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HomeMy WebLinkAboutBld-20-001836 Office Use Only O . y Amount Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508). 398-2231(1Ext.�1261 r CONSTRUCTION ADDRESS: S At t c-L e-l/`Q J /D P/ A ASSESSOR'S INFORMATION: Map: 4/I Parcel: fi/�fOWNER: �l / ` �/�'` `� 4ST ADDRESS Y P41/� TEL. # N CONTRACTOR: 7C-4ari (L v //I 4 r avj m I I fa 3 60 Ye X` ( NAME MAILING w RE1 TEL.# sidential ElCommercial Est.Co of Construction$ Home Improvement Contractor Lic.# / 9t& 5c / Construction Supervisor Lic.# CS' 0793 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor ave Worker's Compensation Insurance Insurance Company Name: 00(.. 6,0060 f c®C/ Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares /'t ' Replacement windows:# I 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: �'/ /e/27l>C 7` v 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 r cation of Syr lice an prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: 4Cc,Jl / Date: s ® ,Owners Signature(or attachment) P,--e4ll� &,Ce...44!"# Date: //;; y.��/ Approved By: Date: !V Building 0 i desi ee) E '41 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 0 No 0 Yes ❑ No The Commonwealth of Massachusetts I Department of Industrial Accidents rAI 1 Congress Street, Suite 100 _Iv Boston, MA 02114-2017 "•`'. www.mass aov/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): % /9-(/)//q,v.Z Address: , 4 9 ail J 04 2 A 1V N h / City/State/Zip: /O p- D ot6 01 Phone #: Are you a plover?Check the appropriate box: Type of project(required): 1. 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. ❑ Remodeling any capacity. [No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. 9. ❑ Demolition ❑ y [No workers'comp.insurance required.]` 10 ❑ Building addition 4.E1 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.❑ 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 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.; 14.E Other s� �7 6.El We are a corporation and its officers have exercised their right 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. ;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: L.6 C142 '(3 CO „� C,cw4 c-e Policy#or Self-ins.Lic.#: T Expiration Date: Job Site Address: &5 M iC rJ/.Q, f ��1/4 City/State/Zip: cY/*i42f17 i/l`4 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 u der the pains and penalties o perjury that the information provided above is true and correct. Signature: Date: ,kr�--i j Phone#: 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#: IF Division of Professional Licensure �'On27u�°�`���'aa�zG� Board of Budding Regulations and Standards Office of Consumer Affairs&Business Regulation ConsttrrU rvisor HOME IMPROVEMENT CONTRACTOR TY corporation i Regist ! Expiration CS-074360 1!1 pires: 06/23/2020 = 08/28/2021 i 'M 4+ t. RA VILLANI INal" RICHARD VII EANI ,5f`i`ttl IJ PO BOX 692 i 11 i ., WEST HYANNISPpFtT ,@2632> K VILLANI RICHAR :- '/�/ �()ISS I �A` 109 WAGON LN. '%;: r.�,! '�G.��loak - HYANNIS,MA 02601 '- Undersecretary Commissioner a.- 10/04/2019 08:09 5087753821 OLDE CAPE COD INS AG PAGE 03/03 RAVIL-1 OP :EB CERTIFICATE OF LIABILITY INSURANCE BATS IMWoormY) 2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE OLD R. 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 pollcy(Ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies this certificate does not confer rights to the certificate holder In lieu of such endorsements may require an endorsement A statement on Oldoo Ca R Cod508-771-330t) �a Cape insurance rNcT Martha J Findlay �— INartl+a Flndhr .508-771-3300 Ff 508-775 821 300 Winter StreetI( ,NOHyannis,MA 02601 .tp ma a bcc a.Com Martha J Findlay rNSlljiER(SIAFFORDINCZGOVERA E NAICo mumR A Villan),Inc. �+auREgA:Evanston Insurance Company P O Box 692 INSURERS; West Hyanniisport,MA 02672 INSURER C: '-- INSURER D; eISUqgIE: . COVERAGES - INSURER F: CERTI CATE UMBE : VISI N NU 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 1MTM 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. J TYPE OFINSURANCE A _— iNlLa POLICY NUMBER POLICY EPP POLIO p(P X commERCIAL GENERAL ummirr LMAITS CLAIMS-MADE OCCUR $t:TF]t4 .1 ACH OCQURRENRF $ I,000, 00 y tatazo111 tala2otaIF4¢ E ,�„ s 100,000 __ MED E (Any or.person) S 5,000 a ADV INJj1kY $ •000,000 POLICY LOC GEhIERAL EGATE g 2,000,000 GEML AOGREG TE LIMIT APPLIES PER: OTHER_ PR UCTS• PLOP 2y000,000 AUTOMOBILE LUIBLITY COMBINEo SINGLE LIMIT $ _ My AUTO (Ea a cidanU S AUTOS ONLY TAU OSWLED LY INJ Par HAUTOS ONE Y .` EDDILYJNJURY Om aociderrl� g i a1nt1 o DA�YIAGE � UMBRELLA LIAR OCCUR $ — EXCESS LIAR _ CLAIMS-0IADE — OCCURRENCE S BED RETENTIONS AGGRE9ATE S AND yEMI�LnY ik L . S +ANY P, RQP_RIETORIPARTNE xECUTNE N N/A =4TAT61TF I�R� 1k„[°.FI �wMryFMEER F.X�UDED? L EACH CIDENT $ H dBer�S6e Yrldef E.L.DISW§-EA EMPLOYEE 3 DRIPT77N OF OPE• 1 -below Commercial Applicel E L bls -POLICY UNIT a egpe -°co uc u}atiar maidositamtsra5salmule,maybe enured R Ellin apace Isrsqulreq) CERTIFICATE $OLD CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BHFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. Building Department 1146 Main Street AUTHORISED REPRseENTAm►E — Yarmouth,MA 02664 1 ACORD 25(2076l03) ©1988-2015 ACORD CORPORATION. All rights reserved, The ACORD name and logo are registered marks of ACORD 10/04/2019 08:22 5087753821 OLDE CAPE COD INS AG PAGE 01/02 ACi;; `moo • CERTIFICA uelooNyrn TE OF LIABILITY INSURANCE DATE( 10/04/20 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.iTHIS 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 ADDi11ONAL 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 endarsement(s), PRODUCER OLDE CAPE COD INSURANCE AGENCY INC Mime Erica(50 Barrett PHONE _ 508 771-3300 FAX INC,No): 300 WINTER ST sS: ericab occla,eom INaURER(S)AFFORDING COVERAGE NAIC M HYANNIS MA 02601 INSURER A; ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: RA VILLAN I INC INSURER C INSURER O: PO BOX 692 INSURER E: WEST HYANNISPORT MA 02872 INSURER F; COVERAGES . CERTIFICATE NUMBER: 456988 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDmON 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. • INS LIT• TYPE OF INSURANCE DI_1 j.. POLICY NUM- - I EEypp/ YWI IMM1'Iry0 YYy I.UrIS COMMERCIAL GENERAL LIABILITY L^'.] I CLAIMS-MADE EOCCUR EACH OCCURRENCE inT c • • 1 s !I N/A GEM AGGREGATE LIMIT APPLIES PER: SENERAL AGGREGATE ■ POLICY n.I li T n LOCPRODUCTS-COMP/OP•<c II OTHER: AUTOMOSK,E LIABII.RY COMBINE SNZ�LIMIT EEO flcodent) IN ANY AUTO BODILY INJURY(Par person) ■ ALL AUTOS OWNED �`SCHEDULED A N/A BODILY INJURY(Per ea t) II HIRED AUTOS ED PROPERTY DAMAGE IPor eoddent) UMBRELLALIAS _ OCCUR IACHQCCURRENCE NXCESS LIAR CLAIMs•6AADE N/A AGGREGATE: Wu 1 I RETENTION S WORKERS COMPENSATION AND EMPLOYERS'LIABILITY rntYIN X Boa Roo AYlOrROEREeMo /RPxARcTLuEpW1ecu NIA WA 6562UB1 K201 33319 02/22/2019 02/22/2020 • (M?ndetory In NN) ,ISEASt-EA EMPLOYE S 500,000 Ijyy%ea,_denim under D -CRIPTION OF OPERATIONS below , r i►000 II N/A • DESCRIPTION OP OPERATIONS/Lac/atom/voile Ea IACORD 181,Manama)Remarlos schedule,may be attached R more space Is raquIredl 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 statue of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govIIwd/workersogmpensatlon/investigatIonsl. • • CERTIFICATE HOLDER CANCELLATION. SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE• THE EXPIRATION DATE THEREOF. NOTICE WILL BE •DELIVERED.:IN TOWf l of Y8rI110U$1 ACCORDANCE WrrM THE POLICY PROVISIONS. 1146•Main St . - • AUTHORm:EO REPRESENTATIVe Yarmouth MA D28G4 "--0 I Daniel M.Cr y,CPCU,Vice•Presidant—Residual Market—WCR)8MA So 1988-2914 ACORD CORPORATION.'All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD