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Home My WebLink AboutBld-20-005067 (/ 1 O //se�Only) $'4' •Y air, y 6/)5 / �✓, Pe t �11 N 7 '�To V! �2s /fie, Coyva p ) �y Amount "`'*wn► E Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (14 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ?e / C)-(g In S( _`e PPrco-e, ic,.,( )N"n C l^0 c k `I- Pe v ASSESSOR'S INFORMATION: �� s Map: Parcel: OWNER: 1:1 e c Keart e4 c L( f\1 Pc-r.Ins i d-e �dimly (c •jat iv?ot41,- 0- t S"ce-3 6a-'C9,7 NAME 121 � PRESENT ADDRESS TEL. # CONTRACTOR: 0144 l 1 ei J[e) - to l-k l.(,rGL 9r—• 5 . E4Ih oitiFtN-.7, - j C8.33 a -?c6 0 NAME MAILING ADDRESS TEL.# Residential 0 Commercial Est. �q V Est.Cost of Construction$ /0 _Od r Home Improvement Contractor Lic.# Fig g / 1 ( Construction Supervisor Lic.# CS "1©3 11( Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietorI have Worker's Compensation Insurance �7 Insurance Company Name: O hA a �SQ U 1 u,r4 K0cCD r.Worker's Comp.Policy# X W Q ? 3 36 . ..:3 WORKWORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Rodin #of Squares i 9, ( ‘/)Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( Re lcin like for like Pool fencing g '�/� P g *The debris will be disposed of at: 0 tV S\"Te PJI"1f0S-Te 2 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 li se d for prosecution under M.G.L.Ch.268,Section 1. Az 01 /licant's Signature: ,d Date: < [G� d Owners Signature(or attachment) ,/� _ iT Date: Approved By: •0"..4i Date: 3— VI —1,6 Building Official(or designee) EMAIL ADDRESS: _ Zoning District: RECEIVED Historical District: ❑ Yes ( No Flood Plain Zone: ❑ Yes l No "" ' 7 Water Resource Protection District: Within 100 ft.of Wetlands: 1 ' C F , ' ?{i 2' 3 ElYes Ll No ElYes No _ '. -s aI'_LANG1DEPARTMEN I Commonwealth of Massachusetts ® Division of Professional Licensure " r Board of Building Regulations and Standards nst5' Ytion S'uppenisor CS-103111 Expires: 05/13/2020 JASON R FREITAS '„ 1111, 5 MCINTOSH TAUNTON MA 02780 A 4 Commissioner CA— �f A �SE�1r� D�kEENRs� •0 ..`i �_ 1 LiCEN�� )nl( ' es, , 7'' t ▪NOT FOR FEDE AL°ID -i I 1 I I. 1 4a1s5 •- dNUMDER • ,t F ' 02lo.1120�s ;—.S9i 002'497 ' 1 ` `,` ,r. - _-3._DDT._ - �I Sh 01 �.. U x 1F • -.� 9aEt®—p ci 1'1.,` 1, � v AEU_.NR fII I. I 1P 11r 11_-,�1 i.1'ri f i ;fl .�360 RCHARDST : 1 ' i .% RAY HAM,MA,276T,1Z11 i 1 • �pp s BLU sp u ki I !'�\iTl 1 kl ,a. -1-.1 15SIXM 16HGTS 1� I Ir j 01] : ,, �� 'T£- 1 r 5 DD 5253 l Rev 9282016 i t 7I 7 - .;m-.rR o i ,l rye (�4/71,92aierue�c� a�,�r�m J¢c i�eLf� Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR '- TYPE bpplement Card • iRe1siitithi Expiration a' , - 11 ._ 7 021 - 24 RESTORE NE:LLG. _ :-t I i; it 1' ED LYONS '., � 10 CHURCH SToG. l4-g j S.EASTON,MA 02375 Undersecretar y. I 1 L ,;'�,i I Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation ; 1000 Washington Street -Suite 710 . Boston,MA 02118 . • 6 ,'' ef)--'4.--L- I' :, Not vali wit , • signature I c C C t RESPOND.RfAMEDIATE•REBUILD 10 Church Street Easton, MA 02375 PH: 1.855.280.3060 Fax: 508.238.4550 Date: 1/23/2020 Contract to perform the following services: Reconstruction per the scope and price of the RCV (Replacement Cost Value) of the claim as determined by the insured's insurance company. Service Start Date: TBD Property Owner: Daniel Kennedy Authorized By: Daniel Kennedy Address: 24 Marshide Drive Yarmouth Port, MA 02675 Relationship: Owner Phone: 508-362-5027 Insurance Co: Mapfre Claim: TCVY30 Scope: I hereby employ and authorize 24 RESTORE NE LLC and its employees and agents to enter and exit the premises described above as necessary to provide the reconstruction services. I understand that I am responsible for securing the premises both during and after the performance of 24 RESTORE'S improvements. 24 RESTORE shall not be responsible for any loss and/or damage to the premises or any personal property located therein caused by failure to secure the premises. Payment: I agree to pay for all materials and labor approved by my insurance company expended by 24 RESTORE in connection with the work they perform as described above. Upon completion of 24 RESTORE'S services,WE will bill your insurance company directly based on the information you provided above. I understand that I may be required to execute an assignment of any insurance benefits; however,I understand that I am primarily liable for payment to 24 RESTORE notwithstanding any assignment of any insurance benefits. 1 RESPOND.7A I •MEDIATE•REBUILD 10 Church Street Easton, MA 02375 PH: 1.855.280.3060 Fax: 508.238.4550 Accounts, which are not paid within 30 days, will be considered delinquent and will result in additional interest/finance charges and potential collection efforts described in"Costs of collection"below. Insurance Authorization: I hereby authorize my insurance company to make direct payment to 24 RESTORE NE LLC for the improvements they make as detailed above. This assignment is for the purpose of expediting payment to 24 RESTORE NE LLC. Authority: I hereby affirm that I possess the authority to authorize the completion of the above improvements. I agree I am personally responsible for any and all charges relating to the services provided by 24 RESTORE NE LLC pursuant to this agreement, if in fact,I do not possess such authority. Dated: /1Cs .71/d,-0 Initials Cost of Collections: If 24 RESTORE is required to engage outside representatives for the purpose of collecting payment hereunder,I agree to pay all costs of collection, including attorney's fees and 24 RESTORES legal expenses incurred with the collection of amounts due them; whether or not a lawsuit is filed. Interest/finance charges will be charged at a rate of 18%per annum on all delinquent accounts; the maximum rate permitted by applicable law. Schedule of Charges: A COST ESTIMATE WILL BE PROVIDED PRIOR TO ANY RECONSTRUCTION WORK BEING PERFORMED. EITHER I OR MY INSURANCE CARRIER WILL APPROVE THE AMOUNT TO BE PAID FOR THE WORK PRIOR TO IT BEING PERFORMED. Governing law: This agreement shall be interpreted and governed by the laws of the Commonwealth of Massachusetts. Complete Agreement: The information contained in this Agreement constitutes the complete agreement of the parties and no representations, oral or written have been relied upon in entering this Agreement, except those representations contained herein. B : I�_�� r ., � Dated: j' �,3p-P 2- Name (� Dated: / )d -ID 0-a d 24 RESTORE N C 2 s ' 1 Construction Supervisor Re:Address 15 e-6Me i H'2 A 1t C. (or)application# '-( _d 941 Name Sckso rVec II S Telephone Number Address 16Cji rC�) 9- Citys` 431-‘ State , Zip 69 License Number 65-CO )?1 License TypeCS Expiration Date 5 /3r-2o:1 Contractors Email -FXi raj reS�b( ft `L Cell# ��' � 1 I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation re uired by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signature Date 4� -67i ao d 6d-O ,___,.......4, 24RESTO-01 GHOUGHTON ACQ/IU" DATE(MM/DD/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE 2/24/2020 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 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 License#1780862 CONTACT NAME: Gretchen Houghton HUB International New England PHONE I FAX 600 Longwater Drive (A/c,No,Est): (A/c,No): Norwell,MA 02061-9146 E-MAILADDuss,9retchen.houghton@hubinternational.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Western World Insurance Company 13196 INSURED INSURER B:Arbel la Protection Insurance Company 41360 24 Restore NE LLC INSURER C:Ohio Casualty Insurance Company 24074 10 Church Street INSURER D:Axis Surplus Insurance Company 26620 South Easton,MA 02375 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 W POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD VD IMM/DD/YYYYI IMM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE X OCCUR EVP100335700 2/20/2020 2/20/2021 DAMAGES( RENTED 100,000 X X PREMISES(Ea occurrence) $ X CPL-Pollution MED EXP(Any one person) $ 10,000 X Environmental Impair PERSONAL&ADVINJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIESPER: GENERAL AGGREGATE $ 4,000,000 POLICY X LOC PRODUCTS-COMP/OPAGG $ 4,000,000 X OTHER:Professional Liability Per Occurence $ 2,000,000 B COMBINED SINGLE LIMIT 1,000,000 AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO X X 1020094653 2/20/2020 2/20/2021 BODILY INJURY(Per person) $ OWNED X AOUED AUTOS ONLY BODILY INJURY (Per accident) $ _ A O -OLA USX ONLY XU NY (PFerr antppAMAGE $Hired&Non Own $ 1,000,000 A UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 X EXCESS LIAB CLAIMS-MADE X x EVX1003358-00 2/20/2020 2/20/2021 AGGREGATE $ 1,000,000 DED RETENTION$ $ C WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE X XW061039279 2/20/2020 2/20/2021 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N N/A 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ D Excess Umbrella x x EMX2000051001 2/20/2020 2/20/2021 Policy Limit 4,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The Western World Liability Policy#EVP100335700 also includes the following: Contractors Pollution Liability Each Pollution Condition:$2,000,000 Contractors Pollution Liability Aggregate:$4,000,000 Transportation Pollution Liability Each Pollution Event: $2,000,000 Transportation Pollution Liability Aggregate:$4,000,000 Environmental Impairment Liability Each Pollution Condition:$1,000,000 Environmental Impairment Liability Aggregate:$1,000,000 SEE ATTACHED ACORD 101 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I tr ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID:24REST0-01 GHOUGHTON /.°11111 LOC#: 1 ACCPR EY ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY License#1780862 NAMED INSURED HUB International New England 10 land 10 Restore NE LLC Church Street POLICY NUMBER South Easton,MA 02375 SEE PAGE 1 CARRIER NAIC CODE SEE PAGE 1 SEE P 1 EFFECTIVE DATE:SEE PAGE 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Description of Operations/LocationsNehicles: Professional Liability Each Wrongful)Act:$2,000,000 Professional Liability Aggregate:$4,000,000 Specified Professional Services Endorsement-Professional services means project management or supervision; or construction means,methods,techniques,sequences and procedures in connection with the named Insured's contracting operations performed by the Named Insured in its capacity of a specialty trade or artisan contractor The Western Word Liability Policy#EVP100335700 includeds Blanket Additional Insured,Waiver of Subrogation and Primary and Non-Contributory Endorsements and apply when required by written contract or agreement. The Commercial Auto Policy includeds blanket additional insured when required by written contract and Waiver of Subrogation. Worker's Compensation policy includes Waiver of Subrogation. Umbrella Policies are follow form to the General Liability ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ,:'•.\ l ttC I.VLtt MVtt rvGutttt Of IY1 u,3LLL/tuJGLia � a Department of Industrial Accidents nl1,�`p Office of Investigations __ ' Lafayette City Center fC _ 2Avenue de Lafayette, Boston,MA 02111-1750 ‘ki�`•y'_ wwwmass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / ' Please Print Legibly Name (Business/Organization/Individual): GI L`/ /?`ec` U h'e__- Address: 16 Chu re 1 Ci"lAe e City/State/Zip: ° Coe-no/7t iYW1 Phone#: 5-0g -,A 3 e - �660 Are you an employer? Check the appropriate box: Type of project(required): 1.II.I am a employer with ac.."--- 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. ❑Remodeling 2.El I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance. required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12X Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other 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: © Alb cCr G-I -iLI �14c came ' b vs fi Policy#or Self-ins. Lic. #: 00& 10 G d 7 l Expiration Date: /15:itc l 01 j �G 'i r Job Site Address:c)17 /i'!a(.f/d s-i a'c Pr" City/State/Zip: /a(112 p 6✓t 0) I ev 4r1 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 ins and penalties of perjury that the information provided above is true and correct Signature: 47 Date: Place It /?l r�090 Phone#: '/ '" qB3' 4( Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 211 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.0Other Contact Person: Phone#: