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HomeMy WebLinkAboutBld-20-001161 * y Office Use Only : r;y4 C Permit# � O - i' - 'I Amount !�] :;_:...% )y 20 v ` ( �`/ •1. Permit expires 180 days from ` j issue date 3 , F VET _' EXPRESS BUILDING PERMIT APPLICATIQ TOWN OF YARMOUTH I s A(1( 3(P ig19 Yarmouth Building Department , i , 1146 Route 28 ` ' South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 5-90— 6 oir RTE Lcg I Lti f r Y$1t/TO O %i /74 ASSESSOR'S INFORMATION: Map: Parcel: OWNER C QEPrr /rtF 1/b P11341 ' 14,c NAME PRESENT ADDRESS TEL. # CONTRACTOR: TA 2A kit D/44, (,Utirf jy we J 0r3 6/9' 607k NAME MAILING ADDRESS TEL.#❑Residential Y Commercial n Est Cost of Construction$ 50 000 Home Improvement Contractor Lie.# 176 q70 Construction Supervisor Lie.# a505g Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor fi(I have Worker's Compensation Insurance Insurance Company Name: TPLA if&L62.S Worker's Comp.Policy#I 6 go 6 r' `,(�Z/,4 70 4/9 WORK TO BE PERFORMED ►,„ nla, ,-�4, Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 10 Replacement windows:# 20 Replacement doors: # it Roofing: #of Squares ( )Remove existing* (max.2 Iayers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at Ygztio/ri+- DPW /9d 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�l/�m�yy license and for prosecution under M.G.L.Ch.268,Section 1. '^ Applicant's Sigiature: / �' Date: l7/zQ//KJ/g Owners Signature(or attachment) Date: ((( ' Approved By: Date: f/ --. ),-/7 Building Offici d ' ee) EMAIL SS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts Department of Industrial Accidents "gul_ 4 1 Congress Street, Suite 100 ?f�=_ 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):TATRA BUILDING COMPANY INC. Address: 1268 RTE 28 City/State/Zip:SOUTH YARMOUTH, MA 02664 phone#:(508)619-6073 Are you an employer?Check the appropriate box: Type of project(required): 1.�✓ I am a employer with 4 employees(full and/or part-time).* 7. ❑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.] 9. E✓ Demolition 30 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 5.0 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.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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. :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:TRAVELERS Policy#or Self-ins.Lic.#:6HUB1 K24420419 Expiration Date:03/15/2020 Job Site Address:590-604 RTE 28, WEST YARMOUTH, MA City/State/Zip:02673 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: /Zg/LO/ Phone#:508.619.6073 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 1.Uliiil Wii rf Ciiliii iil ti,u •su a.s+u..� c.-s felon Division of Professional Licensure Board of Building Regula:inn3 nrl_ta radar s ` �fl n Ctv=:i.+Ys1 i. Siloa}-ril!s _ 7i3:ir2020- tom..$v$.Fif)3'; %}j�ii25:lir rSv:cvc.�: JAN KVIETOW 32 LOCKWOOD DR SOUTH DENNiS,MA 0266G • r► T Commissioner L- - _ CQr,smner Affairs&Business Regulation - HOME{MPROVEMENT CONTRACTOR TYPE:Corbcation Reaistra..o• Expir. ion TATRA BUlLDINC GONiPiWi NC- JAN.••i-O.. \ • 775 lTE 28 SUITE H 'tV CJ i•C;Gi\irtii:.,. Ui ideisa.:-E—m;)' rdV valid for individual u5o,•' :, to. Registration :ration date. if found re ' before the exia ncnBr Affairs and business Ae9ulatlan Office of Caa_Suite 517u '. 10 Park Plat 6211s • aosti,n,MA Not situ ' - A GRD DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 03/15/19 ' 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 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 NAM NAME: JIM HINDMAN FAX PHONE 508-771-8381 (A/C,No): 508-771-0663 Schlegel&Schlegel Ins Broker (A/C NL.E><tr 34 Main Street ADDREss: schlegelinsurance@gmail.com West Yarmouth,MA 02673 INSURER(S)AFFORDING COVERAGE NAIL# INSURERA: NGM INSURANCE INSURED INSURER B: TRAVELERS . TATRA BUILDING CO INC INSURER C: 775 RT 28 SUITE H INSURER D: WEST DENNIS,MA 02670 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 ADDL aUBR POLICY EFF POLICY EXPLIR LIMITS • TYPE OF INSURANCE INSD WVfZ POLICY NUMBER jMMIDDIYYYYJ�jMMIDD/YYYY) , EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL UABIUTY DAMAGE TO RENTED PREMISES(Ea occurrence) $ 500,000 ICLAIMS MADE OCCUR MED EXP(My one person) $ 10,000 A MPT7810M 03/19/19 03/19/20 PERSONAL S ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: 2,000,000 EC I f PRODUCTS-COMP/OP AGG $ POLICY !LOC $ OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE UABIUTY (Ea accident) BODILY INJURY(Per person) $ ANY AUTO '— OWNED —SCHEDULED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS PROPERTY DAMAGE $ HIRED (Per accident) AUTOS ONLY AUTOS ONLY S UMBRELLA UAB I OCCUR EACH OCCURRENCE -$ EXCESS UAB CLAIMS-MADE AGGREGATE S DED I I RETENTIONS $ WORKERS COMPENSATION I S ATUTE I I ERR- AND EMPLOYERS LIABILITY E.L_EACH ACCIDENT $ 100,000 ANY PROPRIETORIPARTNER/EXECUTNE Y I N NIA 6HUB1 K24420419 03/15119 03/15/20 100,000 B (Mandatory in NH) EXCLUDED? EL DISEASE-EA EMPLOYEE $ (Mandatory in NH) 500,000 If es describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CORPORATE OFFICERS HAVE ELECTED TO BE COVERED UNDER THEIR CURRENT WORKERS COMP POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF YARMOUTH BUILDING DEPARTMENT YARMOUTH MA AUTHORIZED REPRESENTATIVE 1 ©19:r ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of A - D