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HomeMy WebLinkAboutBLD-20-567 Office Use Only 'YRR d • =Permit# . `(yam c ,fir y az O .y Amount =� MATTA 14 ese • ""�°"'cad' <Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION i(c TOWN OF YARMOUTH Yarmouth Building Department 4/66 ( . . 1146 Route 28 CO -1' South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 3" A 2i,V 41. W- 2 - 7 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Cjie /Se/t/ /SregA-It-4-4./ 779-26e - 9,7%3 FAME PRESENT ADDRESS ,v TEL. # CONTRACTOR: �0Q7 6/ �ij M., i jaSi 4 —TEL. g 77G f13.S-"9 NAME MAILING ADDRESS TEL.# ( Residential ❑Commercial // Est.Cost of Construction$ 7e000, 00 Contractor Lic.# CSrj9 a�b c5^ 7 C ic.# / 3i 985 Workman's Compensation Insurance: (check one) 0 I am the homeowner oi6 am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# _ WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 4'g Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ()c)Replacing like for like Pool fencing *The debris will be disposed of at: 700,0 CY ?/4 'P7627 L9c/ //1 1111 Location of Facility I declare under penalties of perjury state e here' cont ' d are true d correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or rev of li nse for pr c ion un r M.G.L.Ch.268,Section 1. ,, Applicant's Signature: Date: 7op.„/T .z 2C//7 Owners gnature(or a me Date: Approved By: Date: L " --ly Bu' ing Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts Department oflndustrialAccidents 1 1 Congress Street, Suite 100 _M: .mw Boston, MA 02114-2017 • 44. 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): ,221f T FLU// j' i3g A4. k, rizicc e.erx.) s/ Address: 2 - wyitiv g2 f` City/State/Zip: ka,nitafevt,r 1$4,4 pzd3f Phone #: rpg '7 76' 93,79 Are you an employer?Check the appropriate box: Type of project(required): 1.7/I am a employer with 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.] 3. I am a homeowner doing all work myself. 9. ❑ Demolition ❑ y [No workers'comp.insurance required.]' 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 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.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp. insurance.t 13. Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Eii<her.<7/41 k1�] �� ,it 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. 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. /1 Insurance Company Name: it 402,711 th 4,/Lj tt; C L4--05-7/ Policy#or Self-ins.Lic.#: 383 9a/ Expiration Date: . p ZQ Job Site Address: 351 /Zt' t 71 Ied City/State/Zip: 4t oeg' 73 Attach a copy of the worker(' 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' nd th pai an enalties f perjury that the information provided above is true and correct Signature: cSil 2G j p Date: / Phone#: d_?-$ 774 ,Sf.l 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 CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: o d CERTIFICATE OF LIABILITY INSURANCE °"'E("GOEVV"" D3/29,2019 HS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO FUGNTS UPON THE CERTIFICATE HOLDER.THIS ERTIRCATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORED DATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. &PORTANT: If the certificate holder Is an ADDITIONAL INSURED,the poilcy((es)must be endorsed. If SUBROGATION IS WAIVED,subject to le terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the erdficate holder in lieu of such endorsement(s). oucER CONTACTMarie Raymond .:EANSIDE INSURANCE GROUP PHONEum : (508)775-0500 FAX yip � I INC.Not: ADORES: Marie©oceansideinsurance.com WEST MAIN ST INSURER(S)AFFORDING COVERAGE we. ANNIS MA 02601 INSURER A: LM INS CORP 33600 IREo INSURER B: )BERT ROLANTI INSURER C: 3A M A FROST CONSTRUCTION INSURER D: MAYFLOWER LANE INSURER E: NNISPORT MA 02639 INSURER F: VERAGES CERTIFICATE NUMBER: 383961 REVISION NUMBER: iIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD IDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS ERTIRCATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, XCLUSIONS AND CONDITIONS OF SUCH POLICIES.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADDLIUBR POLICY TYPE OF INSURANCE aY IYYYYY) a fyyy1 � ttasn wvn POLICY NUMBER COMMERCIAL GENERAL LIABLITY EACH OCCURRENCE $ DAMAGE TO RENTF_D COMAS-MADE ❑OCCUR PREMISESoccurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADv wURY $ GENt AGGREGATE EMIT APPLIES PER: GENERAL AGGREGATE _ POLICY ! n LOC PRODUCTS-COMP/OP AGO $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LMIT (Ea accident) ANY AUTO BODLY INJURY(Per Parson) $ — ALL OWED SCHEDULED _ AUTOS AUTOS N/A BODLY INJURY(Per accident) $ PROPERTY DAMAGE HEED AUTOS — NON-OWED (Per oxidate) $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ — EXCESS UAB CLANS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORICERS COMPE SATION _ AND EMPLOYERS'UABLITY Y/N AME ERANYPROPRIETORP _ ExCL� WA WA WA WC5315621268019 03/19/2019 03/19/2020(Mandalay in NH) EL EACH ACCIDENT $ 100,000 yyeess ELDLSEASE-EA EMPLOYEE $ 100,000 DES(XtPT10N OF OPERATIONS below EL DISEASE-POLICY LYTT $ 500,000 N/A RTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addilional Rarnrka Schedule,may be attached tt con space Is required) ricers'Compensation benefits wit be paid to Massachusetts employees only.Pursuant to Endorsement KC 20 03 06 B,no authorization is given to pay claims for benefits to doyen in states other than Massachusetts if the insured hires.or has hired those employees outside of Massachusetts. 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 ificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at N.mass. 3 proprietor has not elected coverage. TTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN IWI'1 of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 16 Route 28 AUTHORIZED REPRESENTATIVE Yaouth MA 02664 "-4 Yarmouth Daniel M.Cry,CPCU,Vice President—Residual Market—WCRIBMA )RD 25(2014/01)_ TFie ACORD name and logo01988-2014 ACORD CORPORATION. AM rights reserved. are registered marks of ACORD i•« ®r Commonwealth of Massachusetts 1 Division of Professional Licensure Board of Building Regulations and Standards Construction,SPj,tor 1 & 2 Family CSFA-046577 ROBERT F.IOLANTI1 L��Ires: 05/03/2021 27 MAYFLOWER DENNIS PORTMA 02639 Commissioner • Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual lal Registration Expiration 07/17/2021 ROBERT ROL € . D/B/A M.A.FR(75' :OI JCTION ROBERT F.ROLANT 27 MAYFLOWER LA �`��/ i" DENNISPORT,MA 02639 Undersecretary 1