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HomeMy WebLinkAboutBld-20-004156 Office Use Only Permit# Oi y: Amount ,A �n• „ cs •-,%)a%me o*",; ,: Permit expires 180 days from 6W---2()-- 1 I S issue date EXPRESS BUILDING PERMIT APPLICAT[ 1~ C E 1 V E TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 BUILD! , .��;-r NT • South Yarmouth, MA 02664 By /(508)/ 398-2231/ Ext. /1261. ) Q ,, �Q CONSTRUCTION ADDRESS: 4'Sl &i-C L_!v/a yt Rd, UM-- 1 v h, U. yak 1 "`" �v ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 7.1-1. - —Jos 11 30. - 921— 8I v NAME ��,, ''"" J PRESENT ADDRESS TEL. # CONTRACTOR: /�/SrotUfd0 Y pC€AIf .3.2 $LIthdwcIDr. fiyotwh-,s 77y-836 (65Cf / NAME ILING ADDRESS TEL.# `PlResidential 0 Commercial Est.Cost of Construction$ (72) toD Home Improvement Contractor Lic.# /90-6/C2 Construction Supervisor Lic.# 09Y/' 3 Workman's Compensation Insurance: (check one) ❑ I am the homeowner A❑/I am the sole proprietor E I have Worker's Compensation Insurancen t' / Insurance Company Name: D" /!'! it -.ht a1 Worker's Comp.Policy# 1 C-(1OO'7036(138.2o/Q,4 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# / Replacement doors: # / S l 1`cleX Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( ►1Replacing like for like Pool fencing *The debris will be disposed of at: Sg3. t X-C. c 00 Gy J Oevit€44..- oA!• S S. lZ41--/S Location of Facility I declare under penalties of perjury that the statements herein containe 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 f pros tion under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: / 9/ 20 Owners Signature(or attachment) Date: Approved By: _ /�, Date: - 1.y- ao Building Official(or designee)` EMAIL ADDRESS: Zoning District: Historical District: C7 Yes "i No Flood Plain Zone: C Yes r No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No r Yes No Ream' emtt.; / : rI chard@ ihs 6 ci !dr n . Aarf-L. The Commonwealth of Massachusetts ►"— �_.!/, Department of Industrial Accidents 1Congress Street, Suite 0_`:1` Boston, MA021142017 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): NHS /3 1-r-i/'C%/ keno cie-f1t�, Ike . Address: 3 2 ek.wood 0)-- City/State/Zip: Rya kt/'w sMfg O26°/ Phone#: `77 Li- ?3 - 6 6 s-se Are you an employer?Cheek the appropriate box: Typeof project(requi red): am a employer with 3 employees(full and/or part-time).* 7. New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t g ❑Demolition 4.0 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 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 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.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 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. f 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: A /IL? /14( - oc.f Policy#or Self-ins.Lic.#: A We-ct OO 703 6 L/ 369 O/q Expiration Date: O S/06`c2O,20 Job Site Address: 48/ &lel/s/ R.d. ttnifgg City/State/Zip: viestVQm sO ' MA 0Z67 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 p . an nalties perjury that the information provided above is true and correct Signature: Date: /2/C'�/ Phone#: -77(4—836-66cv 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): I.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: ,,'peel&,/ llr,�; .:,,rA,,,f/ Office of Consumer Affairs!�Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Coraoration Reaistretlon Fxplration 190612 02/09/2020 IHS BUILDING AND REMODELING,INC. RICHARD J.PECKHAM C2 32 BUCKWOOD DR HYANNIS,MA 02601 Undersecretary Commonwealth of Massachusetts e Division of Professional Licensure Board of Building Regulations and Standards Constructs n iSapervisor CS-094193 Ejtpires:07/29/2021 RICHARD J PECKHAS4 32 BUCKW00D DR. HYANNIS MA 42601 Commissioner Ac, r '" -- ACO® DATE(MMIDWYYYY) CERTIFICATE OF LIABILITY INSURANCE 05/31/2019 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). PRODUCER CONTACT NAME: Toni Davies GH DUNN INSURANCE PHONE ,Exth (508)759-3132 FAX .No): EA-MAIL aliusers@ghdunn.com P 0 BOX 99 INSURER(S)AFFORDING COVERAGE NAIC# W.WAREHAM MA 02576 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B: IHS BUILDING& REMODELING INC INSURERC: INSURER D 32 BUCKWOOD DR INSURER E: HYANNIS MA 02601 INSURER F: COVERAGES CERTIFICATE NUMBER: 409279 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 LIMITS LTR INSD WVD POLICY NUMBER IMM/DD/YYYY) (MMIDDIYYYYI 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 JJEE T LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY (Ea SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/AAUTOS BODILY INJURY(Per ac cident) $ AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ UMBRELLA W1B OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY ANYPROPRIETOA OFFICER/MEMBEREXCLUDED?ECUTIVE N/A N/A N/A AWC40070364382019A 05/06/2019 05/06/2020 EL EACH ACCIDENT $ 500,000 (Mandatory In NH) EL.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL 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.govllwd/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 Town Of Falmouth ACCORDANCE WITH THE POLICY PROVISIONS. 59 Town Hall Sq AUTHORIZED REPRESENTATIVE Falmouth MA 02540 `Daniel M.Cr 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 ti Signatures The signatures that follow constitute confirmation by those signing that they have examined and understand the Contract Documents and agree to be bound by the terms of these documents. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! This agreement is entered into as of the date written below. B ce Joslin, 0 er 11 VIC) (S' ature) (Date) �JC►� G-e._ fps 11 Y1 (Printed Name) IHS Building R deling,Inc, Contractor (Sig ure) (Date) acted Pee/a --4i, ,preria `. (Printed Name and Title) Page 10