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HomeMy WebLinkAboutBld-20-043 Y. Office Use Only /" 2 • • Permit# $ 2. �'R ! gyp: O ,•,- y 'Amount °rarNuta`�E Permit expires 180 days from >=*; ;issue date 1 b2O-g3 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department ILA.. li;_) 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 • • CONSTRUCTION ADDRESS: 37x7 (Jl `A�• tb ot. .Q"c-p `I,(�'(11 1c. ASSESSOR'S INFORMATION: • Map: Parcel: (� OWNER: 4 -7_P7 W )�4() 1�X.- .. NAME PRESENT ADDRESS TEL. # CONTRACTOR: � \ CAA, (0 L C)L)1 al c1 r \.�K' 23 1 3 8 l NAME MAILING ADDRESS TEL.# residential ❑Commercial Est.Cost of Construction$ `I ®©a Home Improvement Contractor Lic.# ) 3 "(i'1 Construction Supervisor Lic.# 1Q0 1 3 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor have Worker's Compensation Insurance Insurance Company Name: .,(,Z O±�(.., Worker's Comp.Policy# )6 CP 1)1 SO i WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares / ((?i Replacement windows:# Replacement doors: # Roofing: #of Squares 3 ( Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at �,r(M..d 1Q(1 -6�, Location of Facility Il I declare under penalties of perjury that statements erein 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 deni re ocati of lic e d for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: 2/2_1,7 Owners Signature(or attachment) Date: 2/ �/!s 5' Approved By: _� J Date: — . (C9 Building 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 Congress Street,Suite 100 �=51. w Boston, MA 02114-2017 www.mass.gov/dia .1Jr4�t` Workers'Compensation Insurance Affidavit:Builders/Contractors/ElectricianslPlumbers. TO BE FILED WITH THE PERMITTINC AUTHORITY. AnDikant inhIPONIOTTH.offAtmenS Please Print Leeibly Name(Business/OrganizatibigMEIB4ETREE A ' eREWSiE 1, MA 02631 Address: City/State/Zip: Phone#: SI+(�. Are you so employer?Check the appropriate box: Type of project(required): 1.44 am a employer with 2 employees(fell and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working forme in S. ❑Remodeling any capacity.(No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t g ❑Demolition 10 Building addition 4.C#I win•homed :yes and will be hiring contractors to conduct oil wont o,my property. I will ensure that all contractors either have workers'compensation insurance or are sole 1 I.❑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 These sub-contractors have employees and have workers'comp.insurance? 13.0 Roof repairs 6.0 We are a corporation and its offices have exercised their right of exemption per MGL c. 14.0 Other 152,1I(4),and we have no employee,flgn workers'comp.insurance required.] *Any applicant that checks box 51 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 subcontractors 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. /�F Insurance Company Name: Aft.epIrklic: Policy#or Self-ins.Lic.#: CV t,3C O t7 SO I Expiration Date: Z I(� Job Site Address: 3 2c (A)►wS'm, e, City/State/Zip: I 1 9 Al.A-- Attach a copy of the workers'compensation policyduration page(showing the policynumbe�and expiration date). 1? ) Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$2.50.00 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 the and es of perjury that the information provided above is true and correct. Signature: Date: 7/2f(/5 Phone#: 7& .? 3--) 3 ( Z--- 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#: • • • Of4;1,c ta6e b • • • , ..f ;yt^xAfiairs RegidaPri, 1PE SJp;)1-''-7*—ti C3.d- - 9w+istra r tpir on - •134tr 10.703/2015',•• ROBERT H.CHf,NtBrBSr ItL ;g to ROBERT H.CHA* = . ' 102 WHIFFLETREE i?YE , • BREWSTER,MA 02631= '" Undersecretary .. • • Commonwealth.of Massachusetts bivision of-Professional Licen'sure= Board of Building Regularicris anciStar,iiards Constructi4 &O`Specialty . - s _ • CSSL-100134 spires 03/16/2020 ` * � sx ROBERT H cHAMBERS4# • 102 WHIFFLETREE AVER • BREWSTER MAi02631 / •' x • • Commissioner ROBER-6 OP ID: MD ACOREY CERTIFICATE OF LIABILITY INSURANCE DA07/02/2019TE Y) 07/02/2019 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 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). PRODUCER 508-255-8000 CONTACT W.Scott Kerry Kerry Insurance Agency Inc. PHONE 508-255-8000 I FAX 508-240-1860 P.O.Box 1945 lac,No,Ext): (ac,No): N.Eastham,MA 02651 E-MAIL kerry@c4.net W.Scott Kerry ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC U INS INSURER A:Western World Insurance Co RobertDH�Chambers,Inc. INSURER B 102 Whiffletree Avenue INSURER C: Brewster,MA 02631 INSURER D: 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. INSR TYPE OF INSURANCE ADDL SUBR POUCY NUMBER YY POLICY EFF POLICY EXP LIMITS LTR INSR WVDIMMIDDIYY) IMM/nn/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR NPP1516991 06/26/2019 06/26/2020 DAMAGE TO RENTED 50,000 PREMISES fEa occurrence) $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY jPa LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTEO�S ONLY _ AUTOS SSWryEp BODILYO INJURY(Per accident), $ AUTOS ONLY _ AUUTOS ONLY (Perr accident)AMAGE UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER PROPRIETOR/PARTNER/EXECUTIVEANY NYICCRMERNDED? N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) carpentry,roofing CERTIFICATE HOLDER CANCELLATION TOWN-15 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. Building Department 1146 Main Street AUTHORIZED REPRESENTATIVE Yarmouth,MA 02675 W.Scott Kerry ACORD 25(2016/03) _ ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD