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HomeMy WebLinkAboutBLD-19-1934 4 YA Office Use Only ;$° Ro -� - /9is y ,;t •o - 1' y Amount i `-:�'re"""" crrra d' Permit expires 180 days from --.-:r::-' issue date . .— RECEIVEDt EXPRESS BUILDING PERMIT APPLICAT il N TOWN OF YARMOUTH OCT 0 2 2018 Yarmouth Building Department I 'E'AR" F 1� 1146 Route 28 -1, I cN b., __ South Yarmouth, MA 02664 (5/ -/ 08)398,-2231 Ext.�1j2�61� CONSTRUCTION ADDRESS: AU( y 1 'k b uowa"`Qoe---- ASSESSOR'S INFORMATION: • . S 6 Mk'Map: Parcel: 6 OWNER: K24 ee,(/,t-A { ekty Geuz__ 60/ ,ere.F Y,n htbele Sao 68.C407o NAME PRESENT ADDRESS At TEL. # CONTRACTOR: Ll)(CA•C•— h:es�0-A)DJ"s n- IftUeiviAi✓ ilAy S-2)a}-Jn.S 7 7 V V57 an > NAME MAILING ADDRESS TEL.# (Residential 0 Commercial /-(� Est.Cost of Construction$ Home Improvement Contractor Lie.# `L� Construction Supervisor Lie.# ei.5.--07 f9 Z-13 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 G' A7I//am the sole proprietor //❑'I have Worker's Compensation Insurance / '7 Z Insurance Company Name: - /Gff'efood J2 CO p• Worker's Comp.Policy# 0 S 6 u3 S ae 6QA V-CV i1 7- DU� -to v- ztil : Deuo '4fk�( o¢. SL-ea: v._ As 0A & Iieot �.rr -cAel.IS73 • $ b€cwttb De omt..r►.svliiioN, beop •WORKTOBEPERFORMED (ZopP`R00PA+k�S-(re4A-Pj Y Cetttwq -(oWeRlevet . Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing /y��,, �( % /' „rr t Oa- 'i .-s-.tc, Th " e debris will be disposed of at [/r rt$WtV 1 1 '3 0,-0,Sl y /f,Le d-. 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) will be just cause for deniall orrrrevocation of my�- ✓license and for prosecution under M.G.L.Ch.268.Section I. / Applicant's Signature: 41."4------...el //' til/' Date: cC�/8 Owners Signature(or attachment) /rr7/tvev'ep I O IKpNr Date: Pot/ Approved By: e�—L Dare: (o' 1.- )� Building Official(or designee) EMAIL ADDRESS: • Zoning District: Historical District: 0 Yes 0 No Flood Plain 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 `S *7r= Department Department ofIndustrialAce(dents 1 Congress Street,Suite 100 ��= Boston,MA 0211¢2017 www.mass.gov/dia Workers'Compensation Insurance Affidavits Builders/ContraetoralEtee(ricians/Plumbera. TO BE FILED WITH=PERMITTING AUTHORITY. AnnfcentInformat(on Please Pilot Leeibiv Name 03 usaaesswOcgeaimdonllndividoal): Whalen Restoration Services Address: 22 American Way City/State/Zip: South Dennis, MA 02660 Phone#: 508 760 1911 Areyen an employer?Cheek theapprepriate hart Type of project(required): 1.12llam a employer wish 25 employees(MWlandIespaMma).e 7. QNewconstuction RQlmaasole proprietor orpartmesbipand lava aoamployeeaw kin formals amcapaaip Wowmken'comp.hennca requhedl • 8. Q Remodeling 3.Q1emshomeownerdoingallworkmysattgeowarkem'temp.lasmmmoraquhailt 9. 0Demolldan • 4.01amahomsownmouton; all aaoaonduetworkonmyproperty.Iwil 100 BulldIn addition enureuutaticontraamraeltherbaveworkers'compansationinsuranceGeamsole 11.0 ElactIcal repairs or additions • praprlemtawitbaaaplayees. 12.DPlumb ing repairs or additions 1.0 I am a fenewl contemn and I have hired the tubeonhaomn listed on the atmched.beat These aub.confractom have employees end have woskers'coup.Insurance.* 13QRdofrepairs • dQWeawacmporatemandheofceshavemarakedtireirrightofaxemptlonperMOLe. 14.00ther 152,$1(4),end we have no employms.(No workers'comp.insmaneerequkod) *Any appltc atthazoheokaboxil must also MI oaths sebenbelow ahowtngtb irwarkam'compensatlonpolicy intbnnation tRomeavaine Maisubmit gdsaf$davitindicadpgthee are doing all work and then him outside cansPrmutMw4ggnowameavIs ManThg5 tContteaemiletcbeokthiabpamustettaohedanaddidonelshootshowingthenameefts sub•conrsmomand Mete mketherarnotthoseeatitinhave employees.If theaub a ave employees,they must provide their workers'com policy number. aman mloyer Thetis providing workers'compensation Insurance for n g employees: Below k the policy and job site Insurance Company Name: Ace American Insurance Company Polley#orSaint Lin 0' 6S62UB5B89454217 Exp b nDate �/4,'1/19 Job Site Address: 60/ gr kA-- City/State/21p; lenesraseAn..2itryiA—. Attache copy of the workers'compensation policy declaration page(showingthe policy number and expiration date). Failure to secure coverage as required under MOL a.152,§2$A is a criminal violation punishable by a fine up to 81,500.00 and/or one-year Imprisonment,as well as civil penalties In the fbrmofa STOP WORK ORDER and afne of up to$250.00 a day against the violator.A copy of tbis statement may be forwarded to the Office ofinvestigations of the DIA forinsurance coverage verification. Ida herebycertijy underlie and penalties ofperjurythatthebifoinsationprovideddaboveistrueondconee& Signature: Date: / aLtG/8 • Phone#: 77Y' `f87 04(37• . Ojpcial use only. Do not write to this area,to be completed 1p'My or town eight City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cltyllown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Persons Phone#: '' Restoration Services Inc. f • Fire,Smoke,Soot,Water Damage&Mold Remediation Services Cleaning • Deodorization • Reconstruction Specializing in Fire Restoration -All Work Guaranteed . Access, Authorization and Direct Payment Request Form • I (we) authorize WHALEN RESTORATION SERVICES to perform work as per estimate at property located at•601 Route 6A, Yarmouthport, MA 02675 . to repair damage caused by fire on 9/28/18 . • 'As owner(s) of this property, I (we) understand that I (we) must authorize this work. I (we) hereby authorize WHALEN RESTORATION SERVICES to perform this work and accept responsibility for payment upon completion. I (we) authorize and direct my Insurance Company nee Claim #2018MA172746 • Policy No. 11MH40345180520 , to make payments directly to WHALEN RESTORATION SERVICES, Insurance Claim Specialists, for doing this work and to that extent I (we) assign the benefits applicable to this loss to WHALEN RESTORATION SERVICES. • I (we) acknowledge receipt of a copy hereof: 2'1 Sal—fv OWNER DATED SIGN • eldi • OWNER WHALEN RESTORATION REP. SIGNED 22 American Way,South Dennis,MA 02660 Phone:(508)760-1911 • Fax: (508)760-9995 • 1-800-244-2598 •E-Mail:restore@whalenrestorations.com Web Page:http://www.whalenrestorations.com . OFFICE COPY=WHITE CUSTOMER COPY=YELLOW rr 3 s' A ® CERTIFICATE OF LIABILITY INSURANCE ��oio nolne 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 NAMCONTACT Theresa Cahalan-Norkus HUB INTERNATIONAL NEW ENGLAND LLC t(NCNNo.Fall: 508 3454446I EMAIL INC.INC.NOL' • ADDRESS- theresa.cahalanenork@hubIntemational.com ' 600 LONGWATER DRIVE INSURER(S)AFFORDING COVERAGE NAICY NORWELL MA 02061 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: WHALEN RESTORATION SERVICES INC INSURER C: INSURER D: 22 AMERICAN WAY INSURER E: SOUTH DENNIS MA 02660 INSURER F: COVERAGES CERTIFICATE NUMBER: 320527 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. INSR TYPE OFINSURANCE ADDL SUBR POLICY EFF POLICY EXP LTRwen wvn POLICY NUMBER IMMIDO/YYYYI £MMIDDNYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS-MADE n OCCUR DAMAGE TO RENTED DAMAGES(Fe occurrence) S MED EXP(Anyone person) 5 N/A PERSONAL a ADV INJURY S _ G��EN- L AGGREGATE UMIT APPLIES PER GENERAL AGGREGATE _ S • 77 I POLICY❑JECT ID LOC PRODUCTS-COMP/OP AGG S , I OTHER S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ /Ea acddenll _ ANY AUTO BODILY INJURY(Per person) S ALL AUTOS ED _ AUTOS U� WA BROPERTJU DAMAGE evJdent) S HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Neer accident) S I UMBRELLA LIAO _ OCCUR EACH OCCURRENCE S _ EXCESS LIAR CLAIMS-MADE N/A AGGREGATE S DEO I RETENTIONS V I • WORKERS COMPENSATION XISTATUIE I /ERµ AND EMPLOYERS'LIABILITY Y N I A OFFIRCERAIEMBEREXCLUDED)ECUTIVE ® N/A NIA 6S62UB5B89454218 04/01;2018 10/17/2018 E.L.EACH ACCIDENT S 1,000,000 (Mandatory In NH) El.DISEASE-EA EMPLOYEE $ 1,000,000 It yesdesbe under DESCRIPTIONaOF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,AddMonM Remarks Schedule,may be attached I mon space Is 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 N 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 ww v.mass.govdwd/workers-compensationTmvestigatIonsl. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ekaterina and Marion Cruz ACCORDANCE WITH THE POLICY PROVISIONS. ' 601 Route 6A AUTHORIZED REPRESENTATIVE YarmouthpoMA 02675 Daniel M.Cr ey,CPCU,Vase President—Residual Market—WCRIBMA ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I • •%� WHALRES-01 TCAHALANENORKUS ACORO' CERTIFICATE OF LIABILITY INSURANCE D10/01ATE 2018Y( 1orov2ota 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 POLJCIES 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 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 License#1780862 CONTACT John Powers NAME' HUB International New England PHONE FAx 265 Orleans Road I¢A�ro,No,Est):(508)845.7866 (Aro,No): North Chatham,MA 02650 AoORFSs'John.Powers@hubinternational.com INSURERS)AFFORDING COVERAGE NAIL S INSURER A:Philadelphia Indemnity Insurance Company 18058 INSURED INSURER B: Whalen Restoration Services Inc. INSURER C; Whalen Services Inc. 22 American Way INSURER D: South Dennis,MA 02660 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. NOTIMTHSTANDING 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.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSftrypE OF INSURANCE ADDL SUER POUCY NUMBER D/YPOLICY EFF POLICY EXP LIMITS LTR NSD WVD (MMIDYYY1 IMMIDDWYYYI A X COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $ 1,000,000 • CLAIMSTAADE El OCCUR PPK1799951 04(01/2018 04(0112019 °e145sMNurren1 $ 100,000 MED EXP IAm onepenonl S 6'000 IPERSONAL SADV INJURY S 1,000,000 I ENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 X POUCY 12& n LOC PRODUCTS-COMP/OP AGQ S 2,000,000 OTHER s AUTOMOBILE UABILITY (Fa B NdeentSINGLE LIMIT S ANY AUTO BODILY INJURY(Per person) S _ OWNED SCHEDULED AUTOSp�� ONLY — AUTOSBODILYpBpgOqDILY INJURY(Peraccident) $ — _ Mow _ AUTOS ONLY (Petr accIRdent) AGE $ S — UMBRELLA UAB — OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE $. DED RETENTION • SS WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABIUTYT,/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S OFFICER/MEMDER EXCLUDED? I I NIA endatory In NH) E.L.DISEASE-EA EMPLOYEE S It yes,descte 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 if men space I.required) •CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Ekaterina 8 Marlon Cruz THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ek erRna 6A ACCORDANCE WITH THE POLICY PROVISIONS. 60Yarmouthport,MA 02675 AUTHORIZEDvyHRIREPRESENTATIVE I V ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • • • cr� --- . - - Commonwealth of Massachusetts 1 - f�e €nnmonwea/IA o/Qif4JiacAwkrl • 1®f Division of Professional Licensure Office of Consumer Affairs&Business Regulation I Board of Building Regulations and Standards �•-r-- i HOME IMPROVEMENT CONTRACTOR . Constr4 tf15it%ISpervisor i*VII a .•r>, TYPE:Corooralon ...z. j. Registration gala= CS-074928 '•TMo 4.7 . vires:08/10/2020 '-, -- - 129244 07/29/2019 1 • R :4I c HALEN RESTORATION SERVICES INC. < " a--- WILLIAM WHALEN t r `-'+ r�i-'�' 122 POND STREET' • ` t '" >�,� r-1- 3 ," D ���,. BREWSTER M�263l_ ,r s WILLIAM W HALEN - - .. 6^"-C--J _ _ ') rss- TdO* r n�..r SOUTH DENNIS,NN M ;-;:-.-..?;-..:••0 ` SOUTH DS,MA 02660 UnderseCfeG3l �� • Commissioner ci- • • . . • • . . _._.____________...._.__.____L__ . , . . . . . • i. • . Registration valid for individual use onlbefore the iration date. If found yrn to: r N. Office of Consumer Affairs and Business Regulation Construction Supervisor • • 10 Park Plaza-Suite 5170 Unrestricted-Buildings of any use group which contain Boston,MA 02116 • less than 35,000 cubic feet(991 cubic meters)of enclosed space. • Not valid without signature . - Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For Information about this license Call(617)7274200 or visit www.mass.gov/dpi