HomeMy WebLinkAboutBld-20-002070 Office Use Only
• ` o� Permit#
Oi ys Amount
‘4,,t MATT q cSi4,1V
444"'•'.0 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 Ext. 1261 (it; 461)C
CONSTRUCTION ADDRESS: /9 a/d 1" 44i/Crrson /eQ
ASSESSOR'S INFORMATION:
Map: Parcel:
'word . q.
OWNER: Garr✓irr /9 apt A/4-iv ercan "14Y. S GIIY'Nv n4 W.64,'f c�'S..lc(-577()
NAME ' ! PRESENT DRESS TEL # Email Address:
CONTRACTOR:Inlinfnt,/N(vc tI e��oston LLC o24Cwn,✓lings i�K 1SA i nhum/"1l} (7 81) g 32-Li8o S�"
NAME MAILING ADDRESS 0(8'o I TEL# Email Addre
idential Commercial Est.Cost of Construction$ /2 76, —
Home Improvement Contractor Lie.# /66 02S Construction Supervisor Lie.# (272-772-
Workman's Compensation Insurance: (check one)
I am the homeowner I am the sole� proprietor I have Worker's Compensation Insurance
Insurance Company Name: ASc jC.iotfcc Gig ploy 2.rs _Worker's Comp.Policy# & C--Sb0 5-0 1-�6QCi—
` .2o!qot
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# /.3 Replacement doors: #
Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like
*The debris will be disposed of at: tit 1 LrJ4a l em ew -ci , 01 A
Location of Facility
I declare under penalties of perjury at the 01, -„ .• 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 rev• ,• / --;+ ;; .:•= M.G.L.Ch.268,Section 1.
Applicant's Signature: r���_ Date: /0 —q—/9
Owners Signature(or at ;...ent) A AdO Date:
Approved By: 11111W _ / Date: /0-/0- /9
e cial(or designee)
Zoning District
Historical District Yes No Flood Plain Zone: Yes No
•
Water Resource Protection District: Within 100 ft.of Wetlands:
Yes No Yes No
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1
Commonwealth of Massachusetts
117 Division of Professional Licensure
Board of Building Regulations and Standards
CoPstruCtion Supervisor
CS-072772 Expires: 04/07/2020
JEFF C STEELE
24 SHERWOOD AVE •
DANVERS MA 01923
Commissioner CL
NI I,U,KI,F(F/164 r ' /61.10flikaFerf:
Office of Consumer Affairs&Business Regulation
HONE IMPROVEMENT CONTRACTOR
TYPE:LLC
BligalfiCE
168025 04/11/2020
WINDOW WORLD OF BOSTON,LLC.
JEFF C.STEELE �Tc CGI -
15A CUMMINGS PARK
WOBURN,MA 01801 Undersecretary
: The Commonwealth of f ssaLia,is?r:ss
`-, ��C.:11` Department of Industrial Accidents
1 Congress Street, Suite 100
' a` Boston, d'A=1 02114-201 7
-.,, www.masssov/dia
-Workers' Compensation Insurance Affidavit:Builders/Contractors/ElectriciansiPlumbers.
TO BE FILED W11"H 111.E PERMITTING AUTHORITY.
Applicant Information PIease Print Legibly
Name(Business/Organisation/Individual):kI/2,,i,s�pil t/JP(4,7(4f 4/1('. -)g./4 A/iia4wrlUr/cl d l
Address: 15 A Cvm,r ir 1).s ar Gc_
City/State/Zip: 1A.lohv/'n t-1A D I R o I Phone#: 7 k I - ,9 ; Z-Leff D 5
Are yoy an employer?Check the appropriate boa: Type of project(required):
1.�(I am a employer with S 0 employees(full and/or part-time).* 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself(No workers'comp.insurance required.]t
9. El Demolition
10 Q Building addition
4.❑I am a homeowner and will be hiring contractors CO 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.❑Plumbing repairs or additions
5. I all 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.: ,/ /
6.El Weare a corporation and its officers have exercised their right of exemption per IvMGL c. 1 .L"I Ofiler t t/t�'1�`t7w P`O v IC
[52,§1(4),and we have no employees.[No workers'comp.insurance required.] r'rpt'Qtesel M
*Any applicant that checks box#1 must also Ell out the section below showing their workers'compensation policy information. i
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.polioy 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 Ss be.o f e cI EM Phu ye r 5 .—
Policy#or Self-ins.Lic.#: WC.c_. -S DO- cc /g(,O ci- 2 O/1 A Expiration Date: L/- S. 2 0
Job Site Address: /1 T t %n /✓e*orSa el • . City/State/Zip: .S/t•1 ,l /VI
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 S1,500.00
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 olator.A Co,, o this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verific 'on.
I do hereby certi un' ,he pa' a ,Aenalties of perjury that the information provided above is true and correct:
Signature: F l I Date: /0-`f-/ i
Phone#: dr l! g 8 - hi 3 9 s
Official use P , 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#:
DATE(MM/DOYYY)
A��R J n
CERTIFICATE OF LIABILITY INSURANCE 03/26I19
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 CONTAcr
NAME: amy roberts
M.P.Roberts Insurance Agency Inc. PHONE
N Ext i 978-83-8073 FAX
No): 978-683.3147
1060 Osgood Street
North Andover, MA 01845 moms: amyimprobertsinsurance.com
INSURER(S)AFFORDING COVERAGE NAIC It
INSURER A: WESTERN WORLD INS COMPANY
INSURED INSURER B: MERCHANTS INS COMPANY
L&P BOSTON OPERATING,INC INSURER C: ASSOCIATED EMPLOYERS
DBA WINDOW WORLD OF BOSTON INSURER D:
15A CUMMINGS PARK
WOBURN,MA 01801 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 POUCIES.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
1NSRR (MMIDD/YVV TYPE OF INSURANCE INSD aWVD POUCY NUMBER POLICY POLICY EXP
1') (MMIDD/YYYYL LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO D
CLAIMS-MADE I- 1I OCCUR PREMISES(Ea ocn currence) $ 100,000
MED EXP(Any one person) $ 5,000
A NPP8525379 04/05/19 04/05/20 PERSONAL BADVINJURY $ 1,000,000
GEML AGGREGATE UMIT APPUESPER: GENERAL AGGREGATE $ 2,000,000
POLICY n JECS-r n LOC PRODUCTS-COMP/OP AGO $ 1,000;000-
OTHER: $
AUTOMOBILE UABIUTY COMBINED SINGLE UMIT $ 1,000,000
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
B OWNED X AUTOS SCHEDULED
AUTOS ONLY MCA1002569 04/05/19 04/05/20•
BODILY INJURY(Per accident) $
X
HIRED X NON-0NMED PROPERTY DAMAGE $
_ AUTOS ONLY AUTOS ONLY (Per accident)
- $
X UMBRELLA LIAR X OCCUR EACH OCCURRENCE S 1,000,000
EXCESS LIAR CLAIMS-MADE AN065362 04/05/19 04/05/20 AGGREGATE S 1,000,000
CEO RETENTION$ $
WORKERS COMPENSATION X STATUTE OTH-
ER
AND EMPLOYERS'LIABILITY Y/N
ANY C OFFICERIMEM LADED?E�n�® N I A WCC-500-5018609-2019A 04/05/19 04/05/20 E.L EACH ACCIDENT $ 1,000,000
(Mandatary In NH) EL.DISEASE-EA EMPLOYEE $ 1,000,000
(ryes,describe under
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 1,000,000
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
EVIDENCE OF INSURANCE ACCORDANCE WITH THE POUCY PROVISIONS.
AUTHORIZED REP NTATIVE
it o o40�—ram1k -
O 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD