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HomeMy WebLinkAboutBld-20-002724 74)1/4 ht# 1 Cf(,I� Permit expires 6 months fromes-j 'r MAttA �'w.e.utew �� •rssu date. �. I EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department '' 1- � 1146 Route 28 South Yarmouth, MA 02664 1 NA ' 3 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: g h►.1i{'( - w` Cl-. , • i�; �p -�- . '-- ASSESSOR'S INFORMATION: Map: Parcel: OWNER: -SO4 kAA-- 3 C1 ''L) b ' t/ /lv NAME / �j� PRESENT ADDRESS TEL # ,/ 'G CONTRACTOR 3Yii l'ei �eciee I7U/VS" 7 7 z( `7 e7 o]�.3 7 NAME MAILING ADDRESS TEL# co Residential ❑Commercial ❑Est.Cost of Construction$ ZV0D 4/6M0 Home Improvement Contractor Lic.# 1 2-9 Z 7 C -0?1-'2-u pConstruction Supervisor Lic.# Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# T1 rP\ � �- eo„t) �� eQIerc e � Remove RPRi)a — Rge� Te 4+��i cr J ^ WORK T BE PERFORMED ' 0 Tent (Fire Retardant Certificate attached) ❑Wood Stove Shed 0 Siding: #of Squares 0 Replacement windows:# f 0 Replacement doors: # • TP4(• keia1 me /4.0 r ❑Re-roof #of Squares 0 Insulation oSS • ()Stripping old shingles* ()going over layers of existing roof 0 Old Kings Highway/Historic District Roofing/Siding(Like for Like) *The debris will be disposed of at: Yita-0110%-144k %s p OS h \ • t eik • 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 loor�revvocation of my license and for prosecution under M.G.L Ch.268,Section 1. f Applicant's Signature: v Date: 5�W�i Owners Signature(or attachment) kT'TWC t & Date: Approved By: .G s Date: Bnilding Official(or designee) Zoning District Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District Within 100 ft,of Wetlands: ❑ Yes ❑ No ❑ Yes ❑ No 3/0I AC WHALRES-01 PDETRAGLIA `,....---- CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDD/YYYY) 11/6/2019 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(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 License#1780862 ACT HUB International New England NPHOMNEE 265 Orleans Road (nrc,No,Ext):(508)945-0446 I FAX No):(508)945-9136 North Chatham,MA 02650tiEss: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Philadelphia Indemnity Insurance Company 18058 INSURED INSURER B: Whalen Restoration Services Inc. Whalen Services Inc. INSURERC: 22 American Way INSURER 0: South Dennis,MA 02660 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. INSR ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER IMMIDD/YYYY) (MM/DD/YYYYI LIMITS A X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PPK1960640 DAMAGE TO RENTED 4/1/2019 4/1/2020 pREMISES():aoecirrence) $ 100,000 MED EXP(Any one parson) $ 5,000 PERSONAL&AOV INJURY $ 1,000,000 GENTAGGREGATE LIMB APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY I J jia LOC 2r 000,000 PRODUCTS-COMP/OP AGG $ OTHER: A $ AUTOMOBILE LIABILITY MBINdEeD SINGLE LIMIT $ ANY AUTO PHPK1960653 OWNED SCHEDULED 4/1/2019 4/1/2020 BODILY INJURY(Per person) $ AUTOS�g�� ONLY X AUTOS y��Ep BODILY INJURY(Per accident) $ 1,000,000 X AUTOS ONLY X AUTt'�S ONLY (Pe=AMAGE $ A X UMBRELLA LIAB X OCCUR $ EACH OCCURRENCE $ 1,000,000 EXCESS[JAB CLAIMS-MADE PUB669684 4/1/2019 4/1/2020 AGGREGATE $ DED X RETENTIONS 10,000 $ 1,000,000 WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STATUTE ERµ ��pFI�PPEWMEIMEE��PROPRIETOR/PARTNER/EXECUTIVE ECUTIVE Y!N N/A E.L.EACH ACCIDENT $ (Mandatory In NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Pollution/Environm PPK1960627 4/5/2019 4/6/2020 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Joshua Dejole&Hillary Hutchinson THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 8 Captain Daniel Road ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE 1 ?99;1*. - ACORD 26(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD '�ORC® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/06/2019 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: Patricia Detraglia HUB INTERNATIONAL NEW ENGLAND LLC PHONE/ Exth (508)945-0446 FAX No): ADDRESS: patricia.detraglia©hubintemational.com 600 LONGWATER DRIVE INSURER(S)AFFORDING COVERAGE NAIC# NORWELL MA 02061 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: WHALEN RESTORATION SERVICES INC INSURERC: INSURER D 22 AMERICAN WAY INSURER E: SOUTH DENNIS MA 02660 INSURER F: COVERAGES CERTIFICATE NUMBER: 470124 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. IIH, TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JET 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) $ NON-OWNED PROPERTY HIRED AUTOS DAMAGE _ AUTOS $ (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION _ AND EMPLOYERS'LIABILITY Y/N X PER ERH A OFFICER/MEMBERANETOR/PXCLUDED ECUTIVE I NIA, NIA NIA 6S62UB5B89454219 04/01/2019 04/01/2020 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more apace 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/iinvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Joshua Dejoie & Hillary Hutchinson ACCORDANCE WITH THE POLICY PROVISIONS. 8 Captain Daniel Road AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 �-=I" ! ( Daniel M.Crq rn y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Restoration Services Inc. iy/ Fire,Smoke, Soot,Water Damage&Mold Remediation Services Cleaning • Deodorization • Reconstruction Specializing in Fire Restoration -All Work Guaranteed Access, Authorization and Direct Payment Request Form I (we) authorize WHALEN RESTORATION SERVICES to perform work as per estimate at property located at 8 Captain Daniel Road, South Yarmouth, MA 02664 . to repair damage caused by fire on 11/1/19 . As owner(s) of this property, I (we) understand that I (we) must authorize this work. I (we) hereby authorize WHALEN RESTORATION SERVICES to perform this work and accept responsibility for payment upon completion. I (we) authorize and direct my Insurance Company Danbury Claim i#c92994 Policy No. R5222549 , to make payments directly to WHALEN RESTORATION SERVICES, Insurance Claim Specialists, for doing this work and to that extent I (we) assign the benefits applicable to this loss to WHALEN RESTORATION SERVICES. I (we) acknowledge receipt of a copy hereof: t o R OWNER DATED 'AI_ OWNER HAL N RESTORATION REP. SIGNED 22 American Way,South Dennis,MA 02660 Phone: (508)760-1911 • Fax: (508)760-9995 • 1-800-244-2598 •E-Mail:restore@whalenrestorations.com Web Page:http://www.whalenrestorations.com OFFICE COPY=WHITE CUSTOMER COPY=YELLOW The Commonwearith ofMatnsachusells F{i Department gfhtdusb*,IAecfdenis 1 Omgram Street,Snits 100 Boston,MA 02114-2017 ^� 4 wwounassigo&dda Workers°Compensation Insurance Affidavit:Builders/Contractors/Etec[ridens/Plumbers. TO BE FILED WITOT THE PrIddiTING AUTHORrr'Y. Anuiicant Intbrmation Please?Apt Lealbly Milan(Basinsss/Orgeaimdonllndividuat): Whalen Restoration Services Address: 22 American Way City/State/Zip: South Dennis, MA 02660 photle#: 508 760 1911 Are you an employer!Check the appropriate ham TLap am a ampioyar with 2 5 employees(fish andtorpart time)* 7 of Newpr consject suctidred); 7. ® cansttttatioa 2,®Imna sole proprietoror partnership and have no employees workios for arein B. ®Remodeling any capaci y.[No wham'comp.inaanmce required.] 3.0i sma homeavmm dokid all work myseM[No workers'comp.insurance required.]t 9. ®Demolition - 4.01 am a homeowner ses win be bides eontramoreto seedcateli work onm many. eny. I wal 10❑Building addition enaaretbetall contreetote either have workers'compensation insurance atom sole 11.®ElecttIcal repairs or additions . wagon with no employees. 12.0Plumbing repairs or additions sa I am a general ennaaetar and I have hired the ettb•conbmetors listed on the attached sheet Those eub.canirecfots have employees and have workens'cosap insurance.: 13.0Roofrepeirss 6®We are aemoted=and its oifim have exeroisel their right ofexemption per M©La 14 • or i�fh�� 152,flea endwo have no employees.[No warble'comp insmumce required.] 'Anyapplicantthataheoks box fit must also fill outthes etionbelowshowiegtheirworkers'conwadonpolicyinformation. tRemeowrtsm ate submit this affidavit indicating limy ore do work and thenblxn ouWd.eonim0rors aunt submit anewafQdavh indicating sob, 'Commas boxmustattaohedan additional sheet showing the name oftbe aub•conhmatomand state whether or not those entities lave eansloyees.Mho subcontractors have employees,they muat provide thalr workers'wrap.policy number, lam an employer math providing workers'conlpensu ion insuraneejormy employees. Below is the policy andjob she irijbrmadon lnsuta:toecompagyName: Ace American Insurance Company Policy#or Self-ins.Lis.#: 6S62UB5B89454219> 4/i/20 Expiration Date: , lob Site Address; 1 I� City/State/Zip: S a�� L� Attach.*copy of the re'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MOL e.152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisomnent,as well as civil penalties in the form of a STOP WORK ORDER arid a fine ofupto$250.00 a day against the violator.A copy ofthis statement may be forwarded to the Office ofInvestigations ofthe DIA for insurance coverage verification. 8do hereby Gerdy under Ike pubs andpmmltles gfperjuiy Thathelnmattonprovlded above Is trueand eorre` Signature: Date: 6 kid 1/ /7' Phone#: 77y WS;7 01'37 • - Official useonyy Do notwrlte in this area,to be completed Lya ►or town gtfficleL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Banding Department 2.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: _ = Commonwealth of Massachusetts Division of Professional Licensure ✓�� ��t../ev 14'�rl/o /47446,l.,,Je/ Board of Building Regulations and Standards Office of Consumer Affairs&Business Regulation Constrl.i.CtiQn-SUperilsor HOME IMPROVEMENT CONTRACTOR TYPE:Corporation Registration EExpirationC5-074928 Eptres 08(10/2020 -- 129244 07/29/2021 -,^ WHALEN RESTORATION SERVICES INC. WILLIAM WHALEN 122 POND STREET BREWSTER MA,02631 W ILLIAM WHALEN 22 AMERICAN WAY • SOUTH DENNIS,MA 02660 Undersecretary Commissioner • Regib(i atlon valid for individual use only Construction Supervisor before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Unrestricted-Buildings of any use group which contain 10 Park Plaza-Suite 5170 less than 35,000 cubic feet(991 cubic meters)of enclosed Boston,MA 02116 • space. Not valid without signature Failure to possess a current edition of th4Massachusetts State Building Code is cause for revocation of this license_ For information about this license Call(617)727-3200 or visit www.mass.govtdpl of cirf-9R,, TOWN OF YARMOUTH BUILDING DEPARTMENT O . 1• - y1\'I 1146 Route 28,South Yarmouth, A 02664 •?ss):t ;Ye:: 508-398-2231 ext. 1261 Fax 508-398-0836 BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR,Chapter 1, Section 111.5, I hereby certify that the debris resultingfrom the proposed work/demolition to be conducted at 84tu1d' Da A`"e(/ itt Work Address Is to be disposed of at the following location: /11171414'(/14 - Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. ‘10/if Signature of Application Date Permit No. Main Level 64'8" 15'7" — 13'9" Dining Room M Kitchen,Bath,Hall&Bedrooms 0 es) Garage 0 N L 19'8" _ I. I 00 19'4" r N N FFFF4-rEb 1JA 11 0 Breezeway R EM o ki a Y F-D - Living Room `' '" 1-Ette_ Sut Tivnl� I 30' '4 14'4" 34'8" I e cAVcAiNi -DA-m E( DE DIE, Main Level DEJOI-SKETCH 11/7/2019 Page: 2 Main Level 64'8" 1 15'7" — 13'9" i_ 34' L t Dining Room M Kitch n,Bath,Hall&B,drooms 0 0 kr N Garage 19'8" I mow.. 19'4" - N N D d FIRE- e-CiEtlE➢ 1 o WALL Breezeway El REW\ovEb BV F-D- Living Room M M Ti`t+lP• ZaS41IM`lOt4 30' (11 I �- 14'4" r i 34'8„ , g L`_.tic17Tfl i 1N( 1) \I I E 1 r !\/lain Level DEJOI-SKETCH 11/7/2019 Page: 2 Main Level 64'8" 15'7" 13'9" 34' 1. Dining Room M ±Kiten,Bath,Hall&E edrooms ~ 0 4 0 N Garage N 198 � e ►- 19'4" -. N N f-iRe eifeLFE P 0 Breezeway "�`� Q V�A t.L —) Living Room i"-- '" in in REKMIED B`I E.iD 30' I 14'4" t' i 34'8" ' 8 C UT- 1\\ I I) -P\ I E L K _K. 1 D E T b i Main Le,Li DEJOI-SKETCH 11/7/2019 Page: 2 .:,,' IMINIZI, ,... 114 _ s ` ma r `-1.- " )4 .: � r 3s — : sL t S _,_:' a .,b,;np, ALL, f - x T - St t 3z a ,c"n,. :sr s J t 1 1. ,r S f .-- � g 2` - �w / E 5. 2 5 n ��1N -.a"E: f"tv..12.0:,_,,,,-4 4.,.,7:f.„6f.,.-.,1*i ram" -...