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HomeMy WebLinkAboutBLD-20-1102 Office Use Only O1•YgR Permit# 0 ! 4. 2 t Amount ..),44...' 6 ' aL" ''I I Permit expires 180 days from ►� issue date EXPRESS BUILDING PERMIT APPLICAT D E_1 V _ D TOWN OF YARMOUTH AUG 2 8 2019 Yarmouth Building Department 1146 Route 28 BUILDING South Yarmouth,MA 02664 By _____ L (508) 398-2231 Ext. 12617 CONSTRUCTION ADDRESS: Z 2 r t 1/L1 L(,e 11 (A44 Li, �/�7L(•-A(/V 1 ASSESSOR'S INFORMATION: Map: Parcel: C OWNER: k E - 7lA/Q-ie Z Z rk M GO etc i.� (-7,4 1,-1 f v t &!/1�7 N `/,� //__ PRESENT ADDRESS A TEL. # /_v CONTRACTOR: 14 O(&1 b y&(fir w V ce Ca.). /9(-f IM/4)6✓si =f/�'t�/ ?-hts 3C� UZtec.(�0 NAME MAILING ADDRESS TEL.# rok /_ �c�t./',� a'Residential 0 Commercial Est.Cost of Construction$ S--ITV -U1 1�E�J Home Improvement Contractor Lic.# t&/ 3' Construction Supervisor Lic.# '4'>P"F 11 Yf4A i'S Workman's Compensation Insurance: (check one) CC-- ait i O L I am the homeowner G I am the sole proprietor [Dif have Worker's Compensation Insurance ^� Insurance Company Name: Gi �C.iVV Worker's Comp.Policy# Li?SttZ J'?,T 7 I 17 t JC/ WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 1 ,' S 1 ' IT .--/ Location of Facility I declare under penalties of rjury that the st is rein conta. ed are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause ford ,or r ion o i for pr io under M.G.L.Ch.268,Section 1. Applicant's Signature Date: —e'a_19 Owners Signature(or attachment) " 7Le —IC? Date: A 'z.—/G5. Approved By: ff��> Date: ^�p-I % Building O icial(or design) EMAIL ADDRESS: Zoning District: Historical District: _. Yes _ No Flood Plain Zone: Yes I_: No Water Resource Protection District: Within 100 ft.of Wetlands: Yes Ci No ❑ Yes 11 No The Commonwealth of Massachusetts 1= Department of Industrial Accidents :iHl.= K 1 Congress Street,Suite 100 _ Boston, MA 02114-2017 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):T ULC,L( de/414‘,1)(7 lift/ CD Address: PL1 1M Av,v1 c% • City/State/Zip: Cal 1 S �Pclo#: S7.) `=" f(or 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.❑I am a sole proprietor or partnership and have no employees working for me in 8. ar emodeling 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 10 ❑Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5. 1 rn a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.t 13.0 Roof repairs 6.0We are a corporation and its officers have exercised their right14.0 Other rpo of exemption per MGL c. 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. tContractors 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 an:an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 1 �1 iyv Policy#or Self-ins.Lic.#: CQSCQZL 4{ ( 'll Expiration Date: CO ' Job Site Address: 7? rtt Wis(-0 6 t � L7 4�v�j)1 ? tate/Zip: `14-14 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 c fy u en ' of perjury that the information provided above is true and correct. Signature: Date: Phone#: L( 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: lc), 1Wej z°Ey ,-° TOWN OF YARMOUTH . 3 ,, °C $ 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 RECEIVED! 'r Telephone (508)398-2231 Ext. 1292-Fax(508)398-0836 1 R ` �\,. e` v KING'S HIGHWAY HISTORIC DISTRICT CO MITTEE! 2� i L' Y/,r-;I• UU►Hi MAR 2 6 2019 APPLICATION FOR OLD KING'S HIGHWAY CERTIFICATE OF APPROPRIATENESS TOWN CLERK ApgMliniii imInftrpsifilqvifAr issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Acts of 1973 as amended,for proposed work as described below &on plans, drawings, photographs, &other supplemental info accompanying this application. PLEASE SUBMIT 4 copies OF SPEC SHEET(S), ELEVATIONS, PHOTOS, &SUPPLEMENTAL INFORMATION. Check All Categories That Apply: Indicate type of Building: Commercial t./ Residential 1) Exterior Building Construction: New Building tr/ Addition ✓ Alterations Reroof Garage Shed Solar Panels Other: 2) Exterior Painting: Siding Shutters Doors Trim Other: 3) Signs/Billboards: New Sign Change to Existing Sign 4) Miscellaneous Structures: Fence Wall Flagpole Pool Other: Please type or print legibly: V, � /fCi Address of proposed work: I.- L t h �r f � '\{( W" y Ma p/Lot# i' /l 3 Owner(s): J tha- 1 & 4rtite..Y 7 t. ` l,C 7 Lug' fit? rn Phone#: E 3 �-•` All applications must be submitted by owner or accompaniedp by letter from owner approving submittal of application. Mailing address: r. 0 . t�j Y Z �" Y r �� 1 -rt Ci LC 7 C Year built: /9C `7/ Email: 5 i C1 f-r v'i.Lr- t v. ''sv 'y ( . �.v Preferred notification method: Phone Email J Agent/contractor: Phone#: Mailing Address: Email: Preferred notification method: Phone Email. Description of Proposed Work: A nn �2�oVe. •eX15-k' th $'X ` ' tcirkr2 W1nckov, re- ? IIctC¢f L Ain Ae'dee5tL1 d01,4Ae Fre.ach oloor 5 PINS 2 stde le is (1 'w x ''4'. h 13tn;Ich c( ‘XCI I !'� e.✓i Pt^e554r2. (:-re fed -fvu�4eaYI d -e oo } Y G �{ s ( '�e hw►d �,,j °� ot¢,c-kt�y• R4AtK� s to 6-e 51-a,nkss 5 '�) Ca(71 , Ceder [ Signed (Owner or agent): t�-, 3, ele ^1 Date: /7( LI/ 19- > Owner/contractor/agent is aware that a permit is required from the Building Department.(Check other departments,also.) > If application is approved,approval is subject to a 10-day appeal period required by the Act. > This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later. > All new construction will be subject to inspection by OKH.OKH-approved plans MUST be available on-site for framing&final inspections. For Committee use only: Y Approved Approved with Modifications Denied Rcvd Date: g- 1-1 ! Reason for Denial: _ Amount aJ i a 4 r Cash/CK#: e se7 I Lau lad" / Signed: 4% Rcvd by: /'v!,/ 45 Days: 17-/ tl'/ 9 Date Signed: 3 2. 37-.zP/et 1 APPLICATION#: AC'�® DATE(MM/DD/YYYY) Ate. CERTIFICATE OF LIABILITY INSURANCE 02/07/2019 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 NAME: Allison Messenger DOWLING&O'NEIL INSURANCE AGENCY (A/CC,,No,Est): (508)775-1620 FAX No): ADDRESS: amessenger@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B UGLY DUCKLING HOUSE COMPANY LLC INSURER C: INSURER D: 194 MAIN STREET INSURER E: WEST BARNSTABLE MA 02668 INSURER F: COVERAGES CERTIFICATE NUMBER: 365972 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 EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MMIDD/YYYYI (MM/DD/YYYY) COMMERCIAL GENERALLIABILnY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PERTUTE ER OTH AND EMPLOYERS LIABILITY ANYPROPRIETORIPARTNERIEXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? N/Al N/A N/A 6S62UB7H71178418 10/04/2018 10/04/2019 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,descrEe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS!LOCATIONS!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/lwd/workers-compensationfinvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 194 Main St AUTHORIZED REPRESENTATIVE re CI West Barnstable • MA 02668 Daniel M.Cro,W,ey,CPCU,Vice President—Residual Market—WCRIBMA 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ACo 0 CERTIFICATE OF LIABILITY INSURANCE DATE/os 20 s Y) 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 POUCIES 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 NAME: John McShera Marshall K Lovelette Insurance Agency Inc PHONE (508)775-4559 FAX (508)775-4577 396 Main St (ac.No.Ext►: (Arc,No): West Yamouth,MA 02673 A : john@Ioveletteinscom INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Western World Insurance Company 13196J INSURED R&R Construction Custom Homes Inc INSURERS: AEIC A0086 90 Nye Road Centerville,MA 02632 INSURER C: INSURER D: 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. BUR ADM SUBR Y IMP TYPE OF INSURANCE IrISD WVD POLICY NUMBER (NP IDD/YYYY) (MIN UCY EFF CDD/YYYY) UPMTS A ✓ commaac L GENERAL LLABILnY NPP1516246 01/29/2019 01/29/2020 EACH OCCURRENCE $ 1,000,000 DTO RENTED CLAIMS-MADE OCCUR PRREEMA Soccurrence)GE ES(Es occurrence) $ 100,000 v l MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN1 AGGREGATE LIMIT APPLES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT PRO- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WCC50037992018A 11/29/2018 11/29/2019 \/ AND EMPLOYERS'UABIUTY ST TUTE ERA ' PI PRETCPPARITERJEKECUnVE Y N N!A EL EACH ACCIDENT $ 500,000 CFFICERMEMBER EXCLIAED? (Mandatory In NH) EL DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarla Schedule,may be attached if mom space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Ugly Duckling Building Company ACCORDANCE WITH TIE POLICY PROVISIONS. 194 Main Street West Barnstable,MA 02668 AUTHORIarD REPRESENTATIVE (2`_ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ,P7Z 6/2 /-i-?,a-/-4e6f-ead‘6>, ac)e,lexe4J-W44.- Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Registration Type: Corporation THE UGLY DUCKLING HOUSE COMPANY,LtrC i 1 �, F Registration: 169134 194 MAIN ST 1 Expiration: 05/18/2021 W.BARNSTALBE, MA 02668 i � I:` 1 ! r SCA 1 Ca 20M-05/17 Update Address and Return Card. Ktirmorniuivifllcn`✓llir.1.1urtde// Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE Corporation before the expiration date. If found return to: RegistratIQR Expiration Office of Consumer Affairs and Business Regulation '- 18�14 i ,)05/18/2021 1000 Washington Street -Suite 710 THE UGLY DUGKLiNG qOUgE COMPANY,LLC Boston,MA 02118 CHRISTINE CALDWELL 194 MAIN ST W.BARNSTALBE,MA 62668 Undersecretary Not valid without signature rr, 4411, Ie. ,..* ', I+4.,.,,••''. . -...allifairia., . . 0, . , ir ' 4,-. ..1. ..i , . - _ .... _ _ - ' - _. ..., - •—• ..... . '..." am.' ,.....' ...../. ...• — ,.... ,, ...... .. _ _. .... , , ,.. '. ,. .n. ...... -.., ..... ,,,,, ,.,.•,`. , ,,,,.. ,..., ,, , ' . ... , , ,. ., '4...:'0 ,•,-, \...4 Z....... -" .?CD LI — 0,-.e.. .-- .... '?.,:4•,:-,..E'' ROBERT J HARRIS ...... ....,, .. ,_..,...._. 90 NYE RD CENTERVILLE MA 02632 , ,.... „., . _ . 4 -,;• _,.. --- iki r,•? _ .414-- , „a.--•.--- „. .. 1 ,,..... ... ... ,....,...„.... ....- ,4--'-'),.- . . -...,,,.......- osom. 4.- --w•:-..-,-. ..--..,: ,-,...„ . ..