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Home My WebLink AboutBld-20-003477 'F;Y--A Office Use Only 4 a' « '`t7Q_ Permit# �/V+_OttyEr- H Amount 1 "*r.r i.. c ' Permit expires 180 days from Bb-- y 3(--i p issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 �� , /�I (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS:61 Helmsman Dr Yarmouth Port, MA 02675 ASSESSOR'S INFORMATION: Map: Parcel: OWNER:JGS Realty Corporation 767 Independence Dr Unit D309 Hyannis ,MA 02601 (603)315-6285 NAME PRESENT ADDRESS TEL. # CONTRACTOR:Excel Building Systems Co Inc PO BOX 436 Forestdale,MA 02644 (508)901-0143 NAME MAILING ADDRESS TEL.# N Residential 0 Commercial Est.Cost of Construction$3,200.00 Home Improvement Contractor Lic.#182094 Construction Supervisor Lic.#CS-0Q8849 Workman's Compensation Insurance: (check one) I am the homeowner ❑ I am the sole proprietor X I have Worker's Compensation Insurance Insurance Company Name: Associated Fmployers Insurance Company Worker's Comp.Policy#WCC50050098182019A WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 16sq Replacement windows:# Replacement doors: # Roof, g: #of Squares ( 1 )Rem ye existing*(max.2 layers) Insulation ,// Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: Yarmouth Disposal Area 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 d or revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. l Applicant's Signatur` ii, Date: ( I / 11 Owners Signature(or attachment) Date: O)/mil lc I r Approved By: r Jf� Date: /2 9—/% ding icial(or designee) IL ADDRESS: Zoning District: Historical District: El Yes l No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No The Commonwealth of Massachusetts ut Department of Industrial Accidents i.m a 1 Congress Street,Suite 100 =i�1_; Boston, MA 02114-2017 ��r•r` 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): 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): I.®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. ®Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. Demolition 10 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that an contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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:Associated Employers Insurance Company Policy#or Self-ins.Lic.#:WCC50050098182019A Expiration Date: 03/05/2020 Job Site Address:61 Helmsman Dr 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 cc' under the pains and penalties of perjury that the information provided above is true and correct ah // j/J1 Signature: 'Or Date: Phone#:(50.*01-0143 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#: Client#:38860 2EXCELBU ACORD, CERTIFICATE OF LIABILITY INSURANCE DATE(MIWDDVYYYY) 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 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 endorsement(s). PRODUCER CONTACT NAME: The Hiib Group of N.E.dba tit, E ttI.508 775-1620_ FAX'No:5087781218 Dowling&O'Neil Insurance Agy I PHo E-MAIL ( ADDRESS: P.O.Box 1990 F — INSURER(S)AFFORDING COVERAGE NAIL i Hyannis,MA 02601 _ INSURER A:NGM Insurance Company 1147B8 INSURED INSURER a.Associated Employers Insurance Company {11104 Excel Building Systems Company,Inc -- - PO Box 436 INSURER c. j INSURER D: Forestdale,MA 02644 INSURER E: II INSURER F: 1 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. INSRI — __—!ADDLSUBR! POLICY EFF : POUCY EXP LTR --___TYPE OF INSURANCE 'INSR w POUCY vD I POCY NUMBER (Msvoomr Y}i(MM,GDrYYY10 -.... LIMITS A X COMMERCIAL GENERAL LIABILITY X 1 X MP02774T 02/22/2019102/22/202 EACH OCCURRENCE $1,000,000 I DAMAG�EETT RENTED j CLAIMS-MADE X OCCUR ( I I I PREMISF$itB occurrence) S500 000 I I MED EXP,Any soperson? 510,000 I PERSONAL&ADV INJURY i.$1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ' I GENERAL AGGREGATE }$2,000,000 l POLICY X{JECT X LOC I PRODUCTS.COMP/OP AGG I S2,000,000 A L AUTOMOBILE LIABam M102774T 1 2/09/201 8 1 �._. I OTHER: 4 1 12/09/2019 EOM dent SINGLE LIMIT $1,OQO,000 L:ANY AUTO I 7 7 BODILY INJURY(Per person •$ OWNED SCHEDULED - BODILY INJURY IPer accident) S - AU:OS ONLY' X AUTOS__ HIRED 1__-- NON-OWNED j PROPERTY DAMAGE $ I X AUTOS ONLY I X i AUTOS ONLY I 1 (Per accident) • 1 s UMBRELLAUAB -1-- OCCUR -EACH OCCURRENCE S i EXCESS UAB 1 CLAIMS-MADE I • AGGREGATE -,-__ •$I ___ QED i I RETENTION$ B WORKERS COMPENSATION i 1WCC50050098182019A 03305✓2019103/35/2020 X STATVTE ERH $ ANO EMPLOYERS'LIABILITY ---- -- - - - YIN{ I ANY CERIM 4ETOR,PARTNER;EXECUTIVE I El.EACH ACCIDENT S500,000 OFFICER/MEMBER EXCLUDED? N I N/A i ? I ----- -- — (Manolatory in NH) ' + E L DISEASE-EA EMPLOYEE s500,000__ It yes,describe under t I I DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 • II i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101.Additional Remarks Schedule may be attached it more space is required) The following coverages applying in the favor of The Valle Group,Valle Redbrook,LLC,&John Parker Road, LLC:Additional insured status on the General Liability;Waiver of Subrogation on the General Liability,as well as other parties as required by contract.General Liability is Primary and Non-contributory for premises,products and completed operations. (See Attached Descriptions) 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 v 1988-2015 ACORD CORPORATION.Ali rights reserved. ACORD 25(2016/03) 1 of 2 The ACORD name and logo are registered marks of ACORD #S230329/M230326 RPJX1 Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor CS-098849 Expires:06/20/202i RENATO SILVA P.O BOX 436 FORESTDALE MA 02614 Commissioner r .�f 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. Reaistratiort 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 Lr t SANDWICH,MA 02563 Not val out signature Undersecretary