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HomeMy WebLinkAboutBld-20-003582 s Office Use Only r"k% t�2 -TO. 'Permit# sii O . * yy.. .Amount /( ,) '� wwrr 'n s .4 l''rarnee c ' Bu)'Zv/, ---a S )_.' Permit expires 180 days from s issue date EXPRESS BUILDING PERMIT APPLICA V E P M TOWN OF YAROUTH Yarmouth Building Department l DEC 2 z 2019 1146 Route 28 �.�... South Yarmouth,MA 02664 u I L u u �F ARI w E is 1- (508)398-2231 Ext. 1261 ...... I CONSTRUCTION ADDRESS: I t V G r kit (C.e , c fO ft+.k. 1 a.r-yll Q t1 ASSESSOR'S INFORMATION: Map: 14 3 t/� Parcel: Q OWNER: I 1,(�„ T tJ'(®.K LI C,) Lk, le T EN RE�no ik. NLi) Ct)( 4,61toN. 026016 PRIES ADD SS /� (� TEL. # CONTRACTOR: I°l�V q L 1 Q.V Lf IC.. 3`1 N. MO ( k �J e.a 11, `IQ.r -a cli jk, Jrof 0 f-0 d 3 NAME , 1 J MAILING ADDRESS TEL.# Residential VV 0 Commercial Est.Cost of Construction$ 100) ))00. Home Improvement Contractor Lic.# I CO01 G It Construction Supervisor Lic.# ,5-G 1 A6 Workman's Compensation Insurance: (check one) D I am the homeowner D I am the sole proprietor- VI haveWorker's Compensation Insurance /' /� Insurance Company Name: s�(' (( ` �.�(,( r l.Ct� Worker's Comp.Policy# �C C'5 00 5'Q 1 1 0 9 0 20 1 q k CCC WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove > 1ding: #of Squares J If , eplacement windows:#/hh/ teplacement doors: # I 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: 2`l- T E.X 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 revocat• n of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: }{ Date: IQ.1 3/I,Owners Signature(or attachment) Te L l` L Date: 12_) 3i q /r. 77 Approved By: � �iy- Date: / -R V i!S Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 7 No Flood Plain Zone: L' Yes L No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes r No Permit Authorization By signing below,the Owners authorize George Davis Inc.to act on Owner's behalf realtaive to the work to be performed at this address. Project Adress: 87 River Street;South Yarmouth Accepted: / Owner Date (I/I /U'►g Kate Philla Stage Island,LLC Owner Date Dustin Delany Stage Island, Owner ���I(� Date Nw I� t 4 Jody miner St a Island,LLC �Contractor / i Date jD,l7. George Davis,President George Davis,Inc. s k a � % '40 x ,, _ -..., E -€ , - ,. t.f` t4� '.' ,yew` -iz 4 '',.. fir ,, 44 '`rya t .; r� ''' _` # t fit_ g a - ' 5r "�: n 'e F5 't ,cam . €' ' r t. 44 William Francis Galvin Secretary of the Commonwealth of Massachusetts Corporations Division Business Entity Summary ID Number: 001115474 Request certificate New search Summary for: STAGE ISLAND HOLDINGS, LLC The exact name of the Domestic Limited Liability Company (LLC): STAGE ISLAND HOLDINGS, LLC Entity type: Domestic Limited Liability Company (LLC) Identification Number: 001115474 Date of Organization in Massachusetts: 09-04-2013 Last date certain: The location or address where the records are maintained (A PO box is not a valid location or address): Address: 87 RIVER STREET City or town, State, Zip code, BASS RIVER, MA 02664 USA Country: The name and address of the Resident Agent: Name: BRADFORD R. MARTIN, JR. Address: 46 CENTER SQUARE City or town, State, Zip code, EAST LONGMEADOW, MA 01028 USA Country: The name and business address of each Manager: Individual name Address KATE PHILLA HEFNER 5125 N 49TH STREET RUSTON, WA 98407 USA r 'Y HEFNER 5125 N 49TH STREET RUSTON, WA 98407 USA ' DELAN THE BUNGALOW, SAVANNAH DRIVE, THE `GA° ISON ST MICHAEL BB14038, BRB siness address of the person(s) h the Corporations Division: , f w &A-Avg titatek press j' FA Q ti 5125 N 49TH STREET RUSTON, WA 98407 1 USA j �` 7 2 11 1 �'' 5125 N 49TH STREET RUSTON, WA 98407 r eta a r Wm/name/az/a alQ•12itzascedwe/ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 160164 07/01/2020 One Ashburton Place-Suite 1301 GEORGE DAVIS,INC. . Boston,MA 02108 GEORGE F.DAVIS 33 NORTH MAIN STREET — U SOUTH YARMOUTH,MA 02664 Not valid without signature Undersecretary • Commonwealth of Massachusetts Division of Professional Licensure • Board of Building Regulations and Standards • Constr; ct' ti�Sifpe,rvisor • CS-056130 fyires 03/01/2021 • • GEORGE F DAVIS / 33 N MAIN STD SOUTH YARMOLJ�H MA'02664 ' • • 4OIRS • Commissioner CL The Commonwealth of Massachusetts !l. Department of Industrial Accidents _=)111= = 1 Congress Street, Suite 100 = =" 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): 60 rd e (,(,V 1^ Address: .(3,1 N©`III t V�, �ectiL, V- , r n et City/State/Zip: ��, 7Q1,!/ H,A Oa,661 Phone#: O -k - DrPjo2 Are you an employer?Check the appropriate box: Type of project(required): 1I am a employer with 14 employees(full and/or part-time).* 7. pNew construction 2.01 am a sole proprietor or partnership and have no employees working for me in $ "Remodeling any capacity.[No workers'comp.insurance required.] �°L'J 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition 10 El 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.El Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We area corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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 insurance for my employees. Below is the policy and job site information. Insurance Company Name: \ ST6C(..Cut 'X, Vl.L(iatr l G:.P Tik,AP kra,I,ec Policy#or Self-ins.Lic.#: (A)CC 600 .4101 )4,396020f Expiration Date: 3/ 5'/ O Job Site Address: p"/ l,V cr ( -L. City/State/Zip: l.fa Utk, 1 eamt,(, 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 ai and penalties of perjury that the information provided above is true and correct. Signature: /� Date: I 2 ��3 119 Phone#: ,.5Dp -�`7�}' op A1o2. 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#: i�....11140 GEORDAV-01 KSCHULTZ ACORO' CERTIFICATE OF LIABILITY INSURANCE DATE D/YYYY) `-� 3/8/2019 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 CONTACT NAME: Mason&Mason Insurance Agency,Inc. PHONE ) 781 447-5531 FAX No): 781 447-7230 458 South Ave. (A/C,No,Ext:( ) ( ) Whitman,MA 02382 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Western World 13196 INSURED INSURER B:NGM Insurance Company 14788 George Davis,Inc. INSURER C:Associated Industries Insuranc 33 North Main St. INSURER D: South Yarmouth,MA 02664-3437 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 LTRINSD WVD (MM/DD/YYYY) (MM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR NPP1516170 1/12/2019 1/12/2020 DAMAGETORENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 _GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY jPNT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ ANY AUTO M9M28491 10/26/2018 10/26/2019 BODILY INJURY(Per person) $ OWNED X SCHEDULED AUTOSRE� ONLY AUTOSNN pBOODILY INJURYp (Per accident) $ X AUTOS ONLY X ASTO ONLY (Perracedent)AMAGE $ . $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WRKERS OTH- AND EMPLOYERS'COMPENSATION Y/N X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE WCC50050143902019A 3/5/2019 3/5/2020 500,000 FICE M EXCLUDED?R N N/A E.L.EACH ACCIDENT $ ianda�oryEfn 500,000 E.L.DISEASE-EA EMPLOYEE $ 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) office copy CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE George Davis Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 33 North Main St. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE 92— I - ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD