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HomeMy WebLinkAboutBld-20-000972 Office Use Only 0:iY• . 4- • ;Permit# l,.r i!.. �` a s+!<'yrg C (,3L Ql \► H =Amount u� 1. _ Permit expires 180 days from =: ------'-'-'-*,it:-::"... 13L1)— vy91 Z '_-. `.issue date EXPRESS BUILDING PERMIT APPLICATI ] 1 TOWN OF YARMOUTH AUG 22 2019 9 Yarmouth Building Department I L_ _ 1 1146 Route 28 j 3 u iT . , , South Yarmouth, MA 02664 (508)�3398-2231 Ext. 1261 �J CONSTRUCTION ADDRESS: �8 / CAL )5/2b, ( PDC/ / `- 4444 ,7 4_ ASSESSOR'S INFORMATION: Map: Parcel: OWNER: V42- 1 ' e Kr,fit-e— Fr to cc-,` so m-e. NAME � I PRESENT ADDRESS TEL. # CONTRACTOR: �d4eJ Yli Ac't-t_ 0 u /c '�/�\ 5-a a a-o-/"79 q NAME MAILING ADDRESS TEL.# 4.esidential ❑Commercial Est.Cost of Construction$ 0 D O Home Improvement Contractor Lic.# f I 2 tiConstruction Supervisor Lic.# //l 3 Workman's Compensation Insurance: (check one) D•I am the homeowner ❑ I am the sole propri or tiZave Worker's Compensation Insurance Insurance Company Name: t/(! Worker's Comp.Policy# WC S:3(-- O / S66?"af '5 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # 3 Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 'I e fOv-®c, i A CA ---" ocation of Facility I declare under penalties of perjury that the ents herein c ' ed 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 revo tion o y license and r cution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date:V2-2 �! 3 Owners Signature(or attic t) Date: Off2 2 2o/J Approved By: ( ` Date: W.- �, Building Dfficial(or design EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 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 oflndustrialAccidents _Aela 1 Congress Street, Suite 100 Boston, MA 02114-2017 �5.• 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): Gr l J j�-��j1.t_/'�-to e,��� Address: W L 6 <�p /�C ee- City/State/Zip: /Yef-1510P /Yr/i Phone #: L8�2�?CD /9-.54 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 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.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑ Demolition 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.D 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.insurances 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.7 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: Policy#or Self-ins.Lic.#: 3IS / 6'7 p/� Expiration Date: 2 /ii,,/l. .)20Job Site Address: �/ / t 'i.0 ic City/State/Zip: Y- e LeS/ 4 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: 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 CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: / ., • I. I 'f, I I c. Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards • , i Const�aLtctjfr�ljSrvisor. .•.,• • CS-111305 'I1 Eoires• 06/01%2021 ANDRE YARMALOVICNI{ j .. V � 204 CINDERELLO TERRACE • MARSTONS MILLS'MA 02648 ��' 'ii.' I�'Ititi 1 1�,1�J 1 V'�Commissioner , i P sxrxarrie�ec/f%a�CY�L/auar�ude/!a , Office of Consumer Affairs&Busines Regulation. HOME IMPROVEMENT CONT" ,CTOR . TYPE;Individual RegIstratioil., •t , 1724•76. 07 r 020 • II ANDREI YARMALOUI . 1 • f D/B/A BEL ISLANDS ;O IMPR• ENT 1 i ANDREI YARMAL�s VICH':t i f 204 CINDERS TAR. MARSTONS MIL S,MA i�'•48 Undersecre I II • ' 1 l A`0 CERTIFICATE OF LIABILITY INSURANCE DATE 3/26/20� 1D 9 Y) 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(les)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 BRYDEN&SULLIVAN INS CONTACT 88 FALMOUTH RD AiCC.o. is INC.F No): HYANNIS, MA 02601 E-MAIL ADDRESS: INSURERIS)AFFORDING COVERAGE NAIC • INSURER A: LM Insurance Corporation 33600 INSURED INSURER S: • BEL ISLANDS HOME IMPROVEMENT LLC INSURER c: 204 CINDERELLA TERRACE MARSTONS MILLS MA 02648 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 47733064 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. iXP LT R TYPE OF INSURANCE ADD°SUER POUCY NUMBER (MMUOIDOIYYY ► IMMMIDFF D/YYY ) UMITS LTR IN30 WVD COMMERCIAL GENERALL.IABIUTY EACH OCCURRENCE S CLAIMS-MADE OCCUR DAMAGE TO REN rED-- PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY S GENT.AGGREGATE UMIT APPUES PER: GENERAL AGGREGATE $ POUCY JECT PRO LOC PRODUCTS-COMP/OP AGG $ OTHER: S AUTOMOBILEUABIUTY COMBINED SINGLE OMIT S _ (Ea accident) ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) S _ 7HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY _ AUTOS ONLY (Per accident) $ UMBRELLA UAB _ OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE S DED I RETENTIONS S A WORKERS COMPENSATION WC5-31 S-615667-019 2/11/2019 2/11/2020 �/ PER STATUTE OTH- • AND EMPLOYERS'UABIUTY ANYPROPRIETOR/PARTNER/EXECUTIVE ER Y7 N/A E. EACH ACCIDENT S 500000 OFFICER/MEMBEREXCLUDED? I ' (Mandatory In NH) E.L DISEASE-EA EMPLOYEE S 500000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY UMIT S 500000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION TOWN OF FALMOUTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 59 TOWN HALL SQUARE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN FALMOUTH MA 02540 ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE + ^ t Jon Smith .- � 45 `---? ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 47733064 I 1-615667 119-20 WC 1 n0270258 13/26/2019 3:57.58 PM (POT) I Page 1 of 1