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HomeMy WebLinkAboutBld-20-004045 •O�.— g VllICC use V[lly k +� 4O i Permit# O ` '1'�� . '1 !Amount � A T CSCJ 'j °"'°""°"9: Permit expires 180 days from -' 8 �✓vdv" �t {Issu�e/d/ate 1 (� / V r � v EXPRESS BUILDING PERMIT APPLICATI TOWN OF YARMOUTH RECEIVED- Yarmouth Building Department 1146 Route 28 JAN 23 2Q? South Yarmouth, MA 02664 g (508) 398-2231 Ext. 1261 BUI p T (� By:CONSTRUCTION ADDRESS: 37 V e r n� rJ- S"�"f e'Z-' ASSESSOR'S INFORMATION: Map: Parcel: � ) OWNER: J c9'`� I IV C..< A- on �.= CO C `�7 7—C7 NAME PRESENT ADDRESS V/ R TEL. # CONTRACTOR: i1 A R- WWLL /f 7 CO �/I� /7 2 I l i/A S c I6:2- S9 / NAME MAILING ADDRESS TEL.# idential 0 Commercial�r Est.Cost of Construction$ 3) a OCU Home Improvement Contractor Lic.# /p 7(3p*/ Construction Supervisor Lic.# / ?O7 6, Workman's Compensation Insurance: (check one) I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: "Z././ I e- tc Worker's Comp.Policy# 62.Z!/9 Li/V99 PD 3 Ss/9 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # 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: Y/4'1&niOuTii 0 Cl Yil 1 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. Applicant's Signature: Date: /072..-a[y Owners Signatu (or ttachment) Date: Approved By: ,, Date: I - d.3 - dOd0 Building 0 icial(or designee) EMAIL ADDRESS: /1n1 cc!A/Roo F 11,16 6) 6iym 1 ` ,C 0 ill Zoning District: Historical District: 0 Yes E No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: bErnL) X ❑ Yes 0 No 0 Yes 0 No REmd nlVg c 1sr )u6 y /3n E V 4N rJ 5 fn/ ) i,v .4LL 1TH I.vj-l//`L `. � The Commonwealth of Massachusetts -. r _W,l,= IDepartment of Industrial Accidents _�� I Congress Street, Suite 100 _'. = C i�l= Boston, MA 02114-2017 '- „ 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): AI A a K AAw— '— /N Address: 7 C ON N ir h CA k) itq City/State/Zip: tuES r 1A Rrh0 UT .-/ Phone #: co as I ?i-?( Are you an employer?Check the appropriate box: _ Type of project(required): 1. I am a employer with employees(full and/or part-time).* 7. El New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp. insurance required.] 8. ❑ Remodeling 3. I am a homeowner doing all work myself. 9. ❑ Demolition ❑ y [No workers'comp. insurance required.]t _ 4.❑I am a homeowner and will be hiring contractors to conduct all work on myproperty. 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.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp. insurance.: 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(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. 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. Insurance Company Name: ' v 1 0- 1L Policy#or Self-ins. Lic. #: 6 2 Z v( � 4 S`(pa,) 3S'/ / Expiration Date: -SS.'-Doc) 6 Job Site Address: YJeS AQ rcL S4 City/State/Zip: 1l11 W\O ( '/ fro__ 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: Date: l" €2— Phone#: ' 0 L2 1 g' tr---f/ 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#: ' *n i C' SOX _ _ 5j--:_v_ __,..T., ------ JaKi-torrtion2oct & 3q OEWlicli [F • oo . a . : f . 64 4 •• • ---- /1- 7?-e--igy iciv-7-7-72/z . . r ,* �� Y)?L) tJ,t/ dooF/T �- ,s/D'� -7v . . . $ " C�l�YIQ '-Ci l O /Y! v1r 1 . gm ,i, :i use ��� s Alt .:. ft-7m,t/E-17 ci-,50e(z/DuA g 0 L-riliv, E cp) N ..1 �oi\AK.A1/) 2Indic N II 0 co c O P `1 C N N In . .. y{.:� .... C p J E _ \1�k 1A 0 , 2 o• ....7. -v _.t., s 54 ookh9-e,, s- .S:Liir 9 17)lool-el A 07 d C1 ce � Q�, 3 Z' i &(7— F77 --00FLIr- o,>m U =42 L. 0 uJ co a 1� C p ,as. U U DATE(MDD/YYYY) ACORCI® MI CERTIFICATE OF LIABILITY INSURANCE o1/22/2020 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 CONTACT NAME: Debra Martin MARGARET J GRASSI INSURANCE AGENCY INC (A/c.No.EMI; (508)295-2007 FAX (A/C,No): E-MAIL ADDRESS: debmjgins@comcast.net 1188 MAIN ST INSURER(S)AFFORDING COVERAGE NAIC# W WAREHAM MA 02576 INSURER A: AMERICAN ZURICH INSURANCE COMPANY 40142 INSURED INSURER B: MULLIN ROOFING & SIDING INC INSURERC: INSURER D: 7 CONNEMARA WAY INSURER E: WEST YARMOUTH MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 496599 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 SUBR POLICY EFF POLICY EXP W LIMITS LTR INSD VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED $ CLAIMS-MADE OCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JERCT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ — ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ ^ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE EOTH AND EMPLOYERS'LIABILITY A OF ICERP TM OFFICER/MEMBER EXCLUDED? E.L.EACH ACCIDENT $ 100,000 D ECUTIVE Y� N/A N/A 6ZZUB4N56223519 08/28/2019 08/28/2020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/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 issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Shaun Law ACCORDANCE WITH THE POLICY PROVISIONS. 22 Saddleback Road AUTHORIZED REPRESENTATIVE t. Mashpee MA 02649 Daniel M.Crq ni y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD