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HomeMy WebLinkAboutBLD-20-001324 Office Use Only 1 PI'Y`AR � Permit# .01 1,'� . Hi Amount ':" MATTAGM ESE d' _ kw.�.gL �C; I Permit expires 180 days from ----.::- --' ' i issue date BLb-2D —13 q EXPRESS BUILDING PERMIT APPLICAT I A C F s V : !' TOWN OF YARMOUTH R Yarmouth Building Department ' SEA' 09 201y 1146 Route 28 South Yarmouth, MA 02664 ; P I u i N� D; ; r (508) 398-2231 Ext. 1261 ,- _ --,.m= CONSTRUCTION ADDRESS: 23 eCiy /nOUAi / Oac i 1 P5//Q(41 v Y7 1271 ASSESSOR'S INFORMATION: Map: Parcel: �J �., OWNER: Los rl CC r j 3 /// er / *Ud✓/ /(-Cc(C/ 1 1711ol , S'91 /` j'i (/ NAME PKESENT ADDRESS TEL. # 7caleinikt CONTRACTOR:/A/074/11.14 rib.)( (CJ; 1'I5 )3 U-4I/'/f Alb v i (-' -/d./ 4-TV, .a NAME MAILING ADDRESS TEL.# (` t residential 0 Commercial Est.Cost of Construction$ /C///lbw. 6r1) • �-//,� /�S J n Home Improvement Contractor Lic.# /7j 5 If Construction Supervisor Lic.# C �4,S-2 Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ I am the sole proprietorKI have Worker's Compensation Insurance 4 �` -5 Insurance Company Name: DC/ a t Yf (b11I/04,74)(5 Worker's Comp.Policy# &}((S V O /? ?, / o WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares a`� ( ✓)Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: /t'w w yo. aim ali f''C1 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 o revocatio of my icense for prosecution under M.G.L.Ch.268,Section 1. / Applicant's Signature: Date: et V/!fi Owners Sign re(or attachme - Date: C Approved By: ��v Date: / ' ' Building 0 al( ignee) EMAIL ADD Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No ❑ Yes ❑ No The Commonwealth of Massachusetts 1) , Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 '1,.,-.s>. 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): ,�c'I:,, a/4 c (U /?/Y� S, /..LC Address: 43 (AJii i(,15- /Z ti (0 City/State/Zip: 5c ?(ce 1414 4#7 t1 f 4 6,166hone #: Sal ' (-7 SAP/ Are you an employer?Check the appropriate box: Type of project(required): 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 Z. 8. �� emodeling any capacity.[No workers'comp. insurance required.] 3._I am a homeowner doing all work myself. 9. Demolition y [No workers'comp. insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on mYproperty. I will I O ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am 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.= 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. I4.❑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_ T 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: 4/55 d Ca /6/- ar rlti//>' / Policy#or Self-ins.Lic.#: A)C C. S a'a 5-0/c 7� ( Jet i Expiration Date: /�,2/y/19 Job Site Address:,: in t' /[y 4/q/ ✓1 i eo City/State/Zip:�Ct1 'd v'f l �'i)[t • 0,1L/ 71 Attach a copy of the workers' c6mpensation 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 tify under th pains and penalties of perjury that the information provided above is true and correct. u.Signature: Date: �"� 2/c ate: Phone#: 45-. &L/ / -5-6 (�f 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#: Sand Dollar Customs LLC Estimate 23 Whites Path Suite G2 Date Estimate# South Yarmouth MA . 7/29/2019 386 02664 Name/Address Lou Ricci 23 Merry Mount Road. West Yarmouth Ma. 02673 Project Description Qty Cost Total Lead Paint Renovator Certificate#R-I-I 8398-09-00120. Worker Compensation Policy Associated Employers# WCC50050197212018 Liability Insurance Policy Mapfre#3AA316498 Auto Insurance Policy Mapfre#BHMWLT Policies to be mailed to customer by insurance company upon signing of contract. Additional work not covered in contract but required by local Building Inspector to be billed as follows;Labor$80.00 per man per hour.Materials to be billed at cost plus 20%,(not expected). Additional work requested by home owner to be billed at$80.00 per hour per man.Materials to be billed at cost plus 20%. Change orders must be agreed to in writing and paid in full in advance. Please checkout our website at www.sanddollarcustoms.com to learn more about our high standards and quality work. Payment Schedule: 50%Upon Acceptance of Contract 50%Upon Completion We accept the above work as described an authorize Sand Dollar Customs to perform the work described above. Homeowner Signature: Total Customer Signature Page 2 SANDD-2 OP ID: DS ,a►coiWY CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/05/2019 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. 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 508-775-6060 NAMEACT Bryden&Sullivan Insurance Bryden&Sullivan Ins Agency PHONE 508-775-6060 I FAX 508-790-1414 88 Falmouth Road (A/C,No,Est): (NC,No): Hyannis,MA 02601 FdDORss: Bryden&Sullivan Insurance INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Mapfre Insurance 34754 Nsu INSURER B:Associated Employers Insurance ncjh es Pathst ms LLC outh Yarmouth, A 02664 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. INSR EXP I TYPE OF INSURANCE JNSD ADDL SUBR POLICY NUMBER IMM/DDY I I EFF MM/DDY 1 LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ' LOC PRODUCTS-COMP/OP AGG $ OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BHMWLT 02/02/2019 02/02/2020 BODILY INJURY(Per person) $ 100,000 OWNED SCHEDULED 300,000 AUTOSE� ONLY X AUTOS WNE BODILYO INJURY(Per accident) $ X AUTOS ONLY X AUOTO ONL( (,err acoiRdent)AMAGE $ 250,000 $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION STATUTEPER ERH AND EMPLOYERS'LIABILITY WCC50050197212018 12/04/2018 12/04/2019 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE YY N/A E.L.EACH ACCIDENT $ FFICER/VEMgg EXCLUDED? 500,000 andatory In N ) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 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) Contractor CERTIFICATE HOLDER CANCELLATION AFRAMEJ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Jay Aframe 11 Collingwood Dt Yarmouth Port, MA 02675 AUTHORIZED REPRESENTATIVE Bryden&Sullivan Insurance ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD F./n -/?,e 6.� 4, Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, M '. husetts 02118 Home Improve • tractor Registration t " Type: Corporation SAND DOLLAR CUSTOMS LLC .1-17 Registration: 193567 M -•w Expiration: 10/29/2020 1851 FALMOUTH ROAD I* ~_ CENTERVILLE,MA 02632 / �4 �Tn � 0 Update Address and Return Card. scA 1 0 2(M-05/17 nenesso cttead e/./dgaVe24 3.0It Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TY orooration before the expiration date. If found return to: i xolratlon Office of Consumer Affairs and Business Regulation 10/29/2020 1000 Washington Street-Suite 710 SAND DOLLAR _ 7,7 Boston,MA 02118 :'' ()U.WALTER R.WA - '"i \2 CGPx� j 1851 FALMOUTH .<, CENTERVILLE,MA 0 632 Undersecretary Not v-'' • 1 out ignature • c. Commonwealth of Massachusetts Ilf Division of Professional Licensure Board of Building Ft ations and Standards Constr sil%tlpervisor CS-091653 ` Upires:09/30/2020 / fret t WALTER R 80 ALEXAN DR YARMOUni ma `• Commissioner CAL