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Home My WebLink AboutBLD-19-1614 OF•YqR • iof ce Use Only 2 4: O i Permit# ryg i4 4'... !Amount 31) �r'd:' .PerrnitexpuesISO days fiom ,- issue da Bids Iq -ro � =" E V E €D EXPRESS BUILDING PERMIT APPLICATI I t4 TOWN OF YARMOUTH 7 2013 Yarmouth Building Department SEP 1 1146 Route 28 Eli South Yarmouth,MA 02664 By IL)df `-P-rW h _Sr" (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: HO 6010f (ISC1rc�.e, South `Iarmou* ASSESSOR'S INFORMATION: Map: 1 0 0 Parcel: -HD OWNER: Jen Nnocrtrrump rim Wes Si-ree + MannNlcld So% -�yg -Sq ( 3 NAME PRESENT ADDRESS TEL # CONTRACTOR: .er2�. tvaxt5 900 Q }- \bU PAcA 7, Un Or- 3C) SOS-LDL-1g'd43a NAME MAILING ADDRESS s o „ l,.l n i C TEL# / 3e-FF &vont VC. J @'Residential 0CommercialIrogllf2 Est.Cost of Constructions I0D0o Home Improvement Contractor Lic.# r C �.^ 1l Construction Supervisor Lie.# C 5 —/e)�?j/� Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 64. Worker's Compensation Insurance Insurance Company Name: S ee a. Otte hi 6' Worker's Comp.Policy# WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# 9 Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist.. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 10wt1 Of "/ril.t'ry OcA74 l Location of Facility I declare under penalties of perju statem herein cojjeiMfd are true and correct to the best of my knowledge and belief. I understand that any false enswct(s) will be just cause for denial or cat f f my I' a and pro n under L.Ch.268.Section 1. nn r� Applicant's Signature: &21 2 Date '1 1 I1 I 7r Ownen Signature(or att ment) See fX ( VA1vU.vlDate: Approved By: Date: Building Official(or designee) EMAIL ADDRESS: 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 Conmonweatth of Massachusetts 17/1 Division of Professional Licensure • Board of Budding Regulations and Standards Constrpctibn Supervisor CS-102315 Expires: it • DEREK REVANS74 ; "' ` ':. 11 FEATHERBED LN '." - " I" WEST YARMOUTH MA 02073 ?. " L Commissioner CL • ty • g%lie Won&mmoluvea/tf t/PArmac/ueoeaa r� Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home ImprovementContractor Registration �p='„- - - (74 Type: Supplement Card JEFF BARON! _ ' E Registration: 169552 • D/B/A CUSTOM CRAFTED HOMES !ha:i �rgin:El ": Expiration: 07/04/2019 900 ROUTE 134 SUITE 3-30 (rt - Y_==. 'f S.DENNIS,MA 02660 t v``- v:-.7J: 1--.3,,F2- iw Update Address and return card. Mark reason for change. SCA t 0 20M-05/11 _ JJ . ..-- .-_. . .0 Address 0 Renewal 0 Employment 0 Lost Card--. ---- rgne'tnr n nntreeti/A t c f(i.uar/we/r Orrice of Consumer Affairs&Business Regulation 4\` ' .f HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only .54,\��,",b�{e, -TYPE:Supplement Card before the expiration date. If found return to: `n, Registration E7ryiratlon Office of Consumer Affairs and Business Regulation .�,�;,�5. e:::.169552 07/04/2019 10 Park Plaza-Suite 5170 JEFF BARON! `- ;, Boston,MA 02116 D/B/A CUSTOM CRAFTED HOMES it DEREK EVANS " -;'' 900 ROUTE 134 SUITE 3-30.. S.DENNIS,MA 02660 UndersecretaryNot valid without signature ® ACORD CERTIFICATE OF LIABILITY INSURANCE DATE pAMd)° ''Y' 04/25/2018 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 policy(les)must 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 ROGERS&GRAY INSURANCE AGENCY INC NAME' Rogers and Gray Processing No.Ertl• (5508)398-7980 FAX (AIC.No): 434 ROUTE 134 ADDRESS: mail@rogersgray.com iNSURERISI Altrolefnlis COVERANI Max* SOUTH DENNIS MA 02660 Nausea A: TRAVELERS PROPERTY CM CO OF AM 25674 INSURED HCCC INC DBA CUSTOM CRAFTED HOMES NSURER : INSURERC suaea c: INSURER D: 900 ROUTE 134 BLDG 3 SUITE 30 INSURER E: SOUTH DENNIS MA 02660 INSURER P: 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. ADUL Sall POLIcY EXP LTM TYPE OF INSURANCE NSD RIND POLICY NUMBER I IIMDONYTY) M OPYYYY) LIMITS COMMERCIAL GENERAL LMBE.ITY EACH OCCURRENCE $ CLAIMS-MADE ❑ODAGE• I occurrence) S It MED EXP(Mry one person) $— _ — N/A - PERSONAL S AW INJURY $ . GENL AGGREGATE LIMIT APPLES PER GENERAL AGGREGATE $ POLICY DT& n LOC PRODUCTS-CWP/OP AGO $ OTHER $ AUTOMOBLE LLABLRY COMB MED SINGLE LIMIT $ IES accearll — — ANY AUTO • BODILY INJURY(Per person) $ ALLOWNED AUTOS LED N/A ' BODILY INJURY(Per accident) $ HIRED AUTOS Auras NON-OWNED PROPERTYaccident)(Per accident) = $ UMBRELLA LIMB �— OCCUR EACH OCCURRENCE $ EXCESS UAB CLANS-MADE N/A AGGREGATE $ DEO RETENTIONS $ WORKERS COMPENSATION v AND EMPLOYERS'LIABILITY YIN ^ STATURE I EN A OFFPRICERMEMBERE'%CLUDEM CUTNE in NM NIAEL.EACH ACCIDENT $ 100,000 (Mandatary In NM) 7PJUB7H91544318 02/24/2018 02/24/2019 XyM deea%elender EL.DISEASE•EA EMPLOYEES 100,000 DESCRIPT)ON OF OPERATIONS below EL.DISEASE-POLICY LNR s 500,000 N/A • DESCRIPTIO/OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached omen two M 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 I 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 daffy by accessing the Proof of Coverage•Coverage Verification Search tool at www.mass.gov/IWdhvorkers-compensauonlmestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N HCCC Inc dba Custom Crafted Homes ACCORDANCE WITH THE POLICY PROVISIONS. 900 Route 134 Bldg 3 Suite 30 • AUTHO IZnED REPRESENTATIVE rk South Dennis MA 02660 ""t �'� Daniel M.Cm y,Bey,CPCU,Vice President—Residual Market—WCRIBMA ®1985-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name end logo are registered marks of ACORD AC ' JEFFBAR-01 DEATON COCERTIFICATE OF LIABILITY INSURANCE I DAn(flco("m 04/25/2018 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 en ADDITIONAL INSURED,the polcy(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 Rogers Luray Insurance Agency,Inc. _NAME FAX . 434 INC,no,ExY. (MC,Noy(877)816.2156 South Dennis,MA 02660 mss.mai�rotte ney.com INSURERS))AFFORDING COVERAGE HAIL S INSURER A:Main Street America Assurance Company 29939 INSURED INSURER B: HCCC,Inc. INSURER C: 64 Christmas Way South Yarmouth,MA 02664 Nsusu o: INSURER E: INSURER F: • 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. ADDLISUBR EXP LTR R TYPE OF INSURANCE IMO WWI POLICY NUMBER (MM/DWYTYPY) �M/AITA LIMITS A x COMMERCIAL GENERAL LIABIJIY � '�l EACH OCCURRENCE ; 1,000,000 CLAIMS-MADE I OCCUR I MPT2557Q 10/22/2017 10/22/2018 YDBEMIRFR fFeAMAGE TO RENTED axuPerme) $ * MED EXP(My ono person) S 10,000 PERSONAL a ADV INJURY f 1,000,000 GENT.AGGREGATE ppL{IIyyM��B APPLIES PER: GENERAL AGGREGATE S 2,000,000 X POICYCJECT ❑LOC PRODUCTS-COMP/OP AGO_f 2,000,000 OTHER: S • AUTOMOBILE LUIBLITY I COMBINED SINGLE LIMIT OEs ecdderin ; ANY AUTO BODILY INJURY(D..parson) $ OWNED SCHEDULED _ AUTOS ONLY NApUTTOSSWNEp - AUTOS ONLY I i AUTOS ONLV IrERWAAMJURY'AGEPer eOdd°^t1 $ _ — UMBRELLA LIAS L I OCCUR IP 1 $ EXCESS lIA9 LI EACH OCCURRENCE 3 I ICLAMS-MADE AGGREGATE DED I RETENTION S Ii WORKERS COMPENSATION S AND EMPLOYERS'LIABUTV I II I STAATUTE FR =WAY= AMYIPROPRIETORPAARTTNEERR/EXECUTtvE Y/N NIA I EL.EACH ACC DENT $ IMsndeRAI N NN) NyyeAdmaes ur)er El.DISEASE-EA EMPLOYEE $ DESDRIPTION OF QPERATIQNS bebw EL DISEASE-POLICY I OMR S • I DESCRIPTION OP OPERATIONS/LOCATIONS/VEHICLES(AGGRO 1N,Additional Remarks Schedule,may be attached Simon space la resolved) • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HCCC Inc.dba ACCORDANCE WITH TTHTION EEPOLICY PROVISIONS. Custom WILL NOTICE BE DELIVERED IN Custom Crafted Homes 900 Route 134 Bldg.93,Suite 30 South Dennis,MA 02660 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) 01983-2015 ACORD CORPORATION. An rights reserved. The ACORD name and logo are registered marks of ACORD Date: Ike/ e To Whom it May Concern: I, Jen Hogencamp, the owner of property located at 40 Golfer's Circle, South Yarmouth, authorize Jeff Baroni the owner of Custom Crafted Homes to work on my behalf on all matter related to the permitting and construction of said address. Agent: :/// � Jeff Baroni Homeowner: Aqr 694/0 Jen Hogencamp • The Commonwealth of Massachusetts _• t Department of Industrial Accidents _ _ldi_; e Office of Investigations • "i•_ �a_ �` 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/individuaD:r i9 SAC¶fl Ct $y M t —S Address:C1005--kt. I '19 t 9 i tf'. 3— O City/State/Zip'S . M8311)t S4, (V`, Phone#:-Sa(ci 419-7907 Are you an employer?Check the appropriate box: Type of project(required): 1.[Q I am a employer with i O 4. 0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition • working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.: 9. 0 Building addition required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions • 3.❑ I am a homeowner doing all work officers havaexercised 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] *Any applicant that checks box al must also fill l out thesection below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contrition must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub conaactan 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&providing workers'compensation Insurance for my employees Below It the policy and Job site Information. Insurance Company Name:"Th.L Tray-acts Ins. C o.- Policy#or Self ins.Lie.#:7 P3 U P/-1 N 9 i Sal�l-3-l7 Expiration Date: a^ I a y I I Job Site Address: 14[) NC)(kt's Cil(• S.Yarmr) i\4n City/State/Zip: IA I- /o -tiu 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 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. Be advised that a copy of this statement may be forwarded to the Office of • Investigations of the DIA for insurance coverage verification. Ido hereby certify,under the pairs andpenalties of perjury that the Information provided above is true and correct Signature: ) `( /(nom Date: 9 /17/i8 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#: