HomeMy WebLinkAboutBLD-19-004079 M
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EXPRESS BUILDING PERMIT APPLICAT E C E I \/ E D
TOWN OF YARMOUTH
Yarmouth Building Department JAN 11 2019
1146 Route 28 eul .�i _�.. r?NT
Yarmouth,MA 02664 tar tr D
1 (508)398-22231 Ext. 1261 _
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CONSTRUCTION ADDRESS: /1- //ayf t,n d A✓ - ✓ 5e a//t "A.vN/et ill—
ASSESSOR'S INFORMATION:
,/ Map: Parcel:
OWNER: f'}int Sinn/!�(,/,y /C /14 y .✓Octal dein_ `v?. 367 - 77?Cv
NAME ( PRESENT*DRESS TEL. #
CONTRACTOR: Feel ter 6rceirar4err 3/ ,[wWdt,yr Roe/ t#1.44 Set-eor-229 c...NAME MAILING ADDRESS TEL.a
®'Residential 0 Commercial Est.Cost ofConstructionS /0/ 000
Home Improvement Contractor Lie.# I/Z C3& Construction Supervisor Lic.# 01 7 0(0P'
Workman's Compensation Insurance: (check one)
0 1 am the homeowner 2 ❑ I am the sole proprietor [have Worker's Compensation Insurance
Insurance Company Name: /XAvt%taSr!w.— re, �o Worker's Comp.Policy# 07 cog// 3 Z—
/ WORK TO BE PERFORMED
Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# Replacement doors: #
Roofing: #of Squares '2- ( ./)Remove existing*(max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
"The debris will be disposed of at: Sn SMI?i. (t(/[e./ g�rt, 414 rile
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 limns for prosecution under M.G.L Ch.268,Section I. /�y
Applicant's Signature: Date: //l if
Owners Slgnato Date: 00 q'
Approved By: � F' Date: /// �/
Build... e _'or designee) E ADDRESS:
Zoning District:
Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes 0 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes ❑ No 0 Yes 0 No
The Commonwealth of Massachusetts
We—ti Department of Industrial Accidents
=♦t c I Congress Street,Suite 100
—rsa_ _y
—'ib Boston,MA 02114-2017
'- ei� .1
o•,�_ wnnttmassgovhdia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
A nplieant Information Please Print tibio
Name(Business/Ortanizntinnimenvidwl): F/ns4'r (a ndiHeel bit.
Address:_j/ Rn_rvc; tut, Qo't
City/State/Zip: agshiratP ,4Q atGW7 Phone#: Soft-YLE--2292
Are you an employer?Cheek the appropriate bet: Type of project(required):
'31 un a employer with f 0 employees(full andror parvume)a 7. 0 New construction
2.0 am•sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity (No worker?comp.insurance required.)
3 01 am•homeowner doing all work myself INo workers'romp insurance required)'
9. ❑Demolition
10❑Building addition
4 01 am a honeowner and will be hiring=minors to conduct all work on my property I will
ensure that all contractors either have workers'cbmpensatron,nsuranc.or are sole 11.0 Electrical repairs or additions
proprietors with no employe.
12.0Plumbing repairs or additions
5C 1 am•general contractor and I have hired the subcemmmors Iined on the enacted shin e 13.00
3. Roof repairs
These sub-contractors have employees and hove workers comp insurances ❑t��t
6.0 We are a corporation and its otters have exercised their right of exemption per MGI.e. 14'S J C her
152.f 1(4),and we have no employees No workers'comp insurance requrredJ
"Any applicant that ducks baa a I mum also fill out the section below showing their warkeri compensauon policy»finnanon.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside convenors mum submit a new affidavit indicating such
leonncmn that check this boa mum attached an additional sheet showing the name of the sub-convenors and slaw whether or not dress entities have
employees. If the subconncters hive employees,they must provide thea worker?comp.policy number
I am on employer that is providing workers'compensation Insurance for my employees Below is the policy and job site
information. ^ —�•
Insurance Company Name:_. &art_ _ A_r -ln,ju "Me
Policy P or Self-ins.nae.H: 02 4/4/1_3 Z- Expiration Date: 9/Lb1/4.f
tot Sat A dcress. City/Statc'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 51,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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 a • attics of perjury that the information provided above is.true and correct
Sirnalur • . •ate.
phone N' 50({ —VZr — 2-2l _
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License p t
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cin•!i'own Clerk d.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone a:
FRASCON-01 ALEVE5011E
A.CORo TE(MWOONTYY)
CERTIFICATE OF LIABILITY INSURANCE °A 10/01/2018
01/01118 8
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 ADDRIONAL 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 p endorsement(s).Nr�
PRODUCER NAME•CT Ashley Levesque
Bearingstar Insurance,Inc. PHONE FA%
Commercial Insurance Center
(AA,xA en):(844)898.9151 I
on.No(508)837.6573
375 Airport Road �pD71lFRa
Fall RIVOr,MA 02720 INSURER(S)AFFORDING COVERAGE NAICI -
INSURER A:AIG
INSURED INSURER B:
Fraser Construction LLC INSURER C;
PD Box 1845 INSURER D:
Colult,MA 02635
INSURER!:
INSURER Ft
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 SUER POLICY NUMBER POLICY EFF POLICY EXP
I TR INS() WVD IMMADM'YYI IMMOD.'YYYYI OMITS
COMMERCIAL GENERAL LIABILITY EACHEAOCCURRENCE 5
CLAIMS-MADE ❑OCCUR PREMIcE5(FaoNsEc1 mm1 $
MED VIP(At,one person) 5
PERSONALS ADV INJURY $
CDEL
F,SATELIMT APPS PER: GENERALAGGREGATE f
POI UUJSOPRppUCTS-CONPNP
AGG
OTHER
AUTOMOBILECOMBINED SINGLE UNIT
LIA&LITY f
:Fa OCOOMt)
_ANY AUTO SCHEDULED
BODILY INJURY(Pot person) S _
_AgTU�Oq���S ONLY _ NrIUpT�uOp BODILY INJURY(Per soSdr,) S
— AUT05 ONLY AllTO Y PEORR(AMAGE S
5
_
UMBRELLA WB _ OCCUR EACH OCCURRENCE S
EXCESSLIAB CLAIMS-MADE AGGREGATE f
OED I RETENTION f
A ANO EMPL OYERS COMPENSATION
�Y1N ICTATLTF ER
ANY PRCPRIETO�WpPARTNER/EXECImVE I-1 WCO24181132 09/26/2018 09126/2019 EL EACH ACCIDEM f 500,000
QFFICER.fl,nNER EXCLUDED? LJ N/A
500,000
�IMMaa"ml° II N) EL.DISEASE•FA EMPLOYEE f
R yea dnaal0a der 500,000
O
DESCRIPTION OF OPERATIONS hope E L.DISEASE•POLICY LIMIT f
DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES(ACCRD 101,AddltlenM Remade Schedule,may be attached If more space Is moulted)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE Town Building Department ACCORDANCE WITH THE POUEOFCYR PROVISIONS.NOTICE WILL BE DELIVERED IN
AUTHOR2ED REPRESENTATIVE
ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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FRASER CONSTRUCTION guarantees the shingles against Blow-Offs for 15 years.
Please note that all pricing is contingent upon current market pricing. If contract is
not accepted within thirty days of date of proposal, change in price may occur due to
deviation in material price.
Any deviation or alteration from above specification will be executed upon written
orders and will become an extra charge over and above the estimate. All agreements
contingent upon strikes, accidents or delays are beyond our control. Owner should
carry necessary insurance upon the above work. We, if not accepted within thirty
days may withdraw this proposal.�j
Work Permit- I 4712/1 (Sign Name) give Fraser Construction
the permission to pu ermit for work being done at
I F, 1-414W000i�u1: we, Se 9 II+ (Address)
FRASER CONSTRUCTION, LLC: Carries Workman's Compensation and Public
Liability Insurance on the above work, certificate available upon request.
DATE OF ACCEPTANCE: it)/aG/ ao t y
g)ipitip„
Homeowner' Fraser Construction, LLC