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HomeMy WebLinkAboutBld-20-3440 1 Office Use Only s f ,:,,,, ,ld L. , i t , , ; Amount 6 o------ `v limit expires days from� EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: r4A, s: s� i',��� T� rbg,,,/7-)— ASSESSOR'S INFORMATION: Map: / // Parcel: '7 (it J f '7 i. OWNER: - /J Z.a/t r0,(./ '/6 /2L�I m,/vr f� ,-"/L $-‘)/;1/ 44-49 J 771 N �C (r C �AD / ,e3 A� x ?�7TF,L # CONTRACTOR: 4-'? 4'e/ xi A� "1/1/1 L_-STD'/i' //-'- /il, °.I�v 5/� NAME Mpdit,ING ADDRESS TEL.# s Residential 0 Commercial// /V 2 0,-- Est.Cost of Construction$ / Home Improvement Contractor Lid.# ` ". / CO Construction Supervisor tic.# /€7 J/ —b Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp-Polio)* WORK TO B FARFORKED Tent Duration (Fire Retardant Certificate attached?) Wood Stove V Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove e3isdng*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool/ fencing /7' *The debris will be disposed of ac 4,1-A-c/ /���'`�' (44A-7-1-0,4i /17• l` ' /ozy�C e. Ce../r"e— ! Location of Facility I declare under penalties of perjury the 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 ` of my prosecution under M.G.L.Ch.268,Section 1. 11 l Applicant's Signature: Dates / /U Owners Signature r a t) / Date / ::7c ' 7 ADDRIBS: Zoning District Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes D No D Yes 0 No j,r1)l rt, Le, i c tr) La,rs, . L, The Commonwealth of Massachusetts „_4yi gl, Department of Industrial Accidents Cj 1_ .0 1 Congress Street,Suite 100 _ f 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 rint Lenibly l/41y( ,�,# � a Name(Business/�O/•ganizatiort�/JI�ndividual):_//_ / �r �+��•�Gl�. /�' �� J Address: /VC / 1 L/l de (,�t✓. CA/ a) / 34 IL',. 1.1/'�''�". Al/ 'l ,l� City/State/Zipal 4 4t 111,72 e. 4 - Phone#:�7? 9' .9,)-6 l ©3'te P Are you an employer?Check thehe appropriate box: Type of project(required): 1. I am a employer with / employees(full and/or part-time).* 7. ❑New construction I am a sole proprietor or partnership and have no employees working for me in 8. ID Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 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 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0Roof 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. 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 insura ce for my employees. Below is the policy and job site information. ��' /�7 A C Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 veri •• ion. Ais i / I do hereby certi u #tlt,c -vi; . ' ' at the information provided above is true and c rect. ./ Date: /Signatur-• Ii O /7 Phone#: -.6 -0 f �V 9.1 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#: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE AIM. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 26158 POLICY NO. l AWC-400-7024208-2019A PRIOR NO. (AWC-400-7024208-2018A1 ITEM 1. The Insured: Scott Smith DBA: Chimney Care of Cape Cod Mailing address: P 0 Box 202 FEIN: * 7764 Marstons Mills,MA 02848 Legal Entity Type: Sole Proprietor Other workplaces not shown above: See Location 2. The policy period is from 04/27/2019 to 04/27/2020 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers'Liability Insurance:Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are. Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. I Total Annual Of I Annual Remuneration Remuneration j Premium INTRA 000859373 INTER SEE!CLASS CODE SCHEDULE Minimum Premium $550 Total Estimated Annual Premium $1,780 GOV GOV Deposit Premium $1,833 STATE CLASS i MA 9014 State Assessments/Surcharges $1,374.00 x 3.8300% $53 This policy,including all endorsements,is hereby countersigned by 4C-7-- 04/17/2019 Authorized Signature Dale Service Office: Twinbrook Insurance Brokerage 54 Third Avenue 400 A Franklin Street Burlington MA 01803 Braintree, MA 02184 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with Its permission. DATE(MM/DD/YYYY) ACoRD® CERTIFICATE OF LIABILITY INSURANCE 11/12/2018 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 CONTACT Robbin Street NAME: Veracity Insurance Solutions,LLC. PHONE A/C (801)763-1375 FAx (A/C,No): (801)763-1374 260 South 2500 West,Suite 303 E-MAIL street@veracityins.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC S Pleasant Grove UT 84062 INSURER A: Mesa Underwriters Specialty INSURED INSURER B: Scott B.Smith,DBA:Chimney Care Cape Cod INSURER C: PO Box 202 INSURER D: INSURER E: Marstons Mills MA 02648 INSURER F: COVERAGES CERTIFICATE NUMBER: 18/19 GL MASTER 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 W /Y LIMITS LTR INSD VD POLICY NUMBER (MM/DDYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ 5,000 A MP0004018003714 10/23/2018 10/23/2019 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO n LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT OTHER: Damage to Premises $ 100,000 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 YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance Only.Covers liability arising out of the operations of the named insured,subject to all policy terms,conditions and exclusion. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN FOR INFORMATION ONLY ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 6/18/2019 My Registrations r..,. i ottp:ll , ss.,,,,winds is an official application of the Commonwealth of Massachusetts " -1g.T.ISZaCt...4c2t1511MILaffikEiLik6102ELBaglislii2DJiltil)://vibminass.goviocabri). , Nlitionse Improientant i . Cantractur Pmglarn 1-422103sUltatM My Registrations • Your company Registrations and/or Applications with their statuses are displayed in the list below. • To manage or view any Registration, click on the appropriate Task button. • To register a new company as a Home Improvement Contractor, click the Start New Application button. Start New Application(/HIC/Register/CheckList?contractorld=0&applicationtd=0) iContractor HIC Registration Effective Expiration ApplicationfApplicationCreate 1 -------- L statue Date !Task Name NurnberStatus Date iDate Type 1 , re6-o-n- _04.:..._ ‘s,.. sue .. - - ; ; iltsibbasitult ' ,stvitil4 164A4as . ,---,e;112#2O1811**1O2O4Renewat' —/awed' t11127/2018-Nlariage Registi, SMITH Issued 1161642 Expired 11/12/2016111/11/2018'Renewal !Registration 11/01/2016 Manage Registi '-- ;SCOTT I 1 _I. ;Issued 1 kei r----- - --- -:-. 161642 11/12/2014111/11/2°16"Renewal i rdon 11/11/2014 Manage Registi] -t- "issuegistra ' . 't I 1CHIMNEY , 1 1Registration I 1161642 Expired 11/15/2012 11/14/20141Renewal 11/14/2012 Manage Registi, :CARE I. Issued • —1 ICHIMNEY ' 161642 Expired 03/18/2011103/17/20131Renewal iRegistratical 103/17/2011'Manage Registi CARE • 4-- ..............._.1 , Issued , !CHIMNEY 1 t Ilnitial 'fRegistration i 161642 Expired 11/12/2008111/11/2010' )11/11/2008 Manage Registi CARE 1 t' a alication Issued I ,--*: ---— -- -- - - - - . ...-._tzl-A*.,;:, ,1,..,j11:, ,?,. , - • ,r":".r 1:-.'-"'. ::",t.-iir.,--,-r..:• ©2019 Commonwealth of Massachusetts / 46 https://hic.oca.state.ma.us/HIC/Register/RegList 1/1 m4 "R`"• d5 igg �. a_ J'h+$'.yx ref �. sty x;.- - -, A�ry, r £ ivx r . d �. "Y t. ' A nxu' y KIZrv4 'SAY C �`. 59"k"'7�t ;F 4 S ty. , , d � t,t4:04.;x:j..!_itt,;,11,:;,V _' v; cx '-i. g V a -_x `.1r, fit +L .` —.,, N • �k u` q , �4 ?tom _ +d Vie' } cif ka r t' t'�.. lj 0,- - - ' - r'° k_ asps . "#-_ ,Yi „tTj �iF4 !."4 • - Y - - - - - t . -+' v s sT> %g- ^ u. ten $i Z ... ; as e -x r2�- N , ' . ,,, , ,,. - .. 4 I safety decal This is a copy of the label that accompanies each ,-' ,N,.,,.8I HI200 Wood Insert.We have printed a copy of F 6Ct .,�,p„a� the contents here for your review. g r S §❑ ! 'la ICI t2. IN NOTE: Hampton units are constantly being g❑ improved. Check the label on the unit and if I I!: 8 I❑ there is a difference, the label on the unit is g g f the correct one. g��u 1 g 30 zi 1: gill ID 10 :fig ❑ IS I i 3❑ 1ill g "-❑ _4 ilia _1.1 10 / g a gig .To, it 152 1 l' h--0 khii3 �: daQgi Z O 4 '69 mo 51 z F1]Zu _ ii 2 C I— -11 2]C LL t� Z saio� U Q o� U < c g € t 1111 W ail i U i ! p lit! 4 ! Ill 1 lill Y zoo els Y 21 .. n t is g Al i k_ 41D1 4 ( HI200 Hampton Wood Cast Insert 8 I installation MASONRY AND FACTORY BUILT FIREPLACE CLEARANCES The minimum required clearances to combustible materials when installed into a masonry or factory built fireplace are listed below. A B C D E F G H 15'(381mm) 20"(508mm) 14"(356mm) 7-3/8"(187mm) 16'(406mm) 1-1/2"(38mm) 6'(152mm)[USA] 19°(483mm) [USA] 8'(203mm)[CAN] 18"(457mm) [CAN) Side and Top facing is a maximum of 1.5"thick. Floor protection must non-combustible,insulative material with an R value of 1.1 or greater. * If the hearth extension is flush with the floor(F) it must extend 19.5"in front of the body face B (E). Note: Hearth Extension Width (G) is meas- ured from edge of fuel door to side of hearth. t�i ***Mantel depth,maximum of 10"(254mm) A ® D fil" *" A non-combustible mantel may be installed H at a lower height if the framing is made of E metal studs covered with a non-combustible ii11111111milit board. Thermal floor protection is not required if the unit is / 1� G raised 3.5"minimum(measured from the bottom of F the stove).However,standard ember floor protection is required.It will need to be a non-combustible mate- Clearance diagram for installations rial that covers 16" (406 mm)in the US and 18"(450 mm)in Canada to the front of the unit and 8"(200 Floor Protection mm)to the sides. If the unit is not raised thermalfloor protection required Please check to ensure that yourfloor protection and hearth will meet the standards for clear- is 18"(450 mm)in the US and Canada. ance to combustibles.Your hearth extension must be made from a non-combustible material. HOW TO DETERMINE IF ALTERNATE FLOOR PROTECTION MATERIALS ARE ACCEPTABLE The specified floor protector should be 3/8" Step(b): DEFINITIONS (18mm) thick material with a K - factor of Calculate R of proposed system. 0.84. 4"brick of C=1.25,therefore Thermal Conductance: Rbrick=1/C=1/1.25=0.80 The proposed alternative is 4"(100mm)brick 1/8"mineral board of k=0.29,therefore C = Btu = W with a C-factor of 1.25 over 1/8"(3mm)mineral Rmin.bd.=1/0.29 x 0.125=0.431 (hr)(ft2)(°F) (m2))(K) board with a K-factor of 0.29. Total R=Rbrick+Rmineral board= 0.8+0.431 =1.231. Thermal Conductivity: Step(a): Use formula above to convert specification Step(c): k = (BtuXinch) = W = Btu to R-value. Compare proposed system R of 1.231 to (hr)(ft3)(°F) (m)(K) (hr)(ft)(°F) R=1/k x T=1/0.84 x.75=0.893. specified R of 0.893.Since proposed system R is greater than required, the system is Thermal Resistance: acceptable. R =(ft2)(hr)(°F) = (m2)(K) Btu W 8 I HI200 Hampton Wood Cast Insert Regulation-Mass.Gov-Internet Explorer ma.us.h c?licdetails.aspx'axtSearchLN-161642 - ti Search... 1<ir F-;itt,4IvIass.gov sur J1011 $ . . „ 'P'9 ern Office of Consumer *. w *,e Affairs and Dataftivacyi Business Housi and a o fa*i C t • „4, , Regulation (OCABR) HIC Registration Complaints Registration# 161642 Registrant SCOTT SMITH Name SCOTT SMITH Address 145 Meadow Lane City, State Zip West Bamstable, MA 02668 Expiration Date 11/11/2020 Complaints Details No complaints found for this registrant You can also view arbitration and Guaranty Fund history. Back To Search Site Policies Contact Us b 2018 Commonwealth of Massachusetts. Mass.Gov®is a registered service mark of the Commonwealth of Massachusetts. yf Trusted sttt ._... _... .... �� a :- , 05