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HomeMy WebLinkAboutbld-20-001013 Y Office Use Only ., . AR`� Permit# - Ou lv` . H t.Amount ✓5� ` HAT7 n ese 4' ,Ala* eo""S:P.,'' 'Permit expires 180 days from •- * ✓ - 10 f 13 issue date EXPRESS BUILDING PERMIT APPLICATION - -- _. TOWN OF YARMOUTH i t,' E. C F. 1 V E Yarmouth Building Department 1146Route28 �:�Ljb ? a : ? South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 Dir , ) °A R- M,E '. . 031\ CONSTRUCTION ADDRESS: (O c (1 )c((i&W / S,c)ov\ m ASSESSOR'S INFORMATION: —�—( Map: l Parcel:L _ p p OWNER: SG..S.O ti l Ob��Orc� P o.QQk d ot'{t� tt� oirie oro O9 6-0 a O — 0 1 NAME PRESENT ADD SS / TEL. # X CONTRACTOR: C6tr:S1,lx/ Tr, , Ia.. Ge hletin(. ata, ceribitiym ,000 774f-a36-/'t NAME MAILING ADDRESS TEL.# g Residential ❑Commercial Est.Cost of Construction$1 /S- ow . ) x d� A Home Improvement Contractor Lic.# I$S6101 Construction Supervisor Lic.# C�S—Ua869_ Workman's Compensation Insurance: heck one) ❑ I am the homeowner I am the sole proprietor i' I have Worker's Compensation Insurance Insurance Company Name: Ckt•JAt p — (,‘S(I,rtAcs._a. Cal 1 Worker's Comp.Policy# 6S6a Al —7 ff7(35T- 6— I WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Sidin : #of Squares Ilk© Replacement windows:# 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: \ di bisoics..9 z(kv\ ei/f 9e.0 be.,ti.,-,5 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 oorr�revocation f icense an r prasesution under M.G.L.Ch.268,Section 1. / '(Applicant's Signature: ®P1 Date: S/�S//19 Owners Signature(or attach nt c�,U. Jt1 J 1 c g rL te..Q n\A1\ Date: S(IS /1 Approved By: Date: ��1 0 3/, Buil b Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 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 l A Sfr if P Il C c ipp Address: 10— Gfte . i ne_ Road1-- City/State/Zip: f ro;t mot OD..63s Phone #: 771123if 40 id Are you an employer?Check the appropriate box: Type of project(required): LE I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 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. [No workers'comp.insurance required.]t 9. ❑ Demolition 10 ❑ 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.❑ Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.gi 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.$ 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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: C (.1 ,I ts(),/rpcsce Cr,, Policy#or Self-ins. Lic.#:G1S DJAE.-7 ftl 255-6- Expiration Date: (0(0 0g Job Site Address: (0ciajtnr Q' 0'g4& City/State/Zip:SO, nAtX MP) 0�.651 Attach a copy of the workers')ompen lion polic 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 under the pains an ties of perjury that the information provided above is true and correct Signature: Date: S/isfiCI Phone#: 7 -)9 33(3"" 10(0 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#: DATE(IMAIDDNYTY) A o° CERTIFICATE OF LIABILITY INSURANCE 0713112019 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 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 CON Karen McHugh Arthur D.Calfee Insurance Agency,Inc. ,1.(508)540-2609 r.No,(508)457-1715 www.calfeeinsurance.com AADDARIESS, karen@caifeeinsurance.com 336 Gifford Street INSURERS)AFFORDING COVERAGE NAIC Falmouth MA 02540 INSURER A; Main Street America INSURED INSURER B; Chubb Insurance Co Master Builders Pro Inc INSURER c; Progressive Ins Co 29 Racheile Court INSURER D Mashpee,MA 02649 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 OF INSURANCE wiw ijnn POLICY NUMBER (PO D (PO 'Y EXP LIMITS COMMERCIAL GENERAL UASLITY EACH OCCURRENCE S 2,000,000. A CLAIMS MADE X OCCUR PPRDAMAGE MISFS(Fa ommence) $500,000• Y Y MPP7166A 04/1512019 04115/2020 MED EXP(Any one person) $10,000. PERSONAL&ADV INJURY $2,000,000. GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000. X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $4,000,000. OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) C ANY AUTO BODILY INJURY(Per person) $250,000 ALL OWNED X SCHEDULED 00862913-0 07/0112019 07/0112020 BODILY INJURY(Per accident) $500,000 _ AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $100,000 AUTOS (Per accident) UMBRELLA LIAR T OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER ItTE 0R AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y EL EACH ACCIDENT $100,000. B OFFICER/MEMBER EXCLUDED? Y N/A 6S62UB-7H71355-6-18 10/06/2018 10/06/2019 (Mandatory In NH) E.L DISEASE-EA EMPLOYEE $100,000. if yea,describe under DESCRIPTION OF OPERATIONS beta( ,E.L.DISEASE-POLICY LIMIT $500,000. DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached I more space is required) Diego Duarte Magnus and Jhonatan Silva opted out of Workers Compensation with a form 153 certificate holder listed as additional insureds on a primary and non-contributory basis including waiver of subrogation as required by written contract. CERTIFICATE HOLDER CANCELLATION Susan Tobelman SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 14 Sailing Village Way THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, S.Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE <KMM> ®1988-2014 ACORD CORPORATION. All rights reserved.' ACORD 25(2014A31) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs&Business Regulation-Mass.Gov 8/22/19,3:58 PM State Zip code Click on the registration number to view complaint history. You can also view arbitration and Guaranty Fund history. The list is current as of Wednesday, August 21, 2019. Search Results christopher tripp tripp, christopher 185690 12 geraidine rd 07/30/2021 Current cotuit, MA 02635 Site Policies Contact Us © 2018 Commonwealth of Massachusetts. Mass.Gov® is a registered service mark of the Commonwealth of Massachusetts. https://services.oca.state.ma.us/hic/ticenseelist.aspx Page 2 of 2 Office of Consumer Affairs&Business Regulation-Mass.Gov 8/22/19,3:58 PM i s\ _. 4-10—~ fillafiaLgaM Home Improvement Contractor Registration Lookup To search by registration number, enter the registration number in the textbox below and click the 'Search' button. Please note pressing the Enter key will clear fields. Search by Registration Number 185690 Search You must click the "Search Registrant" button to search by name or location. Please note pressing the Enter key will clear fields. Search by Registrant Company name Search Registrant Search by Registrant Last name City/Town https://services.oca.state.ma.us/hic/licenseelist.aspx Page 1 of 2 --- ■.munweaitn of Massachusetts / IF Division of Professional Licensure Board of Building Regulations and Standards Constr ,n 'Supervisor S-112862 ' 1pires: 12/22/2022 " CHRISTOPH6R C TRAM .. 12 GERALDINEi,ROAD ',. .... cfl tilik f COTUIT MA 02646 ,.. i Clop a. 7.ommissioner