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Home My WebLink AboutBld-20-002437 u Office Use Only O •Y . Permit# O +f-N H: Amount N ten " ':.,!'""r"' . . q o— '- Permit expires 180 days from issue date 5-20-237 EXPRESS BUILDING PERMIT APPLICA Ifl C E i V r TOWN OF YARMOUTH Yarmouth Building Department 1 OCT :2 (- 1019 • ' 1146 Route 28 I l South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 ...._. CONSTRUCTION ADDRESS: C7° :,7 •••"/ 6:31; f 7 1 ��/2/ ASSESSOR'S INFORMATION: Map: y� Parcel: �' �'?7$OWNER: /> ' G•2''/ 77'�f/ ! `�C%p Z /L CONTRACTOR: C�.(1/YV'1C _ y 4.5 Pv ' .43.,23 � � S ` NAME I Ifi AD� f TEL.# a'', j _Sao -,e_ei residential i ommercial Est.Cost of Construction$ Home Improvement Contractor Lic.# I •S 3 1 q 1 Construction Supervisor Lic.# ► 0 l 0 ,2 Workman's Compensation Insurance: (check one) I am the homeowner 'LLam the sole proprietor f I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 1 Z.�$'/ Replacement windows:# 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: ( & . do A., f� _ . `,, IF Locati of Facility I declare under penalties of perjury that,A. 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 revocati.7.. my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: I Date: Owners Signature(or ttachm. t). t %. Date: /4 %,� Approved By: Date: �e,'— Building Official esi EMAIL ADDRES • — Zoning District: Historical District: ;� Yes I No Flood Plain Zone: 1 Yes 1 No Water Resource Protection District: Within 100 ft.of Wetlands: u Yes C- No f, Yes 1 No V ,per The Commonwealth of Massachusetts ,, Department of Industrial Accidents =':%r E I Congress Street, Suite 100 c y= Boston, MA 02114-2017 ww>ti.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information c Please Print Legibly Name (Business/Organization/Individual): e f r #2e/Y1/tae-a‘....---__ Address: Z G , �. � �� • Y City/State/Zip: S - Phone#: c g D- 3 7 5 -2- Are you an employer?Check the appropriate box: Type of project(required): 1.EA I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] g• El Remodeling 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. 0 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 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and Ihave 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 152,§I(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 Policy#or Self-ins.Lic.#: .3.G013W.5'1.fi1— zoC 7 Expiration Date: 0 q G7.0 C� Job Site Address: Z S `f . City/State/Zip: r ./1/�i Attach a copy of the workers' compensation policy declaration page(showing the policy num er 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: cX Phone#: Sag - 7 qS q, 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#: m 0 qr, , 15. CD 3 ° U N a_ p xiZ.n n 03W3 cF L_N p.� C Ri // 7 4, Z' mV WO r'' CA tc -D m .d F p �a ''`.w" ?rc m O `i� �f• !iPIF1u( -1 C 0 itt m0 g =QO N D) mm us w u)F-2 CO (�\� co ��a N N ' 0 CC UNu N 0 • i CAPS �rvc_ 299 Main Street, West Yarmouth, MA 02673 508-775-6880 Fax: 508-775-6939 E-Mail: horanshAcomcast.net October 27, 2019 To: Town of Yarmouth Building Dept From: Shawn Horan Re: Foxwood Condominiums Building F Dear Building Dept, With regard to the above captioned, please note that C&F Remodeling is authorized to replace the siding at Foxwood Condominiums Building F. Sincerely yours, Shawn Horan Cape Realty Inc Property Manager SALES RENTALS REAL ESTATE MANGEMENT BUYER AGENCY www.caperealtycapecod.com ROs CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 05/02/2019 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 policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED,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 Deborah Kelly NAME: Leonard Insurance Agency,Inc PHONE (508)428-6921 I FAX 508 683 Main Street �.L.Eat): (ANC,No): ( )420"5406 ADDRESS: deborahk©leonardagency.com Suite B INSURER(S)AFFORDING COVERAGE NAIC S Osterville • MA 02655 INSURER A: Atain Specialty Insurance Daum INSURER B: The Commerce Ins.Co. 34754 Carlos Figueiroa,DBA:C&F Remodeling Inc. INSURER C: Associated Ind.Of MA-ARWC 26158 INSURER D: 20 Captain Noyes Road INSURER E: South Yarmouth MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: CL195203710 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. NON LTR TYPE OF INSURANCEMID MD, POLICY NUMBER POLICY EFF POLICY EXP -(MMIDDIYYYY) (MMIDDM/YY) LIMITS COMMERCIAL GENERAL.LIABILT Y EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ 1°°'°°° 1 . MED EXP(Any one person) $ 5,°°° A , CIP383515 04/18/2019 04/18/2020 PERSONAL bADV INJURY $ 1,000.000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY E ECT LOC I PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER: $ AUTOMOBILE UABIUTY COMBINED SINGLE UMIT 8 — (Ea acdden0 ANY AUTO BODILY INJURY(Per person) $ 250,000 B OWNED �/ SCHEDULED RVM277 01/18/2019 01/18/2020 BODILY INJURY(Per accident) $ 500,000 AUTOS ONLY X AUTOS �/ NON-OWNED PROPERTY DAMAGE X AUTOS ONLY !� AUTOS ONLY (Per accident) $ 250,000 Medical payments $ 10,000 UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE 5 _ DED I I RETENTION$ $ WORKERS COMPENSATION I PER I I TM AND EMPLOYERS'LIABILITY Y I N STATUTE ER ANY PROPRIETORIPARTNER/EXECUTIVE E.L EACH ACCIDENT $ 500,000 C OFFICER/MEMBER EXCLUDED? a NIA WCC-500-5018589-2019A 04/30/2019: 04/30/2020 (Mandatory 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 I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space la 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 Mashpee ACCORDANCE WITH THE POLICY PROVISIONS. 16 Great Neck Road AUTHORIZED REPRESENTATIVE • Mashpee MA 02649 oarr4l� c 1 a 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD