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HomeMy WebLinkAboutBld-20-001746 Office Use Only R E Permit Q � �' y `Amount S D 't aaaco"A (d,l Permit expires 180 days from _- •:: issue date 1314b 20- j, - EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 3F1' _$() 111 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: Crt ASSESSOR'S INFORMATION: J, /Map: Parcel: OWNER: NAME PRESENT ADDRESS TEL. # r 7 CONTRACTOR: �'� /`C� 5 2 3 3 -7 S9 NAME MAILING ADDRESS TEL.# c3 �jj0 ❑Residential ❑Commercial Est.Cost of Construction$ v/�')( Home Improvement Contractor Lie.# (5 3-7 `� Construction Supervisor Lic.# l 00 7 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 'I am 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 Replacement windows:# Replacement doors: # Roofing: #of Squares /,S _az )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: X.,A/\ /L'^— — (/ Location of Facility I declare under penalties of perjury that the statements herein cont ' ed 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 revoc ' of m lice and for pro ecutign under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: # J 913 0 3 Owners Signature(or attachme ) C/.E1 _ Date: Approved By: Date: 10, Building 0 cial(or d signee) / ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No . The Commonwealth of Massachusetts _,_ L Department oflndustrialAccidents r:rie- 1 Congress Street, Suite 100 _21iIc ' Boston, MA 02114-2017 dle www.mass.ao v/dia up SO Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): .6 ( /� tiC'4 r S // . '�rc c Address: aG A_- OVA 7 C`-'- /c,4 - &._ City/State/Zip: �S-AAA Phone #: j as, a 3 7 --J f 2- Are you an employer?Chec he appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. E New construction 2 Lam a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity. [No workers'comp.insurance required.] 9. ❑ Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑ Building addition 4.0 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 proprietors with no employees. 12.Q 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.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E 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: A-Cam`-of ..._ Policy#or Self-ins. Lic. #: .il/G.L .. Cld5O/ Sc s 89 JC11 Expiration Date: 'v Y7�-t,d 0 f Job Site Address: 7 ,RA &z...0.-k 5' j City/State/Zip: $' Attach a copy of the workers' compensation policy declaration page(showing the policy number nd 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided��ove s tr and correct. Sicrnature: Date: C Phone#: 7 cr l a--2- Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone#: Contact Person: _- .' J�otssIW 1��� �lO Woo • ^ / sZ/8 ;.'�nPvab� L ZOZ/ O:saa(dj� r 't 9: :10.74 Hi • SOleitfa Jost 40LsPiePuejs � Ot-Sa� sua�l� uolssa Budo asn4ery�o doJJol8�°Pje0B iit Idea ytuouuwoo • ..7fie Fin2,9y0,7,li y ez,Akz ef4 Office of Consumer Affairs$Business Regulation HOME IMPROVEMENT CONTRACTOR TYP ;Corporation Examen C&F REMOQt: l:�= y CARLOS H.FIG }R 20 CAPTAIN NOYES* f __ S.YARMOUTH,MA02604� � Undersecreta A�® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 05/02/2019 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 CONTACT Deborah Kelly NAME: Leonard Insurance Agency,Inc PHONE (508)428-6921 FAX (508)420-5406 (NC.No.Ext1: (A/C,No): 683 Main Street E-MAIL deborahkIleonardagency.com ADDRESS: Suite B INSURER(S)AFFORDING COVERAGE NAIC# Osterville MA 02655 INSURER A: Atain Specialty Insurance INSURED INSURER B: The Commerce Ins.Co. 34754 Carlos Figueiroa,DBA:C&F Remodeling Inc. INSURER C: Associated Ind.Of MA-ARWC 26158 INSURER D: 20 Captain Noyes Road INSURER E: South Yarmouth MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: CL195203710 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 A POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER LIMITS (MM/DDIYYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE n OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 - A CIP383515 04/18/2019 04/18/2020 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY n jE - 0 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) - ANY AUTO BODILY INJURY(Per person) $ 250,000 - B OWNED X SCHEDULED RVM277 01/18/2019 01/18/2020 BODILYINJURY(Peraccident) $ 500,000 AUTOS ONLY AUTOS XHIRED X NON-OWNED PROPERTY DAMAGE $ 250,000 AUTOS ONLY AUTOS ONLY (Per accident) Medical payments $ 10,000 UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y STATUTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE n NIA WCC-500-5018589-2019A 04/30/2019 04/30/2020 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Mashpee ACCORDANCE WITH THE POLICY PROVISIONS. 16 Great Neck Road AUTHORIZED REPRESENTATIVE Mashpee MA 02649 Iiebok.lilZ7��`�� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD