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HomeMy WebLinkAboutBld-20-004025 -; w r �� Office Use Only "O 4.1 0 Permit# / T ''' Amount 3 l D CS:,*:4■v E 1 Permit expires 180 days from ,1�--0--L-1 025 issue date EXPRESS BUILDING PERMIT APPLICATIO W E C E I V E D TOWN OF YARMOUTH Yarmouth Building Department JAN 22 20201 1146 Route 28 South Yarmouth, MA 02664 BUIL A =L.1D (5r,398 231 161 By.CONSTRUCTION ADDRESS: 6 ) R LiC)" & p.., Co ASSESSOR'S INFORMATION: �A A Map: 30'1 0� (,, `Parrce�l:QO`f o3 Q 'Q I OWNER: .1 4`eNC�, ` `(�.` GS r'�"'€�.C� `�ck �b8 3'6 Q_"J `ZZ NAME PRESENT ADDRESS TEL.CONTRACTOR C0 "``clesg' r?bg Vri r)1 /04"`T 02 6 � NAME MAILING ADDRESS TEL.# Sb�•�3'L rC`9Q l residential 0 Commercial(�- I`Z Est.Cost of Construction$ EL\ \1L11.5 S`'� Home Improvement Contractor Lic.# \k\Ck�v, t '6(14 Construction Supervisor Lic.#C$ 0R 7b2 3 tt It 4 Workman's Compensation Insurance: (check one) I am the homeowner I It am the sole proprietor VI have Worker's Compensation Insurance p �p^ Insurance Company Name:N l�� retACL�190,A Worker's Comp.Policy# 5 �-\NT 20t 1 A WORK TO BE ERFORMED Ti:i Z6 Tent`'l/k Duration 6(A (Fire Retardant Certificate attached?) Wood Stove rji ill Siding: #of Squares \_. Replacement windows:# f Replacement doors: # .... Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing ,e59 *The debris will be disposed of at: \A\� \' (,�S ( -��G 'O C\ Location of Facility I declare under penalties of perjury that a 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 revoc on of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: \\Z1\r b Owners Signature(or stem meat) !It... Date: Approved By: _....,' Date: ,' 1"1`— i'llV) Building Official(or designee EMAIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes r No Yes No en, •• r The Commonwealth of Massachusetts ► _- h�/, Department of Industrial Accidents ; I Congress Street, Suite 100 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 (Bu��siness/Organization/Individual) \ cg• . Address?<.C. )( ��� City/State/Zip: jiSA., ,tk\ C9-4A6 Phone#: % .• q9 Are you an employer?Check the appropriate box: Type of project(required): 1. a employer with AV 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.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑ Building addition 4.12I 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. 12.0 Plumbing repairs or additions 5.Ei I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t .11;44149,awA4 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. 'Other t 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. tContractors 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-contactors 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:(] \�S �,(1Cp (t1/4PC.t• Policy#or Self-ins.Lic.#:v3•lSIC�. %4M�[�`Q x iration Date: C'(\a�\20 Job Site Address:\a\t4.0 N1. 'ca City/State/ZipS*I% h tt\A OZio Y 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 verificatio I do hereby c . under the pains and penalties of perjury that the information provi d above is true and correct Signature: Date: \ .Z2"\20 Phone#: SAS eN31. 2299 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#: N W L� E CAPE COASTAL 1 UILDERS January 22, 2020 Re: Andrew N. Fowler 68 Lakefield Road South Yarmouth, MA 02664 Owner Authorization to permit To whom it may concern: I, Andrew Fowler, as the owner of the property located at 68 Lakefield Road, South Yarmouth, Massachusetts, hereby authorize Cape Coastal Builders, Inc., of Harwich Port Massachusetts, to act on my behalf in all matters relative to applying for, issuance of and work authorized by the Town of Yarmouth, Massachusetts Building Department permit. Thank you for your consideration in this matter. Andrew Fowler o ife 4/ 7^ //` Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation CAPE COASTAL BUILDERS Registration: 149685Expiration: 01/26/2020 P.O.BOX 827 HARWICHPORT,MA 02646 Update Address and Return Card. SCA 1 CS 20M-OS'17 III,CII/447 ._ 141...elf /II WY. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Beam Expiration Office of Consumer Affairs and Business Regulation 149665 01/26/2020 10 Park Plaza-Suite 51T0 CAPE COASTAL BUILDERS Boston,MA 02116 PETER HOPPLE HAROUTE 28 RWICHPORT,MA 02846 Undersec Not valid without signature • Commonwealth of Massachusetts ' Division of Professional Licensure y Board of Building Regulations and Standards C o n s t ruct$o r1ttx pe ry i s o r CS-092702 spires: 03/0112021 PETER V HOPPLE . '_C • 626 ROUTE 28 HARWICH PORT%MA 02MS r 1 w 1r� Commissioner Client#:27500 CAPC09 ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 1/22/2020 TtilS 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 ACT Stephen Mealey Sullivan Insurance Group, Inc. (A/C,NN,Est):508 791-2241 FAX 508 797-3689 1 Mercantile Street E-MAIL (A/C,No): ADDRESS: smealey@sullivangroup.com Suite 710 INSURER(S)AFFORDING COVERAGE NAIC# Worcester, MA 01608 INSURER A:Nautilus Insurance Company INSURED Cape Coastal Builders, Inc. INSURER B AIM Mutual : INSURER C: Eastern Atlantic Construction, LLC P.O. Box 827 INSURER D INSURER E: Harwich Port, MA 02646 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. LT RR TYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MM/DD/YYYY) (MM/DD/YYYY) A GENERAL LIABILITY NC482438 03/16/2019 03/16/2020 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occu ante) $50,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $5,000 X BI/PD Ded:500 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO- JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE _ AUTOS (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WCC50050084152019A 07/07/2019 07/07/2020 X TORY LIMITS ERH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Evidence of Liability Insurance on behalf of the Named Insured. Evidence of Insurance CERTIFICATE HOLDER CANCELLATION Andrew Fowler SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 68 Lakefield Road ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE 4r Gee ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD itC4QdF114/M47a7ROI Ker