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HomeMy WebLinkAboutBld-20-002034 O'1'Vali Office Use Only k. Olt - 5 �Amo>mt Permit expires 180 days from BLS C.v c) 3 1 issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department H3 , ' 1146 Route 28 !� South Yarmouth,MA 02664 OCT (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: rp q /3 l� Nv e_ ASSESSOR'S INFORMATION: Map: Parcel: Fiwt OWNER: RAS/. �w/k C/e 2..6 7 5 9 7s-460- Ol to NAME PRESENT ADDRESS TEL. # Email Address: CONTRACTOR:,e4ai co O� r ��lC C X CeJar St.Li) ,,,iA OIrf o /_ /-SOO-3111-2 Z// NAME / • MAILING ADDRESS / TEL.# � Email Addres `Residential Commercial Est.Cost of Construction$ � 72 / — Home Improvement Contractor Lic.# /142 c/' Construction Supervisor Lie.# //O 7 (o.3 Woricman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor have Worker's Compensation Insurance Insurance Company Nam: 6[/u!'G( J-4 S_ Worker's Comp.Policy# /1f E_t✓e /24,77 cf- 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 KingsHighway/Historic Dist. ( )RePla ' 4. Replacing like for like *The debris will be disposed of at: ki4 S i4. ia.'t c Pe•'i-en G�QPei PIA Location P A S Location of Facility / I declare under penalties of.A 4 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• . :. of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: JO " 9- /9 Owners Signatuye(or a ,t) Ye e ot-i`""fa. C�„,7L-a C 4 -�-�-� Date: Approved By: �/�G.,. Date: /G-/4-19 Building Official(or designee) Zoning District Historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: Yes No Yes No !/ ✓' j/�%///l7.—/2.1" //% 7'-f"/ f/ - � .ice %i% ifr Office of Consumer Affairs and 3Lisiness Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home improvement Contractor Registration Type: •Supciernent Card Registration: 146589 NEW PRO OPERATING LLB- Expiration: 05/04 2021 26 CEDAR 57. WOBURN, MA 01301 Update Address and Return Card. 3Cn i :, 23M-05/17 Office of Consumer Affairs 3 Business Regulation -HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Suoolement Card before the expiration date. If found return to: Registration Exoiratiort Office of consumer Affairs and Business Regulation 148589 05iO4i2021 1000 ington Street -Suite 710 NEW PRO OPERATING,i.:LC. Bbston,. A 02118 A „JEFFREY CONNORS ;;', •, 26 CEDAR 3T. ��,�.or�.,«- - ! 1 WOBURN.MA 01801 UnderSecretar/ ° Not valid without signature gra P.tassachuse.tts Department of Pu Iic SaterJ' board of Build;ng Regulations—and Standards License: CS-110763 JEFFREY CONNORS 64 OLD FIELDS ROAD SOUTH BERWICK ME 03908 ..�1.:. '.r... Etp,r3ton. 05/05/2020 . _ . .. . . . .. .. ..__ .. .. . . . , • . ., .•• - , , . . ..-. „ . .• . . . . . . . . . -_. •- . ... . - . . r - - - . -. _ . - '. •. ..•. . . • : - - • -. . ' • , , . ., . . . ,.....,-.:,... ._.,.._.........,,.... • . , . . , . , . • • . . - . : • . ,• , ' '.. ---,r.. '. . . ... ..." „. .. .. ... .. . 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' • ..-- -.), -;;.;:;••••••-•,:.::,-..:',.*. :",;:.:•••,;'-_,,,*i:•':,,,:Ti=r7...',,T:4-.:!..:-"$.1-: . ,. • _ - • -, r• • - ;-.. ,,._c,r,..,_!.':-.--r,:.,-..--,:rr,-,:'•;-,-_,,.1,-,--,:•--:,-,r,',---;.:-,*:‘,7, • ,- ,,i,. - - _,,,••*,:i.-•",-,::-,:,:7 --,--'ir iTrri'''.1:::tir,..*----.*-3,4-'r:_lt_ _• • - - • s,,, '••,„' ..;,--_1:.::,,.„•,;.,,4t,..,,,-;‘ ,"-.'1-:.•74,,,'.1*-1-,7--,.- 1. ••-, -- .-- - '-:r,r;,-.,--!----=,.•.....,-:.-,i;:r.,' :.•.-,r!.....:;•_:,•:,.;,,-,..,.,_ t /..,,..,7-,...--..-;.••-rs: 1,-:--,:..,,..--,.:...,r.--_,-..,....,..-,..-.----a----.- - - ,- . The Commonwealth of Massachusetts 1 Department of Industrial Accidents 'q••-Ys 1 Congress Street,Suite e 100 ' ':' 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): Jk&W Pro (')Q ercv-ti G Li-C Address: 2.(, Ce-cia r SI—; - J, City/State/Zip: Wo 6 v rnt Pk A D t g n I Phone#: I-goo -3 Li Z - Z Z Are you a employer?Check the appropriate box: 1. a em to erwith Z.0Type of project(required): 7.P y -employees(full and/or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working-for me in 8. 0 Rem construction any capacity.