILDERS DESIGN • BUILD in Airport Road Hyannis,Massachusetts 02601 508-778-5757 office 508-778-5111 fax www.lewisandweldon.com PROPERTY OWNER AUTHORIZATION Dennis and Donna Coffey 29 Crest Circle West Yarmouth,Ma 02673 As owner/owners of the subject property hereby authorize Lewis and Weldon to act on my/our behalf, in all matters relative to work authorized by this building permit application and all subsequent sub permits governed by the Electrical Code, as well as Plumbing code C:ft, ///,Signature of Owner/O 41.' / Date ^l /L'KKISP1,27OHO, r air"- Print Name ames / cwR t Lewis & Weldon Authorized Representative Date Print Name 1 'ice CERTIFICATE OF LIABILITY INSURANCE R001 DATE x'" 8 / 9/19/2201018 THIS CERTIFICATEIS 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 ADDmONAL INSURED,the policy(les)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). PROWLS, CONIACr HARTFORD FIRE INSURANCE COMPANY PHCNRoN E F% INC.L EEk II/.S.NO250876 P. F. AD REas PO BOX 33015 slURERISI AFFORDING COVERAGE RAs/ SAN ANTONIO TX 78265 's. A:Twin City Fire Ins Co 29959 .Maw INSURER s: MMMn c: LEWIS AND WELDON wmole: 111 AIRPORT RD Pans: HYANNIS MA 02601 HaMER p: COVERAGES CERTIFICATE NUMBER: 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. DM 1 TRIlls o/PawME .Inoa svee POLRY NM= POLICY EDT roue7Ea (MSN RM DIWODI'RYI /LN9MMY [DOTS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE❑OCCUR DAMAGE TO RENTED PREMISES(Es(mnwp) 5 — Mm DM(MR'aM Psaslll 5 — PERSONAL&ACV INJURY s GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s POLICY El PRI"'❑ JEGT Lam' PRODUCTS.COMPAW AGO $ OTHER 5 AUTOMOBILE LIABILITYCOMBINEp SINGLE LUAU —ANY AUTO (F.soxmR E Q'MEDSLNEDULED BODILY URY(Pr ponce) 5 AUTOS ONLY_AUTOS BODILY INJURY(Pr saMrRl s HIRED NON-OWNED —SONLY PROPFAT,DMMC{ —AUTOS ONLY AUTOS ONLY (RH wwma 5 $ UMBRELLA LW OCCUR EACH OCCURRENCE S EXCESS LW CUIMSMADE — AGGREGATE E Ow Fromm $ NT WORKERS COMADDA n0Y DE AND EM/50RYYMr ITX SFR o5N ANY PROPRITOMPARTNER CUTNE MX YTH ACC I AER OFFICEMEM ABER EXCLUDED? A (LNnderoryMNM ❑ WA �� EL EACH ACCIDENT $100,000 76 NEG JX5703 05/10/2018 05/10/2019 ELDISEAS&EAEMPLOYEE 5100,000 _ I ra d..am.under DESCRIPTION OF OPERATIONS belowELOSFARE•P0.1CYLeaT 5500,000 DESCRIPTION OP OPERATIONS/LOCATIONS/VEHICLES(ACORO 1OI,MdM,al Ramada.SHWA.,may be wrMd If man spew Y nquksd) Those usual to the Insured's Operations, RE: Dennis And Donna Coffey 29 Crest Circle W. Yarmouth, MA 02673 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. Town of Yarmouth Building Dept. AUTHORIZED REPRESENTATIVE 1146 ROUTE 28 J'1*BaflX C'qe ti SOUTH YARMOUTH, MA 02664 ACORD 25 2016/03 ©1963.201 S ACORD CORPORATION.All Hghts reserved. ( ) The ACORD name and logo are registered marks of ACORD • A�. CERTIFICATE OF LIABILITY INSURANCE DATE A MM!DDNYYV) 09/19/2018 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: N the certificate holder is an ADDITIONAL INSURED,the policy(les)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 Ashley Clark Leonard Insurance Agency,Inc PHONE (508)428-6921 - PAX (508)420-5406 ((€A/C.No.E>NI• (AIC,No): _ 683 Main Street ADDRESS: Ashley@Jleonardagency.com Suite B INSURER(S)AFFORDING COVERAGE NAICI Osterville MA 02655INSURER A: MESS Bay ins.Co. 22306 INSURED INSURER B: Safety Ins Company 39454 Lewis and Weldon Custom Cabinetry LLC INSURER C: INSURER D: 111 Airport Road INSURER E: Hyannis MA 02601 INSURER F: COVERAGES CERTIFICATE NUMBER: Master 18-19 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 ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP INSD ,WP POLICY NUMBER (MM/DD/YYYY) (MMIDDM'YY) LIMITS COMMERCIAL GENERAL LIABILITY - 1,000,000 EACH OCCURRENCE f CLAIMS-MADE ®OCCUR PRMAGES( acocurr 100000 DAMAGET RENIL ence) f MED EXP(Any one person) $ 10,000 A _ ZHN906164507 04/01/2018 04/01/2019 PERSONAL SADV INJURY $ 1.000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE f 2,000.000 X POLICY D ECT U LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident ANY AUTO BODILY INJURY(Per person) $ 500,000 B OWNED X SCHEDULED 3951369 0425/2018 04/25/2019 BODILY INJURY(Per accident) $ 1,000,000 AUTOS ONLY NON-OWNED HIRED NON-OWNED PROPERTY DAMAGE • X AUTOS ONLY x AUTOS ONLY (Per accident) f 250,000 f UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION f $ WORKERS COMPENSATION STATUTEPER ETH - AND EMPLOYERS'LIABILITY Y I N ANY PROPMETORPARTNERIEXECUTIVE ❑ NIA EJ..EACH ACCIDENT f OFFICER/MEMBER EXCLUDED? (Mandatoryln NH) EL DISEASE•EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N more space Is required) Project location: Dennis&Donna Coffey 29 Crest Circle West Yarmouth,MA 02673 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE^/iii/ ) South Yarmouth MA 02684 „J d. 0� � ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD