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HomeMy WebLinkAboutBld-20-004743 .611*YqR + E. C \"" I '1 ' i ,, i Office Use Only e /�,�� e „;`,F C C C C1 , 2}�,. i Amount `_ � ,3 '�' `Permit expires 180 days from '� aWDE ARrMENI P Y :..:; issue date y r — — EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 3 19 S-}411 D r4 Pt V L.-- ASSESSOR'S INFORMATION: Map: Parcel: ,�I-{OWNER: 6 t= el- p L - L..0 4 tto E - 3 1 q 54► !IDIJ b4JI NAME PRESENT ADDRESS TEL. # CONTRACTOR: JL'OS qL .T Ae ►ty,4„ J3 ' . ,0C-1.�q?a J die Ags AA .3-agoo34 1I NAME MAILING ADDRESS TEL.# leJ'Residential ❑Commercial Est.Cost of Construction$ CP t-VbC) , Home Improvement Contractor Lic.# 1Cj5pl4 Construction Supervisor Lic.#&V 0l-I'el t 4,1 Workman's Compensation Insurance: (check one) ❑ I am the homeowner Cl I am the sole proprietor 24ave Worker's Compensation Insurance Insurance Company Name: I ' 4 e.g.„-Li kNA,v4 V,A,L Worker's Comp.Policy# 1.1)d a-3 Le G /.'C 9 19 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 1 S ( move existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: ` + 7 )(co ,.(,r)eU v 5 y✓L,. 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 " or revoca my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date:a — /e-2.0 / Owners Signature(or attachment)f•J ki/'Cl/1_, Date: Approved By: Date: —2 7— Building Official de " ee) EMAIL A ESS: Zoning District: Historical District: Li Yes 1 No Flood Plain Zone: C Yes C. No Water Resource Protection District: Within 100 ft.of Wetlands: Yes 1 No LI Yes C No The Commonwealth of Massachusetts Department of Industrial Accidents -i:gil 1 Congress Street, Suite 100 = I�^_ • 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 (Business/Organization/Individual): 4j.,q , ip.u.bh ,004. c— Address: 0044 City/State/Zip:f) \ <, ��b�� Phone#: .a dd 13a al-) 1 Are you an employer?Check the appropriate box: Type of project(required): I.E1 I am a employer with employees(full and/or part-time).* 7. 0 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 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑ Building addition 4.0 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.Q Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.alk.00f repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§I(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. :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: ` ,, e 0. t j a obty(_ — Policy#or Self-ins.Lic. (n 15 ' Expiration Date:L1/.).. /c2D Job Site Address: / _csi 6 i D i( 4 'e, City/State/Zip:y/ Jr? 'e >fo`irt 1/Vl Attach a copy of the workers' compensation policy declaration page(showing the policy ntfmber 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 hereb ;fy under 1 ains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: ' a a 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#: .//11 7/Y1t/i,/'/.+n'iv///4//. /(>11.:-.../e /tii//..' Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:LLC R '.`. ol Exratiwl 1 03/26/2021 SEASIDE ROOFING AND SING LLC JOSEPH JACINTO , 23 RIDGEWOOD RD ORLEANS,MA 02653 Undersecretary Commonwealth of Massachusetts • Division of Professional Licensure Board of Building Regulations_ and Standards Constructs oSt3pef/SQr Specialty CSSL-099163 spires 10/07/2021 . JOSEPH J JACINTO r 23 RIDGEWOOD ROAD, ORLEANS MA,02653 ",' _: Commissioner • ,, 7 ® DATE(MMIDD/YYYY) A n CERTIFICATE OF LIABILITY INSURANCE 04/18/2019 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 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 endorsements). PRODUCER CONTACT NAME: Craig vOkey CRAIG S VOKEY DBA MARK T VOKEY INSURANCE IA PHONE N/co.Ext); (508)945-3535 FAX NO): E-MAIL ADDRESS; craig@vokeyinsurance.com Y P 0 BOX 1247 INSURER(S)AFFORDING COVERAGE NAIC 0 WEST CHATHAM MA 02669-1247 INSURER A: LIBERTY MUTUAL FIRE INS CO _ 23035 INSURED INSURER B: SEASIDE ROOFING AND SIDING LLC INSURERC: INSURER D: 23 RIDGEW00D ROAD INSURER E: ORLEANS MA 02653 INSURER F: COVERAGES CERTIFICATE NUMBER: 391915 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. INSRY EXP LT ADDL TYPE OF INSURANCE INSDSUER POUCYNUMBER IMM/DPOLIDY�) (MM/DDIIYYYY) LIMITS LTR INSD,WVD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO-JECT I LOC PRODUCTS-COMP/OP AGG $ OTHER: $ BINED AUTOMOBILE LIABILITY (Ea accidentSINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ — _ AUTOSED SCHED AUTOSULED N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ — — EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE [ I ERH AND EMPLOYERS'LIABILITY Y I N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT 8 100,000 A OFFICER/MEMBER EXCLUDED? IN/A) N/A N/A WC231S615989019 04/26/2019 04/26/2020 E.L.DISEASE-EA EMPLOYEES 100,000 (Mandatory In NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS/LOCATIONS/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 POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth Building Inspector ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Main Street AUTHORIZED REPRESENTATIVE 7 South Yarmouth MA 02664 `�1. -M CL, I Daniel M.Cro ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD