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HomeMy WebLinkAboutBLD-19-003453 • ce Use Only ,. ortist to N 4i'rQ xH 1Amount sCa 1. �]y cd Permit expires 180 days from 'issue date I • EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 1 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: JN ��wt, Fr4,Ltluc leak fauth yar Vl&n It tk) ASSESSOR'S INFORMATION: Map: 51 Parcel: qi OWNER: 10 /` .J IL.rcl,ti t 99? Cn.p i-�trSENT�DR ry/�IA)a It etc ( I�JE I'l(.d sr NC 0 '19,20 CONTRACTOR: George 3(,WES I�.c. el11 N. [1 LA, Jk. S. Ya,nt ortik, ,41)f-c39 4- Ot3�.. . NAME J MAILING'ADDRESS TEL ti /Residential 0 Commercial Est.Cost of Construction$ 100 0 0.7 Home Improvement Contractor Lia# J 1 0 0104 Construction Supervisor Lic.# U G 1 do Workman's Compensation Insurance: (check one) 0 I am the homeownerr 0 I am the sole proprietor .4I have Worker's Compensation Insurance ^ Insurance Company Name: /itSiraegaterg, Th.d.r�.tl'f,rr&I' Worker's Comp.Policy# 1.Jw1 �OSo1+39onC.O 8k l WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares I ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historics `f" Dist. ( )Replacing like for like Pool fencing t 1 *The debris will be disposed of at: /fly CA Location of Facility I declare under penalties of perjury that th tate ents 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 revoc r of m icense and for prosecution under M.G.L Ch.268,Section 1. In Applicant's Signature: .. Date: I t 1,/I t Owners Signature(or attachment) .. Date: 1111 I Approved By: I Date: /2-—C—/g Buil ' O or &sign&e) E ADDRESS: Zoning District: Historical District: 0 Yes 0 No 1 Flood Plain Zone: 0 Yes ❑ No R Water Resource Protection District: Within 100 ft.of Wetlands: c22`3' ni/T 0 Yes ❑ No ❑ Yes 0 No `��j '(r' / DEC 06 2018 J BUILDING DEPAFT7INENT By e w r e ynsnneonivrald flauackude/A Office of Consumer Malts&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration fxpiratioq Office of Consumer Affairs and Business Regulation 160164 ' 07/012020 One Ashburton Place-Suite 1301 GEORGE DAVIS,INC. Boston,MA 02108 GEORGE F.DAVIS 33 NORTH MAIN STREET SOUTH YARMOUTH,MA 02664 UnderseCreta Not valid without signature ry I, • Massachusetts Department of Public Safety - t Board of Building Regulations and Standards . s License: CS-056130 Construction Supervisor . GEORGE F DAVIS 33 N MAIN ST S YARMOUTH MA 02664 • 177/ lv "Lea-- Expiration: ommissio er 03/01/2019 • • e: The Commonwealth of Massachusetts Department oflndustrialAccidents �nl= 1 Congress Street,Suite 100 tg=I Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information /�� �T Please Print Legibly Naim(Business/Or�ganization/IIndividual): l' a��Or(;�C3Q,`/t '/ -l—(4C. Address: 33 IVov+VL tan,. .PLreet City/State/Zip:J YA,rht•o(Lf.L1 'v1/4 0 2 Gs as t1 Phone#: OP-wp4- O fl2, Are you an employer?Check the/ appropriate box: Type of project(required): 1,21 am a employer with 'I. employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8.,Remodeling any capacity,[No workers'comp.insurance required.] 3.01 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❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0l am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13,2ROOf repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We area corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'camp.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. A Insurance Company Name: ,A tPQ oCiat td, �lin,eLa,tr-bVi Pcp 4'&x(1. ra. kce, Policy#or Self-ins.Liic.#: W CCC 3'06 3' o i i 3q Q,2O let Expiration Date: 3/5111 Job Site Address: 111 AIL tl 1air' IL di quail/ City/State/Zip: (P, Yar-viu 11.,t40 Attach a copy of the workers'compensation policy declaration page(showing the policy number and 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 hereby certify under th ins and penalties of perjury that the information provided above is true and correct. Signature: Date: I a) Co/i ? Phone#: g o P' 3 4q-- 6 Att 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 GEORDAV-01 KMELCHER ACORO' CERTIFICATE OF LIABILITY INSURANCE DATE/MM/00/YYYY) 4....----- 03/05/2018 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(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 rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT Gwen Vosburgh NAME' Mason 8 Mason Insurance Agency,Inc. PHONE Eat (603)356-3392 I FAX 458 South Ave. ( 1: (A/C,NA):(603)356-9290 Whitman,MA 02382 Fooabs.gwen@mmins.com INSURER(S)AFFORDING COVERAGE NAIC S INSURER A:Westem World 13196 INSURED INSURER B:NGM Insurance Company 14788 George Davis,Inc. INSURER c:Associated Industries Insuranc 33 North Main St. INSURERD: South Yarmouth,MA 02664-3437 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LIR INSD W D IMM/DD/YYYY1,4MM/DDIYYYYI A X COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE n OCCUR NPP1477087 01/12/2018 01/12/2019 DAMAGETORENTED 100,000 PREMISES(Eaoaunercal E _ MED EXP(Any me person) $ 5,000 PERSONAL BADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE ; 2,000,000 POLICY I I 3g8t LOC PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY (Ea accideent)INGLEUMIT $ 1,000,000 ANY AUTO _ M9M28491 10/26/2017 10/2612018 BODILY INJURY person) E — - OWNED SCHEDULED _ AUTOS��pONLY X AUTOSUpN{{��WWNNEEop BODILYpINJURYT (Per accident) S X AUTOS ONLY X 'Sera (ale�J trII DAMAGE E E UMBRELLA LIAB _ OCCUR EACH OCCURRENCE J - EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTIONS $ C AND EMPRKERSON X STATUTE FOR" WCC50050143902018A 03/05/2018 03/05/2019 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFF Roily In NHi EXCLUDED? N N/A 500,000 1Ityes a ory n ) ELDISEASE EMPLOYEE $ II yea,describe under - 500,000 DESCRIPTION OF OPERATIONS below _ E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Office Copy CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE i THE EXPIRATION George Davis,Inc. ACCORDANCE WITH TTHE ATE POLICY PROVISIONS. WILL BE DELIVERED IN 33 North Main St. • South Yarmouth,MA 02664-3437 AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD