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Home My WebLink Aboutbld-20-004037 �:. ;y9 l Office Use Only o R C. Permit# — O 1 .4.e.t - ti Amount 5C) ___'''JJJ g Permit expires 180 days from = 3�•••` issue date gL1�-C)u�4 D37 EXPRESS BUILDING PERMIT APPLICATI 0 NR EC E I V E D TOWN OF YARMOUTH Yarmouth Building Department JAN 2 2 2O2 1146 Route 28 Bull.t N ,; . _ South Yarmouth, MA 02664 By: _=, T (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 02 3.a v p/v7b ,/P(O/9D _Of/T N /SAW,01/7 1/ ASSESSOR'S INFORMATION: Map: i Parcel: ?W OWNER: iJ/ /, MO/S.S/9�/y NAME PRESENT ADDRESS TEL. # CONTRACTOR: //0.130A, EG Oaiv" j/ AVA/ro/e IF js✓ 1 ,tiS TAg/e 19 ,46S 7 j/836 68?c NAME MAILING ADDRESS TEL.# (Residential ❑Commercial Est.Cost of Construction$ 7000 Home Improvement Contractor Lic.# /5 1 lC-'1 9 / Construction Supervisor Lic.# 0 9 / / 07 Workman's Compensation Insurance: (check one) D I am the homeowner ❑ I am the sole proprietor II have Worker's Compensation Insurance�j / Insurance Company Name: Slt6Le 6E L Worker's Comp.Policy# /"I PT 848' . /- WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# . Replacement doors: # Roofing: #of Squares 19 ( �)Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing "The debris will be disposed of at: '►//91 fi•O✓r/1 P/5f oS041 / ,p v/'4 P T/g/'L7i f' // 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: Y Date: a'2/010 Owners Signature or attachment Date: 2 Approved By: �,G„_ Date: 1— 4— ,t1, Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes E No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No ❑ Yes _ No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ��.„s•`' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print LeQibt Name (Business/Organization/Individual): GG �L� /✓ e-Oiv Tea CT)Ory Address: /l7 MiWrvN � �w6 Zv. 8f941/(/.S 7/94 L6 � 2�( 0 City/State/Zip: IV- .3,,f e Phone #: 5 83C 66 95 Are you an employer?Check thee appropriate box: Type of project(required): 1.31 am a employer with J 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 all work myself. 9. ❑ Demolition ❑ doingy [No workers'comp. insurance required.] 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 6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E 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.El 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. 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: -,tom/cZE 6 EL Policy#or Self-ins. Lic. #: M P/ Expiration Date: _c/,3/02 a Job Site Address:02 S Q V1 A)TO £V City/State/Zip: Soinii ,V 'uT'`/ 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: G Date: l/°24 C Phone#: 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#: =basfcoaasn.NY6Lsas mLnsNsigokston HOME awe Y CONTRACTOR Registration valid for individual use only �eIndiddual before the aspiration date. Biowd return hoc OMbe of Consumer Affairs and was RapdsBon _ _OS 14/2020 1000 aDNtptan S weet-Suite 710 ADILSON SE ` _ `= Boston.YA 12110 DIB/A SEGOUN t ON t. Z../...T: r ON LANE .RNSTABLE,MA 0Zi56 - Not valid without signature undersaetery COrrMnOriM Ith of Massachusetts � Division of Professional Licensure � . Board of Building Regulations and Standards r Specialty Construy = P' i i CSSL-099907 _ spires:10/14/2021 ,4e,, may 117 IT BAReddtl si Commissioner , _yfi, __ • ACCORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) O5/17/19 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 WANED,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 Mg" JIM HINDMAN Schlegel&Schlegel Ins Broken o E rr. 508-771-8381 Marc Not 50&771-0663 34 Main Street AooaEss: schiegelinsteance*gmail.com West Yarmouth,MA 02673 INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A: NGM INSURANCE COMPANY 14788 INSURED INSURER B: AIM MUTUAL Adilson Segolini INSURER C: DBA SEGOUNI CONSTRUCTION INSURER D: 117 Minton Lane • INSURER E W Barnstable,MA 02668-1818 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 POUCY 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. , TV TYPE OF INSURANCE Jent pI p YY1ID POLICY NUMBER POUCY YN 1YY11) IY MYY1fYL LIMITS X COMMERCIAL GENERAL.LIABSJTY EACH OCCURRENCE $ 1,000,000 DAMAGE TO HEN[-ELT- CLANS-MADE500,000 0 OCCUR PREMISES(Ea occurrence) $ MED EXP(My one parson) S 10,000 A MPT8486U 05/07/19 05/07/20 PERSONAL.aADV INJURY $ 1,000,000 GEN LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 ECT LOC PRODUCTS-COMP/OP AGG $ 2+000 POLICY❑JEC $ ,000 OTHER: • COMBINED SINGLE LIMIT s AUTOMOBILE LIABILITY =Went) +IY BODILY INJURY(Per parson) $ -ANY AUTO 1 OWNED SCHEDULED BODILY INJURY(Per accident) $ _ AUTOS ONLY _AUTOS PROPERTY DAMAGE $ _ AHIRED UTOS ONLY _, AUTOOµ S O ONLY (Per accident) $ UMBRELLA LIAO OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ �y DED RETENTIONS�I $ Ig gRTUTE ' 'ERA WORKERS COMPENSATION AND EMPLOYERS'LAITY YIN E L EACH ACCENT s 1�•� ANY OFFICER/MEMBER EPROPRIETOR/PARTNER/EXECUTIVE/ME ❑ N/A AWC-400-7026025-2015 05123/19 05/23/20 10,000 B {Man datory in NH) EXCLUDED? N E.L.DISEASE-EA EMPLOYEE $ DES yetCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES MCORD 101,Addllianal Remarks Schedule,may be attached It more spats is required) ADILSON SEGOUNI HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CUSTOMER COPY AUTHORIZED REPR A E i 2015 ACORD CORPORATION. All rights reserved ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD PHILIP MOUSS LY 2 Sgwnto Ruud.SeYtb Yarnputh,MA D2 64,j 30Qd)i35 11fYwott i S� � Fy 0" i,tr';••ef".'"4::'''''-",1„,,,,J• 1•'''''f'•-•,f11 '' .�..' �,s,'" ofaw3lgwnedR0idh391aY + - gyp` 1e :',', . � h M g�3' cs -¢ a,w �- '� � by €ems a