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Home My WebLink AboutBld-20-002376 6 V''4r1Att C ; :i i „Amount .: , INAVVA M cS 44 1': ).6) .*01141f. 'c:s° Permit expires 180 days from k issue date EXPRESS BUILDING PERMIT APPLICATI wi' - CEIVEDI TOWN OF YARMOUTH Yarmouth Building Department r -I , 1146 Route 28 OCT 2.8 2019 1 1 1 South Yarmouth, MA 02664 - (508) 398-2231 Ext. 126 1 t a CONSTRUCTION ADDRESS: fq I 4/41-4 / cL e,044 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: ckd g?„,eika pif JI/Alle 1.k Kea Y eonz f A Al. 5o5 237 t723 i 1 NAME PRESENT ADDRESS TEL. # CONTRACTOR:__C,,U.VAllio c,„cirtvefi., 15 ivearfiketi 4-44tt yeuenviA Pd , q7e 419.0 6b0 NAME MAILING ADDRESS TEL # Ir‘sidential 0 Commercial Est.Cost of Construction$ Home Improvement Contractor Lie.# /6513e, 41,x:71101a' Construction Supervisor Lie.# C.C— /es f 911,7 ex: 8/11/94 Workman's Compensation Insurance: (check one) 73 I am the homeowner 71 I am the sole proprietor 1Xhave Worker's Compensation Insurance Insurance Company Name: 4/Y.1.4 %f.5.01-4tee —cr-Viete.., I Worker's Comp. Policy* 63-6 u 6 ViWV/.7 34/9 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares ? Replac ent windows:# Replacement doors: # Roofing: #of Squares / ( VSRemove existing*(max.2 layers) Insulation 110—)Old Kings Highway/Historic Dist. qid Replacing 4ilte4or4ike ilAct'i4." Pool fencing *The debris will be disposed of at: A/If aff bliAnp,541t Agettf „c.d./ biS paS 609 iir.o..19il..S. ,Location of Facility 1 I declare under penalties of per •th the statements herein contained are true and correct to the best drily knowledge and belief. I understand that any false answer(s) will be just cause for denial o o n of m I ense an 'r prosecution under M.G.L.Ch.268,Section I Applicant's Signature:_ Date: /0/ii lit Owners Sig ure(or taehment) Date: ---"... Approved By: Date: Building Official( esi •e EMAIC! SS: Zoning District: Historical District: ,.. Yes 7; No Flood Plain Zone: ..: Yes :..; No Water Resource Protection District: Within 100 ft.of Wetlands: il Yes . No I.: Yes I No . The Commonwealth of Massachusetts 0 /, Department of Industrial Accidents k....... r� 1 Congress Street, Suite 100 =_1is Boston, MA 02114-2017 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): Cc/r V I lO re l?, hUC /`a Address: /5 A)&vf i l_44te' City/State/Zip: )/armpvl4t /e* Rif 4a617C Phone #: q7g lip 6 (0/9 Are you an employer?Check the appropriate box: Type of project(required): l. 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. El 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 D 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. 12.0 Plumbing repairs or additions 5.1F1<m a general contractor and I have hired the sub-contractors listed on the attached sheet 13. 00f repairs These sub-contractors have employees and have workers'comp.insurance.: 14.El Other 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 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: 4)(4 .„_ctir a iU Se r►v;CAL, .Z1C, Policy#or Self-ins.Lic.#: &S(O c2 V J '(A/ Ny/a,3,4/9 Expiration Date: $f/?'f oZd bte Job Site Address: /V? 4ib,J4 /Cdt,K_ aCity/State/Zip: yartrii0/4/ Pd. iffif D. &75 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 certi i Di',r the 'ns an penalties of perjury that the information provided above is true and correct Signature: fi / Date: i0/' /if Phone#: 97g 'iv 6bi? 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#: ACORD CERTIFICATE OF LIABILITY INSURANCE URIC tMia/UU/TTT Ti 10/10/2019 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: Melisha Colon AXIA INSURANCE SERVICES INC (ry PHONE, ); (413)788 9000 FAX No): E-MADDRESS; certificate@axiagroup.net 933 EAST COLUMBUS AVENUE INSURER(S)AFFORDING COVERAGE NAIC# SPRINGFIELD MA 01105 INSURER?,: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: LCT CONSTRUCTION &SERVICES INC INSURERC: INSURER D: 4 EVERGREEN LANE INSURER E: HOPEDALE MA 01747 INSURER F: COVERAGES CERTIFICATE NUMBER: 459583 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 LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM MI/DDYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECOT- LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) _ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X STATUTE ERH Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE A OFFICER/MEMBER E.L.EACH ACCIDENT $ 500,000 EXCLUDED? N/A N/A N/A 6S62UB4N44123A19 08/17/2019 08/17/2020 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/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/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Carvalho Construction ACCORDANCE WITH THE POLICY PROVISIONS. 15 Newfield Lane AUTHORIZED REPRESENTATIVE n r P Yarmouth Port MA 02675 Daniel M.CroWjey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACARf 94 Mid/MI The A(`API1 names mine.Irwin are runic+urrrl m2rtrc of A(ARF% i :II L opo5at Page# of pages \ /01.44 fo :' yeah /5 / Y610m0 6te A ' PROPOSAL SLIBMfTTED TO:147) 1 JOB NAME JOB# iep ADDRESS ``t JOB LOCATION /7 fi itif ` ,_P' AO 0675 675 DATE DATE OF PLANS PHONE# I FAX# ARCHITECT \tea /We hereby submit specifications and estimates for: -kJ& P#Iff -I. Ar:11410 ... ..s-friv ��5► _ °_ _ ............. 1\ so 1- w j -a_ -�tt f'-e. s flig_ Pad a41144441-r cum S /Ar_..... -f 14 :. , c.-� _ a� -_,ASite tit C'_t 4.4 (4/041S dr— (PPM ' c _.___ --__aeY!)k, W-0414 4,461- -Mc* (ter / e propose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of: i /( �D 1 Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs Respectfully will be executed only upon written order,and will become an extra charge submitted - over and above the estimate. All agreements contingent upon strikes, \accidents,or delays beyond our control. e—this proposal may be withdrawn by us if not accepted within days. i gcceptance of firopo5a1 . The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. g '°19 Payments will be made as outlined above. Signature Date of Acceptance /©76 /9 , Signature A-NC3819/T-3850 09-11 F _ I J ICI 1 I I I I i I I j I i ...........- lie �oriurrg-n Registration valid for individual use only Office of Consumer IMPROVEMENT &Business CTOationRegulation HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: TY �ndividug nir ion Office of Consumer Affairs Sand e Business Reg 1000 Washington Street - -- =_�� 0J7116/2021 ' Boston,MA 02118 } (iI JOHN CARVALI1 ' tION / DB/A CARVALF� > f1 F ure JOHN CARVALHO., `tt -� iv � ,.el �� Not vali 15 RMOUTNEWFIELD RT,M ,f-: ;>7 �ndersec , YARMOUTHPORT,MA 02675 retary Commonwealth of Massachusetts Division Buildingon of PRegssional Licensure ulations and Standards Board ofonttr Regulations 7, !J. ..I r) ires:08/0412020 • CS-101942 , i i ° f CAt11 Am, JOHN JOHN M H *' 11 `/ �a 15 NEWFIEL �� YARMOUTH Pak�r ;,,: 6 Commissioner