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HomeMy WebLinkAboutBld-20-4279 0 1;YRR voice use only Permit# O . - • . H Amount '*'+wnu°*-cad Permit expires 180 days from -_' {issue date &D--Zo -(4 Z-7 Cj EXPRESS BUILDING PERMIT APPLICATION ___._ ___._.v.... . TOWN OF YARMOUTH RECEIVED Yarmouth Building Department g""".. i 1146Route28 South Yarmouth, MA 02664 FE + 1_tS?_i.l. (508) 398-2231 Ext. 1261 Lil -- A�_�� CONSTRUCTION ADDRESS: la ft g.... ( opt gb LA). /18-Ro1cyjt 14- ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 'DOOM; ZoLLYsg;. IV. f3€iFvER 81ROOlz RD .508-6q q- ?1 i 7 NAME PRESENT ADDRESS TEL. # CONTRACTOR: He0JT' FERSSaa\l ,a Colo 0y ( U Bout? 1lE_ S S-3ba-acme, NAME MAILING ADDRESS TEL.# 13 sidential D Commercial Est.Cost of Construction$ 7 o`L b. Home Improvement Contractor Lic.# 1 7 3 73 Construction Supervisor Lic.# 7 Workman's Compensation Insurance: (check one) ❑ I am the homeowner D I am the sole proprietor -I have Worker's Compensation Insurance Insurance Company Name: ,j i[3aRTY #)1u17,)f4r Worker's Comp.Policy# lX .-31 5 361 Z1S WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares j a... ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: ,/J f ii ttJ r 1-- pt.)AP 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: `J Ati -Re Date: .2/41/0/0 Owners Signa ure(or attachment) Date: Approved By: _/�L.. Date: d�- L - O Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes = No Flood Plain Zone: ❑ Yes 2 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes G No G Yes _ No 75' °bin woDo( Gt L)- ed Tarr) t rii," 0,01-0 Zob eeRsSDr1 w(Npou..)s .Q,a at31.,care✓ 1;,,,.. The Commonwealth of Massachusetts i'f Department of Industrial Accidents 11.1.„, ' /I", 1 Congress Street, Suite 100 - • Boston, MA 02114-2017 °,M,�5.,%-s 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): /A j-T RSA Address: a a CvioAiY 407- City/State/Zip: Boo,4 NE. Ma oa-34.. Phone #: 57)S 3(00 Qjo(i, Are you an employer?Check the appropriate box: Type of project(required): I.2[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. ❑ Remodeling any capacity.[No workers'comp. insurance required.] 3. I am a homeowner doing all work myself. 9. ❑ Demolition ❑ y [No workers'comp. insurance required.]t — 4.❑I am a homeowner and will be hiring contractors to conduct all work on m YP property. I will 10 _ Building addition 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#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: d/,B&—V 111OTV12—. Policy_or Self-ins. Lic. n: /du c.-4, I S 34u (03 Expiration Date: E3/7 /Q o.o Job Site Address: la._ $ai4k/aEA SR00 c& R City/State/Zip: / r Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date:.214f/o/0 Phone 4: k$ 3e,o 090lo 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=: Commonwealth of Massachusetts litDivision of Professional Licensure Board of Building Regulations and Standards ConstructioupIel rviSpr Specialty CSSL-099507 ,) i Epires:01/0212022 KENT E PERSSON ,1 22 COLONY AVENUE , / BOURNE MA 42532 L. CommissionerAA-4)1( . , .. (1---- I r cue �immosuoeade6y4Aemsacmeli __ __ Office of Consumer Affairs&Business Regulation HOME IMPRO EMENT CONTRACTOR TYPE Corporation cam ` _J�-11105/2020 PERSSONC = i,< 4 C KENT E.PERSS� i!! ' �k 22 COLONY AVE.`za i r BOURNE,MA 02532 Undersecretary J i ACO U® DATE(MMIDONYYY) CERTIFICATE OF LIABILITY INSURANCE 08/29/2019 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 INSUREIt(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 Deborah Hathaway GH DUNN INSURANCE PHONE/ No. ; (508)759-3132 FAX ,N,); ADDRESS: deborah@ghdunn.com 215 MAIN ST INSURER(S)AFFORDING COVERAGE HAIL BUZZARDS BAY MA 02532 INSURERA: LM INS CORP 33600 QNsuRED INSURER B: PERSSON CONSTRUCTION INC INSURERC: INSURER D: 22 COLONY AVE INSURER E: BOURNE MA 02532 INSURER F: COVERAGES CERTIFICATE NUMBER: 443186 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 IMMIDD/YYYY) (MMIDD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO REND CLAIMS-MADE OCCUR PREMISES(Ea occuTEnence) $ MED EXP(My one person) $ N/A PERSONAL&ADV INJURY $ _GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ACT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ NON-OWNED AUTOS AUTOS PROPERTY DAMAGE HIRED AUTOS AUUTOSTOS $ (Per accident) UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ -43ED RETENTION$ $ WORKERS COMPENSATION X PER ERTUTE OT H- ANOMMPLOYERS'LIABILITY A ER ACRE IMIM�EX THE ED ECUTIVE WA WA WA WC531S363103039 08/07/2019 08/07/2020 E.L.EACH ACCIDENT $ 500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I 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.gov/Iwd/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 Heritage Corporation ACCORDANCE WITH THE POUCY PROVISIONS. 1231-2 Washington Street AUTHORIZED REPRESENTATIVE Newton MA 02465 Daniel I Daaniel M.CLn y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Persson Construction, Inc. 22 Colony Ave. Bourne,MA 02532 Phone: (508)360-2906 perssonwindows@hotmail.com PROPOSAL SUBMITTED TO: PHONE: DATE: taoalt9 STREET: JOB NAME: ARCHITECT: 14- BEAVER &Wok RD. CITY,STATE AND ZIP CODE: JOB LOCATION: DATE OF PLANS: 61*VA II #,, 129- We hereby submit specifications for: Strip off old roof shingles from entire roof, and remove to the dump. Inspect roof deck. rN 51Rj-L. N kER. 0110114,1. Install a layer of 30 lb. felt paper on the entire-roof deck. Install ice and water barrier on all eaves and in all valleys. Install new aluminum drip edge on all eaves, new flanges on all plumbing vents, and new flashing where needed. Install new 50 year Owens Corning architect style roof shingles on entire roof. Shingles will be fastened using 6 galvanized roofing nails to insure 130 mph wind rating. REPP.4CE N1ot-DIL1G UNB£ik, TOFF 4N tittaK HOU5 ,. Color will be Itage/209, u Install ridge vents on all ridges. Job site will be left clean, and all debris will be removed to the dump. Start date (weather permitting) finish date MA HIC #173732 MA CSSL #99507 YOU HAVE 3 DAYS TO CANCEL THIS CONTRACT We Propose hereby to furnish material and labor-complete in accordance with above specifications, for the sum of: r s-0 seiFN -Thom sm -rjio HU VDR,..D Fein/ DO14.05 Payment to be made as follows: 4 3o0.°l Dow , sou SUCE.ON Cann&reread We are not responsible for satellite dish Authorized Signature: reception if we have to move the dish. YL' Note:This proposal maybe withdrawn if not accepted within 30 days. Acceptance of Proposal-the above prices, ) ,/ ) specification,and conditions are satisfactory and are Signature:-� i(lC t /�- c`�LZ!ct hereby accepted. Payment will e made as outlined. Date of Acceptance:t natty*a06 Signature: