Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Bld-20-000593
,YA 10ffice Use Only R`r a t; 1 O Permit C Oµ �l�' ...3 Amount ` MATTA M ESE "°""•'E 0 d rlPermit expires 180 days from l issue date add -S`13 EXPRESS BUILDING PERMIT APPLICAT C E I V E D TOWN OF YARMOUTH Yarmouth Building Department AUG 1146 Route 28 South Yarmouth, MA 02664 B U I (508) 398-2231 Ext. 1261 By Nr CONSTRUCTION ADDRESS: (9 ( ipf p rC I,'1/t° I a ASSESSOR'S INFORMATION: 'y� G Map: L Parcel: t/ c�/ d OWNER: �)(J 5C2f (oa5'k QS Ca PT Pefc ►✓8( ll 6\4, .'04A k'A0;26t,q NAME V PRES ADDRESS TE'L. # CONTRACTOR: e{i CJçra M e /Veyozel-ied 0.18 rrtko:�74,9 frf Ga.767 3 .- r-.s-q c, NAME //MAILING ADDRESS TEL.# "-Residential 0 Commercial Est.Cost of Construction$ /, �Oc� Home Improvement Contractor Lic.# /ye0133 Construction Supervisor Lic.# p 6?Y Workman's Compensation Insurance: (check one) 0 I am the homeowner -I am the sole proprietor It I have Worker's Compensation Insurance Insurance Company Name: A�/�/7/i C CAA//er Worker's Comp.Policy#kie✓0 iI y 70 O S WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares /) 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: g7i74!'vt "� ati,ct 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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1.Applicant's Signature: Date: )l3//// Owners Sig afore(or attachment) Date: 9 Approved By: Date: �'" y Building 0 al esign e) EMAIL RESS: 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 rr Department oflndustrialAccidents 1 Congress Street, Suite 100 MA 02114-2017 Q � Boston, ^M �•`''� www.mass.gov/dia N. Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): i L A re,/tyke : t eI,' Address: /y C- i 4- �X y e 1� City/State/Zip: a almoK7kiM/4.oaG7j Phone #: Are you an employer?Check the appropriate box: Type of project(required): I.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2 rLLam 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 all work myself. 9. ❑ Demolition ❑ doing y [No workers'comp.insurance required.]` 4.❑ my I am a homeowner and will be hiring contractors to conduct all work on property. I will I O ❑ 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 6.❑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. 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: /aitr i C 6 a(Fe Policy#or Self-ins.Lic. #: 44-C(./ Qr l I/7p 2 3 Expiration Date: r/ Job Site Address: Cc"'apf "Pe City/State/Zip .yarr-w tA4, 0966 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone 6 g5- Sy s Offcial use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: • fr 9-139s tePu f1 eLSZW W H!notivdfi!v! •ati i�NOAD trl F� -3NNOEI ' r 3IEB; 3NNO IV 0I133 6 LOU./60 ££ uctteJlmc3 uesite4Stkett lenPNPut:No41 is tIOi3YtiINOD 1143W33A0lidLNl 31110H utgeln6aa ssaulsne'g$JIeJ/Jewn5uo3-}a aolgo jomi. s Commonwealth pit Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constrt tki .Ipervisor CS-086694 >5pp ires: 10109/2019 ERIC J ARONNE —"i 'a14 CYGNET ROAD1r / C ' ' WEST YARMOILMI MA 42613 v-to Orsvi-tO'k` Commissioner GENERAL The quoted price does not include any Roofing,Carpentry or Painting work,such as sheathing repair/replacement,that may be required for this job other than listed. Any additions or extras outside of this proposal will be billed separately and charged by labor and material separately. All material and labor is guaranteed for a period of one year from date of job completion. Eric Aronne Remodeling shall not be held responsible for theft or vandalism after any portion of the materials have been delivered and/or installed. If you have any questions regarding this proposal,or if I can be of any further assistance to you,please do not hesitate to contact me. The work,contingent upon signed contract&deposit being received by Thursday August 1st,2019,will begin on approximately Monday September 9th,2019 and is scheduled to be Substantially Completed on Friday September 20th,2019. Respectfully Submitted, Eric Aronne ACCEPTANCE I accept the forgoing as contract this day of ,2019. Signature Please Print Full Name RR r0(0 3. `S(Ad'c or`p�C1 Signature Please Print Full Name DATE(MMIDDIYYYY) ACCORD CERTIFICATE OF LIABILITY INSURANCE TE(MMI DIYY 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 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). CONTACT Marshall K.Lovelette PRODUCER NAME: Marshall K Lovelette Insurance Agency Inc PHONE 508 775 4559 396 Main St (AIC.No.ExIt: ( ) FAX No): E-MAIL marshall@loveletteinscom West Yamouth,MA 02673 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC I/ INSURER A: WESTERN WORLD INS CO INC 13196 INSURED Eric Aronne INSURER B: 14 Cygnet Road INSURER C: West Yarmouth,MA 02673 INSURER D: INSURER E: INSURER F: — COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO INDICATED.CNOTTWITHSTANDING ANY IREQUIREMENT,TERM TOR CONDITIONED BELOW OF ANY CONTRACT E BEEN ISSUED OOR OTHER DOCUMENT WI THE INSURED NAMED DTH RESPECT OFOR THE LW WHICH THICY IS HIIS 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. IN RR ADADMSUER POLICY EFF POLICY EXP LIMBS TYPE OF INSURANCEINSD WVD POLICY NUMBER IMMIDDIYYYY) (MM/DDIYYYY) A J COMMERCIAL GENERAL LIABILITY NPP8604457 04/17/2019 04/17/2920 EACH OCCURRENCE $ 300,000 , DAMAGE TO RENTED 100,000 ^ CLAIMS-MADE v I OCCUR PREMISES(Ea occurrence) $ MED EXP(My one person) $ 5,000 PERSONAL 8,ADVINJURY $ 300,000 GENERAL AGGREGATE i $ 600,000 GENL AGGREGATE LIMO APPLIES PER: 600,000 PRODUCTS-COMP/OP AGG $ POLICY PO- LOC $ OTHER COMBINED SINGLE LIMB AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ — ALINEOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTO S ONLY _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$0 PER OTH- $ WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY Y/N E.L.EACH ACCIDENT $ ANY PRCPPoETOWPART EREXECUINE N/A CFFICERNEk5ER EXCLUDED? EL DISEASE-EA EMPLOYEE $ (Mandatory In NH) If yes,describe under E.L.DISEASE-POLICY LIMB $ DESCRIPTION OF OPERATIONS below ' DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH HE POLICY PROVISIONS. Town of Yarmouth 1146 Rt 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE 14:2416&- I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ,a►coRE, CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDnIYYY) `.� 08/01/2019 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 NAME: John McShera MARSHALL K LOVELETTE INSURANCE AGENCY INC (,gC.No.Ext): (508)775-4559 FAX Nor E-MAIL ohn l ADDRESS: j )oveletteins.com 396 MAIN ST INSURER(S)AFFORDING COVERAGE NAIC# WEST YARMOUTH MA 02673 INSURER A: ATLANTIC CHARTER INS CO 44326 INSURED INSURER B: ERIC ARONNE INSURERC: INSURER D: 14 CYGNET ROAD INSURER E: WEST YARMOUTH MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 431937 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER IMMIDD/YYYY) IMM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 'E LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) _ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED _AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ _ AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBER EXCLUDED? N/A N/A WCV01147005 04/18/2019 04/18/2020 (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/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if 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 for 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 date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govilwd/workers-compensationfinvestigations/. Sole proprietor has not elected coverage. 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 Rt 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 C I Daniel M.Crg1ev 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