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HomeMy WebLinkAboutBld-20-001158 Office Use Only ...,Og•Y4R.. _. S'S' `,Permit O 4 N '.Amount -( 0.--- F' 4*•,..,* , ^� 1 s Permit expires 180 days from ": �: ' Cal/ l issue date RECEIVED_.. EXPRESS BUILDING PERMIT APPLICATI N —1 TOWN OF YARMOUTH AUG 2 8 2019 Yarmouth Building Department 1146 Route 28 B`1 I' South Yarmouth,MA 02664 L. _ -7 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 1191r 'G11l i 'ii,‘ rGir✓1v 41, ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 3GIVt'lE Cl�qvcn ° 3(�,_ Deg NAME 1 PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# P'Residential 0 Commercial Est.Cost of Construction$ /0DV� Home Improvement Contractor Lic.# /0(2`1 34Z- Construction Supervisor Lic.# /0 3 a S d Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor ave Worker's Compensation Insurance Insurance Company Name: 14Vi . l r�Lk Worker's Comp.Policy PPk ( ( ��l'o jJcW &- L^-J WORK TO BE P ORMED `-Q1 — ..�-.-�-I r,ar- dZAQ ( Fri-rzQ tC& Vj Q/\. , 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 Iike Pool fencing *The debris will be disposed of at: J ra Y UA/\ U't� `Z, Location of Facility I declare under penalties of perju 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 for denial or voc ion of my lic d for prosecution unde G.L.Ch.268,Section 1. ��Applicant's Signature: �'`Z�/� �i ii _ � Date: 7 2g /7 Owners Signs re(o 'ttachment) //�j Date: j �j� Approved By: /�, ,✓/ 4: Date: v c.��� Building Official y .es'.:') / EMAIL SS: Zoning District: Historical District: �U Yes 1 No Flood Plain Zone: Yes E No Water Resource Protection District: Within 100 ft.of Wetlands: u Yes No _ Yes Li No nO - \\ 0ck.4s [V cam The Commonwealth of Massachusetts _,�, 1`wl Department of Industrial Accidents 1 Congress Street,Suite 100 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): I1. .S, ixv'ic Address: t 10 0\ w� r� ��;, cc,4 City/State/Zip: �UA\r\ \ILtr ktp,, [ °awl Phone#: 5 C , 6S . g2 14 Are you an employer?Check the appropriate box: Type of project(required): Id am a employer with R employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition 4.0 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 11.0 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.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.ErOther 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. :Contactors 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. R *[Insurance Company Name: b -WAA@`r+t'11n h` N C04J1 Policy#or Self-ins.Lic.#: 1"" K 1 1 1)-- p(o Expiration Date: 1 / ( / C) - Job Site Address: 't it./c 1v LCYtQ, 1)Qv 1`\ \ Car A'• city/State/Zip: M 0 D.6641 Attach a copy of the workers' compensationpolicydeclare 'on page(showingthe policynumber p g 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 certi nder the and pen of erjury that the information provided above is true and correct Signature: 6 Date: Of`7U6 () r' Phone#: . (-� '�— 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: . ', r k; r � 'f ,2,S- - �- _ -- -. .- • - �`s-�". __ �" y. .ham� -�: - - C � _ � t" "ram. .: • • • +b 4 N}�rY s^ ,2P -',mot . 7 s an � _ LL C 141,,t rrAit,X'Il3 o�:r,�r.,, r Attains tion Office of Consumer Affairss&Business Regula HOME IMPROVEMENT CONTRACTOR TYPE:Suoolement Card€ Re lQR 07/22/2020 • 106438 A R S SERVICES INC DB/A ARS RESTORATION SPECIALISTS MARK DIMPFL U !_ 38 CRAFT ST NEWTON,MA 02458 Undersecretary Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Co nstriJctfibfl'Stype rvisor • CS-103250 ttpires: 11/13/2020 MARK K DIMPFL 21 FAIRBANKS ROAD .1 FRAMINGHAM MA 0170fn Commissioner C �...440 RACIINT-02 GHOUGHTON ACORU' CERTIFICATE OF LIABILITY INSURANCE DATE(rrMIDD/YYYY) `------- 01/02/2019 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(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 License#1780862 ACT Gretchen Houghton HUB International New England ,PHONE FFAX 600 Longwater Drive A/C,No,Eat): (WC,No): Norwell,MA 02061-9146 E-MAIL ,gretchen.houghton@hubintemational.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER ATokio Marine Specialty Insurance Company 123850 _ INSURED A.R.S Services LLC INSURER B:Philadelphia Indemnity Insurance Company 18058 _ A.R.S Restoration Specialists LLC INSURER C:Zurich American Insurance Company 16535 ARS Restoration Specialists LLC INSURER D: 38 Crafts Street — Newton,MA 02458 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 LIMBS LTR INSD WVD (MMIDDNYYYI IMM/DOJYYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE X OCCUR X X PPK1921786 01/01/2019 01/01/2020 PREMISES(EaEoaurren $ 100,000 5,000 I MED EXP(Any one person) $ _-- _ PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY Xj JET 1 ! LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: $ B AUTOMOBILE LIABILITY (Ea aBmdeerntSINGLE LIMIT $ 1,000,000 X ANY AUTO X X PHPK1921689 01/01/2019 01/01/2020 BODILY INJURYA erpersonl_ $ OWNED SCHEDULED AUTOSREp ONLY AUTOS E BODILY INJURY(Per accident) $ _ AUTOS ONLY AUTOS ONLY PROPERTY ardent DAMAGE $ 1 $ A X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5,000,000 ---------- EXCESS LIAR CLAIMS-MADE X x PUB659070 01/01/2019 01/01/2020 AGGREGATE $ 5,000,000 DED X [RETENTION 0 ! --- $ --- C WORKERS COMPENSATION f X 1 PER 1OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER- ANY PROPRIETOR/PARTNER/EXECUTIVE r j X iWCO27450801 01/01/2019 01/01/2020 E.L.EACH ACCIDENT $ 1,000,000 Q�FICER/McMBER EXCLUDED? L. N/A (Mandatory m NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A CPL X x PPK1921792 01/01/2019 01/01/2020 Cont.Poll Liability 2,000,000 B Bailment Coverage x x PHPK1921689 01/01/2019 01/01/2020 Customers Property 250,000 1 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) A.R.S Services LLC,ARS Restoration Specialists LLC,A.R.S Restoration Specialists LLC,Blaine Oney Construction Company LLC dba Emergency Services& Reconstruction,South River Restoration-Texas,LLC,and South River Restoration,LLC are wholly-owned subsidiaries of RACI Intermediate Holdings LLC. Policy Named Insureds: A.R.S Services LLC A.R.S Restoration Specialists LLC ARS Restoration Specialists LLC SEE ATTACHED ACORD 101 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE A.R.S.Services LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Evidence of Coverage 38 Crafts Street Newton,MA 02458 AUTHORIZED REPRESENTATIVE rr ACORD 25(2016/03) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID:RACIINT-02 GHOUGHTON LOC#: 0 ACGREr ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY License#1780862 NAMED INSURED HUB International New England A.R.S Services LLC 9 A.R.S Restoration Specialists LLC POLICY NUMBER ARS Restoration Specialists LLC 38 SEE PAGE 1 Newtoonn,,MA 02458 USA CARRIER NAIC CODE SEE PAGE 1 SEE P 1 EFFECTIVE DATE:SEE PAGE 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Description of Operations/LocationsNehicles: Insured Locations: 38 Crafts Street Newton MA 02458 480 St.James Ave Springfield,MA 01109 110 Old Townhouse Road South Yarmouth MA 02664 181 Putnam Pike Johnston RI 02919 1 Rebel Road#3 Hudson NH 03051 2 A Street Auburn MA 01605 355 Sacket Point Road North Haven,CT 06473 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD J""'1 RACIINT-02 GHOUGHTON AWRL) CERTIFICATE OF LIABILITY INSURANCE o� ) iTHIS 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(ie s)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). PRooucER License 01780882 m.Gretchen Houghton HUB International New England FAX,Nok 600 Lon�grat�epr Drive Norwell,1AA 020814146 retchen.hou bintematlonal.com sag 9htorl�hu INSURERS!)AFFORDING COVERAGE NAIC a INSURERA:Tokio Marine Specialty insurance Company 23850 INSURED INSURER a Philadelphia Indemnity Insurance Company 18058 - RACI Intermediate Holdings,LLC INSURER C:Zurich American Insurance Company 16535 38 Crafts Street INSURER D Newton,MA 02458 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. „ILA TYPE of INSURANCE Nam'Y POLICY NUMBER i l I B'YSUBR POUCY EPP POUCY�YYI UNITS A X COMMERCIAL GENERALLWSUTY EACH OCCURRENCE S 2,000,000 CLAMS-MADE X OCCUR X X PPK1921786 01101/2019 01101/2020 DAWSMT ENTEDnc) $ 100'000 MEO IXP(Am ore ) S S.000 PERSONAL&ADV INJURY S 2,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 3,000,000 POLICY X ga - LOC PRODUCTS-COMNOP AGG $ 3,000,000 OTHER; S B AUTOMOBILE LIABILITY C.OM NGLE LIMIT $ 1,000,000 X ANY AUTO BOB X X PHPK1921689 01/0112019 01/01/2020 BODILY INJURY[Perms:IN $ AAUTO ONLY AUT BODILY INJURY[Per accident) S . AOONLY .Mt ppaiMynt1 AGE S S A X UMBRELLALWB X OCCUR EACH OCCURRENCE S 5,000,000 EXCESS UAB CLAIMS-MADE X X PUB659070 01/01/2019 01/01/2020 AGGREGATE $ 5 ,000,000 DED X RETENTION S 0 ViORICERS COMPENSATION X PER CANY ANDEMPLOYERS' �U EC YIN NIA UTIYEX WCO27450801 01/01/2019 01/01/2020 Turf 1,000,000 aQIC.iatersfEROM�MpO EL EACH ACCIDENT .S S ) E.L.DISEASE-EA EMPLOYEE S 1,000,000 Ya. OPEOPE -_. ._.--- I� RI aRATIONS below El.DISEASE-POUCY UNIT S 1,000,000 A Contractor Pollution x x ,PPK1921792 01/01/2019 01/01/2020 CPL-Per Occurrence 2,000,000 B :Bailment Coverage x x IPHPK1921689 01/01/2019 01101/2020 Customers Property 250,000 DESORPTION OF OPERATIONS/LOCATIONS I VENOUS We m 101 AddlUo,W RunaAu ds,nits be atledad a more space is requied) A.R.S Services LLC,ARS Restoration Specie asts LLC,A.R.S Restoration Speecclaists LLC,Blaine Orly Construction Company LLC dba Emergency Services& Reconstruction,South River Restoration-Texas,LLC,and South River Restoration,LLC are wholly-owned subsidiaries of RACI Intermediate Holdings LLC. Coverage applies to all the above insureds and all their locations. Insurance Policies Include additional Insured endorsment with written contract and Is Primary and Non-Contributory. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence Of Insurance Coverage THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Overag ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE q44/ ACORD 25(2016/03) 6 1 988-201 5 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD