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HomeMy WebLinkAboutBld-20-001848 • ltegito - o� O 'mi '/ . y I Amounts L '%A*`�NA vJJ\ •"°°°`° !Permit expires 180 days from -- i issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 i1 �� AJ`i (508) 398-2231 Ext. 1261 (--��11� �� CONSTRUCTION ADDRESS: I, K CJ.f) -- ASSESSOR'S INFORMATION: o (� / ,Map: /P`arcel: //� ,.f ��jl OWNER: l C��LIa CY xC WC C� c�rl L) /of /S f£ k a�U l`�W�n NAME PRESENT AA_DDD/RE/SS / I �y TEL. # CONTRACTOR: !I/�i Ci V J ) L)W/CZ I W/LLaW CT 3/106 ^ in A-- i617`80 -�U2 NAME MAILING ADDRESS /TEL.# Residential ❑Commercial Est.Cost of Construction$ 20•co0 Home Improvement Contractor Lic.# 1946 j/` /1 Construction Supervisor Lic.# CS - 11212 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor 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 /g ./ Replacement windows: # "90 ✓ 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: Zr ij CIAL 17v✓h I0 1. _, 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 for denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: *Owners Signatu for attachments Date: Approved By: - Date: Buildin rc. r de ignee) EMAIL SS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No 0 Yes No The Commonwealth of Massachusetts I 3 Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ,••r• 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): /1 4 COnS4111CliOn ✓ 11Cf) Ad-) UrC2. Address: 00 a Sitc jees' �/774 Q��'rJ,C City/State/Zip: * 0/906 Sc oCirs Phone #: 6/7- S0, S + Are you an employer?Check the appropriate box: Type of project(required): I I.ay I am a employer with 0 employees(full and/or part-time).* 7. ❑New construction 2.E I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity. [No workers'comp.insurance required.] 9. — Demolition 3.�I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 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.❑ Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑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.1 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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. 1 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: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: 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 u e the pains and penalties of perjury that the information provided above is true and correct. Signature: �.,�Cr✓' Date: /v 41 Phone#: 617` 3go ` 572C 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#: .74 Fir 2,2204raead.�a ✓�as,s r Xedea.), Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Etia=IndMdual ElRd[ttloII 02/21/2021 MARLIN AD 1�t c � 1 MARCIN ADAM ��{ 1 WILLOW COUR�;:•• '.N' SAUGUS,MA 019061 ` Undersecretary Commonwealth of Massachusetts ®� Division of Professional Licensure Board of Building Regulations and Standards ConstrCtirtprvisor CS-113123 Ni o i res: 01/15/2023 MARCIN ADAaf1OWIC.4 ji ti 1 WILLOW COOT SAUGUS MA 011$16 Commissioner C#16- Arco® DATE(MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 10/04/2019 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 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 CONTNAME: Lisa Lisa Steele QUARANTELLO INSURANCE AGENCY INC IA/ No.Exq: (781)284-9109 FAX No): E-MAIL ADDRESS: Iisa@quarantell0insurance.COm 91 Hutchinson St INSURER(S)AFFORDING COVERAGE NAIC# REVERE MA 02151 INSURERA: AMERICAN ZURICH INSURANCE COMPANY 40142 INSURED INSURER B ADAMOWICZ MARCI N INSURER C: DBA MA CONSTRUCTION INSURERD: 1 WILLOW COURT INSURER E: SAUGUS MA 01906 INSURER F: COVERAGES CERTIFICATE NUMBER: 457140 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 EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE RENTED $ CLAIMS-MADE OCCUR PREMISESO(Ea occurrence) , $ MED EXP(Any one person) $ N/A PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JERCOT- LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT $ (Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ _ _ NON-OWNED PROPERTY DAMAGE HIRED AUTOS — AUTOS (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER H STATUTE ER AND EMPLOYERS'LIABILITY A OFFICER/MEMBER EXCLUDED?ANYPROPRIETOR/PARTNER/EXECUTIVE Y® E.L.EACH ACCIDENT $ 100,000 N/A N/A 6ZZUB1K95818219 04/10/2019 04/10/2020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govilwd/workers-compensation/investigations/. Sole proprietor has not elected coverage. 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. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Croey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD • Act./Rai DATE(MMIDDI:DDrYYYY) CERTIFICATE OF LIABILITY INSURANCE 10/ 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: Quarantello Insurance Agency,Inc. PU N Ext)• 781-284-9109 Arc V HCO ,No): 781-286-4748 91 Hutchinson St. E-MAILA SS: Lisa@Quarantelloinsurance.com Revere,MA 02151 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Commerce Insurance INSURED INSURERS: Marcin Adamowicz INSURER C: DBA MA Construction INSURER D: 1 Willow Ct Saugus,MA 01906 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 'DLSUBR POLICY EFF POLICY EXP UNITS LTR INSD MID POLICY NUMBER (MMIDD/YYYY) (MM/DDIYYW) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO TED CLAIMS-MADE OCCUR PREMISES(Eat occurrence) $ 50,000 MED EXP(Any one person) $ 5,000 A 8008030015029 04/10/19 04/10/20 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT ri LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS — HIRED NON-OWNED PROPERTY DAMAGE $ _ AUTOS ONLY _ AUTOS ONLY (Per accident) $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ - EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ' NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) '—' E.L.DISEASE•EA EMPLOYEE $ It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I 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-Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED R/RESENTATIVE ♦4 0+ 1 �t ®1 8-2015 AC a RD +RPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD f ACCORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `•.-/'' 10/04/2019 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 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: Lisa Steele QUARANTELLO INSURANCE AGENCY INC ,PHf dQ,Egl (781)284-9109 ;FAX (A/C, E-MAIL lisa ---- ADDRESS_ ©quarantell0insurance,com 91 Hutchinson St —__INSUR!S)AFFORDING COVERAGE • NAICk REVERE MA 02151 INSURER A: AMERICAN ZURICH INSURANCE COMPANY 40142 INSURED INSURER B. ADAMOWICZ MARCIN INSURER C: DBA MA CONSTRUCTION INSURERD: 1 WILLOW COURT INSURER E: SAUGUS MA 01906 INSURERF: COVERAGES CERTIFICATE NUMBER: 457140 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 1 IADDV SUBR -� ' POLICY EFF,. POLICY EXP LTR I TYPE OF INSURANCE JNSD WVD POUCY NUMBER I(MMIDD/YYYY)I(MM/DD/YYYY)1 LIMITS COMMERCIAL GENERAL LIABILITY I 'EACH OCCURRENCE S —I I ISAMA0t TO RENTE15——1- --- ' ;CLAIMS-MADE I i OCCUR ! PREMISESL_Eaoccurrence) ' ;S I _ MED EXP(Any one person) $ _l—__—_____--_ _..___... I N/A INJURYS I GENII_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE I$ i POLICY I !JE LOC i, —, .___._ PRODUCTS-COMP/OP AGG $ OTHER: i$ AUTOMOBILE LABILITY k I COMBINED SINGLE LIMIT ' _ I IEa accident1_--_.- S ANY AUTO t BODILY INJURY(Per person) .$ ALL OWNED ;SCHEDULED N/A 1 BODILY INJURY(Per accident) $ AUTOS I I AUTOS +. AUTOS 1 NON-OWNED PROPERTY accidenDAMAGE S HIRED AUTOS '� _Per t-. I UMBRELLA UAB I OCCUR EACH OCCURRENCE I$ „- --1 EXCEISS�LIAB j --- ----- DED RETENTION$ CLAIMS-MADE ! N/A 1 'AGGREGATE '$ $ WORKERS COMPENSATION 1 - PER I II OTH- 1 i AND EMPLOYERS'LIABILITY YIN; I I X STATUTE_I - ER ANYPROPRIETOR/PARTNER/EXECUTIVE i E.L.EACH ACCIDENT $ 100,000 A 'OFFICER/MEMBER EXCLUDED? N/A WA NIA 6ZZUB1K95818219 04/10/2019 04/10/2020 --- — - f ------' (Mandatory in NH) I I I E_L.DISEASE-EA EMPLOYEE'$ 100,000 If yes.describe under ----- _. DESCRIPTION OF OPERATIONS below ! I ` I I E.L.DISEASE-POLICY LIMIT I$ 500,000 i i N/A i I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more apace Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govilwd/workers-compensation/investigationsi. Sole proprietor has not elected coverage. 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. 1146 Route 28 AUTHORIZED REPRESENTATIVE --_n, J,- ( sc South Yarmouth MA 02664 `" Daniel M..t Cr y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD _ ,I A411C3819/T-3850-3-partcarbonless contractors proposal Paper _...._-__ of _ pars r0P0gat M 4 Cons4-rucon 1 W i(l otj Coco rf- ' Sactous , iM 01106 1D R Q G S JOB NAME JOB Of �/" JOB J'� DATE DATE OF PLANS 93o1 ARCHITECT --- • • a ll ' old _�rndous_ and all rrn . 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