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Home My WebLink AboutBld-20-000913 r-. ...f' (,),9-07) 97 r o 413\ y '► Amount 15:4`0 '""' ,(..„27 Permit expires 180 days from =f issue date EXPRESS BUILDING PERMIT APPLICA TOWN OF YARMOUTH � E I Yarmouth Building Department s 1146 Route 28 1 . ' L'6 1 ) 20/g South Yannouth, MA 02664 e IiI L��N�5 .. (508) 398-2231 Ext. 1261 --,_ �PARrMENT CONSTRUCTION ADDRESS: 83 -PaveVann a\NI-KU-1" r• , S. jt.Yrnolkl4i ASSESSOR'S INFORMATION: Map: 0 24 Parcel: 17'4 OWNER: i b.toiel (—1 tip . f10 l MA �.� 'viCr' 6t -540.273P • '••' �,,IClz.CA tt t Si 1�p RESENTADDRESS r TEL. # l CONTRACTOR: NAME akcird ) C MG ADDRESS Tokyo FATl`1 , t4A C .5- sz5. ce,901(ceko Residential 0 Commercial Est.Cost of Construction$ (p K . Home Improvement Contractor Lic.# 121--To Construction Supervisor Lic.# 070 I 7 7 Workman's Compensation Insurance: (check one) I am the homeowner `` ��E I am the sole proprietor XI have Worker's Compensation Insurance Insurance Company Name: t4t)( Z,) Worker's Comp.Policy# W CO 02�,q7 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 4 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: Chu tAq 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. 1 understand that any false answer(s) will be just cause for denial or revoc ' a of malice d for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: S. (S• V Owners Signature(or attachment) Date:fi1r Approved By: Date: — ,y—1C\ Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: E Yes 1 No Flood Plain Zone: E Yes E No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes ❑ No C Yes 0 No The Commonwealth of Massachusetts rt Department oflndustrialAccidents _Fail.= 1 Congress Street,Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Anolicant Information Please Print Legibly Name (Business/Organization/Individual): yA COSIYY1 �r� Address: 2A a 1" City/State/Zip: -pkynm tAA 9231,o Phone#: 506 - 54_S 15 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 3 employees(full and/or part-time).* 7. 0 New construction 2.❑1 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 doingall work 9. ❑Demolition ❑ myself[No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I wdl 10 Building addition 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 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.* 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other ( 1� vq2(glem 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#i must also fill 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. tContractors 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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: a j (s1&AD Policy#or Self-ins.Lic.#: *C,up 2 1'7 Expiration Date: 8.2f .?p Job Site Address: f33 • Zetw kCkffl&vJ Klki- 1>4r. City/State/Zip: `S. yatrm4h r /A Q24,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 enalties of perjury that the information provided above is true and correct jgnature: Date: S 15•V Phone#:� 6 • 3` 4 - �355 cal 50b - 525. 149D 1 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#: CERTIFICATE OF LIABILITY INSURANCE OD8�1( IN9D/YYYY) A`URO' /20 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 BEOW.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). ,RODUCER CONTACT Paychex Insurance Agency Inc PAYCHEX INSURANCE AGENCY, INC. PHON 150 SAWGRASS DRIVE (AJC,,n o.EXT): 877-266-6850 FAX No): 585-389-7426 ROCHESTER, NY 14620 E-MAIL Certs@paychex.com ArNIRERS- INSURER(S)AFFORDING COVERAGE NAIC• 'ISURED INSURER A: NorGUARD Insurance Company 31470 SHEA CUSTOM CARPENTRY INC. INSURER B: 20 DOTEN RD PLYMOUTH,MA 02360--218 INSURER C: INSURER D: INSURER E: INSURER F: OVERAGES 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. SR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POUCY EFF POUCY EXP LIMITS (Ft INSR WVD (MMIDDIYYYY) (MMIDD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED —(CLAIMS-MADE�CCUR PREMISES person) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPUES PER: PRODUCTS-COMP/OP AGG $ POLICY PROJECT LOC - - - AUTOMOBILE LIABILITY COMBINED SINGLE LIMB ANY AUTO (Ea accident) ALL (Per OWNED SCHEDULED BODILY per son) $ AUTOS AUTOS � HIRED AUTOS NON_OWNED BODILY INJURY AUTOS (Per accident) PROPERTY DAMAGE (Per accident) $ UMSRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I RETENTIONS $ WORKERS COMPENSATION AND X WC STATU- OTH- EMPLOYERS'DABIUTY SHWC002397 08282019 08282020 TORYI IMIIS FR E.L.EACH ACCIDENT $ 100,000.00 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L DISEASE-EA EMPLOYEE $ 100,000.00 (Mandatory in NH) N/A E.L DISEASE-POLICY LIMIT $ 500,000.00 I yes,descrbe under fFSCRIPTICYJ CIF CIPFRATIC* 1W� .ESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remake Schedule,if more space Is required) 3ERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE 1146 Rte.28 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DEUVERED IN South Yarmouth, MA 02664 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ',CORD 25(2016/09) 471988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD tY----4 Fo/9-4/-i-w-nzeoeadio-/ i eacw44- Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation SHEA CUSTOM CARPENTRY,INC. Registration: 124769 20 DOTEN RD. Expiration: 08/19/2021 PLYMOUTH,MA 02360 Update Address and Return Card. SCA 1 0 20M-05/17 /�i 7ivli.werny rir///1/./._-/7-iot fie/6 Office of Consumer Affairs&Business Regulation • HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. if found return to: Registration Exoiration Office of Consumer Affairs and Business Regulation 12476E 08/19/2021 1000 Washington Street -Suite 710 SHEA CUSTOM CARPENTRY,INC. Boston,MA 02118 EDWARD E.SHEA 20 DOTEN RD. ,,(„,,,,,itea. eim4.. PLYMOUTH,MA 02360 Undersecretary Not valid without signature • z. Commonwealth of Massachusetts i Division of Professional Licensure Board of Building Regulations and Standards Constr ttidn'S�tipervisor CS-070177 EDWARD E SA _ P tt�ires:05/30/2021 20 DOTEN RQa 4 PLYMOUTH U231 Commissioner