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HomeMy WebLinkAboutBld-20-001909 Office Use Only k: o '1erit /9O � H i s Amo '!e surf n s K "``" ,"�cad' Permit expires 180 days from a issue date 1 I3Jb--ZO -O01C1D? EXPRESS BUILDING PERMIT APPLICAT C E y E TOWN OF YARMOUTH Yarmouth Building Department OCT 0 8 2C19 1146 Route 28 South Yarmouth,MA 02664 Pev T 11 I�Itt v1 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 90et RAp cue fin- . YCtcmouL-- SAP Oa(a(04 ASSESSOR'S INFORMATION: Map: Li i Parcel: Gig'�ny I m k OWNER: \ e hI044 I° -1O rYActr1r\ 6 - teivsier MA Gaol slor ao7- 377 I NAME PRESENT ADDRESS TEL. # CONTRACTOR: I n,o-1-Lj 1CLmu yb b 5 R-e (o EASiham cc jA t ra' z 5oS 340--c3A NAME MAILING ADDRESS TEL.# ❑Residential Commercial Est.Cost of Construction$ RO—' AV O©0 Home Improvement Contractor Lic.# 1 Si 3,Q E Construction Supervisor Lic.# es= Og \oaO(o Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor II have Worker's Compensation Insurance Insurance Company Name:A S•l'I(\. wuN t&t s.ri5• a 0 Worker's Comp.Policy# P VC-/DO-V)la LI RO 'JD eA WORK TO BE PERFORMED Tent Duration terPRD-diaqS (Fire Retardant Certificate attached?) Wood Stove" 1 Siding: #of Squares I(O Replacement windows:# 1 Z Replacement doors: #3 5 (V U — 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: 140r U? IC 1-4 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 revocatio my license prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: j0/a l/y 40 Owners Signature(or attachment) t ge p tyr�/r Date: la/ 2 i!, Approved By: ✓ -� Date: 1u '%-'c Building Official(or desigifireT EMAIL ADDRESS: VJar»eSore (2) c)i13uu ri4.4Cor%. I .Co,,4-, Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No ACCORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 01/15/2019 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 02136-001 Cat TACT Branch 2136-1 PHONStarkweather&Shepley Ins Brkg Inc (A/C.No.Ext): PO Box 549 EMAIL C.(401)435-3600 (�/X 401)431-9323 No.: IRDocs@starshep.com Providence,RI 02901-0549 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: A.I.M.Mutual Insurance Company 33758 INSURED Land Cape Inc INSURER B The Coastal Companies INSURERC: P 0 Box 1767 INSURER D: Orleans, MA 02653 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. JSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY�__Epp�F_� POLICY EXP .TR INSR WVD (MM/DDrfrim (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES(Ea occurrence) CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 3EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ —1POLICY JECT r OC AUTOMOBILE LIABILITY -COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL AUTOS OVVNED AUTOSULED BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 7 EXCESS LIAB CLAIMS MADE AGGREGATE $ DED RETENTION$ $ y�ORKERSCOMP NSATIDN WCSIATU- OTH- AND EM�PpL�O�YYERpSR IABILITY X TORY LIMITS ER AFFICER/(v)EMBR/PART�FOR/(ECUTIVEYYN N/A VWC-100-6012480-2018A 11/25/2018 11125/2019 E.L.EACH ACCIDENT $ 1.000.000.00 (Mandatory in NH) EXCL EE.L.DISEASE-EA EMPLOYEE $ 1,000,000.00 If ScRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 1.000.000.00 • )ESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) ;ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CA NOE LLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE OO 1988-2010 ACORD CORPORATION.All rights reserved. CORD 25(2010/05) The ACORD name and logo are registered marks of ACORD DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit Number_ is-that the debris-resulting-from-tins work shall-be disposed of in. a properly licensed solid waste disposal facility as defined by MGL c 111, S 150A. The debris will be disposed of in: c..acJ o LC.� LOCATION OF FACILITY ( // Signature of cant ate • AFFIDAVIT As a result of the provisions of MGL c 40, S 54, I acknowledge that as a condition of Building Permit Number all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. I certify that I will notify the Building Official by (two months maximum)of the location ofthe solid waste disposal facility where the debris resulting from the said construction activity shall be disposed of,and I shall submit the appropriate form for attachment to the Building Permit. / 4)/ ate Si e mit Applicant (PRINT OR TYPE THE FOLLOWING INFORMATION) �o l (L Name of Permit Applicant 6C)A5 1-41,4 etc l !tie Firm Name, if any � � Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards • Cons'rttiCe` r{itop,rvl or CS-081206 •• ts Esyires; 02/22/2020 a TIMOTHY KLINK' 240 PLEASANt PAYz ntrilw � '' HARWICH MA 02645 ` 1., _ Sfits� ttj1\ ,, Commissioner Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPks Corporation Reaistrat? Expiration 1372948 11/05/2020 • LAND CAPE,INC D/B/A COASTAL LAND DESIGN • TIMOTHY D.KLINK 6R.CGQ 4665 ROUTE 6 • EASTHAM,MA 02642 Undersecretary COASTAl October 04, 2019 Town of Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 To Whom it may concern, I,Mike Schlott current owner of 909 Rte. 28 Main Street hereby authorize Timothy Klink of Coastal Custom Builders and his representatives to apply for and secure all necessary building permits for 909 Rte. 28 Main Street Yarmouth MA. Sincerely, Mike Schlott N. Eastham Office: 4665 Route 6 Eastham, MA 02642 508-240-2114