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Home My WebLink Aboutbld-20-004385 s.,, , throaty G '€ Ry Amount Nl I `Lc-� Permit eta ISO days fps issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: LOCI 21,101-E CQ 4 ASSESSOR'S INFORMATION. M 1ZZ Itel: l() c i v ;c-term OWNER: f-El i ete&A 'KEeti.v01S C1'31 -tTE6 evN 1'f y I(Sb`/ NAME PRESENT ADDRESS TEL. I S . 501-.09`' } coNTRACI OR: K M .% S`f 104 4.61: 4i• Sr4P.- iii W M 7c I 5`l 7-(c+ NAME MAILING ADDRESS TEL I 0 Commercial Est.Cost of Como S 17E°C)CJ Home Improvement Contractor Lit.it I(Kill/ Construction Supervisor t.ic.if C....-5 —1101 Z. Workman's Coition Insteanc (check one) I am the homeowner I am the sole proprietor T I have Worker's Compensationsa Insurance Insurance Company Name: �7 J5 . orker's's -P 6614 arZr 91 WORK TO BE PERFORMED Teat Duration (Fire Retardant Certificate attached?) ,,,,M Wood Stove /s :JIG SSG, Sides #of Squares Replac nest windows;if . t/b P H Replacement doors: it Roo Itof Squares ( )Remove existing*(sm.2 layers) Insulation i Old Kings Highway/Historie Dist. (WReplaciag the for She Pool leasing *The debris will be disposed of at:fO ei Yetea UT(' i)e-trr yre..._ Flk 4! "� Location of Fealtyr I declare under penalties of palmy that die statements herein contained an tree to the *fury knowledge and belief. I understand that my false answer(s) will be just came for denial or of. x and for pmsaaroion under G.L Ch. ` I. Appticaaut`s s / �E.tt- ,date:�Z !O -LP ZO Owners -- it •r Diet: Z C.J ��By: �./`_ /1`' Date: 2 id EMAIL ADDRESS: , Zoning District_ Historical District: Yes No Flood Plain Zone: Yes No 1 Water Resource Protection District: Within 100 ft.of Wetlands: : Yes No _ Yes No i Massachusetts Department of Public Safety: Heard of Building Regulations and Standards t ' 40792 ;* s„ ,�t 5n S ervisor ' ' KARL MAKI d !VT s. '. (STREET WES TABLE MA 026s8 - omrn.ssioner 12/2212026 Li//e O4n/MC42 aeCL f/P f .klCYCiAte/1 Fi/k- Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual KARL W MAKI Registration: 145441 841 OAK ST Expiration: 01/24/2022 WEST BARNSTABLE,MA 02668 Update Address and Return Card. SCA 1 xr 20M-05/17 cfZ's6i/1.0,o,;e c(//+V-'74,,,•rrcAuje// Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Registration! Expiration Office of Consumer Affairs and Business Regulation 145441 01/24/2022 1000 Washington Street -Suite 710 KARL W MAKI Boston,MA 02118 KARL W.MAKI '' 841 OAK ST i.,�..d lG Ie14,0 - WEST BARNSTABLE,MA 02668 Urldersecretafy Not valid without signature Safety Insurance BUSINESSOWNERS DECLARATIONS AUTO • HOME • BUSINESS policy Number From To Period To Safety Insurance Company BMA0027581 02/16/2820 82/16/2021 12:01 A.M.Standard Time at the described location Transaction Renewal Declarations Named Insured and Mailing Address Agent HIERLOOM CUSTOM BUILDERS, LLC GERMANI INS LLC KARL MAKI 908 MAIN ST 841 OAK ST OSTERVILLE MA 02655 W BARNSTABLE MA 02668 Telephone: 508-428-9194 61704 Form of Business: Type of Business: CARPENTRY RESIDENTIAL DESCRIBED PREMISES LOC BLDG ADDRESS AUTOMATIC INCREASE 001 841 OAK ST. W BARNSTABLE MA 02668 4% PROPERTY LOC BLDG COVERAGE VALUATION DEDUCTIBLE LIMIT OF INSURANCE 001 001 Personal Property Replacement Cost $ 500 $ 3,244 Deductible shown above applies per any one occurrence BUSINESS INCOME:Actual Loss Sustained Not Exceeding 12 Consecutive Months LIABILITY AND MEDICAL EXPENSES Except for Fire Legal Liability, each paid claim for the coverages listed reduces the amount of insurance we provide during the applicable annual period. Please refer to Paragraph D.4. of the Businessowners Liability Coverage Form. BUSINESS LIABILITY COVERAGE LIMITS OF INSURANCE Liability $ 1,000,000 Per Occurrence Medical Expenses $ 18,000 Per Person Fire Legal Liability $ 100,000 Any one Fire/Explosion ADDITIONAL COVERAGES Some property coverages are subject to deductibles specified in the policy forms. Optional Property Coverage Description Limits of Insurance LOC BLDG DESCRIBED COVERAGES 001 001 Contractors Tools - Blanket Basis $ 20,000 Optional Liability Coverage Description Limits of Insurance Non-Owned Auto Liability $ 1,000,000 Hired Auto Liability $ 1,000,000 Amendment - Aggregate Limits-Per Project Contractors-payroll $28,600 Contractors Liability Endorsement CHANGE IN PREMIUM: $ TOTAL PREMIUM: $ 1,612 BPDEC2011 INSURED Safety Insurance BUSINESSOWNERS DECLARATIONS AUTO • HOME • BUSINESS Policy Number Fromolicy Period To Safety Insurance Company BMA0027581 02/16/2020 02/16/2021 12:01 A.M.Standard Time at the described location Transaction Renewal Declarations Named Insured and Mailing Address Agent HIERLOOM CUSTOM BUILDERS, LLC GERMANI INS LLC KARL MAKI 908 MAIN ST 841 OAK ST OSTERVILLE MA 02655 W BARNSTABLE MA 02668 Telephone: 508-428-9194 61704 FORMS AND ENDORSEMENTS SCHEDULE Coverage line Form Number Ed.Date Description Businessowners BP0417 (01/96) Employment Related Practices Exclusion Businessowners BP0108 (03/98) Massachusetts Changes Businessowners BP0439 (01/96) Abuse or Molestation Exclusion Businessowners BP0009 (01/97) Businessowners Common Policy Conditions Businessowners BP0404 (01/96) Hired Auto and Non-Owned Auto Liability Businessowners SB0002 (11/99) Businessowners Special Prop. Cov. Form Businessowners SB0006 (11/99) Businessowners Liability Coverage Form Businessowners SB0518 (04/07) Asbestos or Other Respirable Dust Excl. Businessowners IL0003 (04/98) Calculation of Premium Businessowners SB0517 (04/07) Silica or Silica-Related Dust Excl. Businessowners BP1004 (04/98) Excl of Certain Computer-Related Losses Businessowners SB0542 (02/16) Excl Pun Damage Related to Act of Terror Businessowners BP1005 (04/98) Excl-Year 2000 Computer Related Losses Businessowners SB0514 (05/04) War Liability Exclusion Businessowners BPN109 (12/15) Policy Holder Notice - Snow Removal Businessowners BP0702 (01/97) Amendment - Aggregate Limits-Per Project Businessowners BPN110 (12/15) Snow Removal Advisory Businessowners SB0576 (06/07) Limited Fungi or Bacteria Cov. (Property) Businessowners SBM001 (05/17) Equipment Breakdown Endorsement Businessowners SB0577 (11/02) Fungi or Bacteria Exclusion Businessowners SB0544 (04/07) Roofing Operations Exclusion Businessowners SB0546 (12/15) Exclusion - Snow Removal Operations Businessowners SB0701 (02/19) Safety Contractors Property Endorsement Businessowners SB1307 (04/16) Safety Contractors Liability Endorsement Businessowners STN110 (02/16) Notice of Terrorism Insurance Coverage Businessowners SBM008 (05/17) Massachusetts Equipment Breakdown Chngs Businessowners BP0703 (01/97) Property Damage Liab. Ded (Per Claim) $250 Deductible Businessowners SB0538 (02/16) Excl Acts of Terrorism Outside the US Premium has been waived for this coverage. Businessowners SB0706 (01/97) Contractors Tools and Equipment Coverage Blanket Limit $20,000 Businessowners BP0419 (06/89) Amend-Liquor Liab. Exclusion (Exception) Countersigned By: BPDEC2011 INSURED / _ � The Commonwealth of Massachusetts ►. 1. Department oflndustrialAccidents =1�1= 1 Congress Street, Suite 100 Sl f 7.1 Boston, MA 02114-2017 `,r.' 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): t,c4444.?. _ - 144-'k...:t Li/ftDt V I LL.9 -i- Address: P ( 04-K_6*-- i City/State/Zip: W.. v Phone #: 2-C 6 -Li_ "a° Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.KI am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp. insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑ Demolition 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.❑Plumbing repairs or additions 5.0 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 are a corporation and its officers have exercised their right of exemption per MGL c. 14.27iOther tt� 152,§1(4),and we have no employees.[No workers'comp.insurance required.] i-p *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. �l 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: Policy 4 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 verification. I do hereby certif iii der the p 'ns and penalties of perjury that the information provided bov is true and correct. Si nature: Date: Z l 0 Zba D ' Phone 4: Z 0 7 -biS - 171p f • 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#: