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HomeMy WebLinkAboutBld-20-001668 q /Ace Use Only 0r ,: H Amount )i. Permit expires 180 days from - : : 019 issue date EXPRESS BUILDING PERMIT APPLICATION R E C E I V E D TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 SEP 7 6 2019 South Yarmouth, MA 02664 BUILDING DEPARTMENT (508) 398-2231 Ext. 1261 ,! CONSTRUCTION ADDRESS: ¢6 bbMPi s.)o toll\ , YI MOJ j(} forai M A "/s ASSESSOR'S INFORMATION: Map: Parcel: OWNER: fi‘STiNe- C, Con EioMcs►NC 1/11.000196 tti 1000141 ,MA al 5,e 3(0 ,155 1 NAMEME! PRESENTp ADDRESS i TEL. # CONTRACTOR: (I D GUS OM Cq( Ntit'/ ink, r PI#1 ¢ST )1 r (of1e3Th IC i M(f 0.26411 5°36° ASS f NAME MAILING ADDRESS TEL.# Residential 0 ©Commercial Est.Cost of Construction$ 6poo•00 Home Improvement Contractor Lic.# 164 p 5 Construction Supervisor Lic.#CS— fiI tio( Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 'I have Worker's Compensation Insurance Insurance Company Name: (JTGA Worker's Comp.Policy# 41 6 6 122 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 10 Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation kI&' Old Kings Highway/Historic Dist. ( )C)Replacing like for like Pool fencing *The debris will be disposed of at: C1t i I(`S b eiv is 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 ford r t1L. gJo�6/revocation oo y license and for prosecution under M.G.L.Ch.268,Section 1. // �} Applicant's Signature: c t' _ J Date: a /0� Owners Signature(or attachment) ,C f. to----Ni Date: 7/�S'/�(9 Approved By: J Date: Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No „ � The Commonwealth of Massachusetts ' 1� * ram— i Department of Industrial Accidents kill= 1 Congress Street, Suite 100 it�7_ Boston, MA 02114-2017 �� www.mass.gov/dia N. Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): lib aW.2M C ttJ;T,/ iWC., Address: IZ ii toe c .6 j .J L City/State/Zip: 4/2es i DAl6 I V A- f.) 64i Phone #: ‘,063o0 ,2S/ Are you an employer?Check the appropriate box: Type of project(required): l.gi I am a employer with employees(full and/or part-time).* 7. E New construction 2.E I am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. 9. ❑ Demolition ❑ y [No workers'comp.insurance required.]' 10 E 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.E Electrical repairs or additions proprietors with no employees. 12.E Plumbing repairs or additions 5.E I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E Roof repairs These sub-contractors have employees and have workers'comp. insurance. 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.®Other S f b/q/Ei 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: U Tj CA Policy#or Self-ins. Lic.#: LI 56/ .220 Expiration Date: <Y1..2 3( Job Site Address: (2 QOM(ANO 4 City/State/Zip: N-M /”i M4 4 { 63 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 here ci . tify under he pains an/ enalties of perjury that the information provided above is true and correct. Signature: Al� ^--•� Date: 9/9261,?a/9 Phone#: 50d 360 )SSA 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#: , - R Elk..^...._ E. , tV E_.. E--- SEP 2 6 2019 I. Byuirs6,NG- j B 7R-r,v,L__ ---- `"r`i I- r /60')ja //X it ' a aittIatioo fi a'Pa •/less‘--- ft yk, (6c.firgir &sus%.,,ispor 0 GOT*. ewe of ClivigkoVe.3. 7130rstoo. . 0 • votAs -c/ve, ,,,..G° ei. tot r% _, ..A9JA 'AA 1A91202- Atie _,Itkc GPO°4-Clkl. A f5e'aeta 0\SGO Vrs...p1/414‘,(g0fm-,4 2. 113 0266 ,(pskoosT , . . ,Nsetts 36'1 /e 0.;\t.1:0(3o:146:0:q"12.°1‘kis‘Isi:s7:1‘.5::(P.4512;c:6119:7.1‘62'1'6°57-17.4 co‘•• ok T' ‘00 Ni\SO' .. k V 1,teb ' //e5• - ' ?Pa co'09 ._ .., . •\0443.\ . _ t-t ---- elr'S likOP'D p WA ...• %I's-045,4-00ov• ..., soolv‘ cit, Pi'. GooNc`N Acc a CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 09/26/19 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 poiicy(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 CON r ALT NAME: Fran McEvoy Circle Business Ins.Agcy,Inc (P ic.No.EMr. 978-777-5619 FAX No): 978-777-4898 247 Newbury Street E-MAIL Danvers,MA 01923 ADDREss: fmcevoy@Circlelnsurance.net INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Travelers Insurance INSURED INSURER B: Utica Mutual V.B.Custom Carpentry Inc. INSURER C: 43 Winsome Road INSURER D South Yarmouth,MA 02664 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. NOTVNTHSTANDING 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. ILA TYPE OF INSURANCE ADDLSUBR POUCY EFF POUCY EXP JNSD WVD POUCY NUMBER (MM/DDNYYY) (MM/DD/YYYY) UMITS x COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000 DAMAGE 10 REN1bD CLAIMS-MADE x OCCUR PREMISES(Ea occurrence) $ 300,000 _ MED EXP(Any one person) $ 5,000 A Y 6801C350820 07/23/19 07/23/20 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY lip JECT Ej LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ — (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILYINJURY(Per $ AUTOS ONLY AUTOSaccident) HIRED NON-OWNED PROPERTY DAMAGE $ _ AUTOS ONLY _ AUTOS ONLY (Per accident) $ UMBRELLA LIAB _OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION x PER OTH- AND EMPLOYERS'UABIUTY y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE EACH ACCIDENT $ 500,000 B OFFICER/MEMBER EXCLUDED? N❑ E.L.N/A 4561220 07/23/19 07/23/20 (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) 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. City Hall 1146 Route 28 AUTHORIZE;REPRESENT V Yarmouth,MA 02664-4492 ' it ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ' Doc: 1,375,580 08-02-2019 8: 10 Ctf#:220135 FIDUCIARY DEED • I,Bruce E. Baker,Personal Representative of The Estate of Sarah P.Baker,a/k/a Sara P. Baker, alk/a Sara Painter Baker, Barnstable County Probate Docket No. BA 19P0418EA, pursuant to Power of Sate in said Will,of Yarmouth Port,Massachusetts for consideration paid in the amount of TWO HUNDRED FIFTY THOUSAND & 00/100 1 (S258,000.00)DOLLARS, GRANT to Pristine Cape Cod Homes,'INC. of 43 Winsome Road, South Yarmouth, I. Massachusetts 02664 $ with QUITCLAIM COVENANTS, The land situated in Yarmouth (Port), Barnstable County, Massachusetts, together with the } buildings thereon,described as follows: .87 Plan 36848-B(Sheet 3) a 1•• Said parcel is subject to and has the benefit of all rights,easements,grants,restrictions, reservations,covenants and encumbrances of record insofar as the same are now in force and applicable. . 1 Grantor hereby revokes any and all homestead rights in the property and certifies under the pains 1 and penalties of perjury that there are no other persons who are entitled to homestead rights in the subject premises. For title,see Certificate of Title No.87513. MASSACHUSETTS STATE EXCISE TAX BARNSTABLE COUNTY EXCISE TAX BARNSTABLE LAND COURT REGISTRY BARNSTABLE LAND COURT REGISTRY Date: 08-02-2019 @ 08:10am Date: 08-02-2019 @ 08:10am CtLP: 48 Ct18: 68 Fee: 8855.00 Cons: 8250,000.00 Foe: $765.00 Cons: $250,000.00 Signed under the pains and penalties of perjury this 3o day of July,2019. Bruce E. Bakery peronI rcprestntative COMMONWEALTH OF MASSACHUSETTS Barnstable, ss: On this )O day of July, 2019, before me, the undersigned notary public, personally appeared Bruce E. Baker, proved to me through satisfactory evidence of identification being (check whichever applies): 121, Driver's license or other state or federal governmental document bearing a photograph image; ❑ Oath or affirmation of a credible witness known to me who knows the above signatory, or❑ My own personal knowledge of the identity of the signatory to be the person whose name is signed on the preceding or attached document, and acknowledged to me that he signed it voluntarily for its stated purpose, and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of his knowledge and belief. No ry Pu 1' ANkkkoi. My comma ion expires: (AFFIX SEAL) ( �, ANTHONY J. MAZZEO tr Notary Public ( ,COMMONWEALTH OF MASSACHUSETTS qe My Commission Expires/ 1 ( \ May 1, 2020 MPPHOVEJ FO REGISTRATION BY rHE COUr TIT EXAMINER 2