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HomeMy WebLinkAboutBLD-19-002804 RECEIVED C E I V E D Office use only o`•Y"R A—I,9rf—a ray O0 �„e1tl�, �C y. NOV 07 2018 Amount ///,oi) std. I L a D yr P `�f- fi,r 00 Permit expires ISO days from .:-•:iii 0' 111/ ! __ - 'issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 /^� (508)398-2231 Ext. 1261 6f/ CONSTRUCTION ADDRESS: tuAlwt eiti • ASSESSOR'S INFORMATION: Map: /€e. Parcel: 'q j OWNER: SSUS Till ZSl �'D(/yrj- SDc"72/4r2, NAME PRESENT ADDRESS TEL X CONTRACTOR: me a AiiI is 0244 A/4 krP4-94S 52t' /�7 NAME u - MAILING ADDRESS TEL X4. / Residential 0 Commercial 7 Est.Cost of Constructions h2, ) Home Improvement Contractor Lk.# /3J/ C Construction Supervisor Lk.# 1.11//2/ Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietoro /el have Worker's Compensation Insurance • ,/ ''�I Insurance Company Name:40 //207/41 /16. iU Worker's Comp.Policy# 19Nd 6©O7d3912e2d(94' WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares '3 Replacement windows:# I/ Replacement doors: # Z Roofing: #of Squares ( )Remove existing•(malt.2 layers) Insuiation4/00410a 5 s41p/a..V 4" Old Kings Highway/Historic Dist. ,_^(f,.)Replacing like for forr,like Pool fencing 'The debris will be disposed of at: $VtaAi •". ' S T,". 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 denial or re Iv of my license and for prosecution under M.G.L Ch.268,Section 1. / Applicant's Signature: V A Date: If ..&'/.t Owners Signature(or attachment)_ �•� �� .....-•-•••••-- ,.....—..C. .. Date: / (-v�. 'iipS Approved By: ✓ -4(... Date: Ii Building Offict (or designee) EMAIL ADDRESS: Zoning District: Historical District 0 Yes ❑ No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: D Yes 0 No 13 Yes 0 No J The Commonwealth of Massachusetts vg Department of Industrial Accidents 4—I t Office of Investigations Li a— t� el 6 =g — 9 600 Washington Street G ,: Boston,MA 02111 \ '+:. 5 ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): A4. .T. NA-cDovi E dA1L Pe 'e/ Lee ` Address: 0�90 WWI >Ash City/State/Zip: ),)4.4 YMctat0 ,M4• Le71 4 Phone#: So S,•77 i—T€29 Are you an employer?Check the appropriate box: Type of project(required): 1.21 I am a employer with 6 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. Pi.jtemodeling 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 have exercised their 11.0 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MOL 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#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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 4//It Mimi. hses ea Policy#or Self-ins.Lic.#: AG✓C ye0703Vl/7do?O/8/4- Expiration Date: 3•• 12— 1q Job Site Address: cls -opt:-11diam hn City/State/Zip: S *Alt /Woe 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$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. Be advised that 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 penalties of perjury that the information provided above is true and correct. Signature: A4 Part. Date: 11— g--- it Phone#: 510 5 • 71/-91.27 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#: uommonweaem or massacnuseus Division of Professional Licensure Board of Building Regulations and Standards ..r Con struttion tUpgrvisor CS-081139 E5pires: 09/1612019 • • MICHAEL J NARDONE 299 WHITES PATH , f (k SOUTH YARMOUTH MA 02664)` .r..4 . ir)1t1Hi� ' Commissioner aft __J V2€ owsmoteueea//%e '0(/a.kkrdsuJElfd OffIce of Consumer Affairs&Business HOME IMPROVEMENT CONTRACTOR ion TYPE:LLC Reatstratiort. FxpiratiQn 135887 08/14/2020 M J NARDONE CARPENTRY LLC. MICHAEL J.NARDONE 299 WHITES PATH SOUTH YARMOUTH,MA 02664 Undersecretary Registration valid for individual use only • before the expiration date. If found return to: • Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston,MA 02118 1) \Not vaTld without signature fi • TE ACS® CERTIFICATE OF LIABILITY INSURANCE DAo3/o7/zo BYY) ,/ 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(ies)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 NAMEACT Linda Sullivan DOWLING & O'NEIL INSURANCE AGENCY lac No EMI* (508)7754620 (AA/c,Ha): ADDRESS: Isu l liva n@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAICtI HYANNIS MA 02601 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B M J NARDONE CARPENTRY LLC INSURER C: INSURER D: 299 WHITES PATH INSURER E: SOUTH YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 245269 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMM/DD/YYYY) (MM/DD/YYYYII LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR –DAMAGE TO RENTED PREMISES(Ea occurrence) $ . .— MED EXP(Any one person) $ _ N/A I PERSONAL SADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S i POLICY n JECT PRO- ❑ LOC PRODUCTS-COMP/OP AGG S OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS — AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NON-0WNED PROPERTY DAMAGE $ _ AUTOS (Per accident) $ UMBRELLALIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH- ERAND EMPLOYERS'LIABILITY STATUTE ANYPROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 500,000 A (MandatoryFlnNH'EXCLUDED? n N/A WA AWC40070341722018A 03/12/2018 03/12/2019 E.L.DISEASE-FA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more 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 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/Iwd/workers-compensationlinvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of YarmouthACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZEDIZRIZnED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Cro y,CPCU,Vice President—Residual Market—WCRIBMA I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD