HomeMy WebLinkAboutbld-20-002069 Office Use Only
Y OQ� k 3 , Permit
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Amount -�
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Permit expires 180 days from
sue date
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 280 bo �C�>
j i ou. cs+ South Yarmouth,MA 02664
(508) 398-2231 Ext. 1261 t.1t.
CONSTRUCTION ADDRESS: 23 Sp con 14,/2.
ASSESSOR'S INFORMATION: _
Map: Parcel:
A/ortv.4 /
OWNER: -Lacy.S'Oto e?4 Si-.,psnn e4Je it/Arr.:0 fti. /'I.4 V2(07 3 77./- 39- !q 8/`l/
NAME PRESENT ADDRESS TEL # Email Address:
CONTRACTOR:afnlet„/ k/vc1I aI' slon,LLC C' v.-gS a is-A t✓nhurn/1Pr C781) 432—`{805
NAME MAILING ADDRESS o(go 1 TEL.# Email Addre
sidential Commercial Est.Cost of Construction$ 5 6 C/ —
Home Improvement Contractor Lic.# /66.O2.5 Construction Supervisor Lic.# (272.77L
Workman's Compensation Insurance: (check one)
I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance
Insurance Company Name: 43%6.im4e nn EmFloyt?r'.S_ . Worker's Comp.Policy# c.1 C C. 9)0 S 0 1.2.6Q9—
.2olgat
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# /0 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 V, f ma SC iell 1 - (4:4 veil 4 1i A
J Location of Facility
I declare under penalties of perjury the s,Iy'o, - n 1 are true and correct to the best of my knowledge and belief. 'understand that any false answer(s)
will be just cause for denial or rev.,l'o' ' MG.L.Ch.268,Section 1.
Applicant's Signature: �.f/f�`il1\ Date: /b — 9 /9
Owners Signature(or at ent) A I. 'ate:
Approved By: Date: /U'10 1 y
e6 oral(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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$•L40 Spider foa ills la a e 4x w1 S OO 1l2;Scteens
f.�•PrctuIe[�plxede-(84 i 1JI) S4(9.. _Poaminsulalb0'onJartiba'andH Stt INCC.UOED.
• P)ctute!F.... •Lite:t i (ee.13o Uq 3639'
_^AWn)iig. 5359 _.._boybte Strength,Gless(4000 1: O I) sfSactCUN
„ •Casement , 49(OH.Sesh RelitS379 _Double Locks(>251 •ss'INCLUOEO •
•_-2 0- aseliient. $669 _Fiat Teens• S25'
_30e•04sement i.o sa w, om 1z lal $1029 _,___, ..cglonial:Afids-(Co •urod/Pral� S6S'
_. aseptentHopper 9459' Pr IriaGrids :ETV:
_BpyWlndgw SgiftMount!INS)Seat>f2859 _Stmulaled1 dedlke: .$182
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, ydenl2Vfndov) $2t79 _,OI##„ a.Gt aa.(9S0).(1'SO)' `;7li
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: V►iyi i iid"Pediro oe,,6. at•ei(: -.s(219 Instaq 1t11erlor Caeing Sia At:$95,
_Yntyl'Na) tDFilihi oor M? 5{-. -. - RePat SOL Jenlboireplacas " •n9-$70%
ArilieDemOrkelgr•Dgslom.Aoki hieao!• 269: katSubSill(Single)replae l 3170•
_Fiench440:$6dNg•Palto'PPP'5h,orsa'':51536 Insulate Weight Roves $20.
_F�RI47004Dcteh: StSio39
>9 �MuN4o'Focal MulaU • $30- •
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x rlasryOd.Uow s2trs _..Hei+t:Conat vinyl rRentoval $IY
__,Nroo¢ytAht nteibrs 'S399: ,_New: Eitl:,t1atroi lI d—'
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V Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Cortstruction Supervisor
CS-072772 Expires: 04/07/2020
:141k,
JEFF C STEELE '
24 SHERWOOD AVE
DANVERS MA 01923
Commissioner
VL
^7t4 l(l lit Nm.RV,FIF/IA I fiFei.ko[1'rIJN/f:
Office of Consumer Affairs&BusM.se Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:LLC
BROWNE Fd
166026 04/11/2020
WINDOW WORLD OF BOSTON,LLC.
JEFF C.STEELE CR..CI
15A CUMMINGS PARK
WOBURN,MA 01801 UndORNICretary
Me Commonwealth f ICISSizi?t wserrr
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.,;ov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH DiE PERM1TTI 1G AUTHORITY.
Applicant Information ( Please Print Legibly
Name (Business/Organization/Individual):,4-!j�h. jS/oi► QJP/�-i�4 f-L/'e. .)gA• lode J c'.4 Zas4arl
Address: 1 5 C Xr1 rn
City/State/Zip: inIohv/'n M P� D I R D 1 Phone#: 7 1 - Z-L/,g p
Are yog an employer?Check the appropriate box: Type of project(required):
1. II am a employer with (7 employees(full and/orpart-time).* 7. New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Ej 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.]
❑
10 Q Building addition
4.❑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.❑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.: U.❑Roof repairs
o.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 1$.1J 'filer
152,§1(4),and we have no employees.[No workers'comp.insurance required.] r toehf e.eim' '
*Any applicant that checks box 41 must also Ell out the section below showing their workers'compensation policy information.
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 aot those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
ram an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: A Ssac i Gi f e d Evt Phu ye t- 5 —.
Policy#or Self-ins.Lic.#: tnfG C. -5 oD- SD I'(,O 5- 2 U/ct J{ Expiration Date: y— �- 2 0
Job Site Address: 1 .3 Ste,eso- 4-Je City/State/Zip:tij frio /sr-tA
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 'olator.A co, o this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verifies 'on.
I do hereby certi !un' he pa ay ,lenalties of perjury that the information provided above is true and correct.
Signature: % Date: Jo— c-is'
Phone#: - 8 ' ', 8- 43 9!
Official use . )1, 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#:
�Q� DATE(MM/DEVYYYY)
A
CCI CERTIFICATE OF LIABILITY INSURANCE 03/26/19
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 NAME amy roberts
M.P.Roberts Insurance Agency Inc. PH PAX
Exn: 978-683 8073 fAIC,No): 978-683-3147
1060 Osgood Street �-NWIL
North Andover, MA 01845 AODREss: amyemprobertsinsurance.com
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A: WESTERN WORLD INS COMPANY
INSURED INSURERS: MERCHANTS INS COMPANY
L&P BOSTON OPERATING,INC INSURER C: ASSOCIATED EMPLOYERS
DBA WINDOW WORLD OF BOSTON INSURERD:
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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTRR TYPE OP INSURANCE IN O WVp POUCY NUMBER POLICY EFF POLICY EXP UNITS
(MMIDD/YYYY) (MMIDD/YYVY)
X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000
TO REND
CLAIMS-MADE n OCCUR PREMISEGE S(Ea occccuurrence) $ 100,000
MED EXP(Arty one person) $ 5,000
A NPP8525379 04/05/19 04/05/20 PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000
X POLICY n Ter n LOC PRODUCTS-COMP/OP AGG $ 1,000;000-
OTHER: $
AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
B OWNESDONLY X SAUTOSCHEDULED MCA1002569 04/05/19 04/05/20 BODILY INJURY(Per accident) $
AUTO
x HIRED A ONLY X NAUTOS ONLY ON-0NMED PR(Per accidOPERTYent) MAGE $
UTOS _ DAMAGE
- $
X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000
EXCESS UAB CLAIMS.MADE AN065362 04/05/19 04/05/20 AGGREGATE $ 1,000,000
DED RETENTION S $
WORKERS COMPENSATION X PER OTH-
AND EMPLOYERS'UABIUTY Y/N STATUTE ER
C oFFIc ERAMEMBER EXCLUDED7ECUTNE N/A WCC-500-5018609-2019A 04/05/19 04/05/20 E.L.EACH ACCIDENT $ 1,000,000
(Mandatory In NH) E.L DISEASE-EAEMPLOYEE $ 1,000,000
If yes,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 POLICY PROVISIONS.
AUTHORIZED REP EMTATIVE
OD 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD