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HomeMy WebLinkAboutBld-20-858 .Office Use Only 1.•Y441ie7 il d vj Permit# Ou il • Amount 'sue '' NATTAM G ESE `x'ax,c...00:(d `Permit expires 180 days from ' I L.1 —'21p--ac( issue date EXPRESS BUILDING PERMIT APPLICATIO RECEIVED ! TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 M6_1449019 ., 1 South Yarmouth, MA 02664 � (508) 398-2231 Ext. 1261 By. UiL�L fQ DE'i" V yT 1 CONSTRUCTION ADDRESS: I 5 44�__ 12 " i� ` )1 wV ASSESSOR'S INFORMATION: leAg ' Parcel: ".W r �./ - 44t/- f74 i OWNER: /'�NA� o�J9� �E�i"d� PRESENT ADDRESS ���/ � ��� TEL. # sL� CONTRACTOR: e/(-71- t rc.-rJ 04-. -po1 C))L eg:"..25 5C7 - ?50"8449 NAME MAILING ADDRESS .` /1 r_ TEL.# 1wl` (5 6 Q d ❑Residential ❑Commercial Q^� Est.Cost of Construction$ Home Improvement Contractor Lic.# ��j''iLt-G / Construction Supervisor Lie.# GS fi4—D 6,Loy. Workman's Compensation Insuranc ' eck one) ❑ I am the homeowner r' the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares (6 Replacement windows:# Replacement doors: # Roofing: #of Squares 45— ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: av'f/tk 6 l G ' - ✓% L-s ' J "Let-'I-co el 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 license and for prosecution under M.G.L.Ch.268,Section 1. A plicant's Signature: Date: Owners Signature(or attachment /� /[J Date: /e�'�.. Approved By: �� Date: .0 ✓ / Building cial esignee) EMAIL SS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts 1 Department of Industrial Accidents 1+ , 1 Congress Street, Suite 100 Boston, MA 02114-2017 5••''� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): le- Address: X- `-a"S City/State/Zip: T t.1\ 1•444• 0,)6'6Phone #: cc'' O' 8tLt / Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with employees(full and/or part-time).* 7. El New construction IJ am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling any capacity.[No workers'comp.insurance required.] — 9. —Demolition 3. I am a homeowner doing all work myself. [No workers'comp.insurance required.]t — I0 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will — ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions ro rietors with no employees. p p12.E Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We are a 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'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 1 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. Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: 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'aims and penalties of perjury that the information provided above is true and correct. Signature: Aid Date: 8• C1-(' -y917 Phone#: , -bee)` l l`f q 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 4: KITTHOL-01 ZHELLWIG ACOREY CERTIFICATE OF LIABILITY INSURANCE DATE 8/8/2 D/YYYY) /8/2019 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. It 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 NAME: Ro ere&3Gray Insurance Agency,Inc. (HONE I FAx (A/C,No,Ext):(800)553-1801 (A/C,No):(877)816-2156 South Dennis,MA 02660 RiERlEss:mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Main Street America Assurance Company 29939 INSURED INSURER B: Kittredge Holmes INSURER C: P.O.Box 32 INSURER D: Dennis,MA 02638 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 SUER POLICY NUMBERPOLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY1 (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR MPK8442D 10/16/2018 10/16/2019 pREMISESO(Esoocurence) $ 500,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY P I9 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ AUTOS ONLY NON-OWNEDUUT N (Per PROPERTY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE - AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE 7 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Fir»/r//fi��ecol/ 6/./Xer,),,kze,,,,ece,)eas Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Individual R Expiration =, 01/17/2021 KITTREDGE P KITTREDGE HOEMi=V !,,' 23 APPLE LANE (� DENNIS,MA 02638 Undersecretary Commonwealth of Massachusetts Division of Professional Licensure I Board of Building Regulations and Standards • Construction,Sulder S c.1 & 2 Family CSFA-081484 E pires: 03/11/2020 5 KITTREDGE P-HOLMES ? PO BOX 32 % "* DENNIS MA 02638 1 Commissioner