The URL can be used to link to this page

Home My WebLink AboutBld-20-002260 ,.40.yq4- ' L'r:ice Use Only -076 -c6 ' 6 _� I„ 164 "Amount l�3__6i r �, Off •� 1 rPermit expires 180 days from 1 k.-...., .,. _j .,issue date eI11LDING DEPARTMENT 7 By EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: � k �j Ayr E L t -'T O y/1 r rn ou i 1� L A , ASSESSOR'S INFORMATTON: // [ Map: Parcel: OWNER: L_v_A '1 .1 in 1`Y-)v 4 U-- ,A C1 Y . &—a(ALL CtL1:y,l 1- 561_`"b�3 ' Lola NAME PRESENT ADDRESS TEL. # i CONTRACTOR: ( L.1_TQll--t (t FTI'✓ ,D 1VnLi 1-`) cz— 17)4 G DC) 1(ii 3 Up2(} . 5. Pe Nti O,1-14 NAME MAILING ADDRESS TEL.# Residential 0 Commercial Est.Cost of Construction$ )-2, U e) (.) Home Improvement Contractor Lie.# 1 L 1 J S Construction Supervisor Lic.# C3 " L 1 Lict \3 Workman's Compensation Insurance: (check one) G I am the homeowner L, I am the sole propiietoi ri iiave W orker's Compensation Insurance Insurance Company Name: 1 1 CA, V 2`=C.1 Worker's Comp.Policy# T f J i , 3 -- H `i 1 S (T`I - 3-i'9 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 20 Replac ent windows:# 3 Replacement doors: # Roofing: #of Squares 30 i✓ Remove existing* 2 layers) Insulation ( ) g (max. Y ) Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at /a\l'et i I LL TH ./LL LAP 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,vocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: ` \( Date: Owners Signature(or attachmen�� Date: Approved By: _� Date: 10 - 10� (1 Building Official(or designee EMAIL ADDRESS: t Zoning District: Historical District: i l Yes U No Flood Plain Zone: L Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes I No Yes ❑ No The Commonwealth of Massachusetts I ;? 1_ t Department of Industrial Accidents e. =_cite • I Congress Street,Suite 100 ='�L 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): (t17-v11► A ( cb x, 4,-, E S? Address: q 7,r, Q.f, i 51.1 NA). • Lt. ) l: City/State/Zip: -j.�.�ti�;v5 Phone#: Are you an employer?Check the appropriate box: f I am a employer with 5 employees(full and/or part-time). Type of project(required): 7. ❑New construction ?U I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8. Remodeling 3.DI am a homeowner doing all work myselt[No workers'cramp.insurance required.]t 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 5.0 I 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.t 13.koof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other C Vti n� �; 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. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ;�(L-)(Z Policy#or Self-ins.Lie.#: 1 P S U(7-j.- -i \6\k 0 y - 3.-19 Expiration Date: 2--- Z L\ • 2,n7 Job Site Address: L\\ d�c1 -v1\Q 1 .A City/State/Zip: " L-d-VI\ACC i(i , 1-N- . 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 and penalties of perjury that the information provided above is true and correct Signature: Date: NC \w-20\9 Phone#: 5.^ ' 1 f \61 -—q Ir'p1 Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitlLicense# 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 Commonwealth of Massachusetts Division of Professional Licensure Boat d of Budding Regulatons and Standards ictr ?r,r CS-074943 Expires: 01(04/2021 4.4404,60& TREG C ICAESELAU 36 COUNTRY LANE 4116 DENNIS PORT MA 02639 • At; ' , ,•- Commissioner AI • ��/G%��Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration JEFF BARONI Type: Individual D'B/A CUSTOM CRAFTED HOMES Registration: 169552 900 ROUTE 134 SUITE 3-30 Expiration: 07/04/2021 S.DENNIS,MA 02660 SCA S C3 20M-05,ii Update Address and Return Card. .Te ,l/74.:a,^44e:rfG: Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration valid for individual use only F�oirati4Il before the expiration date. If found return to: Entattatim1 07;04/2021Offi of Consumer Affairs and Business Regulation JEFF BARONI ' 1000 Washington Street -Suite 710 D/B/A CUSTOM CRAFTED HOMES Boston,MA 02118 JEFF BARONI 900 ROUTE 134 SUITE 3-30 �,, ,4.. S.DENNIS,MA 02660 Undersecretary Not valid without signature A t Sri' CERTIFICATE OF LIABILITY INSURANCE I DATE IMMIDDIYYYY) nvnioni F1CATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. This 9 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE • : 'RODUCER.AND THE CERTIFICATE HOLDER. RTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to , a and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to e certificate holder in lieu of such endoraement(s). PRODUCER CONTACT NAME: NFP PROPERTY&CASUALTY PHONE FAX 141 LONGWATER DR #101 (A/C,No,Ext): (A/C,No): AIL NORWELL,MA 02061 ADDDRE ADRE SS: 76JLL INSURER(S)AFFORDING COVERAGE NAIC# INSURED PSURER A: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA HCCC INC DBA CUSTOM CRAFTED HOMES INSURER B: INSURER C: INSURER D: 900 ROUTE 134 BLDG#3 SUITE 30 INSURER E: SOUTH DENNIS.MA 02660 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: This IS TO CERTIFY THAT THE POLICES OF INSURANCE USTED BELOW HAVE BEEN ESUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NDICATED.NOTNIITHSTANDNO ANY REQUITEMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHS:1 THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THS INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO AU.THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS. NSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMDDIYYYY) (AMIBDIYYYY) LMTS GENERAL LIABEIIY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE a OCCUR. DAMAGE TO RENTED $ PREMISES(Es occurrence) MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ El POLICY p PROJECT❑LOG PRODUCTS-COMP/OP AGO I$ AUTOMOBILE LIABILITY COMBINED SINGLE $ — ANY AUTO LIMIT(Es accident) I ALL OWNED AUTOS BODILY INJURY Is _ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per avcident) PROPERTY DAMAGE IS _. (Per accident) UMBRELLA LIAB r OCCUR EACH OCCURRENCEE $ EXCESS LIAR C CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND WC STATUTORY OTHER I EMPLOYER'S LIABILITY Y/N UB-7H915443-19 02/24/2019 X LiMTs ANY PROPEWTORIPARTNERfEXECUTIVE yy N/A E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE 1$ 100,000 If yes,describe under 1Y;RCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIO NSNEHICLES/RESTRiCTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. drFICATE HOLDER CANCELLATION USTOM CRAFTED HOMES SHOULD ANY OF THE ABOVE DESCRIBED POUCES BE CANCELLED 900 ROUTE 134,BLDG#3,SUITE 30 BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENT t�,[,/r�SOUTH DENNIS,MA 02660 ( ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved.