HomeMy WebLinkAboutBLD-19-1830 ' From;Hawkeye Fence 5085879090 09/26/2018 12:03 #334 P.001/004
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EXPRESS BUILDING PERMIT PPLICATION
TOWN OF YARMOUT SEP 26 2018
Yarmouth Building Depart eat'
1146 Route 28
South Yarmouth,MA 02664 By i_ �'■.Q N T
(508)398-2231 Ext. 1261 -
CONSTRUCTION ADDRESS. A,_ _, A•. y.
ASSESSOR'S INFORMATION: I / I
Map; r� �t1 Parcel:
OWNER:. 7N(y,EH .�� P�f"pJr�Arr'RESENT A�OD �.1..-_.1( ted ,�L. aa'.`.L.__..Jails.Mt
CONTRACTOR! Alai R t a ••r7 ,..9,._ ( ka s4r 9 s �{ C .
NAME MAILING ADDRESS — '�. J I EL,a
O Residential )'Commerclyall pII Est.CCM of Construction S 'ar9
Rome Improvement Contractor Lie N I YSt,�b. Contraction Supervisor Lia p CS-N.f 339
Workman's Compensation Insurance: (check one)
O 1 am the homeowner Ilii Jam the sole proprietor O I have Worker's Compensation Insurance
Insurance Conway Name: Worker's Comp.Poticya
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certitkate attached?) Wood Stove
Siding: 1rcit Squaree Replacement windows:It Replacement doors: p-,__
Roofing: #of Squares ( )Remove existing"(max.2 layers) Insulation_
Old Kings Highway/Historic DIM. ( )Replacing like for like Pool fencinp •
•The debits Nill be disposed of et:
' Loatienef Paealty
I decline undsrentities of
n perjury that rhe. . cnn berdo tonteinett inrpresenio treeandeornar.tMant ofny knowledge end ballet luadxnandthu.uy teles uswer(s)
will baton Wore kr dente/or wont •- - wase end forpruealiolt ender MO.L I'3.R6s,Rotten I,
'Apparnt's Signature: _Date�4r_p ��L
._ f OwnenSignatert(et:nehmen Date: .
Approved By: rl1 Date: p 'AG—/c
Seining Official(or•air
EMAIL AGakS.•.-.._--
'Zoning District:
Hlnorkal Dist M. ':I Yes No Flood Plein 7dne: . Yes :: No
Water Resource Protedtion Diction Withlnllki ft.Iof Wetlands: '
•
. Yes No Yes: No •
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Devito
From:Hawkeye Fence 5085879090 09/26/2018 12:03 #334 P.002/004
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as.. T e Co on wealth of Massachusetts
0 i---110,0=--cr spa mane vj fndustrlai Ccldents
r= e I regress Street,Sul a 100
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' Sitar=a' oston,MA 02114.2 17
^v�L.�'' wwwmassgov/dib 1
Workers'Compensation I uranee Affidavit:Builders/Contractors/Electricians/Piombers.
TO BE PILED WITH THE PERMITTING AUTHORITY.
• Aoolkant Information yam,yq Please Print Leah,Leah,iza
Name(Buslneeaforgandonnndiyiduai): ,41/44,41/44 ,kf1 S
Address: 314 GTA i el'5r
City/State/zip: M¢ f.p, t,,,yl.o l,4-zi phone#: 106.4 o '4.154 _
Are you en employer?Oak the appropriate box: r0
Type of project(required):
1.❑)piueployer with , employee'(fulland/o pan-time).'
yam "7 7. ❑New construction
2. a usok ip:opriewrorpam:ershipand haven employees working Por me in 8. ❑Remodeling
any capacity.(No workers'comp,Insurance re sired)
3❑1 am a homeowner doily ell work myself Rio *en'camp,insurance required I t I i• 9. ❑Demolhion
4. Iantahomrownuandw9behirin ml,a , !tilt 100BUildivgaddition
❑ t to all weak on
rime thetas contractors tither ban workers'compo estion lnsuranee or in sole 11.0 Electrical repairs or additions
proprietors with no employees.
)2.0 Plumbing repairs or additions
9.E11 aro a general
Then ntr rw I have hired the mlb•eont,ectore listed on the snitched sheet 13.nr�Roo£ra
mp oven end banworkers'comp,insurancet,-t pairs
6.0 We are a corporation end is officers have exercised their right of cumptton per MGL e. 14.❑Other
132,11(41 and we have no employees,[No workers'comp.insurance required.)
^'Arty applicant that checks boa al must also fill out thesection below showing their workers'comptrwdon policy Information
t Home: ma who submit this affidavit Indicating they arc doing an work and then hire outside eondaemrs must submit a new affidavit indicating such.
*Contractors that deck Ods box must attached an additional that showing the mite of the aub•oonbecmrs and este whether or notCrose wens have
anployees.If the eubtorhaama bane employees,t ey most posWe their weeters'comp,policy etenber.
I am an employer titans workers'compensation insurance for my employees. Below Lc the policy aa(Job site
information,
Insurance Company Name:
Policy#or Self-Ins.Lie.#: Expiration Date:
lobSlteAddress• 2.72b reb t. 'ZS.\sties(toi*tt city/state/4: NAIL. r
Attach a copy of the workers'compensation policy 8eclantion page(show(ngthe policy number and expiration date),
Failure to secure coverage as required under MOL c,152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprtsonxnent,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 DR for Insurance
coverage verification.
I do hereby cwhJy .der the pains and penalties of perjury that the information provided above is true and correct,
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19 et eat ' ( Co- . ge
Phoper SOB - el V5-+IS4
Official use only. Do not write In this area,to be convicted by city or town aL
City or Town: i IPermit/License#,
Issuing Authority(circle one):
I.Board of Health 2.Building Department 4.Cityrfown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other 1
Contact Person: Phone If: •
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From:Hawkeye Fence 5085879090 09/26/2018 12:04 #334 P.004/004
09/28/2018 11:50AM PAX 9789579572772 COUGHLIN INSURANCE lit 0001/0001
A oc RDa CERTIFICATE OF LIABILITY INSURANCE DA'osp"ro1s 1
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
IC°°MWE Cindy
Charles J Coughlin Insurance
FINNS FAX
14 Dinley Street ( SN°FML: (9781957.3588 WC.Ne):
P.O.Box 10 allotcindy@cougNtnins corn
Dracut,MA 01826 INSURERS)AFFORDING COVERAGE NAMI
Ns1AER A: titles First Insurance Company 15328
INSURED Alan R.Michaelis POURER e:
374 West Mein Street
Mltuy MA01527 INSURER C:
INSURER 0•
INSURER!!
INSPIRER F:
COVERAGES • CERTIFICATE NUMBER REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED MOVE FOR THE POLICY PERIOD
INDICATED. NOIWDHSTANONG ANY REQUIREMENT,TERM OR CONDITION OF MY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO NHICH 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
NCR ADD.SUER POLICY EYE POLICY E)P
LTR TWE CF INSUUNCE NSD WYO POLICY PUMPER NWGOIrfrel (MMIDLYYYWI LIMITS
A J COMMERCRL GENERAL]�UAaIRY ART507937502 12/172017 12/172018 EADIOCCuRRENCE $ 500,000
I CLAIMS-MACE lyl OCCUR UANAGETOHENr[p 1000W
PREMISES HENit0et nM t
MED EXP(Any ma pawn) t 5,000
_ PERSONAL t AW INJURY t 500,006
GENL AGGREGATE LIMppT APPLIES PER GENERAL AGGREGATE t 1,000.000
HPOLICY JECI LOC PRODJCTS•COMP/OP AGO I 1,000,000
OTHER', t
AITIOMOIMELMBIUTY COM3NLD SINGLE UMn $
IES acodenll
—M ANY AUTO BODILY INJURY(Ey pram) t
OWNEDSCIEWLC BODILY PALM(Per emSW0 t
_AUTOS OILY _ AUTOS
FIRED LY rNPROPERTY DAMAGE
AUTOS
RHOS ONLY _AUTOS ONLY (Per made*
UMBlELLALIAR H OCCUR EACH OCCURRENCE C
EXCESS LIAR CLAIMS-MADE AGGREGATE t _
CED I I RETENTION S O _ pFp t
WORKERS COMPENSATION nUTE I Piz"
RH
AND EMP1.0YERS'UABLIIY
N11'PRCESETORAMT ERE€ECVrE NIA
Mandatory
EL EACH ACCIDENT e
°FFICERNENEER E+(QLUED?
Mandatory In NO EL DISEASE.EA EMPLOYEE I
Pyet Memo under
=SCRIPTION OF OPERATIONS beat EL DISEASE.POLICY UNIT $
DESORPTION OF OPEWIDOt6ILOCAnON81 VBECLIR(LCORD101,Mdtiral Rambla ScSSJA nibs leached I mon space Is!ARAM
Job Location:228 RI 28, West Yarmouth,MA
CERTIFICATE HOLDER CANCELLATION
FAX# 508-587-9090
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
The EXPIRATION DATE THEREOF. NOTICE FNA BE DELIVERED N
Yarmouth BWkPoig Department ACCORDANCE WITH THE POLICYPROVISONB.
1146 Route 28
SouthYarmouth, MA 02664 AUIIONZEDREPRESElTATIVE
®1988.2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016(03) The ACORD name and logo are registered marks of ACORD
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Commonwealth of Massachusetts - 2
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Division of Professional Licensure x
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• Construction Supervisor CDm
CS-021337 Expires:05114/2020 CD
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ALAN R MICHAEUS SI-"y
374W.MAIN STREET ''<,;"f;
MILLBURY MA 01527
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Commissioner
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