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HomeMy WebLinkAboutBld-20-002560 ,q,, Office Use Only Of.Y `,t4 4•L O Permit# _ y Amount C)� ' —Q � Permit expires 180 days from 1 j3(V D ,;issue date L. EXPRESS BUILDING PERMIT APPLICATIO13 �__._,__.. TOWN OF YARMOUTH ! ` Yarmouth Building Department 1 N O V 01. 1019 1146 Route 28 South Yarmouth, MA 02664 ` `i l ' cy /' (5^08/) 398-2231 Ext.t. 1261,/�� YaCONSTRUCTION ADDRESS: c2cC GAD/ / "o / Jo(i� r 1 "riltIASSESSOR'S INFORMATION: / Map: Parcel: �U(' 76 0-2�/ . OWNER: gC &-ciG vj,1 74/ C l/1 ✓!S/op g7 c' _ gp/4h/ /1 s Q a/✓ne-fiA NAME PRESENT ADDDRES TEL. # CONTRACTOR: 50'lid 2// - (I/S i 0Z3Wi /S ,m 2 So yGtr be ,5?, Y6�.5-.0O NAME MAILINGADDRESS TEL.# sidential 0 Commercial Est.Cost of Construction$ (/ O 0, (a) ((((((Home Improvement Contractor Lic.# /T3,5 7 Construction Supervisor Lic.# CS —097 --S/� Workman's Compensation Insurance: (check one) ❑ I am the homeowner//'',, ❑ I am the sole proprietor p1 have Worker's Compensation Insurance / Insurance Company Name: W CC.S~�$-4/'7), A ro/eWorker's Comp.Policy /7�jF5C/4/ /f//yl(IS- WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Si ' : #of Squares Replacement windows:# Replacement doors: # eitoofing: of Squares /0 ( Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: `�!N/lf g ya.d41Ol4I. cation of Facility 1 declare under penalties of perj- that the state ents herein contained ar 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 r ocation of m li ns and for pr ecuti under M.G.L.Ch.268,Section 1. Applicant's Signature: e Date: /t7/Q�-7/9 • / q Owners Signature(or attachment) Date: / v/5/// Approved By: Date: /7'-'9 Buildin ci design ) EMAIL Zoning District: Historical District: Yes 2 No Flood Plain Zone: [.] Yes No Water Resource Protection District: Within 100 ft.of Wetlands: L. Yes ❑ No L, Yes H No The Commonwealth of Massachusetts pi pi=� �,, 1 Department of Industrial Accidents _EEas1= 1 Congress Street, Suite 100 _?{�=_ k, Boston, MA 02114-2017 �''', ..r,. www mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aoolicant Information Please Print Legibly Name (Business/Organization/Individual): ,S4-t e do/(C / %JS f S Address 3 ( 1h///5 A AA 6-) City/State/Zip: $U . ya/Miw/G1 ma. Phone #: SOCS J�lr 7-.5 'Yd Are you an employer?Check the appro ' to box: Type of project(required): 1 I am a employer with 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 doingall work myself. t 9. ❑Demolition ❑ ys [No workers'comp.insurance required.] 10 ❑ 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.❑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.lur, ' **f repairs These sub-contractors have employees and have workers'comp.insurance.: 6.1=1 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. 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: 4-256 C/ G.*'r'J 1C41,0/yi rS Policy#or Self-ins.Lic.#: `vV(C_S�� $7 /97), /a O/ t Expiration Date: /�/G�//�' Job Site Address: ( L Ce p/ AJG/ City/State/Zip: 5 O. Ya7/12w,/-- A 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 verific tion. I do hereby c tin,under pains id pen ' perjury that the information provided above is tru and correct. Signature: Date: /0/S1 / Phone#: Pe- d 2 U 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: SANDD-2 OP ID:DS ACORL) DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 12/19/2018 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 508-775-6060 FACT Bryden&Sullivan Insurance Bryden&Sullivan Ins Agency PHONE 508-775-6060 I FAX 508-790-1414 88 Falmouth Road INC,No,Eat): (ac,No): Hyannis,MA 02601 E-MA ADDRESS: Bryden&Sullivan Insurance INSURERIS)AFFORDING COVERAGE NAIC# INSURER A:Mapfre Insurance 34754 INSURER B:Associated Employers Insurance talollaFc�Q� thstQms LLC ouut Yarmouth,Crams 02664 INSURER C 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 SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD IMM/DD(YYYY1 IMM/DD/YYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- LOC PRODUCTS-COMP/OP AGG $ JECT OTHER: $ A AUTOMOBILE LIABILITY (Ea OMaBIINden SINGLE LIMIT ANY AUTO BHMWLT 02/02/2018 02/02/2019 BODILY INJURY(Per person) $ 100,000 — AAUTOS ONLY ED X SCHEDULED BODILY INJURY(Per accident) $ 300,000 HIRED pWNE PROPERTY DAMAGE 250,000 X TOS ONLY X AUTOS ONL� (Per accident) $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION PER STATUTE ER EMPLOYERS'LIABILITY Y/N WCC50050197212018 12/04/2018 12/04/2019 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ MFFICER/MEMBgEER EXCLUDED? T N/A andatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 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) Certificate issued for insurance verification. CERTIFICATE HOLDER CANCELLATION COMMUNT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Community Development ACCORDANCE WITH THE POLICY PROVISIONS. Partnership 3 Main St.Mercantile AUTHORIZED REPRESENTATIVE Eastham,MA 02642 Bryden&Sullivan Insurance ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD mene 6›,�� Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, M` husetts 02118 Home Improve • tractor Registration Type: Corporation SAND DOLLAR CUSTOMS LLC _ Registration: 193567 1851 FALMOUTH ROAD r ration: 10/29/2020 CENTERVILLE,MA 02632 " _ _ - = Qw '"'✓ Update Address and Return Card. SCA 1 0 20M-05/17 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TY orooration before the expiration date. If found return to: .xoiration Office of Consumer Affairs and Business Regulation 10/29/2020 1000 Washington Street-Sulte 710 SAND DOLLAR; Boston,MA 02118 j Iry ' WALTER R.WAP 1851 FALMOUTH M:,�,:= CENTERVILLE,MA 02632 Undersecretary Not v • lout Ignature P Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constr r1%UUpervisor CS-091653 r#pires:09/30/2020 WALTER R 1, 40 ALEXAN DK YARMOUTH MA . Commissioner C/"" Let /14