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Home My WebLink AboutBld-20-003933 OY.Y`9R 'Ottice Use Only - fib 3 3 >r :. dyl7! o 0 . 'h+!)l'it .�H. 1 Amount ` *°"""•'t°�9 cad 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 CONSTRUCTION ADDRESS: /9 -01,/, Jil- �- ' 2V, i#/a-/r/e4--'6fri""e". �� i ASSESSOR'S INFORMATION: Map: Parcel: -2- �// z OWNER: ��e4/t' /� ' e �� Q Y .017e- �Ii 2-6 „a�T N�f%} ,� P SENT ADDRESS TEL # CONTRACTOR:��)/eCt Ve.- AtVr2t- C. /j , ��G?4'Lc 57 /11di a7, NAME MAILING ADDRESS TEL.# ��! esidential 0 Commercial Est. Cost of Construction$ " residential Improvement Contractor Lic.# /95at' Construction Supervisor Lic.# �f 9 8 Workman's Compensation Insurance: (check one) D I am the homeowner ❑ I am the sole proprietor /V Q I have Worker's Compensation Insurance Insurance Company Name: Z� � ?1 / 4t(e CO. Worker's Comp.Folic} ` / �/ ` WORK TO BE PERFORMED Tent /Duration / (Fire Retardant Certificate attached?) Wood St e Siding: # Squares /S b of j Replacement windows: # Replaceme doors: # Roofing: #of Squares ( )Remove existing* ax.2 layers) Insulat Old Kings High y/Historic Dist. ( )Re cing like for like Pool fencing *The debris will be disposed of at: ,A147 712,... 014 S//e .:�/ 71` 12-1.-7 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 denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. /G .5 Applicant's Sie a Date: A / L o 2O Owners Signature(or attachment) Date: Approved By: Date: / ' /3 kJ.0 Building Official or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes 7 No Flood Plain Zone: ❑ Yes ri No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No E Yes _ No - . The Commonwealth of Massachusetts . i ,Jivfl, r Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 °,,M..5�•`' 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): /r-e t/--e /'!y-r�ie 5 4([ . Address: /59 X0/(/ Ae„,, ,_- W , 5 l City/State/Zip: /t f , Z6-) Phone #: ' '39 , 53r Are you an employer?Check the appropriate box: Type of project(required): )ZI I am a employer with l/ employees(full and/or part-time).* 7. ❑New construction _.❑I am a sole proprietor or partnership and have no employees working for me in g. ❑ 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.]t 10 ❑ Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contactors either have workers'compensation insurance or are sole 11.[ Electrical repairs or additions proprietors with no employees. 12.[Plumbing repairs or additions 6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[Roof repairs These sub-contractors have employees and have workers'comp. insurance.= 6.[We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Other G!/z2fG!4-1-r/s' 152,§I(4),and we have no employees. [No workers'comp. insurance required.] �i(ele. (7 *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. :Contactors 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: /f/• ,4r S - --7 — Policy 4 or Self-ins. Lic. 4: WC 785/9� Expiration Date: 1 3 e). Z 0 Job Site Address: /9 /!� --e--, -6_ City/State/Zip: Z/(/,, 2:1'712,,e...0-7--€94° 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: /. /3 . 2020 Date: Phone 4: c4' 9 4 7 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License 4 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 rr: Accmor CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 09/07/18 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 NAA10EA_ JIM HINDMAN Schlegel&Schlegel Ins Brokers,Inc. (A/CNN.Eat): 508-771-8381 Fa,No): 508-771-0663 34 Main Street E-MAIL ADDRESS: schlegelinsurance@gmail.com West Yarmouth,MA 02673 INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A: NGM INSURANCE INSURED INSURER B: LM INSURANCE COMPANY KREATIVE BARNS INC INSURER C: 159 OLD MAIN STREET INSURER D SOUTH YARMOUTH,MA 02664 INSURER E: INSURER F 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. INSR ADULBUBN POLICY EFF POLICY EXP LTR TYPE OF INSURANCE !NW WVD POLICY NUMBER (MM/DO/YYYY) (WOO/YYYY) , LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE 10 REN lED PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 A MPP5983J 08/28/19 08/28/20 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY JE¢ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ — OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS _ $ WORKERS COMPENSATION xPER AND EMPLOYERS'UABILITY STATUTE ERH B OFFICER/MEMBER EXCLUDED'ANY ECUTIVE YNN N I A WC-1185197 08/30/19 08/30/20 E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CORPORATE OFFIERS HAVE ELECTED TO BE COVERED UNDER THEIR CURRENT WORKERS COMPENSATION POLICY CERTIFICATE MAY OR MAY NOT BE IN EFFECT AT TIME OF PRESENTATION OF THIS CERTIFICATE,PLEASE CALL TO CONFIRM CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN CUSTOMER COPY ACCORDANCE WITH TH ICY PROVISIONS. KBARNSINC@GMAIL.0 OM, AUTHORIZED REPRESENTAT E I � ©1 88-20 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of RD Kreative Barns inc. Building&Remodeling CS No. 93798 Konstantin Aleksandrov DATE:11.2.19 159 Old Main Street Quotation #11219 S Yarmouth;MA;02664 Job Description: Windows, 508 904 0539;kbarnsinc@gmaiLcom siding Property Address: Contact Quotation valid Prepared For: Billing Address: Information: until:11.15.19 19 Bennet Ave Karen Huges W.Yarmouth MA Payment schedule AMOUNT 1. Prior work start—to order custom materials,pull permits-non refundable $7,846.00 2. At work start and delivery of materials $10,000.00 3. At completion of work as described $10,000.00 PLEASE MAKE ALL CHECKS PAYABLE TO Kreative Barns Inc. TOTAL $27,846.00 All home improvement contractors and subcontractors engaged in home improvement contracting,unless specifically exempt from registration by Provisions of Chapter 142A of the general laws,must be registered with the Commonwealth of Massachusetts,Inquiries about registration and status should be made to the Director,Home Improvement Contract Registration,One Ashburton Place,Room 1301,Boston,MA 02108(617)727-8598. Owners who secure their own construction related permits or deal with unregistered contractors will be excluded from the Guaranty Fund Provision of MGL c.142A. ACCEPTANCE OF PROPOSAL The Above prices and conditions are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. All material is guaranteed to be as specified. All work to be completed Authorized in a professional manner according to standard practices. Any alteration —— of deviation from above specifications involving extra costs will be Signature executed only upon written orders,and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to early fire,tornado, CII.StOlner and other necessary insurance. Our workers are fully covered by Signature Worker's Compensation insurance. Date of j2 2 r /7 Acceptance: