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HomeMy WebLinkAboutBLD-20-547 -;;YA� Office Use Only 454 El • O . - ' H r,Amount •�µ` MATTACn ESE *"P.Alf.V�::;', IPermit expires 180 days from 1 issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 � '4 if (508) 398-2231 Ext. 1261 �'f�� i to 0U • CONSTRUCTION ADDRESS: , ASSESSOR'S INFORMATION: Map: Parcel: C. //��'�� OWNER: N� v� 0+ ,k 0 T , "�U✓�( r041* N PRESENT ADD TEL. # 1 _ „1 CONTRALTO : Cam=. ( (0 ��C �► NAME MAILING ADDRESS TEL.# de Residential ❑Commercial Est.Cost of Construction$ I ) 1003 Home Improvement Contractor Lic.# I 0 1v Construction Supervisor Lic.#_e 3 -O`er t Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the s eproprietor CI have Worker's Compensation Insurance (�QQ Insurance Company Name: L{,1 Worker's Comp.Policy#LX.-- O "e�� "v 't ) ,� _�, ti WORK TO BE PERFORMED --10 Y"'•v�71\t__ -_ (24.11' Tent Duration qZ _ (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # 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 1 Q, �} 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 nial or revocation y license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Si_ • Date: bI(9 Owners Sig or attachment) ------ Date: Approved By: .--G Date: " 3© 1`1 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No ❑ Yes ❑ No The Commonwealth of Massachusetts r it it% Department oflndustrialAccidents 1 Congress Street, Suite 100 `. r 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 �p Please Print Legibly Name (R,isi^.,7c/n _-._ __yir aµ'l) ' �����_ i( L Address: 5' r'' i q , City/State/Zip:L J.tv -Ar (ys) Phone #: 7 Z ` --5( Q Are you an employer?Check the appropriate box: Type of project(required): l.1[ _J am a employer with I © 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.] _— 3._I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ` Demolition I0 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.—I 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. 14.zi Other-'Qf'\l rstmbA...V--se�•6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. z 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. I.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: CZ/ lit.e) Sk--*1.— Policy 4 or Self-ins.Lic. 4:0C -Q LA Expiration Date: fr t.c1 Job Site Address: (SI \QI,G L.Ca<er---\ ` .‘} SA-14----City/State/Zip: Wes_ Attach a copy of the workers' compensation polic de laration 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 I ieby certify u ze pa' Ities of perjury that the information provided above is true and correct. Sian Date: 47 i t()) Phone#: ' 3( 0 _ 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#: ® Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards :instruction Sapenn.sor CS-057291 Expires: 09/17/2019 FRANCIS V WARD,III 61 MOORE ROAD EAST WEYMOUTH MA 02188 Commissioner -&20 Warizemantoeaa,olait4dacked elta • Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation ESISIDIrAgn 1102 1.08388. 07/22/2020 AMERICAN MOBILE HOMES INC. FRANCIS V.WA( D 51 MOORE RD ' � -- E.WEYMOUTH,MA 02189 Undersecretary ACCPREP® DATE(MruDomYn CERTIFICATE OF LIABILITY INSURANCE 06/21/2019 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 CONTACT Paul MacEihiney Duncan & MacRellar Insurance Agency PHONE 781-335-1170 FAX 835 Broad Street MAIL ( No) ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# E. Weymouth, MA 02189 INSURER A:SCOttsdale Insurance Company INSURED INSURERS:Granite State Insurance Company American Mobile Homes, Inc. INS Rc:Arbella Protection Insurance Company 51 Moore Road INSURER D: East Weymouth, MA. 02189 -- INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS fS TO-GERTIFY-THAT-THE-POL E_I USTEn ELOW HAVE BEEN_IRRI IFD1.O_THE_INSJJRED 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 SUER POLICY EFF POLICY EXP UMRS LTR _WW1 MD POLICY NUMBER IMMIDO/YYYY) IMMIDD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000.000 A CLAIMS-MADE X OCCUR X BCS0037636 02/04/19 02/04/20 DAMAGE TO RENTED 100,000 PREMISES(Ea NTED!Ice) $ MED EXP(Any one person) $ EXCL PERSONAL 8.ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- POLICY E LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY (a ac idennt)INGLE LIMIT $ 1,000,000 ANY AUTO 1020014697 02/26/19 02/26/20 BODILYINJURY(Perperson) $ - OWNED x SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE _AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLALUIB OCCUR EACH OCCURRENCE $ - EXCESS LAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER B ANYPROPRIETOR/PARTNER/EXECUTIVE Y� N/A WC 024-28-0994 08/12/18 08/12/19 E.L.EACH ACCIDENT $ 1.000.000 OFFICER/MEMBER EXCLUDED? (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 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Rental of Mobile Homes Additional insured on commercial general liability only CERTIFICATE HOLDER CANCELLATION HUD Administrator, Office of Manufactured HousingPro rt SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 451 7th Street, SW Room 9168 ACCORDANCE WITH THE POLICY PROVISIONS. Washington, DC 20410 RIZEDREP TAME ®1988-2O18-A�RPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Aim ' --------)%' . . AMERICAN MOBIL HOMES INC. 51 Moore Road Weymouth,MA 02189 (781)331-0333 1-800-232-9991 PROPOSAL Fax(781)335-0707 • Date l 1� Name C(J-4 Q,�-,/ 0+ ,' � Est.delivery date Address �:�� l �t�a _-,q1 -. American Mobile Homes,Inc.hereby propo T o furnish the materials and perform the labor necessary for the completion of installing 0( ". 1Nt.. lease mobile home containing: Refrigerator,stove,dining set,living room set,curtains,bedding 1st '(( ,2ndiLit ,3rd „washer and dryer,air conditioning. ,CY/Te porary Plumbing installation to mobile home i`` pplying for building permit for mobile home porary Electric installation to mobile home 0 Rove necessary trees,tree limbs or shrubbery Remove any necessary fencing erOthe 0` .f:/..5. alfiaKk___ Any resulting damage to said property as a result of the installation,removal and existence,of mobile home and its its utility connections shall not be the responsibility of American Mobile Homes,Inc.,specifically driveway,fence, stonewall,septic system,trees,lawn or any other type of landscape items and/or. American Mobile Homes,Inc.,is not responsible for the re-installation of any of these items. Costs: ` The monthly rental of the mobile home mos. The delivery and pick up charge of� -� Air conditionin Pet fees `� other 1 c- er-[cpi-.. r,e4pL There will be additional charges for utility connections,permits,fees,site preparation. • There will be a profit and overhead charge of 10& 10 for all sub contractors and fees paid out. Any applicable sales tax.A 5%carrying cost will be billed and payable on all invoices not paid within 45days of billing. A$1,000.00 security deposit is due on delivery of mobile home.Uwe agree to sign a lease for the mobile home rental at delivery. Projected job cost' l Cli I l-1Act �i �Q�1�fie"-- L- l,� •c Payment Method : 6 Billed directly to insurance company with a signed assignment of payment. O Other: i Any alteration or deviation from above specifications involving extra costs, will become an extra charge over and above the estimate. All agreements Respecttull ubmitte contingent upon strikes,accidents or delays beyond our control. ,---- ACCEPTANCE OF PROPOSAL The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. If insurance company is not willing to honor assignment of payment,Uwe understand Uwe will be responsible for full payment of all services. NOTICE OF RIGHTS TO CANCELLATION You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the Seller,which may be his main office or branch thereof,provided you notify the Seller in writing at his main office or branc by ordinary '1 ed,by telegram sent or by delivery,not later than midnight of the third business day following the signing agreem See attached notice of cancellation form for an explanation of this right. Signature Date `--Nra, Signature [E NO. 7 b S YAP LOT NO . : a 4/ ADDRESS : 88 Av F I rL0 acitO OWNERS NAME : 140pAA Otcrjtki SEWAGE PERMIT NO . : -tr7 NEW : REPAIR : ,/ DATE ISSUED : 16 /6 04 DATE INSTALLED : io / /08 INSTALLERS NAME : ZPAruiliyir ( e1- a) INSTALLATION OF : 1JNj1( 12, ()LAC Fffi F �1 WATER TABLE : --- FINAL INSPECTION BY : B66/1'1A DRAWING OF INSTALLATION ON REVERSE SIDE : TOP Q ciVOO rams a 19.3' Aro 7\ A c RALe e3 2 5 3t 3 57. S