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Home My WebLink AboutBld-20-00391 ti �yA ; Office Use Only :. R • !�,! Q Permit* /,l /(O1 '�11'� - `� -lAmount Lv ` HATTAlM ESE " 1 �,*°^•a••=�0"',�d 1Permit expires 180 days from 1 issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department ;! ; _, > >;i.l! 1146 Route 28 South Yarmouth, MA 02664 �� ' OC�/ - X (508))r �"398-2231� Ext. 1261 '' 7 CONSTRUCTION ADDRESS: 2t/ 30 U 1 S. i12/Lt i (J O . ASSESSOR'S INFORMATION: Map: .3 .., Parcel: q OWNER: f✓A( p6 ,a, f) -,�J Ii ��So Ste, SDO' f i O �/ NAME ,deie. Nl —Oh PRESENT ADDRESS TEL. # CONTRACTOR:/vt�[`�G[�f5On WW1 I. rrnfid✓..¢s'irz.c;-1. ) �i0X iY76 Or1-, s OZ(v53 NAME MAILING ADDRESS TEL#cofr..1A74D• 302I (Residential ❑Commercial Est.Cost of Construction$ 63O0 Home Improvement Contractor Lic.# /1.3 V►5) Construction Supervisor Lic.# ` O//O b Workman's Compensation Insurance: (check one) ❑ I am the homeowner E I am the sole proprietor / I have Worker's Compensation Insurance (� �} Insurance Company Name: A� / "�� k O Worker's Comp.Policy#vW C I x b21 i o I206A WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares q 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: i'�C� � P-t' �1,1 — a rl�s M�Loc�4ialt of c 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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. �] (�, Applicant's Signature: /�� Date: 11 9 ilei Owners Signature(or attachment)SU__ C Date: -VI 9// Approved By: Date: ' s in r 1 1 Building Official(or designee) EMAIL ADDRESS: /4ie/ /i a 652j sok)°.coin Zoning Diict: Historical District: 0 Yes 3, No Flood Plain Zone: 0 Yes 4o Water Resource Protection District: Within 100 ft.of Wet ds: 0 Yes 3/No 0 Yes No The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 5•` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information PIease Print Legibly Name (Business/Organization/Individual): /L SDr) Wool �f��/avem.e l4-- Address: 77U "ay 2474 City/State/Zip: a(/_8✓ ,(eft O2($3 Phone #: SDi' (A/Q . 30.?/ Are you an employer?Check the appropriate box: Type of project(required): 1.❑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. E Remodeling any capacity.[No workers'comp.insurance required.] 9. C Demolition 3.0 I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 10 E Building addition 4.E 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.E Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. of repairs These sub-contractors have employees and have workers'comp. insurance.i ,1, `` 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other dwGC.f 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. lithe 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: Arlo icttVaP` co Policy'#or Self-ins. Lic. m: VW(: mm6 602-1 o / 24q Expiration Date: �/9-0�a ? U: CL y ,-�7 u li fin Job Site Address: City/State/Zip: G2.fp�S 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: Date: / / qh Phone 4: '56k• '7 v. 300 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#: ACCP • DATE(MM/DDMYYY) CERTIFICATE OF LIABILITY INSURANCE 02/28/2019 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 Rogers and Gray Processing ROGERS &GRAY INSURANCE AGENCY INC IA No.Est): (508)398-7980 (A FAx No): A mail r ers ra com ADDRESS: @ 09 9 Y• 434 ROUTE 134 INSURER(S)AFFORDING COVERAGE NAIC# SOUTH DENNIS MA 02660 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B MCAS LLC INSURER C: NICKERSON HOME IMPROVEMENT INSURER D: P O BOX 2476 INSURER E: ORLEANS MA 02653 INSURER F: COVERAGES CERTIFICATE NUMBER: 372540 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 INDIfsA' tP 'NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTWFICIATE:MAY:BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EX(L(t81QN$.M iD CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR, TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTR"`"'�"` INSD WVD POLICY NUMBER (MMIDD(YYYY) (MMIPOIYYYY) DDIYAMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECOT- LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS NON-0WN-O NED PROPERTY DAMAGE $HIRED AUTOS AUTOS (Per accident) $ )7)MRt g4.54AB OCCUR EACH OCCURRENCE $ -.EXCESSLIAB CLAIMS-MADE N/A AGGREGATE $ bt- " ` RETENTIONS $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY ANYPROPRIETOA OFFICER/MEMBER EXCLI 3EDTECUTIVE N/A N/A NIA VWC10060211892019A 03/01/2019 03/01/2020 E.L.EACH ACCIDENT $ 100,000 (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 I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it 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 fot 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 d'aj0 is,,,ceitificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search-101 afwvwv.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 Main Street Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 I Daniel M.Cr o y,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 1 } MARK D NICKERSON " • PO BOX 2476 ORLEANS MA 02663 - _ Office of Consumer Affairs and Business Regulation +�z410 Park Plaza-Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type LLC MCAS LLG �� 133851 DB/A NICKERSON HOME IMPROVEMENT E�€ration 08/16/2019 PO BOX 2476 ORLEANS,MA 02653 Update Address and return card. Mark reason for change. -✓AG f•,,,,,tai){(er/ c afi!aa;[rcfifl�eh3 Elifft lea of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LC - - before the expiration data. it found return to: Exairation 8)�ti>�LftO Office of Consumer Affairs and Business Regulation 133851 08/16/2019 10 Park Plaza•Suite 5170 MCAS LLC Boston,MA 02116 D/13/A NICKERSON HOME IMPROVEMENT MARK 0.NIC,KLRSON �Q ��,-- _ 12 COMMERCE DRIVE C) _ ORLEANS,MA o� Not valid without signature 1 SItVU ky(XDICio, (0)`'PROPOS CAS, LLC •ROOFING Pots NICKERSON HOME IMPROVEMENT •SIDING •SECOND STORIES "2404081 P.O.BOX 2476 •DECKS •RENOVATIONS 508-255.5107 FAX ORLEANS,MA 02653 •ADDITIONS •INTERIOR/EXTERIOR PAINTING www.nlckersonhomeimprovementcom •SKYLIGHTS •WINDOWSJDOORS E Mail mark1202656@yalloo.com •GARAGES •KITCHEN&BATH REMODEUNG 12 Commerce Drive Barbara Pacheco TM771 8249 °A114/2019 To: 28 South Sea Ave West Yarmouth MA 02673 tawLCCAnaa 'pep" acheco@gmail.co" We hereby submit specifications and estimates tor: Remove and dispose of sidewall from right side, left side and rear of house Nail all loose sheathing Install TYVEK or equivalent house wrap on stripped areas • add AZEK trim board over deck •••=•••••••. e„,,,,_p!dUre 14 Supply and install natural white cedar sidewall shingles to right side, left side and rear of house Supply all labor, material and debris removal estimated at • do- We Propose hereby to furnish material and labor—complete In accordance with the above specifications.tor the sum of: dolers(S rayment to be made as follows: - _ -- requested with signed proposal Progress payments on request-balance on completion Ail materiel is gwranteed to be as eperded.Al work to be completed In a prolnetotwt IelAlV"4112'Wk halving exits oosle ad be� aNeketlonorkbden&end ont ove become en sem Signature chugs over abate the esemd&c upon Whin oa ore e.and become One s delays beyond and ow coned Moir b send gentother upon aidleL seance O or walkedsare Gaycovered byWoreesCoa l Munroe. insurance Our Ny u:If not. •trod within da Acceptance of Proposal—me above prices.epeeeoettons and condition*are sedeea Cory and are hereby accepted.rim are aud•raasd to do the work ,Re r as specified Payment will be mate ea outlined above Signature Date of Acceptance: G/7/'`f,