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HomeMy WebLinkAboutBLD-20-004995 R E � 1 ' ' E K 0 Use Only .Qg.Y44 1, 1 1677 _ 't , t�t ' � a 7; a . 'fi�++�+y a I l � 'iY Amount �•+wwt� 3 11 1--„,1_,,L DIN(, f, , - s „Permit expires 180 days from i .�. issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH ,,.; t , '—� Yarmouth Building Department y 1146 Route 28 I M South Yarmouth,MA 02664Lit, 4' (508) 398-2231 Ext. 1261 ; �;; .,/' t3y: ARTtYij CONSTRUCTION ADDRESS: 28 Plymouth Rd in Yarmouth Port ASSESSOR'S INFORMATION: Map:144 Parcel: 11.5 OWNER: Shiela Parenteau 28 Plymouth Rd in Yarmouth Port 774-810-6660 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Michael Ferullo PO Box 549 Yarmouth Port, MA 02675 508-801-3532 NAME MAILING ADDRESS TEL.# Residential 0 Commercial Est.Cost of Construction$ 12,000 Home Improvement Contractor Lic.# 171899 Construction Supervisor Lic.# CS-107347 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor XI have Worker's Compensation Insurance Insurance Company Name: Star Insurance Company Worker's Comp,Policy# WC0869747 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Ondliwcah Siding: #of Squares 2 Replacement windows:# 3 Replacement doors: # Roofing: #of Squares I (\/)Remove existing ax.2 layers) Insulation (e)( +\r,kr --M eArkl //‘ X Old Kings Highway/Historic Dist. (X)Replacing like for like Pool fencing *The debris will be disposed of at: Town of Yarmouth Transfer Station 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 rev io of m license and for prosecution under M.G.L.Ch.268,Section 1 Applicant's Signature: i'� Date: 3/3/2020 Owners Signature(or attachment) Date: Approved By: �, 12 Date: 3 - 10 — 4.0 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 1 Yes 1 No Flood Plain Zone: L. Yes 1 No Water Resource Protection District: Within 100 ft.of Wetlands: Ei Yes No ri Yes Li No The Commonwealth of Massachusetts 1. Department of Industrial Accidents lit- 1 Congress Street,Suite 100 Boston,MA 02114-2017 ",'`< www s mas gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Auulicant Information Please Print Legibly Name(Business/Organization/Individual):Ferullo Remodeling Inc Address:PO Box 549 City/State/Zip:Yarmouth Port, MA 02675 Phone#:508-801-3532 Are you an employer?Check the appropriate boa: Type of project(required): LEI I am a employer with 2 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0✓ 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. El 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 11.0 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. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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:Star Insurance Company Policy#or Self-ins.Lic.#:WC0869747 Expiration Date:4/15/2° Job Site Address:28 Plymouth Rd City/State/Zip:Yarmouth, MA 02675 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 a er the pains an penalties of perjury that the information provided above is true and correct. Signature: Date: v—?7c7Lo Phone#:508-801-3532 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#: Harwich Ecumenical Council for the Homeless, Inc. (HECH) Housing Emergency Loan Program General Contractor and Owner Agreement Attachment A NOTICE TO PROCEED To: Michael Ferullo, Ferullo Remodeling. Inc..: You are hereby given authorization to proceed with the renovations at 28 Plymouth Rd. YarmouthPort in accordance with the General Contractor and Owner Agreement dated February 13. 2020. The work is scheduled to begin on February 13. 2020 and to be completed on or before May 30. 2020. /JJ Owner: eila Parenteau Date -> 07//3 Wit ssed b • • berly : # :ea, HECH Program Director Date ACGREI CERTIFICATE OF LIABILITY INSURANCE DA,E(MM/DD,YYYY) 4/17/2019 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 POUCIES 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 Mason&Mason Insurance Agency, Inc. FAX FAX 458 South Ave. INC.No.Exit 781-447-5531 (A/C.No):781-447-7230 Whitman MA 02382 E-MAIL INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Main Street America Assurance 29939 INSURED FERUREM-01 INSURER B:Ailmerica Financial Benefit 41840 Ferullo Remodeling, Inc.PO Box 549 INSURER c:Star Insurance Company 18023 Yarmouth Port MA 02675 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1734013238 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 LTR INSD WVD POLICY NUMBER (MWDD/YYYY) (MWDD/YYYY) A X COMMERCIAL GENERAL LIABILITY MPP6465G 4/15/2019 4/15/2020 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $500,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILE LIABILITY AWVD225988 4/152019 4/15/2020 COMBINED SINGLE LIMIT $ (Ea accident) 1.000.000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS AUTOS X ANON-0WNED (Per a de tDAMAGE X HIRED $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION WC0869747 4/152019 4/152020 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N NIA E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Ferullo Remodeling Inc PO Box 549 AUTHORIZED REPRESENTATIVE Yarmouth Port MA 02675 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 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: EXOiratioq Office of Consumer Affairs and Business Regulation 171899' 04/29/2020 One Ashburton Place-Suite 1301 MICHAEL FERULLO Boston,MA 02108 MICHAEL,F4RULLO a 52 RIvIOU DR of valid without signature YARMOUTH PORT,MA 02675 Undersecretary y- r Commonwealth of Massachusetts Division of Professional Licensure '-- Board of Building Regulations and Standards Constr t rr:upervisor tl CS-107347 , U ires:09/09/2021 MICHAEL FEBULLO 1 PO BOX 549 r YARMOUTH PRT 5 * ()/1'4'1 1c Commissioner eit..,1.71/. * S\1\-fio\(is [--rbv,c_ o\o‘r)