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HomeMy WebLinkAboutBld-20-004314 O�.ygR orrice use unry �� ram! � Permit# o 4 y 5U ' t 'Amount `��,,TACn CSE �<*.,,A,0°''e . iPermit expires 180 days from ;issue date BLit--zu`131 EXPRESS BUILDING PERMIT APPLICATION_ .-.-- TOWN OF YARMOUTH P RECEIVED Yarmouth Building Department 1146 Route 28 FEB`i 5 2(12 South Yarmouth, MA 02664 I L (508) 398-2231 Ext. 1261 s �� CONSTRUCTION ADDRESS: 1 b 60 n o I1 n 14- ig j ASSESSOR'S INFORMATION: /� Map: Parcel: OWNER: CA eti'T D44-I .s (6 13 o G — 0 - / 1 ( /20( 330 ....9 g 6 - y0 7.S" NAME PRESENT ADDRESS TEL. # CONTRACTOR: / rue? . 'frriyii 50 arc,-rise 14 / Q eittjypee NA Sys- 6y8 - y35-IS-- NAME MAILING ADDRESS TEL.# E"Residential ❑Commercial Est.Cost of Construction$ $, G='J oe, Home Improvement Contractor Lic.# 140 3 S $ Construction Supervisor Lic.# c S'F4 a9 2 .8'Z Workman's Compensation Insurance: (check one) J I am the homeowner C I am the sole proprietor ' 1 have Worker's Compensation Insurance Insurance Company Name: /''Cce p((`k Cxst,ez .,zL 'La' Worker's Comp.Policy# L✓C..19 a 21 7 2 r 9 - 19 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # g 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: ne A igeet Fe, r( L✓ze S re 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 Signatures /7`b Date: 2. /31.24, Owners ' nature(or attachment) s-sDate: Approved By: / Date: a—s --, o Building Official esio EMAIL ADD Zoning District: Historical District: ❑ Yes : No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: D Yes ❑ No ❑ Yes _ No Dar) t• l 4- b �a.ne� M s ..ida The Commonwealth of Massachusetts 1? Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 `��,�5••`'•� www.mass.go v/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): Ors Ca,gs1,„rt 44.red S rre'Ie-k_ Address: 'u (J e c r Fie ( GA ie� City/State/Zippi sh et 07 - . 0)-6 'y Phone #: Cog (- i' y 3S-S Are you an employer?Check the appropriate box: Type of project (required): I. am a employer with / employees(full and/or part-time).* 7. 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 [No workers'comp. insurance required.]; 9 C Demolition — 4.E I am a homeowner and will be hiring contractors to conduct all work on m YProe PrY I will 10 — Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.C Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 6.E1 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✓�ijelpw ✓'c ' G�,-rr G•'� 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. 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:140k a I et. 4 #1 ( vt-v GG 0 Policy#or Self-ins. Lic. #: Lic 0 S L( 7- V.( •/ del Expiration Date: 77$11.t, Job Site Address:/6 I2a - - hu /Z5.t City/State/Zip:y4rwau- yrf& • 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: 1��z,c� Phone#: Cog- - 6V fr-y 3 S S 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#: i Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards / Constructiot46-0 &2 Family /i pines:0912312021 CSFA 092482 / AARON M SrtjtOM , I q • 90 DEERFIELL RD .t ., r MASHPEE MN)02649 1 Commissioner �� rye �omnozurea��o��aasoc>�u�ed/� • (--- Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR nd'nndual e �,� 10/13/2021 AARON STROP 'xI. DB/AD&SC it AARON M.STR �/ �� 2 90 DEERFIELD RD�4• ;W MASHPEE,MA 02649' Undersecretary A�® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 09/20/2019 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 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 CONTACT Michael Bonacorso NAME: Bonacorso Insurance Agency,Inc. PHONE (781)937-3200 FAX (781)937-3202 (A/C.No.Extl: (NC,No): 10 Cedar Street E-MAIL michael@bonacorsoins.com ADDRESS: Unit#32 INSURER(S)AFFORDING COVERAGE NAIC# Wobum MA 01801 INSURERA: Tri-State Insurance Co.of Minnesota 31003 INSURED INSURER B: Acadia Insurance Company 31325 AARON STROM DBA D AND S CONSTRUCTION INSURER C: 90 DEERFIELD ROAD INSURER D: INSURER E: MASHPEE MA 02649 INSURER F: COVERAGES CERTIFICATE NUMBER: 19-20 Master 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 SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE RENTED CLAIMS-MADE {1 OCCUR PREMISESO(Ea occurrence) $ 300,000 MED EXP(Any one person) $ 10,000 - A ADL5212747-14 06/04/2019 06/04/2020 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑jE7 n LOC PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ - A -OWNED SCHEDULED ADL5212747-14 06/04/2019 06/04/2020 BODILY INJURY(Per accident) $ AUTOS ONLY _ AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) HIRED/NON-OWNED $ 1,000,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS UAB CLAIMS MADE CUA5306818-12 06/04/2019 06/04/2020 AGGREGATE $ 1,000,000 DED X RETENTION$ NONE $ WORKERS COMPENSATION X STATUTE ERH- AND EMPLOYERS'LIABILITY Y B ANY PROPRIETOR/PARTNER/EXECUTIVE � NIA WCA5217284-14 07/08/2019 07/08/2020 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 INLAND NLAND MARINE A ADL5212747-14 06/04/2019 06/04/2020 EQUIPMENT $50,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Harwich ACCORDANCE WITH THE POLICY PROVISIONS. 732 Main Street AUTHORIZED REPRESENTATIVE Harwich MA 02645 t41 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD D & S Custom Homes and Remodeling 90 Deerfield Rd. Mashpee,MA 02649 508 648-4355 phone 508 539-0787 fax Work proposed to: Dan Adams Work to be performed at: 16 Bob o link In W Yarmouth Ma. Proposal Window Replacement The sashes in eight windows will be removed.The exterior stops will also be removed.The existing window frames will remain.New vinyl replacement windows will be installed. (vinyl windows to be provided by the homeowner.)They will be screwed to the existing window frame using the factory supplied screws. The windows will be sealed to the opennings using a white chalk.New pvc stops will be installed on the exterior of the windows. Rot repair The contractor recommends using a wood harder to repair any rot on the window sills.The sill will have any rotten wood removed, then a wood harder will be applied. It will be sanded smooth. Painting Painting is not included in this proposal. Disposal All debri to be removed by the contractor Totals Window install with pvc stops on the exterior, $1,580.00 Rot repair $ 150.00 Grand Total $1,730.00 All material is guaranteed to be as specified.All work to be completed in a professional manner according to standard practices.Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become a extra surcharge over and above the estimate. I am fully covered by both workers compensation and liability insurance. Authorized Signature: Date: / --- / ( )�'0 ,f / owner's Signature: