HomeMy WebLinkAboutBld-20-4723 Office Use Only
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a�.»...4 41 Permit expires 180 days from
[z! -Q0 L 713 `-is date
EXPRESS BUILDING PERMIT APPLICATION------a----
TOWN OF YARMOUTHRECEIVED !
Yarmouth Building Department - ,
{
1146 Route 28 ; FFk.x 701. ;
South Yarmouth,MA 02664
(508) 398-2231 Ext. 1261 :?L�aq ' T L
CONSTRUCTION ADDRESS: /IN /( 4 /6i 4-1, l�
V
ASSESSOR'S INFORMATION: -
nn Map: Parcel:
OWN /L //ER: -5 ,//i /yr/4Ird' al-4 ,4/-" �,rf r'(A 02(o 75 4'"/ 3- S-7�76 f 2
NAME PRESENT ADDRES TEL # Email Address
CONTRACTOR:441aa Vex-(16-f''Epslon,LLt o alevoteIvalgs sea !TA ',Abu rn/114 (7 8 I) g 32.-`'18o b
NAME MA1IdNGADDRESS olro I TEL# Email Addr,
side iial Commercial Est.Cost of Construction$ •/6 OS —
Home Improvement Contractor Lic.# /46 025" Construction Supervisor Lie.# 072.774
Workman's Compensation Insurance: (check one)
I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance
Insurance Company Name: 41..S )G ia�Eotn 6.Floy�r c Worker's Comp.Policy# 41 C G-SWS 0 1 X -l--
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# Replacement doors: # 2
.5/,Ser5
Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation
MI/e) &d Kings Highway/Historic Dist. (liplacing like for like
*The debris will be disposed of at: .icle t L?/1Cc 4 y. l e/I- G✓t;4 veil , /1 A
1 Location of Facility
I declare under penalties of perjury : the s -411'' ,iiliF, <.4.v•II-. 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 re .
�r;�, .. . _ •.... . . M.G.L.Ch.268,Section 1.
Applicant's Signature: .4"�� " \ Date: 2 -.2-6 `2.0
Owners Signature(or - ., ) A ' I te:
Approved By: 7-1-re:" ir. .
case(or designee)
Zoning District
Historical District Yes No Flood Plain Zone: Yes No
Water Resource Protection District Within 100 ft.of Wetlands:
Yes No Yes No
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OAP**4019110, i.K1.4001/40co.oft,Irar• 04046.1x#k* ' •
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
struCt1Or Superpsor
CS-072772 Expires: 04/07/2020
JEFF C STEELE
24 SHERWOOD AVE q i
DANVERS MA 01923
Commissioner alwe
- 4' i(I-HI,IMIlllffi/ t/ `f UJ.074/IJFfff:
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:LLC
Reoistratlon Emiratan
168025 04/11/2020
WINDOW WORLD OF BOSTON,LLC.
JEFF C.STEELE �fc ---
15A CUMMINGS PARK
WOBURN,MA 01801 Undersecretary
C ,a (_,):i! of 9�,i i,..:,'. ! .11;J .11 2f
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=`- ==� Bosto , :trW4 0 1_1-I-2017
',,- % www.mass.s ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE 1i 1LED Will THE PERMITTING AL'i'HORITY.
Applicant Information ,( Please Print Legibly
Name (Business/Organi7ation/Individual):,[-/j•,ijS7on �Je/2I�4 f-</1C'. �gi4 ,i c76 'kidrf'e/o-�La s'itvl
Address: 15 ,A Ct )m n. , i s r`K,
City/State/Zip: Li),► M.0 • Phone#: 7 'I - 1 Z-- p()
Are yoq an employer?Check the appropriate box: Type of project(required):
1.frb�fI am a employer with . 0 employees(full and/or part-time).* 7. 0 New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 3. El Remodeling
any capacity.[Io workers'comp.insurance required.]
9. ❑Demolition
3.0I am a homeowner doing all work myself Qo workers'comp.insurance required.]
10 0 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 11.0 Electrical repairs or additions
proprietors with ao employees. o
1 El Plumbing repairs or additions
5 0 I am a general contractor and I Have hired the cub-contractors listed on the attached sheet.
13.0Ro frepairs
These cub-contractors have employees and have workers'comp.insurance.:
14. Other fQ,'1lio An(
5.❑We area corporation end its offrcers nave exercised their right of exemption per YIGL c.
152,31(4),and we have no employees.,No:workers'comp.insurance required.] ( ,. .,..a.1
*Any applicant that checks box 41 must also 3Il out the section below showing their workers'compensation policy nlormation.
I.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 Sgjc, Gt +e 4 Eir ioye.r- 5 —
Policy 4 or Self-ins.Lic.#: titre C. -5 DO- SO i'(,O r'1- 2 O l ci, Expiration Date: 4— j- 20
Job Site Address: f 1/ / /i S C- r b4-1 City/State/Zip: /�isaIA P' /?A
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expirmition date).
Failure to secure coverage as required under 1MIGL 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 'olator.A co o this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verific 'on.
I do hereby certi and he pa' a .4 enalties of perjury that the information provided above is true and correct.
Signature: Date: Z —,2.o
Phone 4: 8- 8- 4 3 ' Si
Official use o 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#:
_ i SATE!ItIM/DDIY`^�!I
,4CQRD CERTIFICATE OF LIABILITY INSURANCE 03/26/19
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 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 CON NAME:VT amy roberts
M.P.Roberts Insurance Agency Inc. a/c No.E:d): 978-683-8073 FAX No): 978-683 3147
1060 Osgood Street ADDRESS: amytmprobertsinsurance.com
North Andover, MA 01845
INSURER(S)AFFORDING COVERAGE NAIC At
INSURERA: WESTERN WORLD INS COMPANY
INSURED INSURER B: MERCHANTS INS COMPANY
L&P BOSTON OPERATING,INC INSURER C: ASSOCIATED EMPLOYERS
DBA WINDOW WORLD OF BOSTON INSURER 0:
15A CUMMINGS PARK
WOBURN, MA 01801 INSURER E:
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.
INSR AUULOUDIC POLICY EFF POLICY EXP
TYPE OF INSURANCE
LTR INSR WM POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
TO D
CLAIMS-MADE X OCCUR PREMASES(Eaoccurrence) $ 100,000
MED EXP(Any one person) $ 5,000
A NPP8525379 04/05/19 04/05/20 PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY n jE 6 LOC PRODUCTS-COMP/OP AGG $ 1,000;000:
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
B - OWNED X SCHEDULED MCAI002569 04/05/19 04/05/20 BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
x HIRED NON-OWNED PROPERTY DAMAGE $
_ AUTOS ONLY _ AUTOS ONLY (Per accident)
. $
X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000
EXCESS UAB CLAIMS-MADE AN065362 04/05/19 04/05/20 AGGREGATE $ 1,000,000
DED RETENTION$ $
WORKERS COMPENSATION
AND EMPLOYERS'LABILITY X STATUTE ER
IA
C ANY OFFICER/MEMBEEREXCLUDED?� ECUTIVE i N/A WCC-500-5018609-2019A 04/05/19 04/05/2Q E.L EACH ACCIDENT $ 1,000,000
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
EVIDENCE OF INSURANCE ACCORDANCE WITH THE POUCY PROVISIONS.
AUTHORIZED REPt NTATIVE
/1.4t6 '.--)L-'
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