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HomeMy WebLinkAboutBld-20-002664 j Y ICC Use Only ' Dl3 {O/ • H Amount ` 4. cs)eu�TT nwc�sr �` """ c' Permit expires 180 days from issue date /yak t. EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 179 Center St. Yarmouth Port ASSESSOR'S INFORMATION: Map: /V Parcel: 33 1 OWNER:AU Realty Corporation 182 Pitchers Way Hyannis,MA 02601 (508)934-6745 NAME PRESENT ADDRESS TEL. # CONTRACTOR:Excel Building Systems Co Inc. Po Box 436 Forestdale , Ma 02644 (508) 901-0143 NAME MAILING ADDRESS TEL.# SI Residential 0 Commercial Est.Cost of Construction$$17,300 00 Home Improvement Contractor Lie.#182094 Construction Supervisor Lic.#CS-09R849 Workman's Compensation Insurance: (check one) 0 I am the homeowner _ I am the sole proprietor It I have Worker's Compensation Insurance Insurance Company Name:A.csociattad Employers Insurance Cnmpany Worker's Comp.Policy#WCC50050098182019A WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 25sf1 Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. (x)Replacing like for like Pool fencing Repair selective rotted trim.Wood Sidding. *The debris will be disposed of at: Town of Yarmouth Landfill 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 4 ocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's SignatuOPP ,/ Date: 11/07/2019 Owners Signat e(or attach e�T4 , „...649/ Date:11/07/2019 Approved BY: Date: // ' l "/ 41111, Building Official .r. ' ' , EMAIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: _ Yes Na Water Resource Protection District: Within 100 ft.of Wetlands: Yes No _ Yes No %' 67.6 T The Commonwealth of Massachusetts Department of Industrial Accidents ell11 1 Congress Street,Suite 100 "4_i1T`_ Boston, MA 02114-2017 www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):Excel Building Systems Co Inc. Address:8 Jan Sebastian Dr Unit 9 City/State/Zip:Sandwich, MA 02563 Phone#:(508)901-0143 Are you an employer?Check the appropriate box: Type of project(required): LEI I am a employer with 4 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. 0 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.❑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 5.0 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.% 6.0 We area 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 employee& Below is the policy and job site information. Insurance Company Name:Associated Employers Insurance Company _ Policy#or Self-ins.Lic.#: WCC50050098182019A Expiration Date:03/05/2020 Job Site Address: 179 Center St. City/State/Zip:Yarmouth Port MA 02675 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 cerdt under the pains and penalties of perjury that the information provided above is true and correct Signature • Date: 11/07/2019 Phone#:(508)901-0143 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#: ACORDTM CERTIFICATE OF LIABILITY INSURANCE 05J02/2019 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 poiicy(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 any rights to the certificate holder In lieu of such h endorsement(s). PRODUCER CONTCT NAME: FAX the Hilb Group of N.E.dba P NE ( ),508 775-1620 ( i ,No 5087781218 fowling&O'Neil Insurance Agy ADDRESS: 2.0.Box 1990 INSURER(S)AFFORDING COVERAGE NAIC s Hyannis,MA 02601NGM Insurance Company 14788 INSURER A: 11104 NSURED INSURER B:Associated Employers Insurance Company Excel Building Systems Company,Inc INSURER C: PO Box 436 INSURER D: Forestdale,MA 02644 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. ADDLSUBR POUCY EFF POLICY EXP IN LTR TYPE OF INSURANCE INSR MID POLICY NUMBER (MWDD/YYYY) (UMIDDMYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY X MP02774T 02/22/2019 02/22/20 EACHEp OEEC CCURRENCE $1,000,000 DAMAGETO(IRENT DDrente) $500,000 CLAIMS-MADE I X I OCCUR MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I X I LOC PRODUCTS-COMP/OP AGG $2,000,000 POLICY XI ECT $ OTHER: COMBINED SINGLE LIMIT 1 000,000 A AUTOMOBILE LIABILITY M102774T 12/09/2018 12/09/201 CO accident) $ BODILY INJURY(Per person) $ ANY AUTO OWNED BODILY INJURY(Per accident) $ X SCHEDULED AUTOS ONLY AUTOS PROPERTY DAMAGE $ HIRED NON-OWNED (Per accident) X AUTOS ONLY X AUTOS ONLY $ EACH OCCURRENCE $ UMBRELLA LIAR _ OCCUR EXCESS LIAR CLAIMS-MADE I AGGREGATE $ DED I I RETENTION$ $ PER OTH- B WORKERS COMPENSATION WCC50050098182019A 03/051/2019 03/05/2020 X 'Mai r(F 1 I FR AND EMPLOYERS LIABILITY E.L EACH ACCIDENT s500,000 OFFICER/MEMBEEREXCLUDED?ECUTIVEIYN N/A E.L.DISEASE-EA EMPLOYEE $500,000 (Mandatory in NH) 000 It yes,describe under E.L.DISEASE-POLICY LIMIT $500, DESCRIPTION OF OPERATIONS below DESCRIPTIONcF OPERATIONS/LOCATIONS/VEHICLES(ACORD holders named additional insured with 01,Acklitional Remarks Schedule,inay be attached It more space is required) Certificate respect to general liability when required by written contract. Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. Commonwealth of Massachusetts ill Division of Professional Licensure Board of Building Regulations and Standards .'onstruCtion Supervisor CS-098849 Expires:06.20/2021 RENATO SILVA P.O.BOX 436 FORESTDALE-MA 02644 Commissioner Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affai and Business Regulation 182094 05/25/2021 1000 Washington Str uite 710 EXCEL BUILDING SYSTEMS COMPANY INC. Boston,MA 02118 RENATO DA SILVA 8 JAN SEBASTIAN DR.STE 9 Not V11 out signature SANDWICH.MA 02563 Undersecretary