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HomeMy WebLinkAboutBld-20-000937 (2) .Y - Office Use Only a .. 4O ..Permit#'si _ s 0 ' ''l.... .H Amount V r ? HA ., « 'x ��e�'ErdPermit expires 180 days from ff bD.h /g 37 tissue date EXPRESS BUILDING PERMIT APPLICATI 1f E C E I O..E TOWN OF YARMOUTH Yarmouth Building Department AUG 20 2019 1146 Route 28 � BUIL D TMENT South Yarmouth, MA 02664 By; (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 1 f\ 'fLI V U Vv IV ASSESSOR'S INFORMATION: Map: 14 Z Parcel: 6 9 OWNER: \D0004 ). C OAA.\oCr�% (M`"e- NAME (( QQQ U / PRESENT ADDRESS TEL. # CONTRACTOR: k0[9 4k T�- VQ►"Cktrha _P J c— l�LAS 3 at-- y- C ✓ NAME MAILING ADDRESS TEL.# Id-Residential 0 Commercial Est.Cost of Construction$ l Z-,4J� Home Improvement Contractor Lic.# 1 3 G p Construction Supervisor Lic.# /0 0 (3 1 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor XI have Worker's Compensation Insurance Insurance Company Name: AA— 9N v•- • CAA. Worker's Comp.Policy# 1 ( ! e, WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 1 LI Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. (i.,)Replacing like for like Pool fencing *The debris will be disposed of at: tO W h 0 r Gkg"'-4-NA-40".- 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 rev tioi�1' ense an r osecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: SI 2f)/i,„ (miners Signature(or attach nt) Date: pproved By: Date: Id /1 1 Building Official(or de pee) 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: ❑ Yes ❑ No 0 Yes 0 No 4 (_ �'O c t � r (9.6 f-e r 4 Con-` �zl - �-e.T ` . The Commonwealth of Massachusetts *—ate— / _ iiDepartment of Industrial Accidents ='"LIl 1 Congress Street, Suite 100 . Boston, MA 02114-2017 5..•`''� www.mass.go v/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): " �' k ► Address: V 2 &J .N,. _ Ay,,, City/State/Zip: 1Mc,. vzi,7) Phone #: Qb V 3 a---C" 4-1-(lS, Are you an employer?Check the appropriate box: Type of project(required): I i(lI 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. E 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 I0 E 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.❑ Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the arrnrhed sheet. 13.❑Roof repairs ese sub-contractors have employees and have workers'comp.insurance.2 6.k e are a corporation and its officers have exercised their right of exemption per MGL c.il 14. 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: �� L Policy#or Self-ins.Lic.#: (.(A) C.(/ Q 06 09,S—C2 l Expiration Date: 112 ) Job Site Address: IC i VA tAel S l3 City/State/Zip: 'jt s % Qu a Pt- Attach a copy of the workers' cohapensation olicy d ration 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi u er ie ain a penalties of perjury that the information provided above is true and correct. Signature: Date: k/2e--,15 Phone#: e . ..3 ") 3 gt-- Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: • �2e (PO7ILn2d'I$UIe U ' UI�CCId�CLC/i.[( A}`sir5 sines Regutatja Hem fills-sPOVEf�tE?a <`3AG i' TYPE 5,Nle.rry nt Card ,.E 13#t69 13703/ 015;: ROBERT H.CHAMBERS il` . ROBERT H.CHAMBER-, = � 102 W H1FFLETREE AYE C BREWSTER,MA 02631 _.- Undersecretaiy • c. Commonwealth.of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructio S Msor Specialty - CSSL-100134 4oires: 03/16/2020 ROBERT H CHAMBERS 102 WHIFFLETREE AVE_. BREWSTER MA263 Commissioner v""_ A!^�® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 08/20/2019 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 W Scott Kerry KERRY INSURANCE AGENCY PHONE o.Ext): (508)255 8000 ADDRESS: SCOtt FAX (AI ,No): E-MAILInsurance.COm Gkef fY P 0 Box 1945 INSURER(S)AFFORDING COVERAGE NAIC# N.EASTHAM MA 02651 INSURER A: ATLANTIC CHARTER INS CO 44326 INSURED INSURER B: ROBERT CHAMBERS INC INSURERC: INSURER D: 102 WHIFFLETREE AVENUE INSURER E: BREWSTER MA 02631 INSURER F: COVERAGES CERTIFICATE NUMBER: 439263 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W M/ LIMITS LTR INSD VD POLICY NUMBER (MDD/YYYY) (MM/DDIYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE RENTED $ CLAIMS-MADE OCCUR PREMISESO(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADVINJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JERCT 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 NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY A OFFICER/MEMBER EXCLUDED?ECUTIVE N/A N/A N/A WCV00609514 01/29/2019 01/29/2020 E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I 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/lwd/workers-Compensationfinvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Cro leey,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 r p ROBER-6 OP ID: MD ACOKU CERTIFICATE OF LIABILITY INSURANCE UATE,MM/°°"""' 08/20/2019 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 508-255-8000 CONTACT W.Scott Kerry Kerry Insurance Agency Inc. PHONE 508-255-8000 I FAX 508-240-1860 P.O.Box 1945 (A/C,No,Ex t: (A/C,No): N.Eastham,MA 02651 EMAIL kerry@c4.net W.Scott Kerry ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Western World Insurance Co INSURED INSURER B: Roberf It Chambers,Inc. 102 Whiffletree Avenue INSURER C: Brewster,MA 02631 INSURER D: 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP/Y LIMITS LTR JN WVD IMM/DD!YYYY1 IMM/DDYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR NPP1516991 06/26/2019 06/26/2020 DAMG TOE EoNccTuErrDe ncel 50,000 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 LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ — OWNED SCHEDULED _ AUTOSO ONLY _ AUTOSN E BODILYO INJURYp (Per accident) $ AUTOS ONLY _ AUTOS ONLYY O'err acrRdent)AMAGE $ _ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY Y/N STATUTE ERH ANY YIPROP IIETORR RLNER E ECUTIVE N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) carpentry,roofing CERTIFICATE HOLDER CANCELLATION TOWN-15 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town Of Yarmouth Building Department 1146 Main Street AUTHORIZED REPRESENTATIVE Yarmouth,MA 02675 W.Scott Kerry ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD