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Home My WebLink AboutBld-20-3830 1 office Use Only O` pii�y y %� Amount •{`er MATTw M ! �� 7 / �f 7 ) "7•wt.' Permit expires 180 days from I issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 909 Rom, cis ma.i n--, 6T ja r rn Erk - rn f\ O (ol o Lk ASSESSOR'S INFORMATION: Map: L 1 Parcel: ?S' OWNER: ( se,L\ )+ J 990 tnRin 6-r 'Bret & ( ma oa(03 i 1-Ial-9.om- 3711 NAME PRESENT ADDRESS TEL. # CONTRACTOR:-mo4hq KLihv, Kra(t)5 Ri-e (o EA57Ac m mA o86y� 5't�S -c140 -6ilq NAME MAILING ADDRESS TEL.# ❑Residential ,8tommercial Est.Cost of Construction S /7, 00 0 . IA? Home Improvement Contractor Lic.# 1 3'a98 Construction Supervisor Lic.# (i 5 -OS'I 40(v Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor el have Worker's Compensation Insurance Insurance Company Name: ,4.i'.fl. ]17wrt{AL Thy • CO Worker's Comp.Policy#t,DVd-/BD- 6C/c 9fO -020/9A WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 3 0 ( ')Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing The debris will be disposed of at: 7o u7A) O j-Ariv tG v Location of Facility I declare under penalties of perjury that the statem nts 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 revocation!film-license and ution under M.G.L.Ch.268.Section 1. p Applicant's Signature: v —� Date: 1 • p .Z020 Owners Signature(or ttachm Date: Approved By: U! •' Date: Buil ' • ci rdesignee) EMAIL SS: V5ames�n ka . UI4kOOA L.CO1t) Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No ❑ Yes ❑ No t.� CoASTAl October 04,2019 Town of Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 To Whom it may concern, i,Mike Schlott current owner of 909 Rte.28 Main Street hereby authorize Timothy Klink of Coastal Custom Builders and his representatives to apply for and secure all necessary building permits for 909 Rte.28 Main Street Yarmouth MA. Sincerely, Mike Schlott N. Eastham Office: 4665 Route 6 Eastham, MA 02642 508-240-2114 DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S 150A. The debris will be disposed of in: O t= t-LZLt_.J LOCATION OF FACILITY Signature of leant 5atel AFFIDAVIT As a result of the provisions of MGL c 40, S 54, I acknowledge that as a condition of Building Permit Number _ all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. I certify that I will notify the Building Official by (two months maximum)of the location ofthe solid waste disposal facility where the debris resulting from the said construction activity shall be disposed of,and I shall submit the appropriate form for attachment to the Building Permit. t if _20u7 Date Si emit Applicant (PRINT OR TYPE THE FOLLOWING INFORMATION) Name of Permit Applicant ()A-S / „kJ 1.9 Les ty,ki Firm Name, if any The Commonwealth of Massachusetts Department of Industrial Accidents :,lira= t Office of Investigations ':el=-si 1 Congress Street, Suite 100 •~ _ ! = Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):. LFi lv1 (A ►� 1-I�C. Address: 9(0(o5 (��U-{t' 6 City/State/Zip: E RS Pry me Oa(o4 Phone #: 50e-3,4 0-dJ I q Are you an employer? Check the appropriate box: Type of project(required): 1. i I am a employer with 4. ❑ I am a general contractor and I I * have hired the sub-contractors 6. ❑New construction employees (full and/or part-time). 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P ty. 9. ❑Building addition [No workers' comp. insurance comp. insurance. required.] 5. DIWe are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 122'koof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *My 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. �t Insurance Company Name: A,1, P1. SN�v(LI(,� Comp A kl i Policy#or Self-ins. Lie. #: VOW,— 100— is "„9,O19.PI Expiration Date: I 16 5 I a°ao Job Site Address: City/State/Zip: 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. Be 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 pain nd penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 50E ago-t ,11t-k 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#: icv CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 12/05/2019 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). (ODUCER 02136-001 NAME:CT Branch 2136-1 Itarkweather&Shepley Ins Brkg Inc met.1 ,EA): (401)435-3600 (NC.No.: (401)431-9323 'O Box 649 Eoighss: IRDocs@starshep.com ,rovidence,RI02901-0549 INSURERISI AFFORDING COVERAGE NAIC 0 INSURERA: A.I.M.Mutual Insurance Company 33758 SURED INSURER B: ,and Cape Inc 'he Coastal Companies INSURERC: 665 Route 6 INSURER D lastham, MA 02642 INSURER E: INSURER F• :OVERAGES 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. R TYPE OF INSURANCE Veii POLICY NUMBER (POLI YNE/y)jIM 9(j y) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ —ThOLICY PE: n_OC COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED (Per r08ERa PROPERTY $ AUTOS $ ) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DED RETENTION $ oMRROEMMPPggnnITY X giI MT ¶ $ ANY PROpFEE7Q�/Pq�7NER/ ECUTIVE / E.L.EACH ACCIDENT $ 1.000.000.00 OFFICER/MtMBH) EXCLUDED? N/A VWC-100-6012480-2019A 11/25/2019 11/25/2020 E.L.DISEASE-EA EMPLOYEE $ (Mandatory In NH) 1,000,000.00 DE4SSCIiaff0 OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1.000.000.00 .ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) Proof of Coverage Worker's Compensation Coverage Applies to Massachusetts Employees Only :ERTIFICATE 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 --,- C- C)1988-2010 ACORD CORPORATION.All rights reserved. ►CORD 25(2010/05) The ACORD name and logo are registered marks of ACORD r Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstrkpCthairi IS`tpervisor CS-081206 A Ey[yires: 02/22/2020 Wit, ' TIMOTHY KLINK' , q 240 PLEASANTAtAY HARWICH MA 02645 ,-._ .= . . ' i r 1{,� V NCR• ' Commissioner CI— .3, Fwi,iii,,,,,/ ,,74i i21' Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation Re gL ` — Expiration 137298`' 11/05/2020 LAND CAPE,INC. D/B/A COASTAL LAND DESIGN TIMOTHY D.KLINK 4665 ROUTE 6 ae- -- EASTHAM,MA 02642 Undersecretary