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HomeMy WebLinkAboutBld-20-000927 Office Use Only $01.•Y4R`7�: Permit# (Q� H Amount V V ` MATT n [s •.,•. -_2_ 47... .....crd` Permit expires 180 days from `= -_-_*.,:- ' issue date EXPRESS BUILDING PERMIT APPLICATIQN------ TOWN OFYARMOUTH RECEIVED r-- __ ---..� _._-____,_-1 Yarmouth Building Department 1146 Route 28 I AUG 20 2019 i South Yarmouth, MA 02664 J I (508) 398-2231 Ext. 1261 BY" Pl ENT CONSTRUCTION ADDRESS: f 8e k i2 y 1d,,t' ASSESSOR'S INFORMATION: Map: Parcel: 777' OWNER: .V%1 A/2" // tA�0,--- L .�?v � Y>7j2 PRES AIIDRESS TEL. # CONTRACTOR: likU�L� (k RMU 7 ..raid. �I "i l VtJ 2 18. b / / UO T7O NAME MAILING DRESS TEL.# esidential 0 Commercial Est.Cost of Construction$ I LI 0 Dtp p� Home Improvement Contractor Lic.# 173 0 7 a Construction Supervisor Lic.# C,5 CX00 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the le proprietor y I have Worker's Compensation Insurance Insurance Company Name: C \\ "1 V�� eAlomp.Policy# gC•Cora/f/V125 -7// WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofmg: #of Squares 4 U (X )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: A R e1, Fv Location of ••:. lity I declare under penalties of perjury tha + e sta ents .-rein contained are ,• - • d correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revo .ion of• y lice, : an. for• osecuti.• der M.G.L.Ch.268,Section 1. i /Applicant's Signature: '. 4 Date: Owners Signature(or a achment) ,_,,,,d_„„,„_ _ ,l , Date: i Approved By: .,���� Date: `9 20 / Building Official,%' .esip•/ EMAIL ADORES Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts Department of Industrial Accidents =�Al= 1 Congress Street, Suite 100 Boston, MA 02114-2017 •„ — .1•‘.> 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): l(� Address: 102 cr I S ,,,1 �—�- • P12 Nf 4 City/State/Zip: IA.A 19L�j b Phone #: ISO? 7767 766 Are you an employer?Check the appropriate box: Type of project(required): i.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.E1 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers'comp.insurance required.] 9. E Demolition 3.0 I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 10 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 11.0 Electrical repairs or additions proprietors with no employees. 12.,E/Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.I-�Roof repairs These sub-contractors have employees and have workers'comp.insurance. �\ 14. 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 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. 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' ompensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: >60 UTS4 k/a�)(7 2//q Expiration Date: S '-2 ,ROOD Job Site Address: 4(7. City/State/Zip: (3127- Attach a copy of the workers' compens lion 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 a pa' and enaltie f per' that the information provided above is true and correct. to Signature: Date: cv 1 , Phone Pr: • 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 ` i • Division of Professional Board of Licensure Building Regulations ConstryaI�yri��� and Standards CS-060855 Pervisor €i 4 0 ires: 11/22/2020 MICHAEL A H ' EALY 72 OLD ' SOUTH Y MAIN ST ' .; r ARMOF/,TH MA 6 10. 266A�` Commissioner • Office of Consumer Affairs&Business R HOME IMPROVEMENT CONTRACtion TYPE: TOR . Individual Ex ira'o MICHAEL HEAL 04/22/2021 MICHAEL A.HEALY - 72 OLD MAIN ST = ,,,,.4-i SOUTH YARRMOUTH M4 02664 �` ----a' ,,e Undersecretary 1 DATE(MWDD/YYYY) AcoRD CERTIFICATE OF LIABILITY INSURANCE 07/18/2019 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 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 John McShera MARSHALL K LOVELETTE INSURANCE AGENCY INC Nc.No.EMI: (508)775-4559 (ac.No): E-MAILDDRESS: iohn@loveletteins.com 396 MAIN ST INSURER(S)AFFORDING COVERAGE NAIC# WEST YARMOUTH MA 02673 INSURER A: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B: HEALY BROTHERS CONSTRUCTION CORP INSURERC: INSURER D: 72 OLD MAIN ST INSURER E: SOUTH YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 426898 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. INSRiADDL SUBR POUCY EFF POUCY EXP LTR TYPE OF INSURANCE INSDLINVP POLICY NUMBER IMM/DD/YYYY) (MM/OD/YYYY) UMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO $ CLAIMS-MADE OCCUR PREMISES(EaENTED occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE i $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ - ALL OWNED ^SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ - EXCESS UAB CLAIMS-MADE' N/A AGGREGATE $ DED RETENTION$ _ $ WORKERS COMPENSATION X PSER ERH AND EMPLOYERS'LIABILITY A OFFICER/MEMBER EXC EXCLUDED?ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 N/A N/A N/A 6560UB4N38257419 05/29/2019 05/29/2020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A - DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rt 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02264 Daniel M.Crowey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD