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Home My WebLink AboutBLD-19-003936 • Office Use Only Sf'Y -.Permit!,Amount y Permit expires 180 days from issue date Bus—P-&03`3(0 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH i`` ECEIVEr.) Yarmouth Building Department ' 1 1146 Route 28 JAN 03 2919 j I South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 Blli' 6-91 r CONSTRUCTION ADDRESS: 33 DANBURY ST South Yarmouth,MA 02664 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: BIZUNOK ALEKSANDR 109 PAWKANNAWKUT DR WEST YARMOUTH,MA 02673 617-803-8032 NAME PRESENT ADDRESS TEL # CONTRACTOR Anatoli Sivitski 27 Mill Pond rd W.Yarmouth,MA 02673 508-685-9720 NAME MAILING ADDRESS TEL e X Residential 0 Commercial Est.Cost of Construction$ 19,500 Home Improvement Contractor Lie.# 168043 Construction Supervisor Lie.# 106040 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor )C I have Worker's Compensation Insurance Insurance Company Name: AMGUARD INSURANCE COMPANY Worker's Comp.Policy# R2WC918542 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 12 7 Replacement windows:# Replacement doors: # Roofing: #of Squares 20 (X )Remove existing'(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing S&J Exco Dennis one debris will be disposed of at 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 revocation of my license andllforor/prosecution under MAL Ch.268,Section I. Applicant's Signature: 4ILa a,,,III��.LAG Date: 01/02/2019 p Owners Signature(or attachment) 11+� i Date: 121'3j l Ito p Approved By: B g y-yC�/ i Date: A��% /� / Bui g cud(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 The Commonwealth of Massachusetts = l Department oflndustrialAccidents 1,34� Boston, 100ess Street,Suite MA 02114-2017 -f'^* 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):Anatoli Sovitski Address: 27 Mill Pond rd W.Yarmouth, MA 02673 City/State/Zip: Phone#: 508-685-9720 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 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] 3.0 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 wployeea 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet ❑ rep 13. X Roof airs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL e. 14.❑Other 152,{l(4),and we have no employees.[No workers'comp.insurance required] *Any applicant that checks box 11 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 tContracton 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:: AMGUARD INSURANCE COMPANY Policy#or Self-ins.Lic.#: R2WC918542 Expiration Date: 02/06/2019 Job Site Address: 33 DANBURY ST South Yarmouth,MA 02664 City/State/Zip: 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 the pains and penalties of perjury that the information provided above Ls true and correct. Si¢nature: 'At , � Date: 01/02/2019 phone#: 508-685-9720 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#: ✓ e re I / /L 0�. /e%(JCLeieia0/1((lei,6/ - . Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston, Mass chusetts 02118 Home Improveniettntractor Registration • _ -11 Type: Corporation CAPE COD HOME IMPROVEMENT,INC. _ Registration: 126042 27 MILL POND RD _ Expiration: 12/06/2020 WEST YARMOUTH,MA 02673 - 11/447:: -s :: 'z sJ Ns V Update Address and Return Card. SCA 1 a 20M-05/17 ...9Z romenonevead/feyideadAza4A/A(4- Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPELCorporauon before the expiration date. If found return to: Expiretion Office of Consumer Affairs and Business Regulation Fri 1380214 _y 12/06/2020 1000 Washington Street-Suite 710 CAPE COD H ME IM OVEI ENT,INC. Boston,MA 02118 4 - // ),O, ANATOL!SIVIT K` � II '' I le � 27 MILL POND RD,-.4... L] r WEST YARMOUTH,MA 02673 Undersecretary Nottvand without signature r .iauoiSSiwwo rs 51 ,. �`L3 ol1SSIg1`fr & 1 4:: £1930 VW Hl'9OWeIVA IS3M ;� ; ' , Y �^. ' `;, ' a2I;aNOd T11W LZ ,; n;ti.� = ^ ,` � sa.. � IISIIAIS IIOIVNV 1 i ;, Cr. ,OZOZ/PL/90 :seal! .2 .. ...%... . Oti0901.-19SO �(;ieiaadS osff?FIRS,Uoi }ana4sup3 spaepue;s pue suogeln6au 6uiplin jo pieog aansuaail leuoisse;oad Jo uoisiAlp 4 , . • s;;asnyoessey jo 4;leamuowwo3 .� • .. • A s CERTIFICATE OF LIABILITY INSURANCE DAo(MI e�eY" 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 tens 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 DNRM� Victoria Sharapova ALD Insurance Agency Inc. PHDNE 617-787-7877 PM 617-787-7876 60A Brighton Avenue INC He.EAH: INC.No): • Allston,MA 02134 E-MAIL ADDRESS: urcomm�aldinsance.com MSURER(SI AFFORDING COVERAGE NAILS INSURER A: ATLANTIC CHARTER INSURANCE COMPANY 44326 INSURED Belcape Construction LLC NSURERB: AMGUARD INSURANCE COMPANY 42390 42 WOODBURY AVE Hyannis,MA 02601 INSURER C: INSURER 0: INSURERE: _ INSURER?: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT IMTH 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. ITR TYPE OF INSURANCE ADDL.SUBR POLICY Ur POLICY EXP INSD VND POLICY NUMBER IMMIDDIYYYY) IMM,VDIYYYYI LIMR1 A J COMMERCIAL GENERAL LIABILITY L270000577 01/14/2018 01/14/2019 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE I OCCUR DAMAGE TO RENTED 100,000 PREMISES Me commence) $ MED EXP(Any one Faxon) $ 5,000 — PERSONAL S ADV INJURY 5 1,000.000 GENt/// AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 VI POLICY❑jE�T n LOC PRODUCTS•COMP/OP AGO $ 1.000.000 I OTHER: $ AUTOMOBILE LIABILRY COMBINED SINGLE UNIT 5 (Ea occident) _ ANY AUTO BODILY INJURY(Per penal S OWNED —SCHEDULED BODILY INJURY(PS occident) 5 AUTOS ONLY AUTOS — HIRED AUTOSOaccident)IED PROPERTY DAMAGE S _ AUTOS ONLY ONLY (Per accident) _ $ UMBRELLA LU1a 1 OCCUR EACH OCCURRENCE _ $ EXCESS LUa CLAIMS-MADE AGGREGATE $ DED I I RETENTION 5 S BsANDo NL1 9 m R2WC918542 02106/2016 02/06/2019 Vi STATUTE EOR ANY PROPRIETOR/PARTNER,EXECUTNE YIN EL EACH ACCIDENT $ 1.000.000 OFFICER/MEMBER EXCLUDED? ElNIA (Mandatory In NH) E.L DISEASE-EA EMPLOYEE i 1,000,000 If yes deafle under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONSI LOCATIONS I VEHICLES(ACORD in AddMonal Remarks SdmduH,may be attached Mmes epees Is nouInel) 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. ALAMOS REPRESENTATIVE -__ __ I . ®1966.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD