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HomeMy WebLinkAboutBld-20-000938 -e/rnc ie &-17,61N ''Yil.4 .. TOWN OF YARMOUTH Building Department BUILDING (508) 398-2231 ext.1261 .o PERMIT O 4„ PERMIT NO BLD-20-000938 k4 "—'k " ISSUE DATE 08/20/2019 JOB WEATHER CARD APPLICANT ROBERT CHAMBERS PERMIT TO Repair AT(LOCATION) 26 QUARTERMASTER ROW,SOUTH YARMOUT / ZONING DISTRICT R 40 s Bldg.Type: :Residential SUBDIVISION MAP BLOCK LOT 1087 152 BUILDING IS TO BE: ICONST TYPE s V B I USE GROUP IR 3 REMARKS Repair-Strip and re roof 19 sq ft(508-385-4546) i CONTRACTOR LICENSE 1134169 'Home Improvement 1 ROBERT H.CHAMBERS, INC. i :ROBERT CHAMBERS 102 WHIFFLETREE AVE AREA(SQ FT) 569 242 080: EST COST($) 110000 00 PERMIT FEE($) '50 00 , BREWSTER, MA 02631 OWNER :DAUGHERTY JANET LEE BUILDING DEPT BY ' ADDRESS ; P O BOX 21 WOODINVILLE 'WA i98072 MI PHONE THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SID A K OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE APPROVED BY THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM INSPECTIONS REQUIRED FOR ALL APPROVED PLANS MUST BE RETAINED ON WHERE APPLICABLE CONSTRUCTION WORK: 1)FOUNDATIONS OR JOB AND THIS CARD KEPT POSTED UNTIL SEPARATE PERMITS ARE FOOTINGS.2)PRIOR TO COVERING STRUCTURAL FINAL INSPECTION HAS BEEN MADE. REQUIRED FOR ELECTRICAL MEMBERS(READY FOR LATH OR FINISH WHERE A CERTIFICATE OF OCCUPANCY IS PLUMBING/GAS AND COVERING)3)FINAL INSPECTION BEFORE REQUIRED,SUCH BUILDING SHALL NOT BE MECHANICAL INSTALLATIONS. OCCUPANCY 4)REFER TO DETAILED INSPECTION BEEN MAD UNTIL FINAL INSPECTION HAS BEEN MADE. SCHEDULE POST THIS CARD SO IT IS VISIBLE FROM STREET BUILDING INSPECTIONS APPROVALS OTHER: I WORK SHALL NOT PROCEED PERMIT WILL BECOME NULL AND VOID IF INPSECTIONS INDICATED ON THIS CARD UNTIL THE INSPECTOR HAS CONSTRUCTION WORK IS NOT STARTED WITHIN CAN BE ARRANGED FOR BY TELEPHONE APPROVED THE VARIOUS SIX MONTHS OF DATE THE PERMIT IS ISSUED AS OR WRITTEN NOTIFICATION. STAGES OF CONSTRUCTION NOTED ABOVE. -r .OI.YRR Office Use Only a .�. O Permit# �s;v d `� -p : n,lv 1-3 amount sC `Permit expires 180 days from 1 ; q3 issue date J ..a EXPRESS BUILDING PERMIT APPLICATIO . E C E I V E TOWN OF YARMOUTH Yarmouth Building Department AUG 20 2019 1146 Route 28 South Yarmouth, MA 02664 BYBUI J RTMENT 1_,....._______________ _ (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 2.4 Q r i�v 44—,-4 3 Yeeor.40:j.E.> ASSESSOR'S INFORMATION: ` Lee Map: 1 eel Parcel: t ,S Z OWNER: "NT�\ Lee �QS � Mom. NAMEI(� n�L ` SENT ADDRESS TEL. # CONTRACTOR: �Y \ .- C. /O2 G3 k1 {ctcc� s-c_ -tYS Li St NAME MAILING ADDRESS is ,s zs- ` TEL.# ❑Residential ❑Commercial Est.Cost of Construction$ /0, Dm J Home Improvement Contractor Lic.# /3 9 l(€1 Construction Supervisor Lic.# 100 . iv I Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ I am the sole proprietor 43!4 have Worker's Compensation Insurance r Insurance Company Name: A -'G..rr Worker's Comp.Policy# WORK TO BE PERFORMED 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 like Pool fencing *The debris will be disposed of at: 1-"Olfryv, Cfb Lo lion of Facility I declare under penalties of perjury that th-statemen ein 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 rev, :tio 'f my li s d for osecution under M.G.L.Ch.268,Section 1. Applicant's Signature: AALL Date:J,'� ` Owners Signature(or attachment) Date: Approved By: Date: 8�4e--cr Building Official(or gne 'ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No • The Commonwealth of Massachusetts Department of IndustrialAccidents 1,7 1 1i.•.. " I Congress Street,Suite 10 Boston,MA 02II4-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Info H.01.1A Please Print Legibly Name(Business/Organizatib TR , BREWSTER,MA 02631 Address: City/State/Zip: Phone#: Sb ass- �. Are you an employer?Check the appropriate box: Type of project(required): 1.41 am a employer with ) employees(full and/or part-time).* 7. Q New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Q 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. Demolition 10 Q Building addition 4,Q I am a homeowner and will be hiring contractors to conduct ail work 04 my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 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 13.12.0 Plumbing rrepairs repairs or additions These sub-contractors have employees and have workers'comp.insurance.tQ 6.0 We are a corporation and its officers have exercised their right of exemption per MOL e. 14.Q Other 152,§1(4),and we have no employees,£lNn wc$v.rs'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. .,a/f ( Insurance Company Name: `'i �ll1 t' Cto r f- r.- Policy#or Self-ins.Lic.#: c O 7 so ( Expiration Date: ((L t7 Job Site Address: , City/State/Zip: I 9 Attach a copy of the workers'compensation policydeclaration page(showing the policy numbe and expiration date). F� P Y p ) Failure to secure coverage as required under MGL c, 152,§25A is a criminal violation punishable by a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do here tit penalties of perjury that the information provldod above is true and correct. Signature: Date: ((7. 0/I Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: • air1.4;P uaelta r 1 a� �p�cairs *3tismesa Regutatiisf T'!PE Syppler'1 nt Card • Fie 's`r3' c 13iai .1 903;201 ;:• . _ ROBERT H.OH,A,MB.FIS • • ROBERT H.CHAMBER f\ ( C U" 102 W H1FFLETREES@VE BREWSTER,MA 02633 yam, Undersecretafy Commonwealth.of Massachusetts 2. bivision of Professional Licen?;ure Board of Buildng Regulations and-Stan-Limbs , . Constructio Wipo`Specialty . - t • CSSL-100134 Empires 03/16/2020 Cam. �� = •$ a".'- • ROBERT H CHAMBERS- • 102 WHIFFLETREE AVE C - A BREWSTER A/0203 ," " p £ • _. • Commissioner C ® DATE(MM/DD/YYYY) A CCP CERTIFICATE OF LIABILITY INSURANCE 08/20/2019 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: W Scott Derry KERRY INSURANCE AGENCY (PAHIcNo.Est): (508)255-8000 FAX (A/C,No): E-MAIL ADDRESS: sCOtt insUranCe.COm Gkef rY P 0 Box 1945 INSURER(S)AFFORDING COVERAGE NAIC# N.EASTHAM MA 02651 INSURERA: ATLANTIC CHARTER INS CO 44326 INSURED INSURER B: ROBERT CHAMBERS INC INSURERC: INSURER D: 102 WHIFFLETREE AVENUE INSURER E: BREWSTER MA 02631 INSURER F: COVERAGES CERTIFICATE NUMBER: 439263 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 INsn WVD POLICY NUMBER (MM/DD/YYYY) IMM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE RENTED $ CLAIMS-MADE OCCUR PREMISESO(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PET LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ _ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE EORH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A WCV00609514 01/29/2019 01/29/2020 (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 I 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.gov/Iwd/workers-compensation/investigations/. 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 I ` Daniel M.Cro vey,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