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HomeMy WebLinkAboutBld-20-001691 v01.Y44:1 'Office Use Only I w r y, C 4 FS n=.. f. � _ . Qu T wet*1 . H - -Amount G MAT n C$ ; � �° °"° Td E i 2 4 2 Q 1(� Permit expires 180 days from 3 �LLt�I[J =issuedate EXPRESS BUILDINGPER APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 rr () South Yarmouth, MA 02664 ` `T ' (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: Lg3 l y '1 ki gr. W,'lz w&nn I�1#ar 62,4 (3 ASSESSOR'S INFORMATION: Map:03.?", / / �,Z,, / Parcel: y OWNER: I V l lC-11-A41,C fa)h11 ) Sry 11E+U,edt 1 �-1G ( c4/t eiiia ee 60&-y2 -9;1 - NAME {PRESENT ADDRESS TEL. # CONTRACTOR: 40.0 1511t>c�,0✓1 4:)103,(O Q)t\et0 PO R •° 3V41. ttg1 J)tA ► 934 .lt C (2 NAME MAILING ADDRES TEL.# ❑Residential 73 Commercial Est.Cost of Construction$ Z.S. allr0•at) o Home Improvement Contractor Lic.# Ita c l _ ct4 s Construction Supervisor Lic.# C 11O 48 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor gt,I have Worker's Compensation Insurance Insurance Company Name: Acct.(,t4 Worker's Comp.Policy# ...),IC`©'o82B WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# ( Replacement doors: # Roofmg: #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: \\Ott W I Ch T rec y t S e✓ St-0A�,,,:yin...,, Loca n of Facility I declare under penalties of perjury that the statements herein contained are true and correct to th- : of my knowledge and belief. I understand that any false answer(s) will be just cause for denial o re ocation of m licens . d for prosecution un.- 68 :ection 1. Applicant's Signature. ii� „�i;.�t �47��i ,..-- D ate: e07e/049 Owners Signature(or atta i went) �� / / Yi Date: 9/ / Ul7 Approved By: / Date: 7- --"/ ° Buil.`�. .-: (or designee) E ;!i ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No • I The Commonwealth of Massachusetts !t = Department oflndustrialAccidents NAM. 1 Congress Street, Suite 100 • =; 1c Boston, MA 02114-2017 'y;,� .•` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information I Please Print Lesibly Name (Business/Organization/Individual):C'�Q't 0 �,OV13 f U CA-1 Ov1 Address t el City/State/Zip: igtwieli ti14- Phone #: `=7� 21 C i 2 BO Are you an employer?Check the appropriate box: Type of project(required): fiI am a employer with 2 . employees(full and/or part-time).* 7. ❑New construction 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 mYP property.e 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. 13. Roof airs These sub-contractors have employees and have workers'comp.insurance.1 ❑ re p 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E Other S 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. i 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. A Insurance Company Name: (" (Ot Policy#or Self-ins. Lic.#: gic , CnZn821 _ Expiration Date: 01' /r 2 V Job Site Address: '2)3 Moo 01, r yvioL � City/State/Zip: alpi00 l i� Attach a copy of the workers' compensation policy decla ation page(showing the policy nu ber 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 un e ai and p n of perjury that the information provided ab ve is tr e and correct Sianatur • Date: q 2i /el 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#: Accma DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE • 09/24/19 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 JIM HINDMAN Schlegel&Schlegel Ins Broker G(qej/c�O�NEo.Ext): 508-771-8381 FAX No): 508-771-0663 34 Main Street E-MAIL West Yarmouth,MA 02673 ADDRESS: schlegelinsurance@verlzon.net • INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: NGM INSURANCE 14788 INSURED INSURER B: ACADIA OCAZO CONSTRUCTION INC INSURER C: PROGRESSIVE PX 319 INSURER D: HARWICH,MA 02645 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. LTRINSR TYPE OF INSURANCE IN D WVD POLICY NUMBER /YPOLICY EFF POLICY EXP LIMITS (MM/DDYYY) (MMIDDIYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 DAMAGE TO CLAIMS-MADE n OCCUR PREMISES(EaENTED occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 A MPT7221 H 04/05/19 04/05/20 PERSONAL 8 ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PET n LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ C AWNED SCHEDULED AUTOS ONLY AUTOS 03402808 12/09/18 12/09/19 BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) X UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE MPT7221 H 04/05/19 04/05/20 AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER B OFFICER/MEM BE EXCLUDED?ANY PROPRIETOR/PARTNER/EXECUTIVE(� N/A WC-1030828 04/11/19 04/11/20 E.L.EACH ACCIDENT $ 100,000 (Mandatory In NH) I 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 it more space Is required) CORPORATE OFFICERS HAVE ELECTED NOT TO BE COVERED UNDER THEIR CURRENT WORKERS COMP POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN THE COVE AT YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS. 183 RT 28 W YARMOUTH MA 02673 AUTHORIZED REPRESENTAA DAIANE I ©1 -2 ACORD CORPORATION. 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