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HomeMy WebLinkAboutBld-20-004208 101'.YRR .j umce use unmy � Permit# r O -} O . - H Amount L ATTAcn [SE`,,, �`°"°•"`°""c�OO Permit expires 180 days from issue date B ZD-y Z,L* EXPRESS BUILDING PERMIT APPLICATIO RI C TOWN OF YARMOUTH 1 . Yarmouth Building Department `�'�� i � f 1146 Route 28 BUILDING DEPARTMENT South Yarmouth, MA 02664 By (508) 398-2231 Ext. 1261 C Ok( D---S- (40 CONSTRUCTION ADDRESS: 3 Q E' A°U t e 6 4 Yarm D u6 Pot ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Qr t y\ ,Ste.U f r • NAME PRESENT ADDRESS// // TEL. #1 r� CONTRACTOR: Lira o1r 0 brl Lo I raV110ArtG0¶9mtiI.. ofn 7'T 7-2t3—©2O NAME ING ADDRESS TEL.# -7 l 2esidential ❑Commercial Est. Cost of Construction$ 1 D Home Improvement Contractor Lic.# 1 8100 1 Construction Supervisor Lic.# CS-/105 y 3 Workman's Compensation Insurance: (check one) 0 I am the homeowner $I am the sole proprietor _I I have Worker's Compensation Insurance Insurance Company Name: L.M ry1 SUret eI C.e Worker's Comp.Policy# M p PPS 1 OtIC WC.5315621764014 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares /2, Replacement windows: # Replacement doors: # Roofing: #of Squares /ip ( 'K)Remove existing* (max.2 layers) Insulation ,�� .n.)e& tr`Cct ,O a I Old Kings Highway/Historic Dist. (1, Replacing like for like Pool fencing *The debris will be disposed of at: / Or/r10001 i{^QII Sfer sta.110 1 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 revocatio of my license d for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: � Date: 0��3� � Owners Signatur (or attachment) �� Date:Approved By: .74/ Date: l—3\ Building Official(or de snee) 1 EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes = No Flood Plain Zone: Yes 2 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes No " The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ..5.• 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): P7rl Lo Sert1,LL) Address: Z 9 Un c% Siam le `3 Uhl City/State/Zip: 9cQ L Detob f11 02660 Phone #: '1 I-Z�e -Oz 06 Are you an employer?Check the appropriate box: Type of project(required): l.—I am a employer with employees(full and/or part-time).* 7. New construction 2.j1 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.❑I am a homeowner doing all work myself. [No workers'comp. insurance required.]t — 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.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.C 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.E Other 152,§1(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box r1 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: MGM G M nsJ r a n e e rofyv94,t y Policy 4 or Self-ins. Lic. #: 1Cif Peg q 0 LiC Expiration Date: 0-1-bO/Z0 Job Site Address: 3Ot3 i4 9tAt 6 A City/State/Zip: trio/wool-4 MA 0 C 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 verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: ilZti/ Date: 61 3/ 20 Phone 4: '1j-Zc 02 06 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#: , ^- , __—_-------_----'' ---------, `r Regulation office om Consumer Affairs u Business i wz»z1 \ - uF;a»LI""~^' BRAULIO BRIT io SAGA wu _ SOUTH,oEmw�.wm'»z«^v Undersecnet^y ' ` ^ Massachusetts Department of Public Safety Board of Building Regulations and Standards - ' ^ License. CS- 10548 Construction Supervisor � \ BRAmLIO BRITO \ "°UNCLE~.~~L^. ~WAY SOUTH DENNIS MAm2660 ` . ~ Expiration: Comniimsio"e, 06m312020 Fallon, Rosa From: braulio brito <ingbrauliobrito@gmail.com> Sent: Friday, January 31, 2020 9:52 AM To: Fallon, Rosa Subject: Fwd: Work on 308 Route 6A Yarmouth Port Attention!This email originates outside of the organization. Do not open attachments or click links unless you are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure. Otherwise delete this email. Forwarded message From: Karen Steuer <karenlouise42(agmail.com> Date: Fri, Jan 31, 2020, 9:49 AM Subject: Work on 308 Route 6A Yarmouth Port To: Cape Brothers <CapeBrothers.Inc@,gmail.com> Cc: <Ingbrauliobrito(a,gmail.com> I authorize Braulio Brito and Cape Brothers to conduct the following work on my house at 308 Route 6A in Yarmouth Port: Replace roof and whatever associated repairs are required, using shingles in the color "weathered wood". Replace existing painted wood shingles on the walls of the house with new white cedar shingles. Karen Steuer 6056 Kestner Cir, Alexandria, VA 22315 571-969-8949 i I DATE(MMIOD/YYYY) ACCoRd CERTIFICATE OF LIABILITY INSURANCE 01109/20 ha✓' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS GE AFFORDED BY THE POLICIES BELOOWC THIS CERTIFICATE OFMINSURANCE DOES NEGATIVELY NOT CONSTITUTE A CONTRACT BETWEENOTHE BISSUING INSURERS) 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 suchc eenAdcoorsement(s). NAME; T JIM HINDMAN PRWUCER PHONE (A/C,No): 508-771-0663 (A1C�No.Eat): 508-771-8381 I FAX Schlegel&Schlegel Ins Broker EAD RL 34 Main Street ADDRESS: schlegelinsurance@gmall.com West Yarmouth,MA 02673 INSURER(S)AFFORDING COVERAGE NAIC S INSURER A: NGM INSURANCE COMPANY INSURER B: LM INSURANCE INSURED BRAULIO BRITO INSURER C: DBA BBRITO SERVICES INSURER D: 25 UNCLE STANLEY'S WAY INSURER E SOUTH DENNIS,MA 02660 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE HAVE ICY IOD INDICATED. NOTWITHSTANDING OANY REQUIREMENT,TERM OR CONDIT BEEN ON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TOLWHICHRTHIS 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 TYPE OF INSURANCE II�t01t 11VD REDUCCED BY PAIII PCL CLAIMS.EXP LlMlrs ILTR AODLSUB}t POLICY NUMBER JMM/DO/YYYY)j MM/DDIYYYY)_ EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 500 000 II XI OCCUR PREMISES(Ea occurrence) $ CLAIMS-MADE MED EXP(Any one person) $ 10,000 MPP8904C 07/10/19 07/10/20 PERSONAL&ADV INJURY $ 1,000,000 A2,000,000 GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY I I JJECOT PRODUCTS-COMP/OP AGG $ 2,000,000 I I LOC $ OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea accident) BODILY INJURY(Per person) $ ANY AUTO OWNED SCHEDULEDS BODILY INJURY(Per accident) S HIRED AUTO ONLY AUTOS NON-OWNED PROPERTY DAMAGE(Per accident) $ ,— AUTOS ONLY ,_„ AUTOS ONLY $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE $ S OLD I I RETENTION$ PER WORKERS COMPENSATION I STATUTE I I ER AND EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT $ 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE R/PARLUDEDXECUTNE N/A WC5315621784019 05/08/19 05/08/20 100,000 B (MOFFICER/MEMBER,deryInNH) EXCLUDED? Y E.L.DISEASE•EA EMPLOYEE $ (Mandatory In IT es,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below - DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) braullo brito has elected not to be covered under his current workers compensation policy OWNER:STANLEY NOWAK,TRUSTEE VILLAGE TRUST CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN STRAWBERRY HILL CONDOMINIUM ASSOC ACCORDANCE WITH THE POLICY PROVISIONS. 40 INDUSTRY ROAD#8 MARSTONS MILLS MA 02648 AUTHORIZED REPRESENTA UNIT 30,1431 IYANNOUGH RD HYANNIS,MA 02601 I ©19 -2 5 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of D