Loading...
HomeMy WebLinkAboutBld-20-004587 O�••ygR uuIce use unsy O "�.yit C Amount s Cy R re TACn,pH.x __. c� `)(! f •�l� Permit expires 180 days from Cissue date EXP1ESS13 DING 4ERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231� Ext�.,1261 CONSTRUCTION ADDRESS: -�'r�� .... C/ /( _et*, et,,v ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 42/fee NAME y��� PRESENT ADDRESS TEL. c26000NTCTOR: h' / PW/ '� i �h $ uL { ?�/` L/ NAv1lE� MAILING ADDRESS TEL.6—v ✓t�67 JY ❑Residential ❑Commercial Est.Cost of Construction$)/ (S/ Home Improvement Contractor Lic:#€t f,ef 3 3 Construction Supervisor Lic.#-k /0y2 9/ Workman's Compensation Insurance: (check one) ❑ I am the homeowner ) I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: .\ Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares /© Replacement windows: # Replacement doors: # 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: , (7WO/ J e )c r_o 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 I. eA Applicant's Signature: Date: Owners Signature(or attachment) �/, ' " Date: y7- O ' ( Approved By: eJ / Date: Building Offi (or sign EMAI DRESS: Zoning District: Historical District: ❑ Yes 2 No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: C Yes 0 No a Yes _ No i` rt The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 'M UPIwww.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly 4";‘DRIV( Name (Business/Organization/Individual): CA"'kK Address: i 1/1/°' �j' City/State/Zip: Oc b` 0/ Phone #: 560- an employer?Check the appropriate box: Type of project(required): 40 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.HP 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. [No workers'comp. insurance required.] 9. ❑ Demolition �1. I am a homeowner and will be contractors to conduct all work on my10 ❑ Building addition C hiring 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 m1 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 contactors 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: ) / (2/'e f Policy or Self-ins. Lic. #: = o e_sz- Expiration Date: Job Site Address: �� /-(�12 City/State/Zip: Q„,, 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 imprisons ent, 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 er thep ' s and penalties of perjury that the information provided above is true and correct. Signature: - Date: �'/ .dp)° 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 m: ✓.d& (90/71...l.(J,M0eaLd d(l ✓UVCl..70U,OW./.vis y Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TARE:LLC before the expiration date. If found return to: Rea t1aU Expiration Office of Consumer Affairs and Business Regulation 07/16/2020 1000 Washington Street-Suite 710 cA"GRADE E� 6 ; (1ONS.LLC Boston,MA S ILYA LAVRENOV j �._►-- 13 BIRCH ST (` HYANNIS,MA 02601 Undersecretary Not valid without signature t Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constr tttlIttlpyrvisor ij CS-107181 +� Eytpires:05/27/2021 ILYA LAVREJPIM' .w+ 13 BIRCH STREET ; i HYANNIS M Commissioner 4,/4. ••)/„ -- ACcoRe DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 02/20/20 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 COCONTACT JIMMY HINDMAN Schlegel&Schlegel Ins Broker PHONE NN Ext): 508-771-8381 FAX No): 508-771-0663 34 Main Street EmAIL West Yarmouth,MA 02673 ADDRESS: schlegelinsurance©gmail.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: NGM INSURANCE 14788 INSURED INSURER B: TRAVELERS A GRADE EXTERIOR SOLUTIONS LLC INSURER C: 393 BUCKSKIN PATH INSURER D CENTERVILLE,MA 02632 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE 10 REN CLAIMS-MADE n OCCUR PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 A MPT7484M 02/18/20 02/18/21 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PET LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 B OFFICER/MEMBER EXCLUDED? Y N/A WC-0183261 03/21/19 03/21/20 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CORPORATE OFFICERS HAVE ELECTED NOT TO BE COVERED UNDER THEIR CURRENT WORKERS COMP POLICY CERTIFICATE HOLDER CANCELLATION 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. 1146 ROUTE 28 SOUTH YARMOUTH MA 02664 ATTN:BUILDING DEPT AUTHO'2 ESENTATIVE ©1988-2015 RD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD