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HomeMy WebLinkAboutBld-20-002792 Penni ftl y� j R Amount e6)0O•• ca tt 7+a(s 52 1 h Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION- ' TOWN OF YARMOUTH Yarmouth Building Department NH V I !in n 1146 Route 28 South Yarmouth, MA 02664 / (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 3!D b tV'a"n J'Q,{t�'jp J /'/4 oa6l�y ASSESSOR'S INFORMATION: /// ����"" Map: Parcel: OWNER: afACP bi 9 + L- is yn 4 -X41 SE 1R ADDRESS 77 4 ? 7 9 '/ '9 NAME V /�Il A CONTRACTOR: NAME Ca Q vG/10 (�hd r /� TEL. # AILM5G /V/ ADDRESS yOftficifri; 9 7C1 YQo 4419 Zesidential 3 Commercial Est.Cost of Construction$ 4 7/ 31f0 Home Improvement Contractor Lie.# /43 73(0 Construction Supervisor Lie.# C —1o/! Y? Workman's Compensation Insurance: (check one) 7 I am the homeowner `' I am the sole proprietor _le have Worker's Compensation Insurance /� Insurance Company Name: f� � .y�f/,(40 ��j{t/, , TN C. Worker's Comp. Policy# C( 6 02 vg if N via M/9 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 35 ( V }Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: t-A fil 071`414 LaN ififT-t -- i (.;(01 Lil L Location f Facility I declare under penalties of perj ••that the statements herein contained arc true and correct to the best of my knowledge and belief. 1 understand that any false answer(s) will be just cause for denial o . o'.Lion o' license and for prosecution under M,G.L.Ch.268,Section 1. Applicant's Signature: r lb./ ) / Date: ,44V /. 9 fq / Owners Signatu _/, aehment) \ Date: Approved By: �v/yr, _ Date: ,i,/i3 / t uilding Official(or designee) EMAIL ADDRESS: h Q Zoning District:_._ Historical District: Yes !: No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: ' Yes No Yes - No The Commonwealth of Massachusetts /, Department of Industrial Accidents M' �' %fl:= 1 Congress Street, Suite 100 _em � Boston, MA 02114-2017 www.mass ovv/dia orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Caie0, 4, ( th 'c 4'oi Address: /5 /Vttilfed City/State/Zip: ) *io4, & fif 0?75 Phone #: 97ir VQ4 G�19 Are you an employer?Check the appropriate box: Type of project(required): 1.❑1 am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑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. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp. insurance required.]t 10 ❑ Building addition 4.0 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. 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. ((11 in Insurance Company Name: A� bt ,l2t-;It yj i U.Z(V,t c,G ' • Policy#or Self-ins.Lic.#: 44 c2 U,j 1//(/9V/0?34/7 Expiration Date: g//7/aCaQ Job Site Address:_ 5/0 Pout/ L 2UA/ City/State/Zip: UOo j ye-0mA 414 (9.26,19g Attach a copy of the workers' compehiation 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 certi u der the pains and penalties of perjury that the information provided above is true and correct. Signature: ,J Date: A / /5 02o/9 Phone#: q 7g 7%a //9 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): I.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: • O 2) ■ 7k , 0 E c . $�zo . n o ` To . . o f §2 < z 3 ),UIO > o � . � i §§� k co 2 k$22 . . c« � © � km0 o_.0 ° ° ��© k :c' 1Iu �§-� . w l \(------ Z »� LH � $ :� ƒ . . f ƒ § § \ s� o ,, q1 = A Vol- r f0 cc< D• . \ 16,+ 205 . § . ■Qp �. 4 1-: : , m ez2,- 9» / \G k>L\: } \ «:, 7 (\ ' &< o \\, 2 §�-. ' (\ 'o oZI \ kw << ~<co k §_ _ƒ ƒ@I- ( z< /§k _.- Iz= §k §ef AcoRD CERTIFICATE OF LIABILITY INSURANCE I VAIC(MMIVVli TTT) 10/10/2019 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 CONTACT NAME: Melisha Colon AXIA INSURANCE SERVICES INC (A/C. EzfJ: (413)788-9000 FAX No): E-MAIL certificate@axiagroup.net 933 EAST COLUMBUS AVENUE INSURER(S)AFFORDING COVERAGE NAIC# SPRINGFIELD MA 01105 INSURERA: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: LCT CONSTRUCTION & SERVICES INC INSURERC: INSURER D: 4 EVERGREEN LANE INSURER E: HOPEDALE MA 01747 INSURER F: COVERAGES CERTIFICATE NUMBER: 459583 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 SUER POLICY EFF POLICY NUMBER (MM D//YYYY) (MM LICY EXP LTR INSD TYPE OF INSURANCE INSD WVD D //DD/YYYY) LIMITS LT COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ECOT- 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 AUTOS NON-OWNED PROPERTY DAMAGE (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY A OFFICER/MEMBER O EXC EXCLUDED?ECUTIVE N/A N/A N/A 6S62UB4N44123A19 08/17/2019 08/17/2020 E.L.EACH ACCIDENT $ 500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/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 CaNalIlO ConstructionACCORDANCE WITH THE POLICY PROVISIONS. 15 Newfield Lane AUTHORIZED REPRESENTATIVE Yarmouth Port MA 02675 Daniel M.Cro*ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ArORf 94/7nlA/l91 The AE ARr1 names and Innn ara ranic+ararl m2rkc of APARII ` 'I' ropoMat Page# of pages / \ 1214&/ r : Celit'VedA i rue....e /5 Ntee-feW ASP 7 o� "'err/ Ate. Oa6 7 5 ?r# 'ilo Olt PROPOSAL SUBMITTED T0� ` r b4'iqi 1 �y �I� 4ie / JOB NAME JOB# ADDRESS /ffj( •t I / _` "_' e JOB LOCATION 3/O W411 J6A, 0264, DATE DATE OF PLANS A A PHONE# �stiN , FAX# ARCHITECT /%%e hereby submit specifications and estimates for: ........... '.,,rif Sfat Ca‘vtts_t_4-e-4 ./ j{etrliAd /41f S444141,64) (661-let' f Ce2 66 le -4;4-e G ___ _ _ ____ _ ........ ..... �. _ems__ 14:11421,1' tie) 1:2-4P /eW jui 01 4-001 _G TAIt / n __L - s __. . J /%2 ,r pose hereby rnish mat 'al and labor—complete in accordance with the above specifications for the sum of: $ ( 5r lad _ , ���(((f '14 l OI Dollars with payments to be made as follows: _L+ � 14( ?Vj �j Any alteration or deviation from above specifications involving extra costs Respectfully 7Th will be executed only upon written order,and will become an extra charge submitted . over and above the estimate. All agreements contingent upon strikes, \accidents,or delays beyond our control. .'. Nbt —thisj roposal may be withdrawn by us if not accepted within days. / Rcceptante of il3r The above prices,specifications and Conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. - Payments will be made as outlined above.1pSignature Date of Acceptance 15/1,1eff � Signature A-NC3819/T-3850,09 11