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Home My WebLink AboutBld-20-2249 , 0471X--4-N, 4,414 ')cl 0., .......c ::. )...z, )C1[RECEIVED , r,--------------7 .: ( ?.? 20h i Office Use Oaly Permit# Amount aSn) ........—i 507) , Permit expires 180 days from % B I issue date r EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department ,13(-D-a\. D-. , LH 1146 Route 28 South Yarmouth,MA 02664 (508) R8-2231 Ext. 1261 CONSTRUCTION ADDRFSSI,Y etipic64 Pg-ire:i gm-Q._ & ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Cqt& 'i8- 77ii- - S 6' NAME PRESENT ADDRESS 5.yai.--fit cat4-1-1 TEL # Email Address: ek-l-terw.,..4i fie. CONTRACTOR:AfttriIattit ith,641-6/1214.44 DA,,GI 2411LtAke,-,MA till?-107-Yat 'i) i7.4.:60".6,1 NAME MAILING ADDRESS ' TEL# Email Address: Residential I„,- Commercial _ , Est.Cost of Construction$ &at -i Pr.I14-(.4". Home Improvement Contractor Lie.# I ficto V Construction Supervisor Lie.# A 51,sy Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor 1.41:ave Worker's Compensation Insurance 7/ i Insurance Company Name: Li b-eir, /714 lug] Dif Worice s Comp.Policy# WO .57(7 Y6 •,i) WQRK 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 Kings Highway/Historic Dist. ( )Replacing like for like The debris will be disposed of at: -1irat4e3 Li fibs Le 40 of Facility I declare under penalties of perjury that the statements h- ' conuti ....... : -true and correct to the hest of my knowledge and belief. I understand that any false=swells) will be just cause for denial or rc.v.,, ,•otii.of my l' •..- ...• ,, proff'on under M.G.I.Ch.268.Section I. Applicant's Sig..... f 41 IO.r Date: / p• 4114. Owners — ” (or .-.A _, >_ ,,.,'•_,041/411,11!:"--,- i Date: Approved By: ,.......iiiid-trillge. ,IIPP--- Date: /P.Zz y, Building OBI 4iips7 ..51!) Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: Yes No Yes No HOME OWNER WEATHERIZATION WORK PERMIT: PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER. I Taborhereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation on the property located at: ?* '( � VA-e The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures: Weather stripping; air sealing; attic& basement insulation; exterior wall insulation; ventilation measures In consideration of the weatherization work to be done at my home I agree to the following: 1. I give permission to Housing Assistance Corporation to access the property with such equipment and materials as may be necessary to perform weatherization. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five (5) years after the weatherization work is completed. I have read the provisions of this agreement and give my consent. b Home Owner(signature) (: Date: q la01 Home Owner email: Agent:(signature) Date: Agency Approved Weatherization Company: Advanced Windows Inc All Cape Energy Alternative Weatherization Cape Cod Insulation Cape Save M. . 'eMatioraTTMon Inc r� Frontier Energy Solutions Lohr Home Improvement Cazeault Agency Signature: Date: 1 L •aot For Natural Gas Customers: I have received the National Grid Discount Rate Application form from my auditor. )67 Customer Initials v. 1.19 The Commonwealth of Massachusetts 1"-==} 1=r, I Department of Industrial Accidents l:Ilfl 1 Congress Street,Suite 100 t=7,i= Boston,MA 02114-2017 ��t 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):ALTERNATIVE WEATHERIZATION, INC.' Address:2 LARK STREET City/State/Zip:FALL RIVER, MA 02721 Phone#:508-567-4240 Are you an employer?Check the appropriate box: Type of project(required): 1.Q✓ I am a employer with 1 6 employees(full and/or part-time).* 7. El New construction I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling - any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 9. ❑Demolition 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. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.' 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other INSULATION 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:LIBERTY MUTUAL INSURANCE Policy#or Self-ins.Lic.#:XW058867158 Expiration Date:06/07/2020 Job Site Address:/c. /Qe., �Ae _J PCity/State/Zi :j /Ram 7/.,Attach a copy of the workers'141 /iiiv mpensation policy declaration page(showing the policy num r 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 S250.00 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 t' s and,: alti•s of ir,ury that the information provided above is true and correct Si_ ature: jAil1111 Alkii Date: Phone#:508-567-4240 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#: ot DATE(MM/DDIYYYY) ACGRD CERTIFICATE OF LIABILITY INSURANCE hi.„---- • 05/24/19 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 NAME: Anthony F.Cordeiro Insurance Agency A/cC.No.Ext): 508-677-0407 (A//C,No): 508-677-0409 171 Pleasant Street E-MAIL HSouza@Cordeirolnsurance.com Fall River,MA 02721 INSURER(S)AFFORDING COVERAGE •NAIC U INSURER A: Liberty Mutual INSURED INSURER B: Ohio Security Alternative Weatherization INSURER C: Ohio Casualty 2 Lark St Fall River,MA 02721 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 CONTRACTOR 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 AUDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE15—‹ OCCUR PRMAGETORENfED PREMISES(Ea occurrence) $ 300,000 MED EXP(Any one person) $ 15,000. A Y Y BKS58867158 06/07/19 06/07/20 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ OWNED B AUTOS ONLY x AUTOSULED Y BAS58867158 06/07/19 06/07/20 BODILY INJURY(Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY — AUTOS ONLY (Per accident) $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A ^ EXCESS LIAB CLAIMS-MADE Y Y US058867158 06/07/19 06/07/20 AGGREGATE $ 1,000,000 DED RETENTIONS $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE— E.L.EACH ACCIDENT $ 500,000 C OFFICER/MEMBER EXCLUDED? n N/A XW058867158 06/07/19 06/07/20 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 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 if more space is required) Action Inc and NGRID,USA,its direct and indirect parents,subsidiaries and affiliatesshall be named as Additional Insured on commercial General Liability and Automobile Liability polcies. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN NGRID USA ACCORDANCE WITH THE POLICY PROVISIONS. 40 Sylvan Road Waltham,MA 02451 AUTHORIZED REPRESENT S F ©198#'-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Commonwealth of`,lassachusetts Division of Professonal Licensure Board of Building Regulations and Standards 0:^.sTr do iaper',.so- CS-105454 Expires: 05/08/2021 TIMOTHY CABRAL 58 DICKINSON STREET FALL RIVER MA 02721 - f - Commissioner t f% �t� "- -- • )//�' t ,/./Vi//i11'////'/'1/7/� j' % 'J//•,e j//!/1//7,;(//' Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration ucro`on NAT ._ .._ .TIER iON ^S Kv 28 2021 7 _ARK z;„ Update Address and Return Card. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:C'or;,ora ion before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 175683 2E,232 1000 Washington Strut -Suite 710 A .. XEAT"ERiZA iCti ;NO. BOeto.n.MA 02118 • P • I '^,'mayCABRAL_ ! :272 ce p Not valid without signature