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HomeMy WebLinkAboutBld-20-1673 . .`••+.....,-- *°_' ..' , . . i • 1 SEP 26 201S. .... usconly °;',. • '.. - ',.20 - I,C73 . ,.. , k• % . .04Pc.cl , /11) .., _. - .., An., /0--; • 1 . Panitt expires 130 days Born issue date ..... EXPRESS BUILDING PERMIT APPLICATION , TOWN OF YARMOUTH Yarmouth Building Department Z", l 1.46 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 gal , A CONSTRUCTION ADDRESS:, 1 51) AA. 9.0 S.C1 ASSESSOR'S INFORMATION: li • Map: 4-7 1 Parcel: 6 4 / gie,14,co g-151 44/4.33 OWNER: Stle.i SIVA; LOpi 1 o,1-0 13b f3144lellx+1 N Hi ti$142 fivt A 6 I 05 ettlitti 411S'43'11-lqi i NAME PRESENT ADDRESS TEL a 1141 263- 2// S CONTRACTOR: I-0Q i Kg, ?2()11A i it3 (On'24/1 1.114 ECtiph CI-, COrti di—d lvt tk-0 z G3 5 NAME MAILING ADDRESS TEL N XResidentlai 0 Commercial Est.Cost of Construction S it-2-j 700 . 0 0 I 7 ?(-01 Ls -Joct Pt 54 Home Improvement Contractor Lic,..0 Construction Supervisor Lic.,* Wm-bruin's Compensation Insurance: (check one) C tam the homeowner 7 I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: N 4.Olt CA I)PAO nil III tfilre..i YLS• t 0• Worker's Comp.Policy* Ni Ct V4 C.C1 20 6 0 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove ' Siding: #of Squares 30s ili Replacement windows:# 1-7 Replacement doors: # (47 ,g -Docie_, ti si.../DaZ Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old lams Righway/Historic Dist. ( )Replacing like for like Pool fencing rite debris sviil he disposed dot . Dante(S 9.tia3c.liN Location of FaciffiS 1 declare under penalties of perjury that the statements herein contained arc true and correct to the best am knoyiietige and belief I understand that any false answer(s) will be just cause fur denial or ' license and for prosecution under tvl,G.I. Ch 268,Section 1. Applicant's Signature: ..--- ,,,, /_ Dols: o-11/0 di 9 >60erners Sigstatnre(or ausehment) — 7P. .i /,/ Date: ''7,,ft '-- / :1 Approved By: /- Data --", .--//1. Buil . gnee) Zoning District: District: Historical District: 7.: Yes 7 No Flood Plain Zone: C Yes - No ' . Water Resource Protection District: Within 100 ft.of Wetlands: Yes L' No D Yes C No The Commonwealth of Massachusetts ►g_ ft Department of Industrial Accidents —_::el 1 Congress Street,Suite 100 =A�_ Boston, MA 02114-2017 vz, www.mass aov/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): TU\eiK0.. 60t61-03 CO&1 V� Address: NN "EQ'�Uh C4-• / City/State/Zip: Co'Knl l M/t 6Z83C- Phone#: 5° '-(95 S"&685" Are you an employer?Check the appropriate box: Type of project(required): 1.r' am a employer with 18 employees(full and/or part-time).* 7. New construction 2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself. r 9. ❑Demolition ❑ ys [No workers'comp.insurance required.] 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.❑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.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§I(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. 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: t\ ( Ll 'I )11 tfre, tn5u nce_ (a Policy#or Self-ins.Lic.#: va N C.Oci 20(o O Expiration Date: 2-I Flo 120 Job Site Address: City/State/Zip: 10411(JtI ►11 m0,02 Attach a copy of the workers'compensation policy declaration page(showing the policy nu ber 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 cer;fy under the pains and penalties of perjury that the information provided above is true and correct Signature: G/��l.I/as y Date: ! / 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#: (294 Wo/1-ivin0t€OeCta ? lkidetCreAltdee4 Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Ma8chusetts 02118 Home improvementContractor Registration Type Corporation , Registration: 188661 TULEIKA BUILDING COMPANY INC Expiration: 08/17/2021 44 EATON CT .4„.;„ carurr,MA 02635 " rlt Update Address and Return Card. SCA 1 204,05117 )4 fomirtv,woralid c "/fa:Ja1l/wd/4 Office at Consumer Matra Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Ccooration before the expiration date. It found return to: thaistration Esokition Office of Consumer Affairs and Business Regulation 188861 08/17/2021 1000 Washington Street -Suite 710 TULEIKA BUILDING COMPANY WC Boston,MA 02110 VIKTAR V TULEIKA 44 EATON CT e;e,....sea COTUIT,MA 02635 ot voi4710-'-disignoture Undersecretary s�co CERTIFICATE OF LIABILITY INSURANCE DTE(MWDD"Y") ‘......--e' I 03/25/2019 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 POLICIF-S 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 statenient on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Robert Monahan NAME: C&S Insurance Agency,Inc. • IA/C. l Ent). (508)339-2951 FAX( Not 339-4811 No.190 Chauncy Street/P.O Box 406 E-MAIL sg: INSURER(S)AFFORDING COVERAGE NAIC I Mansfield MA 02048 INSURER A: National Liability&Fire Insurance Co INSURED _INSURER B: Tuleika Building Company,Inc. INSURER C: 44 Eaton Ct. INSURER D: INSURER E: Cotuit MA 02635 INSURER F: COVERAGES CERTIFICATE NUMBER: Workers Camp 19-20 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 ADOLZuBR TYPE OF INSURANCE INSD O POUCY NUMBER (MMMI CY EFF POLICY EXP LL1R 'MVO (MMIDD/YYYY) , UNITS COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE S DAMAGE TO CLAIMS-MADE 0 OCCUR PREMISES(EaENTED occommae) S I MED EXP(Any one Person) $ PERSONAL&ADV INJURY S - GEM.AGGREGATE UMITAPPUES PER: GENERAL AGGREGATE jE�TSI POUCY� �LOC PRODUCTS-COMP/OPAGG S OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT f (Ea accident) - ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) $ UMBRELLA UAB OCCUR EACH OCCURRENCE S - - EXCESS UAB CLAIMS-MADE AGGREGATE i DED I I RETENTION S $ WORKERS COMPENSATION s./I PER OTH- AND EMPLOYERS'UABIUTY YIN o'''I STATUTE ER A ANY PROPRIETOR/PARTNER/EXECUTIVE El NIA V9WC092060 02/16/2019 02/16/2020 E.L.EACH ACCIDENT $ 1,000.000 (Mandatory OFFICER/MEMBER EXCLUDED') 1 000 D00 (Mandatory b NH) E.L DISEASE-EA EMPLOYEE S If yes, DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE /� A MA 02601 JIC�je,{ (, a...y 1 ,\ ©1988-2015 ACORD CORPORATION. fJI rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ,.z og Itkae 4 r$ , ..•its *, 0 Cl) • , 6 .. . ta) 1:13 ' ' 0 .4. 0 0 t iiiraim 0:0 rg 3 11.11111 lor-4 M gall toil 41111111h riml g2. Ci 0 3 _ awl MI ail* an II 3 -if 0 0 co (4. 3 * v) . g z 0 c 0 0 7:a 0 ailli aft" slat ,1,04., 0 M .104 ,... ....„ z: Am*, mos mom .. ‘ \„) i c- ., -ICI t AM 0 .. , ow% miLi "elm V) (13tviU 1.1" C 041 r** 0 .., ....I NM I co dr, et9 in NIP ,...*--. ,,t,_ V),oil s'411171;404 a fp C k )1‘,114 0 vi cf) 0 m ..., .... 0., • 4.) mit m m (,) = ao fA) Ho •I 4- 11410 CI t, ,'",,.., loft*** 0 .47'* ' i' ',i,''', ha . 0 ‘1 I 1"0 1 lik lisa C,) 1%4 ..,4 • L .