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HomeMy WebLinkAboutBld-20-003063 1.Y� i O I. permit# �, �. • ` i ( Amount •cr,"" e .�d � ) --a 0— 300 ;Permit expires 180 days from :i issue date EXPRES BUILDING PERMIT APPLICATION TOWN OF YARMOUTH :l `.. Yarmouth Building Department ,_, ti 1146 Route 28 IC-4 1/8 South Yarmouth, MA 02664 C (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: V? 5 Stjk.1 1 Dote O 'e Uitit z1 SIMitimitti MA 02664- ASSESSOR'S INFORMATION: Map' I Parcel: OWNER: .AAVIO' itOORPIY1 �t� . �` CI PRESENT ADDRESS � TEL. 50Sgill Wv CONTRACTOR: CsJ F��1�� �4 C�'66/' r7 NAN MAILING ADD 4 TEL. r O Residential C Commercial Est.Cost of Construction /$ rrJ (�p�0 Home Improvement Contractor Lic.# 1 Construction Supervisor Lic.# C�"D04' 16 Workman's Compensation Insurance: (check o e) 17 I am the homeowner I am the ole proprietor tarhave Worker's Compensation Insurance Insurance Company Name: 3 V 552— Worker's Comp.Policy* WCVOI 4506°0 WORK TO BE PERFORMED Tent Duration Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares placement windows:# 1 Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Di t. ( )Replacing like for like Pool fencing 'The debris will be disposed of at: ,,,,,,Air.,(4 O( 1}r. ' - 4,q21, •• tion of Facility I declare under penalties of.-, the . en 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 o i 4;. . my li and for prosecution under M.G.L.Ch.268,Section 1 Applicant's Signature: 414a.. Date: ituno 25 i_Olq Owners Signature(or attachment) O7/e- / 315 r^f J _ ! Date: I I c Approved By: : rrW Date: //a Build._ ,/ or.-igneG) E,4t: t • 'DRESS: Zoning District: Historical District: 2 Yes 2 No Flood Plain Zone: Yes : No Water Resource Protection District: Within 100 ft.of Wetlands: 7 Yes 2.1 No 2 Yes 2 No , T e Commonwealth of Massachusetts el of Industrial Accidents ? i 1 Congress Street, Suite 100 i _M • Boston, MA 02114-2017 ,...rs� www.mass.gov/dia Workers' Compensation Jnsurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print L ibly Name (BusinesslOrEtartizationflndividual): i C oil Address: 6 2s1 City/State/Zip: S 5 9FRP)()Ltall � ©� Phone ,-#:. � �g 06'7 i Are you an employer?Check the appropriate boa: Type of project(required): • i_XI am a employer with i employees(, :l and/or part-time).* 7. E New construction 2.7 1 am a sore proprietor or partnership and have a employees working forme in 8. , 'Remodeling any casoie p pri workers'comp.insurance . l a I • 3 ; 11 I am a homeowner doingall work:myself f]V 9. ❑ Demolition workers'comp.insurance required.]r 4.2 I am a homeowner and wi:i be hiring contac• rs to conduct al:work on my property I will ! 10 r Building addition l — ensure that all contractors either have workers compensation insurance or are sole 11.U Electrical repairs or additions proprietors with no employees. 1 l 12.0 Plumbing repairs or additions s.ri I am a general contractor and I have hued the�,ib-contactors listed on the axached sheet. i 13, Roof repairs These sub-contractors have employees and have workers'comp.insurance.: o. We are a corporation and its c`fictts have exercised t+e>a ri .of I 14.E Other ' exception per MG:,c. :52,i 1(4).and we have no employees. [No workers'camp.insurance required.] 'Any applicant that checks box 41 must also fill out the section below showingtheir workers'co hapensaion policy information. Homeowners who submit this affidavit indicating:boy are doing all work and then hire outside contactors must submit a new affidavit indicatir:g such. :Contractors that check this box must attached an addrtior.al sheet showing the name of the sub-contractors and sone whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'camp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ` Cititalt1146 CP Cow Insurance Company Name: `t P��� Policy:4'or Self ins. Lic.>r: We V 0 Y 45 O Expiration Date: q 3\20zil Job Site Address: 1 J7 -�7uth C Øp city'State/Zip;Mf I A026610- ®Z 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 51,500.00 andior one-year ink. 'sorment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the of-t•r.A copy of this statement may be forwarded to the Office of Investigations of the DR for insurance coverage veri, a•'on. I do hereby •*fi u der the pains and penalties of perjury that the information provided bove is true and correct. Signature: " WI Date: O c 20 rq, Phone#: /OW cog O b� O6 7 Official use only. Do not write in this trea,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 3. Plumbing Inspector 6.Other Contact Person: Phone*: A CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 05/22/2019 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 00906-001 kwiecT McShea Insurance Agency rii8N o,E,rt): (508)420-9011 fic.No.: 1645 Falmouth Road,Rt 28-Suite 2 Edo . Centerville,MA 02632 INSURERS)AFFORDING COVERAGE NAIC# INSURER A: Atlantic Charter Insurance Company VDAC 44326 INSURED HOPKINS CORP INSURERS: INSURER C: 311 Paddocks Path INSURER D Dennis,MA 02638 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. ILTR TYPE OF INSURANCE WOW POLICY NUMBER (M Lo'8YYX) (MEW) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES(Ea occurrence) $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- 1--- OC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DEED RETENTION $ ApDKMpOIS7L% X TO g IU S TH $ OER A arozgg 1k�� P j�F��/��CECUTIVE Y I N N/A WCV01450000 4/23/2019 04/23/2020 E.L.EACH ACCIDENT $ 500,000.00 (Mandatory iin�NH) Policy Coverage State:MA E.L.DISEASE-EA EMPLOYEE $ 500,000.00 DCCRIPTION egg PERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Building Department BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY 1146 Route 28 WILL ENDEAVOR TO MAIL NOTICE WILL BE DELIVERED IN South Yarmouth,MA 02664 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE •`il��l�/'��"� ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD CERTIFICATE HOLDER COPY ACORO® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 05/22/2019 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: Sharon Covino McShea Insurance Agency,Inc FAX lac No,Ext): (508)420-9011 talc,No):(508)420-9010 1645 Falmouth Road, Rt 28 BLDG D ADDRESS: sharon@mcsheainsurance.com Centerville, MA 02632 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: EVANSTON INSURED INSURER B Hopkins Corp INSURER C: 311 Paddocks Path INSURER D: Dennis, MA 02638 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 1 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 W LIMITS LTR INSD VD POLICY NUMBER (MM/DDIYYYYI (MMIDD/YYYY) A X COMMERCIAL GENERAL LIABILITY 3EV2552 04/25/2019 04/25/2020 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE I OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY rai LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY 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 UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers Comp Certificate to come directly from the carrier CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF YARMOUTH THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING SEPT AUTHORIZED PRESENTATIVE (SSC) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by SSC on May 22,2019 at 10:58AM Ca�rnonw•pro of MassaNw> Division of ProfKspnal Lie�nsun of BuiMIng R�Natlons and standards Conat {�` rviso etts . Cs I• 6 90 2 J I op CINs x, ,f fires:OIJpy2021 Mass.gov S.Y ou, MA a . • Commi loner „ it'_4yj4 _1 Offs ce ofConsume Affairs and Business Regulation (oCABR) • HIC Registration Complaints Registration# 171179 Registrant HOPKINS ENERGY CORP. Name NIALL HOPKINS Address 118 LAKEFIELD DR City, State Zip SOUTH YARMOUTH, MA 02664 Expiration Date 04/24/2 320 Complaints Details No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search Site Policies Contact Us