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HomeMy WebLinkAboutBLD-20-003456 Office pap / • P 1 t2 ID /,56. 4 /aS.O �*( '-]; Amount '_� MATT M CS( �•' Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 /3 SIAS0)) / CONSTRUCTION ADDRESS: /qy Cj'e c g'A'L(t S ASSESSOR'S INFORMATION: Map: Parcel: /35 OWNER: � (1 1 7 Gt li C' -Q- ri (cf tM t;�A 5 7 / '�" G�0 NAME PRESENT ,� ADDRESS TEL. # CONTRACTOR: ZeA._ � 57)11)4tr^ Si-- 1 1 ,?/I` '72 Z U NAME MAILING ADDRESS TEL.# ` i sidential 0 Commercial Est.Cos of Construction$ /�£D Home Improvement Contractor Lic.# /7 f ACP l Construction Supervisor Lic.# 0 97-S 7 Workman's Compensation Insurance: (check one) k❑ I am the homeowner ❑ I am the sole proprietor have Worker's Compensation Insurance surance Company Name: A 55 a Ci 7j) e-2144�/ Worker's Comp.Policy# Ale 6 5o()50 WORK TO BE PERFORMED aa` /1 Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 3 Replacement windows:# Replacement doors: # I 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: *neM ik r/i in Locati 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 denial or re on of my license d for prosecution under M.G.L.Ch.268,Section 1. -7 i Applicant's Signature: /� ��'� Date: / 2 - 1 / ' I Owners Signature(or attachment) . ,{ Date: r1 Approved By: Date: 1 eF 1 1 7 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No Harwich Ecumenical Council for the Homeless, Inc. (HECH) Housing Emergency Loan Program General Contractor and Owner Agreement Attachment A NOTICE TO PROCEED To: Ken Moniz, Moniz Home Improvement, Inc.: You are hereby given authorization to proceed with the renovations at 17 Uncle Ephraim's Rd, South Yarmouth in accordance with the General Contractor and Owner Agreement dated November 21, 2019. The work is scheduled to begin on November 21, 2019 and to be completed on or before February 29, 2020. Owner: amela Anderson Date II- a r- itness : Kimberly B ea, HECH Program Manager Date tie;er>w.aapun SP9Z0 WI HOIMWWHH INOY NMN OS ZINOW H13NN3N • ZINOW HI3NN3N 0Z0ZJ60/L0 L9ZSLL 5546:111122 tenPIAIPui:3dJiJ 210.LOVaiNO31NSW3AOMdWi 3WOH uogeln6eu sssulsng siael{y Jewnsuo3 to solllo r/j✓fv vir-ri/ •fu fy,Jd✓iiru�riuf✓2 rue. .4-4 _....._.. .,n._"„see cy�.. • Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor CS.$97544 Expires: 12/11/2020 KENNETH MONIZ 50 MAIN STREET EXT. HARWICH MA 026451,,sr Ty Commissioner V • • • • The Commonwealth of Massachusetts � A __ __ 1 Department of Industrial Accidents 1 Congress Street, Suite 100 =-• i_ Boston, MA 02114-2017 "maw.5. www.mass.gov/dia ` Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): /'tom (`2 1 �, ItrAtANANkt.t -)-- Address: ') )P irrv1 5) �>er City/State/Zip:4100 r/� /1/1 ©%i-(a y Phone #: -77 Uf Are you an employer?Check the appropriate box: Type of project(required): I.k`am a employer with Z employees(full and/or part-time).* 7. 0 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. 9. ❑ Demolition ❑ y [No workers'comp. insurance required.]` 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition 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 5.1:11 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13 RIZoof repairs These sub-contractors have employees and have workers'comp.insurance.= 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other `j', Gc!<.// 152,§1(4),and we have no employees. [No workers'comp. insurance required.] y�jzJ� *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. r 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: pe;.74Eir rmi/ Policy#or Self-ins.Lic.#: (i.)CC- 5Z7) 5 5Z) 1 .77 2/0/9,A Expiration Date: ''/2 D/ie5 Job Site Address: '" l� /01/7(6-•... / (' City/State/Zip: 0,-Qi 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 certify er the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: / Z f 7 ./ 7 Phone#: 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#: ___,.........IN KENNMON-01 _AMBLER '`* Rom! CERTIFICATE OF LIABILITY INSURANCE �"7/� _ ' 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER Warr Rogers,83Gray Insurance Agency,Inc. N Eck( ) Fax 434Rte 800 553-1801 1 tarc,No:(877)816-2156 South Dennis,MA 02660 �: rsgmycom INSURER(S)AFFORDING COVERAGE NAIC a INSURER A:Main Street America Assurance Company 29939 INSURED NSURERB:Associated Employers Insurance Company 11104 Moniz Home Improvement Inc. INSURERC: 50 Main Street Extension INSURER o: Harwich,MA 02645 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ELTR ISR ADOLSUBR POUCY EFF POLICY EXP TYPE OF SEANCE USD MD POLICY NUMBER IIENDIEMY1 orsvoorerm users A X cowman amen UABIUTY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE n OCCUR MPTs148W 5/3/2019 5/312020 PULSES a occurrence) S 500,000 MED EXP(Any one person) S 10,000 PERSONAL&ADV INJURY S 1,000,000 GE AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE S 2'000,000 GEM X POLICY n.IECT LOC PRODUCTS-COMP/OP AGO S 2,000,000 OTHER: S AUTOMOBILE UMeUTY (Ea SINGLENED LIMIT S — ANY AUTO BODILY INJURY(Per person) S PTO ONLY _ AAUUTTO�S�Np�DU BBOOpDIIL�YII�NJJUpRgY�(pPeraccident) S _ AUTOS ONLY _ VMS (Per eEcrin) GE S S — ILIA L� — OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE S DED RETENTION S S _� PER_ OTH- B ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y 1 N WCC-500-5018757-2019A 6/20/2019 6/20/2020 EL EACH ACCIDENT S 100,000 EXCLUDED? N NIA EL DISEASE-EA EMPLOYEE S 100,000 If yes, describe under 500,000 DESC RIPTION OF OPERATIONS be ow EL DISEASE-POLICY UNIT S DESCRWTION OF OPERATIONS I LOCATIONS/VEi5CLES(ACORD 101.Adr#tlonal Ramada Schedule,may be attached a more space is CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES B LCANCELLED BEFORE For Information Only - THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I C .--..):Arar;i1 ACORD 25(2016/03) 0 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD