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Home My WebLink AboutBLD-19-3355 r �, , Office Use Only i°1'' Amo I —t9- 3355 • p •�, R y N `n.- m..."4 lAmount Permit expires 180 days from 1' issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department R E C E I U [3 1146 Route 28 fit& South Yarmouth,MA 02664 DEC 3 2018 (508) 398-2231 Ext. 1261 BUILD' EPARTMENT CONSTRUCTION ADDRESS: Ix J pi-Dein/ MCMvRfila `i kr "Y ASSESSOR'S INFORMATION: Map: Parcel: OWNER: iAtWI QAiJNF) id Tata ist MEM>P,.iIAl- foeag0 at& I NAME // RESENT ADDRESS TEL # CONTRACTOR:J/4FloJi rot,-IV'-1O aJ s r iFAieNIA S'D24'i,2,2,2ia NAME MAILINADRESS TEL # 2Resf idential 0 Commercial Est Cost of Construction S dam. Home Improvement Contractor Lic.# i&gs3q Construction Supervisor Lie.# egg 113 Workman's Compensation Insurance: (check one) � ` 0 I am the homeowner 0 I am the sole proprietor CT l have Worker's Compensation Insurance t J Insurance Company Name: s 1&4'\t.� ('l�u AL. Worker's Comp.Policy#�1) 4..3t �Ct Kig(b I C 1 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # ...-- Roofing: Roofing: #of Squares I ( ,emove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: II4_T m'DQ "Ibtt,tor C Location of Facili 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 f• al or rev.0�f my license and for prosecution under M.G.L,Ch.268,Section 1. Applicant's Signature: (.0.4)..._ • Date: I1,1 be Owners Signature(or attachment) '. . Date: la -.3—iv -,/p Approved By: -s• /,9" l Date: � — S -! tJ • •fficial(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 O A CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 04/17/2018 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 NAMEtCT Craig VOkey CRAIG S VOKEY DBA MARK T VOKEY INSURANCE A C No.MI: (506)945-3535 FAX Nor DRESS: craig@vokeylnsurance.com P 0 BOX 1247 INSURER(S)AFFORDING COVERAGE NAIC 1/ WEST CHATHAM MA 02669-1247 INSURER A: LIBERTY MUTUAL FIRE INS CO 23035 INSURED INSURER B: ' SEASIDE ROFFING AND SIDING LLC INSURERC: INSURER D 23 RIDGEWOOD ROAD INSURER E: ORLEANS MA 02653 INSURERF: COVERAGES CERTIFICATE NUMBER: 258326 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD wvn POLICY NUMBER (MM/DDIYYYY) IMM/PD/YYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S DAMCLAIMS-MADE E OCCUR PREMISES(Ea ocNcurrence) 3 — MED EXP(My one parson) $ — N/A PERSONAL 8(ADV INJURY 3 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY PROT E LOC PRODUCTS-COMP/OP AGO 3 JEC OTHER' $ AUTOMOBILELIABILITY COMBINED SINGLE LIMIT $ (Ea accident) — ANY AUTO BODILY INJURY(Per person) $ AOVMED SCHEDULED N/A BODILY INJURY(Per accident) $ _ AUTOS AUTOSN/A PROPERTY DAMAGE S _ HIRED AUTOS _ AUTOS (Per accident) _ S • UMBRELLA UAB _ OCCUR EACH OCCURRENCE S — EXCESS UAB CLAIMS-MADE N/A AGGREGATE S _ DED RETENTIONS 3 WORKERS COMPENSATION X PER ER OTH- AND EMPLOYERS'LIABILITY A OFFICER/MEMBEREXCLUDED?ANYPROPRIETOR/PARTNEFUEXECllTIVE WA N/A NIA WC231S615989018 04/26/2018 04/26/2019 E.L.EACH ACCIDENT S 100,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE 3 100,000 Ityes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT S 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space I.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 ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth Building Dept 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 'Thp C� I Daniel M.Cro vy,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 The Commonwealth of Massachusetts Department oflndustrialAccidents Congress Street, Site • • _ = 1 Boston, MA 02114-2017 100 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information /` Please Print Legibly Name (Business/Organization/individual): IPA fo / AIM -Ca L(f Address:a9t ithE oa City/State/Zip:fQ`eA 144 w alt„,53 Phone#:`ha13aaa7.11- Are you an employer?Check the appropriate box: Type of project(required): 1.0 1 am a employer with t employees(full and/or part-time).* 7. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working forme in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbinglurepairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0.16-of repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0We are a corporation and its officers have exercised their right 14.0 Other gM of exemption per MGL c. 152,§1(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. 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 andJob site Information. M ) Insurance Company Name: t�) t)t1 f i Policy#or Self-ins.Lie.#: 1 cle'4 _1 �Tgq0J£' Expiration Date: 4\a6LIR Job Site Addressgartil4 4 0 It d4o2►a t. d L City/State/Zip114?-0lt BLit, Attach a copy of the workers' compensation policy declaration page(showing the policy n}}mer an expiration 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 hereb , .67 und��.ains and penalties of perjury that the information provided above is true and correct Signature: . „' Date:as It//S-" Phone#: SQi ' &ani 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#: • r Commonwealth of Massachusetts Division of Professional ensure Board of Building Regulations Licensure Standards Cons tructio{tSlfpdiAsor Specialty it CSSL-099163 Eyires: 10/07/2019 JOSEPH J JACINTO _ 23RIDGEWOODROAD ORLEANS MA•02653 • Md�.� ,it ()ANA 10' Commissioner C :ern /dm" )G,. i $ Office of Consumer Maus 8 Business Re 111:n X', ; `L`, HOMEIMPROVEMENT CONTRACTOR C' ,`' TYPE:UWtvidual F. pegtStrattort Exotration fs _ .138539:. 04,70/2019 JOSEPH J.JACINTO .4 D/B/A SEASIDE ROOFING AND SIDING JOSEPH JACINTO i • 23 Ridgewood Rd Orleans MA 02653 undersecretary