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HomeMy WebLinkAboutBld-20-003686 O�,YRR Vince use Only . i O IPerrnitl o . - • . y Amount i, V NATTAGN CS[,4 41`°"'°""t°"9 c� Permit expires 180 days from Lr r\ 0—'30 ' l0 issue date EXPRESS BUILDING PERMIT APPLICATION ; C. E, i V D TOWN OF YARMOUTH Yarmouth Building Department q 1 If:JAN 0 21320 1146 Route 28 , .0 South Yarmouth, MA 02664 j a ' f (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: S l 8 R a 8 , W e.,T 'A[V iJ« ASSESSOR'S INFORMATION: Map: Parcel: OWNER: SCE Q.. M6.(f S(S Ro, e— a fp L.Jo 11c- CCfr 9 7 5942 NAME PRESENT ADDRESS TEL. # CONTRACTOR: f'1" `4-- V4k J'rS 5 cro ?O.,%JS? Sy,e�Je.,_gaecAN. O 9 Sl 686 3 NAME WY`k,-,‘,,,,, (j,6 k\ MAILING ADDRESS TEL.# ❑Residential Commercial Est. Cost of Construction$ 1 5-0co Home Improvement Contractor Lic.# + -i S 7 a) Construction Supervisor Lic.# C3" I �'L�p 55-7 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I amp the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: fib `' ' u"a -t. (p , Worker's Comp.Policy# 05 — W�C` Ck 2-St(il WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # 3 S 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: (c1('u`u5C` D✓WV °.r 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 1. Applicant's Signature: Date: /44'7943471-b Owners Signature(or attachment) Date: I a/3 ( /? ° (Ct Approved By: :;d2 Date: /' Off!/ Buil . g 0 ia](o designee) EIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No FlOod Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft. of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts r ' 7 Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 5••`'y 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): F'1 ��c ►L � � , See4).-cr 5 Address: 4.0, 15d— 7 City/State/Zip: 0�6� / ��Sc�.- r� ec.rJ�� Phone #: �/5 `5 5 f 7 6 509 547 0 i11' Are you an employer?Check the appropriate box: Type of project(required): I.Tam a employer with 6 employees(full and/or part-time).* 7. ❑New construction 2.—I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers'comp. insurance required.] 3.E I am a homeowner doing all work myself [No workers'comp. insurance required.]t 9. E Demolition 10 ❑ Building addition 4.E 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.E Plumbing repairs or additions 5.E I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E Roof repairs These sub-contractors have employees and have workers'comp. insurance.: 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Tl 'Other 6 6 152,§1(4),and we have no employees. [No workers'comp. insurance required.] IA& *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. t Insurance Company Name: w0rkerS `-ow`Q / kLMoc • Policy#or Self-ins. Lic. #: 013 it) E.C. C.L? c z11-( Expiration Date:I ' .C 2.0 oleo Job Site Address: 578 ( .,(-c ) - City/State/Zip: Ua�,- 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: i��----�— Date: t. l 00 Phone#: $ 6 6 8 B el `3 7$c— Off cial 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#: • ATLADIV-01 MALBIS ACORD" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) `-� 11/1/2019 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 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 ACT NAAME: RogersGray,Inc. PHONE — --_---_----------_—__-._-_--- 434 Rte 134 (A/C,No,Ext):(800)553-1801 FAX No):(877)816-2156 South Dennis,MA 02660 ra E-MAIL mailerog ersg Y com _ADDRESS=—--- --- ---- -__INSURER(S)AFFORDING COVERAGE NA/C# INSURER A:Travelers Casualty Insurance Company of Americ 19046 INSURED INSURER B:Arbella Protection Insurance Company Inc_41360 Atlantic Diversified Services,Inc. INSURER c:Hartford Insurance Company of the Midwest 27478 PC Box 237 !INSURER 0: -- - -- - ---- Sagamore Beach,MA 02562 (--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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR! INSD N/VD i(MMWDDrYYYY1 IMM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY 1,000,000 _ EACH OCCURRENCE $ 6808E8307111942 7/11/2019 7/11/2020 DAMAGE TO RENTED CLAIMS-MADE X OCCUR; 300,000 PREMI$E.$11=a occurrence} _3 __. MED EXP�A�oneperson) 5 O110 _PERSONAL&ADV INJURY $ 1'000,0 0 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 5 2,000,000 POLICY! X JECT !� LOC PRODUCTS-COMP/OP AGG 2,000,000 OTHER: B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000' (Ea accidence ANY AUTO 1020056292 7/12/2019 7/12/2020 BODILY INJURY(per personj $ OWNED X SCHEDULED AUTOS ONLY AUTOS BODILY INJURYJPeraccident) $ X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ _ AUTOS ONLY ,1Per accident_ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE 5 EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTIONS • C WORKERS COMPENSATION ' PER • OTH- AND EMPLOYERS'LIABILITY YIN -X PER -�_--ER 08 WEC CL2544 10/12/2019 10/12/2020 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A E.L.EACH ACCIDENT 5 _ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) -- E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes.describe under 1,000,000 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) The certificate holder is named as an additional insured on a primary non contributory basis as required in a signed written contract. Waiver of subrogation applies if required by contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESEN TATIVE • ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD r / 4 i //' .-• !.. a r ., . 4 i -, t 73 •} �/ • I1'I ,, i i :11----- b t3 c� ° II I S ri N � w a g U