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Home My WebLink AboutBLD-20-003363 G -':Amount Ot y i t"• »t**Ac” e 'Permit expires 180 days from Js c ?issue date EXPRESS BUILDING PERMIT APPLIC , ►_ F 1 V, F0 TOWN OF YARMOUTH Yarmouth Building Department 'c-- u�� 12 ZQ�9 1 1146 Route 28 South Yarmouth, MA 02664 i Bui -DING Ji PieAK I NiENT (508) 398-2231 Ext. 1261 3Y CONSTRUCTION ADDRESS: /64grt , .kV r-- C`"i'-'' ASSESSOR'S INFORMATION: Map: �/ Parcel: jz OWNER: J'C + MA 40 , U - 5 JZ2 7 NAME PRESENT ADDRESS TEL. # CONTRACTOR! it eseisf the: zitAe — NO- NAME MAILING ADDRESS TEL.#y; Residential 0 Commercial Est.Cost of Construction$ " An Home Improvement Contractor Lie.# // ' za Construction Supervisor Lie.# 65✓ 0 7 7 Workman's Compensation Insurance: (check one) I am the homeowner 2 I am the sole` proprietor I have Worker's Compensation Insurance // fy Insurance Company Name:l'A Kt V ' �p yN� Worker's Comp.Policy# WLs V7�3)Y WORK TO BE PERFORMED �z, t r -�;i, .44: �a."-toL*'IteN Tent Duration (Fire Retardant Certificate attached?) gt 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 Pool fencing *The debris will be disposed of at: -?61A `Alk t f 4 [C a Location of Facility I declare under penalties of perjury that the st.e .her tamed 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 revo 4,i o/I,y di prosecution under M.G.L.Ch.268,Section I. /��- Applicant's Signature• ,aAL f.LIKArl .. Date: �/ /� QWtilxs. gnats fl» Om -r///nr L-c- . , l- g .te /2 //D //2 Approved By: � 4*- Date: 1 2 . 0�• /5 Building Official'• ee) t EMAIL ADDRESS: rck Kl�(.6 I v t'.ft' .Gam)i'\ Zoning District: Historical District: 0 Yes K. No Flood Plain Zone: i( Yes n No Water Resource Protection District: Within 100 ft.of Wetlands: it _ Yes No _ Yes No The Commonwealth of Massachusetts g't Department of IndustrialAccidents • _�`l f, 4 - 1 Congress Street,Suite 100 Boston,MA 02114-2017 4:me - 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): Lars Olson Fine Home Building, Inc. Address: 19 Marconi Lane • City/State/Zip: Marion, MA 02738 Phone#: 508-958-8633 Are you an employer?Check the appropriate box: Type of project(required): I. I am a employer with 7 employees(full and/or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working for me in . ❑Rem delingtCtnOn 8 any capacity.[No workers'comp.insurance required.] • ❑Reoeling 3. I am a homeowner doing all work myself.[No workers'comp.insurance required.]t • 9. El 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.Q 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. Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance t 13.0 Roof repairs 6.ElWe are a corporation and its officers have exercised their right of exemption per MGL c. 14. 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, tCantractors 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: Mackinaw Underwriters, Inc. Policy#or Self-ins.Lic.#: WC 0870304 Expiration Date: 6/18/2020 Job Site Address: 109E River Street City/State/Zip: Yarmouth, MA 02664 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 un th e ties of perjury that the information provided above ' tr e and correct Signature:_. fi Date: �(� Phone#: 508-958-8633 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#: ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDo1D Y) 09THIS 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). CONTACT Elise Fiano PRODUCER NAME: Roger Keith&Sons Insurance Agency hNo ): (508)583-1106 I(NC,No): (5°8)583-8478 al 1575 Main St ADDRESS: efiano@rogerkeith.com INSURER(S)AFFORDING COVERAGE NAIC S Brockton MA 02301 INSURER A: Selective Insurance Company of South Carolina INSURED INSURER B: NGM Insurance Company 14788 Lars V.Olson Fine Home Building Inc. INSURER C: Mackinaw Underwriters,Inc. MIG001 19 Marconi Lane INSURER D: PO Box 741 INSURER E: Marion MA 02738 INSURER F: COVERAGES CERTIFICATE NUMBER: 2019-2020 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 EXP TYPE OF INSURANCE INSD Syryp POLICY NUMBER (POLICY DD/DIYYYY) (MMIDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 500,000 CLAIMS-MADE ®OCCUR PREMISES(Ea occurrence) S MED E(P(Any one person) $ 15,000 — A S2228469 06/17/2019 06/17/2020 PERSONAL&ADV INJURY $ 1,000,000 GENAGGREGATELIMITAPPLIESPER: GENERAL AGGREGATE $ 2,000,000 'L RPOLICY ElECT LOC PRODUCTS-COMP/OP AGG $ 2,000'000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT y 1,000,000 (Ea accident) — ANY AUTO BODILY INJURY(Per person) $ B OWNED X SCHEDULED M1T0890P 06/17/2019 06/17/2020 BODILY INJURY(Per accident) S —X— AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE 9 X AUTOS ONLY X AUTOS ONLY (Per accident) $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE S 1,000.000 A EXCESS LAB CLAIMS-MADE S2228469 06/17/2019 06/17/2020 AGGREGATE = 1'000,000 DED >1 RETENTION$ 10'000 8 WORKERS COMPENSATION XI S TUTE I I ER OT AND EMPLOYERS'LABILITY Y I N C ANY PROPRIETOR/PARTNER/EXECUTIVE NIA WC 0870304 06/17/2019 O6/17/2020 E.L.EACH ACCIDENT $ 00 500'0 00 OFFICER/MEMBER EXCLUDED? 000 , (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 00 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space Is required) POLICY LIMITS IN EFFECT AT POLICY INCEPTION. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DEUVERED IN STEPHEN&TINA MOSCA ACCORDANCE WITH THE POLICY PROVISIONS. 109E RIVER STREET AUTHORIZED REPRESENTATIVE SOUTH YARMOUTH MA 02664 . a............„ 1 (� 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD