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HomeMy WebLinkAboutbld-20-00948 �Y Office Use Only � dT'. Permit# ,, !, 0. (0� . :.iy%rv'4 y Amount \J`� ` MATT 1M FSF 4''. - s,,,, ,':'ECa bidb.'CIO (( Permit expires 180 days from` ,issue date EXPRESS BUILDING PERMIT APPLICATI TOWN OF YARMOUTH RECEIVE ® Yarmouth Building Department 1146 Route 28 AUG 21 2019 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BU1101 BY. CONSTRUCTION ADDRESS: / I L, ` 1 72 v 1-...,-) ASSESSOR'S INFORMATION: �1 j Map: Parcel: OWNER: Y2 0 f,v ,-t' c-. `0 „i,, )f C%�tcVi—✓? -J'!- _. l«%rM r,i-e,t k4- 7' .f'3 9—1-`/ 6 - NAME 9/► PRESENT ADDRESS / TEL.!# CONTRACTOR:f" ""\EL `' G %v ',—Z 1 J nc �., S), +:c,--,> ! f �� 1.,, / I "S l�� D U 0L NAME MAILING ADDRESS / TEL.# tesidential ❑Commercial Est.Cost of Construction$ /( J`' j Home Improvement Contractor Lic.# / f 3 Construction Supervisor Lic.# t 17 cJ Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor l I have Worker's Compensation Insurance Insurance Company Name: A .'— ✓ifs!+"t - ,'- / ' ' Worker's Comp.Policy#w(-- '' 0 7 IS-fir. 2-S.20 q 4 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Repl cement 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: />-� J Y •f` , 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 answers) will be just cause for denial or revo o7 license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: �G-2 i, ----", Date: X J a / ) 1 C) �J r� Owners Signature(or attac i t) 7`' +�1 C7.:----<-- 1, - Date: S 1 2-) / / S Approved By: l �' PP ,�� �� Date: �"' /r/s Buil•/g Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes C No The Commonwealth of Massachusetts }. / Department of Industrial Accidents =tee= 1 Congress Street, Suite 100 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 PIease Print Legibly Name (Business/Organization/Individual): f✓In--1.--1—c Gi,.„ Address: Cj�l,t h,-).--.9i-- City/State/Zip: `_ ✓*"-` kA". 04'YI3 Phone #: ) ) — Are you an employer?Check the appropriate box: Type of project(required): I, I am a employer with 6.2 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.] 9. ❑ Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 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.❑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.I 14,0Other -e'? 6.0 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: v Zvi, Policy#or Self-ins. Lic.#: 4 w C I`� " C> 3 f f 2 fZ" Expiration Date:r! 3 / 2`) L' Job Site Address: City/State/Zip: 14'' �f � 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 under the pains and penalties of perjury that the information provided above is true and correct g- Signature: Date: Phone#: I I' 5 F 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#: I .//, Emir,,,i�ii,e¢,,„4.;c(ii,,,,,„1,,//-i Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation Registration Expiration 173583 01/08/2021 MARK R.O'DONNELL INC. MARK R.O'DONNELL AJ2.-Cc 79 ORCHARD ST C LEOMINSTER,MA 01453 Undersecreta t Commonwealth of Massachusetts yiDivision of Professional Licensure t ' Board of Building Regulations and Standards Constroctiori!Supervisor CS-064782 tt Etpires: 09/22/2020 I f MARK R ODONNELL ',4^ .3 ORCHARD-Sy ORCHARDT ,1,,t` LEOMINSTER MA 0145 Commissioner vL i ® DATE(MM/DD/YYYY) ACCORD CERTIFICATE OF LIABILITY INSURANCE 8/21/2019 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 Insurance Marketing Agencies, Inc. PHONE Tara Clancey FAX 306 Main Street (A/C.No.Ext):508-471-1165 (A/C,No):508-471-1862 Worcester MA 01608 ADDRESS: tic@imaagency.com INSURER(S)AFFORDING COVERAGE NAIL ft INSURER A:Nautilus Insurance Co. 17370 INSURED MARKR2 INSURER B: Mark R O'Donnell Inc PO Box 1037 INSURER C: Leominster MA 01453 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:528891899 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W LIMITS LTR INSD VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY NN812161 7/7/2019 7/7/2020 EACH OCCURRENCE $1,000,000 AMAGE TO RENTED CLAIMS-MADE X OCCUR PREM PREMISES Ea occurrence) $100,000 X 2,500 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY JECOT- LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ACCPRO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `..� 08/21/2019 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 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 NAME: Tara Clancy INSURANCE MARKETING AGENCIES INC (plc AILNo.ExU: (508)471-1129 ia"c,No): E-M fic@innaagency.com ADDRESS: �: aagency.Com 306 MAIN ST INSURER(S)AFFORDING COVERAGE NAIC# WORCESTER MA 01608 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B MARK R ODONNELL INC INSURERC: INSURER D: P O BOX 1037 INSURER E: LEOMINSTER MA 01453 INSURER F: COVERAGES CERTIFICATE NUMBER: 439729 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) IMM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY I 1 JE T LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED ^SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ _ _ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH PEATUTE ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? VW N/A N/A AWC40070355252019A 05/03/2019 05/03/2020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) 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 status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Crorey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD