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HomeMy WebLinkAboutBld-20-4073 Office Use Only 01''Y` ii- 'irk-. -Permit# 0 4.1� y, •Amount lv 'T MA.r'1^S .z `•_. <t•• E;d. Permit expires 180 days from <.. issue date ELDaD-1-1O-7. _RECEIVED EXPRESS BUILDING PERMIT APPLICATI N TOWN OF YARMOUTH Yarmouth Building Department ' 2020 1146 Route 28 South Yarmouth,MA 02664 a u I p (508) 398-22311 Ext. 1261 CONSTRUCTION ADDRESS: ' e �(ocic R,7 1�L S \/u'f',)-' GL1? . ASSESSOR'S INFORMATION: Map: Parcel: OWNER: &C rC�/ P C (e}?) NAME y PRESENT ADDRESS TEL. # �LLo CONTRACTOR: Ak' 1 i 6/KI S U ,2? /"// I / /%)k c' / i"r l oe#n / 2JL'6gN o NAME MAILING ADDRESS /f 1 Residential 0 Commercial Est.Cost of Construction$ . O(�✓D V 0 Home Improvement Contractor Lic.# 1' 10 it 3 Construction Supervisor Lic.# '/'i/6'C 7 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor Vhave Worker's Compensation Insurance Insurance Company Name: A-Yri l? Worker's Comp.Policy# 02 2 6 2_WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares . '9 ( " )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like forr like Pool fencing 'The debris will be disposed of at: ac; /ch l i.12/ S Location of/Facility I declare under penalties of perjury that the sta ents herein contained are true and correct to the best of my knowledge and belief. I understand at any false answer(s) will be just cause for denial or revocation nse or prosecution under M.G.L.Ch.268,Section 1. c Applicant's Signature: e / Date: �` Y 2.0 2 v Owners Signature(or attachment) /i 1/ 0./e Date: Approved By: Le � Date: � — t C-i r. G Building 0 ial esignee) EMAI RESS: Zoning District: Historical District: ';:i Yes ii No Flood Plain Zone: Yes I No Water Resource Protection District: Within 100 ft.of Wetlands: 7 Yes L No L. Yes ❑ No The Commonwealth of Massachusetts fr)�*,,, Department of Industrial Accidents f 4, Office of Investigations 1.= 600 Washington Street =` '= Boston,MA 02111 www.mass.gov/dia • Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Legibly ' �0� Name(Business/Organization/Individual): rram�, / �� � � _ Address: 9 ,i,/7 ram`cic.. E1 EJ City/ tate/Zip: W I Uc k'1.7ZO U-4 `"< Phone#: ' D?46'7 C/OE ou an employer? Check the ppropriate box: Type of project(required): /1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. . employees and have workers' 9 ❑Building addition [No workers' comp.insurance comp.insurance.# 10. Electrical repairs or additions required.] 5. ❑ We are a corporation and its ❑ 3.❑ I am a homeowner doing all work officers have exercised their 11.111 Plumbing repairs or additions myself [No workers'comp. right of exemption per MGL 12.pi/Roof repairs t c. § and we have no 13.1(4), insurance required.] Other ,l'2O" 152 '/ employees.[No workers' comp.insurance required.] *Any applicant that chocks 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. tContractoxs 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: • in6j/ / — Policy#or Self-ins.Lic.#: 02 326 Expiration Date: 06/03/Z Job Site Address: 01 keill /oat City/State/Zip: = Ya,,,rVi,0 a L' Attach a copy of the workers'compensation policy declaration page.(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. I3e advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. . • I do hereby certify under the pains a ties perjury that the information provided above is true andcorn ct. _ Signature: Date: '7/ 4 2-C.) Phone#: 372 S-( 69 0/�2 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#: ..- aN .a c : s- .5p vi i k M L c 4 F 1y 4 � ir RY2 F , v °€ ¢ 31 Cro} A � s r ANY ONE y ',,„ �t d a a W+la "t e�` s "7 44." Eagti c{A t:at '4 xT' T. .. a • ` Fx yf , a- q zF 4 p y ?y YT ` C - , t' -.a t ' � p ACCPREP DATE(MM/DDlYWY) CERTIFICATE OF LIABILITY INSURANCE 06(MM/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 I CONTACT Linda Sullivan NAME: DOWLING & O'NEIL INSURANCE AGENCY 1A/°NaExt)• (508)775-1620 Fac,Nol: E-MAIL Isullivan@doins.com doins.co 9RLtF3JesS_: G m 973lYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIL# HYANNIS MA 02601 INSURER A. AMGUARD INSURANCE CO 42390 INSURED INSURER B. -. CAPE COD HOME IMPROVEMENT INC iINSURER c: INSURER D _ 27 MILL POND ROADINSURER E.• WEST YARMOUTH MA 02673 I INSURER F: COVERAGES CERTIFICATE NUMBER: 410125 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 SUBRVO POUCY EFF POLICY EXP LIMITS LTR INSO W POLICY NUMBER IMM/DD/YYYYI (MM/DONYYY1 COMMERCIALGENERAL LIABILITY EACH OCCURRENCE $ SAGE TO RENTED - CLAMS-MADE OCCUR PREMISES(Ea occurrence) -_$ MED EXP(Any one person) $ N/A PERSONAL 8 ADV INJURY $ _ GEN'L AGGREGATE LIMIT APPLIES PER• GENERAL AGGREGATE $ ---- POL CY __- PE 0 LOC PRODUCTS,.,,_COMP/OP AGG,...$ OTHER $ - AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ _—.. Laaccident) ANY AUTO BODILY INJURY(Per person] S ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident)!$ NON-OWNED PROPERTY DAMAGE HIRED AUTOS --.. AUTOS _Per accidenil...-_-- $$ UMBRELLA LIAB OCCUR EACH OCCURRENCE __EXCESS LIAR CLAIMS-MADE N/A AGGREGATE $ UEO RETENTIONS $ WORKERS COMPENSATION X PER KM- AND EMPLOYERS'LIABIUTY _ • STATUTE —_ Y N ANYPROPRIETOR,PARTNER/EXECUTIVE � I E.L.EACH ACCIDENT $ 1.000,000 A OFFICER/MEMBEREXCLUDED? N/A i N/A N/A R2WCO23262 06/03/2019 06/03/2020 - (MandatoryInNH) `-`- E.'_.DISEASE-EA EMPLOYEE S 1,000,000 It yes.oescnbe under ._.._ ..-_ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POL:CY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS I 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 ssue date of this certificate of insurance). The status of this coverage can De monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigatiors/. CERTIFICATE HOLDER CANCELLATION I ) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Anatoli Sivitski ACCORDANCE WITH THE POLICY PROVISIONS. 222 Buck Island Road 6-8 AUTHORIZED REPRESENTATIVE West Yarmouth MA 02673 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA 01988-2014 ACORD CORPORATION. All rights reserves. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Coflin )n ,..,.* i 'ti) or Dvis: B ) arci t on str ct; cp S .klpervlso S S - 10041.j rExpvs J5 142U .41r ANATOL! SIVITSKI 27 MILL POND RD WEST YARMOUTH MA 02673 Commissioner • lam' 0/22/2 /4Ilheadi� � %('(7.444atri 7i,(JP 14- Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation CAPE COD HOME IMPROVEMENT,INC. Registration: 12ration: 12//0 Expiration 06/2/2 020 27 MILL POND RD WEST YARMOUTH,MA 02673 Update Address and Return Card. SCA 1 GS 20M-05/17 Te Y/ f1i(V,'/ irl/f i,/.:l/m i,44e/Li 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: R.ais'aiob• • Expiration Office of Consumer Affairs and Business Regulation 168043 12/06/2020 1000 Washington Street-Suite 710 CAPE COD HOME IMPROVEMENT,INC. Boston,MA 02118 ANATOLI SIVITSKI 27 MILL POND RD WEST YARMOUTH,MA 02673 Not veltd without signature Undersecretary • . . Town of Yarmouth Receipt No.: 53100 till 1146 Route 28 South Yarmouth,MA 02664 Receipt Date: 01/10/2020 508.398.2231 RECEIPT RECORD&PAYER INFORMATION Record ID: BLD-20-003838 Record Type: Residential Express Permit Property Address: 34 VACATION LN,WEST YARMOUTH,MA 02673 Description of Work: Repairs-strip and reroof 33 squares(508-469-0102) Payer: ANATOLI SIVITSKI Applicant: ANATOLI SIVITSKI ANATOLI SIVITSKI West Yarmouth,MA 02673 PAYMENT DETAIL Date Payment Method Reference Cashier Comments Amount 01/10/2020 Check 5297 LCIPRO $50.00 FEE DETAIL Fee Description Invoice# Quantity Fee Amount Current Paid Residential Roofing 56268 1.00 $50.00 $50.00 $50.00 $50.00 ___-a. CAPE COD HOME IMPROVEMENT 5297 27 MILL POND RD WEST YARMOUTH 53.13/110 MA 508 469 0102 //©9 In 26975 DATE I- /2 PAY F v (i/- 0 4 .K i il/ ���✓✓/TO THE --___ 2. I .J-C CO ORDER OF gjr,K /r V °`'/ Photo �� DOLLARS la t. Bank of America' ACHR/r011000138 - FOR 3g _ M 0600 5 2 9 711' 1:0LL000L313,: 00462044:L4Lon'