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HomeMy WebLinkAboutBLD-19-3132 i -- i Office Use Only • l Permit# Q'. Y I O 'ISO' . H Amount ;?�4.i Z a fix 4Permit expires 180 days from 1, w...m - -0•:-.4/.c#1?"...... issue date aLI)-Iq-003 laa EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 . South Yarmouth,MA 02664 (508) 398-2231 Ext. 126 1 • CONSTRUCTION ADDRESS: gbra 5/ t Aft-if tiy ASSESSOR'S INFORMATION: • • ��SMf/ap: "7/ Parcel: OWNER: l7h7Jio Gj$ dtte SZ? ?vsn Dt. 5-ei 5T,'882? NAME/ ^ r, PRESENTE � ADDRESS 744 TEL # • CONTRACTOR: ✓/. t( c A/Nn ea- G.4 �h !�l I4. S cn-fl/-1c NAME O MAILING ADDRESS TEL.# 'Residential 0 Commercial , . Est.Cost of Construction$ txa_'3 - Home Improvement-Contractor Lic.# J. 315 0p- 7 Construction Supervisor Lic.# et//27 / Workman's Compensation Insurance: (check one) ,,( 0 I am the homeowner 0 I am the sole proprietor fl-have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED 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 - t 6 *The debris will be disposed of at: )iv�a G 'r' - a ? ,l/S/A ta14 ( Location of fAcility I declare under penaltie du i 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 de VI t.caq 1.f. license and for prosecution under MG.L Ch.268,Section 1. /MI#.Applicant's Signature: � Date: 49 Owners Signatur p Date: • Approved By: . T` i Date: I) ' dm - is 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 ' SECTION 5:.CONSTRUCTION"SERVICES 5.1 Construction Supervisor License(CSL) Ai 0-AkIrteerier • License Number Expirition Date Name of CSL Holder �I 44:45 4 7 .� 1 /� List CSL Type(see below) 1) No.and Street n',ry�Y7''f Type , . _ Description S y ""r nets?66 U Unrestricted(Buildings up tol 35,000 cu.f.) City/Town,State,ZIP 7 R Restricted 1&2 Family Dwelling M Masonry • RC Roofing Covering WS Window and Siding c ,,/) �,t�• SF Solid Fuel Burning Appliances 5! -7 ' )(l' 27 AliIN M4N 'CO= I Insulation Telephone Email4address D Demolition 5.2 Registered Home Improvement Contractor(HIC) { 7 , _ _ M• JN42bfe HIC Registration Number Expire'on Date HIC2qCompany e i/� egi t Name �`� !r llddi./d /1M-4),Rond.COkt. No.nnd Street M11-- y Email address S Y/7001. ` 1 flag/ cin-,77/ 4)727 City/Town, State, Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes Al No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN . OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT .. I,as Owner of the subject property,hereby authorize /4. S. T ate Brn()(5r— to act on my behalf,in all matters relative to work authorized by this building permit application. cnb 4. 4.. it_g-/t Print Owner's Name(Electronic Signature) Date • • SECTION 7b: OWNER!OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Pit. T 10 00-06-.4.. //-8-• It Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),Mt not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is1 d ovide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) '5C) Habitable room count Number of fireplaces / Gori Number of bedrooms 3 Number of bathrooms Z. Number of half/baths / Type of heating system VI/FTG Number of decks/porches / Type of cooling system a VA-C Enclosed / Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" • • The Commonwealth of Massachusetts • Wit=r Department of Industrial Accidents TN= Office of Investigations 7= 1 n 600 Washington Street 1 Boston,MA 02111 :.._ • • www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): A4. �"• Nt,LDmE Ceire-Pe *C/ LLC• Address: ACP W h l ' City/State/Zip: th,46 StdanootgMA-A2t4WI Phone#: So a•771-5V? Are you an employer?Check the appropriate box: Type of project(required): 1.[g I am a employer with 6 4. 0 I am a general contractor and I 6. 0 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. A Remodeling ship and have no employees These sub-contractors have g• 'Demolition working for me in any capacity. employees and have workers' 9 0 Building addition [No workers' comp.insurance comp. insurance.t 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.❑ 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#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/fit nu9Z nit OS co Policy#or Self-ins.Lic.#: Mitfe yet/70 31070426 l$A- Expiration Date: 3- 12 1$ Job Site Address: g S,4114 f t y City/State/Zip: 5 froth Al-nal/ 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 certi;under the pains and penalties of perjury that the information provided above is true / and correct Signature: A441, dirtcJsr t_ Date: AC-1�/` Phone#: X47 5 • 7?/-q127 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#: VVIIIrIkVI,WCY0.I1 V, :vs rtuact,i • Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor CS-081139 Expires: 09/16/2019 • MICHAEL J NARDONE t 299 WHITES PATH SOUTH YARMOUTH MA 02664 " I• • Commissioner • cii4e 6 ,rnmouraeafA n/C(lajlarA,ne,t Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:LLC Registration Fxol ation 135887 08/14/2020 M J NARDONE CARPENTRY LLC. MICHAEL J.NARDONE 21`—' 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 of valid without signature ,460R00 CERTIFICATE,OF LIABILITY INSURANCE DATE o3/o7nolaTY) 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 CONTACT NAME: Linda Sullivan DOWLING & O'NEIL INSURANCE AGENCY A/ NECu EN): (508)775-1620A/c,No): E•MAIAD ADDRESS: ISull'IVan@doinS.COm 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIL# HYANNIS MA 02601 INSURER A: 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 TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD, POLICY NUMBER (MM(DD/YYYY1 (MM/DD/YYYY)COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ — DAMAGE TO RENTED CLAIMS-MADE 7OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) _ $ N/A PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROT- fl LOC PRODUCTS-COMP/OP AGG $ JEC OTHER' $ AUTOMOBILEUABILITY COMBINED SINGLE LIMIT $ (Ea accident) — ANY AUTO BODILY INJURY(Per person) $ ALL AUTOS OWNED SCHEDULED AUN/A BODILY INJURY(Per accident) $ _ _ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) —$ UMBRELLA MB _ OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE ETH AND EMPLOYERS'LIABILITY A OFFICER/MEMBER EXCLUDED?ECUfIVE Yt N/A N/A AWC4007034172201 SA 03/12/2018 03/12/2019 El..EACH ACCIDENT $ 500,000 (Mandatory In NH) E.L.DISEASE•EA EMPLOYEE S 500,000 K yes,desate urger DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS/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 8,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-compensationfinvestigationsl. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE . THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Y0ff1l0Uth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 CD4.-- I . Daniel M.Cr L, y,CPCU,Vice 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 '.