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HomeMy WebLinkAboutBLD-19-6717 g51'•YA Office Use Only % c c il6� O4. 0454 ;Amount weir" • cs r- ` q`°"°•"°"4 cad Permit expires 180 days from i�iHl o ) 3A issue date EXPRESS BUILDING-PERMIT APPLICATION �\ TOWN OF YARMOUTH Yarmouth Building Department artment 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: // , 1.9.729. 7 Z' sPO ! '``'Gv j ASSESSOR'S INFORMATION: Map: n Parcel: OWNER: yk G ti,7 C cs� eJ1I t k °t I IL' o�1 iC • 3 a 0" let/ AME • PRESENT ADDRESS TEL. # CONTRACTOR: . e.`13 4-1 ,)-1‘ V- .�1.4///,lam 11/A X''?"2.041f r 't o-r�i c.c I 3-''4 5- -?7G NAME MAILING ADDRESS TEL.# G ❑Residential I mmercial 94 o Est.Cost of Construction$ Ci _ Home Improvement Contractor Lic.# /3 Z 3 r' l /Construction Supervisor Lic.# C-r c 3 t Workman's Compensation Insurance: (check one) ✓ //i/Z 0 I am the homeowner 0 I am the sole proprietor 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 Repla/Remove ment windows:# Replacement doors: # ✓ Roofing: #of Squares 3 existing* (max.2 layers) Insulation g q ( Y ) Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: g/e--G-r D( ', O fAe-L- 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 liven and fo rosecution under M.G.L.Ch.268,Section 1. Applicant's Signature:. Date: S 2I / � 9 Owners Signature achment) (-` Date: c_.941—(1 I Approved By: Date: t.5~ `.)) . ' ' uilding 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 ❑ No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite=fir= Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):"�)#57--t/r _I Address: Y3 fix'//mow w�y City/State/Zip M'c c C Phone #: 770 6 Are you an employer?Check the appropriate box: Type of project(required): l._I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.1:1 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑ Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp. insurance required.]t 10 E Building addition 4.❑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.Q Electrical repairs or additions • pro ' ors with no employees. 12.D Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13 oof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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. 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. 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: 'tize s Policy#or Self-ins.Lic. #: ( 7 e/& Expiation Date: ({:7/2—el Job Site Address: l✓?7 firms CO yi9,4-" aJ if City/State/ZipS'cr/7 t✓' �' ' 'L4n4:7ii 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 a pen es of perjury that the information provided abov is true and correct. Z ✓ Slsnature Date: Phone#: 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#: ACo CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDM'YY) `...•'� 04/17/19 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 CONTACT NAME; JIM HINDMAN OE Schlegel&Schlegel Ins Broker PH NN,Ext): 508-771-8381 FAX No): 508-771-0663 34 Main Street E-MAIL West Yarmouth,MA 02673 ADDRESS: schlegelinsurance@gmail.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: NGM INSURANCE COMPANY 14788 INSURED INSURER B: TRAVELERS MARCOS SILVA INSURER C: DBA EMERSON CONSTRUCTION 67 SEA ST APT 11 INSURER D HYANNIS,MA 02601 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 N�WWV POLICY NUMBER SVD D POLICY EFF POLICY EXP LIMITS (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO REN lED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 A MPT9375T 11/09/18 11/09/19 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- 1-1JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE _ AUTOS ONLY _ AUTOS ONLY (Per accident) $ UMBRELLA LIAR OCCUR _ EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER B OFFICER/MEMBER ER EXCLUDED?ANY PROPRIETOR/PARTNER/EXECUTIVE N/A WC-1073205 04/17/19 04/17/2O E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) I ry I E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) MARCOS SILVA HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN DAVID WOOD ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE DAIANE BENFICA I _ ©1988-2015 AC CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD