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HomeMy WebLinkAboutBld-20-004026 01,YRR .10ttice Use Only • �O Permit# O ' 140 . . y j Amount D M ,•- CSE 1 �`°"a'"`°"9 cad Permit expires 180 days from issue date LD—' v—fie U EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 C L-013 CONSTRUCTION ADDRESS: ` X (4 ) CO M rDQ e- t�U l` VA a fug,..- N ASSESSOR'S INFORMATION: 1t A Map: ( 9 Parcel: .-�' OWNER::Rut,.... I- u.'frt\,'L O.> NAME PRESENT ADDRESS TEL. # CONTRACTOR: /"',+tictr+'L.'li 9 II i'vtn Ad Sr tv 4., ' mn 0/tee./ (9 te)ere- ?ter NAME MAILING ADDRESS TEL.# Residential ❑Commercial Est. Cost of Construction$ 2-6, 50041 car 130275 CSU'? /.5'1 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) E I am the homeowner ❑ I am the sole proprietor 9 I have Worker's Compensation Insurance 1 Insurance Company Name: ft-Le yIV.1‘(t- 1.4-/A•✓4e_ Cgap ,Comp.Policy# S-Pc 000 O 7/s72 111 WORK TO BE PERFORMED Tentr Duration (Fire Retardant Certificate attached/?) �Q i Wood Stove 1Zing: #of Squares 13 ,,Replacement windows: # Replacement doors: # s t6) 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: S 15 >V x gU i; 3 9 - </O00 O 6/ltar 74/ Location of Facility J` l/Z 440 v Q�cL� '�„Mi! N'�,4 I declare under penalties of perjury that the state nts 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 ford evocation of m li ense and for prosecutio nder M.G.L.Ch.268,Section I. Applicant's Signature: Date: / JN'v u ZU Owners Signature(or attachment) C Date: A., ZZIZ,V Approved By: Date: 1 11•1•""14-0 Building Official(or designee) EMAIL ADDRESS: ISOM (c p,4 u Li LAN-0054 1 Pei'. coon Zoning District: Historical District: ❑ Yes No Flood Plain Zone: D Yes E No Water Resource Protection District: Within 100 ft. of Wetlands: ❑ Yes ❑ No ❑ Yes 0] No The Commonwealth of Massachusetts e 1 2 Department of Industrial Accidents 1 Congress Street, Suite 100 .... „, ,/t" Boston, MA 02114-2017 o 1.4� .•`. 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 (Bushmess/Organization/Individual):PA 1A.L'-c L AAA,s e 4 e li S ell A.e- / ./W iffn,- /¢u9k�-z,2-'Address: 9 Mit r„i S i# vV T. r�.rr.� A s�� r y�.in 01 el, 1 ctee - City/State/Zip: C/U2 t,ek sn.ta nhv, nAt1 Phone 4: 9 7tf 6 s6 ` 7 Z`°5*` Are you an employer?Check the appropriate box: Type of project(required): I.®I am a employer with .3 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. g Remodeling any capacity. [No workers'comp. insurance required.] 9. ❑ Demolition 3.❑I am a homeowner doing all work myself. [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 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. 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 152,§1(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box 41 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-contactors 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: l-FAa-try r v l l (ie. ►s .,•..t Policy#or Self-ins. Lic. #: E e 000 00 7/S 72 i'', Expiration Date: O i f/C /2 o z-/ 7 Job Site Address: G GO Ass Oa kit S I' ,,,,� OM pi C.y City/State/Zip: ou t14n 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 DR for insurance coverage verification. I do hzby certify under th,•ns and penalties of perjury that the information provided above is true and correct. Signatur ....„....2,„ ....A -----.._ Date: i 3 J-4 h/ 7--4)7c7 7e ec/y - 7se0 97e 6s'? fir' Phone�: '7 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License r 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#: (D.We tPnin~Nivea&tCtyllawac✓ume to Moe of Consumer Make&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPre;Individual %t 1" _ 0?J1t1/2020 PAUL'S LAND SUPPLIES,LTD l ROBERT P.AUTO. -a 23 MILAN AVE. NORTH WOBURN,MA''0i801 Undersecretalyl�;�� l 1 Commonwealth of Massachusetts Division of Professional ure Board of Building Regulations and Standards Const t'th1lA rvlsor j empires: 1111012021 CS-071532 . r '� ROBERT P A�TEN °rot f 23 MILAN An ��1 ,°� - N WOBURN MA 0 E � 4t; Commissioner '" 1�,c,.�.4.)1/ U 4- • i AR D CERTIFICATE OF LIABILITY INSURANCE 1/13i202°0 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 oertifioate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER C°"E Ci Boynton Insurance Boynton Insurance Agency �,,�EE,Exth (781)449-6786 I, )_ (781)449-4269 72 River Park Street ss:certificates@boyntonins.com INSURERS►AFFORDING COVERAGE NAIL N • Needham MA 02494 INBURERA:Harleysville Insurance Company INSURED INSURER B:Safety Insurance Company Paul's Landscaping Service & Supplies LTD aNsuRERC:Hartford Fire Insurance Company 917 Main Street INSURER D: INSURER E: Wilmington MA 01887 INSURERF: COVERAGES CERTIFICATE NUMBER:cL1312906417 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 ADM SUER POUCY EFF POUCY EXP LTR TYPE OF INSURANCE INSR INVD POLICY NUMBER (AAVDDIYYYY) IWAIDDIYYYY) , LIMITS GENERAL WU3RJTY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ 100,o00 A CLAIMS-MADE El OCCUR MED EXP(Any one person) $ 5,000 8PY00000071572M 1/18/2019 1/18/2020 PERSONAL&ADV INJURY $ 1,000,000 1/18/2020 1/18/2021 GENERAL AGGREGATE $ 2,000,000 GGEEN'LAGGREGA�TE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X,POLICY I I.IIFCOT LOC $ AUTOMOBILE IJABII fY COMBINED SINGLE LIMIT (Ea accident) $ 500,000 B --_ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED g SCHEDULED 5900824 1/18/2019 1/19/2020 BODILY INJURY(Per accident) $ I—_ AUTOS _ AUTOS cident) X HIRED AUTOS X AUTOgWNED 1/18/2020 1/18/2021 ((Pe DAMAGE $ $ — UMBRELLA LAB — OCCUR EACH OCCURRENCE $ EXCEIU LJAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION WC STATU- I OTH- AND EMPLOYERS'LIABILITY YIN TORY I NITSER ANY PROPRIETOR/PARTNER/EXECUTIVE ED DBNSCCL7978 1/21/2019 1/21/2020 OFFICER/MEMBER EXCLUDED? NIA E.L.EACH ACCIDENT $ 500,000 C (Ma/datoryln NH) 1/21/2020 1/21/2021 E.L.DISEASE-EA EMPLOYEE $ 500,000 n yes,describe wider DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS(VEHICLES(Mach ACORD 101,Additional Remarks Schedule,If mac.space Is required) CERTIFICATE HOLDER CANCELLATION binkley@yarmouth.ma.us • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. Inspectional. Services Attn: Brad Inkley AUTHORIZED REPRESENTATIVE 1146 Route 28 South Yarmouth, MA 02664 _ A—A , ' I Joseph Micik/JPM `d�t,I�.iC /i/rl ACORD 26(2010/06) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD