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HomeMy WebLinkAboutBld-20-002161 • O . - ' . H•' {Amount '_N M tTTA M.L3ta. _I aa..,�o '. ' 1 Permit expires 180 days from -' * {issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 Jt.i (508)r 398-2231�Ex/t. 1261 CONSTRUCTION ADDRESS: / 7 f cAt {�l�N /O`�c- ''e ASSESSOR'S INFORMATION: ,�j�} Map: 11 Parcel: OWNER: r��,E'eL) t• g�TvLL 5oI ' ?fV fC NAME PRESENTT ADDRESS / TEL. # CONTRACTOR �13e- &fit l u1 gMAILING ADDRESS & P / aatiass # sc � 72J� NAME /y ❑Residential ❑Commercial Est. (� Est.Cost of Construction$ f(.dl 52 .0 0 Home Improvement Contractor Lic.# / 9 f-1 J A Construction Supervisor Lic.# 6‘,9 a. 9,1 Workman's Compensation Insurance:)eheck one) I am the homeowner 1'I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: See 4- ,A_ polo Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# la Replacement doors: # Roofing: #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: Pl/t' cdos iOA _ 40Q.AL S. Ya . c Location of Facility I declare under penalties o pe u th. the sta-. ents 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 deni re s i I of my icense and for prosecution under M.G.L.Ch.268,Section I. A plicant's Signature: �� ti Date: 3 Q C.,4- I Owners Signature(or attachment) ' f/1 .` (.(�/ Date:, OGr i l Approved By: Date: / 9 i7 Build-_ •- ' 1 (o'designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: a Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 7. No The Commonwealth of Massachusetts r 1� Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 A. s�. www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): / 41) ejt`'✓• Address: III Qr .. • 't_tw y City/State/Zip: ('1�s� d I S�4S Phone #: . V ?? ?1s Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. New construction tam a sole proprietor or partnership and have no employees working for me in g 8. ❑ Remodeling any capacity. [No workers'comp. insurance required.] 3. I am a homeowner doing all work myself. 9. E Demolition ❑ y [No workers'comp. insurance required.]' 4.0 I am a homeowner and will be hiring contractors to conduct all work on m Y P roPertY� 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 5.111 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp. insurance.5 n 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other Ate 152,§1(4),and we have no employees. [No workers'comp. insurance required.] n Alt-Zee A- re x-06 Q *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy inforhlation. 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. r Insurance Company Name: Se e f} 4'4�,,.� o is sy, Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: /7 le 401 P��c e— City/State/Zip: (4) Yeti— Attach a copy of the workers' com�sation 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 cop • tement may be forwarded to the Office of Investigations of the DIA for insurance coverage verif ati n. I do hereby c rti un 'r , 'rains and pen, ties of perjury that the information provided above is true and correct. Signature: �� `7 j a y Date: (� c -T /9 Phone#: �� F / C C4 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#: ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 10/10/2019 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 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 CONTNAME ACT Maria Afonso D FRANCIS MURPHY INSURANCE AGENCY INC PHONE (A/C.No.Est): (508)787-5183 FAX (A/C.No): ADDRESS: mafonso@dfmurphy.com 133 MILFORD ST INSURER(S)AFFORDING COVERAGE NAIC# MEDWAY MA 02053 INSURER A: AMGUARD INSURANCE CO 42390 INSURED INSURER B: GQ CONSTRUCTION SRVCS INC INSURERC: INSURER D: 35 E MAIN STREET INSURER E: MILFORD MA 01757 INSURERF: COVERAGES CERTIFICATE NUMBER: 459679 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 POLICY EFF POLICY EXP LTR INSD WVD, POLICY NUMBER IMM/DD/YYYY► fMM/DD/YYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY I$ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECOT- LOC I PRODUCTS-COMP/OP AGG $ OTHER: $ i COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) I g UMBRELLA LIAB I OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE N/A AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION X PER ERH AND EMPLOYERS'LIABIUTY Y/N ANYPROPRIETOR/PA OFFICER/MEMBER EXCLUDED?ECUTIVE N/A N/A N/A R2WC095742 08/25/2019 08/25/2020 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A I I I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more apace Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION 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. 1146 Rte 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 —' � Daniel M.Cro*y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD GQCON-1 OP ID:MA ACOROF CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 10/10/2019 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 508-422-9277 I meCT Murphy Hickey Insurance Agency PHONE 508-422-9277 FAX 508-422-9914 133 Milford Street (NC,No,Ext): (A/C,No): Medway,MA 02053 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Atlantic Casualty Insurance Co 42846 INSURED INSURER B: GQ Construction Srvcs Inc 35aE Main St Apt 1 INSURER C Milford,MA 01757 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. INSRCY EXP TYPE OFINSURANCE INDso SUBRW POUCYNUMBER imminO/CYYNYI (MM/DOIYYYYYL OMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR L2050025100 09/04/2019 09/04/2020 DAMAGE TO RENTED 100 000 PREMISES(Ea 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 Tef LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _(Ea accident) _ $ _ ANY AUTO I BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOSN BODILY INJURY(Per accident) $ ALTOS ONLY AUTOS ONLYY (Perr accRlgAMAGE UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'UABIUTY Y/N ISTATUTE ER ANY PRO RIIETO R EXRTNDED�CUTIVE N/A E.L.EACH ACCIDENTOFF $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMB $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION YARMO-2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Rte 28 South Yarmouth,MA 02664 AUTHORD�DREPRESENTArnrE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ‘Vj Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction.$12t0eHAtore 1 & 2 Family CSFA-069693 Eispires: 05/14/2021 • RALPH E TRUE JR 91 QUAKER HWY. 4i UXBRIDGE IVIA 016001 Commissioner Mat&ButiMets-Rops1606n D*!IMPRNT CONTRACTOR Pr, IndMd* 1:774C 05/26020 RALPH'tRUE • DiB/A TRUE R 44, 17" MR"'E.TRUE , 6e-C4/21%-4 othoiliER Few . UXBIRIDIE,MA 01589 Undersecrebarjf ACVRD DATE(MM/DD/YYYYI CERTIFICATE OF LIABILITY INSURANCE 10/02/2019 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 poiicy(les)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 Julie Parker Robert A Parker Insurance&Financial Services INC_N!1,Exn: (508)234-3439 FAX Nol: (508)234-2778 174 Church Street EMAIL afker ra Ins.com ADDRESS: 1P C�1 P INSURER(S)AFFORDING COVERAGE HNC* Whitinsville MA 01588 INSURER : Nautilus Insurance Co. 0 INSURED INSURER B: Republic Franklin Ins Co 12475 True Remodeling Inc INSURER C: PO Box 201 INSURER D: 91 Quaker Hwy INSURER E: Uxbridge MA 01569 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. INSRLTR ADTYPE OF INSURANCE MSC SIN O POLICY NUMBER (BR NMMIIDDY EFF D I IMM/DDDIIYYYYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1000000 AMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100000 MED EXP(Any one person) $ 5000 A NC271832 12/22/2018 12/22/2019 PERSONAL&ADV INJURY $ 1000000 GENt AGGREGATE LIMIT APPUES PER: GENERAL AGGREGATE $ 1000000 POLICY JEcT LOC PRODUCTS-COMP/OPAGG $ 1000000 OTHER: $ AUTOMOBILE LIABILITY M COMBINED SINGLE UNIT $ 1000000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNAUTOSEDONLY AUTOS X SCHEDULED 4872009 07/09/2019 07/09/2020 BODILY INJURY(Per accident) $ _ HIRED NON-OWNED PROPERTY DAMAGE $ 1000000 _ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'UABIUTY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICERAIEMBER EXCLUDED? (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 I VEHICLES IACORD 101,Additional Remarks Schedule,may be attached It 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 Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE I S Yarmouth MA 02664 Fax: Email: ®198S-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD