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HomeMy WebLinkAboutBld-20-00533 Office Use Only 01"Y`!R Permit „fir':v, c y' Amount 60 .N MAT IM '�•+n..,L•*'1 d•` Permit expires 180 days from ..; issue date C3u)-La-53 3 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department JUL i () J r 1146 Route 28 South)armouth,MA 02664 CV-4-1��� 508 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: G lei°rctutA t tty Mitt, YarNocutkport ASSESSOR'S INFORMATION: �l Map: j/ (� Parcel: J� q /+ OWNER: eraL�ii Lt)arre� , Oiiw tp I ! - 3( - t,3�0µ NAME ll..,, PRESENT ADDRESS(� TEL. CONTRACTOR: Ge0 r 'e O mvt,sJ Ill c. 1��� N, MQ I.�Lr U t. �, YctrnLou, j O f-39 4- o(3.2 NAME MAILING JADDRESS TEL.# Residential 0 Commercial Est.Cost of Construction$ �P ZOO. Home Improvement Contractor Lic.# )COL 01 G i Construction Supervisor Lic.# ' 'G /,3 6 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor \VI have Worker's Compensation Insurance ��" Insurance Company Name: OS o c Lat ed, If.d r�,df-, r(.e(J Worker's Comp.Policy# cc o 0\5'0 i 73 0 L p01 6k WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares v Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation ViAlld Kings Highway/Historic Dist. (Replacing like for like Pool fencing *The debris will be disposed of at: S +( Ex Co Location of Facility I declare under penalties of perjury that th fateqtents 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 revoc of m icense and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: Owners Signature(or attachment) Caj se pktk Date: Approved By: f.4- , Date: ' o / Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes No Flood Plain Zone: 07 Yes ❑ No Water Resource Protection District: Within 100 R.of Wetlands: 0 Yes 0 No 0 Yes ❑ No rj_Ne ((n.wzneanweala afd i(er.lacAute!tj Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 16016'44 07/01/2020 One Ashburton Place-Suite 1301 GEORGE DAVIS,INC. Boston,MA 02108 33 ORGENORTH F.DAVIS 33 NORTH MAIN S7REE'T' U SOUTH YARMOUTH,MA 02664 Undersecretary Not valid without signature • • • " Commonwealth of Massachusetts Division of Professional Licensure -I Board of Building Regulations and Standards • ConstrgCtt6ri fi'prvisor • • CS-056130 rpires: 03/01/2021 • • GEORGE F DAVIS 1 €�` 33 N MAIN ST n SOUTH YARMOU�H MA 02664 )� • 01.cS i.t0il� f y Commissioner Ch • • • • • nk The Commonwealth of Massachusetts l. •/ Department ofIndustrial Accidents - =aili-- ' 1 Congress Street, Suite 100 _iE�2}= 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): �O(64 e, ( V t J'/ TILL Address: 33 I V d r tk_, „, City/State/Zip: `�, y(1,1�po tak P A D ,60Phone#: MI O K "k1 9 " O&O2 Are you an employer?Check the appropriate box: Type of project(required): 1; I am a employer with is) employees(full and/or part-time).* 7. El New construction 2.E]I am a sole proprietor or partnership and have no employees working for me in 8. : 'emodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. U Demolition 10 Q 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.Q 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. p • ❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We area corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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: ST6C L tit6lAtcfit r-c(.p rkil u rO .cc, Policy#or Self-ins.Lic.#: (A)CC U d 'Q 11{,3 16 r.2,Q 1 q Expiration Date: 31 e J a Job Site Address: (,702, M eYC�� A�/G• City/State/Zip: yQ,r�{�('(( rf, Attach a copy of the worker compensation policy declaration page(showing the policy number and expiratio"(7n 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 ai and penalties of perjury that the informgtion provided above is true and correct. � Signature: /� Date: / Jiq Phone#: D p -c3 q - U d o2• 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#: GEORDAV-01 KSCHULTZ ACORO' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 3/8/2019 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 CONTACT NAME: Mason&Mason Insurance Agency,Inc. PHONE FAX 458 South Ave. (A/c,No,Ext):(781)447-5531 (A/C,No):(781)447-7230 Whitman,MA 02382 E-MAILDESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Western World 13196 INSURED INSURER B:NGM Insurance Company 14788 George Davis,Inc. INSURER C:Associated Industries Insuranc 33 North Main St. INSURER!): South Yarmouth,MA 02664-3437 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 SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY) IMM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR NPP1516170 1/12/2019 1/12/2020 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 POLICY jE8T LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 _(Ea accident) $ _ ANY AUTO M9M28491 10/26/2018 10/26/2019 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOSRE� ONLY X AUTOS BODILY pBRODILY INJURYp (Per accident) $ X AUTOS ONLY x foam )Perraccl t)AMAGE UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY STATUTE ER WCC50050143902019A 3/5/2019 3/5/2020 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICE�tM1FIM�F_F2 EXCLUDED? N N/A 500,000 ( anda ory n ) E.L.DISEASE-EA EMPLOYEE $ 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) office copy CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE George Davis Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 ACCORDANCE WITH THE POLICY PROVISIONS. 33 North Main St. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE 92-1" ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD July 23, 2019 Town of Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 Re: permit authorization for: • 62 Merchant Avenue Yarmouthport, MA 02664 I, Geralyn Warren, as owner of the subject property, hereby authorize George Davis, Inc. to act on my behalf, in all matters relative to work authorized by this building permit application form for the above referenced property. ‘e----C-e----- -2/ -C-// r Sig ture Date Pr' t Name