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HomeMy WebLinkAboutBld-20-003028 Office Use Only Of.Y.114 a it# D 0 lAmount N,, . t _%" wu '6rd Permit expires 180 days from ,►. issue date EXPRESS BUILDING PERMIT APPLICATION • TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 a 3 (508)398-2231 Ext. 1261 n r CONSTRUCTION ADDRESS: 3 9 � SOJ1L1 gar( Ot)J-A ASSESSOR'S INFORMATION: Map:/ A( Parcel: / OWNER: 6 f�C� C.t0 11,41W5 P OIJ. /L7c n 57tAct So X.,/ & —. 144 440 50i'?`7.7d+�53 NAME 0 PRESENT ADDRESS TEL. # CONTRACTOR:04rvh, Au;Id,-, l, 20/11 Vale f So •y�H.�,,1�. /'1R Oa a 9 SO' 3')r •i d9 3 NAME )/1 y MAILING ADDRESS TEL.# ❑Residential hmmercial Est.Cost of Construction$ 000 Home Improvement Contractor Lic.# Construction Supervisor Lie.# 7/3 35 Workman's Compensation Insurance: (check one) I am the homeowner `�Li I am the sole proprietor I have Worker's Compensation Insurance G�Insurance Company Name: (JlL(Cif Worker's Comp.Policy# JC ao-35 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # 4 vod Roofing: #of Squares 7 (a()Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: /Vt-.1 r. Cl )q'Y-.J-k" OthA"jO 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 revoc n my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: f//Ol 5/i?c/" Owners Signature(or attachment) Date: ///e?5/ j 9 n Approved By: G J. Date: //=G 5 > il ' fficial( r designee) IL ADDRESS: Zoning District: Historical District: Yes ;...1 No Flood Plain Zone: 2 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: TE Yes :.- No i= Yes ❑ No Ni 0 : e a y « 3\ §¥ G»\ ` In a, © 3 : 2 G' \ Viz \ _«\ \ ^ & a ;5 } d&Ry, LLI }fa ) � z$ ( £}{ = %� a # 5 / 24 _ ± _ ` \ / iƒJ7 ��a . \ z /»J , \¢& ' oc$ « z _ \\\ � / + u ` oe ° 5S_< I o o Q §a2 / \ ^ / / ( ! t;ommonweaitn or Massacnusetts �; Division of Professional Licensure Board of Building Regulations and Standards • Constr ctibri Supervisor • CS-113356 Expires 05/08/2022 CHRISTIAN EDAVENPORT 20 NORTH MAIN ST 7 t ; SOUTH YARMOUTH MA 02664 ' Commissioner //A n II?/J/nrvmF-, r �741.1404ff.u1//i Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 106024 07/20/2020 1000 Washington Street -Suite 710 DAVENPORT BUILDING CO.TRUST Boston,MA 02118 CHRISTIAN DAVENPORT 46/6 20 NORTH MAIN STREET 1 a' (zelo..4" SOUTH YARMOUTH,MA 02664 Undersecretary Not valid without signature • DAVEREA-01 NCANUSO ,ACOR[J CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) `"� 02/11/2019 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 CONTACT NAME: Valley Forge Captive Advisors AHONN, (610)458-3659 FAX 630 Freedom Business Center Drive ( Ext): (A/c,No):(484)965-9627 Suite 203 E-MAIL ADDRESS: King Of Prussia,PA 19406 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Zurich American Insurance Company 16535 INSURED INSURER B: Davenport Building Co INSURER C: c/o Davenport Realty Trust 20 North Main Street INSURER D: South Yarmouth,MA 02664 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 VNTH 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 SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE -INSD WVD POLICY NUMBER A X COMMERCIAL GENERAL LIABILITY 1MM/DDM'YYL(MMIDD/YL'YY1 LIMITS EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR GL08196255 03/01/2019 03/01/2020 DAMAGE TO RENTED 1,000,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 1,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JE Q LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: _ A COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea accident) $ 1,000,000 X ANY AUTO BAP8196256 03/01/2019 03/01/2020 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY _ AUTOS BODILY INJURY(Per accident)_ $ _ AUTOS ONLY _ NON-OWNED ONLDY PROPERTY)AMAGE (Per accident) $ _ _ $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ _ $ A WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE WC8196035 03/01/2019 03/01/2020 1,000,000 OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory in NH) 1,000,000 If yes,describe under E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below _ E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/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 Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ... "FiW"‘ ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • The Commonwealth of Massachusetts Department oflndustrialAccidents e I Congress Street,Suite 100 =i t if—= ' 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 D Please Print Legibly Name (Business/Organization/Individual): ;Rn }- �j�,ic(,n t (—_�.4.-y Address:dp f'l&o /1'4:^ r.µ+ City/State/Zip: -yWy►-+ '-, I"4 CV,C.Ctif Phone#: 50(-3`1 fl- a2/93 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑1 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 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.coof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑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. 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: Z.r'ZL ArNei-i U.. 7aczktilPolicy#or Self-ins.Lic.#: INC�I q�d3S Expiration Date: / Job Site Address: 32:) D‘Vrt City/State/Zip:S M A c c 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: // A5/da/ Phone#: SDI • Ssg 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#: