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HomeMy WebLinkAboutBLD-19-003268 • Of•1 qR fr 1 Office Use Only tk gC Permit# 0 �" Amount 6D— '. it%"'i'3�c .Permit expires 180 days from t tissue.me - , 51,0-Iq-oD EXPRESS BUILDING PERMIT APPLICATI! E C E I V E D TOWN OF YARMOUTH Yarmouth Building Department NOV 2 8 2018 1146 Route 28 South Yarmouth, MA 02664 6 U I fir 1 r� (508)398-2231 Ext. 1261 - CONSTRUCTION ADDRESS:,01Arthur Lane in Yarmouth Port ASSESSOR'S INFORMATION: Map: 114 Parcel: 61 OWNER: Elizabeth Bader Same 508-362-6389 NAME PRESENT ADDRESS TEL N CONTRACTOR: Michael Ferullo PO Box 549 in Yarmouth Port 508-801-3532 NAME MAILING ADDRESS TEL N residential ❑Commercial Est.Cost of Construction$ 5,800.00 Home Improvement Contractor Lie.# 171899 Construction Supervisor Lie.# CS-107347 Workman's Compensation Insurance: (check one) - / 0 I am the homeowner ❑ I am the sole proprietor NI have Worker's Compensation Insurance Insurance Company Name: Star Insurance Company Worker's Comp.Policy# WC0869747 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# 1 Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation 01101% Old Kings Highway/Historic Dist. (V)Replacing like for like Pool fencing *The debris will be disposed of at Town of Yarmouth Transfer Station 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 v ali of my lice and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: o�.,ae Date: 11/28/18 Owners Signature(or attachment)t)// Date: Approved By: B����Y �e,.-�[/ Date: 7/%2a 719 Bu' n iael(or designee) UJJ EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 it of Wetlands: 0 Yes 0 No 0 Yes 0 No • The Commonwealth of Massachusetts _:_t=1 :_t= Department of Industrial Accidents lti—_ Office of Investigations I _�s,_ $ 600 Washington Street . a /t_ la Lv,� Boston,MA 02111 • tr. to'° www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Ferullo Remodeling Inc Address: PO Box 549 City/State/Zip: Yarmouth Port/MA/02675 Phone #: 508-801-3532 Are you an employer?Check the appropriate box: Type of project(required): 1. ✓ I am a employer with 3 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub contractors 6. New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ✓ Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance.: 9• Building addition required.] 5. We are a corporation and its 10. 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. Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13. 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: Star Insurance Company Policy#or Self-ins.Lic.#: WC0869747 Expiration Date: 04/15/2019 Job Site Address:_ 50 Arthur Lane City/State/Zip: Yarmouth Port/MA/0M 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: Date: 11/27/18 Phone#: 508-801-3532 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#: Owner Authorization Form Authorization must accompany application if the owner is not the applicant. I, 15//u4P c4' Soder as owner of the property located at 50 Arthur Lane in Yarmouth Port Authorize Michael Ferullo to file an application for a building permit. Authorization Michael Ferullo, Ferullo Remodeling Inc Name of Authorized Agent/Contractor Owners — Signature /001 Date • • ACORO DATE(MWDDYYYY) CERTIFICATE OF LIABILITY INSURANCE 4/20/2018 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(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 Mason&Mason Insurance Agency, Inc. r�oM E FAX 458 South Ave. H . , •781447-5531 - No:781447-7230 Whitman MA 02382 E-MAIL SS: INSURER(S)AFFORDING COVERAGE NAIC INSURER A:Main Street America Assurance 29939 INSURED FERUREM-01 INSURER B:Alimerica Financial Benefit 41840 Ferullo Remodeling, Inc. PO Box 549 INSURER c:Star Insurance Company 18023 Yarmouth Port MA 02675 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:430241202 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP LIWTS LTRINSD IND POLICY NUMBER IMWDD/YYY•n IMWDDIVYYYI A X COMMERCIAL GENERAL LIABILITY MPPOI65G 4/192018 4/152019 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $500,000 MED EXP(My one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE _ $2,000,000 POLICY 0 ECT LOC PRODUCTS•COMP/OP AGG $2,000.000 I OTHER: $ B AUTOMOBILE LIABILITY AWVD225988 4/15/2018 4/15/2019 COMBINED SINGLE LIMIT $ fEa ecddaMl 1000 Q00 ANY AUTO BODILY INJURY(Per person) $ ALL DIVINED x SCHEDULED BODILY INJURY(Per acddenl) $ AUTOS AUTOS X HIRED AUTOS X AUUTNOSVMED Per axRide() DAMAGE $ $ UMBRELLA WB OCCUR EACH OCCURRENCE _ $ EXCESS UAB CLAIMS-MADE - AGGREGATE $ DED RETENTIONS S C WOR KERSCOMPENSATION Y.00869747 4/152018 4/152019 X PER OTH- AND EMPLOYERS'LIABIUTY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? n NIA (Mandatory In NH) EL DISEASE•EA EMPLOYEE $500,000 rc yea deswee Wer DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may Be attached K more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Ferullo Remodeling Inc PO BOX 540 AUTHORIZED REPRESENTATIVE Yarmouth Port MA 02675 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD (Yee ifaanmoneneald rfC/47.0m-hart* Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. H found return to:. Registration _ Fxnlration Office of Consumer Affairs and Business Regulation ,...171899 f_._04/29/2020 One Ashburton Place-Suite 1301 MICHAEL FERULLO y`_ Boston,MA 02106 MICHAEL FFRULLO IL.Gf,�Q1--- . —.V YARMOUTH 2 RE OR C.� of valid without signature PORT,MA 02675 Undersecretary - rCommonwealth of Massachusetts ®, Division of Professional Licensure Board of Building Regulations and Standards Constryuettorl tdpervisor CS-107347 ` ' "`? ,, Lrgpyes:09/09120:9 MICHAELFERULLO v ,l . PO BOX 649 %• ' ° (� , YARMOUTH PORT MA 02676 %.%`-- ati f 4 Commissioner