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Home My WebLink AboutBLD-19-3836 V ) te i Office Use Only St /A R-1'%'t 0 J/ 91/4 f p �A- 0. .. , i Permit# l G • ,'l'. H $Amount 5 Q— S `.% _ •.,, , s f. .Permit expires 180 days from `- •%: '" issue date ., 13LA- lc/-ob38.3f0y� ECEIVEL EXPRESS BUILDING PERMIT APPLICATION —I 1 TOWN OF YARMOUTH I DEC 2 8 2018 I Yarmouth Building Department - 1146 Route 28 BUr.iDIiNG DLPA2TMcNT South Yarmouth, MA 02664 "" ,(5508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: "70/ ✓(/)./L Oat J( iAs 01/t —CO c4.:51-4 )1f 1Qy...42 ate, ASSESSOR'S INFORMATION: • Map: Parcel: �J OWNER: 4L PEralief4 7o/ up(`OU) Sr / 1/ ?6 y 573/ N ` r PRESENT ADDRESS TEL. # CONTRACTOR: / ry E A 0vI 70 —/ it NAME MAILING ADDRESS # �� esidential ❑Commercial Est Cost of Construction$ 6b0 b•CD Home Improvement Contractor Lic.# Intl Construction Supervisor Lie.# C 5--//1,3 o S Workman's Compensation Insurance: (check one) 4 I am the homeowner/n` ❑000�II aam the�sole e proprietor\n. // have Worker's Compensation Insurance //'� �� /�1 Insurance Company Name: E42 y (/"C 'd K`[r vo worker's Comp.Policy# w C5 �S-C/'y-/U j/// WORKUTO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of SquaresReplacement windows:# Replacement doors: # Roofing: #of Squares ��++(> - ( ) ove existing"(max.2 yers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing fencing *The debris will be disposed of at g 0 et % Pe-t- /// Location of Facility , �/ I declare under penalties of perj at the st ,, ents herein co f',ed 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 re 0.ation of it license and for• osecution under M.G.L.Ch.268,Section 1. Applicant's Signature: �y, ,/ Date: Owners Signature(or attach ent) ,....e � - /,[jam(,[ Date: /a-a 0�/-/ P Approved By: 40—../ _ Date: h— 2 1 it Building Ofhe or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ 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 . The Commonwealth of Massachusetts __,cam gr/ Department oflndustrialAccidents L =!r! 1 Congress Street, Suite 100 t!_= Boston, MA 02114-2017 ,-,,..%.7... 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): b`t/`i Tit ick Address: 2-o ' di ?) -'ac City/State/Zip: f43'►$ A'A-5 NES Phone#: n 20"17.9r7 , Are yo a employer?Check the appropriate box: Type of project(required): 1. I am a employer with employees(full and/or part-time).* 7. 0 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 doingall work myself t 9. ❑ Demolition ❑ y [No workers'comp. insurance required] 4.❑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 contactors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.D Other 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-contactors have employees,they must provide their workers'comp.policy number. .1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. / / Insurance Company Name: ��ry� ecce,/lt/1'til ! Asa f'nee , Policy#or Self-ins.L7ic.#: M'C/S s— ``co''p-`a iration Date: Q2��/ �l�s Job Site Address: —0/ C � f (�4W .i/ City/State/Zip:eSt K J enc_o fr1 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 statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the p ns and pen',/'es of perjury that the information provided above ' true and correct. Signature: /l t4 ` ^n Date: 12 G2 "WN 62Y87Phone#: 62Y8711d v / y 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#: :�-� • �' ; Commonwealth of Massachusetts, . . . �L7 Division of Professional Licensure Board of Building Regulations and Standards • Constructidd%iipervisor CS-111305 '" Egpire*: 06/01/20: ANDRE YARMALOVICH,it 204CINDERELLO TERRACE r � ti' ,. � • MARSTONS MILLS MA 02648• i. t,, .i4• } Commissioner • i• r `92, f(•ofnmontoeal/A a`'Q ffauacAxaueta Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT C9NTHACTOl TYPE:Indivitl pealstration Expiration . 172476 07/01/2020x ANDREI YARMALOUICH oB/A BEL ISLANDS HOME IM MENT ANDREI YARMALOVICH 204CINDERELLA TEFL C.� MARSTONS MILLS,MA 02648 Undersecretar J , ® DATE(MM/DOIYYYY) A`ORO CERTIFICATE OF LIABILITY INSURANCE 4/3n018 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 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 BRYDEN& SULLIVAN INS NAMEACT 88 FALMOUTH RD PHONE FAX HYANNIS, MA 02601 E.MAIL No FFM), IANC.No): ADDRESS: INSURERIS)AFFORDING COVERAGE • NAIcI • INSURERA: LM Insurance Corporation 33600 INSURED INSURER B: BEL ISLANDS HOME IMPROVEMENT LLC 204 CINDERELLA TERRACE INSURER C: MARSTONS MILLS MA 02648 INSURER D: INSURER E INSURER F: COVERAGES - CERTIFICATE NUMBER: 41181950 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. NOTMTHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO NMICH THIS CERTIIICA IE 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 ADDLSUBR POLICY EFF POLICY EXP LIMITS • LTR INSD WVn POLICY NUMBER (MMIDOD'YVYI (MMIDDryYYY) I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE DAMAGE TO RENTED CLAIMS-MADE E OCCUR PREMISES(Ea occurrence) E _ MED EXP(Any one person) $ _ - PERSONAL CV INJURY E GENII AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE E POLICY 0 PR6T LOC PRODUCTS-COMP/OP AGG S JECI OTHER. • E • AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) S — OWNED SCHEDULED BODILY INJURY(Peracudent) E — AUTOS ONLY I AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY ` AUTOS ONLY (Per accident) _ I UMBRELLA LIAB _ OCCUR EACH OCCURRENCE E EXCESS LIAB CLAIMS-MADE AGGREGATE E DED RETENTION S A WORKERS COMPENSATION WC5-31S-615667- 2/11/2018 2/11/2019 ,i I STATUTE 1 W- AND EMPLOYERS'LIABILITY ANYPROPRIETORIPARTNERIEXECUTIVE Y�uIN1 E EACH ACCIDENT 5500000 OFFICER/MEMBEREXOLUDED9 IJ NIA (Mandatory In NH) EL DISEASE-EA EMPLOYEE 5500000 If yes,deacnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 5500000 DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES(AGGRO 101,Additional Remarks Schedule,may be attached if mon space Is required) WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION PHIL RYAN - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE HARBOR FARMS RD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN • 7 EAST FALMOUTH MA 02536 AccoRDANCEWTHTHEPOLIcvPRovlsloNs. AUTHORIZEDREPRESENTATIVE .. Jon Smith i . I 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 41181950 I 1-615667 118-19 WC I n0254981 14/3/2018 2:10:29 FH ICOTI I Fag* 1 of 1