(No workers'comp.insurance required.] ❑ eodeling 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]* 9. 1::-.1 Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sol MO Electrical repairs or additions proprietors with no employees. 5.0[am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.0 Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.: 13•❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 4/1,iC -t,.i 152,§1(4),and we have no employees.[No workers'comp.insurance required.] r' *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 riot those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I anz an employer that is providing workers'coy nation insurance for my employees. Below is the policy and job site information.Insurance Company Name: ✓ �SI( ,( ��-�(,�t6 C Policy#or Self-ins.Lic.#:� 2�� 7 r Expiration Date:1/45" !/2-0 Job Site Address: l A/ I Q r/< . 4A je y Attach a copy of the workers'compensation policy declaration page(showing the p licypnumber- and ex�tilo d�. Failure to secure coverage as required under MGL'c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00) and/or one-year impriso$merit,as well as civil penalties:in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the viol. . O .y of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificatio I do hereby certify grid,.pains and penalties of perjury that the information provided above is true and correct. Si• afore: . \-' Date: • -g -- - • Phone#• - ` —8114-. 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#: '_, •1..-+m.r Jib c. P } •1 rs DATE(MM/DD/`^ i 1 i J �ii Jl ►oJ� 3'l�J i r INSURANCE� 1.��; o�/3D/2D19 f THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERT)F 1CA T E HOLDER..THiS } i CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE,AFFORDED 3Y THE POLICIES Ilf BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER iIMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must ha7/e 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 Melissa Pflug Mackintire Insurance Agency Inc PHONE (508)366-6161 (�C NO: (508)366-5202 iplC,ryo,Est):11 West Main Street E L melissap®maGdntire.com -ntAr ADDRESS: INSURER(S►AFFORDING COVERAGE NAIC/1 Westborough MA 01581-1931 INSURER A: Sentry Insurance INSURED INSURER B: Middlesex Insurance Co Newpro Operating LLC INSURER c: Guard Insurance Group 28 Cedar St. INSURER o: Colony Insurance Co INSURER E: Woburn MA 01801 INSURER F COVERAGES CERTIFICATE NUMBER: 19-20 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 �i DUL'SUHR POUCYEFF POLICYeXP LTR TYPE OF INSURANCE INSQ MP POLICY NUMBER JMM10D/YYYY)JMM/DDMlYYL UNITS X COMMERCIAL GENERAL UABILITY EACH OCCURRENCE S 1,000,000 'DAMAtit+UN NItU CLAIMS-MADE ©OCCUR 1 PREMISES(Ea accunence) S 500,000 MED EXP(Any one person) S 15.000 A A0092403003 12/31/2018 12/31/2019 PERSONAL aAOVINJURY 3 1,000,000 GEN'LAGGREGATE UMITAPPLIES PER: I GENERALAGGREGATE 3 3,000,000 POUCY JEC7 (LOC I PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: 3 AUTOMOBILE UASIUTY I (Ea c COMe1NidenpE0 SINGLC UNIT S 1,000,000 ANY AUTO BODILY INJURY(Per person) S B OwNED SCHEDULED A0092403004 12/31/2018 12/31/2019 3001LY INJURY(Per accident) S AUTOS ONLY + AUTOS aI HIRED NON-OWNED PROPERTY DAMAGE S r AUTOS ONLY AUTOS ONLY (Per accident) Uninsured motorist BI s 250,000 X UMBRELLA LIAB H OCCUR _EACH OCCURRENCE 5 5,000.000 A EXCESS UAB CLAIMS-MADE A0092403006 12/31/2018 12/31/2019 AGGREGATE S 5.000,000 DEO XI RETENTION S 0 _ S WORKERS COMPENSATION _ AND EMPLOYERS'U1aIUTY Y!N STATUTE ERH C ANY PROPRIETOR/PARTNER/EXECUTIVE (� NIA NEWCO287T8 05/01/2019 05/01/2020 E.LEACHACCIDENT s 500,000 OFFICER/MEMBER EXCLUDED? I I 500,000 i (Mandatory inNH) EL DISEASE- a- II yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY UNIT S 500,000 Pollution Liability Limit S1,000,000 D CSP304242 12/31/2018 12/31/2019 Aggregate $2,000,000 DED 55,000 DESCRIPTION OF OPERATIONS t 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 THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE MA 01504 !' ••"' I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD