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HomeMy WebLinkAboutBld-20-005007 ,YR .:10 e Use Only • i .i E x i. 7 $O R 3 f., f P rmrT#_ v_�_ .C • OC : Amount y` 6c *`09,....0"'c d t'r Permit expires 180 days from ' L i issue date ' ��� A(df f EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: < S A9-04 /h4=0/%' i4i1Y ‘,�' ..-/i/sfc x/ ASSESSOR'S INFORMATION: Map: /L./ 7 Parcel: g' OWNER: /'f:;r / T / 9 S"f-4,L/4'�,1' f ir.'�.4'od�t��%Q L'/ Gy1 t''� �S G G `jI AME PRESENT ADDRESS TEL. # CONTRACTOR: �/: c r✓ L'inpe,e!lj« yy,H,,� ,0, / I17//. 3,.— ,F ._J'G,7 •lC F! NAME MAILING ADDRESS TEL. /# %Residential ❑Commercial Est. Cost of Construction$ m/., G U- Home Improvement Contractor Lic.# /?. ' / 0 Construction Supervisor Lic.# G S " O 7 y-evg Workman's Compensation Insurance: (check one) I am the homeowner ❑ I am the sole proprietor X I have Worker's Compensation Insurance �,9 r�Ac,t' w6. 64..2 y fy® Insurance Company Name: .Ltis; Worker's Comp.Policy# £ A#rive,/ /6,n,i'•`' WORK TO BE PERFORMED /&/774'vl e1.•n've/r o "Pejo(' lwe. /Pl.✓i4..v= /ly,1 ,d a' .x,:, . .Lti rf// C✓r�e-f/w� Tent Duration (Fire Retardant Certificate attached?) Wood Stove ��� �c�Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares ( )Remove existing* (max. 2 layers) Insulation VOo ld Kings Highway/Historic Dist. ( placing like for like Pool fencing *The debris will be disposed of at: G�!> ` S 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 I ense and for pr ution under M.G.L.Ch.268,Section I. Applicant's Signature: ,/ ,1/_,) .1,.�''� �`"�' Date: ill • / 4:7' ` -'G' Owners Signature(or attachment (' dr' jrZ_ Date: Approved By: al Date: 3 -10 - eo Building Offrci (or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes _ No The Commonwealth of Massachusetts 1� 17, Department of Industrial Accidents 1 Congress Street, Suite 100 4 i Boston, MA 02114-2017 °i.._ 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): .S/C/Liv /frr„ry,,i/../e-e, Address: / Z -6:2444-' AR.t�t.- City/State/Zip: �4✓,iu,IZ .0e,(/ "74. ')G7i> Phone t. 1 " G -, - /6C/ Are you an employer?Check the appropriate box: Type of project(required): I.'I am a employer with ,,2 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._I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition 10 ❑ Building addition 4.7 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 5.111 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp. insurance.= ` ,4 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other G�,/J ��Cy �L� � 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 afidavit 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. y Insurance Company Name: ,e-a s/�4,.—, 1 y c- 33 1-c: 1v c / Z .2e,Policy or Self-ins. Lic. #: c//6 y7)(yG_2)- Expiration Date: L/ Job Site Address: 'Ys 6�4T r'i�,--.Ae - / City/State/Zip: y1�'''j"�/N�0f=l/ /7- e"d‘ 73 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 p 'ns anities of perjury that the information provided above is true and correct. Signature: �, , `� Date: ?- /v • 1!:7 Phone#: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License n 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#: STEVEN CAPPELLUCCI , ,� ► ` J'° MASON CONTRACTOR .,....+ 12 GORDON LANE : -,,',i N ' YARMOUTI-IPORT, MA 02675 . `, .508-362-1681 PROPOSAL DATE: February 2, 2019 SUBMITTED TO: JOB LOCATION: Mary Fish 43 Dartmoor Way 19 Strickland Street Yarmouthport • Manchester, CT 06042 868-656-4693 cell 860-313-8181 rlfish@hotmail.com JOB DESRIPTION: 1—Remove main center chimney to existing Chatham pan lead,install $4,800.00 new Chatham pan lead,rebuild chimney from lead up,install new stainless steel chimney cap. Optional copper pan +$1,800.00 2—Remove center chimney at addition/family room to roofline,set up $5,200.00 for new Chatham pan lead,rebuild chimney from pan up. Optional copper pan +$1,800.00 3—Building permit fee/time. $20 00 Price includes:Labor,materials,disposal fees. TOTAL AMOUNT $10,200.00 TERMS: All material is guaranteed to be as specified. All work to be PROPOSAL GOOD FOR 60 DAYS completed Ina workmanlike manner according to specifications submitted,per standard practices. Any alteration or deviation from TERMS OF PAYMENT:$4,200.00 deposit,balance to be above specifications involving extra costs will be executed only upon invoiced. written orders,and will become an extra charge over and above the estimate. All agreements contingent upon weather,ac idents,or delays beyond our control. Property owner to supply any water and/or electrical hook-ups. AUTHORIZED SIGNATURE ACCEPTANCE OF PROPOSAL: The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. SIGNATURE2,...n, DATE OF ACCEPTANCE " Aco® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `.� 3/10/2020 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 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 Helen Medeiros NAME: Eastern Insurance Group LLC PHONE (800)333-7234 FAX Wc.No.Ext): (A/C,Not E-MA233 West Central St ADDRESS:hmedeiroa@easterninsurance.com INSURER(S)AFFORDING COVERAGE NAIC# Natick MA 01760 INSURERA:Central Insurance Company 20230 INSURED INSURER B Steven Cappellucci INSURERC: 12 Gordon Ln INSURER D: INSURER E: Yarmouth Port MA 02675-1815 INSURERF: COVERAGES CERTIFICATE NUMBER:2 019 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 LIMITS LTRMDWVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY), X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE X OCCUR DAMAGETO RENTED PREMM ISES(Ea occurrence) $ 100,000 CLP 7944623 11/30/2019 11/30/2020 MED EXP(Any one person) $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: PD DEDUCTIBLE $ AUTOMOBILE UABIUTY (EaCO BINED SINGLE LIMIT $ 1,000,000 A ANY AUTO BODILY INJURY(Per person) $ 20,000 ALL OWNED R SCHEDULED SAP 8458349 10/28/2019 10/28/2020 BODILYINJURY(Peraccident) $ 40,000 AUTOS _ AUTOS NON-OWNED PROPERTY DAMAGE X AUTOS (Per accident) $ X HIRED AUTOS Uninsured motorist BI split limit $ 100,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION Steven Cappellucci ie x PER X OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE included OFFICER/MEMBER EXCLUDED? N N/A E.L.EACH ACCIDENT $ 1,000,000 A (Mandatory in NH) WC 8624990 12/8/2019 12/8/2020 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 114 6 Route 2 8 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE John Koegel/MAMURP < �","'"_> =5e.— ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025/mou4on oivw ,,f',,rPee7t c/ /l11,f:(71/14e/45 Division of Professional Licensure Office of Consumer Affairs&Business Regulation Board of Building Regulations and Standards • HOME IMPROVEMENT CONTRACTOR ConstRi$ttir{' up,rvisor • TYPE:Individual 'I Registration Ex iriT anon CS-074635 q Unires: 07/16/2020 132610 01/19/2021 • 6 I STEVEN D.CAPPELLUCCt r. ' STEVEN D CAPPELL,UCD, 12 GORDON YARMOUTHPOR7AMA 02675 's7 • STEVEN D.CAPPELLUCCI 12 GORDON LN e YARMOUTHPORT,MA 02675 Undersecretar} Commissioner