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SECTION 5:.CONSTRUCTION SERVICES .. . 5.1- Construction Supervisor License(CSL) r S �g�n . ' .r /� (A ger e A _ 13 c—,4 License License Number Expirati Date G Name of CSL Holder RD &16 nj $ List CSL Type(see below) (, and Street4.e Description .drab Unrestricted(Buildings up to 35,000 cu.ft.) u SCe 4 f k ato 9. I R Restricted l&2 Family Dwelling Cit'tTown,State,ZIP M Masonry RC Roofing Covering WS Window and Siding atJ�//3 Zarin L f✓ a(�ta Zeit .4* SF Solid Fuel Burning Appliances bo lJ I Insulation Telephone Email address D Demolition 5.2 Registered Home Imnprovement Contractor(HIC) Lae6 9s vt Vett, 114.ael L 'ciena �} HIC Registration Number Exp' on Date HIC Compae or HIC Registr lame /,�dSrPOCC. GwCo t4?A2rb1.94 1tJr d ��rf).• 6 -6s-scree(ljr� Email address City/Town,State,ZIP �/ 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 No ❑ • . -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 /LID _ 'c+¢1� to act on my bL� 1 ehalt inall matters relative to work authorized by this building permit application. w� Print Owner's Name(Electronic Signature) Da • • 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. Ln2:th. 131 I1gan1a�fte 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 t HIC)Program),will 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.gov/ocq Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" • • . • The Commonwealth of Massachusetts • =-g, , �'I Department of Industrial Accidents E_=iFlnl_ a 1 Congress Street,Suite 100 r _' :E- Boston,MA 02114-2017 _ www.mass.gov/dia J t Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Ppo, Far)44.r.) CL.sm ��_^^��s 71 .40 1__,1__ cam , Address: RO'be P Moo, City/State/Zip: f, ft,o QcQ 4A, Phone#: y13 S62'-O/oo Are you an employer!Cheek the appropriate box: Type of project(required): Ii am a employer with 3 employees(full and/or part-time).* 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees working for me in $.',Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself. t 9. ❑Demolition ❑ Y [No workers'comp.insurance required.] 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor end I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs 6.0 We area corporation and its officers have exercised their right of exemption per MGI.c. 14.❑Other 152,§I(4),and we have no employees.[No workers'comp.insurance required] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. !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. lithe 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: Le/►t L• , . , Policy#or Self-ins.Lic.#: be,WQC A/N7900 Expiration Date: 2/6 Z Job Site Address: ,3R Al aeA City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and a piration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c under the pains and penalties of perjury that the information provided a e is true and correct Signature: ` J1y,Q_ Date: he 019 t e Phone#: 111/ __CA - --©/LU o eti,?> Dec S Official use only. Do not write in this area,to be completed by dty 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#: • oF'1°'Rt� TOWN OF YARMOUTH c BUILDING DEPARTMENT •,Ra 1146 Route 28,South Yarmouth,MA 02664 • FCsr.•:,,:;; 0 508-398-2231 ext. 1261 Fax 508-398-0836 BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L.Chapter 40, Section 54 and 780 CMR,Chapter 1, Section 111.5, I hereby certify that the debris resulting from the proposed work/demolition to be conducted at 3% 4Jspy, to A Work Address Is to be disposed of at the following location: Pa J p,h I;��tio,l �, 4t�CX .gip I Said disposal site shall be a licensed solid waste fachity as defined by M.G.L. Chapter 111, Section 150A. 1/6, Ce.-4)C2 /12e Sign re of Application /Dte Permit No. • % C RO CERTIFICATE OF LIABILITY INSURANCE DAo fteMIU ,tea» 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 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 tights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT GLona Linzi NAME: Bates Fullam Insurance Agency,Inc PHONE INC NEXtI: (4,3)737.3539 (AICFA%,No): (413)731-8255 O. 975 Elm Street ADDRESS: glinzi@batesfullam.com INSURER(S)AFFORDING COVERAGE NMC IS West Springfield MA 01089 INSURER A: Twin City Fire Insurance Co 29459 INSURED INSURER B: New England Custom Countertops Inc INSURER C: P.O.Box 2102 INSURER D: INSURER E: Westfield MA 01086 INSURER F: COVERAGES CERTIFICATE NUMBER: 18-19 WC 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 EXP LTR TYPE OF INSURANCE NSD WYD POLICY NUMBER (MMUCIDDIYYYY) (MMLNO LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS-WOE OCCUR PREMISES(Eso rrencee)) _S_ MED EXP(Any one person) $ PERSONALS ADV INJURY $ GGEL ENAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE H _ S POLICY❑jEa D LOC i PRODUCTS-COMP/OP AGO $ OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE UM S (Ea accident) ANYAUTO BODILY INJURY(Per person) $ OWNED — SCHEDULED BODILY INJURY(Per accident) $ _ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) S UMBRELLA UAB OCCUR EACH OCCURRENCE _ $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION VI PER vl OT- AND EMPLOYERS'LIABILITYY STATUTE �I ER A ANY PROPRIETORNARTNER/EXECUTNE � NIA OBWECNN7000 02108/20,8 02/06/2019 EL EACH ACCIDENT $ ¶'00.000 OFFICERMEMBER EXCLUDED? (Mandatory In NH) i E.L DISEASE•EA EMPLOYEE $ )•000,000 If yes,describe under 1"°•0°°000 000 DESCRIPTION OF OPERATIONS below E.L DISEASE•POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached Emote space Is required) Custom Countertops: CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Blackman ACCORDANCE WITH THE POLICY PROVISIONS. 38 Alden Rd AUTHORIZED REPRESENTATIVE (� West Yarmouth MA 02673 C 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD ACCPRO CERTIFICATE OF LIABILITY INSURANCE DATE( AE( a°8n' • 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 The Dowd Agencies,LLC PHONE FAX 14 Bobala Road _AIC.No.EMT:413-538-7444 wc.No):413-536-6020 Holyoke MA 01040 IDDRIESS: info(Idowd.com CUSTOMER CUSTOMER ID S• NEWENGL-26 INSURER(S)AFFORDING COVERAGE NAIC S INSURED INSURER A:MAPFRE Insurance Company 23876 New England Custom Countertops, Inc INSURER e: P. O. Box 2102 Westfield MA 01085 INSURER C: INSURER 0: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:920184514 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 ADDL SUER POLICY EFF POLICY EXP LTR INSR wVD POLICY NUMBER (MMIDO/YYYYI (MWDD/YYYY) LIMITS A GENERAL LIABILITY 8008030009148 8/232010 8232019 EACH OCCURRENCE 51,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES RENTrtelKq) 550,000 _ CLAIMS-MADE n OCCUR MED EXP(Any one person) $5,000 PERSONAL B ADV INJURY S11000,000 _ GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIESPLIEPER: - PRODUCTS-COMP/OP AGG $2000,000 POLIC _ Y Jri E CT I ^ I LOC S A AUTOMOBILE LIABILITY BHKCTV 8/23/2018 823/2019 COMBINED SINGLE LIMIT 51000000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Peraccident) $ X NON-OWED AUTOS $ UMBRELLA UAB _ OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE $ - DEDUCTIBLE _ S RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY I IMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory In NH) EL DISEASE-EA EMPLOYEE S lives,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If mon spew Is required) CERTIFICATE HOLDER CANCELLATION 30 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Blackman 38 Alden Road West Yarmouth MA 02673 AUTHORED REPRESENTATIVE 01988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD [. 1, GU1E'NG'L'AN . liU5_ _ i MaTERTOP.S 4., isit our Showroom at South Maple St. • Westfield, MA AYNE &LISA BUSH BUSH.LW@VERIZON.NE 1 • O. Bo i Ph:413-56B-010f GRANITE • QUARTZ • MARBLg 'UPON' CORIAN • CUSTOM LAMINATE 10.. ." 7.1d.firrsIWNTWI APPOINTMENT of ce, DATE .. ♦ J r , Commonwealth of Massachusetts Division of Professional Licensure • [:-and of Building Regulations and Standards Con structten'$upervisor CS-082536 - 14 Expires: 11/25/2019 WAYNE A BUSH 3 C ] • -POBOX 178 RUSSELL MA 01071 'Noe.; 't%rte �.., Commissioner . V" - - c9L i(4aJn)!rant ltA ribilalaeArfae(/J Office of Consumer Affairs&Business Regulation s—sY HOME IMPROVEMENT CONTRACTOR TYPE:COvvoratlon . _o Registration. Exofratlon -14667505/09/2019 NEW ENGLAND CUSTOM COUNTERTOPS,INC. WAYNEA BUSH 7 SOUTH MAPLE ST -2 U _ .. WESTFIELD,MA 01086 Undersecretary' • st.Y TOWN OF YARMOUTH • c HEALTH DEPARTMENT * y ; ' t• PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: Building Site Location: 3' Wee, Rosa, Clle S4 \kis r ekWit. r NW\ Proposed Improvement: Raaii ;a-. d-f M a,c-143r- C v*t�• Applicant: Cr`a< Qin('KVWX . Tel. No.: ' fl-VY-i -OS.ad Address: )1WoL010-rnnavil•, 1(V\A O46CA Date Filed: UUNAIR **lfyou would like e-mail notification of sign off please provide e-mail address: eriKL /4400 (cw C.c S1.r e Owner Name: E r:l< Mott k Mc r. Owner Address: ilmor (} ,vo �oa;r�Fi�l1SMY� 01CAO Owner Tel. No.: 1-1k\-1l4'Oaa� C +ro at..� SAJay�t_.i'sui t (lS-a10-Sc‘ � — RESIDENTIAL AND/OR COMMERCIAL BUILDING HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements For Septage Disposal and other Public Health Activities. Please submit three (3) copies of plans, to include: (1.) Site Plan showing existing buildings, water line location, and septic system location; (2.) Floor plan labeling ALL rooms within building (all existing and proposed)— Note:Floor plans not required for decks,sheds, windows, roofing; (3.) If necessary, Title 5 application signed by licensed installer with fee. REVIEWED BY: "bat ger DATE: /2- --6 PLEASE NOTE COM NTS/COND TIONS. , 4, s. eetiC evifiAcm-x_ a$4r , /fig/akayiA TOWN OF YARMOUTH REVIEWED FOR BUILDING AND ZONING CODE COMPLI- Elevation 2 ANCE. ERRORS OR OMMISSIONS DO NOT RELIEVE THE' FILECOPY E2 APPLICANT FROM THE RES NSIBIUIYY�► k BUILT' COMPLIANC DATE ��EZ7 -/ ff BUILDING OFFIC y 5017'-q" > r-IC — E4'-515/16" II ILI rn .... E> D-] STIT: I rn 3 ` (0 I - o E3 0 I n r � W V ' • ifI `` 1824901U182490R I -1� iN271524R U I 3088 • EXISTING HOME Elevation 2 E2 501 T-1" > • r —i - _ - -- 1 < 4'-5 15/16" ii 46 ,� 1. — I I RI N m =. E1 1 . m F.iv O w to E3 I . & _...0q 1824901 1182490 I 3068 EX 15T I N& HOME Yarmouth Health Department PRO D • • ame 5O 7 Z 1 • 1,..`V A6. �� � AiliL. JEWng fir. • ..� IIIA , &KUM ,a®i d �� .�z BEE t ®tib �[IN 4 k .® . �� ,�+ v � v ;:: ^��H amp L rvV�t d A4 �� "'� �,. ,rte: p ...iIM Nor- 1 1 i 'I Maki Mile ir. • linaliVanfri *RIME RIM fl �'"' • ! M v, x ZTM"wi I, : ul �;wrl� 1 • � �G� 1 ''I rad _ in- - HMI R ins,*utirS roi,• ' 1' Ant °j.. it i ngstw sads�u�# a xalmalYeina•mast rt ento um .rt- .`t+. t ,J i i 1 L 1 f•t. t Mr.'l.�a i L, Elevation 3 Elevation 1 ZIBINalli 11 1 S Si II immemmonsonabibliTibirsomm� �rc��..Iti ommm SZI1 iI„Eggiffignmegunkrtai �4. VIIIIIINNIE onsommilsalEmalis 1 � SEMI MI IN ®p® ®® ® IIS=IIII'rmot MEW 41ME ZMZIMMIBIENIZEINEMEMBEZEINIZZIVEINIENIM m1&IfseimUIIIIl1AAAlIRY.MAR1A11 umml AfIINIM111A9 watt MIcomptis mmo Elevation 2 38 Alden Road,West Yarmouth,MA 02673 GorztP- ROOM BATHROOM ROOM FOR MASTER BEDROOM RENOVATION DIING ROOM LIVING ROOM ALDEN ROAD KITCHEN DRIVEWAY