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Home My WebLink Aboutbld-20-000910 Office Use Only • Iw Q'. O !'I '- 411 :Amount =fin n s '0 crd' 'Permit expires 180 days from j - : issue date EXPRESS BUILDING PERMIT APPLICAT ----� i TOWN OF YARMOUTH 71st-e- EIVEDil Yarmouth Building Department 5 \ '3(�l' 1146 Route 28 1 L� ; 3 '.t L South Yarmouth, MA 02664 , B w (508) 398-2231 Ext. 1261 B or, v. PART CONSTRUCTION ADDRESS: 2 cc-4,41 il,2 St- vi, \( w•.- 41Pv ASSESSOR'S INFORMATION: . getzhl, Map: Parcel: ',e ��JOWNER: / //YID 9D QS pi.n Hats LVJ eat, tut 700 aa0' uNAME PRMENT ADDRESS / EL. # CONTRACTOR: AIRNO A.S. V IA I(F,P CF 1-1•1 l) (11 i- 5o 'Zq Z25 8,1 NAME MAILING ADDRESS TEL.# ( Residential 0 Commercial Est.Cost of Construction$ G SCV,cz Home Improvement Contractor Lic.# I ( / `0 0 ( Construction Supervisor Lic.# CS oc1 b5 vC Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor IX-have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# J 6 G p WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares I Replacement windows:# 4 Replacement doors: # i 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: Ir IMdJ(., iln 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 or rev ation of my license and for prosecution under M.G.L.Ch.268,Section I. /Q� Applicant's Signature: '�� Date: I 1 )6 Owners Signature(or attachment) /...--7 :. " Date: Ltq 13, 61. Approved By: -e--- Date: 1—I 7 —)C Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts •_*.W, — Department of Industrial Accidents _�'e': 1- 1 Congress Street, Suite 100 0�s N= Boston, MA 02114-2017 M`5�•`'V www.mass.gov/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): qQA-Laki woo 9 u►O£ems l u G Address: ( giY1 vWi c City/State/Zip: CATO t i ( `t f IS- 02 63 f Phone #: 608'24 LZc,67 y 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.❑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. 9. ❑ Demolition ❑ y [No workers'comp.insurance required.]` 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.: 6. 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. r 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: //�� c7 C L L `J le•� g 4-(Q,v-< b Policy#or Self-ins.Lic. #: S 6 Z U$y N S`' 3 j' 3kxpiration Date: 5-[ 0 9 /20 Job Site Address: 7, -1K4 It-1-( IV cq-- City/State/Zip: 0, 1/4/1Mr11 Y® I t( 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: 4ç't_ \__. Date: 81 IO tq I Phone#: 5 Egg 24/ 2�'j g%-t Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: y r l.unununweaun ui massacnuseus �/�eov�zrrrMrraea�l'�z cyf,il/6 �ac<r�e�c/L� �z�f Division of Professional Licensure Board of Building Regulations and Standards Office of Consumer Affairs&Business Regulation ConstrylCtil�ri iti�pgrvisor HOME IMPROVEMENT CONTRACTOR TYPE.Corporation CS-093566 14 Epires: 02/20/2020 Re18180tlorl ' Expiration 1$'I$01 10/28/2020 ,,-Y ,t l QUALITY W OOD?W Q< INC , ARMINAS DIMSA ` . ' 17 PATIENCE IN ! a ' COTUIT MA 0/-6 �` n ` ARMINAS DIMSA 2,.CG(2,e-r-----' 1()/S\ I,IL.\ ___ 17 PATIENCE LN � COTUIT,MA 02635 Undersecretary Commissioner l 'r" y A`oRIJ CERTIFICATE OF LIABILITY INSURANCE 005.21- 19 '�' • THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATWELY 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(es)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 NAME: SULUVAN GARRITY& PHONE I FAX 161 OXFORD DR ( •No,Ea): IA/C.No): COTUIT,MA 02635 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC i INSURER A:ACE AMERICAN INSURANCE COMPANY INSURED INSURER 8 QUALITY WOODWORKS INC )NguRERC: 17 PATIENCE LANE COTUIT,MA 02655 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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. LTR TYPE OF INSURANCE gap WVr POLICY NUMBER pwavoo yYYYYY) may) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ICUUMS-MADE I—I OCCUR PREMISES TO RENTED (Ea occurrence) MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE UNIT APPLIES PER: GENERAL AGGREGATE $ POLICY I PRO- LOC PRODUCTS-COMP/OP AGG $ JECT OTHER: $ AUTOMOBILE LIABILITY COMBIaOtlSINGLE LIMIT $ ANY AUTO 4Ea OWNED n SCHEDULED BODILY INJURY(Per person) $ H • AIRED ONLY } ! P U-0WNEp BODILYO INJURYR (Per accident)$ AUTOS ONLY i AUTOS ONLY IPe�aentl AMAGE UMBRELLA LIAR I OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION PER _ AND EMPLOYERS'LABILITY Y/N I STATUTE I ERH EXEXECUTIVE OFFICER/fAEMBER Y N/A E.L.EACH ACCIDENT $$1,000,000 EXCLUDED? 6S62UB 05 09 2019 05 09-2O2U E.L DISEASE-EA (Mandatory in too 4N353413 EMPLOYEE $$1,000,000 If yes,desorbe under E.L DISEASE-POLICY DESCRIPTION OF OPERATIONS below LIMIT $$1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD 101,Add lional Remarks Schedule,may be attached I more space is required) CERTIFICATE HOLDER CANCELLATION IC 47 I�,0 �-Y( SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED f ^� �J \ `\ BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE H,' +2645 ^ DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. �1 r" O r AUTHORIZED REPRESENTATIVE I 01988-2015 ACORD CORPORATION.All rights reserved. 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