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HomeMy WebLinkAboutbld-20-004599 1.VulCC u e Vllly ;; � j •0I'YARD RhPa - /s1; O 0 i,,, • y: 1,Amount \.? MATTAIM ESE �1 _ ,t;� _,00s !d;' iPermitexpires 180 days from � .: _ .. {issue date EXPRESS BUILDING PERMIT APPLICATI a I , TOWN OF YARMOUTH Yarmouth Building Department i - �� 1146Route281 , FE 202 0 I. South Yarmouth, MA 02664 M_LOWEIViii-ail sv (508) 398-2231 Ext. 1261 By' .e.•..._ CONSTRUCTION ADDRESS: // ".ef 'z. CA w... t S •° ASSESSOR'S INFORMATION: Map: Parcel: OWNER: I.) ,i 7l r)) // 5-- -NT. S Jo RESSx� 1 — 5 E0 ' c y/ t/� CONTRACTOR::: eNAIVE / g ` ee'7 " . — 9 5 NAME ING ADD SS O7 3 J TEL.# Residential ❑Commercial Est.Cost of Construction$ 2-__S hrf'- ---�' Home Improvement Contractor Lic.# j 6' �Z_ / Construction Supervisor Lie.# 6 eP S ' Workman's Compensation Insurance: (check one) 0 I am the homeowner 414tem the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove _ Siding: #of Squares Replacement windows:# Replacement doors: # 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: N y , /J A,5.7-' 5AL Yi cl r . ' e L 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 license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: '- Z...e C -c: ' Owners Signature(or attachment) s? Date: Approved By: Date: 2----.2:, .7.C.l Buildup:, 1 ' (o esi gnee) L ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No lip , L,....\ * The Commonwealth of Massachusetts Department of Industrial Accidents r1301 .-.IF 1 Congress Street, Suite 100 i:� Boston, MA 02114-2017 '"..5 www.rnass.go v/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information PIease Print Legibly Name (Business/Organization/Individual). Address: i City/State/Zip:_ �'' p2� I T hone #:_/-- ,��$ - 7-- 9 2--- Are you an employer?Check the appropriate box: I. I am a employer with Type of project(required): ❑ employees(full and/or part-time).* — 2.• I am a sole proprietor or partnership and have no employees working for me in T New Jelin construction any capacity.[No workers'comp. insurance required.]— 8. _ Remodeling 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]; 9 ❑ Demolition — 4 _ I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12. Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.': 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14 Other T r.� 152,§1(4),and we have no employees. r. [No workers'comp. insurance required.] zr- *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. � 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: c c Policy#or Self-ins. Lic. #: ' /9 ' 3 1/ cr Expiration Date: r 1 -- 2 , - ›—e2 Job Site Address: l' ,k't.- r °' City/State/Zip: Attach a copy of the workers' c mpensation p cy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152 2 ana fine up to $1,50.00 d/or one-year imprisonment, as well as civil penalties in the form of STOP 5A is a criminal violation ORDER andya fine of up to$250.00 a lay against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. r do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. >itrnature: Alldr � �j re Date: ��— -�,c:, 'hone#: - 2 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 CIerk 4. EIectrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: mew _____...4,10 HALLCUS-01 BCARLSONI ACISPRL7. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �—. 4/17/2019 THIS CF.'TIFICATE 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). License#1780862 CONTACT PRODUCER NAME: HUB International New England PHONE 781 792 3200 IFAX A/c,No):(781)792-3400 600 Longwater Drive (E No,Est): ( ) Norwell,MA 02061-9146 E-MAILADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Evanston Insurance Company 35378 INSURED INSURER B:Associated Industries of Massachusetts Mutual Insurance Compan 33758 Hall Custom Builders,Barry E.Hall dba INSURER C: 8 Mayflower Knoll INSURER D: East Sandwich,MA 02537 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 LTR ADDL SUER POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE INSD WVD POLICY NUMBER IMDDIVYYY) (MM/DD/YYYY1 A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 3AA331989 4/1/2019 4/1/2020 FRA MISEsO(EaEoTEu D nce) $ 50,000 MED EXP(My one person) $ PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 1,000,000 POLICY E. LOC PRODUCTS-COMP/OP AGG $ OTHER $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ AUTOS ONLY _ SCHEDULED BODILY INJURY(Per accident) $ HIRED NON-OWNER D PROPERTY DAMAGE AUTOS ONLY — AUTOS ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION P ATUTE YIN OER TH- ANDEMPLOYERS'LIABILITY VWC1006017430 4/13/2019 4/13/2020 1,000,000 ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ (Mandatory in NH) CLUDED? N/A 1,000,000 E.L.DISEASE-EA EMPLOYEE $ If yes,describe under E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Proof of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ?,..g.- .4.,-;:9---- ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Division of Professional Licensure Board of Building Regulations and Standards Constr9tt%1111 b0,rvisor CS-006501 + 6cpires.02/18/2022 BARRY E.HALL : • 8 MAYFLOWER KNOL / ; EAST SANDWICH MA`r► Commissioner 4 / /17* --- • • / Cipro, Linda From: Dave Hill <dlhillberg57@gmail.com> Sent: Thursday, February 20, 2020 3:11 PM To: Cipro, Linda Subject: 115 Evergreen St. S Yarmouth. New Siding Attention!This email originates outside of the organization. Do not open attachments or click links unless you are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure.Otherwise delete this email. I David Hill of 115 Evergreen St.S.Yarmouth give Hall Builders permission to take out a building permit for new siding at said address. David Hill 2/20/20 Sent from my iPhone i